Chapter 25: Loss, Death, and Palliative Care

12. While awaiting the imminent death of her sister, an older woman makes arrangements to bury her sister in the survivor's home state because she cannot reach the other family members. Which step should the nurse implement? a. Ask questions, including questions about the location of her sister's family. b. Instruct this woman that this is not her decision to make. c. Try to contact the family to inform them of the decision. d. Question her about holding behaviors that she will want.

ANS: A In a countercoping intervention, the nurse assists the older adult to cope with the loss by collecting information and encouraging her to avoid acting on impulse. The older adult can arrive at a hasty decision when not effectively coping with grief; therefore the nurse acts to help restore some control for the bereaved and helps avoid a decision that might be regretted later. The nurse can ask the older adult if she believes that this is her decision to make but avoids informing her that it is not. The nurse avoids acting without the sister's knowledge; the nurse does not have the right to impose personal feelings on the family or on the patient. At a time when the older adult is acting impulsively, it can be reasonable to have her cool off; however, the woman has made a hasty decision and needs help to resolve that issue. In addition, the nurse can be considered insensitive for asking about this issue before the patient is dead.

2. The health care provider believes an older woman has approximately 6 weeks to live. After 2 months, the family remains at the bedside but, in the last few days, are becoming increasingly impatient and irritable. This pattern is least indicative of which of the following statements? a. Family is experiencing anticipatory grief for the older adult. b. Family desires that the patient be relieved of her misery. c. Anticipatory grieving can fail to attenuate acute grief upon death. d. Grievers deal more easily with known losses at known times.

ANS: B The family is not impatient because they want her death to take place and want her to be relieved of her misery; they are impatient because of the emotional fluctuations of waiting. The remaining three statements are true.

1. Which of the following characteristics are associated with acute grief? (Select all that apply.) a. Preoccupation with the loss of a loved one b. Waves of grief or distressing emotion c. Prolonged inability to sleep after a loss d. Exacerbations of grief on specific dates e. Change in attitude toward the future loss f. Inability to perform simple self-care tasks

ANS: A, B, F In acute grief, the bereaved is preoccupied with the deceased or the loss in a manner similar to daydreaming, combined with a sense of unreality. Specific activities, items, people, or other things can trigger an overwhelming pain in acute grief. The bereaved can be incapacitated by acute grief, making simple tasks such as dressing nearly impossible to complete or taking much longer to complete a task. Chronic grief is characterized by prolonged insomnia and an extended period of inhibited activities and suboptimal performance. Chronic grief is characterized by periods of pain exacerbated on specific dates such as anniversaries, birthdays, and holidays, among others. Anticipatory grief is characterized by a change in attitude toward the individual who is about to die when the death does not occur as planned.

5. Which of the following statements is true about end-of-life care? a. The physician is the ultimate authority in the decision to use or not to use life-sustaining medical treatment. b. The proxy appointed in a living will cannot speak for the testator in health care matters other than terminal illness. c. A patient with dementia cannot be capable of making personal wishes known about life-sustaining treatment. d. The American Nurses Association encourages nurses to participate in assisted suicide.

ANS: B According to the Patient Self-Determination Act, the adult patient has the ultimate authority to accept or forgo treatment. By contrast, the health care advocate designated by a durable power of attorney for health care can speak for the patient in other health care matters. A study showed that up to 30% of patients with dementia understand the issues and can express their preferences. The American Nurses Association calls for nurses not to participate in assisted suicide.

7. The primary difference between the Loss Response Model (LRM) and the Worden model of grief is which of the following? a. In the Worden model, those grieving pass through stages in order. b. The LRM uses a systems approach that acts to uphold stability. c. In the Worden model, the system helps maintain equilibrium. d. In the LRM model, those who are grieving transition through several stages.

ANS: B In the LRM, a systems approach is used to explain grieving wherein the system responds to the loss with chaos at first and then works to restore equilibrium. The Worden model describes grieving as a series of evolving tasks that do not necessarily occur in a distinct order.

