Peds: Death and Dying

Behaviors exhibited by parents when informed nothing more can be done medically to treat their child's illness

- anticipatory grief - grief in stages similar to when the illness was first diagnosed - lack of acceptance of the situation so that treatments continue instead of ending treatments - a desire to continue treatment with a curative focus rather than a palliative focus

Fluid intake

- Lung secretions may increase if there is an increase in fluid intake making suctioning a necessity - Restrict fluid intake if kidney function is declining - The dying child's favorite drinks provide physical and emotional well-being - Provide choice of liquids to allow the patient some sense of control - Be careful not to cause choking when administering fluids to the dying child

Reactions to dying

- Being ill is worse than dying - The treatment is worse than dying - Relief and acceptance of death - Behaviors and feelings of loved ones influence the response and actions - Spiritual beliefs - Visions of angels or higher beings - Near-death awareness (happens weeks to hours before death) - Heightened sense of understanding and awareness as death nears - Gaining closure regarding an event in the child's life or life of a loved one

Why families choose hospice

- Child's physical and emotional care requirements are too great for family caregivers to manage - Child's physical symptoms require aggressive management - Child's pain requires intensive and complex medication control - Home may not be conducive to adaptations needed for the child's care

Timing of palliative care

- Children with chronic and life-threatening illnesses should receive palliative care early in the disease process - Palliative care can be provided throughout the disease process - It can occur while a child with a life-threatening illness is still receiving treatment focused on sustaining life

Experimental treatments

- Experimental treatments may be the parent's final attempt to cure their child. The treatments may be obtained in countries outside of the United States. - may not be approved by the FDA - Most experimental treatments will not cause harm to the child and may provide emotional benefits for the child and parents, such as hope. - Any treatments that are potentially harmful to the child should not be allowed by the health care team.

Normal behaviors exhibited by family members when child diagnosed with life threatening condition

- Having difficulty allowing the child to die - Reassuring the dying child that it is okay to die - Affirming their love for the child as death approaches - Telling the dying child that the child will be ok right after they die - Telling the dying child they will remember them always

Common family issues

- Most common issue is whether to inform the child that the illness will lead to death. - The needs of the dying child must take precedence over those of the family members. - Parents may not want to talk with the child about death, so open communication with the child is important. - Nurses may be caught in the middle when a child desires to talk about death and the parents forbid any such conversations. - The nurse must address the needs of the patient first, so difficult discussions with the parents may ensue. - Lying to the child about the prognosis damages the nurse-patient relationship. Trust between the nurse and child is vitally important. - Nurses should inform parents that they will not initiate any discussion of the child's death but need and intend to respond openly and honestly if the child asks questions or wants to talk. - Parents may make treatment decisions that do not seem to be in the best interest of the child. They might continue treatment that is traumatic and not likely to provide long-term survival for the child. - Consulting the ethics committee may be necessary when family members and health care providers disagree on the plan of care.

Oral care

- Nurses and family provide mouth care to the dying child to promote comfort and prevent mouth sores - Clean the mouth and lips with sponge swabs and use artificial saliva preparations to provide moisture - Lip balm is used for dry chapped lips - Avoid products with alcohol as they have a drying effect on the mucous membranes - Appropriate and frequent oral care will minimize the child's discomfort

Pain management

- Pain management and the comfort level of the child are often seen as the most important intervention. - The nurse educates the child and family regarding pain control methods and then provides consistent reassurance that all appropriate interventions will be done to provide for the child's continued comfort. - It is necessary at times to increase the medication dosages or change the medication regimen in order to control escalating pain. - Educate family regarding pain management as soon as possible so that information can be reinforced with every administration. - Under specific circumstances, PCA units can be used by the nurse or parents.

Parental response to the death of a child

- Parents often find comfort in talking about their child. - Parents may be relieved when the child is no longer suffering physically and emotionally. - Parents may feel guilt over relief that their child is no longer suffering. - Health care staff should educate the parents that feelings of relief are normal. - Feelings of relief at the death of the child are replaced by numbness, intense sadness, loss, and emptiness. - Parents may adopt coping strategies, such as having another child or adopting a new role to neutralize the negative impact of losing a child. - The grief of other family members such as grandparents should be considered. - Grandparents grieve for the grandchild and for their child, who is experiencing the death of a child.

Palliative care goals

- Relieve suffering including physical, psychologic, social, and spiritual - Improve the child's quality of life - Facilitate informed decision making including end-of-life decisions - Assist with coordination of care

Sibling response to the death of a child

- Sibling responses to death and dying vary according to the age and developmental level of the child. - Children usually experience all 5 stages of grief which include denial, anger, bargaining, depression, and acceptance. - It may be considered an appropriate coping mechanism for a child to re-experience one stage several times. - The emotions of the child may mimic those experienced by the parents. - Unresolved grief may be related to immature cognitive and developmental abilities and may manifest itself in the child's adult life if not dealt with during childhood. - Often benefit from attending a children's grief support group. - Siblings may experience survivor's guilt before or after the sibling's death.

Physical signs of impending death: respiratory changes

- The force of the respiratory effort may decline. - An increased work of breathing, along with apnea, may be noted. - Respirations may fluctuate between the two states-rapid, increasingly shallow breaths followed by cessation or Cheyne-Stokes respiration leading to respiratory arrest.

