Fundamentals Chapter 17 - Loss, Grief, and Dying

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1

Define Loss

The undesired change or removal of a valued object, person, or situation.

2

Actual versus perceived loss

Actual loss includes the death of a loved one (or relationship), theft, deterioration, destruction, and natural disaster. Actual loss can be identified by others, not just by the person experiencing it (e.g., hair loss during chemotherapy).

In contrast, perceived loss is internal; it is identified only by the person experiencing it (e.g., a woman diagnosed with an STD may perceive herself as having lost her purity.

3

Physical versus psychological loss

Physical loss includes (1) injuries (e.g., when a limb is amputated); (2) removal of an organ (e.g., hysterectomy); and (3) loss of function (e.g., loss of mobility).

Psychological losses challenge our belief system. They are commonly seen in the areas of sexuality, control, fairness, meaning, and trust. Some losses may be mixed. Ex: after removal of a prostate gland, a man may feel both the physical and psychological loss of sexuality.

4

External versus internal loss

External losses are actual losses of objects that are important to the person because of their cost or sentimental value (e.g., jewelry, pets, a home). These losses can be brought about by theft, destruction, or disasters such as floods and fire.

Internal loss is another term for perceived or psychological loss.

5

Loss of aspects of self

This includes physical losses such as body organs, limbs, body functions, and/or body disfigurement. Psychological and perceived losses in this category include aspects of one’s personality, developmental change (as in the aging process), loss of hopes and dreams, and loss of faith.

6

Environmental loss

This involves a change in the familiar, even if the change is perceived as positive. Examples include moving to a new home, getting a new job, and going to college. These losses can be perceived or actual.

7

Loss of significant relationships

This includes, but is not limited to, actual loss of spouses, siblings, family members, or significant others through death, divorce, or separation (e.g., military deployment)

8

Define Grief

Physical, psychological, and spiritual responses to a loss.

The intensity of the grief depends on the meaning the person attaches to the loss. Although each person may express grief differently, some aspects of grief are shared by almost everyone.

9

Define Mourning

Consists of actions associated with grief (ex: crying, wearing black clothing.

10

Define bereavement

The mourning and adjustment time after a loss.

11

Factors Affecting Grief:

Significance of the loss

The meaning the person has attached to the person or object lost will be different for each person. The more attachment to the relationship or object, the more difficult is the grieving.

12

Factors Affecting Grief:

Support System

the amount of support for the bereaved: People with more emotional and psychosocial support typically have less complicated grief.

13

Factors Affecting Grief:

Unresolved Conflict

Conflict existing at the time of death: A conflict left unresolved may cause prolonged grief.

14

Factors Affecting Grief:

Circumstances of the loss

Was there an opportunity to prepare for it?

If the circumstances of the loss leave the bereaved feeling guilty or responsible, his or her healing process may be impeded. (this may occur in losses other than death such as loss of a job)

15

Factors Affecting Grief:

Previous Loss

If the person has sustained more than one loss in a short period of time, the grieving process can become more complicated.

16

Factors Affecting Grief:

Spiritual/Cultural Beliefs and Practices

Can help or hinder the grieving process. One person might believe the deceased is in a place of contentment and happiness, where all suffering is over. Another may believe that the deceased person will be reborn into another form. Yet another may believe that death is final and there is no afterlife.

17

Factors Affecting Grief:

Timeliness of death

The death of a child or a young person is almost universally more difficult to accept that the death of an older person. In addition to the loss there is a sense of unfairness because of the loss of potential - of what the child might have become or achieved.

18

Types of Grief:

Uncomplicated Grief

aka normal grief; it is the natural response to a loss. The bereaved person experiences the feelings, behaviors, and cognitions that are expected in light of his or her culture, social status, and relationship to the lost person or object. The emotions are intense but gradually diminish over time (several months to several years). Some emotions will always be present, but the intensity will change.

19

Types of Grief:

Complicated Grief

This type of grief is distinguished from uncomplicated grief by length of time and intensity of emotion. The person’s responses last longer than 6 mos and are maladaptive, dysfunctional, unusually prolonged, or overwhelming. Complicated grief results when the grieving process has been impeded for some reason (e.g., something keeps the person “stuck” in the grief process).It has been associated with depression, suicidal ideation, and hypertension. Risk factors include: previous loss, exposure to trauma, sudden death of a significant other, emotional instability and lack of social support.

