CHPN Care at the Time of Death 2 — Questions and Answers
Question 1: The most appropriate nursing intervention for a hospice patient experiencing the death rattle is to:
- Perform vigorous oral suctioning to clear secretions
- Reposition the patient to facilitate postural drainage and administer anticholinergic medication as ordered (Correct answer)
- Increase IV fluid rate to thin secretions
- Place the patient in a supine position with the head flat
Correct answer: Reposition the patient to facilitate postural drainage and administer anticholinergic medication as ordered
Repositioning (e.g., lateral or semi-prone) facilitates drainage of secretions, and anticholinergic agents such as glycopyrrolate or hyoscine reduce secretion production, addressing the death rattle without distressing the patient.
Question 2: When a patient is actively dying and can no longer swallow oral medications, the preferred alternative route of administration in hospice care is:
- Intravenous (IV) bolus injection
- Subcutaneous or sublingual administration (Correct answer)
- Rectal suppositories only
- Intramuscular injection in the deltoid
Correct answer: Subcutaneous or sublingual administration
Subcutaneous continuous infusion or sublingual administration are preferred in hospice because they are comfortable, effective, and do not require venous access, which is often difficult in dying patients.
Question 3: A family member of an actively dying patient asks: 'Can my mother still hear us?' The best hospice nurse response is:
- 'No, hearing is the first sense to be lost as death approaches.'
- 'We don't know for certain, but hearing is believed to be one of the last senses to fade—continue speaking to her.' (Correct answer)
- 'She may only respond to her name; avoid other conversation to prevent overstimulation.'
- 'She cannot hear you, but touching her may provide comfort.'
Correct answer: 'We don't know for certain, but hearing is believed to be one of the last senses to fade—continue speaking to her.'
Research and clinical experience support that hearing may persist near death even when the patient cannot respond, so encouraging family to speak to their loved one is both supportive and evidence-informed.
Question 4: Mouth care for an actively dying patient who can no longer swallow should be performed:
- Only once daily to minimize disruption
- Every 15 to 30 minutes with moistened swabs to maintain comfort (Correct answer)
- Only when the patient requests it
- With toothbrush and toothpaste as per standard oral hygiene
Correct answer: Every 15 to 30 minutes with moistened swabs to maintain comfort
Frequent mouth care with moistened swabs prevents dry mucous membranes and maintains comfort, which is the primary goal when the patient can no longer take fluids orally.
Question 5: A hospice nurse is repositioning an actively dying patient. Which principle should guide repositioning decisions?
- Reposition every 2 hours strictly to prevent pressure injuries
- Turn to both sides alternately regardless of patient response
- Limit repositioning to what the patient tolerates comfortably; pressure injury prevention is secondary to comfort (Correct answer)
- Avoid all repositioning to prevent pain
Correct answer: Limit repositioning to what the patient tolerates comfortably; pressure injury prevention is secondary to comfort
In the actively dying phase, comfort is the primary goal; aggressive repositioning schedules are not appropriate if they cause distress, and pressure injury prevention takes lower priority.
Question 6: Which medication is most commonly used to manage terminal secretions (death rattle) in hospice patients?
- Lorazepam
- Glycopyrrolate (Correct answer)
- Haloperidol
- Methadone
Correct answer: Glycopyrrolate
Glycopyrrolate is an anticholinergic agent that reduces glandular secretion production without significant CNS sedation, making it a first-line choice for managing terminal secretions.
Question 7: A hospice nurse notices a dying patient is showing signs of terminal agitation (restlessness, moaning, picking at bedclothes). The first-line pharmacological intervention is typically:
- High-dose morphine
- Lorazepam or midazolam (benzodiazepine) (Correct answer)
- Haloperidol alone in all cases
- Diphenhydramine
Correct answer: Lorazepam or midazolam (benzodiazepine)
Benzodiazepines such as lorazepam or midazolam are first-line agents for terminal agitation/restlessness, providing sedation and anxiolysis; haloperidol may be added if delirium is present.
CHPN Care at the Time of Death 2
The most appropriate nursing intervention for a hospice patient experiencing the death rattle is to: