Ch. 9 - Palliative Care at End of Life (Lewis)

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.

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 which of the following? 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 it, and the second is that the physician certifies that the patient has a prognosis of 6 months or less to live.

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 10 point 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 breadkdown d. ask family about patient's food and fluid intake

b. administer PRN pain medication

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

b. decreased socialization

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 wife? a. a priest b. dying wife c. hospice staff d. husband of dying wife

b. dying wife

Mr. Johansen died at the age of 71 following a myocardial infarction that he experienced while performing yard work. Mrs. Johansen would be experiencing prolonged grief disorder if she A. Initially denied that Mr. Johansen died. B. Talked about her husband extensively in the years following his death. C. Stated that she expects him home soon on the anniversary of his death. D. Cried 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.

During admission of a patient diagnosed with metastatic lung cancer, the nurse would assess for which of the following 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 assess for depression routinely when working with patients with a terminal illness.

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 of dealing with grief d. demands for involvement in patient care

c. patterns of dealing with grief

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

c. wife and adult children

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." The nurse would 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.

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.

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

d. prolonged grief disorder

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 families

d. provide comfort and support for dying patients and their families

As the nurse admits a patient in end-stage kidney disease to the hospital, the patient tells the nurse, "If my heart or breathing stop, I do not want to be resuscitated." Which action is best for the nurse to take? a. Ask if these wishes have been discussed with the health care provider. b. Place a "Do Not Resuscitate" (DNR) notation in the patient's care plan. c. Inform the patient that a notarized advance directive must be included in the record or resuscitation must be performed. d. Advise the patient to designate a person to make health care decisions when the patient is not able to make them independently.

A A health care provider's order should be written describing the actions that the nurses should take if the patient requires CPR, but the primary right to decide belongs to the patient or family. The nurse should document the patient's request but does not have the authority to place the DNR order in the care plan. A notarized advance directive is not needed to establish the patient's wishes. The patient may need a durable power of attorney for health care (or the equivalent), but this does not address the patient's current concern with possible resuscitation.

Which action is best for the nurse to take to ensure culturally competent care for an alert, terminally ill Filipino patient? a. Ask the patient and family about their preferences for care during this time. b. Let the family decide whether to tell the patient about the terminal diagnosis. c. Obtain information from Filipino staff members about possible cultural needs. d. Remind family members that dying patients prefer to have someone at the bedside.

A Because cultural beliefs may vary among people of the same ethnicity, the nurse's best action is to assess the expectations of both the patient and family. The other actions may be appropriate, but the nurse can only plan for individualized culturally competent care after assessment of this patient and family.

The nurse cares for a terminally ill patient who is experiencing pain that is continuous and severe. How should the nurse schedule the administration of opioid pain medications? a. Give around-the-clock routine administration of analgesics. b. Provide PRN doses of medication whenever the patient requests. c. Offer enough pain medication to keep the patient sedated and unaware of stimuli. d. Suggest analgesic doses that provide pain control without decreasing respiratory rate.

A The principles of beneficence and nonmaleficence indicate that the goal of pain management in a terminally ill patient is adequate pain relief even if the effect of pain medications could hasten death. Administration of analgesics on a PRN basis will not provide the consistent level of analgesia the patient needs. Patients usually do not require so much pain medication that they are oversedated and unaware of stimuli. Adequate pain relief may require a dosage that will result in a decrease in respiratory rate.

The spouse of a patient with terminal cancer visits daily and cheerfully talks with the patient about wedding anniversary plans for the next year. When the nurse asks about any concerns, the spouse says, "I'm busy at work, but otherwise things are fine." Which nursing diagnosis is most appropriate? a. Ineffective coping related to lack of grieving b. Anxiety related to complicated grieving process c. Caregiver role strain related to feeling overwhelmed d. Hopelessness related to knowledge deficit about cancer

A The spouse's behavior and statements indicate the absence of anticipatory grieving, which may lead to impaired adjustment as the patient progresses toward death. The spouse does not appear to feel overwhelmed, hopeless, or anxious.

The nurse admits a terminally ill patient to the hospital. What is the first action that the nurse should complete when planning this patient's care? a. Determine the patient's wishes regarding end-of-life care. b. Emphasize the importance of addressing any family issues. c. Discuss the normal grief process with the patient and family. d. Encourage the patient to talk about any fears or unresolved issues.

