Unit II; Alterations in Patterns of Health; Chapter 5; Nursing Care of Clients Experiencing Loss, Grief, and Death

Following an automobile accident, a client in the ICU has been unresponsive and on a respirator after experiencing multiple injuries including a serious head injury. When the physician orders an electroencephalogram (EEG), the nurse understands that: a. absence of independent respiratory muscle activity indicates the need for comfort care measures. b. measuring brain activity is the most common criterion to establish death. c. lack of brain activity must be established to move the client to hospice care. d. electrical activity of the muscle neurons is the last response measurable before death.

measuring brain activity is the most common criterion to establish death. Rationale: The electroencephalogram only measures brain activity, so respiratory or other muscle activity measurements are not correct. There is no brain activity requirement for hospice. Nursing Process: Assessment Client Need: Safe, Effective Care Environment Cognitive Level: Application Objective: Discuss legal and ethical issues in end-of-life care. Content Area: Theories of Loss, Grief and Dying Strategy: Immediately eliminate answers you know are incorrect; understand the pathophysiology of the dying process.

A client is being admitted to the hospital for open-heart surgery. When discussing the procedure and answering questions for a client and his wife, the nurse should ensure that they have information regarding: a. physicians who will provide a second opinion. b. necessary information to formulate advance directives. c. available legal counsel to assist in executing a will. d. financial advisors to assist with the surgical costs.

necessary information to formulate advance directives. Rationale: Nurses are patient advocates who explain the components of and need for advance directives to clients. The nurse has no role in choosing a physician, discussing a client's will or their financial situation. Nursing Process: Implementation Client Need: Safe, Effective Care Environment Cognitive Level: Application Objectives: Discuss legal and ethical issues in end-of-life care. Content Area: Nursing Consideration for End-of-Life Care: Legal and Ethical Issues Strategy: Eliminate incorrect answers and choose the answer that implements the appropriate nursing action.

As an Hispanic client nears death, the spouse begins to weep and call out loudly at the bedside. The nurse responds by: a. quietly sitting with the spouse. b. leading the spouse away to grieve in another room. c. explaining the importance of a peaceful death to the spouse. d. ask another relative to help control the spouse's reaction.

quietly sitting with the spouse. Rationale: Cultural traditions may differ from what the nurse considers "normal" but should be respected and supported. Leading the spouse away, telling the spouse not to express cultural traditions, or trying to control the expression of grief is not correct. Nursing Process: Diagnosis Client Need: Psychosocial Integrity Cognitive Level: Application Objective: Provide individualized care for clients and families experiencing loss, grief or death Content Area: Factors Affecting Responses to Loss: Rituals of Mourning Strategy: Look for critical words in the question; be familiar with the grieving process

Mourning

the actions or expressions of the bereaved, including the symbols, clothing, and ceremonies that make up the outward manifestations of grief

Grieving

the internal process the person uses to work through the response to loss

Dysfunctional Grieving

the state in which an individual experiences an exaggerated response to an actual or potential loss of person, relationship, object, or functional abilities

Anticipatory Grieving

the state in which an individual experiences responses to an actual or perceived loss of a person, relationship, object, or functional abilities before the loss occurs

A nurse assigned to a client with a terminal illness appears increasingly reluctant to spend time with the client, rushing through routine assessments and speaking to the client in short, quick sentences. The nursing supervisor suspects that the nurse is experiencing: a. unresolved issues preventing a therapeutic relationship. b. "burn out" necessitating a brief leave of absence. c. a client load too heavy to provide thorough care. d. the denial phase of grieving for the client.

unresolved issues preventing a therapeutic relationship. Rationale: #2, "burn out" would affect all clients assigned to a nurse, as well as the nurses' attitude and attendance, not just one client who has a terminal illness. #3 - Again, more than just the one terminally ill client would be affected and heavy client would also affect other staff members loads. #4 - there is no evidence that the nurse has formed a relationship that would personally affect the nurse in this way, in fact, quite the opposite is true. The key, #1 is the best choice based on the evidence of increasing reluctance to care for this particular client. Nursing Process: Assessment Client Need: Safe, Effective Care Environment Cognitive Level: Analysis Objective: Discuss legal and ethical issues in end-of-life care Content Area: Support for the Client and Family: Nurse's Grief Strategy: Interpret the data in a therapeutic manner based on thoughtful attention.