20

Types of Grief:

3 types of Complicated Grief: Chronic, Masked, and Delayed

  • Chronic begins as normal grief but continues long term, with little resolution of feelings and inability to rejoin normal life.
  • Masked occurs when the person is grieving but expressing the grief through other types of behavior. EX: drinking heavily after a loss.
  • Delayed is grief that is put off until a later time (e.g., “I’ll think about it later. Right now, I’m busy trying to keep a roof over our heads and care for my children.”).
21

Types of Grief:

Disenfranchised Greif

experienced in connection with a loss that is not socially supported or acknowledged by the usual rites or ceremonies. Disenfranchised grief may be experienced by a man whose wife has had a miscarriage, a mistress whose lover dies, or a bereaved partner in a homosexual relationship not recognized by the families. In each of these instances, the bereaved person lacks the communal support that is helpful in grieving.

22

Types of Grief:

Anticipatory Grief

experienced before a loss occurs. The potential negative outcome of anticipatory grief is that the survivor may detach from a dying person too early in the dying process, leaving the person without emotional support during that period. This does not always happen, of course.

23

A young woman’s fiancé died in a car accident one month prior to their wedding day. Since his death, she has become sexually promiscuous. What type of grief, if any, is the woman displaying?

a.Chronic

b.Disenfranchised

c.Masked

d.No grief

c.Masked

24

How is Death Defined?

Historical definition

Historically, Death was defined as the cessation of the flow of vital bodily fluids. This evolved into the traditional definition of heart-lung death.

25

How is Death Defined?

Heart-lung death

The irreversible cessation of spontaneous respirations and circulation. This was later replaced with whole-brain death.

26

How is Death Defined?

Whole-brain death:

The irreversible cessation of all functions of the brain, including the brain stem. Spontaneous respirations cannot continue once the brain stem stops functioning; however, the heart may continue to beat until it becomes oxygen starved from cessation of respirations.

27

How is Death Defined?

Higher-brain death

In the 70s many practitioners began using this term.

Defines death as the irreversible cessation of all "higher" brain functions (cognitive fx, consciousness, memory, reasoning). The brain stem can still be functioning, so both respiratory and cardiac activity may continue even though the person does not make purposive responses to external stimuli, cephalic reflexes are absent, and the electroencephalogram shows no activity.

28

How is Death Defined?

Uniform Determination of Death Act

This provides a highly reliable means of declaring death for respirator-maintained bodies—loss of brain stem function.

It states: [Determination of Death] An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards.

29

Define Coma

A prolonged, deep state of unconsciousness lasting days or even years. The patient can not be aroused and may or may not have decreased brainstem reflexes.

30

Define Persistent Vegetative State (PVS)

Sometimes follows a coma, but can also occur after any event that affects cerebrovascular flow. In PVS, the person does not purposefully respond to stimuli, is unaware of the environment, and has no cognition or affective mental functions.

31

Physiological Stages of Dying:

1-3 months prior to death

The dying person begins to withdraw from the world and people. Sleep increases; it becomes difficult for the body to digest food, especially meats; and appetite and food intake decrease. Liquids are preferred. Anorexia may be protective. The resulting ketosis can diminish pain and increase the person’s sense of well-being.

32

Physiological Stages of Dying:

1-2 weeks prior to death

A host of physical changes indicates the body is beginning to lose its ability to maintain itself. Cardio deterioration brings reduced BP, changes in pulse and skin color (yellowish pallor), and extreme pallor of the extremities. Temp fluctuates and perspiration increases. Respirations may increase or decrease.

33

Physiological Stages of Dying:

Days to hours prior to death

Often a surge of energy brings mental clarity and a desire to eat and talk with family members. However, as death approaches, patients tend to become dehydrated and have difficulty swallowing, which results in decreased blood volume. In the final hours of life, many patients become restless and agitated. This response may be caused by medications, liver failure, cerebral hypoxia, renal failure, stool impaction, distended bladder, increased pain, or unresolved emotional or spiritual issues. Near to the time of death, some people unexpectedly become more coherent and energized for a time. Others become less communicative, quiet, and withdrawn (Pitorak, 2003). Fatigue is common. Cheyne-Stokes respirations may occur.

34

Physiological Stages of Dying:

Moments prior to death

The dying person does not respond to touch or sound and cannot be awakened. Typically, there is a short series of long-spaced breaths before breathing ceases entirely and the heart stops beating.

35

Name the 5 psychological stages of dying

  • Denial
  • Anger
  • Bargaining
  • Depression
  • Acceptance

When you study the Kübler-Ross stages, it is important to understand that dying people:

  • May not go through every stage
  • May not go through the stages in a linear fashion, but rather in random order
  • Do not necessarily complete one stage and move on to the next
  • May experience two or three stages simultaneously

Remember that it is not the nurse’s responsibility to move people on to the next stage so that everyone dies accepting death. It is our responsibility to accept and support people “where they are” and help them to verbalize their feelings. We need to understand patients, not change them.

