Purpose:
To provide students with the opportunity to provide end-of-life and postmortem care while supporting a grieving family in a manner consistent with their spiritual beliefs and cultural values.
Overview
Samuel Green is a 75-year-old Jewish male diagnosed 15 months ago with inoperable pulmonary adenocarcinoma. He became acutely ill after his last round of chemotherapy and was admitted to the inpatient hospice unit for palliative care. His code status is documented as do not resuscitate
(DNR). Mr. Green's wife and son are at his bedside and are aware that he is actively dying. The scenario takes place on his first hospice day at 1300. During this scenario, students will have the opportunity to provide end-of-life and postmortem care while supporting a grieving family in a manner consistent with their spiritual beliefs and cultural values.
Recommended scenario time limit: 20-25 minutes
Recommended debriefing time limit: 20-25 minutes
The identifiable actions that the student is expected to perform during this scenario are based on the nursing process and have been organized according to the Quality and Safety Education for
Nurses (QSEN) quality and safety competencies.
The student will:
1.
Provide individualized patient-centered care by:


Conducting a focused assessment
 Utilizing therapeutic communication with the patient and grieving family
Supporting the patient's and family's cultural and spiritual desires throughout and after the dying process
2.
Function competently as a member of the health care team by:



Initiating care within nursing scope of practice
Notifying provider of patient's death
3.
Implement best clinical practices by:
 Recognizing:
 Cessation of cardiovascular and respiratory functions as indication of patient death
 Grieving family members
 Prioritizing and implementing appropriate care:
 Eliciting and respecting the family's values and preferences related to death rituals
 Inquiring about the family's desire to be involved in postmortem care
4.
Promote safety for patient, self, and others by:


Following postmortem care policy and procedure
Assessing and maintaining a safe environment
5.
Identify factors that influence quality of care by:
 Evaluating family's response to care provided
6.
Utilize information technology to support patient care by:
 Documenting care in the electronic medical record
Physiologic State
Wife calls out, "We need a nurse right away!"
T = 95.0 F (35.0 C)
BP = 60/30, trends down to 0/0
P = 60, trends down to 0
RR = 4, trends down to 0
O
2
Sat = Does not register
 Heart sounds: Initially present (low
 volume), then absent
Lung sounds: Initially coarse (low volume), then absent
 Abdominal sounds: Absent
 Pulses: Initially weak, then absent
 Patient is unresponsive to verbal or tactile stimuli.
Situation/Transition
Samuel Green is lying supine in bed with head of bed at 30 degrees. He is unresponsive to verbal and tactile stimuli. His skin is cool and his extremities are mottled. Vital signs are detectable initially, but within 1 minute, he experiences loss of respiratory and cardiovascular function.

When called, the provider makes the following statement:
 "Thank you for notifying me of Samuel's death. Please allow the family to stay with his body until the Jewish Burial Society arrives. I will be in shortly to pronounce him. Please wait with the family until I arrive."
Recommended time to advance to Phase II: 3 minutes
Expected Student Performance
1.
Conducts initial assessment recognizing loss of respiratory and cardiovascular functions as indication of patient's death.
2.
Utilizes therapeutic communication to acknowledge the family's grief.
3.
Supports the patient's and family's cultural and spiritual desires throughout and after the dying process.
4.
Notifies provider of patient's death using SBAR communication.
Physiologic State
No vital signs  Wife, crying softly, states, "He is gone." Son joins mother on the opposite side of the bed. They both bow their heads and are silent.
Situation/Transition
Samuel is unresponsive without any discernable vital signs. Wife is at the bedside, holding
Samuel's hand and her son's hand. The son is on the opposite side of the bed from his mother, holding Samuel's other hand and his mother's hand across his father's body.
Recommended time to advance to Phase III: 15-20 minutes
Expected Student Performance
1.
Follows the postmortem care policy and procedure.
2.
Elicits and respects the family's values and preferences related to death rituals.
3.
Inquires about the family's desire to be involved in postmortem care.
4.
Elicits the family's preferences for removal of medical devices.
5.
Inquires as to whether the family wishes for their religious leader to be called.
6.
Inquires as to whether any arrangements have been made with a funeral home.

Physiologic State
If therapeutic communication is used and the family's religious death ritual practices are respected:
No vital signs  Son states, "Bless you for allowing us to stay with him until the rabbi gets here. You do not know how much we appreciate your understanding. Thank you for the wonderful care of our loved one."
If therapeutic communication is NOT used and the family's religious death ritual practices are
NOT respected:
No vital signs 

Wife says, "Oh, God! Help us! I thought I was ready for
Samuel to go. Oh, what am I going to do? What do I do now? Please do not touch my Samuel."
Son says, "Stop what you are doing right now! Please have some respect for my father! Get our rabbi immediately!"
Situation/Transition
If therapeutic communication is used and the family's religious death ritual practices are respected, the family will calmly mourn at the bedside.
If therapeutic communication is NOT used and the family's religious death ritual practices are
NOT respected, the wife and son will become very disturbed and agitated.
(Note: The scenario may end before full postmortem care is completed, or the provider may pronounce the patient dead and the scenario continue through postmortem care.)
Expected Student Performance
1.
Continues to provide support to the family.
2.
Evaluates family's response to care.
3.
Documents all findings and care provided.
End the scenario.

