Chapter 16: End-of-Life Care
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? A.) Lack of fully credentialed and trained hospice nurses B.) Clients and families view hospice care as giving up C.) Lack of Medicare/Medicaid funding for hospice D.) Difficulty obtaining Medicare certification for hospice services
Answer: B.) Clients and families view hospice care as giving up Rationale: Clients often equate hospice with giving up and are reluctant to accept hospice care. Lack of fully credentialed and trained hospice nurses is not a barrier to hospice care. Lack of Medicare funding and lack of certification for hospice service providers have not been documented as barriers to access of hospice services.
According to Kübler-Ross, when a dying client pleas for more time to reach an important goal, the client is in which state of grief? A.) Anger B.) Bargaining C.) Denial D.) Acceptance
Answer: B.) Bargaining Rationale: Bargaining occurs when a client and/or family pleads for more time to reach an important goal. Anger includes feelings of rage or resentment. Denial includes feelings of isolation. Acceptance occurs when the client and/or family are neither angry nor depressed.
A patient's family member asks the nurse what the purpose of hospice is. What is the best response by the nurse? A.) "It will hasten the death of the patient." B.) "It will prolong life in a dignified manner." C.) "It will use artificial means of life support if the patient requests it." D.) "It will enable the patient to remain home if that is what is desired."
Answer: D.) "It will enable the patient to remain home if that is what is desired." Rationale: The goal of hospice is to enable the patient to remain at home, surrounded by the people and objects that have been important to him or her throughout life. The patient and family make up the unit of care. Hospice care does not seek to hasten death or encourage the prolongation of life through artificial means.
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? A.) "I can't do that, I will go to jail." B.) "I am surprised that you would ask me to do something like that." C.) "I will see if the physician will order enough for that to occur." D.) "I will notify the physician that the current dose of medication is not relieving your pain."
Answer: D.) "I will notify the physician that the current dose of medication is not relieving your pain."
The nurse is caring for a client who just learned of his 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? A.) The principle of justice B.) The principle of nonmaleficence C.) The principle of fidelity D.) The principle of autonomy
Answer: D.) The principle of autonomy Rationale: By promoting open discussion and informed decision making, the nurse is empowering the client to make his own decisions leading to autonomy. The principle of justice requires fairness and justice to all clients. The principle of nonmaleficence requires that nurse does not intentionally or unintentionally inflict harm on others. The principle of fidelity maintains that nurses are faithful to the care of the clients.
Which of the following is the nurse's primary concern when providing end-of-life care for a client and the family? Select all that apply. - Maintaining client comfort - Arranging plans for after death - Supporting family members - Providing personal care - Completing a head-to-toe assessment - Encouraging fluids
Answer: - Maintaining client comfort - Supporting family members - Providing personal care Rationale: Nursing care of dying clients focuses on providing palliative care to the client and supporting family members. Arranging the plans after death is not a priority at this time. Completing a head-to-toe assessment may be completed for information but is not a priority at the end of life. There is no need to encourage fluids.
A patient near the end of life is experiencing anorexia-cachexia syndrome. What characteristics of the syndrome does the nurse recognize? (Select all that apply.) - Alterations in carbohydrate, fat, and protein metabolism - Endocrine dysfunction - Anemia - Neurologic dysfunction - Bladder incontinence
Answer: - Alterations in carbohydrate, fat, and protein metabolism - Endocrine dysfunction - Anemia Rationale: Anorexia and cachexia are common in the seriously ill. The profound changes in the patient's appearance and a lack of interest in the socially important rituals of mealtime are particularly disturbing to families. The approach to the problem varies depending on the patient's stage of illness, level of disability associated with the illness, and desires. The anorexia- cachexia syndrome is characterized by disturbances in carbohydrate, protein, and fat metabolism; endocrine dysfunction; and anemia. The syndrome results in severe asthenia (loss of energy).
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? A.) "You will be able to stay only for approximately 1 month and then you will be discharged." B.) "You will be able to stay for 2 months before being discharged." C.) "There is no time limit for your stay. You can stay until you die." D.) "When your stay reaches 6 months, you will be recertified for a continued stay."
Answer: D.) "When your stay reaches 6 months, you will be recertified for a continued stay." Rationale: Federal rules for hospices require that eligibility be reviewed periodically. Patients who live longer than 6 months under hospice care are not discharged, provided that their physician and the hospice medical director continue to certify that they are terminally ill with a life expectancy of 6 months or less (assuming that the disease continues its expected course).
