Test 10 - End of Life, Grief, Loss, Spirituality, and Legal
A terminally ill patient in pain asks the nurse to administer enough pain medication to end the suffering forever. What is the best response by the nurse?
"I will notify the physician that the current dose of medication is not relieving your pain."
How do you manage oral / resp secretions?
Administer atropine IV/IM/SubQ every 4-6 hr Atropine for eye watering as well (drops) can be given SUBLINGUAL Atropine = dries you out Administer glycopyrrolate (Robinal) PO every 8 hours (reduces saliva) Administer scopolamine transdermal patch behind ear X 3 days (reduces saliva)
Based on the most common concern of a dying patient, the hospice nurse should:
Administer pain medication on a schedule that prevents pain from intensifying
The client becomes unconscious. Their pulse becomes weak and thready, and they begin to sweat profusely. Mucous collects in their airway, and respirations become extremely noisy. Which intervention should the nurse implement?
Administer prescribed atropine drops sublingually
What is mourning?
Individual, family, group, and cultural expressions of grief and associated behaviors
What is double effect?
Many good actions have both a good and bad effect
What is the eligibility for hospice care?
Must be given 6 mnths to live After 6 mnths still living - must be recertified Pt may revoke care and restart later
What is complicated grief?
Prolonged period of time of sadness and feelings of worthlessness and hopelessness
What are the four levels of hospice care?
Routine home care: care provided at home Inpatient respite care: 5 day inpatient stay to relieve family caregiver Continuous Care: provided in the home for management of medical crisis General inpatient care: inpatient stay for symptom management
What is autonomy?
Rule of self
The nurse is providing care to a terminally ill client and his family who practice the Islamic faith. Which of the following concepts would the nurse need to integrate into this client's plan of care? Select all that apply. The caste of the client and family will determine their view of death The way a person dies is of great individual importance Pain is viewed as a mechanism for cleansing The family will create a new ethereal body the first 10 days after death Death occurs through God's permission
The way a person dies is of great individual importance Pain is viewed as a mechanism for cleansing Death occurs through God's permission
Which medication does the nurse expect to give to prevent a common side effect of the fentanyl patch?
Ducusate sodium (This is a stool softener and it is given to help prevent constipation, a common side effect of this medication)
A client has designated a family member to make healthcare decisions for the client if the client is not able to do so. What type of advance directive is this considered?
Durable power of attorney (DPOA) for healthcare
Which statement by the nurse identifies the purpose of advance care planning?
During advance care planning, I will help you identify what you want your healthcare team to do if you cannot speak for yourself
What are the nursing interventions for anorexia?
Encourage intake without stress Assess meds that may cause anorexia Manage anxiety + depression Position (sit up) Assess for GI issues Frequent mouth care
A patient's family member asks the nurse what the purpose of hospice is. What is the best response by the nurse?
"It will enable the patient to remain home if that is what is desired."
A mother of three young children has been diagnosed with stage III breast cancer and is distraught. Which statement best communicates a spirit of hopefulness to this client?
"Let's take this one day at a time; remember you have your daughter's dance recital next week."
What are some therapeutic communication techniques?
"Tell me more about what is on your mind" Provide reassurance only when it is realistic Proactive approach Allow sufficient time to process new information
A terminally ill patient is admitted to the hospital. The patient grabs the nurse's hand and asks, "Am I dying?" What response would be best for the nurse to give?
"Tell me more about what's on your mind." NOT Why do you think that?
Which statements made by the nurse demonstrates that the nurse is providing spiritually sensitive care?
"Tell me who or what gives you strength."
The primary healthcare provider also prescribes morphine sulfate elixir 8 mg by mouth every 4 hours as needed for breakthrough pain. The morphine sulfate elixir is supplied 5 mg per mL. What is the maximum volume in mL that the client can receive per day?
9.6 5 mg / 8mg x 1 mL = 1.6 mL x 6 doses (every 4 hours = 6 times max per 24 hours) = 9.6 mL
A patient with end-stage chronic obstructive pulmonary disease is admitted to a hospice facility and asks the admitting nurse, "How long will I be allowed to stay here?" What is the best response by the nurse?
"When your stay reaches 6 months, you will be recertified for a continued stay."
What are the 5 stages of grief? Kubler-Ross
1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance
For individuals known to be dying by virtue of age and/or diagnosis, which sign indicates approaching death?
1. Refusal of food, fluids 2. Urinary output decreases 3. Weakness, sleep 4. Confusion, increased restlessness 5. Impaired vision, hearing 6. Secretions in throat + dry mouth 7. Irregular breathing pattern 8. Decreased temperature control 9. Incontinence
What are the signs of approaching death?
1. Refusal of food, fluids 2. Urinary output decreases 3. Weakness, sleep 4. Confusion, increased restlessness 5. Impaired vision, hearing 6. Secretions in throat + dry mouth 7. Irregular breathing pattern 8. Decreased temperature control 9. Incontinence
What are imminent death signs?
