Terminal Illness - Iggy chap 7, Varc chap 30
Terms in this set (49)
hospice and palliative care
-hospice is an interdisciplinary approach to assess a families needs.
-hospice ideal is a peaceful death
-prognosis is usually less than 6 months to live.
-this makes you qualified.
-drug therapy is a major component of hospice.
-hospice is used more for quality of life rather than providing care to die.
-used for people who are sick but can live longer than 6 months
-provided by a physician, or NP in order to provide continued care.
HOSPICE VS PALLIATIVE CARE
-prognosis of less than 6 months
-curative treatment is stopped (chemo)
-60 to 90 day periods with a choice to continue
-ongoing care by RN, social workers, chaplains and volunteers
-can be at any stage of illness
-curative therapies continue
-care is not limited to time periods
-recommendations are still made for treatment
near death assessment
-skin is often cold, mottled, and cyanotic
-less oxygen or perfusion
-BP is way low
-HR may be increased, irregular, and gradually decrease
-apnea and cheyne stokes (apnea with rapid breathing) is common
-sleeping more than 23 hours a day
-people facing death may have fear or anxiety about the impending fact.
-assess cultural considerations and values
-needs and preferences are met
-control of symptoms of distress
-meaningful interactions with family
-a peaceful death
-with hospice you will have drug therapy
-they want your death to be painless and peaceful.
-drugs help this happen
patient distress during end of life care;
-breathless or apnea
-nausea and vomit
-restless and agitation
-pain is the most distressing symptom that dying patients fear the most
-when the patient can no longer swallow, rectal or dermal patches or IV can be used.
-fentanyl IV has less occurrences of delirium from failing kidney function and toxic buildup.
complementary and alternative therapies
-massage may decrease pain (especially cancer)
-short massages not deep.
-weakness and fatigue occurs when death nears
-risk for aspiration
-soft foods and sips of liquids (if the pt wants)
-anorexia is a normal stage of death
-stopping food and liquid intake is a normal part of the dying process.
-giving fluids can actually increase discomfort in a person with multi system letdown
-fluids can cause respiratory secretions, GI secretions, nausea, vomit, edema, ascites
-people think dehydration close to death is actually a good thing and releases endorphines
breathless / dyspnea management
-opiods are a standard treatment for dyspnea near death.
-they reduce anxiety, reduce air hunger, and reduce pulmonary congestion with dilating vessels
-morphine is mainstay treatment
-can be as often as every half
-can progress to IV
-o2 therapy near death has not been shown to be a standard of car.e
-you should offer it near dyspnea anyway.
-oxygen can be a stress reducer
-albuterol or ipratropium can also be used
-diuretics if crackles are present
-common sense treatments
-loud, wet respirations
-reposition to one side to reduce gurgling
-keep a fan near them to promote circulation of air
nausea and vomit management
-common with AIDs
-breast, stomach, or gynecologic cancers
-enema can help
agitation and delirium management
-agitation at end of life first requires assessing for pain or other issues
-delirium is a syndrome manifested by acute changes in arousal.
-memory, attention, sleep, perceptual issues
-considered terminal delirium
psychosocial interventions for care of a dying patient
-being with the patient
-respect their cultural preferences
-avoid explanations of the loss
-communicate with the patient
-bereavement specialists may be needed
-emergency assistance isn't needed if the death was meant to be at home and waiting for it.
-family calls hospice if they were enlisted.
-would you like to spend time with the body?
-autopsy is usually only done if the death is suspicious of unknown
-orthodox jews do not allow autopsy
concept of euthanasia
withdrawing or with holding life sustaining therapy;
-discontinuing therapies that might help you
-"let the person die naturally"
-the withdrawal of interventions isn't what kills you, your progression of poor health status does.
-most health care policies respect the decision to stop treatment once it's at a point
-close to death and interventions are considered medically futile or capable of harming you
-HCP takes an action with medicine or treatment
-purposefully and directly causes death
-this is not supported by most organizations, including ANA
-Washington, oregon, and Vermont, this is allowed
-nurses should not be involved in this process
The nurse at the hospice center is caring for a terminally ill client. What psychosocial intervention by the nurse provides support to the client and family?
