Ch. 16: End of Life Care
A nurse who sits on the hospital's ethics committee is reviewing a complex case that has many of the hallmarks of assisted suicide. Which of the following would be an example of assisted suicide? A) Administering a lethal dose of medication to a patient whose death is imminent B) Administering a morphine infusion without assessing for respiratory depression C) Granting a patient's request not to initiate enteral feeding when the patient is unable to eat D) Neglecting to resuscitate a patient with a "do not resuscitate" order
A) Administering a lethal dose of medication to a patient whose death is imminent Assisted suicide refers to providing another person the means to end his or her own life. This is not to be confused with the ethically and legally supported practices of withholding or withdrawing medical treatment in accordance with the wishes of the terminally ill individual. The other listed options do not fit this accepted definition of assisted suicide.
You are caring for a 50-year-old man diagnosed with multiple myeloma; he has just been told by the care team that his prognosis is poor. He is tearful and trying to express his feelings, but he is having difficulty. What should you do first? A) Ask if he would like you to sit with him while he collects his thoughts. B) Tell him that you will leave for now but will be back shortly. C) Offer to call pastoral care or a member of his chosen clergy. D) Reassure him that you can understand how he is feeling.
A) Ask if he would like you to sit with him while he collects his thoughts. The most important intervention the nurse can provide is listening empathetically. Seriously ill patients and their families need time and support to cope with the changes brought about by serious illness and the prospect of impending death. The nurse who is able to listen without judging and without trying to solve the patient's and family's problems provides an invaluable intervention. The patient needs to feel that people are concerned with his situation. Leaving him does not show acceptance of his feelings. Offering to call pastoral care may be helpful for some patients, but should be done after you have spent time with the patient. Telling the patient that you understand how he is feeling is inappropriate because it does not help him express his feelings.
The nurse is assessing a 73-year-old patient who was diagnosed with metastatic prostate cancer. The nurse notes that the patient is exhibiting signs of loss, grief, and intense sadness. Based on this assessment data, the nurse will document that the patient is most likely in what stage of death and dying? A) Depression B) Denial C) Anger D) Resignation
A) Depression Loss, grief, and intense sadness indicate depression. Denial is indicated by the refusal to admit the truth or reality. Anger is indicated by rage and resentment. Acceptance is indicated by a gradual, peaceful withdrawal from life.
An adult oncology patient has a diagnosis of bladder cancer with metastasis and the patient has asked the nurse about the possibility of hospice care. Which principle is central to a hospice setting? A) The patient and family should be viewed as a single unit of care. B) Persistent symptoms of terminal illness should not be treated. C) Each member of the interdisciplinary team should develop an individual plan of care. D) Terminally ill patients should die in the hospital whenever possible.
A) The patient and family should be viewed as a single unit of care. Hospice care requires that the patient and family be viewed as a single unit of care. The other listed principles are wholly inconsistent with the principles of hospice care.
The nurse is caring for a patient who has been recently diagnosed with late stage pancreatic cancer. The patient refuses to accept the diagnosis and refuses to adhere to treatment. What is the most likely psychosocial purpose of this patient's strategy? A) The patient may be trying to protect loved ones from the emotional effects of the illness. B) The patient is being noncompliant in order to assert power over caregivers. C) The patient may be skeptical of the benefits of the Western biomedical model of health. D) The patient thinks that treatment does not provide him comfort.
A) The patient may be trying to protect loved ones from the emotional effects of the illness. Patients who are characterized as being in denial may be using this strategy to preserve important interpersonal relationships, to protect others from the emotional effects of their illness, and to protect themselves because of fears of abandonment. Each of the other listed options is plausible, but less likely.
A patient who is receiving care for osteosarcoma has been experiencing severe pain since being diagnosed. As a result, the patient has been receiving analgesics on both a scheduled and PRN basis. For the past several hours, however, the patient's level of consciousness has declined and she is now unresponsive. How should the patient's pain control regimen be affected? A) The patient's pain control regimen should be continued. B) The pain control regimen should be placed on hold until the patient's level of consciousness improves. C) IV analgesics should be withheld and replaced with transdermal analgesics. D) The patient's analgesic dosages should be reduced by approximately one half.
A) The patient's pain control regimen should be continued. Pain should be aggressively treated, even if dying patients become unable to verbally report their pain. There is no need to forego the IV route. There is no specific need to discontinue the pain control regiment or to reduce it.
You are caring for a patient who has just been told that his illness is progressing and nothing more can be done for him. After the physician leaves, the patient asks you to stay with him for a while. The patient becomes tearful and tries several times to say something, but cannot get the words out. What would be an appropriate response for you to make at this time? A) "Can I give you some advice?" B) "Do you need more time to think about this?" C) "Is there anything you want to say?" D) "I have cared for lots of patients in your position. It will get easier."
