Exam 1 blueprint
Sixty items (Approximately 14-15 questions per concept. One dosage and calculation question)
Questions may refer to or require you to:
End of life care & Ethical Concerns -Chapter 8:
Determine stages of grief
- Stages: denial, anger, bargaining, depression, and acceptance
- Denial- refusal to believe that its actually happening ex: This can’t be me
- Anger- express resentment (Blame)
- Bargaining- “maybe I should take another multivitamin,” or “I should go to this doctor
instead.”
- Depression- they may cry, stop interacting, stop talking
- Acceptance- coming to terms with it
Compare and contrast palliative care vs hospice
- Palliative Care:
- broader, can be provided alongside curative treatment.
- Goal is improve quality of life for pt and family
- Paired with treatment of pts condition
- Can be used at any point after diagnosis ( at any stage of disease)
- Provided in clinical /home setting
- Hospice Care
- reserved for those with a prognosis of 6 months or less and focuses on comfort, not cure.
- All measures must be used to ensure alleviation of symptoms
- Often provided to those with terminal cancer, dementia, end stage COPD, cardiac disease,
neurologic disease
- Death must be accepted
- Pain and other symptoms must be managed
- Bereavement care must be provided to family
- Home care of dying necessary
- Patient /family viewed as single unit of care
- In home setting
- TERMINAL
- Both:
- Pt with serious illness
- Comfort and supportive care
- Pain management
- Symptom relief
Manifestations of end of life and dying
- General decline: weakness, ↑ sleep, anorexia, LOC, changes in VS
- Cardiovascular:↓ perfusion → cold; ↓ BP, irregular HR → stops.
- Respiratory:shallow/rapid ↑ breaths, apnea, Cheyne-Stokes, inability to cough or clear secretions
causing grunting, gurgling, or noisy congested breathing. Irregular breathing
- Neurologic: ↓ LOC → lethargy → unresponsiveness → coma, confusion
, - Integumentary : mottled, cyanotic extremities, cold clammy skin
- Sensory: hearing is last to go, ↓sensation & perception , ↓level of awareness , loss of blink reflex
- GI- slowing GI tract (can be d/t meds), distention/nausea, incontinence d/t losing sphincter
muscle tone (don’t force feed) , BM may occur before imminent death or at time of death
- Urinary- incontinence/ or unable to urinate ( kidneys are shutting down ) , ↓ in Urinary output
- Musculoskeletal- gradual loss of ability to move , sagging of jaw , dysphagia(risk of aspiration)
& loss of gag reflex , difficulty maintaining body posture & alignment
Indications of death :
- No respiration , no pulse, pupils fixed & dilated ,pallor, hypothermia, muscles & sphincter
relaxation ( releasing stool & urine ), jaw may (drop) fall open .
Compare advance directives
Types of Advance Directives
- A group of instructions clearly stating a person’s wishes concerning their healthcare in case they
are incapacitated
- DNR and POLST has to be signed by HCP
Durable Power of Attorney for Health Care
- AKA health care proxy, health care agent.
- A person chosen to make health care decisions once a patient loses capacity.
- Different from financial power of attorney ( It may or may not be the same person)
- A document that identifies a person who will make healthcare decisions on behalf of you when
you are unable to
Decision-making capacity requires ability to:
- Receive information (but not necessarily be totally oriented)
- Process/deliberate and mentally manipulate information
- Communicate a treatment preference
● Comatose patients → lack decisional ability.
Living Will
- States what treatments are desired or refused if death is near
- Examples: CPR, ventilation, artificial nutrition/hydration.
- Specifics about life-prolonging treatments such as DNR, NG tube, ventilator
Do-Not-Resuscitate (DNR) /Do-Not-Attempt-Resuscitate
- Signed by physician or authorized provider.
- For patients with life-limiting conditions.
- Prevents initiation of CPR in cardiac/respiratory arrest.
- Portable DNR/DNAR bracelets, documents across care settings.
- Withhold CPR- do not perform it
Physician Orders for Life-Sustaining Treatment
- Medical orders that outline broader wishes (beyond resuscitation)
- Follow patients across health care settings.
- More comprehensive; covers present and future care
- Covers current treatment and DNR
Explain patient self determination act and the role of the health care team
Patient Self-Determination Act (PSDA), 1991
, - Gave Americans the right to decide medical care if incapacitated
- Requires health care agencies to ask about advance directives upon admission.
- Patients w/o ADs must be given info + chance to complete forms.
