endoflife curriculum

You are caring for the following four patients. Which patient is at the highest risk for developing constipation?

A 48-year-old with metastatic cancer of the breast on high doses of opioids for pain.

Which of the following patients are you MOST concerned may have undiagnosed depression?

A 71-year-old grandmother with pancreatic cancer who reports trouble sleeping, fatigue, and does not care to see her grandchildren on the weekends anymore.

John's lung cancer is causing him severe shortness of breath. Which pharmacologic intervention would be of MOST benefit for symptom management of his dyspnea?

An opioid like morphine sulfate

During your assessment, you notice Robert, who has a diagnosis of dementia, rubbing his right shoulder. What should you do next?

Ask Robert if he is in pain.

You are caring for a 76-year-old patient who is unresponsive and close to end of life from a massive stroke. The patient has a history of breast cancer and had been experiencing severe bone pain in her left hip prior to her stroke. How do you assess her pain now that she is unresponsive?

Assume she continues to have pain and assess for evidence of wincing or facial grimacing.

Which of the following is an important way nurses can improve palliative care access for those who should receive it?

Being knowledgeable of the benefits of palliative and hospice care

John tells you that he does not want his wife to know that he has cancer. You sit down to talk about this with him. How can you BEST begin this conversation with John?

Can you tell me what it is about your wife knowing about the cancer that is bothering you?

Which of the following statements about dyspnea in patients at end of life is correct?

Dyspnea may be relieved by a cool fan blowing on the patient.

Which of the following demonstrates the impact serious illness has on the social domain of quality of life?

Financial burdens resulting from the high costs of medical care

You are caring for a veteran who served in World War II and is now near the end of life. He has shared with you how important his service in the Navy was to him. Which of the following interventions would be MOST appropriate for you to do to honor his military service?

Find out if he would like you to see if the local veterans group could visit him.

Which of the following statements reflects the importance of learning about palliative care as a student or new nurse?

Future employers expect you to have education and training in palliative care services.

Mr. X has end-stage liver cancer, multiple organ failure, and probably has about 6 weeks to live. He wants to be home and comfortable. Which intervention would be most appropriate to offer him?

Hospice services

You are assessing Mrs. Smith's husband's well-being during her recent hospitalization. Mr. Smith has had trouble with heart failure this past year. He tells you that all that matters to him is his wife. He states he does not have time to go to the doctor or get his own prescriptions filled. What is your BEST response?

I am concerned about you too. Keep in mind you can't take care of Mrs. Smith if you get sick; you need to get your prescriptions filled.

Roland was just told that his therapy for advanced prostate cancer is not working. He asks you why this is happening to him. What is the most appropriate response?

I don't know. I wish you did not have to go through this.

You are caring for a 12-year-old child who is imminently dying from leukemia. The child has been unconscious for days. The child's mother tells you that she hopes that her daughter will open her eyes one last time before dying. Knowing that this is unlikely, what is your BEST response?

If that is not possible, what else might you hope for?

Mr. G has just been told he has a serious illness. Which of the following statements by the healthcare team reflects respectful communication with him about his treatment and illness?

It is important that we understand what your hopes are for the treatment of this illness.

You are caring for an older adult who is dying from Parkinson's disease. Her husband died years ago and all of her friends are also now deceased. She has no children or living family members. You are sitting with her and she tells you how lonely she feels. What is your BEST response?

It must feel so lonely with your family and friends no longer with you..

Which of the following BEST describes palliative care's philosophy and delivery?

It supports the patient and family's hope for quality of life and dignity.

You are caring for Ms. P, a 55-year-old woman with cancer. She received pain medication less than two hours ago. A nursing assistant reports that Mrs. P is complaining of pain again. The nursing assistant tells you that Ms. P. cannot be hurting as much as she says she is. What is your most appropriate response?

Pain is whatever the patient says it is. Let's assess her further.

You are developing a plan of care for a patient with cancer-related pain who is taking sustained-release morphine sulfate 30 mg twice a day, along with 15 mg of immediate release morphine sulfate every three hours as needed for breakthrough pain. Which goal is important to include in the patient's plan of care?

Patient will have a bowel movement at least once every three days.

Which disease and dying trajectory best represents the course for a person with Alzheimer's disease?

Progressive deterioration

You are caring for a 55-year-old female patient with metastatic breast cancer. During a home visit, you find the patient's 22-year-old daughter weeping at the kitchen table. The daughter explains that she just realized that her mother will not be alive when she gets married or has children of her own. Recognizing anticipatory grief in the young woman, what is the BEST intervention to complete FIRST?

