Loss, Grief, and Death Case Study

Bertha Klein, who is 70-years-old, suffered a stroke a year ago. She remains weak, and she has right-sided paralysis and dysphagia. Her husband, Frank, has been caring for her at home. A home health nurse visits every other day and the Kleins’ synagogue has been providing one meal a day. The Kleins’ daughter, Carol, lives several states away with her husband and their three children, who are ages 15, 8, and 3.

1. Which assessment should be done immediately?
A. Determine Frank’s knowledge about feeding a dysphagic person.
B. Auscultate Bertha’s lungs for adventitious breath sounds.
C. Assess Bertha’s LOC with the mini-mental status exam.
D. Determine Bertha’s ability to swallow liquids.

B. Auscultate Bertha’s lungs for adventitious breath sounds.

Bertha’s lungs should be assessed immediately for adventitious breath sounds since she is at risk for aspiration pneumonia secondary to the choking incident.

Home health nurse reports findings to the healthcare provider (HCP). Oral temp: 102 F and diminished breath sounds with crackles in the right lung. The HPC admits Mrs. Klein to the acute care facility with the diagnosis of aspiration pneumonia.
Stage 1:
Bertha was sitting upright while Frank fed her broth from chicken noodle soup. She started spitting out the broth and turning blue around her mouth. Frank stopped feeding her and patted her back forcefully. Bertha was able to catch her breath and the blueness resolved. Two days later, Frank tells the home health nurse about the incident during a scheduled visit. The nurse notices that Bertha’s LOC has declined.
Legal Considerations

Mrs. Klein is disoriented when she is admitted to the hospital.
2. During the admission procedure, what is the nurse’s responsibility regarding advance directives?
A. Determine if Mrs. Klein has completed a living will and a durable power of attorney.
B. Explain the Patient Self-Determination Act (PSDA) requires a living will,
C. Instruct Mr. Klein to have his wife sign a living will when she is no longer disoriented.
D. Clarify that the healthcare provider cannot be a witness for these legal documents.

A. Determine if Mrs. Klein has completed a living will and a durable power of attorney.

The Patient Self-Determination Act (1991) requires healthcare institutions to provide written information concerning the client’s rights to refuse treatment and formulate advance directives. The nurse should ask Mr. Klein if his wife has completed a living will and a durable power or attorney.

Mr. Klein has a copy of his wife’s living will and durable power of attorney for health care. He states, “I do not want her to suffer.” He also requests that the staff call them Frank and Bertha.
3. How should the nurse respond to Franks’s remarks?
A. Document that the client is aware of the Patient Self-Determination Act.
B. Place a copy of the living will in the medical record and document its presence.
C. Notify the healthcare provider that the spouse desires euthanasia for his wife.
D. Report to the charge nurse that Frank seems to be in denial about the seriousness of his wife’s condition.
B. Place a copy of the living will in the medical record and document its presence.

The nurse is responsible for placing a copy of the living will in the medical record and documenting its presence.

Nutritional Issues
Bertha receives intravenous antibiotics to treat the pneumonia. The clinical dietitian assesses Bertha’s nutritional status. Bertha continues to have difficulty swallowing, so the dietitian posts a “swallow precautions” sign on the wall by Bertha’s bed. Frank notices the sign and asks the nurse what it means. The nurse explains that thin liquids can cause pneumonia because the liquids may go into the trachea and then the lungs instead of the stomach, since Bertha does not have adequate swallowing ability. Suddenly, Frank gets a shocked look on his face and says, “Oh, no! I did that. I gave her pneumonia!”
4. How should the nurse reply?
A. “How was she positioned when you fed her?
B.”Saliva entering the lungs can also cause pneumonia.”
C. “You know you did the best you could.”
D. “We know it was not intentional on your part.”
B.”Saliva entering the lungs can also cause pneumonia.”

The nurse is correct in giving Frank reassuring information that aspiration pneumonia can also be caused by Bertha’s inability to swallow saliva. The pneumonia is being treated, and it will do no good at this point to speculate about the cause of the pneumonia.

Four days later, Bertha becomes more disoriented and she is unable to swallow thickened liquids or pureed foods w/o choking. Her weakness has progressed to the point at which she cannot bear her own weight or sit in a chair. The healthcare provider suggests inserting a nasogastric feeding tube to provide nutrition; however, Bertha’s living will excludes tube feedings and intravenous nutrition. Frank says he supports Bertha’s decision and that this information was shared with their daughter.
5. Which response demonstrates that the nurse understands the underlying premise of a living will?
A. “We will honor Bertha’s directives in her living will.”
B. “Are you sure that this is what you really want for Bertha?”
C. “Your healthcare provider wants to do all he can to preserve life.”
D. “Have you spoken to your rabbi about Bertha’s wishes?”
A. “We will honor Bertha’s directives in her living will.”