Explanation of the impending loss
Encouraging reminiscence @
Refraining from discussing physical signs of death
Avoiding discussion about spirituality
The nurse should encourage reminiscence for both the client and family to provide the ability to attain perspective and enhance meaning. The nurse should not try to explain the impending loss to the family; it may not be acceptable. The nurse should teach about the physical signs of death to the family, and should promote spirituality, if the client and family are receptive, and be culturally sensitive.
When does the nurse recognize that death has occurred in a client?
Pupils become constricted
Jaw closes tightly
Breathing stops @@
When breathing stops, the heart stops beating and it is evident that death has occurred in the client. Other physical manifestations of death include fixed and dilated pupils. The eye may close or remain open without blinking. The jaw may fall open.
A client with terminal lung cancer is admitted to a hospice center. What is the focus of hospice care?
It facilitates quality of life and peaceful death.
It allows natural death to take place.
It postpones the death of the client.
It supports functional independence of the client.
The focus of hospice care is to facilitate the quality of life and peaceful death by using an interdisciplinary approach to assess and address the holistic needs of the client and family. A "do not resuscitate" (DNR) order allows a client to die a natural death. Hospice care does not postpone or hasten the death of a client. Palliative care supports functional independence of the client.
The nurse is caring for a client who has a POLST (physician orders for life-sustaining treatment). What is a POLST?
A special bracelet worn by the client
A special necklace worn by the client
A document where additional treatments in case of cardiac or pulmonary arrest are ordered
A portable DNR order
A POLST is an advanced directive in which documentation for additional treatments in case of cardiac or pulmonary arrest are ordered by the patient's physician. A POLST follows the patient across all healthcare settings. A portable DNR order is a state-designated, signed wallet card that is completed before the client is admitted to the hospital. Like the POLST, a portable DNR follows the patient across healthcare settings. The client may also wear a special DNR bracelet or necklace.
Which activity must the nurse attending to a terminally ill client avoid?
Advocating for the client's wishes.
Participating in active euthanasia@@@.
Ensuring quality symptom management.
Providing support at end of life.
The nurse caring for the terminally ill client must not participate in active euthanasia or primary health care provider-assisted euthanasia. Active euthanasia is not supported by the American Nurses Association. Nurses however, play a major role in advocating for the client's wishes such as advance directives. Nurses are also expected to ensure quality symptom management by administering prescribed medications. Nurses provide moral support to the family and client at the end of life
The nurse arranges for bereavement counselors to meet a terminally ill client and family. What does the bereavement counselor do?
Explains the loss in philosophic or religious terms.
Fosters hope for the client and family by listening and caring.
Helps the client and family to cope prior to and after death. @@
Assesses the spiritual needs of the dying client.
The bereavement counselor helps the client and family to cope with the situation before and after death. They are aware of the grieving process and encourage the family to be part of a support group. They do not explain loss in philosophic or religious terms. Hope gives the family the strength to go forward in darkest times. The nurse fosters hope for the client and family by listening and caring, while explaining the gravity of the situation. The nurse also assesses and identifies the spiritual needs of the dying client. This facilitates an open expression of the client's beliefs and needs.
Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds. Continue to analyze the options. If you can eliminate one more choice in a four-option question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago had seemed completely forgotten.
The nurse manager for home health and hospice is scheduling daily client visits. Which client is appropriate for the nursing assistant to visit?
Advanced cirrhosis of the liver; called the hospice agency reporting nausea
Aggressive brain tumor; needs daily assistance with ambulation and bathing@@@@
Inoperable lung cancer; considering whether to have radiation and chemotherapy
Prostate cancer and bone metastases; has new-onset leg weakness and tingling
Assisting clients with activities of daily living (ADLs) is a common role for nursing assistants working in home health or hospice agencies. Assessing and acting upon a new symptom (nausea), helping clients make decisions, and evaluating a new-onset symptom all require more complex assessment skills and interventions, which are within the RN scope of practice.
The nurse at the hospice center is caring for a client approaching death. The client is unable to cough up secretions effectively. What interventions does the nurse perform for this client?
Offer ice chips at frequent intervals.
Massage the client's forehead.
Position the client on the side.@@@@@
Use moist swabs to keep the lips and mouth moist.
If the client is unable to cough up secretions, the nurse should position the client on the side. The client is offered ice chips to prevent dryness of the mouth and lips. The client's forehead is massaged to soothe the restless client with decreased metabolism and slowed circulation to the brain. Moist swabs are used to keep the lips and mouth moist in clients with reduced metabolic needs.