Which term refers to the period of time during which mourning of a loss takes place? A.) Grief B.) Mourning C.) Hospice D.) Bereavement
Answer: D.) Bereavement Rationale: Bereavement is the period of time during which mourning of a loss takes place. Grief is defined as the personal feelings that accompany an anticipated or actual loss. Mourning is defined as the individual, family, group, and cultural expressions of grief and associated behaviors. Hospice is a coordinated program of interdisciplinary care and services provided primarily in the home to terminally ill clients and their families.
Which "awareness context" is characterized by the client, family, and health care professionals understanding that the client is dying, but all pretend otherwise? A.) Mutual pretense awareness B.) Closed awareness C.) Suspected awareness D.) Open awareness
Answer: A.) Mutual pretense awareness Rationale: In mutual pretense awareness, the client, the family, and the health care professionals are aware that the client is dying, but all pretend otherwise. In closed awareness, the client is unaware of his or her terminal state, whereas others are aware. In suspected awareness, the client suspects what others know and attempts to find it out. In open awareness, all are aware that the client is dying and are able to openly acknowledge that reality.
A nurse is providing hospice care in Portland, Oregon to a client with terminal liver cancer. The client confides to the nurse, "I'm in agony all the time. I want this to be over now—please help me." Which interventions should the nurse implement? Select all that apply. - Control the client's pain with prescribed medication. - Advise the client's health care provider of the client's condition. - Comfort the client by saying it will all be over soon. - Encourage the client to explain his or her wishes. - Recommend that the client consider physician-assisted suicide.
Answer: - Control the client's pain with prescribed medication. - Advise the client's health care provider of the client's condition. - Encourage the client to explain his or her wishes. Rationale: This client lives in Oregon, one of five states that have decriminalized physician-assisted suicide, the practice of providing a means by which a client can end his or her own life. This practice is controversial, with proponents arguing the client has a right to self-determination and a relief from suffering when there is no other means of palliation. Opponents, on the other hand, find it contrary to the Hippocratic Oath. In this scenario, the nurse should determine exactly what the client is asking and then support his or her wishes. It is not the nurse's role to suggest physician-assisted suicide voluntarily, however.
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? A.) "Let's take this one day at a time; remember you have your daughter's dance recital next week." B.) "You should seek a second medical opinion about your diagnosis." C.) "I believe that you will fight hard to beat this and see your babies grow up." D.) "I know another client with the same diagnosis who has been in remission for 10 years."
Answer: A.) "Let's take this one day at a time; remember you have your daughter's dance recital next week." Rationale: Helping a client to find reasons to live and look forward to events promotes positive attitudes and ability to live for the moment, which in turn communicates a spirit of hopefulness. The statement about a second opinion is inappropriate because it gives the client false hope that her current diagnosis is inaccurate. Although he client may choose another medical opinion, she needs to come to that decision without the nurse's advice. Reponses should not convey false hope to the client. Nurses and clients should not confuse hope with unrealistic optimism.
All nurses care for clients who are grieving. It is important for the nurse to understand the grieving process for which reason? A.) Allows for the nurse to facilitate the grieving process B.) Allows for the nurse to take the client through in the appropriate order C.) Allows for the nurse to understand when the grieving process should be concluded D.) Allows the nurse to express his or her feelings
Answer: A.) Allows for the nurse to facilitate the grieving process Rationale: Grieving is a painful yet normal reaction that helps clients cope with loss and leads to emotional healing. The nurse is responsible for facilitating the grieving process and helping the client and family deal with their emotions.
Immediately on cessation of vital functions, the body begins to change. The nurse would expect which physical change to occur following death? A.) Dusky appearance B.) Increased body temperature C.) Flushed appearance D.) Absence of incontinence
Answer: A.) Dusky appearance Rationale: The body becomes dusky or bluish, waxen-appearing, and cool; blood darkens and pools in dependent areas of the body, and urine and stool may be evacuated.
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? A.) Encourage the family members to express their feelings and listen to them in their frank communication B.) Encourage conversations about the impending death of the client C.) Be a silent observer and allow the client to communicate with the family members D.) Encourage the client's family members to spend time with the client
Answer: A.) Encourage the family members to express their feelings and listen to them in their frank communication Rationale: Family members usually find it difficult to communicate frankly with a dying person. When a nurse encourages family members to express their feelings and listens to them as they frankly communicate, family members may feel more prepared to carry on a similarly honest dialogue with the dying client. It is not advisable for the nurse to encourage conversations about the impending death of the client. Being a silent observer or encouraging the family members to spend time with the dying client may not help the family members express their feelings.