- ADs ideally completed before crisis
- The pt’s right to have a say in their medical care in cases where they are unable to verbalize their
wishes
- Ex- don’t want to be on a ventilator, don’t want CPR, etc
- Health care providers need to follow up with the patient on this
Nurse’s Role
- Nurses = advocates for ACP.
- Facilitate informed decisions → aligned with patient’s values, beliefs, goals.
- Support families in discussions about end-of-life wishes.
Discuss: Palliative sedation vs withholding life sustaining measures vs. euthanasia vs physician
assisted suicide.
Euthanasia Physician-Assisted Withdrawing or Voluntary Stopping of Eating Palliative sedation
Death /Medical Withholding and Drinking
Aid in Dying Life-Sustaining Therapy
(PAD)
Ending a person’s A physician -Stopping or not starting -Competent pt with -Used to relieve refractory
life, usually to provides the treatments that artificially terminal/incurable illness symptoms :
relieve suffering. means (usually prolong life when cure is chooses to refuse food and -Administration of meds t
-HCP take prescription drugs) not possible. fluids in order to hasten death. increase comfort & induce
deliberate action for the pt to -Discontinuing 1/> -Reasoning behind VSED: a decreased level of
(giving med or self-administer & therapies resulting in a -Desire to maintain control over consciousness/ awareness
treatment) to cause their own natural death the end of life. for terminally ill pts
directly cause death. -Also known as: -Relief from severe suffering -Comfort & not death is
death. Provider -United States: “Allowing natural death” (pain, decline). the intent
gives the lethal Legal in 11 states “Letting the person die -Reduction of caregiver burden -Requires consent
dose to the pt (as of 2022). Other naturally” on family/significant others.
-Even if a pt states are -Cause of death: Pt’s -Outcome: Leads to terminal
consents, this is considering disease progression or poor dehydration
not supported by legislation. health status—not the -Management: Palliative care
most U.S. health -Nurses - no role withdrawal itself. interventions (oral care, lip
professional but must provide -Ethical and legal support: moisture, comfort measures).
organizations. education -Professional health care -Ethical standing: Seen by some
-Not legal in the Patient has to be organizations support as the only legal/moral
U.S. mentally patient’s/surrogate’s right alternative to relieve intolerable
componentant to to stop interventions. suffering.
Voluntary or make the -Many religious
involuntary decisions, has to communities accept this
be a resident of the practice when treatment is
Sixty items (Approximately 14-15 questions per concept. One dosage and calculation question)
Questions may refer to or require you to:
End of life care & Ethical Concerns -Chapter 8:
Determine stages of grief
- Stages: denial, anger, bargaining, depression, and acceptance
- Denial- refusal to believe that its actually happening ex: This can’t be me
- Anger- express resentment (Blame)
- Bargaining- “maybe I should take another multivitamin,” or “I should go to this doctor
instead.”
- Depression- they may cry, stop interacting, stop talking
- Acceptance- coming to terms with it
Compare and contrast palliative care vs hospice
- Palliative Care:
- broader, can be provided alongside curative treatment.
- Goal is improve quality of life for pt and family
- Paired with treatment of pts condition
- Can be used at any point after diagnosis ( at any stage of disease)
- Provided in clinical /home setting
- Hospice Care
- reserved for those with a prognosis of 6 months or less and focuses on comfort, not cure.
- All measures must be used to ensure alleviation of symptoms
- Often provided to those with terminal cancer, dementia, end stage COPD, cardiac disease,
neurologic disease
- Death must be accepted
- Pain and other symptoms must be managed
- Bereavement care must be provided to family
- Home care of dying necessary
- Patient /family viewed as single unit of care
- In home setting
- TERMINAL
- Both:
- Pt with serious illness
- Comfort and supportive care
- Pain management
- Symptom relief
Manifestations of end of life and dying
- General decline: weakness, ↑ sleep, anorexia, LOC, changes in VS
- Cardiovascular:↓ perfusion → cold; ↓ BP, irregular HR → stops.
- Respiratory:shallow/rapid ↑ breaths, apnea, Cheyne-Stokes, inability to cough or clear secretions
causing grunting, gurgling, or noisy congested breathing. Irregular breathing
- Neurologic: ↓ LOC → lethargy → unresponsiveness → coma, confusion
, - Integumentary : mottled, cyanotic extremities, cold clammy skin
- Sensory: hearing is last to go, ↓sensation & perception , ↓level of awareness , loss of blink reflex
- GI- slowing GI tract (can be d/t meds), distention/nausea, incontinence d/t losing sphincter
muscle tone (don’t force feed) , BM may occur before imminent death or at time of death
- Urinary- incontinence/ or unable to urinate ( kidneys are shutting down ) , ↓ in Urinary output
- Musculoskeletal- gradual loss of ability to move , sagging of jaw , dysphagia(risk of aspiration)
& loss of gag reflex , difficulty maintaining body posture & alignment
Indications of death :
- No respiration , no pulse, pupils fixed & dilated ,pallor, hypothermia, muscles & sphincter
relaxation ( releasing stool & urine ), jaw may (drop) fall open .
