Chapter 04: End-of-Life Care and Palliative Care in Critical Care Settings

Sole: Introduction to Critical Care Nursing, 7th Edition

Multiple Choice

1. A patient who is undergoing withdrawal of mechanical ventilation appears anxious and agitated. The patient is on a continuous morphine infusion and has an additional order for lorazepam (Ativan) 1 to 2 mg IV as needed (prn). The patient has received no lorazepam (Ativan) during this course of illness. What is the most appropriate nursing intervention to control agitation?

a. Administer fentanyl (Duragesic) 25 mg IV bolus.

b. Administer lorazepam (Ativan) 1 mg IV now.

c. Increase the rate of the morphine infusion by 50%.

d. Request an order for a paralytic agent.

ANS: B

Lorazepam (Ativan) 1 mg IV is an appropriate drug dose for a patient who is experiencing agitation during withdrawal of life support. Because it is ordered but not yet given, the nurse should give this drug now. Fentanyl treats pain and morphine controls pain. Paralytic agents are not warranted.

DIF: Cognitive Level: Apply/Application

REF: p. 46

OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

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2. A 75-year-old patient, who suffered a massive stroke 3 weeks ago, has been unresponsive and has required ventilatory support since the time of the stroke. The physician has approached the spouse regarding placement of a permanent feeding tube. The spouse states that the patient never wanted to be kept alive by tubes and personally didn’t want what was being done. After holding a family conference with the spouse, the medical team concurs, and the feeding tube is not placed. This situation is an example of a. euthanasia. b. palliative care. c. withdrawal of life support. d. withholding life support.

ANS: D

Because the tube feeding had not been yet placed in the care of this patient, this scenario is an example of withholding of life support. Withholding of life support does not constitute euthanasia. Withdrawal of life support involves the discontinuation of previously established therapies in a terminally ill patient.

DIF: Cognitive Level: Remember/Knowledge REF: p. 43

OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and health care providers. TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment a. Clear communication is typical in the relationships between most patients and health care providers. b. Critical care units often meet the needs of dying patients and their families. c. Disparities exist between patients’ care preferences and the actual care provided. d. Pain and suffering of patients at end of life is well controlled in the hospital.

3. What were the findings of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT)?

ANS: C

Disparities and lack of communication are common in the relationships between patients and health care providers. Critical care units are often poorly equipped to meet the needs of dying patients. The SUPPORT study demonstrated that pain and suffering are widespread in hospitals.

DIF: Cognitive Level: Remember/Knowledge REF: p. 40

OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and health care providers. TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment

4. A statement that provides a legally recognized description of an individual’s desires regarding care at the end of life is a (an) a. advance directive. b. guardianship ad litem. c. health care proxy. d. power of attorney.

ANS: A

Legally recognized documents that provide guidance on an individual’s end-of-life choices are advance directives. Advance directives include living wills, durable powers of attorney for health care, and health care surrogate designations. A guardianship ad litem is a parent who files legal action on the behalf of a child. A health care proxy is an individual who is legally designated through statute to make decisions for an incapacitated person. A power of attorney is an individual who is, through filing of legal papers, authorized to act on the behalf of an incapacitated person in legal matters.

DIF: Cognitive Level: Understand/Comprehension REF: p. 47

OBJ: Describe ethical and legal concerns related to end-of-life care.

TOP: Integrated Process: Communication and Documentation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment a. Medical futility b. Palliative care c. Terminal weaning d. Withdrawal of treatment

5. A patient with metastatic lung carcinoma has been unresponsive to chemotherapy. The medical team has determined that there are no additional treatments available that will prolong life or improve the quality of life in any meaningful way. Despite the poor prognosis, the patient continues to receive chemotherapy and full nutritional support. This is an example of which end-of-life concept?

ANS: A

Medical futility is a situation in which therapy or interventions will not provide a foreseeable possibility of improvement in the patient’s health status. Palliative care focuses on symptom relief and is not limited to the dying. Terminal weaning refers to withdrawal of artificial ventilation interventions. Withdrawal of treatment refers to the removal of established therapies in a terminally ill patient.

DIF: Cognitive Level: Remember/Knowledge

REF: p. 41

OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and health care providers.