13. An older patient who has end-stage pulmonary disease decides to accept care from the palliative care nurse. This older adult will most likely benefit from the palliative care nurse in which patient needs of Weisman's six needs for the dying? a. Closure c. Composure b. Control d. Cohesiveness

ANS: B The dying patient is most likely to benefit from the care of the palliative care nurse by affording the patient as much control as possible, providing effective nursing care for symptom control and by providing continuity of care as the palliative care team directs total patient care. In providing control, the nurse asks the patient to determine activities and how time is spent. Palliative care can indirectly benefit the patient by providing a better quality of life at the end of life, but palliative care does not provide for closure. Nurses use countercoping techniques to help the patient maintain composure. Cohesiveness is not one of the six needs of a patient who is dying.

10. A patient loses her husband because of a sudden myocardial infarction, and she blames herself for not recognizing the warning signs. Which patient outcome associated with her loss should the nurse use to plan care? a. Meets her daily responsibilities b. Expresses feelings of guilt, fear, anger, or sadness c. Assesses the causes of the dysfunctional grieving processes d. Identifies problems connected to anticipatory grief

ANS: B The nurse plans care that will help this patient resolve her grief and will work to accomplish this by determining a suitable patient outcome—the ability of the patient to express feelings of guilt, fear, anger, or sadness within 3 months. Being able to express herself in this manner is part of the work of grief. Expecting the patient to meet her daily responsibilities is a nursing intervention suitable for dysfunctional grieving. Assessing the causes of the dysfunctional grieving processes is a nursing intervention suitable for the grieving patient. Identifying problems connected to anticipatory grief is a patient outcome suitable for anticipatory grief.

6. After the loss and burial of a beloved pet, an older man loses weight because he eats very little. Three months later, he starts to paint pictures of the pet and his appetite slowly improves. Describe this individual's mourning for his pet. a. Weight loss from inadequate intake b. Pet's burial and painting pictures of the pet c. Loss of his appetite resulting in weight loss d. Increased food intake after painting begins

ANS: B This older adult mourns and incorporates into his life the loss of his pet by burying the pet and then by memorializing the pet in pictures he created. Weight loss from inadequate intake: grief is displayed by a decreased appetite that results in weight loss; the older adult's response is not weight loss, it is anorexia. Loss of his appetite resulting in weight loss: grief is displayed by a decreased appetite that results in weight loss. The transition from the loss through the burial to painting the pictures is how this man mourns his pet; the improved appetite is a result of effective coping and mourning.

2. Which of the following indicate a person is effectively coping? (Select all that apply.) a. Avoids avoidance c. Focuses on solutions b. Confronts realities d. Redefines problems

ANS: B, C, D People who cope well confront reality and deal with situations. They focus on the solution and redefine the problem. People who cope well avoid avoidance.

8. When the older woman who is close to death asks the family to leave after short visits and acts withdrawn in their presence, the family becomes distraught. Which of the following does the nurse include in family teaching to explain the patient's behavior? a. She is preoccupied with her own death. b. She must have unresolved family issues. c. She can be experiencing anticipatory grief. d. Her body prepares for death in this manner.

ANS: C Anticipatory grief occurs before the death and can be experienced by the patient or the potential survivors. When the patient who is dying experiences anticipatory grief, the individual detaches from the environment into a state sometimes described as psychological death. The person is no longer involved in day-to-day activities and enacts a premature death. Preoccupation with death is acute grief, but since the death has not occurred, preoccupation cannot describe this patient. The patient might have unresolved issues with the family, but this behavior is an unusual way to express it. The body prepares for death through the deterioration of organ system functioning; for example, the kidneys stop producing urine, the patient stops drinking and eating, and the extremities become cold, among other functions.

14. Which of the following is a true statement about loss, dying, and death for older adults? a. Men and women tend to respond similarly to the loss of a spouse. b. Visions on the part of a person who has lost a spouse are not normal grief reactions and should be regarded as signs of underlying defects. c. The grieving process is not rigidly structured. d. Bereaved persons regain their normal capability approximately 6 months after loss, and regressive behavior after that time should be discouraged.

ANS: C Men and women do not always respond similarly to the loss of a spouse. The grieving process is not rigidly structured and is not always predictable. Visions, hallucinations, and an inability to communicate in a logical, sustained manner on the part of a person who has lost a spouse are not normal grief reactions and should be regarded as signs of underlying defects; all these reactions are common in the first several months of bereavement. A bereaved person ordinarily begins to recover personal control and capabilities after approximately 6 months; at first, recovery is sporadic and interspersed with periods of depression.