The nurse demonstrates support and gives reassurance to Frank that Bertha’s decision will not be ignored by her providers, which is the intent of the will.

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Bertha is transferred to the hospice unit. She remains weak and disoriented, and subtle vital sign changes indicate that the dying process has begun. Under the guidelines of Bertha’s living will, no lifesaving measure are ordered. Care measure are instituted to keep Bertha comfortable. She develops cheilosis and stomatitis.
6. What nursing intervention should be instituted to care for Bertha’s mouth?
A. Giver her sips of water through a straw.
B. Offer her an ounce of ice chips every hour.
C. Provide mouth care daily with her bath.
D. Clean her mouth frequently with oral swabs.
D. Clean her mouth frequently with oral swabs.

Bertha’s nurse is correct to ensure that frequent mouth care is given with oral swabs.

Bertha has become very difficult to arouse.
7. What is the safest manner of giving oral care to Bertha?
A. Have two nurses or UAPs perform the procedure.
B. Remove dentures if the client has them.
C. Demonstrate the procedure to Frank so he can assist the nurse if he wishes.
D. Moisten oral swabs with a minimal amount of water.
A. Have two nurses or UAPs perform the procedure.

The nurse is correct to first ensure that two staff members are available to provide safe oral care.

The inability to swallow salivary secretions causes frequent episodes of coughing and choking. The nurse identifies the nursing diagnosis of “Ineffective breathing pattern” for Bertha.
8. What intervention will help Bertha breathe more comfortably?
A. Tracheal suctioning of secretions.
B. Oral suctioning of secretions from mouth and throat.
C. Encourage deep breathing every hour wile awake.
D. Teach Bertha how to use an incentive spirometer.
B. Oral suctioning of secretions from mouth and throat.

Oral suctioning of accumulated secretions is gently done with a tonsil tip or Yankauer suction device to provide more effective breathing and to add to Bertha’s comfort.

Grief Process
The Kleins’ daughter Carol, arrives to visit her mother. Carol’s husband and children accompany her. Carol last saw her mother 3 months ago, and she is alarmed that her mother has lost weight, is weaker, and is not eating. Carol acknowledges to the nurse that her mother talked to her about the living will but says angrily, “Don’t you think you should do something? This is a hospital, isn’t it?”
9. What is the best response by the nurse?
A. Yes, this is the hospice unit of the hospital.
B. It must be difficult to see the changes in your mother.
C. Why are you angry at the nurses and other healthcare providers?
D. You are in the stage of denial in the grief process.
B. It must be difficult to see the changes in your mother.

Empathetic statements are therapeutic and can help Carol in moving through the grief process.

Carol tells the nurse that she feels helpless and doesn’t know what to do to make her mother more comfortable. She asks the nurse if it would be all right to have a massage therapist come in a gently massage her mother’s limbs and back.
10. How should the nurse respond to Carol’s request?
A. Ask Carol what purpose she thinks massage will serve.
B. Inform Carol that she must produce the therapists’s credentials first.
C. Tell Carol that massage therapists are welcome in the hospice.
D. Share with Carol that she uses alternative therapies herself.
C. Tell Carol that massage therapists are welcome in the hospice.
Nontraditional therapies are encourages in the hospice environment if they give comfort to the client and are not harmful. Additionally, supporting Carol will give her a sense of control.
Carol’s 15-year-old daughter enters the room, kisses Bertha, and remarks, “I think my grandmother can get better if we just give her more time. Just because she was moved to this hospice doesn’t mean she will die.” The nurse recognizes that the adolescent has already begun to grieve the loss of the grandmother she loves.
11. According to Kubler-Ross, which stage of grief is exemplified by the adolescent’s statements?
A. Acceptance
B. Depression
C. Bargaining
D. Denial
D. Denial

The adolescent is experiencing a common initial reaction to a real or impending loss. Feelings of numbness, shock, and disbelief occur. This stage is healthy and permits the individual to develop other coping mechanisms.