B) "Do you need more time to think about this?" Prompt gently: "Do you need more time to think about this?" Giving advice is inappropriate and it is obvious from the scenario that the patient has something to say. Referring to other patients negates the patient's feelings at this time.
Patients who are enrolled in hospice care through Medicare are often felt to suffer unnecessarily because they do not receive adequate attention for their symptoms of the underlying illness. What factor most contributes to this phenomenon? A) Unwillingness to overmedicate the dying patient B) Rules concerning completion of all cure-focused medical treatment C) Unwillingness of patients and families to acknowledge the patient is terminal D) Lack of knowledge of patients and families regarding availability of care
B) Rules concerning completion of all cure-focused medical treatment Because of Medicare rules concerning completion of all cure-focused medical treatment before the Medicare hospice benefit may be accessed, many patients delay enrollment in hospice programs until very close to the end of life. Hospice care does not include an unwillingness to medicate the patient to keep him or her from suffering. Patients must accept that they are terminal before being admitted to hospice care. Lack of knowledge is common; however, this is not why some Medicare patients do not receive adequate attention for the symptoms of their underlying illness.
A patient's rapid cancer metastases have prompted a shift from active treatment to palliative care. When planning this patient's care, the nurse should identify what primary aim? A) To prioritize emotional needs B) To prevent and relieve suffering C) To bridge between curative care and hospice care D) To provide care while there is still hope
B) To prevent and relieve suffering Palliative care, which is conceptually broader than hospice care, is both an approach to care and a structured system for care delivery that aims to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies. Palliative care goes beyond simple prioritization of emotional needs; these are always considered and addressed. Palliative care is considered a "bridge," but it is not limited to just hospice care. Hope is something patients and families have even while the patient is actively dying.
A patient has just died following urosepsis that progressed to septic shock. The patient's spouse says, "I knew this was coming, but I feel so numb and hollow inside." The nurse should know that these statements are characteristic of what? A) Complicated grief and mourning B) Uncomplicated grief and mourning C) Depression stage of dying D) Acceptance stage of dying
B) Uncomplicated grief and mourning Uncomplicated grief and mourning are characterized by emotional feelings of sadness, anger, guilt, and numbness; physical sensations, such as hollowness in the stomach and tightness in the chest, weakness, and lack of energy; cognitions that include preoccupation with the loss and a sense of the deceased as still present; and behaviors such as crying, visiting places that are reminders of the deceased, social withdrawal, and restless overactivity. Complicated grief and mourning occur at a prolonged time after the death. The spouse's statement does not clearly suggest depression or acceptance.
A patient has just been told that her illness is terminal. The patient tearfully states, "I can't believe I am going to die. Why me?" What is your best response? A) "I know how you are feeling." B) "You have lived a long life." C) "This must be very difficult for you." D) "Life can be so unfair."
C) "This must be very difficult for you." The most important intervention the nurse can provide is listening empathetically. To communicate effectively, the nurse should ask open-ended questions and acknowledge the patient's fears. Deflecting the statement or providing false sympathy must be avoided.
The organization of a patient's care on the palliative care unit is based on interdisciplinary collaboration. How does interdisciplinary collaboration differ from multidisciplinary practice? A) It is based on the participation of clinicians without a team leader. B) It is based on clinicians of varied backgrounds integrating their separate plans of care. C) It is based on communication and cooperation between disciplines. D) It is based on medical expertise and patient preference with the support of nursing.
C) It is based on communication and cooperation between disciplines. Interdisciplinary collaboration, which is different from multidisciplinary practice, is based on communication and cooperation among the various disciplines, each member of the team contributing to a single integrated care plan that addresses the needs of the patient and family. Multidisciplinary care refers to participation of clinicians with varied backgrounds and skill sets, but without coordination and integration. Interdisciplinary collaboration is not based on patient preference and should not prioritize medical expertise over other disciplines.
A patient with end-stage heart failure has participated in a family meeting with the interdisciplinary team and opted for hospice care. On what belief should the patient's care in this setting be based? A) Meaningful living during terminal illness requires technologic interventions. B) Meaningful living during terminal illness is best supported in designated facilities. C) Meaningful living during terminal illness is best supported in the home. D) Meaningful living during terminal illness is best achieved by prolonging physiologic dying.
C) Meaningful living during terminal illness is best supported in the home. The hospice movement in the United States is based on the belief that meaningful living is achievable during terminal illness and that it is best supported in the home, free from technologic interventions to prolong physiologic dying.