1. Withdrawal 2. Sleep for longer intervals + somnolent 3. Gradual diminish of body functions 4. Increase intervals between resp 5. Weakened and irregular pulse 6. Low BP 7. Skin color changes (cyanosis) or mottling
Who declares that a patient has died?
2 nurses in the hospital The hospice nurse in the home If the hospice nurse is not there - pt is not declared dead until they arrive
What is delirium?
A disoriented reaction with restlessness and confusion Disturbance in: LOC Psychomotor Memory Thinking Attention Sleep / wake
The family members of a dying client are finding it difficult to verbalize their feelings for and show tenderness to the client. Which intervention should a nurse perform in such a situation?
Encourage the family members to express their feelings and listen to them in their frank communication
What is mutual pretense awareness?
A situation in which patients know they are dying, and the hospital and family members know but everyone pretends that death is not imminent
What is a living will?
A written statement detailing a person's desires regarding their medical treatment in circumstances in which they are no longer able to express informed consent
What is medical aid in dying?
AKA assisted suicide Nursing participation = violation of code of nurses Physician assisted suicide Oregon Death With Dignity Act (1994) Withholding or withdrawing medical treatment Non-escalation of care
What is the grief and mourning after death?
Accepting loss Feel pain of seperation Preparing to live without the person Conflicting feelings of relief Guilt and grief / unresolved issues More difficult if pt was in pain + unwanted interventions + unattended Most find a way to reconcile loss and reengage
A client has been a resident of a long-term care facility for several years. The client's condition has deteriorated to the point that the client is now unable to eat. The physician has recommended surgical implantation of a feeding tube. The client's family has a legal document outlining the client's wishes in regard to measures such as this. What is this document?
Advanced directive
What is a do not resuscitate (DNR) order?
Advanced directive Difficult decision Withhold CPR In Florida to be legal MUST BE ON YELLOW PAPER Signed by pt + MD + ARNP (hospice)
Which nursing intervention is therapeutic for the family immediately after the client dies?
Allow the family to spend as much time as they request at the client's bedside
What is pediatric hospice care?
Allows for both curative and end-of-life care of children Parent is taught on how to comfort + interact with sick child Spiritual support Pain management = most important
The client's respirations quiet. Despite having Cheyne-Stokes respirations for 2 hours while unconscious, the client suddenly regains consciousness. Which explanation should the nurse offer to the family about this change in status?
An unexpected alertness, referred to as 'a rally,' sometimes occurs when a client is near death
What is a rally?
An unexpected alertness, referred to as 'a rally,' sometimes occurs when a client is near death. Client will suddenly become aware and awake. This is not an uncommon occurrence. Nurses prepare families for the possibility of a rally, but a rally does not mean that there is an improvement in the client's condition.
A hospice client expresses concern about her daughter and how angry her daughter has been regarding the clients failing health. How should the nurse respond to the client about their family concerns?
Anger is part of the grieving process. I would suggest you encourage her to talk about her feelings
What is important regarding nutrition + hydration with end of life care?
Anorexia Cachexia syndrome Results in severe asthenia Lack of interest in mealtime
Based on the client's concern about their daughter, which nursing diagnosis should the nurse add to the plan of care?
Anticipatory grieving related to potential loss of parent
Which is the best response to the client's concerns about their children?
Ask the client if they are interested in having a volunteer help record their thoughts (This is a service offered by trained hospice volunteers that helps clients pass along information to their family and friends)
How do you be culturally sensitive when providing care?
Assess + document Beliefs Preferences End of life practices Death prep After death ritual Honor + support wishes
How do you provide care after death?
Ausc for absence of breathing / heart sounds Body becomes dusky + blue + waxen + cool Blood darkens and pools in dependent areas of body Urine + stool evacuated Encourage visitation Honor privacy
The nurse is caring for a client who just learned of a terminal diagnosis. After the physician leaves, the nurse remains to answer further questions so that the client can make an informed decision about further treatment. By providing all available information, the nurse is promoting which ethical principle?
Autonomy
What are the treatments for dyspnea?
Blood transfusion for anemia or erythropoietin Low dose morphine Bronchodilators Corticosteroids Low flow O2 Benzodiazepines (depressants) Diuretics for FVO Energy conservation
A family of a dying client reports that their loved one is experiencing more shortness of breath. Which nursing intervention is most appropriate at this time?
Call the health care provider to obtain an oxygen order
What is palliative care?
Care for pt who disease is not responsive to cure Prevent / relieve suffering Care extends to pt families Pain / symptom control GOAL = improve quality of life All palliative care = hospice care
What is uncomplicated grief?