36

Psychological Stages of Dying:

Denial

"Not me." "This cannot be happening. I don't believe it."

Usually the person is in a state of shock. It is not necessarily negative; it gives the person a chance to prepare psychologically for accepting the news.

37

Psychological Stages of Dying:

Anger

"Why me?" "Why is this happening?"

Anger can be obvious or subtle. It is the person's response to the feeling that the situation is unfair. The person may take his anger out of people who are "safe" (loved one) or from whom there will be no reprisals (nurses, drs)

38

Psychological Stages of Dying:

Bargaining

"If only I can live until..." "Yes me, but,..."

Usually this takes the form of a bargain with God or a Higher Power, in which the person asks to live to see a birth, graduation, wedding etc.

39

Psychological Stages of Dying:

Depression

A withdrawn sadness, not to be confused with clinical depression. This is a response to the current loss as well as to any accumulated and or future losses

40

Psychological Stages of Dying:

Acceptance

Not necessarily wanting death (or the loss), but coming to terms with it and ceasing to fight it. The person may seem almost devoid of feelings.

41

Define End of Life Care

A recent set of guidelines provides a working definition that includes the following situations:

  • The pt has a fatal condition
  • Death is likely with the next exacerbation of disease
  • The pt acknowledges the seriousness of the situation

End of life care includes palliative care and hospice care, which are similar in that both may involve caring for dying pts, and neither focuses on cure.

42

Define Palliative Care

It is aggressively planned, holistic comfort care. General issues for most end-of-life care patients include the following:

  • Supporting families and caregivers
  • Ensuring continuity of care
  • Ensuring respect for persons
  • Ensuring informed decision making
  • Attending to emotional and spiritual concerns
  • Supporting function and survival duration
  • Managing symptoms (e.g., pain, dyspnea, depression)

Pts do not necessarily have to be "actively dying" to receive it; it's also provided over a long period of time for those who have slowly progressive diseases.

43

Define Hospice Care

It is based on two key premises: (1) the quality of life is as important as the length of life, and (2) those who are terminally ill should be allowed to face death with dignity and surrounded by the comfort of their homes and families. Thus, hospice providers consider helping family members an essential part of their role.

44

What is the primary difference between palliative care and hospice?

For a pt to be eligible for hospice insurance benefits, a physician must certify that the pt is likely to die within 6 mos.

45

Legal and Ethical Considerations:

Advance directives

are a group of instructions (written or oral) stating a person’s wishes regarding his or her healthcare if he or she were incapacitated or unable to make that decision. An ordinary power of attorney does not give another person the right to make healthcare decisions for the patient; only a durable power of attorney for healthcare decisions can do that.

46

Legal and Ethical Considerations:

DNR/AND

An order to not attempt resuscitation of the patient in the event of a cardiac or respiratory failure. The ANA recommends “allow natural death”

47

Legal and Ethical Considerations:

Assisted suicide

means making available that which is needed for the patient to end his or her own life (e.g., pharmacological agents or weapons). The patient is physically capable of ending his or her own life, has expressed the intention to do so, and has turned to the healthcare provider merely to supply the means. “The ANA (2013) prohibits nurses’ participation in assisted suicide and euthanasia because these acts are in direct violation of the Code of Ethics for Nurses with Interpretive Statements (2001), the ethical traditions and goals of the profession, and its covenant with society. Nurses have an obligation to provide humane, comprehensive, and compassionate care that respects the rights of patients but upholds the standards of the profession in the presence of chronic, debilitating illness and at end-of-life.”

48

Legal and Ethical Considerations:

Palliative Sedation

The Hospice and Palliative Nurses Association promotes palliative sedation as the "controlled and monitored use of non opioid meds intended to lower the patient's level of consciousness to the extent necessary, for relief of awareness of refractory and unendurable symptoms".

49

Legal and Ethical Considerations:

Euthanasia (Active and Passive)

refers to the deliberate ending of a life of someone suffering from a terminal or incurable illness.

Active euthanasia occurs as a result of a direct action (e.g., giving an overdose of medication).

Passive euthanasia occurs as a result of a lack of action (e.g., withholding medications or food necessary to sustain life).

50

Legal and Ethical Considerations:

Autopsy

is a medical examination of the body to determine the cause of death that involves removals of the organs and extractions of tissue samples. Autopsies have also provided relevant data about disease processes and causes. It requires signed permission from the next of kin, except in cases in which autopsy is required by law (e.g., deaths that are suspicious or unwitnessed).

