Chapter 13: Palliative Care at End of Life

The hospice nurse identifies an abnormal grief reaction in the wife of a dying patient who says, 1. "I don't think that I can live without my husband to take care of me." 2. "I wonder if expressing my sadness makes my husband feel worse." 3. "We have shared so much that it is hard to realize that I will be alone." 4. "I feel guilty about leaving him to go to lunch with my friends."

1. "I don't think that I can live without my husband to take care of me." (abnormal grief and possible sucuidal)

A patient with advanced cancer is referred for hospice care. The nurse explains to the patient and the family that the goal of hospice care differs from the goal of traditional care in that hospice care 1. Provides for more complete pain control. 2. Focuses on helping the patient and family prepare for death. 3. More readily recognizes advance directives related to "right to die." 4. Is delivered in the home and does not rely on the technology of hospitals.

2. Focuses on helping the patient and family prepare for death because it provides compassion, concern, support dying

A 74-year-old female admitted for pneumonia tells the nurse that she does not want health care professionals to attempt CPR. What is important for the nurse to verify in the medical record related to the patient's directive? A. The physician has written and signed the DNR order. B. The living will is signed by the patient and two witnesses. C. The patient's durable power of attorney agrees with the decision. D. There is an advance directive related to artificial nutrition and hydration.

A CPR will be performed for respiratory or cardiac arrest unless a DNR (do not resuscitate) order is written and signed by the physician in the patient's medical record. The DNR order documents the patient's desire to avoid CPR.

A patient with terminal cancer tells the nurse, "I know I am going to die pretty soon, perhaps in the next month." What is the most appropriate response by the nurse? A. "What are your feelings about being so sick and thinking you may die soon?" B. "None of us know when we are going to die. Is this a particularly difficult day?" C. "Would you like for me to call your spiritual advisor so you can talk about your feelings?" D. "Perhaps you are depressed about your illness. I will speak to the doctor about getting some medications for you."

A The most appropriate response to psychosocial questions is to acknowledge the patient's feelings and explore his or her concerns. This option does both and is a helpful response that encourages further communication between the patient and nurse.

Which aspects of anticipatory grief are associated with positive outcomes for the caregiver of a palliative patient (select all that apply)? A. Strong spiritual beliefs B. Medical diagnosis of the patient C. Advanced age of the patient D. Acceptance of the expected death of the patient E. Adequate time for the caregiver to prepare for the death

A, D, C Acceptance of an impending loss, spiritual beliefs, and adequate preparation time are all associated with positive outcomes regarding anticipatory grief. The age and diagnosis of the patient are not key factors in influencing the quality of the anticipatory grief of the caregiver. Awarded 1.0 points out of 3.0 possible points.

A 39-year-old woman near death from metastatic cancer becomes restless and confused. What interventions would be the most appropriate for the nursing management of these symptoms? A. Avoid administering pain medication until the patient is calm and alert. B. Stay physically close to the patient and use a soothing voice and soft touch. C. Turn on the television to provide a distraction, and contact the hospital chaplain. D. Restrain the patient to prevent injury, and ask family and visitors to leave the room.

B Appropriate interventions for restlessness and confusion when a patient is near death include the following: use soft touch and voice, stay physically close to the patient, and remain calm. Use soothing music instead of the radio or television. Make referrals (e.g., hospital chaplain, spiritual leader) based on patient's spiritual and cultural preferences. Family visitors may provide comfort. Uncontrolled pain may be the cause of restlessness and confusion. Withholding pain medication or restraining the patient would be inappropriate and may cause more restlessness.

The nurse is providing anticipatory guidance to the family of a patient who is expected to die within the next 12 to 24 hours. What physical manifestations of approaching death will the nurse discuss with the family? A. The patient will be incontinent of urine after frequent seizures. B. The skin will feel cold and clammy, with mottling on the extremities. C. The patient will have increased pain, and the sense of touch will be enhanced. D. The gag reflex is exaggerated, and the patient will exhibit deep, rapid respirations.

