A client who has advanced heart failure is admitted to the hospital for symptom management. The client tells the nurse that he does not want any resuscitation measures if his heart stops. Which of the following actions should the nurse take?
A) Respect the client's wishes and document them in the medical record.
B) Inform the client that he needs to have a written advance directive to refuse resuscitation.
C) Encourage the client to reconsider his decision and discuss the benefits of resuscitation.
D) Notify the health care provider and request a referral to a palliative care team.
Respect the client's wishes and document them in the medical record.
Inform the client that he needs to have a written advance directive to refuse resuscitation.
Encourage the client to reconsider his decision and discuss the benefits of resuscitation.
Notify the health care provider and request a referral to a palliative care team.
The Correct Answer is D
The nurse should notify the health care provider and request a referral to a palliative care team, which can help the client and his family explore his goals of care, preferences, values, and beliefs regarding end-of-life care. The palliative care team can also assist with completing an advance directive, which is a legal document that specifies the client's wishes for medical treatment in case he becomes unable to communicate them.
Option A is incorrect because respecting the client's wishes is not enough; the nurse should also ensure that they are communicated to the health care team and documented in an advance directive.
Option B is incorrect because although an advance directive is recommended, it is not required; the client can verbally express his wishes to his health care provider, who can then write a do-not-resuscitate (DNR) order.
Option C is incorrect because it is not appropriate for the nurse to impose her own values or opinions on the client; rather, she should respect his autonomy and support his decision.
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Correct Answer is D
Explanation
The nurse should continue to provide comfort measures and emotional support to the client, as well as respect his DNR order, which means that no resuscitation measures should be attempted if he experiences cardiac or respiratory arrest.
Option A is incorrect because initiating CPR and calling a code blue would violate the client's DNR order and his right to refuse treatment.
Option B is incorrect because administering oxygen via nasal cannula may be considered a form of resuscitation, depending on the client's wishes and goals of care; moreover, monitoring his vital signs may not be necessary or beneficial at this stage of his illness. Option C is incorrect because notifying the health care provider and the client's family of his status may not be a priority at this time; rather, the nurse should focus on providing compassionate care to the client until he dies.
Correct Answer is D
Explanation
The nurse should notify the health care provider and request a referral to a palliative care team, which can help the client and his family explore his goals of care, preferences, values, and beliefs regarding end-of-life care. The palliative care team can also assist with completing an advance directive, which is a legal document that specifies the client's wishes for medical treatment in case he becomes unable to communicate them.
Option A is incorrect because respecting the client's wishes is not enough; the nurse should also ensure that they are communicated to the health care team and documented in an advance directive.
Option B is incorrect because although an advance directive is recommended, it is not required; the client can verbally express his wishes to his health care provider, who can then write a do-not-resuscitate (DNR) order.
Option C is incorrect because it is not appropriate for the nurse to impose her own values or opinions on the client; rather, she should respect his autonomy and support his decision.
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