Eliopoulos Chapter 36- End of Life Care

1. The 45-year-old son of a dying woman is profoundly uncomfortable with discussions of her expected time of death, funeral preparations, and the signs and symptoms that may signal that death is imminent. Which of the following historical phenomena may have contributed to the son's reluctance to acknowledge the reality of death?

A) In the past, death was viewed positively as a welcome transition, while it is now often seen as an undesirable evil.

B) The declining death rate means that individuals live longer and survive to experience more unsettling symptoms and discomfort

than in past generations.

C) Many people now die in institutional settings, limiting the amount of previous exposure to death that many individuals have.

D) Modern medical technology and increasing vigilance of treatment has brought about a mistrust of the natural dying process.

Ans: C

Because many people now die in hospitals and care facilities rather than homes, many individuals have minimal exposure to the reality of death, exacerbating their fear and discomfort about the process. Death was not necessarily viewed positively in the past and

pain and discomfort have always been realities. Fear of the dying process is not necessarily a result of advances in medical

technology.

2. A 79-year-old woman with a longstanding diagnosis of chronic leukemia experienced a blast crisis one week ago and died overnight. Place the stages of the coping mechanisms that the woman's family will go through in the most likely chronological order. Use all the options.

A) Anger

B) Denial

C) Acceptance

D) Bargaining

E) Depression

Ans: B, A, D, E, C

Kübler-Ross' conceptual framework of the coping mechanisms surrounding death progress through stages of denial, anger,

bargaining, depression and acceptance.

3. The daughter of a 79-year-old man with a diagnosis of small-cell lung cancer has learned that her father has been found to have bone metastases. The daughter has approached the oncologist who is caring for him with information that she has found on the Internet that promises to cause remission of cancer through intensive antioxidant therapy. She is adamant that the physician facilitate the treatment and liaise with the providers who are located overseas. Which of the stages of Kübler-Ross' conceptual framework is the daughter most likely experiencing?

A) Depression

B) Anger

C) Denial

D) Bargaining

Ans: C

The quest for a more positive outcome from unlikely sources is associated with the stage of denial.

4. Faced with the crushing reality of her imminent death, a 72-year-old female patient with advanced pancreatic cancer has become withdrawn and quiet, with her family stating that they believe she is depressed. Which of the following interventions should the nurse prioritize?

A) Create a physical environment with more natural light and privacy

B) Emphasize the patient's need for a sustained serotonin reuptake inhibitor (SSRI) to her care team.

C) Provide gentle encouragement and assure the patient that the care team will prioritize her pain control.

D) Focus on being truly with the patient and using therapeutic touch appropriately.

Ans: D

Given the gravity of the dying patient's circumstances, encouragement, modifications to the physical environment or

antidepressants are unlikely to be as therapeutic as simple touch and presence.

5. The children and wife of a man dying of renal failure are eager to interact with him as much as possible in the days before his death. Consequently, the daughter has questioned the nurse's decision to administer the man's scheduled hydromorphone, stating that he does not appear to be in pain at the present time and that the drug tends to make him drowsy. What is the nurse's most appropriate first action?

A) Explain the rationale for preventative pain control to the family

B) Document the family's reservations and administer the drug after they have completed their visit

C) Administer an analgesic that is less likely to have a sedative effect

D) Administer a partial dose of hydromorphone to the patient

Ans: A

An explanation of the principle of preventative pain control may help the family be more at ease with the nurse's administration of the

drug and this should constitute the nurse's initial response. If the family remains resistant after an explanation, then the nurse needs to decide about choosing one of the other options or giving the drug.

6. Mrs. H, aged 80, experienced a severe hemorrhagic stroke 7 days ago, and is not expected to survive the night. Mrs. H's family is gathered at her bedside with a member of her church's clergy. Her son has taken the nurse aside and asked how the family will be able to tell that their mother is about to die. How can the nurse best respond?

A) "People usually experience a gradual slowing of their heart rate in the hours before death."

B) "A lack of sweating, even though they have a fever, often means that someone is coming to the end."

C) "Often as death approaches, the individual's eyes stop responding to light or else respond very slowly."

D) "When a person's veins become prominent from the sudden increase in blood pressure, it means the heart is making its final efforts."