A client states, "My children still need me. Why did I get cancer? I am only 30." This client is exhibiting which stage according to Kübler-Ross? A.) Denial B.) Anger C.) Bargaining D.) Acceptance
Answer: B.) Anger Rationale: Anger is the second stage and is exhibited by statement similar to "Why me?" Denial occurs when the person refuses to believe certain information. Bargaining is an attempt to postpone death. During the acceptance stage, the dying clients accept their fate and make peace spiritually and with those to whom they are close.
A 50-year-old client is an alcoholic. The client has been diagnosed with pancreatic cancer and underwent surgery to remove the tumor. Despite the tumor being removed, the physician informs the client that chemotherapy needs to be started immediately. Using evidence-based practice, which intervention might the nurse expect the physician to include, with the goal of improving quality of life, mood, and median survival. A.) Palliative care B.) Radiation C.) Angiogenesis D.) Respite care
Answer: A.) Palliative care Rationale: In a study of referral to palliative care for clients newly diagnosed with a disease with very poor prognosis, researchers found that those clients receiving palliative care plus standard oncology demonstrated improved quality of life and mood and had longer median survival. Radiation is primarily used when a cancer spreads to other organs, and it has not been proven to affect mood. Angiogenesis is the growth of new capillaries from the tissue of origin. This process helps malignant cells obtain needed nutrients and oxygen to promote growth. Respite care is provided on an occasional basis to relieve the family caregivers.
A group of nursing students is reviewing information about palliative care. The students demonstrate a need for additional review when they identify which of the following? A.) Palliative care is the same as hospice care. B.) Palliative care developed after hospice care developed. C.) Palliative care is conceptually broader than hospice care. D.) Palliative care is often provided along with disease-lessening treatments.
Answer: A.) Palliative care is the same as hospice care. Rationale: Palliative care is not synonymous with hospice care. All hospice care is palliative but not all palliative care is hospice care. Palliative care is conceptually broader than hospice care and is an approach to care as well as a structured system for delivering care. Palliative care followed the development of hospice care. It does not begin when cure-focused treatment ends but is most helpful when provided along with disease-remitting treatment.
A nurse is caring for a client with a terminal illness. The client asks the nurse to help him end his own life to alleviate his suffering and that of his family. When responding to the client, the nurse integrates knowledge of which of the following? A.) Participating in assisted suicide violates the Code of Ethics for Nurses. B.) Nurses may administer medications prescribed by physicians to hasten end of life. C.) A client has the right to make independent decisions about the timing of his or her death. D.) Most states have enacted laws that allow for physician-assisted suicide.
Answer: A.) Participating in assisted suicide violates the Code of Ethics for Nurses. Rationale: The American Nurses Association Position Statement on Assisted Suicide acknowledges the complexity of the assisted suicide debate but clearly states that nursing participation in assisted suicide is a violation of the Code for Nurses. Legally, nurses are not allowed to administer medications even if prescribed by a physician if that medication will hasten the client's end of life. Proponents of physician-assisted suicide argue that terminally ill people should have a legally sanctioned right to make independent decisions about the value of their lives and the timing and circumstances of their deaths. However, this is not the case at the present time. Two states have enacted legislation for physician-assisted suicide. These laws provide access to physician-assisted suicide by terminally ill clients under very controlled circumstances.
The spouse of a terminally ill client is confused by the new terminology being used during discussions regarding the client's treatment. The nurse should explain that palliative care is: A.) care that will reduce the client's physical discomfort and manage clinical symptoms. B.) care that is provided at the very end of an illness to ease the dying process. C.) an alternative therapy that uses massage and progressive relaxation for pain relief. D.) offered to terminally ill clients who wish to remain in their homes in lieu of hospice care.
Answer: A.) care that will reduce the client's physical discomfort and manage clinical symptoms. Rationale: Palliative care is used in conjunction with other end-of-life treatments and has many principles. Its aim is to reduce physical discomfort and other distressing symptoms but does not alter a disease's progression. Palliative care is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life. Palliative care of a terminally ill client not only provides relief from pain and other distressing symptoms but it integrates other facets of patient care as well, including psychological and spiritual aspects. Palliative care is part of hospice care.
While providing care to a terminally ill client, the client asks, "Am I dying?" Which response by the nurse would be most appropriate? A.) "What makes you think that you might be dying?" B.) "Tell me some more about what is on your mind." C.) "You're just having a bit of a set-back. You'll be fine." D.) "What has your physician told you about your condition?"