The SNF faxes a copy of the DNR to your facility. It is legible and specific in regards to code status. Don is crying, calling relatives on his cell phone. What nursing diagnosis is appropriate for this situation?

Anticipatory grieving related to declining health status of mother, manifested by son's sorrow (crying).

Mrs. Gallagher is transport into a private room, after the ventilator is removed. You notice her oxygen saturation is dropping, and that she has experienced a large bowel movement. What is your priority of care?

As Mrs. Gallagher approaches the end of her life, it is common for there to be soiling, both urine and stool. Given her DNR status, her comfort is your priority. Care should be given to provide a clean comfortable environment. Her oxygen saturation will continue to fall, as her respiratory status declines.

Comfort Measures Only Order

indicates that no further life-sustaining interventions are necessary and that the goal of care is a comfortable, dignified death

Advance Directives

legal documents that allow a person to plan for the management of health care and/or financial affairs in the event of incapacity

Bereavement

the time of mourning experienced after a loss

Do-Not-Resuscitate (DNR, or "no-code") Order

this order is usually based on the wishes of the client and family that no cardiopulmonary resuscitation be performed for respiratory or cardiac arrest

What interventions can you implement for the Gallagher family?

- Assess for factors causing or contributing to the grief. Ask about support systems and previous experiences with loss and grief. - Use open-ended questions to encourage the person to share concerns and the possible effect on the family. - Promote a trusting nurse-client relationship: Allow enough time for communications; speak clearly, simply, and concisely; listen; be honest in responses to questions; do not give unrealistic hope; offer support; and demonstrate respect for the person's age, culture, religion, race, and values. - Ask about strengths and weakness in coping with the anticipated loss. - Teach the client and family the stages of grief. - Provide time for decision making. - Provide information about appropriate resources, including support from family, friends, and support groups, community resources, and legal/financial aides.

Chapter Review

- Grief is the emotional response to a loss, experienced by a person as grieving. Bereavement, a form of depression accompanied by anxiety, is a common response to loss of a loved one by death. Death, although inevitable, is an immensely difficult loss. - There are many different theories of how people respond to loss and grief. These theories are useful when providing nursing care to clients and their families. - A person's response to loss is influenced by age, social support, family members, cultural and spiritual beliefs, and rituals of mourning. Nurses need to assess the way in which they respond to loss to better care for clients. - Legal and ethical issues involved in end-of-life care include advance directives (living wills, healthcare surrogate, and durable power of attorney), do-not-resuscitate orders, and euthanasia. - Hospice, a model of care for clients and their families when faced with limited life expectancy, supports a dignified and peaceful death. Palliative care is focused on the relief of physical, mental, and spiritual distress for people with an incurable illness. - To provide knowledgeable and compassionate care at the end of life, nurses must recognize physiologic changes as the client nears death, support the client and family, provide postmortem care, and resolve their own grief. - Nursing care of clients experiencing an actual or potential loss includes accurate physical, spiritual, and psychosocial assessment; and interventions for the human responses of anticipatory grieving, chronic sorrow, and/or death anxiety.

A hospice client who is being cared for at home begins to experience changes in respiration, becoming increasingly restless and unresponsive. Based on these symptoms, the nurse would implement which of the following measures? Select all that apply. a. Provide soft lighting. b. Administer anxiolytics as needed. c. Instruct the family to speak in low voice tones. d. Apply soft restraints. e. Place the bed in semi-Fowler's position. f. Call for transport to the hospital. g. Initiate low-flow oxygen per nasal cannula

- Provide soft lighting. - Administer anxiolytics as needed. - Place the bed in semi-Fowler's position. - Initiate low-flow oxygen per nasal cannula Rationale: The hospice client is entering the terminal phase of illness, which is to be expected, so comfort measures only are initiated. Low lighting, raising the head of the bed along with low-flow oxygen to ease respiration and anxiolytics as needed to decrease agitation are standard practice. The family should speak as if the client can still hear them, restraints are never used, and as a home hospice client, death in the home is planned for, so transport to a hospital is not necessary. Nursing Process: Implementation Client Need: Physiologic Integrity Cognitive Level: Application Objective: Identify physiological changes in the dying client. Content Area: Physiological Changes in the Dying Patient Strategy: Eliminate incorrect answers immediately; use principles and concepts of the dying process.