Privacy for child and family

- The need for napping and extended nighttime sleep increases as the child nears the end - The child may experience: Frequent wakefulness, Sleep deprivation, Nightmares - Limit visitors to promote sleep and rest - Disruptions by the staff should be minimized if requested by the family

The Child's Wants and Needs

- To feel safe - To not be alone - To not be in pain

Variations in the Child's response

- Varied - Different than child's age, developmental, and or cognitive level - Advanced due to the traumatizing experiences of the chronic condition - More mature than expected or "wise beyond their years"

Practices and beliefs surrounding death

- Wearing prayer cloths - The laying on of hands - Use of holy water or oil - Viewing religious pictures, icons, or other objects - Extemporaneous prayer gatherings - The preparation and serving of certain foods

Immediately following death

- family members should have the opportunity to spend time with their child, even before the body is cleaned. It may be preferred to clean and prepare the body first because of the drainage, bleeding, and spontaneous elimination of body wastes that often occur at the time of death. - family may want to make hand and footprints or cut lock of hair - explain to family what will be involved in the care of the body. Family can be invited to assist in bathing the body - Family should be provided information before the child's death if an autopsy will be required and how this will affect their time and involvement with the child after death

Physical changes and signs of impending death

- heart rate increases with a concomitant decrease in strength and quality of peripheral pulses - blood pressure decreases. Pulse and BP may become difficult or impossible to palpate, a state that can last for hours - cardiac changes generally occur before respiratory changes - continuing respiratory and cardiac changes may lead to cool extremities and cyanosis. Often begins in lower extremities and progresses toward face

Near death sounds

- noisy breathing caused by rattling secretions in the upper airway (death rattle) due to losing strength and ability to clear airway secretions - audible respirations and expiratory sigh

Management of respiratory changes

-pharyngeal suctioning - atropine or diphenhydramine to decrease amount of secretions - position in side-lying position with cloth under mouth - educate the parents that the heart may still beat for a few minutes after respirations cease - final gasping noise may occur after death, which is normal - you can assume the child is comfortable if the pt appears comfortable and has not verbalized discomfort

Unresponsive child

Although a dying child may appear unresponsive, hearing is the last sense to stop functioning before death. The nurse should encourage the family members to talk to the child and maintain physical contact such as touching or holding the child's hand until death occurs and even after. The child may hang on to life, feeling unable to leave the parents. The parents may need to tell the child that they are loved and will be missed, but that it is okay to die. The nurse assesses the needs of the family during the final moments of their child's life and offers assistance as indicated to facilitate contact and communication with the child.

Palliative care

Care designed to meet the unique and special needs of children living with life-threatening conditions. Pediatric palliative care focuses on the needs of the patient and all members of the family including pain and symptom management, information sharing and advance care planning, practical, psychosocial and spiritual support, and coordination of care.

Emotional needs of the family and dying child

Children, parents, and siblings may need assistance to understand their intense emotions, especially anger and guilt. Parents, other adult family members, and siblings need opportunities away from the dying child to express their feelings. The goal is to have the child and family together in an environment that is as soothing, comfortable, and as stress-free as possible.

Concept of death: Early childhood (2-7yr)

Death as a reversible and temporary separation "Daddy went to heaven but he'll be back soon."

Concept of death: adolescence (12+yr)

Death as inevitable and irreversible but often a distant event "We all will die someday. It will be a long time before that happens."

Concept of death: infant and toddler (0-2yr)

Death as loss of the caregiver- the infant or toddler views death as not having a caregiver "Mommy is gone." "Where did mommy go?"

Concept of death: Middle Childhood (7-12yr)

Death as sad and irreversible but not necessarily inevitable "Grandpa died; he is gone now but I won't die."

Stages of grief

Denial Anger Bargaining Depression or Sadness Acceptance

Anticipatory grief

Feelings of grief that develop before, rather than after, a loss.

Professional boundaries

Necessary for the nurses to provide clinically sound, compassionate care while maintaining their own emotional, physical, and spiritual health. To maintain professionalism and boundaries, nurses must understand and accept their own feelings and beliefs about death. The psychologic, spiritual, and ethical needs of the health care professional should be addressed by the palliative care team

Do not attempt resuscitation (DNAR)

No interventions to initiate a heartbeat and respirations after cardiac or respiratory arrest are performed. DNAR order does not withhold treatment when the child is alive; it involves not initiating treatment after the child has died.

Factors that affect response of child to death and dying

Personal/spiritual beliefs, and past experiences with death. The age of the infant or child is influential, as is the quality of the relationship with family members.

Hospice care

Specialized, comprehensive system of care that provides support and assistance to patients and their families during the last phase of a terminal illness The hospice team ensures medications, health care supplies, and medical equipment are delivered to the home.

Suctioning

Suctioning a patient at end of life can often be perceived as painful or aggressive, and is difficult for parents and/or caregivers to watch. Discuss with the health care team the option of medications to minimize respiratory secretions as appropriate, to decrease the anxiety often associated with oral or nasal suctioning.

Changes in family routines

The availability of loved ones becomes more important to the child with a terminal illness who will experience more frequent periods of prolonged sleep. Regardless of the duration (moments, minutes, or hours), intervals spent with the child can become treasured memories. Special care must be taken to explain to siblings the reasons for rearranging life around the ill child's wakeful hours.

Responsiveness of the dying child

The child may become unresponsive in the days or hours before death or may be intermittently responsive until the actual moment of death. Many children have been noted to experience a period of time immediately before they die when they are stronger, more alert, and show increased interest in their family members. This occurrence may cause family members to have unrealistic expectations for recovery; therefore, nurses must prepare and educate families about this possible event.

Respite care

short-term health services either at home or in an institutional setting

Communication with the dying child and family

The dying child should consistently be reassured that the illness and approaching death are not the result of any action or omission committed by the child and that the child won't be left alone. As death approaches, communication between child and family can decline in both extent and effectiveness. The nurse should consider communication strategies the family has used effectively during previously stressful times and encourage them to use them again.