B As death approaches, the following physical manifestations occur: cold, clammy skin; mottling on hands, feet, arms, and legs; jerking (not seizures) occurs in patients on large amounts of opioids; bowel and bladder incontinence; decreased perception of pain and touch; loss of gag reflex; and Cheyne-Stokes respirations.

The dying patient is experiencing confusion, restlessness, and skin breakdown. What nursing interventions will best meet this patient's needs? A. Encourage more physical activity. B. Assess for pain, constipation, and urinary retention. C. Assess for spiritual distress and restrain in varying positions. D. Assess for quality, intensity, location, and contributing factors of discomfort.

B Assessing for all reversible causes of delirium (i.e., pain, constipation, urinary retention, dyspnea, sensory hyperstimulation) so they can be reversed may help decrease confusion and restlessness. Encouraging more physical activity may prevent further skin breakdown, but it will be difficult as weakness and fatigue are expected at the end of life. Keeping the skin clean and dry and preventing shearing forces will better avoid further skin breakdown. Spiritual distress may be a cause of restlessness, but the patient should not be restrained.

The nurse is caring for a patient who has been admitted to the hospital while receiving home hospice care. The nurse interprets that the patient has a general prognosis of ___________. A. 3 months or less to live B. 6 months or less to live C. 12 months or less to live D. 18 months or less to live

B There are two criteria to be eligible for hospice care. The first is that the patient wishes to receive hospice, not curative care, and the second is that the physician certifies that the patient has a prognosis of 6 months or less to live.

When the nurse assesses the patient, what manifestation indicates to the nurse that the patient is very near death? A. The patient responds to noises. B. The patient's skin is mottled and waxlike. C. The heart rate and blood pressure increase. D. The patient is reviewing his life with his family.

B When a patient is very near death, the skin will be waxlike, cold, clammy, and mottled or cyanotic. Although hearing is the last sense patients lose before death, it is unlikely that they will be responding to noises when very near death. Initially the heart rate increases, but later slows and the blood pressure decreases. Near death, speaking may be slow and unusual and indicate confusion.

Your 88 year old pt with terminal lung cancer is visited frequently by his spouse, 46 year old daughter and her 23 year old son. In view of the client's extreme weakness and dyspnea, client care plans should include: A. Allowing self-activity whenever possible B. Encouraging family members to feed and assist the client. C. Limiting family visiting hours to the evening before the client sleeps. D. Planning all necessary care at one time with long rest periods in between.

B. Encouraging family members to feed and assist the client. because family members are old enough to understand the client's needs, they should be encouraged to particpate in the care. A would increase fatigue, C would deprives the client of a support system and D would over work the client causing undue fatigue; frequent rest periods are indicated

When going to the hospital, which forms should patients be taught to bring with them in case end-of-life care becomes an ethical or legal issue? A. Euthanasia B. Organ donor card C. Advance directives D. Do not resuscitate (DNR)

C Advance directives are written documents that provide information about the patient's wishes for medical care and treatments and his or her designated spokesperson. Euthanasia is not a form; it is a deliberate act of hastening death. Organ donor cards only state that the patient wants to donate organs or their body for transplants or for scientific research. Do not resuscitate (DNR) or comfort measures only is a written order from the physician that documents a patient's wishes to avoid CPR.

A man died at the age of 71 following a myocardial infarction that he experienced while performing yard work. What would indicate that his wife is experiencing prolonged grief disorder? A. Initially she denied that he died. B. Talking about her husband extensively in year following his death C. Stating that she expects him home soon on the anniversary of his death D. Crying uncontrollably and unpredictably in the weeks following her husband's death

C Denial of an individual's death that persists beyond 6 months is indicative of prolonged grief disorder. Strong emotions or denial immediately following the death are considered to be expected responses, and talking about the deceased loved one is not considered to be evidence of the disorder.

How should the nurse provide appropriate cultural and spiritual care for the patient and family to best be able to help them when nearing the end of the patient's life? A. Assess the individual patient's wishes. B. Call a pastor or priest for the family to help them cope. C. Assess the beliefs and preferences of the patient and family. D. Do not insult African Americans by suggesting hospice care.

