End of Life Care

Question 1

death is defined as the…

Answer 1

the cessation of integrated tissue and organ function, manifested by any one of these:
Lack of heartbeat
Absence of spontaneous respirations
Irreversible brain dysfunction
Although dying is part of the normal life cycle, it is often feared as a time ofpainand suffering

Question 2

what is the patient self-determination act

Answer 2

grants people the right to determine the medical care they want provided (or not provided) if they become incapacitated

Documentation of this self-determination is accomplished by completing anadvance directive (AD)

The PSDA requires that a representative in every health care agency ask patients when admitted if they have written advance directives

Most ADs have a section where one names adurable power of attorney for health care (DPOA)

Question 3

living will

Answer 3

which identifies what one would (or would not) want if he or she were near death
Treatments that are discussed include cardiopulmonary resuscitation (CPR), artificial ventilation, and artificial nutrition or hydration

Question 4

DNR do not resuscitate form

Answer 4

an actual order from a physician or other authorized health care provider who instructs that CPR not be attempted in the eventof cardiac or respiratory arrest

Question 5

palliative care

Answer 5

an interdisciplinary model of care, focusing on symptom management and psychosocial/spiritual support for those with serious, life-limiting illnesses

Question 6

palliative care aims to improve

Answer 6

quality of life for people and families through early integration into the plan of care strategies for managing pain and symptoms and for reducing burdensome care transitions through interdisciplinary teamwork, care coordination, clinician–patient communication, and decisional support

It is appropriate for patients at any age and at any stage in a serious illness, even while pursuing disease-directed or curative therapies, and extending into bereavement for families

Question 7

the delivery of palliative care is typically through an interdisciplinary consultation service where primary teams consult specialists for one or more of the following reasons:

Answer 7

Pain management
Symptom management
Goals of care discussions
End-of-life issues
Psychosocial distress
Spiritual or existential distress

Question 8

hospice

Answer 8

a type of palliative care, focusing on comfort at the end-of-life. When patients enroll in hospice, they have made the decision to forego disease-directed therapies and focus solely on the relief of symptoms associated with their illness and the dying process

Question 9

hospice is a holistic approach…

Answer 9

neither hastens nor postpones death but provides relief of symptoms and is provided in a variety of settings

Question 10

hospice care focuses on…

Answer 10

quality of life, and by necessity, it usually includes realistic emotional, social, spiritual, and financial preparation for death. Hospice in the United States is not a place but a philosophy of care in which the end-of-life is viewed as a developmental stage

Question 11

role of the nurse in a family meeting

Answer 11

Advocate for patient based on values shared by patient and family.
Act as interpreter when medical jargon is not clearly understood by patient and family.
Respond to emotion expressed in meeting.
Prior to meeting, encourage and assist patient and family with developing questions to ask of interdisciplinary teams during meeting.
Express concerns.
Share clinical nursing updates.

Question 12

Patient and family needs

Answer 12

Care for their loved one as a person
Care to prevent suffering and pain of their loved one
Availability of clinicians
Demonstrate collaboration and communication amongst team members
Appropriate, accurate and understandable information about prognosis
Permit time to allow families to share concerns
Direction on what to focus on

Question 13

SPIKES mnemonic for giving bad news:

Answer 13

S: Setting – Make sure the setting is conducive as possible

P: Patient’s perception – Ask what they know of their disease

I: Invitation – Ask what they want to know if this becomes more serious

K: Knowledge – Give them the facts they want to know

E:Exploring/empathy/emotion – Allow the patient to express their feelings and worries and provides support

S: Strategy/summary – Develop a plan and follow-through with the patient

Question 14

non-pharm interventions regarding pain

Answer 14

Massage to manipulate the patient’s muscles and soft tissue, which improves circulation and promotes relaxation
Music therapy based on patient preferences to decreasepainby promoting relaxation
Therapeutic touch by moving one’s hands through the patient’s energy field to relievepain
Aromatherapy to decreasepainby promoting relaxation and reducing anxiety
Avoid any iatrogenic sources

Question 15

pharm interventions regarding pain

Answer 15

Morphine
Stool softeners

Question 16

non-pharm interventions regarding breathlessness/ dyspnea

Answer 16

Elevate the head of bed &/or position the person on his or her side
Mechanical ventilation (invasive or non-invasive)
Conserve energy, consider a Foley catheter
Paracentesis or thoracentesis

