Problems r/t Terminal Illness

Question 1

Death, Dying, & End-of-Life

Nurses can affect the dying process
* Preventing death w/o dignity
* Promoting a peaceful, meaningful death
* Helping pt remain free from distress
* Minimizing suffering for pt & families

Part of the normal life cycle

Answer 1

Planning for End-of-Life & Advance Directives

Patient Self-Determination Act (PSDA)
Documentation associated w/PSDA

• Advance directive
• Durable power of attorney for healthcare (DPOAHC)
• Living will
• Do not resuscitate (DNR) [only gives instruct about CPR)
• Physician orders for life-sustaining treatment (POLST)/MOLST

Question 2

Hospice

Model for quality, compassionate care for those facing life-limiting illness or inj

• Usually <6 mos to live

Answer 2

Palliative

Philosophy of care for those w/life-threatening dz

• Provided by physician, NP, or team

Question 3

Physical assessment findings

↣ Weakness
↣ Sleeping more
↣ Anorexia
↣ Changes in organ system function

Answer 3

↣ Cold, mottled, cyanotic extremities

↣ Changes in breathing pattern - Cheyne-Stokes respirations

↣ Decr LOC

Question 4

Psychosocial assessment findings

• Fear and/or anxiety
• Difficulty coping
• Assess cultural considerations, values, religious beliefs

Answer 4

Spiritual assessment: HOPE mnemonic

H: source(s) of hope & strength
O: organized religion
P: personal spirituality, rituals, & practices
E: effects of religion & spirituality on end-of-life decisions

Question 5

Outcomes

✓ Needs & preferences met
✓ Control of sx’s of distress
✓ Meaningful interactions w/family
✓ Peaceful death

Answer 5

Pain Management

! Pain is the sx that dying pts fear most

! Opioid & non-opioid analgesics are used

Question 6

Complementary & Alternative Therapies

✐ Massage
✐ Music therapy
✐ Therapeutic touch
✐ Aromatherapy

Question 7

Managing Weakness

✐ Aspiration precautions - dysphagia
✐ Provide mouth care: apply emollient to lips
✐ Altered routes of medication admin
- Choose least invasive route w/most effective treatment

Question 8

Managing Dyspnea

✐ Opioids, bronchodilators, diuretics, abx, anticholinergics, benzodiazepines
✐ Oxygen (for comfort)
✐ Electric fan for air circulation
✐ Reposition

Question 9

Managing N/V

Anti-emetic agents
* Prochlorperazine
* Ondansetron
* Dexamethasone
* Metoclopramide

Answer 9

✐ Remove any source of odors
✐ Comfortable room temp
✐ Aromatherapy

Question 10

Managing Delirium

✐ Assess for pain, urinary retention, constipation, other reversible cause

✐ Pharmacologic agents

Answer 10

✐ Music therapy, aromatherapy

Question 11

Interventions (for the grieving family & pt who will be losing their life)

✐ Presence
✐ Reminiscence
✐ Therapeutic communication
✐ Spirituality
✐ Life review
✐ Religion

Answer 11

Postmortem Care

Legal considerations
* Pronouncement of death
* Death certificate

✐ Allow family & caregivers to spend time w/the pt if they desire
✐ Determination of need for autopsy
✐ Transfer of body

Question 12

Ethics & Dying

Active euthanasia
* NOT supported by most organizations
* Legal in some situations in some states

• Physician-assisted suicide (PAS)
• Passive euthanasia
• Voluntary stopping of eating & drinking (VSED)

Answer 12

Kubler-Ross’ Stages of Grief

1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance

Question 13

John Bowlby’s Grief Process

Stage I Numbness or protest

Stage II Disequilibrium

Stage III Disorganization & despair

Stage IV Reorganization

Answer 13

Question 14

___ ___’s Grief Process

Stage I Shock & disbelief

Stage II Developing awareness

Stage III Restitution

Stage IV Resolution of the loss

Stage V Recovery

Answer 14

George Engel

Question 15

Stages of the grief process according to J. William Worden

Task I: Accepting the reality of the loss

Task II: Processing the pain of grief

Answer 15

Task III: Adjusting to a world w/o the lost entity

Task IV: Finding an enduring connection w/the lost entity in the midst of embarking on a new life

Question 16

The grief response is more difficult when:

☞ The bereaved person was strongly dependent

☞ The relationship was an ambivalent one

☞ The individual has experienced a # of recent losses

☞ The loss is that of a young person

Answer 16

☞ The bereaved person’s health is unstable

☞ The bereaved person perceives some responsibility for the loss

☞ The loss is secondary to suicide

☞ The loss is a traumatic death such as murder

Question 17

The grief response may be facilitated when:

☞ The individual has the support of significant others

☞ The individual has the opportunity to prepare for the loss

Question 18

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Is the experiencing of feelings & emotions assoc w/the normal grief process in response to anticipation of the loss

• Is thought to facilitate the grief process when the actual loss occurs
• Difficulty arises when family members complete the process of & detachment from the dying person occurs prematurely

Answer 18

Anticipatory grieving

Question 19

Maladaptive Responses to Loss

• Delayed or inhibited grief
• Exaggerated or distorted grief response
• Chronic or prolonged grief