51

Organ Donation

A conflict between a potential organ donor's advance directives and measures to ensure the viability of his organs (eg, life support) must be resolved asap, by one of the following, in this order:

  1. The donor (if able)
  2. The surrogate decision maker
  3. Another person as authorized under state law

Until resolution, maintaining the suitability of the organs has the highest priority. You should advocate that your patient's advance directives are clear on end of life care and organ donation.

52

Assessment for Terminally Ill Client and Family includes?

  • Knowledge base
  • History of loss
  • Coping abilities and support systems
  • Meaning of the loss/illness
  • Depression or grief?
  • Physical assessment
  • Cultural and spiritual assessment

In addition:

  • When the client and family are ready, encourage them to talk about the client’s wishes for burial or cremation or tasks that the client would like taken care of (e.g., giving away valuables, calling family members).
  • Determine whether the dying client has a living will or advance directives.
  • Discuss with client and family the possibility of organ donation, if appropriate for the client’s circumstances
53

Diagnosis for Terminally Ill Client and Family

  • Loss and grieving are the problem.
  • Loss and grieving as an etiology occurs when they create problems in other areas of patient or family function. The following are examples of such nursing diagnoses:
  • Situational or Chronic Low Self-Esteem related to inability to change the event for self or significant other; or related to dying while having “unfinished business”
  • Anxiety related to possible inability to cope with the loss; or related to unknown outcome of situation
  • Death Anxiety (or Fear) related to impending death
54

Therapeutic Communication:

  1. Perfect your ___ skills.
  2. Encourage and accept expression of ___.
  3. Reassure it is not wrong to feel __, relief, or other "unacceptable" feelings.
  4. Respond to nonverbal cues with touch and __.
  5. Increase your __.
  6. Continue to ___, even in case of coma.
  1. Listening
  2. Feelings
  3. Anger
  4. Eye contact
  5. self awareness
  6. communicate
55

Facilitating Grief:

Expressing Feeling

  • Encourage questions, and respond to them within a reasonable time.
  • Sit beside the head of the bed; do not appear rushed.
  • When you observe the patient or family member expressing feelings, either verbally or nonverbally, encourage him or her to continue.
  • Expect and accept a wide range of feelings, including anger, fear, and loneliness.
  • Ask, “How would you like me to help?” “What do you need?”
  • Be sure that everyone on the healthcare team understands and follows the care plan.
  • Ask yourself what you would do if this were your family member.
  • Do not compare another person’s loss to your own experience. For example, avoid comments such as, “I know how you feel.” Instead, say, “Tell me how you feel.”
56

Facilitating Grief:

Recalling Memories

One way to encourage recall is to go through photo albums with them and ask questions about the people in the pictures. Also look for objects of sentiment (e.g., a family heirloom) in the environment and ask the dying or bereaved person to share their significance.

57

Facilitating Grief:

Finding Meaning

Facilitating life review is one technique to help the patient and/or family recognize the unique contributions this person has made to family, friends,
and society.

Begin by asking about the various aspects of the patient’s life, commenting on pictures in the room, or picking up on verbal cues that are expressed.

58

Helping Families of Dying Clients:

  1. Have family help with __, if able
  2. Encourage __
  3. Provide follow up for __ as needed
  4. Encourage visit to __ or to talk with clergy
  5. Provide anticipatory __
  6. Acknowledge __ of family
  7. Explore __ mechanisms
  8. Remind family members and others to take __of themselves
  9. Teach what to expect and provide __
  10. Ask directly if the family wants to be present at the time of __
  11. At the moment of death, __
  1. care
  2. questions
  3. referrals
  4. chapel
  5. guidance
  6. feelings
  7. Coping
  8. Care
  9. reassurance
  10. death
  11. do not intrude
59

Care of the Dying Person:

Meeting physiological Needs

Physiological needs during this time include mobility, oxygenation, safety, nutrition, fluids, elimination, personal hygiene, and control of pain and symptoms (nausea, vomiting).

60

Care of the Dying Person:

Meeting psychological needs

Everyone involved with the patient should know exactly what the patient and the family have been told. Most patients want to know their prognosis as soon as possible so that they can put personal affairs in order, share their feelings with family members, and come to terms with their life and death.

61

Care of the Dying Person:

Addressing spiritual needs

The person may be looking for forgiveness and/or acceptance or be reaching out to feel connected. Ways to address this need include (but are not limited to) empathetic listening, contacting pastoral care or clergy if the patient asks for this service, special rituals, praying with the patient, music, meditation, or special readings.