Question 17

pharm interventions regarding breathlessness/dyspnea

Answer 17

Oxygenation
Morphine
Bronchodilators
Corticosteroids
Diuretics
Antibiotics

Question 18

non-pharm interventions regarding oral secretion or loud wet respirations

Answer 18

Position the patient on his or her side
Place a small towel under his or her mouth to collect secretions

Question 19

pharm interventions regarding oral secretion or loud wet respirations

Answer 19

Atropine sulfate drops
Scopolamine patches

Question 20

non-pharm interventions regarding weakness

Answer 20

Teach families about the risk for aspiration
Reassure them that anorexia is normal at this stage
To avoid a dry mouth and lips, moisten them with soft applicators and apply an emollient

Question 21

non-pharm interventions regarding increased lethargy

Answer 21

Spend time sitting quietly with the person
Do not force the person to stay awake
Talk to the person as you normally wound, even if he or she does not respond

Question 22

non-pharm interventions regarding N/V

Answer 22

Discontinue enteral feedings; put PEG to drainage
Offer nourishment only when the patient has an appetite or thirst
Avoid NGT decompression
Apply a cool wet cloth on the patient’s face
Avoid any smells or foods that may induce the symptoms
Aromatherapy using chamomile, camphor, fennel, lavender, peppermint and rose

Question 23

pharm interventions regarding N/V

Answer 23

Antiemetics
Anticholinergics

Question 24

non-pharm interventions regarding decreased nutrition/fluid

Answer 24

Do not force the person to eat or drink
Offer supplements or protein shakes if tolerated
Assess for any medications causing the problem, or environmental causes (such as unpleasant odors) causing decreased appetite
Offer small sips of liquids or ice chips at frequent intervals if the person is alert and able to swallow
Use moist swabs to keep the mouth and lips moist and comfortable, coat the lips with lip balm
Assess for oropharyngeal pain or ulcers causing the decreased appetite

Question 25

non-pharm interventions regarding severe agitation and restlessness (and delirium)

Answer 25

Assess for underlying cause, acknowledge the family’s distress, educate and reassure
Play soothing music, keep the room dimly lit and use aromatherapy
Do not restrain the person
Apply wet cloths on the patient’s face
Reduce the environmental stimuli
Talk quietly and keep the noise level to a minimum

Question 26

pharm interventions regarding severe agitation and restlessness (and delirium)

Answer 26

Haloperidol
Benzodiazepines

Question 27

non-pharm interventions regarding seizures

Answer 27

Decrease stimuli
Avoid any triggers (if any are known)

Question 28

pharm interventions regarding seizures

Answer 28

Benzodiazepines
Barbiturates

Question 29

non-pharm interventions regarding incontinence

Answer 29

Keep the perineal area clean and dry
Use disposable underpads or chux pads and disposable undergarments
If the person would be more comfortable, consider a Foley catheter

Question 30

non-pharm interventions regarding coolness of extremities

Answer 30

Cover the person with a blanket
Do not use an electric blanket, hot water bottle, electric heating pad, or hair dryer to warm the person

Question 31

Psychosocial interventions for the dying patient and the family

Answer 31

Offer physical and emotional support by “being with” the patient
Respect cultural preferences
Be realistic
Encourage reminiscence
Promote spirituality and hope
Avoid explanations of the loss
Communicate with the patient
Provide referrals to bereavement specialists
Teach about the physical signs of death
Ensure that the patient is receiving palliative care, with an emphasis on symptom management

Question 32

Basic beliefs regarding care at end of life and death rituals for Hinduism:

Answer 32

This life is a transition between the previous life and the next
Postdeath rituals are important. Bodies are cremated. During the first 10 days after death, relatives must create a new ethereal body
Karma is the manner through which one reaps benefits and penalties of pas actions. “Good karma” leads to good rebirth or release, and “bad karma” leads to bad rebirth or pain and suffering during release
Health care decisions may be made communally with senior family members as final authority

Question 33

Basic beliefs regarding care at end of life and death rituals for Judaism:

Answer 33

The dying person is encouraged to recite the confessional or the affirmation of faith, called theShema
Disclosure is important, most patients want to know the truth
According to Jewish law, a person who is extremely ill and dying should not be left alone
The body should not be left unattended until the funeral, which should take place as soon as possible (preferably within 24 hours)
Autopsies are not allowed by Orthodox Jews, except under special circumstances
The body should not be embalmed, displayed, or cremated