Carol expresses concern about her daughter’s statement. The nurse invites Carol to step out of the room to get a cup of coffee, and Carol’s husband joins them. The nurse explains the stages of grief and ways Carol and her husband can support their daughter as she moves back and forth among the stages. Carol states that she and her husband began reading age-appropriate books and talking to the younger children (ages 8 and 3) about death as soon as they received the news that Bertha was hospitalized. Carol’s husband expresses concern because their 8-year-old son repeatedly asks questions about what happens to the physical body after death and wants specific information about what the funeral home will do to the body.
12. How should the nurse respond?
A. Tell the parents to take the child to a grief counselor immediately.
B. Call the family’s rabbi to get information that is culturally appropriate.
C. Recommend that their son’s questions be answered honestly in simple terms.
D. Ask to speak to the child to assess what is really bothering him.
C. Recommend that their son’s questions be answered honestly in simple terms.

Children at this age are often interested in the physical and biological aspects of death. They usually recognize that death is permanent and are very concrete in their thinking. Questions should be answered honestly and simply, giving the child enough information to answer the question but not overwhelming the child with information. Parents can expect that repeated explanation will be necessary.

Carol and her husband ask the nurse what they should tell their 3-year-old daughter when Bertha dies.
13. Which phrase should the nurse recommend?
A. “Your grandma went to sleep and didn’t wake up.
B. “Grandma died and that makes us feel very sad.”
C. “God wanted your grandma because she was so good.”
D. “We’ve lost Grandma and will miss her very much.”
B. “Grandma died and that makes us feel very sad.”

This statement is truthful and acknowledges the parents’ feelings of sorrow and grief. The parents may also want to tell the child that the person who died is not coming back and then answer any questions. This process may need to be repeated many times.

Bertha begins to sleep more, and she has less alert time. Over the last few days, she has become more restless, has increased grimacing, and periodically clenches her fists. The nurse notes an increase in pulse, respiration, and blood pressure during these episodes. The healthcare provider is contacted and oxycondone HCL immediate-release concentrate solution (OxyFAST) is prescribed to be administered via the oral transmucosal route every 4 hours as needed for pain. Frank asks the nurse why oxycodone is given in this manner.
14. The nurse answers Frank’s question based on which information? (Select all that apply)
A. This route is least likely to produce drug addiction.
B. There is no other route by which to give this medication.
C. The medication is rapidly absorbed and acts quickly.
D. This route decreases the chance of aspiration.
E. Risk for respiratory depression is lessened using this route.
C. The medication is rapidly absorbed and acts quickly.

Because the oral mucosa has a thin epithelium and abundant blood vessels, drugs administered via this route are rapidly absorbed. Passing directly into the bloodstream, medication acts quickly while avoiding the damaging effects of gastric juices and liver metabolisms.

D. This route decreases the chance of aspiration.

This route is particularly beneficial in the client with cancer who is unable to tolerate oral administration because of nausea and vomiting or the client with dysphagia.

Because Bertha has been losing weight and she has a decreased metabolic rate due to the dying process, the healthcare provider prescribes 0.2 mg/kg oxycodone HCL (OxyFAST) of Bertha’s weight. Bertha weighs 110 pounds. The medication is available as 20 mg/mL in a 30 mL bottle with a measured dropper.
15. How many milliliters of medication will the nurse administer? (nearest 10th)
0.5 mL

First converts lbs–>kg
(110/2.2=50kg)
Next, calculate how many mg Bertha should receive: 0.2mg/kg X 50kg=10mg
10mg X 1mL/20mg=0.5mL

Bertha rests more comfortably after the medication is initiated, and she is able to speak with her family when she is awake. Bertha awakens while the rabbi is visiting and asks him to read from the Book of Psalms and to pray. The nurse enters the room to obtain vital signs while the rabbi is praying. Frank asks the nurse to remain with them while the rabbi prays and then obtain the vital signs.
16. What action should the nurse take?
A. Quickly take the vital signs as prescribed.
B. Stand quietly until the prayer is over.
C. Express discomfort by leaving the room.
D. Ask the rabbi to come back later to pray.
B. Stand quietly until the prayer is over.

This action expresses respect for the family’s spiritual needs and offers support to the family and clergy. Respecting spiritual needs is one of the many priorities of hospice care. The nurse does not need to be of the same religion/denomination as the client to remain in the room during readings and prayer.

Frank tells the nurse that their faith in God has seen them through life’s problems and that he relies on that faith every day.
17. What is the best response to support Frank and Bertha spiritually?
A. Do you have any wishes I should convey to the staff?
B. I wish my faith was as strong as yours.
C. Does your daughter share your faith?
D. Would you like to visit the chapel on the first floor?
A. Do you have any wishes I should convey to the staff?

The nurse is correct in intervening by asking what Frank and Bertha prefer in terms of faith and spiritual care.