A The nurse's initial action should be to assess the patient's wishes at this time. The other actions may be implemented if the patient or the family express a desire to discuss fears, understand the grief process, or address family issues, but they should not be implemented until the assessment indicates that they are appropriate.

Which nursing actions for the care of a dying patient can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN) (select all that apply)? a. Provide postmortem care to the patient. b. Encourage the family members to talk with and reassure the patient. c. Determine how frequently physical assessments are needed for the patient. d. Teach family members about commonly occurring signs of approaching death. e. Administer the prescribed morphine sulfate sublingual as necessary for pain control.

A,B,E Medication administration, psychosocial care, and postmortem care are included in LPN/LVN education and scope of practice. Patient and family teaching and assessment and planning of frequency for assessments are skills that require registered nurse level education and scope of practice.

A hospice nurse who has become close to a terminally ill patient is present in the home when the patient dies and feels saddened and tearful as the family members begin to cry. Which action should the nurse take at this time? a. Contact a grief counselor as soon as possible. b. Cry along with the patient's family members. c. Leave the home as soon as possible to allow the family to grieve privately. d. Consider whether working in hospice is desirable because patient losses are common.

B It is appropriate for the nurse to cry and express sadness in other ways when a patient dies, and the family is likely to feel that this is therapeutic. Contacting a grief counselor, leaving the family to grieve privately, and considering whether hospice continues to be a satisfying place to work are all appropriate actions as well, but the nurse's initial action at this time should be to share the grieving process with the family.

A young adult patient with metastatic cancer, who is very close to death, appears restless. The patient keeps repeating, "I am not ready to die." Which action is best for the nurse to take? a. Remind the patient that no one feels ready for death. b. Sit at the bedside and ask if there is anything the patient needs. c. Insist that family members remain at the bedside with the patient. d. Tell the patient that everything possible is being done to delay death.

B Staying at the bedside and listening allows the patient to discuss any unresolved issues or physical discomforts that should be addressed. Stating that no one feels ready for death fails to address the individual patient's concerns. Telling the patient that everything is being done does not address the patient's fears about dying, especially since the patient is likely to die soon. Family members may not feel comfortable staying at the bedside of a dying patient, and the nurse should not insist that they remain there.

The nurse cares for a patient with lung cancer in a home hospice program. Which action by the nurse is most appropriate? a. Discuss cancer risk factors and appropriate lifestyle modifications. b. Encourage the patient to discuss past life events and their meaning. c. Teach the patient about the purpose of chemotherapy and radiation. d. Accomplish a thorough head-to-toe assessment several times a week.

B The role of the hospice nurse includes assisting the patient with the important end-of-life task of finding meaning in the patient's life. Frequent head-to-toe assessments are not needed for hospice patients and may tire the patient unnecessarily. Patients admitted to hospice forego curative treatments such as chemotherapy and radiation for lung cancer. Discussion of cancer risk factors and therapies is not appropriate.

The son of a dying patient tells the nurse, "Mother doesn't really respond any more when I visit. I don't think she knows that I am here." Which response by the nurse is appropriate? a. "You may need to cut back your visits for now to avoid overtiring your mother." b. "Withdrawal may sometimes be a normal response when preparing to leave life." c. "It will be important for you to stimulate your mother as she gets closer to dying." d. "Many patients don't really know what is going on around them at the end of life."

B Withdrawal is a normal psychosocial response to approaching death. Dying patients may maintain the ability to hear while not being able to respond. Stimulation will tire the patient and is not an appropriate response to withdrawal in this circumstance. Visitors are encouraged to be "present" with the patient, talking softly and making physical contact in a way that does not demand a response from the patient.

A hospice patient is manifesting a decrease in all body system functions except for a heart rate of 124 and a respiratory rate of 28. Which statement, if made by the nurse to the patient's family member, is most appropriate? a. "These symptoms will continue to increase until death finally occurs." b. "These symptoms are a normal response before these functions decrease." c. "These symptoms indicate a reflex response to the slowing of other body systems." d. "These symptoms may be associated with an improvement in the patient's condition."