TOP: Integrated Process: Communication and Documentation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment

6. Designated health care surrogates should base health care decisions on a. personal beliefs and values. b. recommendations of family members and friends. c. recommendations of the physician and health care team. d. wishes previously expressed by the patient.

ANS: D

Health care surrogates attempt to have decisions match the wishes of the patient. Although suggestions of family and friends may provide insight into patient desires, actual decisions should be based upon known patient wishes. The physician and health care team may provide recommendations, but decisions should be based on the patient’s wishes.

DIF: Cognitive Level: Remember/Knowledge

REF: p. 41

OBJ: Describe ethical and legal concerns related to end-of-life care.

NURSINGTB.COM

TOP: Integrated Process: Communication and Documentation

MSC: NCLEX Client Needs Category: Psychosocial Integrity a. Basic nursing care is a critical element in palliative care management. b. Common conditions that require palliative management are nausea, agitation, and sleep disturbance. c. Palliative care practices are reserved for the dying client. d. Palliative care practices relieve symptoms that negatively affect the quality of life of a patient.

7. Which statement made by a staff nurse identifying guidelines for palliative care would need to be corrected?

ANS: C

The purpose of palliative care is to relieve negative symptoms that affect the quality of life of a patient. Palliative care is an integral part of every injured or ill patient's care. Basic nursing care, including repositioning, skin care, and provision of a peaceful environment, promote comfort. These conditions all commonly require palliative care techniques.

DIF: Cognitive Level: Remember/Knowledge

REF: p. 41

OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and health care providers. TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment a. Cultural beliefs should not take precedence over health care team decisions. b. It is easy and common to assess cultural beliefs affecting end-of-life care in the intensive care unit. c. Culture and religious beliefs may affect end-of-life decision making. d. Perspectives regarding end-of-life care are similar between and within religious groups.

8. Which statement is true regarding the impact of culture on end-of-life decision making?

ANS: C

Religious doctrines and cultural beliefs have profound impact on end-of-life decisions. Patient and family culture and preferences in end-of-life care should guide treatment and not be overruled by the wishes of medical personnel. It is difficult to assess end-of-life desires in the intensive care unit due to many constraints, and nurses need to become more proficient at this. Language barriers make it even more difficult and time consuming, but nurses should strive to respect the patient’s and family’s wishes. Perspectives on end-of-life care vary within and between religious groups.

DIF: Cognitive Level: Remember/Knowledge REF: p. 48

OBJ: Discuss cultural considerations in end-of-life care.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Psychosocial Integrity

9. The most critical element of effective early end-of-life decision making is a. control of distressing symptoms, such as nausea, anxiety, and pain. b. effective communication among the patient, family, and health care team throughout the course of the illness. c. organizational support of palliative care principles. d. the relocation of the dying patient from the critical care unit to a lower level of care.

ANS: B

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The failure of clinicians, family members, and patients to openly discuss prognoses, end-of-life wishes, and preferences contributes to care conflicts such as in the Schiavo case. Early discussion of end-of-life wishes is required to promote positive outcomes for the patient and family; such discussions actually should predate illness. Even though symptom control is a significant dimension of palliative care, it is not involved in initial end-of-life decision making. Adequate staffing and facility policies that support the dying patient are critical but should not impact family decision making. The patient should be cared for in an environment that best supports the needs of the patient and family. Even though organizational support of palliative principles is important, it should not drive individual decision making.

DIF: Cognitive Level: Remember/Knowledge

REF: p. 42

OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and health care providers.

TOP: Integrated Process: Communication and Documentation

MSC: NCLEX Client Needs Category: Psychosocial Integrity

10. A patient with end-stage heart failure is experiencing considerable dyspnea. Appropriate palliative management of this symptom includes: a. administration of midazolam (Versed). b. administration of morphine. c. an increase in the amount of oxygen being delivered to the patient. d. aggressive use of inotropic and vasoactive medications to improve heart function.

ANS: B

Morphine is an excellent agent to control the symptom of dyspnea. Midazolam is used for anxiety. An increase in oxygen or aggressive use of medications to improve the patient’s heart function is inappropriate in this case.

DIF: Cognitive Level: Apply/Application

REF: p. 46 | Fig 4-2

OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity a. Dying is viewed as a failure on the part of the system and providers. b. Most Americans would prefer to die in a hospital to spare loved ones the burden of care. c. People die of distinct, complex illness for which a cure is always possible. d. The purpose of the health care system is to prevent disease and treat symptoms.