Frank states that he and Bertha have been married for 52 years. He sighs and wipes his eyes, softly remarking that he won’t know what to do when she is gone.
18. Which feedback from the nurse will encourage Frank to talk more about his feelings?
A. Praise Frank for being able to stay married so long.
B. Ask Frank to share memories of the couple’s time together.
C. Remark that Frank and Bertha are role models for the synagogue.
D. Share with Frank memories of own grandparents.
B. Ask Frank to share memories of the couple’s time together.

Asking him to talk about his memories of their time together will allow Frank the opportunity to share his feelings and reminisce about their marriage.

Bertha now lies quietly with her eyes closed. She no longer responds verbally, but she smiles when her family speaks to her.
19. To assist Frank and Bertha in life review, what is the best intervention by the nurse?
A. Encourage visitors to talk quietly so Bertha is not disturbed.
B. Suggest that Frank bring photo albums to show Bertha.
C. Urge Frank to talk to Bertha about their experiences.
D. Encourage visitors to use touch when communicating with Bertha.
C. Urge Frank to talk to Bertha about their experiences.

Reminiscing is a means of setting one’s life in order, which is the task of the final stage of Erikson’s developmental theory called Integrity vs. Despair. Frank’s retelling of significant life experiences can help both of them feel a sense of meaning in their lives, which is the goal of this stage. It is also in keeping with the Jewish concept of the value of life on this earth, good deeds, and the legacy of the deceased.

Frank decided to go home to sleep in his own bed. Bertha’s daughter, Carol, spends the night at the bedside. Early the next morning, Bertha’s vital signs are pulse 50 and thready, respirations 10 and shallow, BP 70/30, Glasgow Coma Scale 3.
20. What other physical symptom should the nurse anticipate?
A. Hyperreflexia in legs and arms.
B. Increased urinary output.
C. Mottling of hands and feet.
D. Head turned away from light.
C. Mottling of hands and feet.

Cyanosis and mottling occur first in the hands and feet and then progress centrally.

Based on the assessment findings, what action should the nurse take?
A. Inform Carol that Bertha’s condition is worsening.
B. Suggest that Carol tell Frank to rush back to the hospital immediately.
C. Hold Carol’s hand, but do not disclose Bertha’s vital signs.
D. Notify the family that Bertha will probably die today.
A. Inform Carol that Bertha’s condition is worsening.

The nurse should keep family members informed of Bertha’s worsening condition to provide them the opportunity to communicate with Bertha and to notify their rabbi if desired.

Carol has been observing the nurse and the UAP perform oral suction for Bertha. Carol says, “I know Mama is dying. I can do the suctioning. Would you watch me once?”
22. How should the nurse respond?
A. “Do you think you are strong enough?”
B. “Yes. I would be happy to watch you.”
C. “I am not sure that is a good idea.”
D. “I think there is a policy against it.”
B. “Yes. I would be happy to watch you.”

Carol wants to participate in the care of her mother. Allowing her to help will lessen her sense of helplessness during the dying process.

Carol notifies her father that her mother’s condition is worsening. Frank arrives with his son-in-law and grandchildren. The rabbi is called ot be with the family. The family recites the Shema, which reaffirms the basic tenets of the Jewish faith. Bertha moves her lips as they speak but does not open her eyes. As the day goes on, at least one family member remains at Bertha’s side at all times. Members of the synagogue bring food to the waiting room for the family to eat.

The family members are at the bedside very early the next day when Bertha stops breathing. The healthcare provider arrives and pronounces the death. As the rabbi is being consulted regarding the preparation of the body, a group of women from the synagogue arrive to assist with postmortem care.

23. How should the nurse respond?
A. Instruct the family and the rabbi to leave the room.
B. Remain available to assist the women of the synagogue as needed.
C. Tell the rabbi that postmortem care must be done by the hospice staff regardless of the religion.
D. Remind the family that an autopsy must be performed before the burial.

B. Remain available to assist the women of the synagogue as needed.

It is not uncommon for a group of persons from the synagogue to come and prepare the body. Men will come for men who have died, and women come for women. While there are specific ways that the body must be cleansed, positioned, and wrapped, the nurse can assist by removing all external catheters and medical equipment attached to the body and ensuring that all incisions and wounds are dressed.

Frank comes to the nursing station to say goodbye and offers his thanks. He says, “I will miss my dear wife, by it helped that we could all be with her when she died.” Frank and his family leave when the funeral home staff arrive to take Bertha’s body. The nurses are able to spend time talking with one another about the experience of helping Bertha and her family through the dying process before they return to caring for other hospice patients.
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