Ch 36: End of Life Care

Question 1

definitions of death

Answer 1

-Inevitable, unequivocal, universal experience
-People can be reluctant to accept mortality
-“Cessation of vital functions without the capacity of
resuscitation”

Question 2

types of medical deaths

Answer 2

• Brain death: death of brain cells; flat EEG
• Somatic death; absence of cardiac and pulmonary functions
• Molecular death; cessation of cellular functions

Question 3

3 ways of nurses assessing for brain death

Answer 3

• corneal reflex
• pain response
• pupillary response

Question 4

family experiences with the dying process

Answer 4

Western culture has limited experiences with death/dying
* Few people dying earlier
* Deaths occurring in institutionalized settings
Avoid discussions about death/not making a will  lack of internalization of
mortality
Understanding one’s own mortality can be therapeutic and help with care of
dying clients

Question 5

supporting the dying individual

Answer 5

 Offer humanistic approach
 Meet the total needs of the client in a holistic manner
 Involve family members and significant others
 Individualized nursing intervention
 Carefully assess previous experiences with death, age, health status, philosophy of life, religious/spiritual/cultural beliefs, and attitudes/beliefs/values related to death

Question 6

hospice care

Answer 6

 Specialty that supports individuals through the
dying process
 Provided in a variety of settings

Question 7

includes interdisciplinary efforts to provide:

Answer 7

 Pain relief
 Symptom control
 Social work and counseling services
 Coordinated home care and institutional care
 Medical equipment and supplies
 Volunteer assistance and support
 Bereavement follow-up and counseling

Question 8

kubler-ross stages of grief

Answer 8

denial
anger
bargaining
depression
acceptance

Question 9

denial

Answer 9

• Denying the reality of the situation
• Provides an opportunity to test certainty of information
  and gives time to internalize
• Nursing: accept reactions and open door for honest
  dialogue; accept use of defenses

Question 10

anger

Answer 10

• Feels nothing is right; family could have guilt,
  embarrassment, grief, or anger
• Nursing: Create a beneficial environment, don’t take it
  personal, anticipate needs, maintain a pleasant attitude,
  vent to a colleague

Question 11

bargaining

Answer 11

• Negotiation of the inevitable
• Nursing: understand disappointment may occur;
  explore feelings; be mindful of spiritual/cultural
  considerations

Question 12

depression

Answer 12

• Depression that doesn’t resolve with encouragement
  or reassurance
• Nursing: don’t use many cheerful words; encourage
  clergy-patient relationship

Question 13

acceptance

Answer 13

• Comes to terms of death and found a sense of peace
• Nursing: touching, comforting, and being near the person; hope; family needs assistance with this stage

Question 14

what is rational suicide

Answer 14

Competent adults makes a reasoned decision to die by
suicide; cognitively intact; relatively free from pain

Question 15

what is assisted suicide

Answer 15

Individual has decided to end life with an aid of another
person (medical professional)
 Legal in some states, not all

Question 16

s/s of pain:

Answer 16

pain/discomfort,
nausea,
irritability,
restlessness,
anxiety,
sleep disturbances,
reduced activity,
diaphoresis,
pallor,
poor appetite,
grimacing,
withdrawal,
confusion

Question 17

goal of pain management

Answer 17

prevent pain, rather than treating it

Question 18

analgesia contraindicated in older adults

Answer 18

Meperidine and pentazocine are contraindicated due to adverse effects

Question 19

palliative care

Answer 19

prevents and relieves pain, not only for dying clients

Question 20

alternative to meds for pain

Answer 20

guided imagery,
hypnosis,
relaxation,
massage,
acupressure,
acupuncture,
therapeutic touch,
diversion,
application of heat/cold

Question 21

respiratory distress interventions

Answer 21

elevate HOB,
pacing,
relaxation exercises,
administering 02,
narcotics,
atropine or furosemide to reduce bronchial secretions

Question 22

constipation interventions

Answer 22

increase activity,
increasing intake of fluids and fiber,
laxatives on a regular schedule;
monitor for impaction

Question 23

poor nutritional intake

Answer 23

small portioned meals,
providing favorite foods,
antiemetics,
antihistamines,
ginger,
clean/pleasant environment for eating;
company during meals;
assisting with feeding,
oral hygiene

Question 24

spiritual care needs

Answer 24

Each religion has its own practices related to
death
 Nurses should be sensitive to differences and
ensure spiritual needs are met
 ***Review table 36-2 for specific religious
beliefs and practices related to death.
 Perform spiritual assessment
Clergy and family involvement as the
client/family allow

Question 25

signs of imminent death

Answer 25

Use this data to ensure the family has an opportunity to
see the client
Decline in BP
Rapid, weak pulse
Dyspnea or periods of apnea
Slower or no pupil response to light
Profuse perspiration
Cold extremities
Bladder/bowel incontinence
Pallor/mottling of skin
Loss of hearing and vision
Clergy as necessary; speak to and comfort the client during this time even if unresponsive

Question 26

Organizations must provide information about Patient Self-Determination Act - advance directives

Answer 26

Outlines preferences in care if they aren’t able to
communicate it

Question 27

Medical Orders for Life-Sustaining Treatment
(MOLST) or Physician Orders for Life-Sustaining Treatment
(POLST)

Answer 27

• Describes medical
  treatments that they wish to
  receive in a medical
  emergency
• NOT legal documents and
  don’t contain information
  about surrogates about who
  can make decisions; just list
  medical orders
• Specific forms vary by state

Question 28

SUPPORTING FAMILY AND FRIENDS DURING THE DYING PROCESS

Answer 28

Family/friends go through stages of grief
 Denial  avoid talking/thinking about death, visit less frequently, states they will get better when they get home, shop for doctors
 Anger  criticizing staff, questioning why this is happening, direct anger to other family members
 Bargain  may bargain to complete an action to help the client feel/get better
 Depression  more dependent on staff, crying, limiting contact
 Acceptance  wanting to spend more time with the client, request special things for the client, make arrangements in their own
life
Nursing
 Be aware of the state-by-state legal interventions
 Offer an opportunity to discuss death openly

Question 29

SUPPORTING FAMILY AND FRIENDS AFTER DEATH

Answer 29

-Nurse should be available to support the family
-Respect the personal desires of family/friends and don’t make judgments
-Allow an environment to express grief openly
-Advocate for the family
-Teach family to learn about the funeral industry
-Nurse can arrange visiting nurse, church member, social worker to check on family weeks after death
-Support groups

Question 30

post-mortem care

Answer 30

Determine if there are any tissues/organs to be
donated
 Contact organ donation company
Determine if death needs an autopsy or not
Determine if the family wants to participate
Follow organizational policy!
 Remove equipment (except for autopsy)
 Clean body and cover with clean sheet, place pillow
on the head and leave arms outside the sheet
 Offer privacy of the family
 Return belongings to family
 Attach identification tags per policy and apply shroud

Question 31

supporting nursing staff in end-of-life care

Answer 31

• May be difficult for nurses to accept a client’s death; may be considered a failure and feel powerless
• Can experience stages of grief
• Express feelings about client’s death; don’t bottle it in