A 14-year-old child with terminal brain cancer has months left to live. The child's pain is increasing, along with problems ambulating due to unsteady gait and increasing difficulty in swallowing. The parents ask the nurse about hospice care. Which response by the nurse is appropriate? Select all that apply. a. "Hospice care can be provided in your home." b. "With hospice care, your family is able to receive respite care." c. "With hospice care, your child doesn't have to be admitted to the hospital." d. "Hospice care allows for a comfortable death while ensuring the dignity of your child." e. "With hospice care, some of the physical and emotional burdens of caring for your child are taken care of."

a. "Hospice care can be provided in your home." Hospice care can be provided in the patient's home or in a hospital setting, and therefore this is the best response for the nurse to make. b. "With hospice care, your family is able to receive respite care." A child may be admitted to the hospital when in hospice care for pain control and respite care, and therefore this is the best response for the nurse to make. d. "Hospice care allows for a comfortable death while ensuring the dignity of your child." Hospice care allows for a less-chaotic, home-like environment that enhances the ability to have a comfortable death. The dignity of the child is enhanced as well.

A 12-year-old patient has been in hospice for one month and expresses feelings of discontent and would like to go back to the hospital. The patient states missing being with other children and liking the food there better. How will the nurse respond? Select all that apply. a. "It is okay to change your mind." b. "Tell me more about how you are feeling." c. "I'll let your parents know you want to go back to the hospital." d. "I'll call the hospital and see how soon you can be transferred back." e. "Why don't you give this place a little more time before going back to the hospital"

a. "It is okay to change your mind." The child should know that they have the right to change health care environments and that there won't be trouble for wanting to change. b. "Tell me more about how you are feeling." It is important to allow the child to express emotions regarding hospice care, and therefore this is the best response for the nurse to make. c. "I'll let your parents know you want to go back to the hospital." This demonstrates to the child that you are working on accommodating the change from hospice to the hospital setting.

A 4-year-old child with chronic sickle cell crisis is terminal and unable to walk, requires continuous oxygen administration, is moaning and crying with position changes, and has refused to eat meals for the last 2 days. The parents ask the nurse how they will care for their child and what they should do now. Which response by the nurse is appropriate? a. "Learning about hospice care services would be appropriate at this time." b. "Initiating home health nursing services will help you care for your child at home." c. "Initiating palliative care services for your child would be important right now." d. "Learning how to care for your child at home would be appropriate at this time."

a. "Learning about hospice care services would be appropriate at this time." The goal of hospice care is to improve the quality of life and decrease the stress on the child and family members and can be introduced at any time during the child's treatment.

The hospice nurse is caring for a school-aged child who has a glioblastoma with metastasis throughout the body. The toddler has been declining in health for the past 7 days, has had no oral intake, has a labored, irregular respiratory rate of 6 breaths per minute and is bradycardic at 50 bpm. The parents ask the nurse what they can do to help the child through the process. Which is an appropriate response by the nurse? a. "Tell the child it is ok to die." b. "Your child's body is wearing out and will die soon." c. "It's hard to know why your child hasn't died. It should be soon." d. "Your child's condition has plateaued; your child could last for weeks like this."

a. "Tell the child it is ok to die." The child may be hanging on to life because the child cannot die without permission by the parents. The parents must convey feelings of love to child, a sense that child will be missed, and finally give the child permission to die.

A parent is taking care of her child dying of cancer and asks the nurse about oral care since the child often complains of a dry mouth. What education on oral care can the nurse provide to this parent? Select all that apply. a. "You can moisten her lips with this sponge swab." b. "Use the artificial saliva drops as needed to provide comfort." c. "A mint flavored mouth spray may decrease the dry sensation." d. "Using the mouth swabs every shift will provide comfort for the child." d. "Petroleum jelly on the lips provides moisture for a longer period of time."

a. "You can moisten her lips with this sponge swab." Sponge swabs provide moisture for the lips and mouth of the dying child. b. "Use the artificial saliva drops as needed to provide comfort." Artificial saliva drops add moisture to the mouth and provide comfort. e. "Petroleum jelly on the lips provides moisture for a longer period of time." Petroleum jelly or lip balm is used to treat dry, chapped lips.

A 4-year-old child is dying of an inoperable brain tumor. The child is conscious for only a few hours out of every day and doesn't talk much when awake. The parents tell the nurse what the child has told them. "Don't be sad when I die. I will go to sleep and then wake up and be here with you." The parents ask the nurse how to respond to the child's statements. Which response by the nurse is appropriate? a. "Your child's perception of death is that death is reversible and temporary and is appropriate for the developmental age." b. "Your child perceives death as a sad but reversible separation. This is an inappropriate perception for the child's developmental age." c. "Your child's perception of death is abnormal and concerning for the developmental age. Your child should be focused on death as a distant event." d. "Your child's perception of death is that death is temporary with the loss of you as the care provider. This is appropriate for the developmental age."

a. "Your child's perception of death is that death is reversible and temporary and is appropriate for the developmental age." In early childhood, children are at the preoperational cognitive stage and perceive death as reversible and temporary.

What are the cardiovascular signs that death of a child is approaching? Select all that apply. a. Cool hands and feet b. Decreasing heart rate c. Weak peripheral pulses d. Increased blood pressure e. Cyanosis in the hands and feet

a. Cool hands and feet Cardiovascular changes affect the extremities first and are related to the changes in cardiac functioning. Cooler extremities will be an expected finding in patients who are about to die. c. Weak peripheral pulses Pulses and blood pressure may become difficult or impossible to palpate when the child's death is approaching. e. Cyanosis in the hands and feet Cardiovascular changes affect the extremities first and are related to the changes in cardiac functioning. This can lead to a decrease in oxygen supply to the extremities.