A client with end-stage breast cancer is experiencing severe dyspnea with a harsh cough, causing distress to the client and family. The nurse initiates the following measures: Select all that apply. a. give oral guaifenesin. b. raise the head of the bed. c. place a fan in the room. d. begin pharyngeal suctioning. e. perform postural drainage. f. administer nebulized morphine. g. start an intravenous furosemide drip.

- raise the head of the bed. - place a fan in the room. - administer nebulized morphine. Rationale: Raising the head of the bed, placing a fan for air circulation help relieve dyspnea, and morphine is the drug of choice for dyspnea in end-stage disease care, often nebulized. Guaifenesin is an expectorant which liquefies secretions and encourages mobilization of secretions resulting in --- increased coughing; suctioning and postural drainage are not indicated and would cause discomfort to the client. Starting an IV would also cause discomfort, and furosemide is a diuretic, and nothing in the stem indicates the need for that type of drug. Nursing Process : Implementation Client Need: Physiologic Integrity Cognitive Level: Application Objective: Provide nursing interventions to promote a comfortable death Content Area: Physiological Changes in the Dying Client: Dyspnea Strategy: Use Maslow's Hierarchy to help determine interventions, keeping in mind the normal dying process.

Case Study 1 - The Case of "Do Not Resuscitate!"

Client's Name: Claudine Gallagher Abstract: Claudine Gallagher is a 72 year old SNF resident who choked on her lunch, and 911 was called. She subsequently was intubated, and put on ventilator support despite an existing DNR order. The family feels this has been violated. Objectives: Discuss legal and ethical issues in end-of-life care. Claudine is a 72 year old female resident at SNF following Rt. sided CVA. Mrs. Gallagher is ambulatory, with minimal right side weakness. She has some speech and memory deficits, as well as swallowing difficulty. While in the dining room, Mrs. Gallagher choked on her noon meal of pureed pork chops, and subsequently 911 was called. She was transported to an area hospital, and during the course of events, she was intubated, and mechanical ventilations started. When her son arrives at the ED, he is furious, stating "my mom would have never wanted this! Why did you put a tube in her throat? She is a DNR!" You are Mrs. Gallagher's nurse and are dealing with an upset family.

Case Study 2 - Client Experiencing Loss, Grief and Death

Client's Name: Martin Cain Abstract: Martin Cain, age 74, was admitted to the hospital for treatment of a fractured hip and dehydration. Since the surgical repair of his hip, he has refused to get OOB and participate in rehabilitation exercises important to regain the ability to ambulate. Mr. Cain's son tells the nurse that his mother died 2 months ago and that his father has not been the same since. Objectives: Provide individualized care for clients and families experiencing loss, grief, or death. Explain factors affecting responses to loss. Martin Cain, age 74, was found on the floor of his apartment in a dehydrated state and unable to get up. His son, Jerry became concerned when he could not reach his father by phone and requested the apartment manager to let him into the apartment. Following admission to the hospital, Martin Cain was found to have a fractured right hip necessitating an open reduction and internal fixation of his injured hip two days after admission. Following the surgical repair of his fractured hip, Martin Cain has been refusing to get OOB and participate in the prescribed physical therapy program. Martin is alert and oriented, however, he responds only briefly to questions and does not look at the person talking with him. During visiting hours, the nurse caring for Mr. Cain talks with his son, Jerry, about his father's refusal to get up and the fact that he is eating only minimal amounts of food from his meal trays. Jerry tells the nurse that his mother died 2 months ago after a long bout of illness related to cancer. He further stated that his father hasn't been himself since the funeral and has lost weight and has been refusing to visit Jerry and his family. Jerry describes his father prior to his mother's illness as an active 74 year old who enjoyed walking outdoors and playing with his grandchildren.