Answer: B.) "Tell me some more about what is on your mind." Rationale: When responding to the client, the nurse needs to acknowledge the client's fears. Having the client tell the nurse what's on his or her mind acknowledges the client's feelings and opens the way for more discussion. Asking the client about what makes him or her think he or she is dying is probing and does not address the client's feelings or needs. Telling the client that he or she will be fine gives the client false reassurance and does not address his or her fears. Asking about what the physician has told the client redirects the conversation away from the client's feelings and is inappropriate.
The family of a terminally ill client tells the nurse that the client has been breathing irregularly and, at times, it appears that he is not breathing at all. The client's daughter states, "He moans when he breathes. Is he in pain?" Which response by the nurse would be most appropriate? A.) "His moaning does indicate pain, so we'll increase his pain medication." B.) "The moaning you hear is from air moving over very relaxed vocal cords." C.) "He has secretions that are collecting at the back of the throat." D.) "He is getting less oxygen to the brain, so the moaning means he is dreaming."
Answer: B.) "The moaning you hear is from air moving over very relaxed vocal cords." Rationale: As a client approaches death, certain signs appear. The family is reporting irregular breathing with periods of apnea. The moaning that they hear reflects the sound of air passing over very relaxed vocal cords. It does not signify pain or distress. Therefore, no additional pain medication would be needed. Secretions collecting at the back of the throat are noted by a rattling or gurgling sound. Decreased oxygen to the brain would lead to confusion, which may be reported by the client as strange dreams or visions.
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? A.) Physician's orders B.) Client's goals C.) Length of required treatment D.) Invasiveness of the treatment
Answer: B.) Client's goals Rationale: When managing the symptoms of a client with a terminal illness, the client's goals take precedence over the clinician's goals to relieve all symptoms at all costs. Although the length and invasiveness of the treatment may influence decision making, ultimately it is the client's goals that determine what will be done.
Which term is used to describe the personal feelings that accompany an anticipated or actual loss? A.) Bereavement B.) Grief C.) Mourning D.) Spirituality
Answer: B.) Grief Rationale; Grief is defined as the personal feelings that accompany an anticipated or actual loss. Bereavement is a period during which mourning for a loss take place. Mourning is an expression of grief and associated behaviors. Spirituality is a personal belief system that focuses on a search for meaning and purpose of life.
When describing the term "grief" to a group of students, which of the following would the instructor include? A.) A part of the life cycle in the form of change, growth, and transition B.) The response experienced by anyone who has suffered a loss C.) A feeling of connectedness with one's self and others D.) Feelings of apprehension or worry in response to a situation
Answer: B.) The response experienced by anyone who has suffered a loss Rationale: Grief refers to the universal response to any loss. It is experienced by anyone suffering any type of loss. Loss is part of the life cycle and occurs in the form of change, growth, and transition. Spirituality refers to the feeling of connectedness with self, others, a life force, or God that allows people to find meaning in life. Anxiety refers to feelings of apprehension or worry in response to or about a situation.
A type of comprehensive care for clients whose disease is not responsive to cure is A.) a terminal illness. B.) palliative care. C.) euthanasia. D.) interdisciplinary collaboration.
Answer: B.) palliative care. Rationale: Palliative care is a type of comprehensive care for clients whose disease is not responsive to cure. Terminal illness is a progressive, irreversible illness that despite cure-focused medical treatment will result in the client's death. Euthanasia means the intentional killing by act or omission of a dependent human being for his or her alleged benefit. Interdisciplinary collaboration is communication and cooperation among members of diverse health care disciplines jointly to plan, implement, and evaluate care.
The nurse is caring for a pediatric client who is dying. The best way to provide care and comfort to dying clients and their families is to first do which of the following? A.) A workshop on caring for the dying client B.) Use evidence-based practice in daily care regimen. C.) Explore own feelings on mortality and death and dying. D.) Participate in a support group to learn clients' feeling on care.
Answer: C.) Explore own feelings on mortality and death and dying. Rationale: To care for others in the dying process, the nurse must explore his or her own feelings about mortality and death and dying. Understanding self provides a perspective to cope with and then support clients and families experiencing pain and grief. The other options are helpful in determining appropriate nursing care but not the first step.
For individuals known to be dying by virtue of age and/or diagnosis, which sign indicates approaching death? A.) Increased wakefulness B.) Increased eating C.) Increased restlessness D.) Increased urinary output
Answer: C.) Increased restlessness Rationale: As the oxygen supply to the brain decreases, the client may become restless. As the body weakens, the client will sleep more and begin to detach from the environment. For many clients, refusal of food is an indication that they are ready to die. Based on decreased intake, urinary output generally decreases in amount and frequency.