A hospice client has just died. Which of these postmortem nursing tasks is most appropriate to delegate to a nursing assistant?
Assessing the client for cessation of respiratory effort and lack of pulse
Documenting the time of death and required assessment data on the chart
Notifying the spouse and other family members about the client's death
Removing or cutting all IV lines or tubes according to the hospice policy
Preparing the body for viewing by the family (such as removing tubing and lines) and/or transfer to the morgue is an appropriate task for unlicensed assistive personnel (UAP). Assessing for signs of life, documenting about the death, and spousal and family notification all require broader education and should be done by licensed nursing staff.
A dying client becomes increasingly withdrawn and begins to refuse to eat and drink. What intervention does the nurse implement?
Brings in the client's favorite Chinese takeout food
Calls the family to come in right away
Gives intravenous hydration
Offers ice chips@@@@
The dying client should not be forced to eat or drink, but small sips of liquids or ice chips at frequent intervals can be offered if the client is alert and able to swallow. This helps the client with problems of dehydration and "dry mouth." The dying client's metabolic needs have decreased, so the client will not want any food or drink. Calling the family is not yet necessary in this client's case. Because the dying client's metabolic needs have decreased, invasive procedures are not necessary at this point.
A client with terminal pancreatic cancer is near death and reports increasing shortness of breath with associated anxiety. Which hospice protocol order does the nurse implement first?
Albuterol (Proventil) 0.5% solution per nebulizer
Morphine sulfate (Roxanol) 5 to 10 mg sublingually as needed@@@@@@@@
Oxygen 2 to 6 L/min per nasal cannula
Prednisone (Deltasone) elixir 10 mg orally
Morphine sulfate is the standard treatment for the dyspneic client who is near death. Albuterol (Proventil), oxygen, and steroids may be useful, but should be used as adjuncts to therapy with morphine.
Test-Taking Tip: Get a good night's sleep before an exam. Staying up all night to study before an exam rarely helps anyone. It usually interferes with the ability to concentrate.
A hospitalized client of the Islamic (Muslim) religion is dying. What concept does the nurse share with the health care team about this client's beliefs about death?
Death is seen as the beginning of a new and better life.@@@
Life experiences do not affect the individual's preparation for "everlasting life."
The timing of death is under the power of the person who is facing death.
Plans for burial will take days, maybe even weeks, after the death
In the Muslim faith, death is seen as the beginning of a new and better life.This is a fundamental belief of the religion. Life is meant to be a test of preparation for everlasting life in the hereafter; life experiences do affect the person's afterlife existence. Muslims believe that God, Allah, rather than the person, has prescribed a time of death for everyone. Preparation for burial takes place as soon as possible after death has occurred.
A client dying of cancer is receiving high doses of opioids. In addition, which intervention is the most effective for this client?
Deep muscle massage
More pain medication
Short, light massage@@@@@
Massage has been shown to decrease pain in individuals with cancer. Light pressure is best, and deep or intense pressure should be avoided. Although music therapy may be effective, the type of music played should be the client's choice; it should not be assumed that the client wants to hear classical music. The dying client who is frail may not tolerate an extensive deep massage. The client is already receiving high doses of opioids; complementary or alternative therapy can replace the need for increased pain medication.
What religious belief of the client who is Jewish does the nurse consider when providing postmortem care?
The body must not be embalmed.@@@@
The body is displayed before cremation.
The soul leaves this world as soon as death occurs.
The family observes a 14-day mourning period.
As per the Jewish religion, the body of a deceased client is not embalmed. The body is also not displayed or cremated. The Jewish faith believes that the soul does not leave this world until after burial. The body is not left unattended until the funeral, which takes place preferably within 24 hours. The family of the deceased client observes a 7-day mourning period called Shiva.
The nurse is caring for a dying client. The family is disturbed as they watch their loved one alternating between periods of apnea and periods of rapid breathing. What is the most suitable response by the nurse?
The changes in breathing are a common sign of the end of life."
"These signs generally do not cause physical discomfort to the client."@@@@@
"The client will die when the respirations stop."
"Pain medication will be administered when the client reports pain."