C Differences among spiritual and culture beliefs and values related to death and dying are innumerable. The individual patient and family must be assessed to avoid stereotyping individuals with different spiritual and cultural belief systems.

During admission of a patient diagnosed with metastatic lung cancer, what should the nurse assess for as a key indicator of clinical depression related to terminal illness? A. Frustration with pain B. Anorexia and nausea C. Feelings of hopelessness D. Inability to carry out activities of daily living

C Feelings of hopelessness are likely to be present in a patient with a terminal illness who has clinical depression. This can be attributed to lack of control over the disease process or outcome. The nurse should routinely assess for depression when working with patients with a terminal illness.

After an 18-year-old patient died of severe injuries from a motor vehicle crash, the nurse who provided care is feeling helpless and powerless. What intervention would be most appropriate to help this nurse deal with these emotions and the death of this patient? A. Maintain daily contact with the adolescent's family for the next 2 to 3 months. B. Request a prescription for an anxiolytic to aid in dealing with the death of this patient. C. Attend a debriefing session with health team members to allow expression of feelings. D. Avoid caring for any other patients who are terminally ill until the feelings of grief subside.

C he nurse needs to express feelings of loss and grief. Interventions such as a peer support, professionally assisted groups, or informal discussion sessions are appropriate ways for the nurse to express feelings related to death and dying.

A client with a terminal illness reaches the stage of "acceptance". The client has been hostile towards staff and difficult to work with during his hospitalization. The nurse can best help the client during this stage by: A. Verbal defense of the staff's actions. B. Reasonable exploration of the situation. C. Silent acceptance of the client's behavior. D. Complete physical withdrawal from the client

C. Silent acceptance of the client's behavior.( At this time client is using the behaviors as a defensive, Quiet acceptance can be effective)

While caring for his dying wife, the husband states that his wife is a devout Roman Catholic but he is a Baptist. Who is considered the most reliable source for spiritual preferences concerning EOL care for the dying if? a. a priest b. dying wife c. hospice staff d. husband of dying wife

Correct answer: b Rationale: Assessment of spiritual needs for palliative care is a key consideration, and individual choices should be respected. The preferences of the patient and family with regard to spiritual guidance or pastoral care services should be assessed and appropriate referrals made. The patient is the most reliable source for the spiritual assessment.

A 67 year old woman was recently diagnosed with inoperable pancreatic cancer. Before the diagnosis she was very active in her neighborhood association. Her husband is concerned because his wife is staying at home and missing her usual community activities. Which common EOL psychologic manifestation is she most likely demonstrating? a. peacefulness b. decreased socialization c. decreased decision making d. anxiety about unfinished business

Correct answer: b Rationale: Decreased socialization is a common psychosocial manifestation of approaching death.

The home health nurse visits a 40 year old patient with metastatic breast cancer who is receiving palliative care. The patient is experiencing pain at a level of 7 (on a 10point scale). In prioritizing activities for the visit, the nurse would do which first? a. auscultate for breath sounds b. administer PRN pain medication c. check pressure points for skin breakdown d. ask family about patients's food and fluid intake

Correct answer: b Rationale: Meeting the patient's physiologic and safety needs is the priority. Physical care focuses on the needs for oxygen, nutrition, pain relief, mobility, elimination, and skin care. The patient is not experiencing oxygenation problems; the priority is to treat the severe pain with pain medication.

A nurse has been working full time with terminally ill patients for 3 years. He has been experiencing irritability and mixed emotions when expressing sadness since four of his patients died on the same day. To optimize the quality of his nursing care, he should examine his own. a. full-time work schedule b. past feelings toward death c. patterns for dealing with grief d. demands for involvement in patient care.

Correct answer: c Rationale: Caring for a dying patient is intense and emotionally charged, and nurses must be aware of how grief affects them. The nurse may have feelings of loss, helplessness, and powerlessness when dealing with death. Feelings of sorrow, guilt, and frustration need to be expressed. Recognizing personal feelings allows openness in exchanging feelings with the patient and family.