11. Which statement is consistent with societal views of dying in the United States?

ANS: A

Death is viewed as a failure by society and health care providers, a view that results in aggressive management of disease, even in unfavorable situations. Research has indicated that most Americans would prefer to die at home. There is a commonly held belief that people die of distinct diseases, implying that a cure is possible. There is a commonly held belief that the health care system exists to treat illness, disease, and injury and to “save” lives.

DIF: Cognitive Level: Understand/Comprehension

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REF: p. 41

OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and health care providers. TOP: Nursing Process Step: N/A

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment a. Control of distressing symptoms such as dyspnea, nausea, and pain through the use of pharmacological and nonpharmacological interventions b. Limitation of visitation to reduce the emotional distress experienced by family members c. Patient and family education on anticipated patient responses to withdrawal of therapy d. Provision of spiritual care resources as desired by the patient and family

12. Which nursing intervention would need to be corrected on a care plan for a patient in order to be consistent with the principles of effective end-of-life care?

ANS: B

Active involvement of family is a critical dimension of end-of-life care. Family members should have access to the patient and inclusion in care to the degree they desire. Limitation of visitors is not consistent with effective end-of-life care practices. Control of distressing symptoms is a dimension of end-of-life care. Family education and anticipatory guidance are critical elements of end-of-life care. Meeting the emotional and psychological needs of the patient and family through provision of spiritual resources and bereavement care is a critical element of end-of-life care.

DIF: Cognitive Level: Apply/Application

REF: p. 47 | Box 4-4

OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Psychosocial Integrity a. When a dying patient requires extensive heavy sedation, such as benzodiazepines and narcotics, to control distressing symptoms b. When a dying patient who is competent requests to withdraw treatment against the wishes of the family c. When a dying patient who is competent requests to continue treatment against the recommendations of the health care team d. When a dying patient who is competent is receiving prn treatment for pain and anxiety

13. In which of the following situations would a health care surrogate or proxy assume the end-of-life decision-making role for a patient?

ANS: A

A patient who requires heavy sedation, such as IV infusions of pain medications or anxiolytic medications, would not be competent to make health care decisions. A health care proxy or surrogate would be required in this situation. A patient who is deemed competent by the medical team may be responsible for health care decisions even if these are not consistent with family beliefs. A surrogate would not assume decision-making responsibilities in this situation. A health care team member who cannot support decisions would be responsible for finding an alternative care provider who could support the patient's wishes.

DIF: Cognitive Level: Analyze/Analysis

REF: p. 40

OBJ: Describe ethical and legal concerns related to end-of-life care.

NURSINGTB.COM

TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment a. Attendance at funerals is inappropriate and will only create additional stress in nurses who are already at risk for burnout. b. Caring for dying patients is an expected part of nursing and will not affect the emotional health of the nurse if he or she maintains a professional approach with each patient and family. c. Most nurses who work with dying patients are able to balance care needs of patients with personal emotional needs. d. Provision of aggressive care to patients for whom they believe it is futile may result in personal ethical conflicts and burnout for nurses.

14. Which statement is true regarding the effects of caring for dying patients on nurses?

ANS: D

Burnout may occur when nurses must provide aggressive care to patients for whom they believe it is futile or when the care choices made by patients and/or surrogates differ from those of clinicians. Attendance at funerals may relieve emotional strain in some situations. Meeting the emotional needs of patients and families often requires that the nurse invest emotionally while providing care. Maintaining a professional, healthy distance and being human when working with the dying is a difficult task that requires a great deal of balancing.

DIF: Cognitive Level: Remember/Knowledge

REF: p. 41

OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and health care providers. TOP: Integrated Process: Caring

MSC: NCLEX Client Needs Category: Psychosocial Integrity a. Any treatment may be withdrawn and withheld, including nutrition, antibiotics, and blood products. b. Doses of analgesic and anxiolytic medications must be adjusted carefully and should not exceed usual recommended limits. c. Life-sustaining treatments may be withdrawn while a patient is receiving paralytic agents. d. The goal of withdrawal and withholding of treatments is to hasten death and thus relieve suffering.

15. The family is considering the withdrawal of life-sustaining measures from the patient. The nurse knows that ethical principles for withholding or withdrawing life-sustaining treatments include which of the following?