A client with a brain tumor recently stopped radiation and chemotherapy for treatment of the cancer. The client recently reported dry mouth. Which intervention by the hospice nurse demonstrates that the nurse understands treatment measures for dry mouth? A.) Begin 9% normal saline IV at 125 mL/hr. B.) Place two drops of atropine ophthalmic 1% solution sublingually. C.) Provide gentle oral care after each meal. D.) Gently suction the client's mouth and buccal cavity.
Answer: C.) Provide gentle oral care after each meal. Rationale: Dry mouth can generally be managed through nursing measures such as mouth care. The use of artificial hydration (IV fluids) carries considerable risks and does not contribute to comfort at the end of life. Atropine ophthalmic 1% drops administered sublingually help to reduce oral secretions. Gentle oral suctioning reduces the production of secretions.
A client is declared to have a terminal illness. What intervention will a nurse perform related to the final decision of a dying client? A.) Share emotional pain. B.) Abide by the dying client's wishes. C.) Respect the client's and family members' choices. D.) Ask the family members about spiritual care.
Answer: C.) Respect the client's and family members' choices. Rationale: In the final decisions of a dying client, the nurse will present options for terminal care and respect the client's and family members' choices. Sharing emotional pain is a role in providing care and comfort to dying clients and their families. When the client has a living will, physicians must abide by the client's wishes. The nurse should ask the family members about spiritual care only if the client wants someone associated with his or her religion.
As the moment of death approaches, which of the following does the nurse encourage the family to do? A.) Have the family sit in front of the client so they can be seen. B.) Rub the client's hand and arm to comfort the client. C.) Speak to the client in a calm and soothing voice. D.) Lie next to the client and hold the client.
Answer: C.) Speak to the client in a calm and soothing voice. Rationale: Sight and touch diminish as the client approaches death; however, hearing tends to remain intact. Speaking to the client calmly is most appropriate.
Which of the following does not coincide with Kübler-Ross's stages related to a dying client? A.) Clients don't always follow the stages in order. B.) Some client regress, then move forward again. C.) The dying client usually exhibits anger first. D.) The client may be in several stages at once.
Answer: C.) The dying client usually exhibits anger first. Rationale: The dying client does not usually exhibit anger first. The client may be in several stages at once, clients don't always follow the stages in order, and some regress and then move forward.
A nurse is evaluating a client with a terminal illness. What should the nurse report so that the health care team can consider alternative nutritional approaches and fluid administration routes for the client at the end of life? A.) altered gastrointestinal function B.) drop in blood pressure and rapid heart rate C.) weight loss and inadequate food intake D.) irregular eating habits
Answer: C.) weight loss and inadequate food intake Rationale: The nurse should report weight loss and inadequate food intake so that the team can consider adding appetite stimulants and the nutritionist can alter the meal plan to give more satisfying meals as a comfort measure. The nurse knows that changes of gastrointestinal function such as irregular eating or bowel changes occur as part of the dying process and are not relevant to the desired intervention. Deteriorating vital signs are part of the dying process so that these signs are not relevant to the desired intervention.
Which statements made by the nurse demonstrates that the nurse is providing spiritually sensitive care? A.) "A key component of hospice care is following your family for up to a year after your death." B.) "Denial, sadness, anger, fear, and anxiety are normal grief reactions." C.) "Mourning may be demonstrated by emotional feelings of sadness, anger, guilt, and numbness." D.) "Tell me who or what gives you strength."
Answer: D.) "Tell me who or what gives you strength." Rationale: Spirituality is a personal belief system that focuses on a search for meaning and purpose of life. Assessment of people or things that provide strength to a terminally ill client is one way the nurse provides spiritually sensitive patient care. Grief is defined as the personal feelings that accompany an anticipated or actual loss. Bereavement is a period during which mourning for a loss take place. Mourning is an expression of grief and associated behaviors.
A nurse is conducting a spiritual assessment of a terminally ill client using the four step FICA process and asks the question, "What gives your life meaning?" The nurse is assessing which of the following? A.) Importance and influence B.) Community C.) Address in care D.) Faith and belief
Answer: D.) Faith and belief RationalE: The question about what gives life meaning provides information about the client's faith and belief. Importance and influence are addressed by questions focusing on the role faith plays in the client's life and how his or her beliefs affect the way the client cares for self and illness. Community is addressed by questions focusing on the client's participation in a spiritual or religious community and the support obtained from it. Address in care focuses on how the nurse would integrate the issues involving spirituality in the client's care.