What information do you collect from Mrs. Gallagher's son regarding her care?

It is important to determine if Mrs. Gallagher has appointed anyone as her power of attorney (POA) specifically in the area of health care directive. The SNF would have that information in her records, and it should have been consulted prior to calling the ambulance. If there is such a determination, the documentation needs to review by the attending physician so that her wishes are followed. In the event that there is not a directive, the closest living relative of Mrs. Gallagher would need to be contacted for medical direction.

What factors does the nurse identify as affecting Mr. Cain's response to the loss of his wife and his current refusal to participate in his rehabilitation?

Mr. Cain's age is a significant factor, experiencing the loss of a long-time spouse radically changes one's way of living and requires major adaptation. The process of his wife's long illness can certainly strain coping and Mr. Cain is now not only coping with the loss of his wife, but with the debilitating effects of a traumatic injury and the resulting hospitalization. Social support is an important factor in recovery from grief because it provides validation of the significance of the loss and the feeling that one is accepted and understood. In Mr. Cain's case, however, the loss of his wife has resulted in his withdrawal from the support of his son and his son's family and this has complicated the working through of his grief. Spirituality, or the principles, values, personal philosophy, and the client's identification of the meaning of life are quite significant in the resolution of grief. The nurse does not have any information at this point regarding Mr. Cain's spiritual belief system. It is not uncommon, because of a fear of intruding on the personal spiritual beliefs and practices of the client, that the nurse often feels at a loss regarding this issue. Since Mr. Cain is in the stage of life of integrity vs. despair, an important psychosocial task of this stage is looking back on one's life and accepting both the positive and negative events in preparation for one's own death. Mr. Cain may be anticipating his own death and this may also contribute to his current depression.

Care Plans

Shaleria Smith is a 46-year-old female dying from breast cancer and she is being admitted to your unit for palliative care. During the admit history and assessment, Ms. Smith tells you that she has 2 children, a son age 21, and a daughter, age 24. She and her husband divorced 7 years ago, but remain on good terms. Ms. Smith owns her own health club, which she established 15 years ago. She confides that she knows neither one of her children want to take over the health club because they have chosen different careers. She states it makes her sad to know that the business she worked so hard for will not stay in the family after she has died, and wishes she had been able to live long enough to have grandchildren. She states she is not certain if she wants her children to watch her die, and perhaps it would be better if she just died alone.

Planning and Intervention: What is your goal for the priority nursing diagnosis? What interventions are the most appropriate for this goal?

The goal for Anticipatory Grieving is to assist the client and the client's family with grief resolution. Interventions include: - Ask client about support systems - Encourage the client to share concerns and the possible effect on the family - Promote a trusting nurse-client relationship - Allow enough time for communication - Be honest in responses to questions - Demonstrate respect for the client's age, culture, religion, race, and values - Ask client and family about strengths and weakness in coping with anticipated loss - Teach the client and family the stages of grief - Provide time for decision-making - Provide information about appropriate resources, including support for family - Encourage client to share her concerns about the business to her family

What nursing interventions does the nurse utilize for Mr. Cain in order to help him work through the grieving process?

The nurse first establishes a trusting nurse-client relationship by allowing enough time for communication; speaking clearly, simply and concisely. The nurse will listen carefully to Mr. Cain's responses and accept his feelings and attitudes as expressed. Encourage Mr. Cain to talk about his wife, using a question such as: "Tell me what your wife was like?" This open-ended question may provide the impetus for Mr. Cain to begin the process of expressing his feelings. The nurse can also acknowledge the reality of Mr. Cain's situation by use of a statement such as: "It must be very difficult for you at this time, both losing your wife and now being in the hospital and going through surgery." Inquiring about Mr. Cain's spiritual/religious affiliation is appropriate in order to initiate a referral to a spiritual counselor. When Mr. Cain begins to talk about the loss, it is important to acknowledge his feelings and teach him about the normal stages of grief. The nurse can also identify Mr. Cain's previous experiences with death/dying and how he coped in that situation. His personal support system can be identified and he can be encouraged to utilize this available support in dealing with his grief. Providing information about community support groups and encouraging him to attend when he is discharged will help decrease feelings of loneliness and isolation and facilitate grief work.