Question 20

Delayed or inhibited grief

✏ The absence of grief when it ordinarily would be expected

✏ Potentially pathological b/c the person is not dealing w/the reality of the loss

Answer 20

✏ Remains fixed in the denial stage of the grief process

✏ Grief may be triggered much later in response to a subsequent loss

Question 21

Distorted (exaggerated) grief

✏ All of the sx’s assoc w/normal grieving are exaggerated

✏ Individual becomes incapable of managing ADLs

Answer 21

✏ Individual remains fixed in the anger stage of the grief process

✏ Depressed mood disorder is a type of distorted grief response

Question 22

Chronic or prolonged grieving

✏ A prolonged grief process may be considered maladaptive when certain behaviors are exhibited

✏ Behaviors aimed @ keeping the lost loved one alive

Answer 22

✏ Behaviors that prevent the bereaved from adaptively performing ADLs

Question 23

Normal vs Maladaptive Grieving

! Loss of self-esteem

! Marked feelings of worthlessness

Answer 23

Understanding death

Question 24

Birth to age 2

Unable to understand death but can experience the feelings of loss & separation

Answer 24

Ages 3 to 5

Have some understanding about death but have difficulty distinguishing between fantasy & reality; believe death is reversible

Question 25

Ages 6 to 9 Beginning to understand the finality of death; difficult to perceive their own death; normal grief reactions incl regressive & aggressive behaviors

Answer 25

Ages 10 to 12 Understand that death is final & eventually affects everyone; feelings of anger, guilt, & depression are common; peer relations & school performance may be disrupted

Question 26

Adolescents ✏ Usually able to view death on an adult lvl ✏ Have difficulty perceiving their own death ✏ May or may not cry; may withdraw ✏ May exhibit acting-out behaviors

Answer 26

Elderly adults ✏ A time in life of the convergence of many losses ✏ May lead to "bereavement overload" ✏ Bereavement overload may result in depression

Question 27

Death and Culture

Answer 27

**African Americans** ✿ Similar to those of the American culture of the same religion & social class, w/a blending of cultural practices from the African heritage ✿ Feelings are expressed openly & publicly

Question 28

**Chinese Americans** ✿ Death & bereavement in the Chinese tradition are centered on ancestor worship ✿ Chinese people have an intuitive fear of death & avoid references to it ✿ They don't openly express their emotions

Answer 28

**Japanese Americans** ✿ Predominant religion is Buddhism ✿ Body is prepared by close family members ✿ Cremation is common

Question 29

**Vietnamese Americans** ✿ Buddhism is predominant religion ✿ Believe that birth & death are predestined ✿ Cremation is common ✿ The 1-year anniversary of an individual's death is commemorated

Answer 29

**Filipino Americans** ✿ Week-long wake takes place in home of the deceased ✿ Among Catholic families, 9 days of novenas are held in the home or church, finishing on the last day w/a fiesta ✿ Wear dark clothing for 1 yr >a death

Question 30

**Jewish Americans** ✿ Traditional Judaism believes in an afterlife ✿ Dying person is never left alone ✿ No wake & no viewing are part of a Jewish funeral; cremation prohibited ✿ 7-day period beginning w/the burial is called shiva, during which mourners think only about the deceased

Answer 30

**Mexican Americans** ✿ View death as a natural part of life ✿ Death rituals reflect Catholic beliefs ✿ Burial is preceded by a velorio, a festive watch over the body ✿ Mourning is called luto & is symbolized by wearing dark or black & white clothing & by subdued behavior

Question 31

**Native Americans** ✿ Navajo of the Southwest conduct a cleansing ceremony before burial to prevent the spirit of the dead person from trying to assume control of someone else's life ✿ Dead are buried w/their shoes on the wrong feet & rings on their index fingers

Answer 31

✿ They do not express grief openly & are reluctant to touch the body of a dead person

Question 32

Spiritual Distress Short-Term Goal: Client **identifies meaning & purpose in life**, moving forward w/hope for the future

Answer 32

Long-Term Goal: Client expresses achievement of support & personal satisfaction from spiritual practices

Question 33

Spiritual Distress: Interventions ↣ Be accepting & nonjudgmental when client expresses anger & bitterness (toward God, the universe, etc.); stay w/client ↣ Encourage client to ventilate feelings r/t meaning of own existence in the face of current loss ↣ Encourage client as part of grief work to reach out to previously used religious practices for support. Encourage client to discuss these practices & how they provided support in the past

Answer 33

↣ Assure client that he or she is not alone when feeling inadequate in the search for life's answers ↣ Contact spiritual leader of client's choice, if he or she requests

Question 34

Nursing interventions for the bereaved individual ↠ Provide assistance through the grief process in a healthful manner toward resolution ↠ Encourage the individual to express feelings about the loss & how the loss will affect his or her life ↠ Review the circumstances of the loss & the reality that it could not be prevented

Answer 34

↠ Encourage the individual to participate in usual religious practices from which he or she derives support ↠ Assist the client to identify positive aspects about his or her life, past relationships, & prospects for the future