Provide active listening and therapeutic presence.

Mr. Jones is taking two oxycodone/acetaminophen 5/325 mg tablets every four hours for bone pain related to metastatic cancer. His pain is a constant 6 on a 0 to 10 scale. Since the current regimen is not meeting his goals, and is keeping him from moving, you decide to call his physician. The doctor suggests increasing the medication to two tablets every three hours around-the-clock. What would your action be?

Question the safety of the total daily dose of acetaminophen that Mr. Jones would be taking.

Your unit has experienced many deaths in the past month and the staff is feeling very sad. What might you suggest to address this issue?

Recommend starting a reflection ritual to honor patients who die on the unit.

An 85-year-old patient with end-stage heart disease arrives unconscious at the emergency department after sustaining her third myocardial infarction. The physician has told the daughter that without resuscitation, her mother could die today. You find the daughter crying at the bedside. Which intervention is most appropriate in communicating with this family member?

Remain present with the daughter, using silence to impart comfort.

Mr. Rodriquez tells you that he is very frightened by not knowing what happens after death. Which domain of quality of life is being affected by his serious illness?

Spiritual

You and your colleagues in ICU have been talking about how hard it is to readmit patients who have stated that they do not want aggressive treatments. Today, you find one of your colleagues crying in the bathroom. They state that they just admitted another patient to ICU who told them last week, at discharge, they never wanted to come back to ICU. What is your BEST response?

Suggest you both talk with the ICU manager about the unit needing the chaplain or psychiatric nurse liaison for emotional support.

Mr. Lopez is the partner of the 50-year-old woman you have been caring for who has just died following a long struggle with breast cancer. He is crying at the bedside and lying across the patient. What is your BEST initial response?

Support his privacy but offer to stay in the room if he would like you to

Jane, a 72-year-old woman with end-stage renal disease, tells you she does not want to continue

That is a very important statement, can you tell me more about that?

A 92-year-old patient dying of end stage heart failure tells you that she is worried that her life had no meaning. What member of the palliative care team would you want to be sure is involved in her care?

The chaplain

Which of the following family members is at greatest risk for complicated grief?

The daughter who has a long history of substance use and has just recently returned home to be at her dying mother's bedside.

You are caring for a 65-year-old male patient who has just died. In planning for follow-up bereavement care, which person is at risk for disenfranchised grief?

The ex-wife of the patient who lives nearby

Where is the majority of hospice care delivered?

The home

Which of the following is the MAIN reason symptom management in older adults with serious illness is complicated?

They have multiple comorbidities.

A patient tells you they have decided to stop chemotherapy, but their physician wants to continue it. Which of the following is the MOST appropriate response in a conflict between you and the physician regarding continuing the chemotherapy?

This decision is the patient's decision - it is not ours to make.

You are teaching a patient how to take her new prescription for morphine, an opioid pain medication. Which of the following teaching statements reflects an understanding of potential adverse effects?

This medication causes constipation, so you need to take a laxative to prevent that.

You are doing a spiritual assessment on Mrs. H. Which of the following questions is the MOST important for understanding her spirituality?

What gives your life meaning?

You are performing a pain assessment on Matilda. Your assessment reveals that Matilda has pain rated as a 5 in her left hip that worsens with movement. She has been having this pain off and on for the last three years. Which of the following pain assessment components have you not addressed in your assessment?

Alleviating factors

Yolanda has osteoarthritis of the left knee for which she is receiving acetaminophen 1000mg every six hours. She rates her pain at a 4 every time you ask. What do you think an appropriate next step would be at this time?

Ask Yolanda what an acceptable pain score is for her.

Your patient, Mr. W, has been unresponsive for the past day and is actively dying. His family is with him. He had appeared comfortable but has been showing some signs of restlessness and agitation over the past hour. What should you do FIRST?

Assess for evidence of pain, constipation, urinary retention, or other possible physical cause.

Mr. Johnson tells you that taking one tablet of his opioid medication was no longer controlling his pain so he increased it to two tablets. He states that taking two tablets provides much better pain relief than one tablet did. You are aware he has a past history of substance use disorder. What should be your next action?

Discuss this issue with the provider and the team for next steps.

Ms. H is very ill and her family has been told she will probably die during this hospital admission. You are walking by the waiting room and you see her family members seated together, crying. What is your BEST response?

