MS2 - Chapter 16: End of Life

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?

Faith and belief 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.

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?

weight loss and inadequate food intake 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.

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:

care that will reduce the client's physical discomfort and manage clinical symptoms. 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.

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?

"Let's take this one day at a time; remember you have your daughter's dance recital next week." 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.

While providing care to a terminally ill client, the client asks, "Am I dying?" Which response by the nurse would be most appropriate?

"Tell me some more about what is on your mind." 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.

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?

"When your stay reaches 6 months, you will be recertified for a continued stay." 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).

Based on the most common concern of a dying patient, the hospice nurse should:

Administer pain medication on a schedule that prevents pain from intensifying. Pain management is the most common concern for the dying patient. Medication should be given on a PRN schedule that keeps the patient comfortable.

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?

Anger 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.

While providing care to a terminally ill client, the client's niece asks the nurse about the client's condition and prognosis. Which of the following would be most appropriate?

Ask the client's consent before sharing any information with the niece. Before disclosing any health information about a client to family members, nurses should follow the agency's policy for obtaining consent from the client in accordance with the Health Insurance Portability and Accountability Act (HIPAA) rules. Information is shared only with the client's consent.

Which of the following may be contained in an "emergency kit" for a hospice patient exhibiting restlessness?

Benzodiazepine A kit might contain small doses of oral morphine liquid for pain or shortness of breath, a benzodiazepine for restlessness, and an acetaminophen suppository for fever. Atropine sulfate drops may be used for excess respiratory secretions.

A family of a dying client reports that their loved one is experiencing more shortness of breath. Which nursing intervention is most appropriate at this time?

Call the health care provider to obtain an oxygen order Obtaining an oxygen order can reduce the client's shortness of breath and help the family feel more comfortable. It is difficult for families to see the client with shortness of breath. The dying client and family need support, and the bedpan, sitting in a chair, or offering sips to drink do not address the feelings of shortness of breath.

Glaser and Strauss (1965) identified four "awareness contexts." Which awareness context occurs when the client is unaware of their terminal state, whereas others are aware?

Closed awareness Closed awareness occurs when the client is unaware of their terminal state, whereas others are aware. Suspected awareness occurs when the client suspects what others know and attempts to find out details about the condition. Open awareness occurs when the client, the family, and the health care professionals are aware that the client is dying and openly acknowledge that reality. Mutual pretense awareness occurs then the client, the family, and the health care professionals are aware that the client is dying but all pretend otherwise.

A hospice nurse performs a follow-up telephone call to the spouse of a client who died about 1 year ago. The spouse tells the nurse, "I'm always feeling so sad. Life just doesn't feel worth living." Further conversation reveals that the spouse is having trouble sleeping and eating since her husband's death and that the spouse is "drinking more since he died." The nurse identifies which nursing diagnosis as the priority?

Complicated grieving Complicated grieving is characterized by prolonged feelings of sadness and feelings of general worthlessness or hopelessness that persist long after the death, prolonged symptoms that interfere with activities, or self-destructive behaviors such as alcohol or substance abuse and suicidal ideation or attempts. Thus, the nursing diagnosis of complicated grieving would be the priority and most appropriate. Although the client may be having trouble coping or experiencing stress, complicated grieving is more applicable. Although there is no time table to denote grieving, the nursing diagnosis of grieving would be more appropriate in the period surrounding the husband's death, rather than 1 year later.

Which is the initial stage of grief, according to Kübler-Ross?

Denial The stages of grief include denial, anger, bargaining, depression, and acceptance. Anger is the second stage of the process. Bargaining is the third stage of the process. Depression is the fourth stage of the process.

The family members of a dying client are finding it difficult to verbalize their feelings for and show tenderness to the client. Which nursing interventions should a nurse perform in such a situation?

Encourage the family members to express their feelings and listen to them in their frank communication. Family members usually find it difficult to communicate frankly with a dying person. By encouraging family members to express their feelings and listening to them as they frankly communicate, you may help family members 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 to express their feelings.

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?

Explore own feelings on mortality and death and dying. 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.

The family of a client in hospice decides to place their loved one in a long-term care facility to establish an effective pain control regimen. Which aspects of hospice care is the family using?

Palliative care Long-term care is increasing as a setting to provide palliative care that addresses management of symptoms such as pain. Inpatient respite care is a 5-day inpatient stay provided on an occasional basis to relieve the family caregivers. Continuous care is provided in the home to manage a medical crisis. General inpatient care provides inpatient stay for symptoms management that cannot be provided in the home.

A client is declared to have a terminal illness. What intervention will a nurse perform related to the final decision of a dying client?

Respect the client's and family members' choices. 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?

Speak to the client in a calm and soothing voice. Sight and touch diminish as the client approaches death; however, hearing tends to remain intact. Speaking to the client calmly is most appropriate.

During unplanned, spontaneous moments, dying clients usually discuss fears or concerns that nurses should not ignore or rush. What is the nurse's best response in such situations?