Question 34

Basic beliefs regarding care at end of life and death rituals for Buddhism:

Answer 34

Treatment by someone of the same gender is preferable
Cremation is the most common way of disposing of the dead
Some Buddhists may be unwilling to take pain-relieving medications or strong sedatives, as it is believed that an unclouded mind can lead to a better rebirth
Buddhists believe that after death there is either rebirth or nirvana – the latter being enlightenment that frees the soul from the cycle of death and rebirth

Question 35

Basic beliefs regarding care at end of life and death rituals for Islam

Answer 35

Based on belief in one God Allah and his prophet Muhammad. Qur’an is the scripture of Islam, composed of Muhammad’s revelations of the Word of God (Allah)
Death is seen as the beginning of a new and better life
God has prescribed an appointed time of death for everyone
Qur’an encourages humans to seek treatment and not to refuse treatment. Belief is that only Allah cures but that Allah cures through the work of humans
Upon death, the eyelids are to be closed and the body should be covered. Before moving and handling the body, contact someone from the person’s mosque to perform rituals of bathing and wrapping body in cloth
Fasting during the month of Ramadan is a pillar of Islam

Question 36

Basic beliefs regarding care at end of life and death rituals for Christianity

Answer 36

There are many Christian denominations, which have variations in beliefs regarding medical care near end of life
Christians believe in an afterlife of heaven or hell once the soul has left the body after death, this believe in eternal salvation sets Christianity apart
Roman Catholic tradition encourages people to receive Sacrament of the Sick, administered by a priest at any point during an illness. This sacrament may be administered more than once. Not receiving this sacrament will NOT prohibit them from entering heaven after death
People may be baptized as Roman Catholics in an emergency situation (e.g., person is dying) by a layperson. Otherwise, they are baptized by a priest

Question 37

Emotional signs & symptoms of imminent death:

Answer 37

Withdrawal
Vision-like experiences
Letting go
Saying goodbye

Question 38

Physical signs & symptoms of imminent death:

Answer 38

Periods of apnea and Cheyne-Stokes respirations
Wet, gurgle ”death” rattle as the patient breathes
Blood pressure decreases
Peripheral circulation decreases
Skin is cold and mottled
Hypersomnolence

Question 39

Signs that death has occurred:

Answer 39

Breathing stops
Heart stops beating
Pupils become fixed and dilated
Body color becomes pale and waxen
Body temperature drops
Muscles and sphincters relax
Urine and stool may be released
Eyes may remain open, and there is no blinking
The jaw may fall open
Observers may hear trickling of fluids internally

Question 40

Pronouncement of death:

Answer 40

Note time of death that the family or staff reported the cessation of respirations
Identify the patient by the hospital identification (ID) tag; note the general appearance of the body
Ascertain that the patient does not rouse to verbal or tactile stimuli. Avoid overtly painful stimuli, especially if family members are present
Auscultate for the absence of heart sounds; palpate for the absence of carotid pulse
Look and listen for the absence of spontaneous respirations
Record the time at which your assessment was completed
Document the time of pronouncement and all notifications in the medical record (i.e., to attending physician). Document if the medical examiner needs to be notified (may be required for unexpected or suspicious death). Document if an autopsy is planned per the attending physician and family
If your state and agency policy allows an RN to pronounce death, document as indicated on the death certificate

After the patient dies, ask the family or other caregivers if they would like to spend time with the patient to assist them in coping with what has happened and say their good-byes
Call organ donation within 1 hour of death
Before preparing the body for transfer, ask the physician whether an autopsy will be required
After the family or significant others view the body, follow agency procedure for preparing the patient for transfer to either the morgue or a funeral home
In the hospital, a postmortem kit is generally used with a shroud and identification tags

Question 41

Grief

Answer 41

is the emotional feeling related to the perception of the loss. Patients who are dying suffer not only from the anticipated death but also from the loss of the ability to engage with others and in the world

Question 42

mourning

Answer 42

refers to individual, family, group, and cultural expressions of grief and associated behaviors

Question 43

bereavement

Answer 43

refers to the period of time during which mourning for a loss takes place

Question 44

Kübler-Ross’s Stages of Grief and Loss

Answer 44

Denial
Anger
Bargaining
Depression
Acceptance

Question 45

Symptoms of grief:

Answer 45

Crying
Headaches
Difficulty sleeping
Questioning the purpose of life or their spiritual beliefs
Feelings of detachment
Isolation from friends and family
Abnormal behavior
Anxiety
Frustration
Guilt
Fatigue
Anger
Loss of appetite
Aches and pains
Stress

Question 46

Interventions for grief: non-pharm

Answer 46

Encourage story telling and reminiscing
Assess for coping skills
Assess for social support
Support groups, bereavement groups, counseling
Assess for signs of complicated grief

Question 47

interventions for grief: pharm

Answer 47

Antidepressants
Anti-anxiety
Sedatives

Question 48

special issues for Nurse: ethical dilemmas

Answer 48

In caring for patients at the end-of-life, questions of right and wrong may arise in relation to treatment options
The ANA’s Code of Ethics for Nurses provides a framework for the nurse to support patients, with guiding principles being the patient’s right to self-determination and the nurse’s adherence to professional nursing standards
The most common ethical dilemmas a nurse will encounter are determining decisional capacity, withholding or withdrawing life-prolonging measures such as:
Ventilator support, dialysis, artificial nutrition and hydration, requests for hastening death, and concerns related to proxy decision making

Question 49

Special Issues for Nurse: nutrition

Answer 49

As illness progresses, patients, families, and clinicians may believe that without artificial nutrition and hydration, patients who are terminally ill will starve, causing profound suffering and hastened death, however:
The use of artificial nutrition and hydration (tube and intravenous fluids and feeding) carries considerable risks and generally does not contribute to comfort at the end-of-life
Similarly, survival is not increased when patients who are terminally ill with advanced dementia receive enteral feeding
No data supports an association between tube feeding and improved quality of life in these patients

Question 50

Special Issues for Nurse: request to hasten death

Answer 50

Health care recognizes the right to choose for or against medical treatments when a patient is of sound mind and can relay a rationale for or against treatments. Further, patients may choose to withdraw or withhold life-sustaining treatments and allow natural death if such therapies are not aligned with their wishes
When faced with a progressive life-limiting illness, some cannot fathom suffering at the end-of-life and explore options to hasten death
In its 2013 position statement on Euthanasia, Assisted Suicide, and Aid in Dying, the ANA acknowledged the complexity of the assisted suicide debate but clearly stated that nursing participation in assisted suicide is a violation of the Code for Nurses

Question 51

Withdrawing or withholding life-sustaining therapy

Answer 51

: (aka passive euthanasia) An act of omission (e.g., withholding or withdrawing treatment) that might prolong the life of a person who cannot be cured by the treatment. In this situation, the withdrawal of the intervention does not directly cause the patient’s death

Question 52

Voluntary active euthanasia:

Answer 52

An act by which the causative agent or treatment in the death of a patient is administered directly by another

Question 53

Involuntary active euthanasia:

Answer 53

The action to end the patient’s life is taken without the patient’s consent

Question 54

Physician-assisted suicide:

Answer 54

A practice whereby a physician provides a means (e.g., medication) to a patient with the knowledge that the patient will use the means to commit suicide

Question 55

Principle of double effect:

Answer 55

Involves taking an action intended to have a good effect, which also has a known harmful effect. This is not active euthanasia

Question 56

special issues for nurse: COVID

Answer 56

During the pandemic, symptom management at the end-of-life has required revisions due to logistical challenges such as medication shortages and preservation of personal protective equipment
Due to high risk of infectious transmission, family members may not be permitted to see loved ones at the end-of-life
Family meetings are primarily virtual, where proxies must make difficult decisions such as resuscitation and intubation, and even removal of life support
Meanwhile, health care providers are struggling from high physical workload demands while simultaneously experiencing moral and psychological distress

Question 57

Special Issues for Nurse: Losing a patient

Answer 57

Nurses might learn how to help family members grieve, but seldom learn how to deal with their own feelings of sadness or loss
Debrief with staff
Help with rituals of the patient and family if appropriate
Discuss the death with friends and family
Attend the funeral
Pray or draw strength from spiritual beliefs
Use relaxation techniques
Healthy personal habits, including diet, exercise, stress reduction activities (e.g., dance, yoga, meditation), and sleep, help guard against the detrimental effects of stress