Compare advance directives
Types of Advance Directives
- A group of instructions clearly stating a person’s wishes concerning their healthcare in case they
are incapacitated
- DNR and POLST has to be signed by HCP
Durable Power of Attorney for Health Care
- AKA health care proxy, health care agent.
- A person chosen to make health care decisions once a patient loses capacity.
- Different from financial power of attorney ( It may or may not be the same person)
- A document that identifies a person who will make healthcare decisions on behalf of you when
you are unable to
Decision-making capacity requires ability to:
- Receive information (but not necessarily be totally oriented)
- Process/deliberate and mentally manipulate information
- Communicate a treatment preference
● Comatose patients → lack decisional ability.
Living Will
- States what treatments are desired or refused if death is near
- Examples: CPR, ventilation, artificial nutrition/hydration.
- Specifics about life-prolonging treatments such as DNR, NG tube, ventilator
Do-Not-Resuscitate (DNR) /Do-Not-Attempt-Resuscitate
- Signed by physician or authorized provider.
- For patients with life-limiting conditions.
- Prevents initiation of CPR in cardiac/respiratory arrest.
- Portable DNR/DNAR bracelets, documents across care settings.
- Withhold CPR- do not perform it
Physician Orders for Life-Sustaining Treatment
- Medical orders that outline broader wishes (beyond resuscitation)
- Follow patients across health care settings.
- More comprehensive; covers present and future care
- Covers current treatment and DNR
Explain patient self determination act and the role of the health care team
Patient Self-Determination Act (PSDA), 1991
, - Gave Americans the right to decide medical care if incapacitated
- Requires health care agencies to ask about advance directives upon admission.
- Patients w/o ADs must be given info + chance to complete forms.
- ADs ideally completed before crisis
- The pt’s right to have a say in their medical care in cases where they are unable to verbalize their
wishes
- Ex- don’t want to be on a ventilator, don’t want CPR, etc
- Health care providers need to follow up with the patient on this
Nurse’s Role
- Nurses = advocates for ACP.
- Facilitate informed decisions → aligned with patient’s values, beliefs, goals.
- Support families in discussions about end-of-life wishes.
Discuss: Palliative sedation vs withholding life sustaining measures vs. euthanasia vs physician
assisted suicide.
Euthanasia Physician-Assisted Withdrawing or Voluntary Stopping of Eating Palliative sedation
Death /Medical Withholding and Drinking
Aid in Dying Life-Sustaining Therapy
(PAD)
Ending a person’s A physician -Stopping or not starting -Competent pt with -Used to relieve refractory
life, usually to provides the treatments that artificially terminal/incurable illness symptoms :
relieve suffering. means (usually prolong life when cure is chooses to refuse food and -Administration of meds t
-HCP take prescription drugs) not possible. fluids in order to hasten death. increase comfort & induce
deliberate action for the pt to -Discontinuing 1/> -Reasoning behind VSED: a decreased level of
(giving med or self-administer & therapies resulting in a -Desire to maintain control over consciousness/ awareness
treatment) to cause their own natural death the end of life. for terminally ill pts
directly cause death. -Also known as: -Relief from severe suffering -Comfort & not death is
death. Provider -United States: “Allowing natural death” (pain, decline). the intent
gives the lethal Legal in 11 states “Letting the person die -Reduction of caregiver burden -Requires consent
dose to the pt (as of 2022). Other naturally” on family/significant others.
-Even if a pt states are -Cause of death: Pt’s -Outcome: Leads to terminal
consents, this is considering disease progression or poor dehydration
not supported by legislation. health status—not the -Management: Palliative care
most U.S. health -Nurses - no role withdrawal itself. interventions (oral care, lip
professional but must provide -Ethical and legal support: moisture, comfort measures).
organizations. education -Professional health care -Ethical standing: Seen by some
-Not legal in the Patient has to be organizations support as the only legal/moral
U.S. mentally patient’s/surrogate’s right alternative to relieve intolerable
componentant to to stop interventions. suffering.
Voluntary or make the -Many religious
involuntary decisions, has to communities accept this
be a resident of the practice when treatment is