A hospice nurse is caring for a 22-year-old with a terminal diagnosis of leukemia. When updating this patient's plan of nursing care, what should the nurse prioritize? A) Interventions aimed at maximizing quantity of life B) Providing financial advice to pay for care C) Providing realistic emotional preparation for death D) Making suggestions to maximize family social interactions after the patient's death
C) Providing realistic emotional preparation for death Hospice care focuses on quality of life, but, by necessity, it usually includes realistic emotional, social, spiritual, and financial preparation for death. Financial advice and actions aimed at post-death interaction would not be appropriate priorities.
The nurse has observed that an older adult patient with a diagnosis of end-stage renal failure seems to prefer to have his eldest son make all of his health care decisions. While the family is visiting, the patient explains to you that this is a cultural practice and very important to him. How should you respond? A) Privately ask the son to allow the patient to make his own health care decisions. B) Explain to the patient that he is responsible for his own decisions. C) Work with the team to negotiate informed consent. D) Avoid divulging information to the eldest son.
C) Work with the team to negotiate informed consent. In this case of a patient who wishes to defer decisions to his son, the nurse can work with the team to negotiate informed consent, respecting the patient's right not to participate in decision making and honoring his family's cultural practices.
A 66-year-old patient is in a hospice receiving palliative care for lung cancer which has metastasized to the patient's liver and bones. For the past several hours, the patient has been experiencing dyspnea. What nursing action is most appropriate to help to relive the dyspnea the patient is experiencing? A) Administer a bolus of normal saline, as ordered. B) Initiate high-flow oxygen therapy. C) Administer high doses of opioids. D) Administer bronchodilators and corticosteroids, as ordered.
D) Administer bronchodilators and corticosteroids, as ordered. Bronchodilators and corticosteroids help to improve lung function as well as low doses of opioids. Low-flow oxygen often provides psychological comfort to the patient and family. A fluid bolus is unlikely to be of benefit.
The nurse is admitting a 52-year-old father of four into hospice care. The patient has a diagnosis of Parkinson's disease, which is progressing rapidly. The patient has made clear his preference to receive care at home. What interventions should the nurse prioritize in the plan of care? A) Aggressively continuing to fight the disease process B) Moving the patient to a long-term care facility when it becomes necessary C) Including the children in planning their father's care D) Supporting the patient's and family's values and choices
D) Supporting the patient's and family's values and choices Nurses need to develop skill and comfort in assessing patients' and families' responses to serious illness and planning interventions that support their values and choices throughout the continuum of care. To be admitted to hospice care, the patient must have come to terms with the fact that he is dying. The scenario states that the patient wants to be cared for at home, not in a long-term setting. The children may be able to participate in their father's care, but they should not be assigned responsibility for planning it.
A clinic nurse is providing patient education prior to a patient's scheduled palliative radiotherapy to her spine. At the completion of the patient teaching, the patient continues to ask the same questions that the nurse has already addressed. What is the plausible conclusion that the nurse should draw from this? A) The patient is not listening effectively. B) The patient is noncompliant with the plan of care. C) The patient may have a low intelligence quotient or a cognitive deficit. D) The patient has not achieved the desired learning outcomes.
D) The patient has not achieved the desired learning outcomes. The nurse should be sensitive to patients' ongoing needs and may need to repeat previously provided information or simply be present while the patient and family react emotionally. Telling a patient something is not teaching. If a patient continues to ask the same questions, teaching needs to be reinforced. The patient's response is not necessarily suggestive of "noncompliance," cognitive deficits, or not listening.
The nurse in a pediatric ICU is caring for a child who is dying of sickle cell anemia. The child's mother has been unable to eat or sleep and can talk only about her impending loss and the guilt she feels about the child's pain and suffering. What intervention has the highest priority? A) Allowing the patient to express her feelings without judging her B) Helping the patient to understand the phases of the grieving process C) Reassuring the patient that the child's death is not her fault D) Arranging for genetic counseling to inform the patient of her chances of having another child with the disease
A) Allowing the patient to express her feelings without judging her Listening to the patient express her feelings openly without judging her is the highest priority. The nurse should not impose his or her own values on the patient. The nurse should also help the patient to understand the grieving process and use all the support systems that are available to assist her in coping with this situation. Genetic counseling may be appropriate at a later time.
The nurse is caring for a patient who has terminal lung cancer and is unconscious. Which assessment finding would most clearly indicate to the nurse that the patient's death is imminent? A) Mottling of the lower limbs B) Slow, steady pulse C) Bowel incontinence D) Increased swallowing
A) Mottling of the lower limbs The time of death is generally preceded by a period of gradual diminishment of bodily functions in which increasing intervals between respirations, weakened and irregular pulse, and skin color changes or mottling may be observed. The patient will not be able to swallow secretions, so suctioning, frequent and gentle mouth care, and, possibly, the administration of a transdermal anticholinergic drug. Bowel incontinence may or may not occur.
