Copyright Ó 2002 Delmar Learning, a Division of Thomson Learningô, Inc

Miles Luchterhand

Background scenario

Miles is a student nurse conducting a community health home care visit. Mr. Rosenthal is a 92-year-old male with terminal lung cancer being cared for at home. He has been alert, and they have established a good nurse-client relationship. Mr. Rosenthal has been joking with Miles has been the best medicine he has had. Miles believes that he has been doing a very good job caring for this client.

During his visit, he assists the client to the commode and is present when Mr. Rosenthal suddenly stops breathing. He has no pulse. Mr. Rosenthal has a home "Do Not Resuscitate" (DNR) order, in writing, at his home, which Miles has read. He also is wearing a DNR order on a bracelet. Miles makes him comfortable, calls his supervisor, and stays with him. Mr. Rosenthal dies. When Miles returns to the community health center, he is distraught and you have been asked to counsel him.

Interview

Miles:

"Mr. Rosenthal was such a nice man. I just didn't expect him to die so suddenly. There was no warning."

"This is my first experience with having a client die in my care. I always thought that the first time would be with a client that I knew was dying and that it would be a welcomed event."

"At school, we have not explored death in any great depth. We spoke about loss in general, and how to care for a body. We didn't discuss how to cope with it on a personal level. I'm really having a hard time. I know I should just shake it off and get back to work, but how do you do that?"

Examination

Not appropriate.

Background education

Death is one of the realities of caring for the ill and/or elderly. Students learning to care for ill adults may be very fearful of confronting death and dying. It is frightening for some to even be near a dying person, especially if that person happens to be someone they cared for. Fears regarding how they will react, being too cold or too overly sensitive, or treating death as routine and becoming jaded are common concerns. Student nurses are often told that they will "get used to it."

Research suggests that student nurses may not be receiving adequate education to prepare them to care for dying clients. Students may feel that their practical skills were not adequate; they may feel helpless and anxious. In addition, they feel the pain of losing a client. Nursing students that are especially close to a client may find it difficult to provide end of life care. There is satisfaction in providing excellent, quality care to a failing client in the final days of life.

Home "do not resuscitate" orders allow an individual to specify that they not wish to be resuscitated if breathing and heart stop while they are at home. A legal form that varies from state to state, a DNR order prevents unnecessary resuscitation attempts by emergency personnel, ambulance services, or any care providers in the home. The form is usually signed by the client who must be competent, over 18, have appropriate medical findings, and are certain they do not wish to receive emergency treatment. Witnesses and the client's physician sign this form. Appropriate medical findings usually include; a terminal illness, an illness where resuscitation would impose an extraordinary burden in light of the medical outcome and expected resuscitation outcome, or where resuscitation would be medically futile.

Simple comfort procedures can be carried out even while the DNR order has been activated and while the client is dying. These vary, but can include suctioning the airway, giving oxygen, providing pain relief, positioning the client for comfort, providing emotional support, controlling bleeding, and contacting appropriate health care providers.

The community health nurse preceptor can take a mentoring and supervising role in helping students cope with new and stressful situations while learning skills in "hands-on" situations. The nurse can provide individual support to supplement information learned in lectures and classes, as well as provide anticipatory guidance students in situations where a death may occur. This support might include exploring the student's previous experiences with deaths of friends or family members, assessing specific fears and concerns, role-playing difficult situations, and arranging group discussion with other students to talk in greater depth about death-related concepts learned in the classroom.

The nurse can link the student to additional resources to help the student integrate the death experience into their education, to learn additional coping skills, and to learn appropriate care skills for the dying client. Finally the nurse can assess the student's personal reactions to the experience, and link the student with counseling and mentoring as appropriate to help the student deal with personal fears, pain, and feelings of loss or helplessness surrounding the care of the dying client.

List your findings and conclusions:

Stress and anxiety secondary to unexpected death of a client.

Nursing diagnoses:

00126 Deficient knowledge (death and dying issues)

00152 Risk for Powerlessness

00153 Risk for situational low self-esteem

00061 Risk for caregiver role strain

00146 Anxiety

00147 Death anxiety

00067 Risk for spiritual distress

Quiz

1. The community health nurse can provide individual support and guidance to help students cope with the unexpected death of a client. What would the community health nurse most likely do in this situation?

a. Tell the student to talk with friends as it is inappropriate for the nurse to perform psychological counseling with a student.

b. Assess the student's reactions and link the student with counseling and mentoring.

c. Study the experience to determine if the student is at fault.

d. Medicate the student.

2. Miles Luchterhand is a student nurse that has just experienced the unexpected death of one of his clients. Which statement is the most appropriate nursing diagnosis for this case?

a. Disturbed thought processes

b. Anxiety and risk for spiritual distress

c. Ineffective role performance

d. Impaired social interaction

3. Research findings are available regarding students and dying patients. What was the appropriate finding?

a. Students are very prepared to care for dying clients.

b. Students should treat death as routine.

c. Students must "get used to" caring for dying clients.

d. Students may not be receiving adequate education to prepare them to care for dying clients.

4. Home "do not resuscitate" orders are legal documents that provide peace of mind to dying individuals while they are at home. What does a valid DNR do?

a. The order prevents unnecessary resuscitation attempts by emergency personnel, ambulance services or any care providers in the home.

b. The order specifies that caregivers cannot give oxygen to the client.

c. The order prevents any medication from being given to the client.

d. The order specifies that caregivers must contact appropriate health care providers.

5. The DNR order is usually signed by a client whose condition meets the appropriate medical findings requirement. What is else is necessary in order for a DNR order to be valid?

a. The client must be in a coma and the legal guardian must sign the DNR order.

b. The client must be unable to make decisions about his or her own care.

c. The client must be incubated and 18 or older.

d. The client must be competent, 18 or older, and have appropriate medical findings.

6. "Appropriate medical findings" is one of the requirements of a DNR. What is a condition that would not satisfy this requirement?

a. A terminal illness

b. An illness where resuscitation would impose an extraordinary burden in light of the medical outcome

c. An Illness where resuscitation would be medically futile

d. The client’s desire to die.

7. When a DNR has been activated, the health care provider is restricted in the amount of care that can be provided to the client. In the event of a client's imminent death, what is the health care provider instructed to do?

a. Provide pain relief.

b. Do not provide pain relief.

c. Provide pain relief if the client specifically requests it.

d. Rescind the DNR order if the client is in pain.

8. The DNR is a legal form that is recognized by health care professionals in the United States. How are DNR guidelines applied?

a. They are the same for each state.

b. They are different for each state.

c. They are only available in California, Texas and Oregon.

d. They have reciprocity between states.

9. Students learning to care for ill adults may be very fearful of confronting death and dying. What would be an unlikely emotion that a student would experience?

a. Relief that the client is dead

b. Inadequately prepared to deal with death

c. Afraid that he or she contributed to the client's death

d. Euphoria that the client is no longer suffering

10. The community health nurse can often act as a mentor and assist students in new and stressful situations. What might a community health nurse mentoring a student commonly do?

a. Help the student obtain permission for a leave of absence for additional counseling

b. Help the student move on to another client quickly

c. Investigate the student's actions closely to discover if they contributed to the death

d. Helped the student explore their personal feelings, reactions and coping skills surrounding the death