62

Care of the Dying Person:

Addressing cultural needs

  • Some cultures may emphasize keeping emotions more subdued and limiting expressions of grief to private settings, whereas others gauge the value of the deceased by the amount of wailing and crying.
  • Blacks and Hispanics may be reluctant to withdraw life-sustaining treatment or to use a hospice, whereas Arab Muslims may be reluctant to prolong life unnecessarily
63

The client is dying of cancer and can no longer swallow. The son states to the nurse, “You MUST give dad some water, he always drank a lot of water.” The nurse’s best response is

a.“You sound very upset. Tell me more about your dad.”

b.“Your father is dying from cancer and water will not stop this process.”

c.“Research shows that withholding oral fluids decreases edema.”

d.“I will call the physician and get orders to insert a nasogastric tube for the water.”

a.“You sound very upset. Tell me more about your dad.”

These are statements that will begin a therapeutic conversation and encourage the son to express his feelings about his father's impending death. Options B and C close communication and do not reflect caring. Option D is incorrect and does not address the underlying concern.

64

Postmortem Care

includes care of the patient’s body after death and fulfilling any legal obligations, such as arranging transportation to the morgue or funeral home and determining the disposition of the patient’s belongings.

65

A patient is hospitalized with severe depression after her divorce is finalized. Which type of loss is the patient experiencing?

1) Actual

2) Perceived

3) Physical

4) External

Answer:

1) Actual

Rationale:

The loss of a relationship is an actual loss. An actual loss is a reality that can be identified by others, not just by the person experiencing it. Perceived loss is internal; it can only be identified by the person experiencing the loss. Physical loss includes injuries, removal of an organ or body part, or loss of function. An external loss is an actual loss of an object.

66

The nurse is caring for a patient who is terminally ill with lung cancer. Recently, the patient's blood pressure has been decreasing and heart rate increasing. He is experiencing temperature fluctuations and perspires profusely with limited movement. Based on these findings, the patient will most likely die within which time period?

1) 1 to 3 months

2) 1 to 2 weeks

3) Days to hours

4) Moments

Answer:

2) 1 to 2 weeks

Rationale:

One to 2 weeks before death, patients typically exhibit decreased blood pressure, increased heart rate, increased perspiration, and temperature fluctuations; 1 to 3 months before death, the patient withdraws from the world: sleep increases and appetite decreases. Days to hours before death, the patient may experience a surge in energy. Very near the time of death, the dying patient is typically not responsive to touch or sound.

67

A family member asks the nurse to explain the purpose of hospice care. Which of the following is the best response? Hospice care:

1) Is appropriate when the patient desires to intentionally end his life

2) Focuses on minimizing the disease process as rapidly as possible

3) Focuses on symptom management for patients not responding to treatment

4) Is holistic care for patients dying or debilitated and not expected to improve

Answer:

4) Is holistic care for patients dying or debilitated and not expected to improve

Rationale:

Hospice care focuses on holistic care of patients actively dying or not expected to improve. It helps patients face death with dignity and comfort. Euthanasia refers to the deliberate ending of a life. Palliative care is aggressively planned care that manages symptoms of patients whose disease process no longer responds to treatment. Aggressive medical treatment is aimed at stopping the disease process.

68

After a patient dies of ovarian cancer, her daughter says to the nurse, "You'll probably think I'm terrible, but I'm glad she can finally rest peacefully." Which response by the nurse is best?

1) "Your feelings are a normal response to watching your loved one suffer."

2) "It's unusual for family members to be grateful that a loved one has died."

3) "Your mother's death has been very hard on you; you should seek counseling."

4) "I don't understand what you mean by this comment."

Answer:

1) "Your feelings are a normal response to watching your loved one suffer."

Rationale:

The nurse should reassure the patient's daughter that her feelings are normal; there is no need for the daughter to seek counseling based on the information provided in this situation. Keep in mind that people can grieve in a dysfunctional manner for which they would benefit from counseling or other mental health support services. By responding, "It's unusual for family members to be grateful that a loved one has died," the nurse is being judgmental. The nurse who states she doesn't understand the family member's comment should at least seek clarification and prompt further exploration of the person's feelings. A comment of this nature can be a discussion starter for the daughter to release feelings and begin the grieving process.

69

A nurse is caring for a dying patient who is nonresponsive. Which of the following is it important for the nurse to do?

1) Be alert to the patient's nonverbal cues.

2) Direct explanations about care to family members.

3) Tell the patient when the nurse is about to leave the room.

