Unit 4.5: End of Life and Palliative Care

• Topic 01

  Principles of Palliative Care

  45 questions
• Topic 02

  Recognising Dying

  45 questions
• Topic 03

  Advance Decisions and DNACPR Orders

  46 questions
• Topic 04

  Bereavement Support and Communication with Families

  45 questions

A few questions from this unit, with the answer and a full explanation. The complete bank is available when you start practising.

1. A patient with advanced dementia has no family, no registered LPA, and no ADRT. The clinical team is considering a DNACPR decision. Which step is MOST important to ensure the decision-making process complies with MCA 2005 requirements?

   • A
     Make the DNACPR decision and send a letter to the patient's last known address to notify them retrospectively
   • B
     Ask two nurses to witness the clinical discussion and countersign the DNACPR form as a substitute for advocacy
   • C
     Ask the ward manager to act as proxy decision-maker in the absence of an LPA
   • D
     Appoint an Independent Mental Capacity Advocate (IMCA) to represent the patient's interests before making the serious life-sustaining treatment decision
     Correct answer
   Explanation

   Under the MCA 2005, an IMCA must be appointed for unbefriended adults who lack capacity and face a serious medical decision, including decisions about life-sustaining treatment such as a DNACPR. The IMCA's role is to represent and promote the patient's interests and to ensure the best-interests decision-making process has been followed. Proceeding without involving an IMCA in this situation is a legal breach of the MCA 2005.

2. A patient's peripheries are cold and mottled and their urine output has reduced to less than 10 ml per hour. What does this indicate?

   • A
     Circulatory failure with reduced peripheral perfusion and renal hypoperfusion, consistent with the dying phase
     Correct answer
   • B
     Anaphylactic shock requiring immediate administration of adrenaline
   • C
     Opioid-induced peripheral vasodilation reducing limb circulation
   • D
     Hypothermia caused by inadequate ward temperature, requiring warming measures
   Explanation

   Cold, mottled peripheries combined with oliguria (less than 10 ml/hour) reflects a combination of peripheral circulatory failure (reduced cardiac output reducing perfusion to extremities) and renal hypoperfusion (reduced renal blood flow). Together, these are recognised dying-phase signs when occurring in the context of a life-limiting illness with a deteriorating trajectory. Reversible causes (sepsis, dehydration) must still be excluded before conclusively attributing these signs to the dying phase.

3. A nurse is reviewing a bereaved family member three weeks after a patient's death. The family member reports: 'I spent yesterday sorting through his clothes for the charity shop, but today I can't stop crying and just want to look at photos of him.' Applying the Dual Process Model, what is the MOST appropriate nursing assessment?

   • A
     This is a normal pattern of oscillation between restoration-orientation (practical tasks) and loss-orientation (emotional engagement with grief) described by the Dual Process Model — both are adaptive and indicate healthy grief
     Correct answer
   • B
     This pattern is typical of denial followed by acceptance, as described by Kübler-Ross, and is progressing normally
   • C
     The practical activity yesterday indicates the person has moved past grief and the return to tearfulness today suggests regression that requires intervention
   • D
     The alternating pattern indicates unstable mood and should be referred to a psychiatrist for assessment of a mood disorder
   Explanation

   The Dual Process Model explicitly predicts and validates this oscillation as normal and adaptive. Bereaved individuals move back and forth between loss-orientation (actively processing grief) and restoration-orientation (practical and life adjustment activities). Neither orientation is superior or more 'advanced'. The nurse should reassure the family member that this pattern is normal and healthy, not a sign of instability or regression.