Ans: C

Slow or absent pupil response is a sign of imminent death, as are diaphoresis, a rapid, thready pulse, and low blood pressure.

7. The death of an 86-year-old male hospital patient was overshadowed by the fact that his son and his daughter disagreed vehemently on

the type and quantity of medical interventions undertaken near the end of their father's life. The daughter insisted, "Dad would want us to do everything reasonable that we could to save him" while the son countered, "He would want to go with dignity, not with tubes sticking out of him."

When should the issue of terminal care and life-sustaining measures have been raised?

A) When the patient received a diagnosis from his primary care provider

B) When a family meeting could be organized by the care team

C) When standard interventions had been exhausted

D) When the patient was first admitted to the hospital

Ans: D

The Patient Self-Determination Act requires that end-of-life care be discussed, and the best time for this to be undertaken is immediately following admission to the hospital or care facility.

8. At the beginning of her shift, a nurse has entered the room of a 78-year-old male patient who is in the late stages of liver failure. The patient's son, who has interacted with the nurse appropriately in the past, states, "If you all wouldn't have botched his treatment when he first had this problem, he wouldn't be lying here dying." The nurse understands that which of the following phenomena may underlie the son's statement?

A) The son is exhibiting the effects of depression common in those experiencing a loss.

B) A common manifestation of anger about the death of a loved one is to direct it elsewhere.

C) The son is reacting inappropriately to his imminent loss.

D) Survivors of a dying individual often attempt to bargain for their return to health.

Ans: B

The son is likely exhibiting the effects of the anger stage of the dying process. This is less likely to be an expression of

bargaining or depression. It would be simplistic to characterize his statement as inappropriate.

9. Which of the following interventions is likely to be of greatest benefit to the family of an 81-year-old woman who has just died from a sudden myocardial infarction?

A) Begin working with the family immediately after the woman's funeral has been completed.

B) Negative emotions toward the deceased woman need to be explored before healing can begin.

C) Even though few survivors want to speak directly with a counselor or therapist, it is important to present the opportunity.

D) Survivors benefit from medical support, not just spiritual and psychosocial support.

Ans: D

Schneidman notes that survivors benefit from medical evaluation and monitoring. It is best to begin working with the family as soon as possible after the tragedy; negative emotions should not be explored early in the process. Very few survivor-victims are resistant to speaking with someone.

10. The nursing staff on a palliative care unit are helping an unlicensed care provider, who has had little prior exposure to death, adjust to the unique demands of working in such an environment. Which of the following actions are likely to benefit the care provider? Select all that apply.

A) The nurses encourage the care provider to find a confidante outside the hospital in order to avoid showing emotion openly while on duty

B) The nurses encourage stepping back from intense situations and examining whether strong reactions are impacting the

therapeutic relationship.

C) The nurses teach the care provider how to be therapeutic while still maintaining an emotionally detached relationship from

patients and families.

D) The nurses try to help the care provider verbalize emotions and reactions to death.

E) The nurses provide a location on the unit where all staff members can retreat during intense encounters.

Ans: B, D, E

Reflection, verbalization, and the opportunity for retreat can be beneficial to persons who provide care for the dying and their

families. Requiring emotions to be stifled while at work and striving for emotional detachment are not appropriate goals.

11. Mrs. W, a 70-year-old woman with cancer, has been told she could die at any time. Her illness is more serious than it appears, and her daughter is not sure what to tell the grandchildren, who are aged 10 and 12. Which of the following is the best thing a nurse might tell the grandchildren?

A) Tell them that Mrs. W is going to die.

B) Tell them nothing until Mrs. W worsens.

C) Tell them that Mrs. W is ill and that the nurses are concerned.

D) Tell them that Mrs. W is ill but will recover.

Ans: C

Lying to children about illness and death is unfair and deprives them of a chance to have some close moments with a dying grandparent. On the other hand, knowing that death is imminent may create a barrier to their normal relationship. If the daughter says nothing to the grandchildren until Mrs. W gets worse, Mrs. W may die so suddenly that there is no chance to prepare the grandchildren

for her death. There is no easy answer to this dilemma, but choice C seems to be best.

12. After an elderly hospital patient had a heart attack, his cardiac and pulmonary functions ceased. How is that criterion of death

documented?