A patient on the medical unit is dying and the nurse has determined that the family's psychosocial needs during the dying process need to be addressed. What is a cause of many patient care dilemmas at the end of life? A) Poor communication between the family and the care team B) Denial of imminent death on the part of the family or the patient C) Limited visitation opportunities for friends and family D) Conflict between family members
A) Poor communication between the family and the care team Many dilemmas in patient care at the end of life are related to poor communication between team members and the patient and family, as well as to failure of team members to communicate with each other effectively. Regardless of the care setting, the nurse can ensure a proactive approach to the psychosocial care of the patient and family. Denial of death may be a response to the situation, but it is not classified as a need. Visitation should accommodate wishes of the family member as long as patient care is not compromised.
A medical nurse is providing end-of-life care for a patient with metastatic bone cancer. The nurse notes that the patient has been receiving oral analgesics for her pain with adequate effect, but is now having difficulty swallowing the medication. What should the nurse do? A) Request the physician to order analgesics by an alternative route. B) Crush the medication in order to aid swallowing and absorption. C) Administer the patient's medication with the meal tray. D) Administer the medication rectally.
A) Request the physician to order analgesics by an alternative route. A change in medication route is indicated and must be made by a physician's order. Many pain medications cannot be crushed and given to a patient. Giving the medication with a meal is not going to make it any easier to swallow. Rectal administration may or may not be an option.
A medical nurse is providing palliative care to a patient with a diagnosis of end-stage chronic obstructive pulmonary disease (COPD). What is the primary goal of this nurse's care? A) To improve the patient's and family's quality of life B) To support aggressive and innovative treatments for cure C) To provide physical support for the patient D) To help the patient develop a separate plan with each discipline of the health care team
A) To improve the patient's and family's quality of life The goal of palliative care is to improve the patient's and the family's quality of life. The support should include the patient's physical, emotional, and spiritual well-being. Each discipline should contribute to a single care plan that addresses the needs of the patient and family. The goal of palliative care is not aggressive support for curing the patient. Providing physical support for the patient is also not the goal of palliative care. Palliative care does not strive to achieve separate plans of care developed by the patient with each discipline of the health care team.
One aspect of the nurse's comprehensive assessment when caring for the terminally ill is the assessment of hope. The nurse is assessing a patient with liver failure for the presence of hope. What would the nurse identify as a hope-fostering category? A) Uplifting memories B) Ignoring negative outcomes C) Envisioning one specific outcome D) Avoiding an actual or potential threat
A) Uplifting memories Hope is a multidimensional construct that provides comfort as a person endures life threats and personal challenges. Uplifting memories are noted as a hope-fostering category, whereas the other listed options are not identified as such.
You are caring for a patient, a 42-year-old mother of two children, with a diagnosis of ovarian cancer. She has just been told that her ovarian cancer is terminal. When you admitted this patient, you did a spiritual assessment. What question would it have been most important for you to evaluate during this assessment? A) Is she able to tell her family of negative test results? B) Does she have a sense of peace of mind and a purpose to her life? C) Can she let go of her husband so he can make a new life? D) Does she need time and space to bargain with God for a cure?
B) Does she have a sense of peace of mind and a purpose to her life? In addition to assessment of the role of religious faith and practices, important religious rituals, and connection to a religious community, you should further explore the presence or absence of a sense of peace of mind and purpose in life; other sources of meaning, hope, and comfort; and spiritual or religious beliefs about illness, medical treatment, and care of the sick. Telling her family and letting her husband go are not parts of a spiritual assessment. Bargaining is a stage of death and dying, not part of a spiritual assessment.
A patient's daughter has asked the nurse about "helping him end his terrible suffering." The nurse is aware of the ANA Position Statement on Assisted Suicide, which clearly states that nursing participation in assisted suicide is a violation of the Code for Nurses. What does the Position Statement further stress? A) Educating families about the moral implications of assisted suicide B) Identifying patient and family concerns and fears C) Identifying resources that meet the patient's desire to die D) Supporting effective means to honor the patient's desire to die
B) Identifying patient and family concerns and fears The ANA Position Statement further stresses the important role of the nurse in supporting effective symptom management, contributing to the creation of environments for care that honor the patient's and family's wishes, as well as identifying their concerns and fears. Discussion of moral implications would normally be beyond the purview of the nurse.
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 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.