A 7-year-old child has recently died after being treated for leukemia for the past 5 years. The child was unresponsive for days prior to dying and the parents were at the bedside the entire time. The nurse overhears the parents say statements such as, "I feel like this is a dream. I don't know what to do now." "Thank God it is finally over; he's at peace." "Is it wrong to feel this way?" Which emotions or reactions are being expressed? Select all that apply. a. Indifference to activities of daily living b. Relief that the child is no longer suffering c. Numbness to any emotions when around others d. Guilt related to being relieved over the death of the child e. Hostility related to the pain experienced during the dying process by the child

a. Indifference to activities of daily living Emptiness and lack of interest in activities can be displayed as indifference to many aspects of daily living in someone who has experienced a great loss, such as the death of a child. b. Relief that the child is no longer suffering Parents may be relieved when the child is no longer suffering physically and emotionally, and therefore it is normal for the parents to express these emotions. c. Numbness to any emotions when around others Numbness may be displayed by parents whose child has just died. It is an expected emotion for parents who have lost a child. d. Guilt related to being relieved over the death of the child Parents may feel guilt related to the relief experienced when the child died, and therefore this is an expected statement for the parents to make.

A mother of a dying 14-year-old is trying to decide whether to order a do not attempt resuscitation (DNAR) order on her child. Which are the next best actions for the nurse to take? Select all that apply. a. Inform the mother that the DNAR order can be stopped at any time. b. Try to prevent the DNAR order since it is a time-consuming and difficult process. c. Intervene immediately since DNAR orders prevent new treatments from being initiated. d. Discuss how the DNAR order withholds treatments to the child, which facilitates the dying process. e. Inform the mother that DNAR order prevents interventions from being performed after the child stops breathing.

a. Inform the mother that the DNAR order can be stopped at any time. A DNAR order can be revoked at any time, and therefore the nurse should inform the mother. e. Inform the mother that DNAR order prevents interventions from being performed after the child stops breathing A DNAR order does prevent chest compressions, ventilations, and advance life support treatments from being initiated when the patient's breathing or heartbeat ceases.

A child has passed away and it is now time to clean the body. Which should the nurse do next? a. Invite the parents and siblings to assist in preparing the body b. Quickly clean the body before the parents have time with the dead child c. Ask the parents to leave the room until death cares are completed d. Remove all elimination waste from the body and prepare the body for the morgue

a. Invite the parents and siblings to assist in preparing the body Including the family in the final act of care for the child may provide a means of closure for them, and therefore this is an appropriate action for the nurse to take.

What is the purpose in allowing family members to interact with the body after the patient dies? a. It allows the family members to say their final good-byes. b. To assist the nurse with preparing the body for the funeral home. c. To make sure the wishes of the family are upheld until the body goes to the funeral home. d. To complete the legal paperwork associated with a child's death prior to the body going to the funeral home.

a. It allows the family members to say their final good-byes. Allowing interaction with the body after the patient dies allows for emotional closure for the family members, which is important for grieving.

Which environment would the nurse prepare for a child in the dying process? Select all that apply. a. Low lighting and soft music playing. b. Quiet space away from a lot of activity. c. Multiple opportunities to create cherishing moments. d. An energetic, social environment with friends and family. e. An environment conducive to allowing family members to stay with the child.

a. Low lighting and soft music playing. The goal of nursing care for the dying child is to create a calm and peaceful environment. b. Quiet space away from a lot of activity. The goal of nursing care include creating a quiet and secluded environment. c. Multiple opportunities to create cherishing moments. Creating memories allows the family to spend time together, which become a source of comfort after the child dies. e. An environment conducive to allowing family members to stay with the child. One of the goals of nursing care for the dying child is to allow family members to stay with the child.

Two healthy siblings of a child with chronic illness are talking with a nurse about the expected death of the child. One sibling begins to cry and the other sibling punches the crying sibling in the arm. The parent expresses concern over the differences in coping. How should the nurse respond? Select all that apply. a. Reassure the parents that differences in grieving are normal. b. Explain what resources are available for children experiencing grief. c. Explain that most families progress through the stages of grief together. d. Explain that grief presents differently according to the developmental stage of the child. e. Reassure the parents that their children will eventually progress through the stages of grief together.

a. Reassure the parents that differences in grieving are normal. A sibling's response to death and dying varies, and the child can experience one stage of grief many times or out of sequence. b. Explain what resources are available for children experiencing grief. Children who are grieving may benefit from attending support groups created just for children. Therefore this is an appropriate response for the nurse to make. d. Explain that grief presents differently according to the developmental stage of the child. A sibling's response to death and dying varies according to the sibling's age and developmental level.

The parents of a 4-year-old child have decided to try an herbal remedy to help relieve their child's suffering. After observing this, what should the nurse do next? Select all that apply. a. Research the herb to see if it is appropriate to use. b. Provide emotional support and comfort to the family members. c. Report the herbal supplement use to the primary care provider. d. Report the treatment to the FDA because it is not an approved herb. e. Remind the parents that only medications ordered by the health care provider are able to be administered to the patient.

a. Research the herb to see if it is appropriate to use. The nurse must ensure that there are no harmful effects of the herbal supplement. b. Provide emotional support and comfort to the family members. Use of alternative therapy may provide hope to the patient and family. Emotional support and comfort aids in providing hope to the family and patient. c. Report the herbal supplement use to the primary care provider. The health care provider should be aware of all of the treatments utilized by the patient. Interactions between drug and herbal supplements may occur, so the provider should know everything the patient is utilizing.

A 10-year-old child with leukemia is dying after a failed bone marrow transplant. The child is anxious when approached by the nurses, expresses fear about going to sleep at night, and cries when the parents are not present in the room. The nurse is concerned with the child's ability to cope with dying. Which actions should the nurse take next? Select all that apply. a. Stay in the room with the child while they fall asleep. b. Have the child life specialist play games with the child. c. Give the child a stuffed animal to cuddle while they go to sleep. d. Have a volunteer stay with the child while the parents are gone. e. Talk with the parents about being present at the hospital around the clock.

a. Stay in the room with the child while they fall asleep. A child who is dying wants to feel safe and not be alone. Staying in the room with the child while they fall asleep assists with the patient accepting death. d. Have a volunteer stay with the child while the parents are gone. A child who is dying will not want to be alone. Having a volunteer stay with the child while the parents are gone prevents the child from being alone.