Mr. Cain's son, Jerry further tells the nurse that his father has not talked at all about the death and did not cry at the time of the death and funeral. What psychosocial nursing diagnosis does the nurse select for Mr. Cain and why?

The nurse selects the diagnosis of Dysfunctional grieving related to the inability to express feelings of sorrow or grief following the loss of his wife manifested by loss of appetite, weight loss, lack of spontaneous participation in conversation and lack of energy for participation in activity. The fact that Mr. Cain has not been able to talk with anyone about his loss nor has he been able to openly grieve is the rationale for this diagnosis. The nurse understands that the expression of sorrow and grief is important in order to work through the loss and come to the state of acceptance in which activities resume and the person has a state of hopefulness for the future.

When attempting to take the blood pressure of a client newly admitted to a hospice program, the client pushes the stethoscope away, loudly stating that nothing the nurse can do will help anyway, and asks the nurse to leave. The nurse's response should be based on the knowledge that: a. anger at impending loss may be directed at health care providers. b. dying clients' anger must be reduced to promote a peaceful environment. c. vital signs should be deferred as they are not necessary for hospice clients. d. changing to a different nurse may diffuse the situation.

anger at impending loss may be directed at health care providers. Rationale: Anger is a normal stage in the dying process and should never be restrained. The nurse should continue to work with the client to provide optimal care, while supporting the client's feelings. Nursing Process: Diagnosis Client Need: Psychosocial Integrity Cognitive Level: Analysis Objective: Compare and contrast theories of loss and grief Content Area: Theories of loss, grief and dying. Strategy: Look for critical words in the question.

An end-stage hospice client as been turning away from food and refusing to eat for the past week. Although the client appears comfortable and takes sips of water, the family has been repeatedly attempting to feed the client. In spite of the clients' expressed wishes and discussion of disease progression with the nurse, the family is requesting feeding tube placement. The nurse should next: a. call the hospice physician to arrange for the procedure. b. arrange a family meeting with the social worker. c. suggest a transfer from hospice care to an acute care setting for treatment. d. explain that hospice philosophy does not support feeding tubes.

arrange a family meeting with the social worker. Rationale: Requesting a social work consult when families and the client disagree on the plan of care is part of client advocacy. Hospice philosophy does not automatically exclude the use of feeding tubes; rather, the reason the feeding tube is being requested is carefully explored. Transferring the client out of hospice care may not be necessary and may deprive the client of expert support and treatment for the end-stage disease process. The social worker should be involved before the physician is called to make sure all of the questions and concerns of the family and client are addressed openly. Nursing Process: Planning Client Need: Safe, Effective Care Environment Cognitive Level: Analysis Objective: Describe the philosophy and activities of hospice Content Area: Nursing Considerations for End-of-Life Care: Legal and Ethical Issues Strategy: Assist the client and family to work toward therapeutic goals.

In discussing end of life care with a terminally ill client, the nurse explains that in a hospice program: a. the length of care is limited to six months. b. care is provided mainly by volunteers. c. bereavement care is not provided beyond six months. d. private insurance is accessed for most clients.

bereavement care is not provided beyond six months. Rationale: Length of care is unlimited as long as the client is eligible; modern hospice care is provided mainly by professionals with a volunteer component; most care is covered by Medicare/Medicaid; and bereavement care is provided to the family for at least 13 months after the death of a client. Nursing Process: Planning Client Need: Health Promotion and Maintenance Cognitive Level: Application Objective: Describe the philosophy and activities of hospice. Content Area: Settings and Services for End-of-Life Care: Hospice Strategy: Understand the basic processes for end-of-life care options.