Go into the waiting room, sit next to them, and allow them the opportunity to talk if they want to.

You are talking with the staff on your unit about the emotional challenges of working with dying patients and their families. Which of the following is an appropriate response to the grief the staff has been experiencing recently?

Consult with the hospital chaplain or spiritual care counselor for staff support.

Mrs. Smith has suffered with terrible bone pain from metastatic breast cancer during the past three admissions to your unit. She is now nearing end of life. Her family requests that you not give her any pain medications because they are afraid it will hasten her death. What should you do?

Educate the family about the importance of keeping her comfortable and that the pain medication will not hasten her death.

You are upset with the healthcare provider who wants the patient you are caring for to continue chemotherapy when that is not what the patient wants to do. Which of the following actions would help you BEST handle this conflict?

Help the healthcare professional understand that the most important outcome is honoring the patient's wishes.

Mr. J is in the final hours of life. He is dying from his end-stage chronic lung disease. His breathing pattern has changed and is very irregular and he is even going 10-15 seconds without a breath. The family asks you to please call respiratory therapy to see what they can do to help his breathing. What is your BEST response?

His breathing pattern is difficult to watch, but the irregularity is a normal part of the dying process.

During your pain assessment, Randall describes his pain as a burning pain in his lower extremities. What type of pain does this describe?

Neuropathic pain

You are caring for a patient who is in the advanced stages of AIDS. The patient is reporting severe fatigue. Which finding is commonly associated with the symptom of fatigue?

Sedating medications

You have been assigned to care for a woman who was recently admitted for advanced cancer, and who reports ongoing fatigue. Her husband offers observations about his wife's fatigue. Which statement by the husband indicates the most correct understanding of his wife's fatigue?

She's been in pain. If we control that maybe she'll have more energy.

Mr. F has advanced prostate cancer with bone metastasis and is unresponsive. His daughter is caring for him at home. You are teaching the daughter about assessing her father's pain. Which statement by the daughter indicates an understanding of her father's pain status?

Since he was in pain when he was responsive, I assume he's still in pain.

You are speaking with the family of a patient recently diagnosed with end-stage heart failure. How can you best demonstrate attentive listening?

Stay silent and when it is your turn to talk, repeat back a 2-3 word phrase.

Mr. Lopez's partner just died and he has been unable to leave her side. He is grieving and tells you he will never be able to get over losing the love of his life. What is your BEST response?

You must have loved her very much; this has to be so hard for you.

You are working with Mr. T who has just been told his heart failure is getting worse. You go into his room to see how he is doing after the team has shared this information with him. He is staring out the window, looking sad. How should you start your conversation to begin to understand his needs?

I saw that the team was just here, can you tell me about their conversation with you?

You are caring for Ms. F who is dying from lung cancer. She is no longer taking in food or fluids and the family asks you why the team does not feed her with a tube. They state that the team is trying to starve her to death. What is your BEST response?

Ms. F's body can no longer handle food or fluids; it would cause her more harm than good to feed her with a tube.

John is a 70-year-old male whose wife died from COPD two months ago. They were very close, married for 52 years, and had no children. He comes by the nursing unit to bring you all candy and a thank you note. He tells you he is struggling with eating since his wife was always the cook and he is just not ready to go out to dinner with his buddies, even though they keep asking him. What is John experiencing?

Normal grief after his wife died two months ago

Mrs. Smith is suffering with severe bone pain from metastatic cancer. Which domain of quality of life is this affecting?

Physical

The family of a patient who is imminently dying asks you why the nurses always come in and look under the sheets at his legs when they are checking his blood pressure. Which of the following is your BEST explanation?

They are checking for signs of decreased blood circulation.

You are teaching the son of a 65-year-old male patient with cancer about his father's anorexia. Which statement by the son reassures you that the son understands your teaching and ways to help his father?

We can offer Dad small, frequent feedings rather than large, overwhelming meals.

You are working in the emergency room and a patient came in with a massive heart attack and cannot be resuscitated. The physician has just informed the family that the patient is dead. While sitting with the family, they ask you if the body can stay in the emergency room until the other family members arrive. The remaining family live 2 hours away. The ER is full and the secretary told you they need the room. What should you tell the family?

We will do everything we can to give the other family members time to get to the ER.

The parents of a 2-year-old child who is dying from leukemia tell you they are so afraid that they will forget who their child was years after he dies. How can you BEST respond?

Would you like me to call our child life team who can help you with some memory making activities?