Lewis Chapter 11 Palliative Care at End of Life
Terms in this set (14)
According to the World Health Organization, palliative care is an approach that improves quality of life for patients and their families who face problems associated with life-threatening illnesses. From the list below, identify the specific goals of palliative care (select all that apply).
a. Regard dying as a normal process.
b. Minimize the financial burden on the family.
c. Provide relief from symptoms, including pain.
d. Affirm life and neither hasten nor postpone death.
e. Prolong the patient's life with aggressive new therapies.
f. Support holistic patient care and enhance quality of life.
g. Offer support to patients to live as actively as possible until death.
h. Assist the patient and family to identify and access pastoral care services.
i. Offer support to the family during the patient's illness and their own bereavement.
a, c, d, f, g, i. Table 10-1 lists the goals of palliative care. Overall, goals of palliative care are to prevent and relieve suffering and to improve the quality of life for the patient.
Priority Decision: The husband and daughter of a Hispanic woman dying from pancreatic cancer refuse to consider using hospice care. What is the first thing the nurse should do?
a. Assess their understanding of what hospice care services are.
b. Ask them how they will care for the patient without hospice care.
c. Talk directly to the patient and family to see if she can change their minds.
d. Accept their decision since they are Hispanic and prefer to care for their own.
a. The family may not understand what hospice care is and may need information. Some cultures and ethnic groups may underuse hospice care because of a lack of awareness of the services offered, a desire to continue with potentially curative therapies, and concerns about a lack of minority hospice workers.
List the two criteria for admission to a hospice program.
Patient must desire services and agree in writing that only hospice care can be used to treat the terminal illness (palliative care)
b. Patient must meet eligibility, which is less than 6 months to live, certified initially by two physicians
For each of the following body systems, identify three physical manifestations that the nurse would expect to see in a patient approaching death.
a. Cheyne-Stokes respiration
b. Death rattle (inability to cough and clear secretions)
c. Increased, then slowing, respiratory rate
(Also: irregular breathing, terminal gasping)
a. Mottling on hands, feet, and legs that progresses to the
b. Cold, clammy skin
c. Cyanosis on nose, nail beds, and knees
(Also: waxlike skin when very near death) Gastrointestinal
a. Slowing of the gastrointestinal tract with accumulation
of gas and abdominal distention
b. Loss of sphincter control with incontinence
c. Bowel movement before imminent death or at time of
a. Loss of muscle tone with sagging jaw
b. Difficulty speaking
c. Difficulty swallowing
(Also: loss of ability to move or maintain body position, loss of gag reflex)
Priority Decision: A terminally ill patient is unresponsive and has cold, clammy skin with mottling on the extremities. The patient's husband and two grown children are arguing at the bedside about where the patient's funeral should be held. What should the nurse do first?
a. Ask the family members to leave the room if they are going to argue.
b. Take the family members aside and explain that the patient may be able to hear them.
c. Tell the family members that this decision is premature because the patient has not yet died.
d. Remind the family that this should be the patient's decision and to ask her if she regains consciousness.
b. Hearing is often the last sense to disappear with declining consciousness and conversations can distress patients even when they appear unresponsive. Conversation around unresponsive patients should never be other than that which one would maintain if the patients were alert.
A 20-year-old patient with a massive head injury is on life support, including a ventilator to maintain respirations. What three criteria for brain death are necessary to discontinue life support?
b. Absent brainstem reflexes
A patient with end-stage liver failure tells the nurse, "If I can just live to see my first grandchild who is expected in
5 months, then I can die happy." The nurse recognizes that the patient is demonstrating which of the following stages of grieving?
a. Prolonged grief disorder
b. Kübler-Ross's stage of bargaining
c. Kübler-Ross's stage of depression
d. The new normal stage of the Grief Wheel
b. Bargaining is demonstrated by "if-then" grief behavior that is described by Kübler-Ross. Kübler-Ross's stage of depression is seen when the person says "yes me, and I am sad." Prolonged grief disorder is seen when there is a dysfunctional reaction to loss and the individual is unable to move forward after the death of a loved one. In the Grief Wheel model, the new normal stage is when the grief is resolved but the normal state, because of the loss, is not the same as before.