When admitting a client to a hospice program, the nurse assures the client's wishes are included in the plan of care by: a. recommending a reliable lawyer. b. consulting with the attending physician. c. relaying information to a social worker. d. documenting voiced preferences.

documenting voiced preferences. Rationale: A nurse should never recommend legal counsel - it's a violation of the client/nurse relationship and opens the nurse to liability; it is the nurse's role to first document the client's preferences and needs as the client defines them. Nursing Process: Application Client Need: Health Promotion and Maintenance Cognitive Level: Application Objective: Describe the philosophy and activities of hospice. Content Area: Settings and Services for End-of-Life Care: Hospice Strategy: Identify core issues; eliminate incorrect answers immediately.

When the breathing patterns of a terminally ill client become more irregular and noisy, the hospice nurse responds by: a. performing nasotracheal suctioning b. elevating the head of the bed c. requesting arterial blood gases d. initiating postural drainage

elevating the head of the bed Rationale: suctioning, blood gases, and postural drainage can all cause discomfort and distress to a dying client at a time when less invasive measures can provide relief in keeping with a peaceful death. Nursing Process: Implementation Client Need: Physiologic Integrity Cognitive Level: Application Objective: Provide nursing interventions to promote a comfortable death. Content Area: Physiological Changes in the Dying Client Strategy: Choose the most therapeutic action for this particular scenario.

Following the death of a spouse, an elderly widow stops going to church and shows little interest in leaving the house. To promote the grieving process, the nurse should: a. explore finding a different church to avoid painful memories. b. discuss learning a new hobby to occupy time. c. respect the need for social isolation. d. encourage brief visits from close friends.

encourage brief visits from close friends. Rationale: Grief causes fatigue so learning new tasks is not necessarily helpful. Loneliness and lack of social support to share grief are barriers to successful grieving. Previously established social networks are important to decrease loneliness, and the sharing of loss with friends supports successful grieving. Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Analysis Objective: Explain factors affecting responses to loss. Content Area: Factors Affecting Responses to Loss Strategy: Use Maslow's Hierarchy of Needs to address psychosocial needs

While taking routine vital signs on a palliative care unit, a client suddenly begins to weep, telling the nurse that "I know my cancer is punishment for the things I did when I was younger". The nurse would best support the client by: a. assuring the client that cancer can strike anyone. b. inquiring if the client has a spiritual support person. c. calling for the facility chaplain. d. providing privacy for the client's expression of grief.

inquiring if the client has a spiritual support person. Rationale: #1 - Assuring the client he did not cause cancer by smoking - ignores the underlying spiritual distress voiced by the client; #3 - The nurse needs to determine the spiritual needs before sending in a chaplain who the client does not know. #4 - providing privacy, by implication leaving the client alone instead of addressing the client's spiritual needs is avoidance on the part of the nurse. The Key, #2 - inquiring about spiritual support - acknowledges the unspoken need of the client and opens up the opportunity for a therapeutic dialogue. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Analysis Objective: Provide individualized care for client and families experiencing grief, loss or death. Content Area: Nursing Care: Spiritual Assessment Strategy: Interpret the psychosocial data in the question to determine the correct answer.

Chronic Sorrow

a cyclical, recurring, and potentially progressive pattern of pervasive sadness experienced in response to continual loss, throughout the trajectory of an illness or disability

Living Will

legal document that formally expresses a person's wishes regarding life-sustaining treatment in the event of terminal illness or permanent unconsciousness

Death Anxiety

worry or fear related to death or dying

Durable Power of Attorney for Health Care

(health care proxy) legal document written by a competent adult empowering another competent adult to make health care decisions on his or her behalf in the event of incapacitation

Evaluation: How do you evaluate Ms. Smith's progress toward meeting the established goal?

Evaluate Ms. Smith's communication with her family. Is she able to discuss the business and last wishes with the family? Does the family interact with Ms. Smith? Does Ms. Smith verbalize satisfaction regarding communication with the family? Do Ms. Smith's children communicate any understanding of Ms. Smith's needs at this time?

Using Kubler-Ross's theory of the grieving process, what stage does the nurse identify as appropriately describing Mr. Cain's behaviors and why is this so?