A 4-year-old child is expected to die within the week. The child sleeps all day and has not eaten in 2 days. What should the nurse communicate to the child? Select all that apply. a. That the child will not be left alone to die. b. That the hospital chaplain will visit and pray with the child. c. That the child is loved and supported by the nurses and family members. d. That the child will need to communicate more clearly with the nurses and family. e. That the illness and impending death are not the child's fault or a result of poor judgement.

a. That the child will not be left alone to die. For reassurance it should be consistently and frequently communicated to the child and family members that the child won't be left alone to die. c. That the child is loved and supported by the nurses and family members. Children who are dying need to experience complete love and acceptance. e. That the illness and impending death are not the child's fault or a result of poor judgement. The dying child should be consistently reassured that the illness and approaching death are not the result of any action or omission committed by the child.

A young nurse who does not deal well with death is looking for support. What is the best way a more experienced nurse can respond? Select all that apply. a. The experienced nurse offers to mentor the young nurse. b. Tell the young nurse to exercise every day to "blow it off". c. Explain the need to suppress emotions as this is part of the job. d. Inform the young nurse about availability and time to talk. e. The experienced nurse refers the young nurse to grief programs offered at the hospital.

a. The experienced nurse offers to mentor the young nurse. Mentoring the young nurse provides the support the nurse needs while learning how to deal with death and dying. d. Inform the young nurse about availability and time to talk. Meeting with a nurse and taking the time to listen shows support for what that nurse is experiencing. e. The experienced nurse refers the young nurse to grief programs offered at the hospital. Providing a resource for dealing with grief demonstrates support and concern for the young nurse. Grief programs are important for health care professionals to use to repair, maintain, or enhance their emotional well-being.

A young nurse developed a friendship with a teenaged patient who died. What can this nurse expect during the grieving process? a. The grieving process for the nurse may take a lot longer to get over. b. The grieving process should be shorter since the nurse works with terminal patients. c. The nurse may become more involved with a new patient that has a similar diagnosis. d. The nurse may experience certain stages of grief repetitively when working through the grieving process.

a. The grieving process for the nurse may take a lot longer to get over. When a nurse becomes more involved with a patient, a more intense response or a delay in the resolution of grief may occur.

Which scenario accurately reflects a parent experiencing anticipatory grief? a. The parents cry when holding their sleeping child. b. The parents research treatment options available to cure the illness. c. The parents pray for a cure at the bedside of the child hourly while reading the Bible. d. The parents suggest a desire for treatment to continue for their child even though no benefits are provided.

a. The parents cry when holding their sleeping child. Crying when hold a sleeping child is an example of anticipatory grief, a response to the impending death of a loved one.

Cheyne-Stokes respiration

an abnormal pattern of respiration, characterized by alternating periods of apnea and deep, rapid breathing. The respiratory cycle begins with slow, shallow breaths that gradually become abnormally rapid and deep. Breathing gradually becomes slower and shallower and is followed by 10 to 20 seconds of apnea before the cycle is repeated. Each episode may last from 45 seconds to 3 minutes.

The mother of a 14-year-old child who recently died tells the nurse that the 10-year-old sibling has become very withdrawn, angry, and aggressive. The child has said to the mother, "It should have been me." The mother asks the nurse how to respond to the child. Which responses by the nurse are appropriate? Select all that apply. a. "Your child's aggression is concerning. Is there a history of behavioral problems?" b. "A child's response to death is varied because of age and developmental level." c. "Your child is working through the stages of grief. Sometimes a child stays in one stage longer than others." d. "The child's response demonstrates the need for psychologic counseling. I can provide you with a referral." e. "Your child may be experiencing survivor's guilt related to the death of your child and needs to express feelings."

b. "A child's response to death is varied because of age and developmental level." Children respond to a sibling's death in a variety of ways based on their age and developmental level. c. "Your child is working through the stages of grief. Sometimes a child stays in one stage longer than others." Children usually experience all 5 stages of grief, not always in order. They can also experience one stage several times as a way of coping with their feelings. This child is in the anger stage of grief. e. "Your child may be experiencing survivor's guilt related to the death of your child and needs to express feelings." Siblings often feel guilt for being the child who survived. Allowing the child to express feelings provides a way for those feelings to resolve.

A parent of a child who has terminal cancer is concerned with the child's weight loss due to a decrease in appetite. The parent becomes frustrated and expresses to the nurse, "My child needs to be fed; she is starving!" What is the best response? a. "Tell me why you feel your child is starving." b. "Your child's lack of interest in food is a normal part of the dying process." c. "We can use liquid nutritional supplements with your child to help them gain weight." d. "We will have the dietician work with you to create food options that will help your child gain weight."

b. "Your child's lack of interest in food is a normal part of the dying process." The lack of interest in food and liquids is a normal part of the dying process and a source of great distress for family members. Educating the parent on the reason for the weight loss dispels the misconception that the child is starving to death

At the end of every shift a nurse feels drained and begins crying, grieving the loss of patients. What can the nurse do to increase coping mechanisms? Select all that apply. a. Start taking a multivitamin supplement prior to each shift. b. Ask a more experienced pediatric nurse to mentor the nurse. c. Obtain at least 8 hours of uninterrupted sleep every night. d. Attend monthly social hour events with other nurses from the pediatric floor. e. Meet monthly with other pediatric nurses to discuss the past month's events.

b. Ask a more experienced pediatric nurse to mentor the nurse. Mentoring provides support to the nurse who is struggling with the grief associated with losing patients. c. Obtain at least 8 hours of uninterrupted sleep every night. Obtaining the proper number of hours of uninterrupted sleep allows the nurse to take care of own physical health, which assists with increasing coping mechanisms. e. Meet monthly with other pediatric nurses to discuss the past month's events. Expressing feelings with other nurses provides support to the nurse who is struggling with the grief associated with losing patients.