9. The son of an older adult couple ends his life suddenly and violently. The husband proceeds with living as usual. After 1 year, the wife remains in seclusion and is hospitalized for dehydration. Which steps should the nurse implement to help improve the wife's mental health and wellness? a. Encourage additional fluids and social activity. b. Instruct the husband to display empathy for her. c. Establish a trusting, caring relationship with her. d. Ask social services for a survivor's support group.

ANS: C This couple is at high risk for chronic grief because of the nature of their son's death. The nurse can help this older woman work toward better mental health by establishing a trusting and caring relationship with her to encourage expressions about her son. Afterward, the nurse can pose probing questions to determine the best plan of care to help this older adult resolve or reframe enough grief to allow improved functioning. Encouraging fluids can be a reasonable nursing intervention for this woman; however, encouraging social activity without a complete assessment and without being in the environment of a trusting relationship is unlikely to help improve functioning. The husband can be displaying disenfranchised grief and be unable to help until his grief is managed. A survivor's support group can be helpful to survivors of a loved one's suicide; however, expecting this older adult to attend such a group is unrealistic until the nurse establishes a trusting relationship with her.

3. After the older adult dies, the brother who has a history of alcohol abuse upsets the family by going on a drinking binge instead of attending the funeral. Which of the following is the best description of the brother's behavior? a. Personality disorder c. Disenfranchised grief b. Disrespectful attitude d. Chronic grief

ANS: C When a family is in discord, a grieving member can be unable to or consider him or herself permitted to express grief by socially acceptable means. The brother's behavior is most likely a grief reaction, although it could be indicative of a personality disorder. The brother can feel that the most respectful thing he can do for the family members is to stay out of their way. The brother has suffered an acute loss.

3. Those who cope less effectively may exhibit which of the following? (Select all that apply.) a. Avoids avoidance c. Is demanding b. Confronts reality d. Is rigid

ANS: C, D Those who cope less effectively have few if any of these abilities listed by Weisman. They tend to be more rigid and pessimistic, are demanding, and are given to emotional extremes. Those who cope well avoid avoidance and confront reality.

11. The actions of the family members of an older adult who just died are chaotic, and they are unable to decide on a funeral home. Which recommendation should the nurse implement? a. Help them make a list of the problems. b. Provide a list of preferred funeral homes. c. Allow them privacy to work it out alone. d. Suggest they call someone who can help.

ANS: D A characteristic of a good coper is one who has good communication with others; however, immediately after the older adult's death, this family is ineffectively coping with the loss. To facilitate the family with decision making, the nurse asks one family member to consider calling another person who will likely help the family face the reality of the death. After making the suggestion, the nurse ensures that the family has enough time for holding behaviors, to prepare the body if they wish, and to express their grief in privacy and in their own way. Effective coping includes a focus on the solutions rather than on the problems. The nurse avoids recommending funeral homes, which could be a potential conflict of interest. The family can be unable to solve the problem alone because of ineffective coping in the immediate mourning period.

4. Which of the following interventions is recommended for an older adult in the final stages of dying? a. Apply an electric blanket to keep the patient warm. b. Lower the head of the bed, and turn the head to the side. c. Decrease the number of visitors. d. Support the preservation of energy.

ANS: D Conserving energy should be a focus in the care of a patient in the final stage of dying. Completing only the necessary activities of daily living (ADLs) would be an example. An electric blanket should not be used; it can increase the patient's distress by overheating. Elevating the head of the bed and turning the patient's head to the side is a recommended intervention to help clear uncomfortable respiratory congestion. Nurses should not withhold visitors; the patient needs to have closure, as well as the family.

1. Which of the following statements is true about loss in older adulthood? a. A person experiences each stage of grief once, and then grieving is resolved. b. Antianxiety agents are frequently recommended for reducing the pain of grief. c. The loss response model is concerned with the effect of loss on an individual. d. Referring to the deceased in the past tense can acknowledge the death's reality.

ANS: D The widow may say, for example, that her husband "just loved to garden" rather than "just loves to garden." Although the bereaved person passes through the stages according to the Bowlby model, the person may experience the cycle more than once as different aspects of the loss are encountered. Such medications do not reduce the pain of grief; they only deaden it for a time. The loss response model considers the effect of the loss on the family as a system.