Mr. Cain is exhibiting the signs and symptoms of the stage of grieving labeled depression. He has the physical signs of depression such as the loss of appetite, weight loss, lack of spontaneous participation in conversation and lack of energy for participation in activity. His behavior is also characteristic of withdrawal from others, both from his family and the nurse. Furthermore, Mr. Cain's son describes his father as someone who was an active 74 year old who enjoyed walking outdoors and he is now refusing to get OOB and participate in physical therapy to regain his ability to ambulate.

What are the expected outcome(s) of nursing interventions for the nursing diagnosis established for Mr. Cain?

Mr. Cain will be expected to admit the reality of his loss and agree to participate in grief recovery therapy. He will be expected to use coping mechanisms in adapting to the loss of his wife. Finally, he will be expected to re-engage in his normal activities. The resolution of Mr. Cain's grieving will take time, therefore the outcome may be years away. It is important to realize that grief is individual and cannot be mapped. Mr. Cain might not have the coping mechanisms he needs to re engage.

Assessment and Diagnosis: What questions could you ask Ms. Smith to determine her physical, spiritual, and psychosocial needs. What is the priority Nursing Diagnosis for Ms. Smith at this time?

Open-ended questions regarding pain and comfort should be asked. Ask the client if she has a religious preference and what you can do to fulfill her spiritual needs. Ask the client if she would like you to contact her family members or any friends and encourage her to have family and friends with her. Anticipatory Grieving is the priority nursing diagnosis. The client acknowledges her inevitable death, and expresses concern about what will happen to her business and children after her death. She is uncertain at this point whether her children should be with her during her impending death.

You discover while talking to Mrs. Gallagher's son, Don, that an Advanced Directive does exist, and that she requested a DNR (Do Not Resuscitate) order. Her son wants the ventilator removed. What are your options?

Without the documentation of DNR, you have the responsibility to provide safe competent care to Mrs. Gallagher. It is prudent to involve the physician in these discussions, so that he/she can support Mrs. Gallagher's wishes. Document conversations with the family, and attempt to get the Advanced Directive from the SNF. As a side note, this is a stressful situation for all involved. Given the level of her son's response, it would be good to involve support personnel from the hospital (such as social services or chaplain) or to ask Don if there is anyone he would like to contact for support as well.

Euthanasia

a killing that is prompted by some humanitarian motive

Hospice

a model of care (rather than a place of care) for clients and their families when faced with a limited life expectancy. Hospice care is initiated for clients as they near the end of life, emphasizing quality rather than quantity of life

Loss

an actual or potential situation in which a valued object, person, body part, or emotion that was formerly present is lost or changed and can no longer be seen, felt, heard, known, or experienced

Palliative Care

an area of care that has evolved out of the hospice experience, but exists outside of hospice programs and is not restricted to the end of life. Palliative care is focused on the relief of physical, mental, and spiritual distress for individuals who have an incurable illness and is used earlier in the disease experience than hospice care. The goal of palliative care is to prevent and relieve suffering by early assessment and treatment of pain and other physical, psychosocial, and spiritual needs to improve the client's quality of life

Death

an irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain, including the brain stem

The family of a client receiving palliative care for colon cancer is concerned that morphine is being given too often to the client. The nurse explains to the family that: a. the dose can safely be increased as necessary. b. addiction doesn't matter if the client is dying. c. death may be hastened as the pain is relieved. e. the medication will be stopped if respirations decrease.

the dose can safely be increased as necessary. Rationale: Morphine has no analgesic ceiling and can safely be increased to the dose needed to relieve pain. Addiction doesn't occur if the medication is properly titrated to the pain, nor does it hasten death. Some respiratory depression may occur, but it is transient and treatable, and the medication should not be stopped. Nursing Process: Implementation Client Need: Health Promotion and Maintenance Cognitive Level: Analysis Objective: Provide individualized care for client and families experiencing grief, loss and death. Content Area: Nursing Considerations for End-of-Life Care: Support for the Client and Family. Strategy: Read memory aid boxes; use knowledge of the drug to correctly answer the question.

Grief

the emotional response to loss and its accompanying changes