4) Sit by the head of the bed when speaking to the patient.

Answer:

3) Tell the patient when the nurse is about to leave the room.

Rationale:

The nurse should continue to communicate with dying patients even if they are nonresponsive. Research indicates that patients continue to hear even though the level of consciousness is low, sometimes up to the moment of death. Nonverbal actions would not communicate meaning for a patient who is nonresponsive; nor would the patient be aware that the nurse is sitting instead of standing when speaking. The nurse should direct explanations of care to the patient, as always; nurses should not talk about the patient to others in the patient's presence, even when the patient is comatose.

70

A patient has been in the dying process for about 10 days. His wife has left his side only for very short periods during that time, and she looks pale and exhausted. The nurse, realizing the wife has not eaten much, suggests that she take a break to eat and rest. The woman refuses, saying, "I don't want to leave him. I won't have him much longer, and I don't want him to go when I'm gone." What should the nurse do?

1) Explain that she will be of more help to her husband if she is rested and well.

2) Tell the wife that it is safe to leave her husband for an hour or two because he won't die that soon.

3) Call the primary care provider to come and try to persuade her to take physical care of herself.

4) Arrange for a cot for the wife at the bedside and arrange to have food brought to her.

Answer:

4) Arrange for a cot for the wife at the bedside and arrange to have food brought to her.

Rationale:

The nurse was correct to suggest that the woman needs to eat and rest. However, this is primarily for the woman's well-being, not because she needs to be of more help to her husband. The nurse should not assure her that her husband will not die in an hour or two, because she does not know exactly when he will die. It would be inappropriate to ask anyone else to try to persuade her to change her mind; the nurse should support the wife's decisions in a therapeutic manner and not try to change them. The nurse should not rely on the physician to encourage basic care and comfort for the family. She should make the wife as comfortable as possible if she does not wish to leave the room. This would include arranging for her to rest in the patient's room and having food and drink brought to the room.

71

According to the Uniform Determination of Death Act, which bodily function must be lost to declare death?

1) Consciousness

2) Brainstem function

3) Cephalic reflexes

4) Spontaneous respirations

Answer:

2) Brainstem function

Rationale:

According to the Uniform Determination of Death Act, death can be declared when there is a loss of brainstem function. Higher-brain death occurs when there is a loss of consciousness, cephalic reflexes, and spontaneous respirations.

72

Mr. Jackson is terminally ill with metastatic cancer of the colon. His family notices that he is suddenly more focused and coherent. They are questioning whether he is really going to die. The nurse recognizes that a sudden surge of activity may occur:

1) moments before death

2) days to hours before death

3) 1 to 2 weeks before death

4) 1 to 3 months before death

Answer:

2) days to hours before death

Rationale:

Days to hours before death, patients commonly experience a surge of energy that brings mental clarity and a desire to speak with family. One to 3 months before death, the dying person begins to withdraw from the world by sleeping more and eating less. One to 2 weeks before death, the body loses its ability to maintain itself, and body systems begin to deteriorate. Near the time of death, the dying person does not respond to touch or sound and cannot be awakened.

73

A patient with a history of chronic obstructive pulmonary disease has a living will that states he does not want endotracheal intubation and mechanical ventilation as a means of respiratory resuscitation. As the patient's condition deteriorates, the patient asks whether he can change his decision. Which response by the nurse is best?

1) "I'll call your physician right away so he can discuss this with you."

2) "You have the right to change your decision about treatment at any time."

3) "Are you sure you want to change your decision?"

4) "We must follow whatever is written in your living will."

Answer:

2) "You have the right to change your decision about treatment at any time."

Rationale:

The nurse should inform the patient that he has the right to change his decision about treatment at any time. Next, the nurse should notify the physician of the patient's decision so that the physician can speak to the patient and revise the treatment plan as needed. Questioning the patient's decision is judgmental. The patient has the right to change his living will at any time. The medical team should not follow the living will if the patient changes his decision about what is in it.

74

Which intervention should be included in the plan of care for a patient in the end-stage death process?

1) Encourage the patient to accept as much help as possible.

2) Avoid administering laxatives.

3) Wet the lips and mouth frequently.

4) Administer pain medication on a prn basis.

Answer:

3) Wet the lips and mouth frequently.

Rationale:

If the patient is unable to take fluids, prevent dryness and cracking of lips and mucous membranes by wetting the lips and mouth frequently. Encourage the patient to be as independent as possible. Administer laxatives if constipation occurs. Administer pain medications on a regular schedule instead of waiting for the patient to request them.

75

Higher-brain death includes irreversible cessation of which of the following?