The family attorney informed a patient's adult children and wife that the patient did not have an advance directive after he suffered a serious stroke. Who is responsible for making the decision about EOL measures when the patient cannot communicate his or her specific wishes? a. notary and attorney b. physician and family c. wife and adult children d. physician and nursing staff

Correct answer: c Rationale: In the event that the patient is not capable of communicating his or her wishes, the surrogate decision maker, who is usually the next of kin (spouse or other family member), determines what measures will or will not be taken. The surrogate decision maker is responsible for making the final decision. The physician and nurse should discuss with surrogate decision makers what the options are.

The primary purpose of hospice is to a. allow patients to die at home b. provide better quality of care than the family can c. coordinate care for dying patients and their families d. provide comfort and support for dying patients and their family

Correct answer: d Rationale: Hospice provides support and care at the end of life to help patients live as fully and as comfortable as possible. The emphasis is on symptom management, advance care planning, spiritual care, and family support, including bereavement.

For the past 5 years Tom has repeatedly asked his mother to donate his deceased father's belongings to charity, but his mother has refused. She sits in the bedroom closet, crying and talking to her long-dead husband. What type of grief is Tom's mother experiencing? a. adaptive grief b. disruptive grief c. anticipatory grief d. prolonged grief disorder

Correct answer: d Rationale: Prolonged grief disorder is prolonged, intense mourning and includes symptoms such as recurrent distressing emotions and intrusive thoughts related to the loss of a loved one, severe pangs of emotion, self-neglect, and denial of the loss for longer than 6 months

The children caregivers of an elderly patient whose death is imminent have not left the bedside for the past 36 hours. In the nurse's assessment of the family, what findings indicate the potential for an abnormal grief reaction to occur(SATA)? a. family cannot express their feelings to one another b. dying patient is becoming more restless and agitated c. a family member is going through a difficult divorce d. Family talks with and reassures the patient at frequent intervals e. siblings who were estranged from each other have now reunited

Correct answers: a, c Rationale: The nurse must be able to recognize signs and behaviors among family members who may be at risk for abnormal grief reactions. They may include dependency and negative feelings about the dying person, inability to express feelings, sleep disturbances, a history of depression, difficult reactions to previous losses, perceived lack of social or family support, low self-esteem, multiple previous bereavements, alcoholism, and substance abuse. Caregivers with concurrent life crises are especially at risk.

An 80 year female patient is receiving palliative care for heart failure. Primary purpose(s) of her receiving palliative care is (are) to (SATA) a. improve her quality of life b. asses her coping ability with disease c. have time to teach patient and family about disease. d. focus on reducing the severity of disease symptoms e. provide care that the family is unwilling or unable to give

Correct answers: a, d Rationale: The focus of palliative care is reduction of the severity of disease symptoms. The goals of palliative care are to (1) prevent and relieve suffering and (2) to improve quality of life for patients with serious, life-limiting illnesses.

A patient has been receiving palliative care for the past several weeks in light of her worsening condition following a series of strokes. The caregiver has rung the call bell, stating that the patient now "stops breathing for a while, then breathes fast and hard, and then stops again." What should the nurse recognize that the patient is experiencing? A. Apnea B. Bradypnea C. Death rattle D. Cheyne-Stokes respirations

D Cheyne-Stokes respiration is a pattern of breathing characterized by alternating periods of apnea and deep, rapid breathing. This type of breathing is usually seen as a person nears death.

The nurse is evaluating whether a hospice referral is appropriate for a 69-year-old man with end-stage liver failure. What is one of the two criteria necessary for admission to a hospice program? A. The hospice medical director certifies admission to the program. B. The physician guarantees the patient has less than 6 months to live. C. The patient has completed both advance directives and a living will. D. The patient wants hospice care and agrees to terminate curative care.

D here are two criteria for admission to a hospice program. The first criterion is the patient must desire the services and agree in writing that only hospice care (and not curative care) can be used to treat the terminal illness. The second criterion is that the patient must be considered eligible for hospice. Two physicians must certify that the patient's prognosis is terminal with less than 6 months to live.

A nurse is aware that characteristic behavior in the initial stage of coping with dying includes: A. Crying uncontrollably. B. Criticizing medical care. C. Refusing to receive visitors. D. Asking for additional medical consultations.