A) Brain death

B) Molecular death

C) Somatic death

D) Cardiopulmonary death

Ans: C

Brain death refers to the death of brain cells, as indicated by a flat EEG; molecular death refers to the cessation of cellular function. Somatic death refers to the body and is indicated by cessation of cardiac and pulmonary functions. Cardiopulmonary death sounds correct but is not a technical term.

13. A nurse is worried about his health because he believes he carries a gene for a fatal disease. What does he need to do for the sake of his own mental health and for that of his seriously ill patients?

A) Work with patients who are likely to recover

B) Come to grips with his own mortality

C) Work in the maternity ward

D) Adopt a cheerful demeanor with all patients

Ans: B

Many nurses like the cheerful atmosphere of a maternity ward or other hospital section where patients usually get better and go home. Working in such a section might help him temporarily, but not for long. Also, a nurse may put on a cheerful mask that helps himself and others for a short time, but eventually he needs to confront his own mortality. If he tries to deal with dying patients and their families before doing so, he may deny them the comfort and understanding they need during a crucial time.

14. Which of the following is the most important nursing action to take during a patient's denial stage of dying?

A) Act as a shock absorber for the patient's emotions while the patient confronts reality

B) Allow the patient to express the feeling that nothing is right

C) Accept the dying patient's reactions and provide an open door for honest dialogue

D) Impress upon the patient and his or her family that the inevitable cannot be postponed

Ans: C

The nurse must be sensitive to the patient's need for defenses while also being ready to participate in discussion on death when the patient needs to do so. Choice A is a description of the function of denial. Choice B is a nursing action for the anger stage. Choice D is related to the bargaining stage.

15. Knowing that she was dying, Mrs. P tried to use her condition to obtain sympathy and special treatment from the staff. Worse, she became

angry at the slightest provocation. If a nurse failed to answer a light signal immediately, Mrs. P started cursing loudly. Once, she threw a saucer at a nursing assistant who annoyed her. How can a nurse who feels disturbed by her handle this patient?

A) Accept Mrs. P's anger without comment, and forget about it

B) Return Mrs. P's anger to let her feel justified in being difficult

C) Turn her or his own anger into a joking response to Mrs. P

D) Accept Mrs. P's anger without comment, but talk with a colleague about it

Ans: D

Patients vary greatly in behavior and needs, but in general dying patients go through a stage in which they react to everyone with anger. Nurses need to be aware that this will happen and talk with someone about their feelings rather than vent them on the patient.

With experience, a nurse may become able to accept the situation without feeling disturbed.

16. Mr. G has been an atheist for many years, although he was raised as a Catholic. In talking with his nurse, he says he wants nothing to do with organized religion. Now he is dying and depressed. What helpful advice might the nurse give his family about dealing with Mr. G's depression?

A) Make his physical environment more pleasant

B) Bring in a priest to visit with him

C) Make an effort to improve his mood

D) Stay with him for support

Ans: D

At this stage, Mr. G needs to feel the love of his family. There is little use in pretense or cheerfulness. Although he may be silently coming to terms with his lack of religious beliefs, he should not be pushed into being visited by a priest unless he expresses a desire

for it; if he does express such a desire, every effort should be made to bring a priest to him.

17. Miss L is dying. She is pale and irritable, and the hospice nurse thinks she may be in pain. What should the nurse do?

A) Assume that Miss L must be in pain

B) Ask Miss L if she is feeling pain

C) Provide Miss L pain relief without asking

D) Consult Miss L's chart for her previous presentation of pain

Ans: B

Patients react in very different ways to pain and express themselves differently. The nurse should assume nothing, but ask Miss L about pain and have her rate it on a scale of 0 to 10. This self-appraisal should be recorded with other information.

18. An elderly man dying of cancer tells a nurse that his pain is becoming much worse and rates it as 9 on a scale of 0 to 10. What pain relief

should be provided?

A) Codeine

B) Meperidine

C) Oxycodone

D) Morphine or hydromorphone

Ans: D

The patient should receive an analgesic immediately to prevent the pain from becoming even more severe. Morphine or

hydromorphone is given for severe pain. Codeine and oxycodone are for moderate pain, and meperidine is contraindicated in elderly

patients because it causes psychoses and other adverse effects at low dosages.