ANS: A

Any treatment that is used to sustain life, including nutrition, fluids, antibiotics, blood products, and respiratory support, may be withdrawn in consultation with the patient and/or surrogate provided that the patient has been deemed terminal or persistently vegetative. Any dose of anxiolytics or analgesics may be used to relieve suffering, although these may have the potential to hasten death. Life-sustaining treatment should not be withdrawn while the patient is receiving paralytic treatments. Death occurs as a consequence of the underlying disease, and the goal of care is to relieve suffering, not to hasten death.

DIF: Cognitive Level: Analyze/Analysis

REF: p. 44

OBJ: Describe ethical and legal concerns related to end-of-life care.

NURSINGTB.COM

TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment

16. The patient’s spouse is terrified by the prospect of removing life-sustaining treatments from the patient and asks why anyone would do that. The nurse explains, a. “It is to save you money so that you won’t have such a large financial burden.” b. “It will preserve limited resources for the hospital so that other patients may benefit from them.” c. “It is to discontinue treatments that are not helping your loved one and that may be very uncomfortable.” d. “We have done all we can for your loved one, and any more treatment would be futile.”

ANS: C

The goal of withdrawal of life-sustaining treatments is to remove treatments that are not beneficial and that may be uncomfortable.

DIF: Cognitive Level: Understand/Comprehension REF: p. 43

OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and health care providers.

TOP: Integrated Process: Communication and Documentation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment

17. All of the patient’s children are distressed by the possibility of removing life-support treatments from their mother. The child who is most upset tells the nurse, “This is the same as killing her! I thought you were supposed to help her!” The nurse explains to the family, a. “This is a process of allowing your mother to die naturally after the injuries that she sustained in a serious accident.” b. “The hospital would never allow us to do that kind of thing.” c. “Let’s talk about this calmly, and I will explain why assisted suicide is appropriate in this case.” d. “She’s lived a long and productive life.”

ANS: A

Forgoing life-sustaining treatments is not the same as active euthanasia or assisted suicide. Killing is an action causing another’s death, whereas allowing dying is avoiding any intervention that interferes with a natural death following illness or trauma. Telling the family that the hospital would not allow this, or asking the family to talk calmly belittles their feelings and does not provide useful information.

DIF: Cognitive Level: Apply/Application REF: p. 43

OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and health care providers.

TOP: Integrated Process: Communication and Documentation

MSC: NCLEX Client Needs Category: Psychosocial Integrity

18. To prevent any unwanted resuscitation after life-sustaining treatments have been withdrawn, the nurse should ensure that: a. “do not resuscitate” (DNR) orders are written before the discontinuation of the treatments.

NURSINGTB.COM b. the family is not allowed to visit until the death occurs. c. DNR orders are written as soon as possible after the discontinuation of the treatments. d. the change-of-shift report includes the information that the patient is not to be resuscitated.

ANS: A

DNR orders should be written before withdrawal of life support; this will prevent any unfortunate errors in unwanted resuscitation during the time period between initiation of withdrawal and the actual death.

DIF: Cognitive Level: Apply/Application REF: p. 44

OBJ: Describe ethical and legal concerns related to end-of-life care.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment

19. The patient’s spouse is very upset because his loved one, who is near death, has dyspnea and restlessness. The nurse explains that there are some ways to decrease this discomfort, including: a. respiratory therapy treatments. b. opioid medications given as needed. c. incentive spirometry. d. increased hydration.

ANS: B

Dyspnea is best managed with close evaluation of the patient and the use of opioids, sedatives, and nonpharmacologic interventions (oxygen, positioning, and increased ambient air flow).

DIF: Cognitive Level: Apply/Application

REF: p. 46

OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage.

TOP: Integrated Process: Communication and Documentation

MSC: NCLEX Client Needs Category: Physiological Integrity

20. The patient’s spouse tells the nurse that there is no point in continuing to visit at the bedside because the patient is unresponsive. The best response by the nurse is a. “You’re right. Your loved one is not aware of anything now.” b. “This seems to be very difficult for you.” c. “I’ll call you if she starts responding again.” d. “Why don’t you check to see if any other family member would like to visit?”

ANS: B

The most therapeutic response by the nurse is to acknowledge the distress of the spouse.

DIF: Cognitive Level: Apply/Application

REF: p. 47 | Box 4-4

OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage.

