Abuse, grief and end-of-life care

Mandated reporting

• Nurses are mandated reporters of suspected abuse or neglect of children, older adults and adults at risk.
• The standard is reasonable suspicion: proof isn't required.
• Report promptly to the agency your state names, such as Child or Adult Protective Services, or the police. Be as specific as possible about what you saw and heard.
• Document objectively: the client's own words in quotes, and exact descriptions of injuries.
• Trauma-informed care builds safety, trust, collaboration, and the client's voice and choice. Introduce yourself and your role every time.

Partner violence: asking safely

• Screen everyone routinely, and always ask in private, with the partner out of the room. Explain confidentiality and its limits under your state's reporting laws.
• Ask a few open questions about being hurt or treated badly, not about being abused.
• Never share your concerns with the partner, and don't ask why the client hasn't left.
• Deadliest risks: past strangulation, a gun in the home, a suicidal abuser.
• Leaving is the most dangerous time; the danger stays high after separation, especially in the first months, so safety planning continues. Before discharge: referrals and a personal safety plan.

Red flags

Hotline: The National Domestic Violence Hotline is 1-800-799-7233.

Violence toward staff

• Warning signs: loud speech, clenched fists, gripping the rails, pacing, throwing things. Violence can erupt without warning, especially with medical illness or dementia.
• Verbal de-escalation first: speak calmly, honestly and simply. Ask what they want, listen, restate it. Set a clear limit that violence isn't allowed, and offer choices.
• Stand at least two arm's lengths away, hands relaxed, not from behind. Keep a clear path to the door. No stethoscope or badge around your neck.
• Arguing, condescending, ordering them to calm down, or threatening security can escalate things. Never lie; take every threat seriously. If talking fails, step out and get help.
• Restraints follow protocol, never for convenience or punishment, and come off as soon as possible.

Grief, palliative and hospice care

• Grief is the personal response to loss; mourning is the outward, cultural expression. Anticipatory grief starts before the loss; disenfranchised grief isn't recognized by others; complicated grief is prolonged and intense.
• Grief isn't orderly or predictable, and it can take months or years. It follows any loss, not only death.
• Kubler-Ross: denial (this can't be happening), anger (may be aimed at staff; it isn't personal), bargaining (a deal for more time), depression, acceptance.
• The most important intervention is active listening and a supportive presence.
• Report signs of depression, suicidal thoughts, or symptoms lasting more than 6 months.
• Palliative care relieves suffering in serious illness, alongside other treatment. Hospice: expected to live 6 months or less, and curative treatment stops.

Advance directives and code status

Capacity: Advance directives guide care once legal capacity and activation rules are met. Trouble communicating doesn't, by itself, mean a lack of capacity.

Admission and family conflict

• On admission, ask whether the client has an advance directive, get a copy for the chart, and put it in the plan of care. Care can't depend on whether they have one.
• A valid directive speaks for the client; family wishes don't override it. Bring it to the provider, support the family, involve social work or the ethics committee.
• A living will refusing CPR doesn't settle it alone: law, valid portable orders and policy govern whether staff resuscitate.
• A nurse never changes code status herself. A provider who won't follow a directive must promptly tell the proxy, arrange transfer, and keep caring until then.

Comfort, final hours, after death

• Dyspnea doesn't always match the oxygen level: a fan or open window, head of the bed raised, a calm, cool room.
• Morphine relieves pain and air hunger, by mouth or under the tongue until the end. Double effect: relieving suffering is right even if it might hasten death.
• Death rattle: reposition on the side, give anticholinergics like atropine or scopolamine; suctioning isn't recommended.
• Death is near: cool, mottled skin, a rapid or irregular pulse, little urine, noisy or Cheyne-Stokes breathing. Death may follow within hours to a few days, but no one can predict the exact time.
• After death: apical pulse for a full minute; document the time and who was present. Remove tubes unless the coroner must review.