A 5-year-old patient with a terminal illness is expressing sadness and confusion about dying. What can the nurse do to help the child cope and understand the dying process? Select all that apply. a. Give the child a hug and settle the child in for the night. b. Read the book "Fall of Freddy the Leaf" with the child. c. Do a Google search about pediatric terminal illnesses and coping mechanisms. d. Review the dying process using appropriate terms with the child when the child is awake. e. Access the Children's Hospice International website for information on hospice for the child.

b. Read the book "Fall of Freddy the Leaf" with the child. Reading a book about death and dying to the child may provide information on dying that decreases the patient's confusion. d. Review the dying process using appropriate terms with the child when the child is awake. Using appropriate terms when reviewing the dying process with the child may decrease the sadness and confusion experienced by the patient. e. Access the Children's Hospice International website for information on hospice for the child. The Children's Hospice International website is an excellent resource for the nurse to use to obtain information regarding pediatric hospice, palliative care, and end-of-life care. Information from this site may assist in decreasing the confusion experienced by the patient in relation to death and dying. Previous

The nurse is caring for a 17-year-old who has been ill for many years. The child is told that she is expected to have 12 months left to live. What action by the nurse is most appropriate? a. Find an anger outlet for the patient. b. Support the child as they experience feelings of denial. c. Reassure the patient that the illness is not something they caused. d. Provide comfort as the child experiences overwhelming feelings of sadness.

b. Support the child as they experience feelings of denial. Denial is often the first reaction of the grieving process experienced by individuals going through the dying process. The nurse can expect that this will likely be the first response of the child that the nurse will provide care for.

The nurse wishes to educate parents on what to expect as the child is approaching death. Which response regarding the child's breathing pattern is most appropriate? a. The child breathes deeply and rapidly with a fruity odor on the breath. b. The child will have Cheyne-Stokes respirations, leading to respiratory arrest. c. The child breathes shallowly but with a normal rate until respiratory arrest occurs. d. The child may breathe more shallowly and faster than normal, which leads to respiratory arrest.

b. The child will have Cheyne-Stokes respirations, leading to respiratory arrest. Cheyne-Stokes respirations is a cyclic period of slowing respirations with apnea, followed by an increased respiratory rate to a peak, and then slowing into apnea again. The respirations are associated with impending respiratory arrest.

A patient is dying with a rare disorder and an autopsy will be required. At what stage of the dying process will the parents be notified that an autopsy will occur? a. The parents should be made aware immediately after the child has died. b. The parents should be made aware of the autopsy request prior to the death of the child. c. The parents should be made aware of the need for an autopsy after death cares are completed. d. The parents should be made aware of the need for an autopsy shortly after receiving the initial diagnosis.

b. The parents should be made aware of the autopsy request prior to the death of the child. Families should be provided information before the child's death because it affects their time and involvement with their child after death occurs.

Which is an example of an activity that can help the child who is going through the dying process? Select all that apply. a. Providing the child with audiobooks. b. Writing a letter to the child's mother and father. c. Journaling about a favorite memory with the family. d. Watching favorite TV shows on Netflix during treatments. e. Creating a scrapbook of pictures from the last family vacation.

b. Writing a letter to the child's mother and father. Memories can be created for the family through the writing of letters by the child. A child life specialist can assist with this activity if the child requires assistance with writing. c. Journaling about a favorite memory with the family. Journaling provides memories for the child and family member to read throughout the dying process. It is a lasting memory for the family members after the child has died. e. Creating a scrapbook of pictures from the last family vacation. Memories can be created for the child and family through creating a scrapbook of pictures from past family events.

Parents of a 12-year-old child with cancer ask the nurse about the policy on discussions of death with their child. Which is the most appropriate response by the nurse? a. "I will not initiate any discussion regarding dying." b. "I will be contacting the ethics committee because your request is unethical." c. "I will not lie to the child as lying may harm our nurse-patient relationship." d. "My Nursing Code of Ethics will not allow me to be dishonest with the child."

c. "I will not lie to the child as lying may harm our nurse-patient relationship." The needs of the patient come first so this response provides the parents with an honest response regarding their question.

A 4-year-old patient has died and the nurse is extremely distraught because of the strong bond the nurse developed with the child. Which statement provides an example of how the nurse can cope better in the future? a. "In the future I must try to get more sleep each day." b. "In the future I will attend weekly grief support meetings." c. "In the future I will spend equal amounts of time with each patient." d. "In the future I will wait to visit my patients until they are discharged to home."

c. "In the future I will spend equal amounts of time with each patient." Spending equal amounts of time with every patient is an example of setting professional boundaries, which prevents the formation of strong bonds with patients.

The nurse is treating a child who is approaching death within hours. Which respiratory responses are likely findings in a child who is approaching death? Select all that apply. a. Respiratory rate of 28 breaths per minute b. Relaxed appearance to the face of the child c. Apneic episodes of 40 seconds between respirations d. Retraction of muscles under the sternum and ribcage e. Loud sighing at the end of each respiration with a loud rattle noise

c. Apneic episodes of 40 seconds between respirations Periods of apnea increase as death approaches, and therefore this can be expected. d. Retraction of muscles under the sternum and ribcage Increased work of breathing is evident by retractions and is associated with impending death. e. Loud sighing at the end of each respiration with a loud rattle noise The death rattle is associated with secretions in the upper airway that cannot be cleared by the child.