Characterized by emotional feelings of sadness, anger, guilt, numbness, and family feels like their stomach is hollow and a tightness in their chest Kubler Ross
A nurse is providing care to a client experiencing symptoms associated with terminal illness. Which of the following would be most appropriate to use as a means for managing the client's symptoms?
Client's goals
Medicare and Medicaid hospice benefit criteria allow clients with a life expectancy of 6 months or less to be admitted to hospice. However, the median length of stay in a hospice program is just 21.3 days. Which reason explains the underuse of hospice care services?
Clients and families view hospice care as giving up
The nurse observes the client's emotional responses when discussing their desires about death. Which emotional response is uncommon?
Confusion and disorientation
What are emergency kits?
Contain ready to administer doses of meds Small doses of oral morphine liquid for pain or shortness of breath Benzodiazepine for restlessness / dyspnea Acetaminophen suppository for fever Family members can be instructed to administer
What is open awareness?
Death is acknowledged and discussed
Which action should the nurse take first when addressing the client's fear of falling in the shower?
Determine if safety equipment is needed for bathing or showering
What are the treatments of anorexia?
Dexamethasone (Decadron) Megestrol (Megace) Dronabinol (Marinol) Steroids increase appetite Temporary weight gain, not an increase in lean body mass Taper or d/c after 4 - 8 weeks if no response
The nurse notices that the client's partner appears to be losing weight. The nurse discovers that they have only been sleeping about 2 hours per night. When questioned, the partner reports feeling as if they might collapse if they are not able to take a break from caring for the client. What action should the nurse take?
Discuss with the family the possibility of a brief hospitalization for respite care
What is important regarding organ donation with end of life care?
Discussion is done with someone trained Discussion is separate from discussions related to care Written consent is necessary All expenses taken on by recipient NOT donor CCMH = Lifelink HCA = Life Alliance Organ Procurement Can make tragedy less painful
What is non-maleficence?
Do no harm
What is beneficence?
Doing good
Which intervention by the nurse will facilitate the anticipatory grieving process?
Encourage their partner to verbally give the client permission to die
What is important regarding pain with end of life care?
Final stage pain = common Believe reports of pain Under treating pain is common Poorly managed pain = psychological issues + emotional issues + social issues + financial issues
The nurse is caring for a pediatric client who is dying. The best way to provide care and comfort to clients who are dying and their families is to first do which of the following?
Explore own feelings on mortality and death and dying
What is cachexia?
Extreme wasting and malnutrition
What is the Patient Self-Determination Act?
Federal legislation that requires all clients admitted to a health care facility to be asked if they have advance directives
What is depression?
For end of life = situational depression Clinical depression should not be ignored Relieve physical symptoms Attention to emotional / spiritual distress Pharmacologic interventions
The client tells the nurse that the new pain regimen is working much better but they have started having burning, electric-like pain in their hands and feet. Which medication would the nurse expect the healthcare provider to prescribe to treat the type of pain the client described?
Gabapentin (This drug is an anticonvulsant commonly used to treat neuropathic pain because of its effect on the central nervous system)
Which of the following nursing interventions will a nurse perform to transfer heat and improve circulation in a dying client?
Gently massage the arms and legs
What drugs are included in palliative sedation?
Haloperidol Midazolam Phenobarbital Ketamine Chlorpromazine
What is a mature minor doctrine?
If a child has sufficient maturity to understand the nature, purpose and risks of a medical procedure, parental consent might not be necessary
What are the five wishes?
Includes: 1. Healthcare power of attorney 2. Kind of treatment they want 3. How comfortable they want to be 4. How they want to be treated by others 5. What they want loved ones to know
The nurse schedules a home visit with the family unit to discuss common expressions of grief. What information should the nurse include during the discussion about the grieving process?
It is common to have several emotional responses to grief and loss Grief is a normal reaction to loss Grief includes both physiologic and psychological responses Grief is a complex and intense emotional experience
What is distributive justice?
Judging fairness
Which of the following is the major long-term goal associated with end-of-life care?
LONG TERM Dying with dignity
What is anorexia?
Loss of appetite Can be controlled early on Progressive anorexia is natural and common
What is palliative sedation?
Offered to those close to death that are not responsive to usual therapies Controversial NOT euthanasia Goal is to relieve symptoms NOT hasten death Used for seizures + pain + dyspnea + delirium PT and family fully informed Induced unconsciousness
What is organ donation?
Offering your organs and tissues to be donated to someone in need if dying / death occurs
A type of comprehensive care for clients whose disease is not responsive to cure is
Palliative care
What is hospice care?
Palliative care given at end of life Goal is to enable the pt to remain at home / where they are comfortable
How do you involve the dying child into decision making?
Parent / child wishes may conflict Children >7 YO may assent to continuation / withdrawal Talk with pt WITH parents AND alone Assure that comfort is the priority Be supportive + respectful
What is a durable power of attorney?