D. Asking for additional medical consultations. -(seeking other opinions to disprove the inevitable is a form of denial employed by individuals having illness w/ a poor prognosis)

For each of the following body systems, identify three physical manifestations that the nurse would expect to see in a patient approaching death. Respiratory a. b. c. Skin a. b. c. Gastrointestinal a. b. c. Musculoskeletal a. b. c.

Respiratory a. Cheyne-Stokes respiration b. Death rattle (inability to cough and clear secretions) c. Increased, then slowing, respiratory rate (Also: irregular breathing, terminal gasping) Skin a. Mottling on hands, feet, and legs that progresses to the torso b. Cold, clammy skin c. Cyanosis on nose, nail beds, and knees (Also: waxlike skin when very near death) Gastrointestinal a. Slowing of the gastrointestinal tract with accumulation of gas and abdominal distention b. Loss of sphincter control with incontinence c. Bowel movement before imminent death or at time of death Musculoskeletal a. Loss of muscle tone with sagging jaw b. Difficulty speaking c. Difficulty swallowing (Also: loss of ability to move or maintain body position, loss of gag reflex)

The dying patient and family have many interrelated psychosocial and physical care needs. Which ones can the nurse begin to manage with the patient and family (select all that apply)? a. Anxiety b. Fear of pain c. The dying process d. Care being provided e. Anger toward the nurse f. Feeling powerless and hopeless

a, b, c, d, e, f. Teaching, along with support and encouragement, can decrease some of the anxiety. Teaching about pain relief, the dying process, and the care provided will help the patient and family know what to expect. Allowing the patient to make decisions will help to decrease feelings of powerlessness and hopelessness. The nurse who is the target of anger needs to not react to this anger on a personal level.

According to the World Health Organization, palliative care is an approach that improves quality of life for patients and their families who face problems associated with life-threatening illnesses. From the list below, identify the specific goals of palliative care (select all that apply). a. Regard dying as a normal process. b. Minimize the financial burden on the family. c. Provide relief from symptoms, including pain. d. Affirm life and neither hasten nor postpone death. e. Prolong the patient's life with aggressive new therapies. f. Support holistic patient care and enhance quality of life. g. Offer support to patients to live as actively as possible until death. h. Assist the patient and family to identify and access pastoral care services. i. Offer support to the family during the patient's illness and their own bereavement.

a, c, d, f, g, i. Table 10-1 lists the goals of palliative care. Overall, goals of palliative care are to prevent and relieve suffering and to improve the quality of life for the patient.

List the two criteria for admission to a hospice program. a. b.

a. Patient must desire services and agree in writing that only hospice care can be used to treat the terminal illness (palliative care) b. Patient must meet eligibility, which is less than 6 months to live, certified initially by two physicians

A 20-year-old patient with a massive head injury is on life support, including a ventilator to maintain respirations. What three criteria for brain death are necessary to discontinue life support? a. b. c.

a. Coma b. Absent brainstem reflexes c. Apnea

In most states, directives to physicians, durable power of attorney for health care, and medical power of attorney are included in which legal documents? a. Natural death acts c. Advance care planning b. Allow natural death d. Do Not Resuscitate order

a. Natural death acts in each state have their own requirements. Allow natural death is the new term being used for the Do Not Resuscitate order. Advance care planning is the process of having patients and their families think through their values and goals for treatment and document those wishes as advance directives.

A terminally ill man tells the nurse, "I have never believed there is a God or an afterlife, but now it is too terrible to imagine that I will not exist. Why was I here in the first place?" What does this comment help the nurse recognize about the patient's needs? a. He is experiencing spiritual distress. b. This man most likely will not have a peaceful death. c. He needs to be reassured that his feelings are normal. d. This patient should be referred to a clergyman for a discussion of his beliefs.

a. Spiritual distress may surface when an individual is faced with a terminal illness and it is characterized by verbalization of inner conflicts about beliefs and questioning the meaning of one's own existence. Individuals in spiritual distress may be able to resolve the problem and die peacefully with effective grief work but referral to spiritual leaders should be the patient's choice.