Administration of diphenhydramine can help with which physiologic response expected near the time of death? a. Apnea b. Bradycardia c. Death rattle d. Cyanosis of the hands and feet

c. Death rattle Diphenhydramine may be given to decrease the amount of secretions found in the oral airway of the child, which will decrease the death rattle heard with respiration.

A nurse is caring for a child and notices that as the child's last days are approaching, the family is becoming more withdrawn. Which action is most important to ensure the child is not left alone during the dying process? a. Discuss utilizing a one-to-one staffing model so the nurse only cares for the child. b. Discuss the withdrawn behavior observed by the nurse and how it impacts the child's last days. c. Discuss the need to talk to the child, touch the child, and remain at the bedside of the child during the last days. d. Discuss the situation with the child life specialist and see if volunteers are available to provide coverage if the parents are gone.

c. Discuss the need to talk to the child, touch the child, and remain at the bedside of the child during the last days. The dying child needs to experience complete love and acceptance and know that they will not be left alone to die. Discussing the expectations with the parents provides them with how to interact with their child before the child dies and may decrease their withdrawnness.

A 5-year-old child has been placed in hospice care for terminal cancer. The child overhears the parents discussing a local hospice center for placement of the child. The child asks the nurse, "Why do I have to go away? I don't want to be away from my parents and pets." What action should the nurse take in response to the child's concern? a. Talk to the child about staying at the hospital to receive hospice care there. b. Discuss with the parents, the option of allowing the child's pets to visit in the hospital. c. Discuss the option of home hospice care with the parents, after sharing the concerns of the child with them. d. Tell the child that the hospice center will help the child to feel more comfortable and that the parents can spend the night, if they desire.

c. Discuss the option of home hospice care with the parents, after sharing the concerns of the child with them. Hospice at home allows the child to remain at home and have family, pets, and friends around the child. The home environment provides familiarity and comfort to the child.

An oncology nurse experiences exhaustion at the end of every shift and is looking for a way to cope. Which is an example of the best way the nurse's needs can be met? a. Limit the nurse's patient assignment to 3-4 patients b. Utilize team nursing to complete all patient care needs c. Encourage the nurse to talk with other nurses about what they are experiencing d. Talk with the nurse manager about how to improve time management and organization skills

c. Encourage the nurse to talk with other nurses about what they are experiencing Discussing feelings with coworkers demonstrates concern, respect and support for the nurse. Mutual support of each other is important for nurses who work with terminally ill children.

A family has decided to gather in the room of a child who has impending death. A prayer has started and then all the family members begin praying and laying their hands on the patient. What action will the nurse take? a. Ask the chaplain to come and pray with the family. b. Lay hands on the patient and pray with the parents. c. Observe the child for restlessness, moaning, or increased muscle tension. d. Remind the parents that only 2-3 visitors are allowed in the room at a time.

c. Observe the child for restlessness, moaning, or increased muscle tension. Restlessness, moaning, and increased muscle tension demonstrate increased agitation and could negatively impact the child's comfort level.

A mother discusses options about hospice care for an only child who has three months to live. The child has osteosarcoma (bone cancer) and has had frequent admissions to the hospital for pain control. The mother states they live on a farm 30 miles from the hospital. Which piece of information is most important in influencing the decision for hospital-based hospice care? a. The child has bone cancer. b. The child has 3 months to live. c. The family lives 30 miles from the hospital. d. The patient has been readmitted frequently for pain control.

c. The family lives 30 miles from the hospital. The family lives quite a distance away from the health care facility. This could make home hospice care difficult as resources are limited, and it is a great distance to obtain medical assistance.

Parents are devastated that their child is dying of cancer and express to the nurse that "they are going to do everything to keep their child alive." Which are the most appropriate responses by the nurse? Select all that apply. a. "Have you talked with your child about this decision? You must talk with your child soon." b. "The health care team will look at everything and revise the treatment plan accordingly." c. "Your actions may increase the suffering experienced by the child. You should think about this a little more." d. "As the child's advocate, the health care team must work together with the family to provide reasonable treatments for the child." e. "Together the family and the health care team must look at the child's needs to ensure we are not prolonging or worsening the child's condition with the treatments."

d. "As the child's advocate, the health care team must work together with the family to provide reasonable treatments for the child." The family and the health care team work together to remain the child's advocate with a focus on what the treatment is doing for the child versus what it is doing to the child. e. "Together the family and the health care team must look at the child's needs to ensure we are not prolonging or worsening the child's condition with the treatments." The health care team works with the family to be the child's advocate with a focus on what the treatment is doing for the child versus what it is doing to the child.

A dying child, who has been unresponsive for the past two days in hospice at the hospital, opens his eyes and softly talks to his mother. He asks his mother how she is and where his siblings are and can he see them. The mother tells the nurse, "I think he is getting better." Which response by the nurse is appropriate? a. "Your child is not going to get better. He is dying." b. "Your child may be improving; we will have to wait and see." c. "Your child is showing signs of strength and may live for a few more weeks." d. "It is not uncommon to be more alert and interested in the family right before a child dies."

d. "It is not uncommon to be more alert and interested in the family right before a child dies." Children have been noted to have a surge of energy and alertness immediately before they die. Parents must be educated that this is not a sign of improvement.