Patient designates a surrogate to make medical decisions in event he/she loses decision making capacity
What is suspected awareness?
Patient suspects prognosis (dying) but is not told by those who know
What is closed awareness?
Patient unaware of impending death despite others knowing Can be lack of communication
What is bereavement?
Period during which mourning or grief for a loss takes place
The client qualifies for in-home county support services and the family hire a home care aide. Which information about the client's care should the nurse convey to the home care aide?
Place hygienic supplies within the client's reach when the client is using the shower chair (This will promote independence and decrease the risk for falls)
How do you handle perinatal loss?
Pregnancy or neonatal loss up to 1mnth of age Sit quietly + observe Provide cultural care Provide time with newborn Avoidance is common Convey concern + acknowledge loss Active listen
The nurse recognizes end of life signs and prepares the family for the client's imminent death. What intervention should the nurse implement at this time?
Reinforce prior education about the dying process
The nurse teaches the client's partner how to apply the transdermal fentanyl patch. Which information is most important for the nurse to teach the client's partner?
Remove the old patch before applying the new patch
A client is declared to have a terminal illness. What intervention will a nurse perform related to the final decision of a dying client?
Respect the client's and family members' choices
Which techniques should the nurse use when communicating with the client about their terminal illness?
Respect the client's pattern of communication and ways of dealing with stress (The nurse should respect the client's readiness to talk about and deal with the illness while offering support when needed)
What are moral dilemmas?
Situations in which there are moral pros and cons for each set of possible actions
What are the nursing interventions for nutrition?
Small portions of favorite foods Cool foods = better tolerated Cheese + eggs + PB + mild fish + chicken + turkey Milk shake + ensure Place nutrition at bedside Schedule meals Ice chips of frozen fruit juice Allow pt to refuse
What is the legal hierarchy of who is given durable power of attorney?
Spouse Adult children Parent of patient Adult sibling of patient
What are the interventions for grief?
Support expressing feelings Assess social support Assess coping skills Assess for signs of complicated grief / mourning
What are slow codes / show codes?
Symbolic resuscitation Resembles CPR but no effort Like a "show" Short and vigorous resuscitation to benefit family while minimizing harm to patient
The client again becomes unconscious, their respirations deteriorate, and their pupils become fixed and dilated. The client's partner begins to panic and tells the nurse to revive the client if they stop breathing. Which response by the nurse is therapeutic, given the partner's anxiety?
Tell me about the conversations you had with your partner about this moment
When talking with the family about hospice care, what information should the nurse include?
The care provided is client and family focused Hospice nurses regard dying as a normal process Bereavement follow-up is provided after the client's death Interdisciplinary care focuses on symptom management
What is anticipatory grief?
The dying person or his family is expecting the death Patient + family sits around and they reminisce about the good times and their life
What is grief?
The personal feelings that accompany an anticipated or actual loss
In conducting a home visit with a new client, which problem should the hospice nurse address first?
The problem that the client identifies as the first priority, the problem that most concerns the client
The client asks the nurse what physical experiences occur at the end of life. Which of the following physical occurrences are likely at end of life?
There is a decreased perception of pain Mottling on hands, feet, arms, and legs occur Breathing becomes slowed and irregular
What are physician orders for life sustaining treatment (POLST)?
Translates patient preferences expressed in advance directives to medical "orders" Specifies preferences related to: •CPR •Use of IV meds or fluids •Antibiotics •Artificial nutrition •Medical interventions
A primary care provider makes a referral to the nurse. Which statement by the client indicates an understanding of palliative care?
Treatments and medications will be utilized to control my pain and increase my comfort.
In spite of administering the prescribed pain medication, a dying client is still experiencing dyspnea due to fear and anxiety. Which nursing intervention should the nurse use to potentiate the effects of pain medication and help reduce the dyspnea?
Use imagery, humor, and progressive relaxation
Which nursing intervention describes the use of guided imagery to control pain?
Visualize a pain free mental scenario while achieving a deep state of relaxation
The clients partner is afraid that if the client takes pain medication at night, they might not wake up in the morning. How should the nurse respond to the partner's concern?
We can collaborate with the primary care provider to try to find a dose of pain medication that works for your partner
What is important regarding artificial nutrition + hydration with end of life care?
Weight loss + dehydration are expected characteristics of progressive illness Starvation does not = failure Tube or IV feedings are not comfortable Survival will not be increased Separate feeding from care Symptoms of dry mouth + confusion will not improve
What is important regarding dyspnea with end of life care?
What is the intensity + distress? (0-10) Interfere with activity Ausc lung sounds Assess fluid balance Temp Skin turgor Sputum characteristics Cough Can be frightening + feel like drowning / suffocation
What is the spiritual assessment tool FICA?
• Faith & belief • Importance and Influence • Community • Address (how can we address)