Chapter 20 - End of Life Flashcards
Parents tell the nurse they do not want to let their school-age child know his illness is terminal. What response should the nurse make to the parents?
a.
“Have you discussed this with your health care provider?”
b.
“I would do the same thing in your position; it is better the child doesn’t know.”
c.
“I understand you want to protect your child, but often children realize the seriousness of their illness.”
d.
“I praise you for that decision; it can be so difficult to be truthful about the seriousness of your son’s illness.”
ANS: C
Terminally ill children develop an awareness of the seriousness of their diagnosis even when protected from the truth. Acknowledging parents feelings but giving them truthful information is the appropriate response. Asking about discussing this with the health care provider is avoiding the issue. Sharing your own feelings by stating “I would do the same thing” and giving praise for the decision is nontherapeutic.
What characterizes a preschooler’s concept of death? (Select all that apply.)
a.
Belief their thoughts can cause death.
b.
They have a concrete understanding of death.
c.
Death is seen as temporary and gradual.
d.
Death is seen as a departure, a kind of sleep.
e.
They usually have some sense of the meaning of death.
ANS: A, C, D, E
A preschool child’s concept of death includes believing that his or her thoughts can cause death, seeing death as temporary and gradual and a kind of sleep, and having some sense of the meaning of death. Having a concrete understanding of death is a characteristic of a school-age child’s concept of death.
What factor is most important for parents implementing do not resuscitate (DNR) orders?
a.
Parents’ beliefs about euthanasia
b.
Presence of other children in the home
c.
Experiences of the health care team with other children in this situation
d.
Acknowledgment by health care team that child has no realistic chance for cure
ANS: D
Earlier implementation of DNR orders, use of less aggressive therapies, and greater provision of palliative care measures are associated with an honest appraisal of the child’s condition. Euthanasia involves an action carried out by a person other than the patient to end the life of the patient suffering from a terminal condition. DNR orders do not involve euthanasia but give permission for health care providers to allow the child to die without intervention. Parents state that regardless of the number of children they have, the death of a child is a new experience and nothing can prepare them for it. Health professionals may base their discussions with families on prior experiences, but families base their decision on an honest appraisal of their child’s condition.
What nursing intervention is most appropriate when providing comfort and support for a child when death is imminent?
a.
Limit care to essentials.
b.
Avoid playing music near the child.
c.
Whisper to the child instead of using a normal voice.
d.
Explain to the child the need for constant measurement of vital signs.
ANS: A
When death is imminent, care should be limited to interventions for palliative care. Music may be used to provide comfort to the child. The nurse should speak to the child in a clear, distinct voice. Vital signs do not need to be measured frequently.
The nurse is often the individual who is in the optimum position to suggest tissue donation to a family (after consultation with the practitioner). What will occur if a family chooses organ or tissue donation?
a.
The funeral will be delayed.
b.
Cremation is the preferred method of burial.
c.
Written consent is required for tissue or organ donation.
d.
An open casket cannot be used subsequent to this procedure.
ANS: C
Organ and tissue donation cannot proceed without the family’s written informed consent. There is usually no delay in the funeral. Organs are usually retrieved before actual death, and tissue must be removed soon after. No obvious disfigurement of the body occurs, and an open casket can be used for the funeral.
What characterizes a toddler’s concept of death? (Select all that apply.)
a.
They are unable to comprehend an absence of life.
b.
They may recognize the fact of physical death.
c.
They understand the universality and inevitability of death.
d.
The are affected more by the change in lifestyle than the concept of death.
e.
They can only think about events in terms of their own frame of reference—living.
ANS: A, D, E
Toddlers are egocentric and can only think about events in terms of their own frame of reference—living. Their egocentricity and vague separation of fact and fantasy make it impossible for them to comprehend absence of life. Instead of understanding death, this age group is affected more by any change in lifestyle. Toddlers do not understand the universality and inevitability of death and do not recognize the fact of physical death.
Parents ask the nurse, “When should palliative care be initiated?” What is the best response by the nurse?
a.
“When curative care is not feasible.”
b.
“When the child’s prognosis is uncertain.”
c.
“It should be included along the continuum of care.”
d.
“It should begin when curative treatments are no longer appropriate.”
ANS: C
The current approach by palliative care experts promotes the inclusion of palliative care along the continuum of care from diagnosis through treatment, not merely at the end of life. It should not wait to be initiated when curative care is not feasible, the child’s prognosis is uncertain, or curative treatments are no longer appropriate
A school-age child is diagnosed with a life-threatening illness. The parents want to protect their child from knowing the seriousness of the illness. The nurse should provide which explanation?
a.
This attitude is helpful to give parents time to cope.
b.
This will help the child cope effectively by denial.
c.
Terminally ill children know when they are seriously ill.
d.
Terminally ill children usually choose not to discuss the seriousness of their illness.