A terminally ill man tells the nurse, "I have never believed there is a God or an afterlife, but now it is too terrible to imagine that I will not exist. Why was I here in the first place?" What does this comment help the nurse recognize about the patient's needs?
a. He is experiencing spiritual distress.
b. This man most likely will not have a peaceful death.
c. He needs to be reassured that his feelings are normal.
d. This patient should be referred to a clergyman for a discussion of his beliefs.
a. Spiritual distress may surface when an individual
is faced with a terminal illness and it is characterized
by verbalization of inner conflicts about beliefs and questioning the meaning of one's own existence. Individuals in spiritual distress may be able to resolve the problem
and die peacefully with effective grief work but referral to
spiritual leaders should be the patient's choice.
In most states, directives to physicians, durable power of attorney for health care, and medical power of attorney are included in which legal documents?
a. Natural death acts c. Advance care planning
b. Allow natural death d. Do Not Resuscitate order
a. Natural death acts in each state have their own
requirements. Allow natural death is the new term being used for the Do Not Resuscitate order. Advance care planning is the process of having patients and their families think through their values and goals for treatment and document those wishes as advance directives.
A patient is receiving care to manage symptoms of a terminal illness when the disease no longer responds to treatment. What is this type of care known as?
a. Terminal care c. Supportive care
b. Palliative care d. Maintenance care
b. Palliative care is aimed at symptom management rather than curative treatment for diseases that no longer respond to treatment and is focused on caring interventions rather than curative treatments. "Palliative care" and "hospice" are frequently used interchangeably.
Priority Decision: A patient in the last stages of life is experiencing shortness of breath and air hunger. Based on practice guidelines, what is the most appropriate action by the nurse?
a. Administer oxygen.
b. Administer bronchodilators.
c. Administer antianxiety agents.
d. Use any methods that make the patient more comfortable.
d. There currently are no clinical practice guidelines to relieve the shortness of breath and air hunger that often
occur at the end of life. The principle of beneficence would encourage any of the options to be tried, based on knowing that whatever gives the patient the most relief should be used.
End-of-life palliative nursing care involves
a. constant assessment for changes in physiologic functioning.
b. administering large doses of analgesics to keep the patient sedated.
c. providing as little physical care as possible to prevent disturbing the patient.
d. encouraging the patient and family members to verbalize their feelings of sadness, loss, and forgiveness.
d. In assisting patients with dying, end-of-life care promotes the grieving process, which involves saying goodbye. Physical care is very important for physical comfort but assessment should
be limited to essential data related to the patient's symptoms. Analgesics should be administered for pain but patients who are sedated cannot participate in the grieving process.
The dying patient and family have many interrelated psychosocial and physical care needs. Which ones can the nurse begin to manage with the patient and family (select all that apply)?
b. Fear of pain
c. The dying process
d. Care being provided
e. Anger toward the nurse
f. Feeling powerless and hopeless
a, b, c, d, e, f. Teaching, along with support and encouragement, can decrease some of the anxiety. Teaching about pain relief, the dying process, and the care provided will help the patient and family know what to expect. Allowing the patient to make decisions will help to decrease feelings of powerlessness and hopelessness. The nurse who is the target of anger needs to not react to this anger on a personal level.
A deathly ill patient from a culture different than the nurse's is admitted. Which question is appropriate to help the nurse provide culturally competent care?
a. "If you die, will you want an autopsy?"
b. "Are you interested in learning about palliative or hospice care?"
c. "Do you have any preferences for what happens if you are dying?"
d. "Tell me about your expectations of care during this hospitalization."
d. Using the open-ended statement to seek information related to the patient's and family's perspective and expectations will best guide the plan of care for this patient. This will open the discussion about palliative or hospice care and preferences for end-of-life care.