TOP: Integrated Process: Caring

MSC: NCLEX Client Needs Category: Psychosocial Integrity a. Withholding and withdrawing life-sustaining treatment are distinctly different in the eyes of the legal community.

21. Which of the following statements about palliative care is accurate?

NURSINGTB.COM b. Reducing distressing symptoms is the primary goal of palliative care. c. Only the patient can determine what constitutes palliative care for him or her. d. Withdrawing life-sustaining treatments is considered euthanasia in most states.

ANS: B

The goal of palliative care is to reduce the distressing symptoms many patients experience due to serious illnesses.

DIF: Cognitive Level: Remember/Knowledge REF: p. 41

OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and health care providers.

TOP: Nursing Process Step: N/A

MSC: NCLEX Client Needs Category: Physiological Integrity

Multiple Response

1. Select interventions that may be included during “terminal weaning” include which of the following? (Select all that apply.)

a. Complete extubation following ventilator withdrawal b. Discontinuation of artificial ventilation but maintenance of the artificial airway c. Discontinuation of anxiolytic and pain medications d. Titration of ventilator support based upon blood gas determinations e. Titration of ventilator support to minimal levels based upon patient assessment of comfort

ANS: A, B, E

“Terminal weaning” may include titration of ventilator support to minimal levels, removal of the ventilator with maintenance of the artificial airway, and complete extubation. Pain and anxiolytic medications may be required to control dyspnea and anxiety that may accompany ventilator withdrawal. Blood gas determinations would be used in therapeutic ventilator management.

DIF: Cognitive Level: Remember/Knowledge

REF: p. 44 | p. 46 | Fig 4-2

OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity a. Antibiotics b. Dialysis c. Nutrition d. Pain medications e. Simple nursing interventions such as repositioning and hygiene

2. Which therapeutic interventions may be withdrawn or withheld from the terminally ill client? (Select all that apply.)

ANS: A, B, C

Any treatment that is life sustaining may be withheld from a terminally ill patient during the end of life. These treatments include nutrition, dialysis, fluids, antibiotics, respiratory support, therapeutic medications, and blood products. Any dose of analgesic or anxiolytic medication may be used to prevent suffering and should not be withdrawn. Dignity should be maintained during the course of dying. This would include ongoing provision of basic nursing care and comfort.

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DIF: Cognitive Level: Analyze/Analysis

REF: p. 43

OBJ: Describe ethical and legal concerns related to end-of-life care.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity a. Communication of uniform messages from all health care team members b. An integrated plan of care that is developed collaboratively by the patient, family, and health care team c. Facilitation of continuity of care through accurate shift-to-shift and transfer reports d. Limitation of time for families to express feelings in order to control family grief e. Reassuring the patient and family that they will not be abandoned as the goals of care shift from aggressive treatment to comfort care

3. Which interventions can the nurse use to facilitate communication with patients and families who are in the process of making decisions regarding end-of-life care options? (Select all that apply.)

ANS: A, B, C, E

Effective and consistent communication among the patient, family, and health care team members is required to promote positive outcomes during end-of-life care. Family members should be provided ample time to express feelings in order to improve the level of satisfaction and prevent dysfunctional bereavement patterns.

DIF: Cognitive Level: Apply/Application

REF: pp. 42-43

OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Psychosocial Integrity a. relieving pain. b. relieving nausea. c. psychological support. d. withdrawing life-support interventions. e. withholding tube feedings.

4. Palliation may include (Select all that apply.)

ANS: A, B, C

Palliation includes the relief of symptoms that may have a negative effect on the family or the patient.

DIF: Cognitive Level: Remember/Knowledge

REF: p. 41

OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and health care providers. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity a. Unmarried life partners of same sex b. Unmarried life partners of opposite sex c. Roommates d. Close friends e. Parents

5. When providing palliative care, the nurse must keep in mind that the family may include which of the following? (Select all that apply.)

ANS: A, B, C, D, E

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The definition of family varies and may include unmarried life partners of the same or opposite sex, close friends, and other close individuals who have no legal relationship with the patient. The patient gets to define who will be regarded as “family.”

DIF: Cognitive Level: Remember/Knowledge

REF: p. 47

OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage.

TOP: Integrated Process: Caring

MSC: NCLEX Client Needs Category: Psychosocial Integrity