The nurse should inform the family that breathing irregularities generally do not cause physical discomfort to the client. The changes in breathing are a sign/symptom of physical decline; pain, weakness, and breathlessness are common symptoms of the end of life. The client will eventually die when the heartbeat and respirations stop. Even if the client does not express the presence of pain and discomfort, pain medication should be administered at regular intervals or as needed.
Test-Taking Tip: Read every word of each question and option before responding to the item. Glossing over the questions just to get through the examination quickly can cause you to misread or misinterpret the real intent of the question.
A dying client cannot swallow and is accumulating audible mucus in the upper airway (death rattles). The nursing assistant reports that these noises are upsetting to family members. What does the nurse tell the assistant to do?
Assist the family in leaving the room so that they can compose themselves.
Place the client in a side-lying position so secretions can drain.@@@@
Position the client in a high Fowler's position to minimize secretions.
Use a Yankauer suction tip to remove secretions from the client's upper airway.
Placing the client in a side-lying position to facilitate draining of secretions (by gravity) is the appropriate nursing care intervention. As secretions diminish, noisy respirations will decrease. Asking the family to leave at this important time is not appropriate. Placing the client in a high Fowler's position is ineffective in helping the client who has lost the ability to swallow; the danger of choking and aspiration would increase. Not only is oropharyngeal suctioning outside the scope of practice of the nursing assistant, it is also not recommended for removal of secretions, because it is not effective and may even agitate the dying client.
The nurse is caring for a Jewish client in the hospice center. What is this client's likely attitude and belief regarding terminal illness?
Foregoing treatment is morally permissible.
The sacrament of the sick must be administered by a priest.
The client should not be left alone.@@@
Lie facing Mecca during the last days of life.
As per Jewish law, a person who is extremely ill and dying should not be left alone. A Christian client may forego treatment if it is morally permissible, and may also receive the sacrament of the sick administered by a priest. A client of Islamic faith may want to lie facing Mecca during the last days of life.
-holistic approach to care
-focuses on reducing severity of disease
-should be initiated upon diagnosis
-not so much worried about delaying or reversing progression but rather don't allow it to worsen
-treatment aligns with their spiritualistic beliefs as well as there wants
-prevent and relief suffering
-improve quality of life with serious issues
-compassion, concern, and support for a dying pt
-begins once someone decides to forego curative treatments
-i no longer want medications for my pancreatic cancer.
-this exists to provide comfort in last phases of terminal illness
-must want hospice
-must have less than 6 months to live
-2 physicians verified you have less than 6 mo to live
-occurs once all vital organs stop working
-cardio, respiratory, brain function
end of life care
-final phases of life and death is imminent
end of life care;
-provide comfort and support
-improve quality of life that remains
-help ensure dignified death
-provide emotional support to a family
-metabolism is lost
-body gradually begins to slow down
-respiration generally ceases first
-heart stops shortly after
physical manifesations of end of life
-irregular breathing or cheyne stokes
-inability to clear secretions causing a death rattle. this is dealt with side lying position
-hearing is usually last sense to disappear
-decreased perception of pain and touch
-mottling of hands and feet
-cold clammy skin
-wax like skin (very close to death)
-gradual decrease in urine
-incontinent of urine
-unable to urinate
-do not give a person close to death fluids. it can cause more issues like distention and vomiting.
-period of time following the death of someone that a loved one griefs and experiences mourning
-this and grief counseling is an important aspect of palliative care.
-normal process reacting to a loss
-complex and emotional experience
model of grief
kubler ross; five stages
the grief wheel;
-people can begin to feel these emotions before the actual death
-can also occur for the dying person
-grief that helps accept the reality
-revealed in positive memories and seeing some good from the death
-prolonged grief disorder
-recurrent and severe distress
-denial of the loss for longer than 6 months
-affects 1 in 5 people
-some people feel like their spiritual beliefs help the death
-why is this happening to me
-questioning of a higher power
-doesn't always mean a God. can be something like are you happy with the decisions you made in your life. spirituality and religion are 2 different things.
-advance care planning is having patients think about and docuement their values and goals of treatment.
-advance directives are written documents of wishes
-ANA does not support this
-nurses do not participate in active euthanasia
-decisions to with hold nutrition and hydration is made with patients or surrogates and the health care team.
4 specific fears
shortness of breath
loneliness and abandonment