A child is dying of sickle cell disease and parents are expressing concern over the large amounts of opiates needed to control the child's pain. The father states, "I am worried that my child will become addicted to the medication." Which statement by the nurse addresses this parent's concern? a. "If we observe signs of addiction, we will use other medications to provide comfort to your child." b. "Addiction is a common concern when using opiates, but we don't worry about it in these situations." c. "Addiction occurs over a long period of time. Your child's prognosis is shorter than that time frame." d. "Our goal with your child is to effectively manage the pain and maintain an acceptable comfort level which may include using larger doses of opiates."

d. "Our goal with your child is to effectively manage the pain and maintain an acceptable comfort level which may include using larger doses of opiates." Parents are often concerned about addiction problems, but when educated on pain management techniques and drug dosages, an understanding related to why large doses of opiates are utilized occurs and the concern about addiction is resolved.

A child with osteosarcoma (bone cancer) rates her pain 10/10 despite narcotic administration, has lost 20 lb since starting chemotherapy, and cries with every movement and position change. The parents approach the nurse and ask how the pain can have an emotional impact on the child. Which response by the nurse is appropriate? a. "Your child has given up on living and wants to die." b. "Your child is in so much pain and doesn't know what is being said." c. "Your child is speaking out because of pain. Try not to worry about what is being said." d. "The child's thoughts of having to stay alive while living in pain are worse than the thoughts regarding dying."

d. "The child's thoughts of having to stay alive while living in pain are worse than the thoughts regarding dying." When a dying child works through the stages of grief, the child may reach a point where being ill is worse than dying.

Parents of a child with a terminal illness are choosing hospice care for their 7-year-old child. The child has difficulty swallowing, is bedridden, and requires frequent morphine administration to keep the pain at a 4/10 level. An interdisciplinary team meeting has been scheduled with hospice and the parents to discuss the child. The parents ask the nurse what to expect at this meeting. Which response by the nurse is appropriate? a. "The provider and hospice RN will only discuss pain management and home care options for your child." b. "This will be just like other care meetings we have had. The providers and case manager will discuss treatment options." c. "We discuss when we can deliver the hospital bed, prescriptions, and other medical equipment to your house for your child." d. "The health care providers, child life specialist, social workers, nurses, home health aides, case managers, and grief counselors meet to discuss your child's plan of care."

d. "The health care providers, child life specialist, social workers, nurses, home health aides, case managers, and grief counselors meet to discuss your child's plan of care." The hospice team is an interdisciplinary team that focuses on all areas of care for the terminal patient. This is therefore the most appropriate response by the nurse.

A four-year-child with 6 months to live tells parents about angels who come to visit her at night. The parents are concerned and ask the nurse how they should handle this. What is the nurse's best response? a. "This response is based on your family's belief in God and should bring you comfort." b. "This response is concerning; you should talk to your child about fantasy versus reality." c. "This response demonstrates that your child may be declining faster than we thought. Let us know if the child says anything else." d. "This is a normal response for a 4-year-old child who is terminally ill. Continue to allow the child to share the experiences with you."

d. "This is a normal response for a 4-year-old child who is terminally ill. Continue to allow the child to share the experiences with you." The responses and actions of the dying child are affected by such things as visions of angels and are considered to be normal responses for the child.

The parent of a 15-year-old with terminal cancer approaches the nurse and asks what care options are available for when the child is dying. The parent states the child is very close to family and siblings and loves to be around the pet dogs. Which is the best response? a. "Your child could spend the last weeks in the hospital." b. "You could care for your child at home with your family helping." c. "You could use palliative care services to make your child comfortable." d. "You could use home hospice care so the child is in a comfortable and relaxed environment."

d. "You could use home hospice care so the child is in a comfortable and relaxed environment." Hospice care can be provided in the home and allows for a more comfortable and relaxed environment than the hospital setting.

Which scenario reflects the type of interaction allowed in the hospital moments after a child passes away? a. The child's body is brought to the morgue for an autopsy. b. The nurse asks the family to leave the room until the body has been cleaned. c. The family spends time with the child but then leaves for the nurse to clean the body and prepare the child for the funeral home. d. The family members remain in the room with the child immediately following the death of the child and the nurse provides privacy.

d. The family members remain in the room with the child immediately following the death of the child and the nurse provides privacy. Family members should have the opportunity to spend time with their child, even before the body is cleaned.

A nurse is tending to the emotional needs of the parents who have just lost a child. What is an example of the type of communication necessary during this time? a. The nurse tells the family that the chaplain has been called to come and pray with them. b. The nurse promises the family to be back in an hour to bring the body to the morgue. c. The nurse tells the family of the plan to remain in the room with them until the family goodbyes are done being said. d. The nurse tells the family members that the nurse is available to talk if they desire and will return when needed or requested.

d. The nurse tells the family members that the nurse is available to talk if they desire and will return when needed or requested. The nurse should provide privacy for the family but remain close by and return as needed or requested.

A sibling is noticeably upset at the death of a sister. Which is an example of an activity that allows the sibling to assist in the immediate care of the body? a. The sibling gives the sibling a hug before the body leaves the room. b. The sibling brings the nurse the clothes the deceased child will wear to the funeral home. c. The sibling places the child's teddy bear with the body before it goes to the funeral home. d. The sibling washes the hands and face of the sibling alongside the nurse during death care.

d. The sibling washes the hands and face of the sibling alongside the nurse during death care. Care of the body immediately after death includes washing the hands and face of the deceased child

Palliative care interdisciplinary team

health care providers, nurses, social workers, case managers, spiritual care providers, ethical care providers, bereavement specialists, and child life specialists

Hospice facilities

home - more comfortable, family, pets, friends, familiarity freestanding facility or separate unit - provide environment for the dying child that is less threatening and more home-like than acute-care hospital

Hypercapnia due to respiratory changes

may actually contribute to increased comfort because of sedative and analgesic effects

Hospice care interdisciplinary team

nurses, health care providers, social workers, chaplains, home health aides, physical and occupational therapists, child life specialists, bereavement counselors, and volunteers

Hypoxia due to respiratory changes

treated with oxygen and either intravenous (IV) or sublingual morphine