B An increase in heart and respiratory rate may occur before the slowing of these functions in the dying patient. Heart and respiratory rate typically slow as the patient progresses further toward death. In a dying patient, high respiratory and pulse rates do not indicate improvement, and it would be inappropriate for the nurse to indicate this to the family. The changes in pulse and respirations are not reflex responses.

A middle-aged patient tells the nurse, "My mother died 4 months ago, and I just can't seem to get over it. I'm not sure it is normal to still think about her every day." Which nursing diagnosis is most appropriate? a. Hopelessness related to inability to resolve grief b. Complicated grieving related to unresolved issues c. Anxiety related to lack of knowledge about normal grieving d. Chronic sorrow related to ongoing distress about loss of mother

C The patient should be reassured that grieving activities such as frequent thoughts about the deceased are considered normal for months or years after a death. The other nursing diagnoses imply that the patient's grief is unusual or pathologic, which is not the case.

Which patient should the nurse refer for hospice care? a. 60-year-old with lymphoma whose children are unable to discuss issues related to dying b. 72-year-old with chronic severe pain as a result of spinal arthritis and vertebral collapse c. 28-year-old with AIDS-related dementia who needs palliative care and pain management d. 56-year-old with advanced liver failure whose family members can no longer provide care in the home

C Hospice is designed to provide palliative care such as symptom management and pain control for patients at the end of life. Patients who require more care than the family can provide, whose families are unable to discuss important issues related to dying, or who have severe pain are candidates for other nursing services but are not appropriate hospice patients.

The nurse cares for an adolescent patient who is dying. The patient's parents are interested in organ donation and ask the nurse how the decision about brain death is made. Which response by the nurse is most appropriate? a. "Brain death occurs if a person is flaccid and unresponsive." b. "If CPR is ineffective in restoring a heartbeat, the brain cannot function." c. "Brain death has occurred if there is no breathing and certain reflexes are absent." d. "If respiratory efforts cease and no apical pulse is audible, brain death is present."

C The diagnosis of brain death is based on irreversible loss of all brain functions, including brainstem functions that control respirations and brainstem reflexes. The other descriptions describe other clinical manifestations associated with death but are insufficient to declare a patient brain dead.

A patient who has been diagnosed with inoperable lung cancer and has a poor prognosis plans a trip across the country "to settle some issues with sisters and brothers." The nurse recognizes that the patient is manifesting which psychosocial response to death? a. Restlessness b. Yearning and protest c. Anxiety about unfinished business d. Fear of the meaninglessness of one's life

C The patient's statement indicates that there is some unfinished family business that the patient would like to address before dying. Restlessness is frequently a behavior associated with an inability to express emotional or physical distress, but this patient does not express distress and is able to communicate clearly. There is no indication that the patient is protesting the prognosis, or that there is any fear that the patient's life has been meaningless.

1. The nurse cares for a terminally ill patient who has 20-second periods of apnea followed by periods of deep and rapid breathing. Which action by the nurse would be most appropriate? a. Suction the patient. b. Administer oxygen via face mask. c. Place the patient in high Fowler's position. d. Document the respirations as Cheyne-Stokes.

D Cheyne-Stokes respirations are characterized by periods of apnea alternating with deep and rapid breaths. Cheyne-Stokes respirations are expected in the last days of life. There is also no need for supplemental oxygen by face mask or suctioning the patient. Raising the head of the bed slightly and/or turning the patient on the side may promote comfort. There is no need to place the patient in high Fowler's position.

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.

Which of the following 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 palliative patient D.Acceptance of the expected death of the patient E.Adequate time for the caregiver to prepare for the death

a, d, e. 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 caregivers; anticipatory grief.

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 terminal cancer tells the nurse, "I know I am going to die pretty soon, perhaps in the next month." Which of the following 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 patient and nurse.

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 (select all that apply)? 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 form each other have now reunited.

a. family cannot express their feelings to one another c. a family member is going through a difficult divorce

An 80 year old female patient is receiving palliative care for heart failure. Primary purpose (s) of her receiving palliative care is (are) *select all that apply a. improve her quality of life b. assess 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 to give

a. improve her quality of life d. focus on reducing the severity of disease symptoms