Debriefing is an integral part of every quality simulation. The best debriefing experience allows the students to discuss, digest, and discover. The facilitator's role in debriefing is to guide the discussion and to keep the conversation on topic. However, the facilitator's comments about the simulation should be kept to a minimum. The student participants should provide the majority of the discussion.
Phase 1: Student Reaction
Simulation experiences can be very emotional. The reaction phase allows the students to vent their feelings so that further discussion and learning can occur.
Examples of appropriate facilitator comments include:


"Tell us about what you experienced during the simulation."
"Please share some initial thoughts about the case."
Phase 2: Student Reflection
During the reflection phase, the facilitator asks the students to reflect on their decision-making process and on the actions taken during the simulation. Observers can comment using the
Observer Evaluation Rubric.
Examples of appropriate facilitator comments include:
 "Describe your thought process as you made decisions about _______."
 "What patient response (or assessment) led you to _______?"
 "Did the patient respond the way you thought he/she would?"
Phase 3: Responsive Inquiry
Facilitators can use the Performance Checklist to identify and guide areas for inquiry.
Examples of appropriate facilitator comments include:
 "I noticed _______. What did you think about that?"
 "I am wondering why _______. Would you describe more about this?"

Phase 4: Integration
During the integration phase, the facilitator assists the students to apply theoretical content to the simulation as well as to anticipate the transfer of knowledge to the clinical setting.
Linking Theory to Practice:
 Use the debriefing questions designed for the specific scenario.
Assimilation:
 "How will this experience influence your patient care?"
 "What will you now do differently to prepare for clinical?"
Phase 5: Closure
With 1-2 minutes left, ask for any final thoughts on the scenario or the simulation experience.
End with positive comments, such as:
 "I really appreciate how you _______."
 "It seems like this was a really good learning experience."
 "I really appreciate everyone's participation."
1.
Samuel Green was admitted for palliative care. Describe the goals of palliative care.
Possible Answers
Palliative care is:


Non-curative
 Symptom-management focused
A holistic approach to care
 Aimed at addressing the needs of both patient and family
 Aimed at providing patients and families with the best quality of life possible
Hospice care is the final phase of palliative care.
Rationale pp. 471-473: Palliative care is a continuum of care that provides interventions to assist patients and their families from the onset of illness to the end of life.
2.
Identify the preferences for care outlined by Samuel Green's family. Why is it important to honor cultural beliefs and rituals surrounding death?

Possible Answers
Preferences for care:
 Closing Samuel's eyes and mouth
 Not leaving the body alone
 Awaiting arrival of the Jewish Burial Society
Every culture makes sense of life transitions in a unique manner. Death rituals will vary depending on one's cultural or religious beliefs. Respecting and supporting care preferences related to death is a priority intervention in end-of-life care.
Rationale pp. 112-113: In order to provide culturally congruent care, the nurse must be aware of the patient's and family's preferences for care at the time of death. Allowing for rituals and mourning practices provides the family with a sense of fulfilled obligations and may assist with acceptance of death.
3.
Identify the steps that should be taken when providing postmortem care.
Possible Answers


Contact attending provider to make aware of expiration and need for declaration of death
 Prepare the body for family viewing with consideration of cultural customs
Provide sensitive and dignified nursing care
 Close the patient's eyes


Leave dentures in or close mouth
 Remove jewelry, clothing, and personal effects as indicated by the family
Bathe body as needed


Remove invasive lines, drains, tubes and catheters (if no autopsy)
 Straighten the body, place pillow under head, cover with clean sheet
Ensure proper body identification


Refer to agency policy
 Plan for transfer of body
Complete documentation
Rationale pp. 480-481: Policies for postmortem care may vary depending on the care setting. The body of the deceased is to be treated with the same amount of dignity as a living person and in accordance with religious and cultural beliefs.