SELECT ALL THAT APPLY.

1) Memory
2) Flow of vital bodily fluids
3) All functions of the brain, including the brainstem
4) Cognitive functioning
5) Consciousness
6) Spontaneous respirations and circulation

1 4 5

Correct!

Feedback 1: Higher-brain death is defined as the irreversible cessation of all "higher" brain functions (e.g., cognitive functioning, consciousness, memory, and reasoning).

Feedback 2: Historically, death was defined as the cessation of the flow of vital bodily fluids.

Feedback 3: Whole-brain death is defined as the irreversible cessation of all functions of the brain, including the brainstem.

Feedback 4: Higher-brain death is defined as the irreversible cessation of all "higher" brain functions (e.g., cognitive functioning, consciousness, memory, and reasoning).

Feedback 5: Higher-brain death is defined as the irreversible cessation of all "higher" brain functions (e.g., cognitive functioning, consciousness, memory, and reasoning).

Feedback 6: Heart–lung death is defined as the irreversible cessation of spontaneous respirations and circulation.

76

Which of the following is the definition of death established in the Uniform Determination of Death Act of 1981?

1) Either irreversible cessation of circulatory and respiratory functions OR irreversible cessation of all functions of the entire brain, including the brainstem

2) Both irreversible cessation of circulatory and respiratory functions AND irreversible cessation of all functions of the entire brain, including the brainstem

3) Irreversible cessation of circulatory and respiratory functions

4) Irreversible cessation of all functions of the entire brain, including the brainstem

1

Correct!

The Uniform Determination of Death Act of 1981 defines death as either the irreversible cessation of circulatory and respiratory functions OR the irreversible cessation of all functions of the entire brain, including the brainstem.

77

You are caring for a client with depression who is grieving the loss of his life partner, who died recently after a long bout with AIDS. The client plans a funeral for his partner and invites his parents. His mother, however, tells him not to expect them to attend: "He's just your boyfriend, after all." Which of the following types of grief is the man most likely to experience in this case?

1) Anticipatory grief

2) Disenfranchised grief

3) Chronic grief

4) Masked grief

2

Disenfranchised grief is experienced in connection with a loss that is not socially supported or acknowledged by the usual rites or ceremonies. Some examples include a couple who experienced a miscarriage, the unplanned termination of a foster child placement, a mistress whose lover dies, or a bereaved partner in a homosexual relationship.

78

You are providing grief education to a family who lost their wife and mother earlier in the day. Which of the following should you do?

SELECT ALL THAT APPLY.

1) Explain the stages of grief.
2) Inform them that grieving typically lasts several weeks.
3) Explain that grief may ease on the anniversary of the death.
4) Tell the family that the feelings may be so intense that they wonder whether they are losing their sanity.
5) Give the family instructions on the proper way to grieve.
6) Assure the family that although the grief process takes time, the symptoms won't last foreve

1 4 6

Correct!

Feedback 1: When providing grief education, you should explain the stages of grief.

Feedback 2: Explain that grief may take months or even years to resolve, not several weeks.

Feedback 3: Explain that grief may become more intense, not ease, on the anniversary of the death (or other loss) and on significant dates (e.g., birthdays).

Feedback 4: Recall that once the bereaved person accepts that the loss is real, his feelings may be so intense that he may wonder whether he is losing his sanity.

Feedback 5: Reassure the family that there is no single right way to grieve.

Feedback 6: Assure the family that although the grief process takes time, the symptoms won't last forever.

79

You are caring for a number of clients who have experienced losses. Which of the following is an example of a perceived loss, as opposed to an actual loss?

1) Death of one's grandmother

2) Theft of one's wedding ring

3) Loss of one's dignity through bullying

4) Destruction of one's home by a tornado

3

Correct!

Perceived loss is internal; it is identified only by the person experiencing it, such as the loss of one's dignity through being bullied.

80

Which of the following is true of hospice care that is not true of palliative care?

1) Holistic

2) Comfort focused

3) Death within 6 months

4) End-of-life care

3

Correct!

Hospice care focuses on holistic care of patients who are dying or debilitated and not expected to improve. For a patient to be eligible for hospice insurance benefits, a physician must certify that the patient is likely to die within 6 months. A patient does not necessarily have to be "actively dying" to receive palliative care. It is also provided over a long period of time for those who have slowly progressive diseases.

81
  • Below are Kübler-Ross's stages of dying and grief. Put them in the correct order.
  1. Anger
  2. Depression
  3. Acceptance
  4. Bargaining
  5. Denial

Correct!