19. Mr. E is dying and has a great deal of pain. His oncologist is considering adding some alternative measures, such as hypnosis and acupuncture, to the drugs he already takes. What effect may such alternative measures have?

A) They may reduce the required drug dosages or potentiate their effects.

B) They may be useful substitutes for the analgesics.

C) They may interfere with the effects of the analgesics.

D) They may be effective but detract from the nurses' time to care for Mr. E.

Ans: A

Alternative measures cannot substitute for drugs but are often useful adjuncts in pain therapy. Such measures are unlikely to interfere with effects of analgesics. The truly time-consuming alternatives will probably be supplied by their practitioners rather than by nurses.

20. An elderly dying woman becomes panicky, convinced that she is suffocating. What is a likely cause of the discomfort she is feeling?

A) Dyspnea

B) Anxiety

C) Dropping levels of blood gases

D) Hypokalemia

Ans: C

One cause of respiratory distress is deteriorating blood gas levels. The respiratory distress (or dyspnea) she is experiencing is common in dying patients; it results in anxiety and fear. Hypokalemia is a lowered blood level of potassium.

21. Even if they are hungry, dying patients may find it difficult to eat and keep food down. To help with this problem, which of the following is best for a hospice nurse to give such a patient?

A) Small-portioned meals

B) Analgesia with meals

C) More nutritious meals

D) Reduced fluid intake

Ans: A

Appealing but small-portioned meals are more likely than larger ones to be successfully kept down. Analgesia would not

necessarily promote intake. Reduced fluid intake would most likely result in constipation.

22. Four patients with terminal cancer are in a hospital ward. A nurse observing them on her rounds realizes that one may be near death. Which patient is it?

A) Patient A has a rapid, weak pulse

B) Patient B is not perspiring

C) Patient C has very red skin

D) Patient D's blood pressure has risen suddenly

Ans: A

Patient A has one of the many signs that bodily functions are slowing down. Some of the other signs are profuse perspiration, pallor, and decline in blood pressure.

23. When a patient is admitted to a hospital, he or she is asked if an advance directive is available in case terminal care is necessary. What does an advance directive do?

A) It gives the patient's family control over terminal care.

B) It gives the patient control over terminal care.

C) It gives the hospital control over terminal care.

D) It gives the attending physician control over terminal care.

Ans: B

By signing an advance directive, a patient can ensure receiving the terminal care he or she wishes, rather than burdening family

members with making those decisions. Without an advance directive, a patient may be resuscitated even if there is no hope of

meaningful life returning.

24. Rev. M, a minister in his early 70s, has pancreatic cancer and is expected to die soon. His son and daughter both visit him often. The son causes trouble for the staff by continually criticizing them for no apparent reason. He also asks repeatedly why his father, a good and loving minister,

should have to die at a relatively young age. The daughter talks and prays with their father and brings him his favorite books for comfort. Although she is obviously distressed, she is already making tentative plans to move out of the family house and into an apartment. These preparations seem callous to her brother, who becomes further angered. Which stages of grief are the two exhibiting?

A) The son has reached the stage of acceptance; the daughter is in the stage of anger.

B) The son has reached the stage of bargaining; the daughter is in the stage of denial.

C) The son is in the stage of anger; the daughter has reached the stage of acceptance

D) The son is in the stage of denial; the daughter has reached the stage of anger.

Ans: C

The son's anger about his father's dying is being directed toward the staff and his sister. The daughter is unhappy but has accepted the situation and will be ready to move on after their father dies. Both have passed through denial that he will die, and

neither is trying to bargain with God.

25. The hospital's nursing staff has become very attached to Rev. M. When he dies, the nurse on duty hugs the son and daughter and cries

with them. Which of the following is the best description of the nurse's behavior?

A) It is appropriate in any similar situation.

B) It is appropriate in this situation.

C) It is unprofessional.

D) It is inappropriately emotional.

Ans: B

A family might not welcome this behavior in some instances, but the nurse has a genuine fondness for Rev. M, and that may help the son and daughter in their own grief. Although nurses must behave with objectivity in making decisions about patient care, warmth and

caring are also important aspects of their work.