The nurse can communicate interest and a willingness to listen by sitting down, leaning forward in the client's direction, and making direct eye contact. The nurse should communicate interest and a willingness to listen by sitting down, leaning forward in the client's direction, and making direct eye contact with the client. Calling out to the client's family members and asking them to sit next to the client may not be the best intervention. The nurse should not distract the dying client's attention and should not administer a pain killer or sedative.

When describing the term "grief" to a group of students, which of the following would the instructor include?

The response experienced by anyone who has suffered a loss 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.

Despite having been administered prescribed pain medication, a dying client is still experiencing dyspnea due to fear and anxiety. Which nursing intervention should the nurse use to potentiate the effects of pain medication and help reduce the dyspnea?

Use imagery, humor, and progressive relaxation Imagery, humor, and progressive relaxation are the various techniques to potentiate the effects of pain medication and to reduce dyspnea. Offering small amounts of nourishment frequently will not help potentiate the effects of pain medication. Gentle massaging of the arms and legs helps to regulate body temperature. Encouraging the client to fall asleep will not help in potentiate the effects of pain medication.

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 -Anemia -Endocrine dysfunction 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).

Which is also known as a proxy directive?

Durable power of attorney for health care A durable power of attorney for health care is also known as a health care power of attorney or a proxy directive. The other options are incorrect.

Which action by the nurse demonstrates an effective method to assess the client and the client's family's ability to cope with end-of-life interventions?

Remaining silent, allowing the client and family to respond after asking a question related to end-of-life care A key to effective listening includes allowing the client and family sufficient time to reflect and respond after asking a question. Hospice nurses with effective listening skills resist the impulse to fill the empty space in communication with talk, avoid the impulse to give advice, and avoid responses indicating, "I know just how you feel."

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.

-Advise the client's health care provider of the client's condition. -Control the client's pain with prescribed medication. -Encourage the client to explain his or her wishes. 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.

The nurse practitioner has four patients with chronic illness that require consistent medical and nursing management. Select the condition that is the best example of a "chronically critical and progressively ill" condition.

End-stage renal disease Certain illnesses require advanced technology for survival, or intensive care for periods of weeks or months, as in end-stage renal disease (ESRD). People with this condition are chronically critical and progressively ill. Some chronic illnesses have little effect on quality of life, but others, like ESRD, have a considerable effect because it can result in a chronic progressive deterioration.

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.

Palliative care 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 nurse is developing a teaching plan for a terminally ill client and his family about the stages of dying and emotional reactions experienced. The nurse integrates knowledge of which of the following in the teaching plan?

The stages are applicable to any loss. The five stages of dying describe the five emotional reactions applicable to the experience of any loss. Not every client or family member experiences every stage. Many clients never reach a stage of acceptance. Clients and family fluctuate on a sometimes daily basis in their emotional responses.

A dying patient wants to talk to the nurse. The patient states, "I know I'm dying, aren't I?" What would an appropriate nursing response be?

"This must be very difficult for you." Using open-ended questions allows the nurse to elicit the patient's and family's concerns, explore misconceptions and needs for information, and form the basis for collaboration with physicians and other team members. For example, a seriously ill patient may ask the nurse, "Am I dying?" The nurse should avoid making unhelpful responses that dismiss the patient's real concerns or defer the issue to another care provider. In response to the question "Am I dying?" the nurse could establish eye contact and follow with a statement acknowledging the patient's fears ("This must be very difficult for you") and an open-ended statement or question ("Tell me more about what is on your mind").

All nurses care for clients who are grieving. It is important for the nurse to understand the grieving process for which reason?

Allows for the nurse to facilitate the grieving process 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.

A client is dying, and the client and loved ones are in the grieving period. The nurse wants to support them in the grieving process. Which is the best intervention the nurse could perform?

Encourage loved ones to express their feelings. The nurse can encourage the client and loved ones to express their feelings. The nurse should listen in a nonjudgmental manner and avoid delivering criticism or advice. To help with this, the nurse should assess the client's family or other companions in terms of characteristics such as roles, cohesion, flexibility, and communication. Spending time alone with the client does not facilitate the grieving process for the client and loved ones. Disengaging is also not an effective intervention, as the grieving individuals often value the nurse's teaching about what to expect during the process of dying. Providing palliative care is often done during this time, but it does not address the grieving process.

Which term is used to describe the personal feelings that accompany an anticipated or actual loss?

Grief 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.

Which "awareness context" is characterized by the client, family, and health care professionals understanding that the client is dying, but all pretend otherwise?

Mutual pretense awareness 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 acknowledge that reality openly.

Nursing students are reviewing information about attitudes related to death and dying. The students demonstrate understanding of the information when they identify which of the following as most accurate?

There remains a conspiracy of silence about dying despite progress in the area. Despite the progress on many fronts associated with attitudes toward death and dying, there still is a belief in a conspiracy of silence about dying. Although a growing number of clinicians are becoming more comfortable with assessing clients' and families' information needs, many still avoid the topic in the hope that the client will ask or find out on his or her own. In addition, there are misconceptions that clients would subsequently lose all hope, give up, or be psychologically harmed by disclosure of a serious or terminal illness and that clients would ask for information if they really wanted to know.