Kübler-Ross's stages of dying and grief are as follows: 1. denial, 2. anger, 3. bargaining, 4. depression, and 5. acceptance.

82

Which of the following are examples of mourning, as opposed to grief?

SELECT ALL THAT APPLY.

1) Wearing black clothing after the death of a sister
2) Weeping at a funeral of a cousin
3) Feeling depressed because of the loss of a husband
4) Being exhausted after the death of a child
5) Wrestling with one's faith after the death of a friend
6) Drawing the shades in the windows of one's home following the death of a son

1 2 6

Correct!

Feedback 1: Mourning consists of actions associated with grief, such as wearing black clothing.

Feedback 2: Mourning consists of actions associated with grief, such as weeping at a funeral.

Feedback 3: Grief is the physical, psychological, and spiritual responses to a loss, such as feeling depressed.

Feedback 4: Grief is the physical, psychological, and spiritual responses to a loss, such as being exhausted.

Feedback 5: Grief is the physical, psychological, and spiritual responses to a loss, such as wrestling with one's faith.

Feedback 6: Mourning consists of actions associated with grief, such as drawing the shades in the windows of one's home.

83

A patient has just died and his family is standing around the body grieving. Which of the following postmortem interventions should you make immediately and in the coming hours?

SELECT ALL THAT APPLY.

1) Straighten the bedcovers.
2) Inform the family that they may have 10 minutes alone with the body.
3) Remove all tubes.
4) Make the patient look as natural as possible.
5) Arrange for transportation to the morgue or funeral home.
6) Determine the disposition of the patient's belongings.

1 3 4 5 6

Correct!

Feedback 1: If the family wishes to be alone with the body, straighten the bedcovers, remove all tubes (unless contraindicated), and make the patient look as natural as possible.

Feedback 2: Give family members whatever time they need—not just 10 minutes—before you prepare the body.

Feedback 3: If the family wishes to be alone with the body, straighten the bedcovers, remove all tubes (unless contraindicated), and make the patient look as natural as possible.

Feedback 4: If the family wishes to be alone with the body, straighten the bedcovers, remove all tubes (unless contraindicated), and make the patient look as natural as possible.

Feedback 5: Postmortem care includes care of the patient's body after death and fulfilling any legal obligations, such as arranging transportation to the morgue or funeral home and determining the disposition of the patient's belongings.

Feedback 6: Postmortem care includes care of the patient's body after death and fulfilling any legal obligations, such as arranging transportation to the morgue or funeral home and determining the disposition of the patient's belongings.

84

You are caring for a client whose ex-husband died in a car accident 6 months after a bitter divorce. This is the client's first significant loss of a loved one. She is has many friends, is a member of a tight-knit family, and has a strong religious faith. Based on these circumstances, which of the following factors will most likely complicate and prolong the client's grief?

1) Support system
2) Unresolved conflict

3) Previous loss
4) Spiritual beliefs and practices

2

Correct!

The client's bitter divorce 6 months before the death of her ex-husband makes it likely that she will have unresolved conflict that will complicate and prolong her grief.

85

A mother has just learned that her child, who has leukemia, likely has no more than a couple of weeks to live. The mother is sitting in the child's hospital room in a state of shock. Which of following actions should you take to help her express her feelings?

1) Sit beside her and ask, "How would you like me to help you?"
2) Stand at a distance and ask, "What do you need?"
3) Place your hand on her shoulder and say, "I know how you feel."
4) Pat her on the back and say, "Hang in there and be tough. You'll be fine."

1

Correct!

You should sit beside the client's mother and not appear rushed. To encourage the expression of feelings, ask, "How would you like me to help?" or "What do you need?"

86

You are providing care for a client whose husband died a month ago. The client says she still cries every day, has little appetite, and finds it difficult to be out of the house and around other people for long. Which of the following nursing diagnoses would be most appropriate for this client?

1) Grieving
2) Complicated Grieving
3) Denial
4) Spiritual Distress

1

Correct!

The client is grieving the loss of her husband and experiencing emotions and symptoms that are to be expected following such a loss.

87

You are caring for a patient who has just learned that his illness is terminal. The patient informs you that he has made legal arrangements for his son to make healthcare decisions on his behalf should he lapse into an irreversible coma. Which of the following is the type of arrangement that the patient is referring to?

1) Living will
2) Durable power of attorney
3) Power of attorney
4) DNAR

2

Correct!

A durable power of attorney, or healthcare proxy, exists when another person is identified to make decisions for the individual regarding healthcare choices when he is unable to do so based on circumstances (e.g., irreversible coma, terminal illness).