4.
Identify evidence from the scenario demonstrating that the Green family had discussed end-of-life decisions. Explain the importance of discussing end-of-life decisions.
Possible Answers
Evidence from the scenario:
 Patient had an advance directive.
 Physician had written DNR order.
End-of-life planning empowers the patient to control his or her end-of-life experience and ensures that survivors are not left to make the decisions at a stressful time. Planning also allows the family to know that the wishes of the deceased have been honored.
Rationale p. 478: End-of-life decisions can be very stressful for family members if there has been no prior discussion of patient wishes preceding death. When ethical decisions are made in advance of urgent need, the survivors achieve a sense of control.
1.
Risk for compromised family coping related to lack of respect for care preferences
Patient Goal
 The patient's and family's preferences for care will be respected and carried out.
1.
Explore needs of family
Key Points
 Discuss common emotional responses to impending death and encourage expression of feelings and concerns.
 Determine if extended family members need to be notified of patient's death.
 Determine if family desires the presence/notification of their religious leader.
Text Reference: pp. 477-478
2.
Death process
Key Points
 Discuss changes in patient's condition that indicate impending death: o o
Irregular breathing patterns
Noisy respirations

o o o o o o
Decreased level of consciousness
Skin changes of lower extremities
Cold hands and feet
Weak pulse
Decreased urine output
Diminished swallow
1.
Developmental Stage
Old age
Erikson psychosocial developmental stage: Integrity versus despair
Key Points
Older adults often:
 Experience physical and social losses
 Engage in retrospective life appraisal
Working through these challenges left Samuel Green at peace with his impending death.
Text Reference: p. 140
2.
Gerontologic Considerations
Cancer and aging
Key Points
 Cancer is ranked as the second most common cause of death in older adults.
 Early detection can be difficult due to the similarity of cancer symptoms to the physiological changes seen with aging.
Text Reference: p. 206
1.
Judaism
Key Points
Postmortem rituals associated with the Jewish faith:
 Preparation of the body should not be initiated until it is known whether the Jewish
Burial Society will be coming.




The body should not be left alone.
The eyes and mouth are closed by the son or nearest relative.
A sheet is placed over the face of the body.
Culturally congruent care should be provided by assessing the family's individual death ritual practices and allowing the family to participate in postmortem care as desired.
This hospitalization marks the end of Samuel Green's life, thereby making adherence to his and his family's death ritual practices extremely important.
Text Reference: pp. 112, 481
1.
A nurse is caring for a terminally ill patient of a different culture. Discuss the implications for practice when the nurse implements culturally competent care.
Correct answer(s):
 Cultural beliefs influence who makes up a patient's support network and the expected forms of receiving care at the end of life.
 Assess each patient and family for culturally meaningful practices for end-of-life care.
Nurses often have a cultural orientation to death and loss that differs from the patient's.
Honoring patient and family cultural values characterizes expert end-of-life care.
 Care provided at the end of life within the patient and family's cultural context draws from the traditions of their entire lives.
2.
A nurse is caring for a patient who has expired. After completing postmortem care, the nurse prepares to complete the required documentation. List the information that the nurse will document.
Correct answer(s):
 Time and date of death and all interventions performed in response to the impending death


Name of health care provider certifying the death


Persons notified of the death (family members, health care providers, funeral home, etc.)
 Whether a request for organ or tissue donations has been made and by whom
Special preparations of the body (religious or cultural)
Medical tubes, devices left in or on the body


Personal articles left on and secured to the body
 Personal articles given to the family with description, date, time, and to whom given
Location of body identification tags
 Time of body transfer and destination

 Relevant information or family requests clarifying special circumstances
3.
Utilizing therapeutic communication is essential when caring for terminally ill patients and their families. List barriers to communication that a nurse should avoid.
Correct answer(s):
 Denying the patient's grief
 Providing false reassurance
 Avoiding discussion of sensitive issues
 Giving personal opinions
1.
Samuel Green practices the Jewish faith. Discuss the various cultural considerations in care of the body after death that are specific to the Jewish culture.
Correct answer(s): In Orthodox Judaism, there should be no preparation of the body until it is known whether members from the Jewish Burial Society are coming to the facility. A family member may stay with the body until burial. Usually the burial occurs within 24 hours of death, but not on the Sabbath. In some, but not all types of Judaism, cremation, autopsy, and embalming are avoided.
2.
The nurse caring for Samuel Green and his family utilized therapeutic communication techniques. List five therapeutic communication techniques that are helpful when communicating with patients.
Correct answer(s): Therapeutic communication techniques include active listening, sharing observations, sharing empathy, sharing hope, sharing humor, sharing feelings, using touch, using silence, providing information, and asking relevant questions.
3.
The nurse caring for Samuel Green is planning an educational session with Mr. Green's family regarding care for a dying patient. List the topics that the nurse should include.
Correct answer(s): Topics that the nurse should include:
 Feeding techniques and food choices that facilitate chewing and swallowing
 Demonstration of hygiene measures such as bathing, skin and oral care


Demonstration of safe transfer techniques
 Discussion of the need to balance activity and rest, adjusting to patient preference
Discussion of common emotional responses to impending death and how to encourage patient expression of feelings and/or concerns



Discussion of changes in patient's condition that signal impending death
Information about who to call for questions, emergencies, and at time of death