Priority Decision: The husband and daughter of a Hispanic woman dying from pancreatic cancer refuse to consider using hospice care. What is the first thing the nurse should do? a. Assess their understanding of what hospice care services are. b. Ask them how they will care for the patient without hospice care. c. Talk directly to the patient and family to see if she can change their minds. d. Accept their decision since they are Hispanic and prefer to care for their own.

a. The family may not understand what hospice care is and may need information. Some cultures and ethnic groups may underuse hospice care because of a lack of awareness of the services offered, a desire to continue with potentially curative therapies, and concerns about a lack of minority hospice workers.

A patient with end-stage liver failure tells the nurse, "If I can just live to see my first grandchild who is expected in 5 months, then I can die happy." The nurse recognizes that the patient is demonstrating which of the following stages of grieving? a. Prolonged grief disorder b. Kübler-Ross's stage of bargaining c. Kübler-Ross's stage of depression d. The new normal stage of the Grief Wheel

b. Bargaining is demonstrated by "if-then" grief behavior that is described by Kübler-Ross. Kübler-Ross's stage of depression is seen when the person says "yes me, and I am sad." Prolonged grief disorder is seen when there is a dysfunctional reaction to loss and the individual is unable to move forward after the death of a loved one. In the Grief Wheel model, the new normal stage is when the grief is resolved but the normal state, because of the loss, is not the same as before.

Priority Decision: A terminally ill patient is unresponsive and has cold, clammy skin with mottling on the extremities. The patient's husband and two grown children are arguing at the bedside about where the patient's funeral should be held. What should the nurse do first? a. Ask the family members to leave the room if they are going to argue. b. Take the family members aside and explain that the patient may be able to hear them. c. Tell the family members that this decision is premature because the patient has not yet died. d. Remind the family that this should be the patient's decision and to ask her if she regains consciousness.

b. Hearing is often the last sense to disappear with declining consciousness and conversations can distress patients even when they appear unresponsive. Conversation around unresponsive patients should never be other than that which one would maintain if the patients were alert.

A patient is receiving care to manage symptoms of a terminal illness when the disease no longer responds to treatment. What is this type of care known as? a. Terminal care c. Supportive care b. Palliative care d. Maintenance care

b. Palliative care is aimed at symptom management rather than curative treatment for diseases that no longer respond to treatment and is focused on caring interventions rather than curative treatments. "Palliative care" and "hospice" are frequently used interchangeably.

End-of-life palliative nursing care involves a. constant assessment for changes in physiologic functioning. b. administering large doses of analgesics to keep the patient sedated. c. providing as little physical care as possible to prevent disturbing the patient. d. encouraging the patient and family members to verbalize their feelings of sadness, loss, and forgiveness.

d. In assisting patients with dying, end-of-life care promotes the grieving process, which involves saying goodbye. Physical care is very important for physical comfort but assessment should be limited to essential data related to the patient's symptoms. Analgesics should be administered for pain but patients who are sedated cannot participate in the grieving process.

Priority Decision: A patient in the last stages of life is experiencing shortness of breath and air hunger. Based on practice guidelines, what is the most appropriate action by the nurse? a. Administer oxygen. b. Administer bronchodilators. c. Administer antianxiety agents. d. Use any methods that make the patient more comfortable.

d. There currently are no clinical practice guidelines to relieve the shortness of breath and air hunger that often occur at the end of life. The principle of beneficence would encourage any of the options to be tried, based on knowing that whatever gives the patient the most relief should be used.

A deathly ill patient from a culture different than the nurse's is admitted. Which question is appropriate to help the nurse provide culturally competent care? a. "If you die, will you want an autopsy?" b. "Are you interested in learning about palliative or hospice care?" c. "Do you have any preferences for what happens if you are dying?" d. "Tell me about your expectations of care during this hospitalization."

d. Using the open-ended statement to seek information related to the patient's and family's perspective and expectations will best guide the plan of care for this patient. This will open the discussion about palliative or hospice care and preferences for end-of-life care.