ANS: C
The child needs honest and accurate information about the illness, treatments, and prognosis. Because of the increased attention of health professionals, children, even at a young age, realize that something is seriously wrong and that it involves them. Thus, denial is ineffective as a coping mechanism. The nurse should help parents understand the importance of honesty. Parents may need professional support and guidance from a nurse or social worker in this process. Children will usually tell others how much information they want about their condition.
A critically injured child has died and is being removed from a ventilator in the pediatric intensive care unit. What is a priority nursing intervention for the family at this time?
a.
Ensure that parents are in the waiting room while the ventilator is removed.
b.
Help the parents understand that the child is already dead and no further interventions are necessary.
c.
Control the environment around the child and family to provide privacy.
d.
Encourage them to wait to see their child until the funeral home has prepared the body.
ANS: C
Around the time of death, nursing care can be invaluable to the parents. The nurse should attempt to control the environment to ensure that the family and child have privacy. Other individuals such as clergy can be present if the family wishes. Attention to religious and cultural rituals may be important to them. The family should decide where they would like to be during removal from the ventilator. The family should be allowed to be with the child if they wish rather than waiting until the funeral home has prepared the body. Explain all interventions used for the child before death.
The family and child have decided that hospice care best meets their needs during the terminal phase of illness. The nurse recognizes that the parents understand the principles of this care when they make which statement?
a.
“It will be good to be at home and care for our child.”
b.
“What a relief it will be not to need any more medicines.”
c.
“We are going to miss the support of the hospice team when our child dies.”
d.
“We know that once hospice care starts, we will not be able to return to the hospital if the care is difficult.”
ANS: A
A major principle of hospice care is that the family members are the principal caregivers and are supported by a team of professionals. Pain and symptom management is a priority. The family and visiting nurses administer medications to keep the child as pain and symptom free as possible. The hospice team provides bereavement support to help the family in the postdeath adjustment. This may last for up to a year or more. If the family decides they can no longer care for the child at home, readmission to a freestanding hospice or hospital is possible.
What statement is most descriptive of a school-age child’s reaction to death?
a.
Very interested in funerals and burials
b.
Little understanding of words such as “forever”
c.
Imagine the deceased person to be still alive
d.
Can explain death from a religious or spiritual point of view
ANS: A
School-age children are interested in naturalistic and physiologic explanations of why death occurs and what happens to the body. School-age children do have an established concept of forever and have a deeper understanding of death in a concrete manner. Adolescents may explain death from a religious or spiritual point of view
The nurse understands that a school-age child may react to death with what reaction?
a.
Joking
b.
Having no reaction
c.
Fearing the unknown
d.
Seeing it as a distant event
ANS: C
They tend to fear the expectation of the event more than its realization. Their fear of the unknown is greater than that of the known. They would not joke or have no reaction. Adolescents see death as a distant event.
A child in the terminal stage of cancer has frequent breakthrough pain. Nonpharmacologic methods are not helpful, and the child is exceeding the maximum safe dose for opiate administration. What approach should the nurse implement?
a.
Add acetaminophen for the breakthrough pain.
b.
Titrate the opioid medications to control the child’s pain as specified in the protocol.
c.
Notify the practitioner that immediate hospitalization is indicated for pain management.
d.
Help the parents and child understand that no additional medication can be given because of the risk of respiratory depression.
ANS: B
The child on long-term opioid management can become tolerant to the drugs. Also, increasing amounts of drugs may be necessary for disease progression. It is important to recognize that there is no maximum dosage that can be given to control pain. Acetaminophen will offer little additional pain control; it is useful for mild and moderate pain. Immediate hospitalization is not necessary; increased dosages of pain medications can be administered in the home environment. The principle of double effect allows for a positive intervention—relief of pain—even if there is a foreseeable possibility that death may be hastened.
A 7-year-old child is in the end stages of cancer. The parents ask you how they will know when death is imminent. What physical sign is indicative of approaching death?
a.
Hunger
b.
Tachycardia
c.
Increased thirst
d.
Difficulty swallowing
ANS: D
The child begins to have difficulty swallowing as he or she approaches death. The child’s appetite will decrease, and he or she will take only small bites of favorite foods or sips of fluids in the final few days. The pulse rate will slow.
The sibling of a 4-year-old girl dies from sudden infant death syndrome. The parents are concerned because the 4-year-old girl showed more outward grief when her cat died than now. How should the nurse explain this reaction to the parents?
a.
The child is not old enough to have a concept of death.
b.
This suggests maladaptive coping, and referral is needed for counseling.
c.
The death may be so painful and threatening that the child must deny it for now.
d.
The child is not old enough to have formed a significant attachment to her sibling.
ANS: C
Children of this age believe that their thoughts can cause death. The child may feel guilty and responsible. The loss may be so deep, painful, and threatening that the child needs to deny it for a time. Denial is within the range of a normal response to the death of a sibling. Counseling is not indicated at this time. Denial is also characteristic of the child’s developmental level. These children do have a concept of death, seeing it as a separation. The child also would have formed an attachment to the sibling, who was in the house and sharing the parents’ time and attention.
