10 loss grief and dying
TRANSCRIPT
Loss, Grief and Dying
Loss – when something of value is changed or made inaccessible
so that its value is diminished or removed Actual Loss – recognized by others
E.g.: loss of a limb Perceived Loss – intangible to others
E.g.: loss of youth Physical Loss Psychological loss
E.g.: diminished body image Maturational Loss – result of natural development
E.g.: kids growing up Situational Loss – result of an unpredictable event
E .g.: trauma, accident, death, natural disaster Anticipatory loss – feeling the loss before it happens;
E.g.: mourning for the terminally ill
Grief – emotional reaction to a loss Bereavement – state of grieving w/ grief reaction
May neglect health to extremes Mourning – period of acceptance of a loss
Return to normal habits
Grief Reactions Engel (1964)
Shock and disbelief – refusal to accept Developing awareness – anger, emptiness Restitution - rituals Resolving the loss – dealing with void Idealization – exaggeration of good qualities Outcome – resolution of grief
Kubler- Ross (1969) D enial and isolation A nger B argaining D epression A cceptance
Stages of Grief & Related Grief Work Denial – support initially then assist in awareness when
ready Isolation – listen and spend time Depression – problem solving then positive
reinforcement Anger – allow crying and release of energy; listen;
support system Guilt – listen; allow crying; help express feelings Fear – help recognize feelings; explore attitude toward
loss Rejection - allow expression; watch for rejection of
self/others
Normal Grief Abbreviated – short but genuine Anticipatory – before actual loss
Dysfunctional Grief Abnormal or Distorted Unresolved – trouble expressing feelings; denies feelings Unresolved – extends over a long period Inhibited – suppresses feelings but presents somatic
symptoms
Interventions in Grieving Interpersonal skills to demonstrate empathy Encourage verbalization Respond to inquiries honestly
Promote grief work through each stage of grieving Appropriate referrals Alert about patient who is moving through grief work
Death and Dying Death –
Heart-Lung Death – irreversible cessation of spontaneous respiration and circulation
Whole brain death – irreversible cessation of all functions of the entire brain
Higher Brain death – irreversible loss of all “higher” brain functions, cognitive functions
Signs of impending death: Inability to swallow Pitting edema Decreased GIT & UT activity Bowel & bladder incontinence Loss of motion, sensation & reflexes Elevated temperature but cold & clammy skin;
cyanosis Low BP Noisy/irregular respiration Cheyne-Stokes respiration
Dying Person’s Bill of RightsI have to the right to--1. be treated as a human being until I die.2. maintain a sense of hopefulness, however changing its
focus may be.3. be cared for by those who can maintain a sense of
hopefulness, however changing its focus may be.4. express my feelings and emotions about my approaching
death in my own way.5. participate in decisions concerning my care.6. expect continuing medical and nursing attention even
though “cure goals” must be changed to “comfort goals.”
7. not die alone.8. be free from pain.9. have my questions answered honestly.10. be not deceived.11. die in peace and dignity.12. retain my individuality and not be judged for my
decisions, which may be contrary to the beliefs of others.13. discuss and enlarge my religious and/or spiritual
experiences, whatever these may mean to others.14. expect that the sanctity of the human body will be
respected after death.15. be cared for by caring, sensitive, knowledgeable
people who will attempt to understand my needs and will be able to gain some satisfaction in helping me face my death.
Death and Dying (Kozier)AGE Beliefs
Infancy to 5 years old
NO clear concept of DeathIt is Reversible, temporary sleep
preschool
- death is permanent-may believe that he is responsible-death is a punishment
5 to 9 years
Understands DEATH is FINAL but can be AVOIDED
9-12 years
Death is INEVITABLEUnderstands own mortality
12-18 Fears a lingering Death18-45 Attitude is influenced by
religion45-65 Experiences peak of death
anxiety65 and Death as multiple meanings
Terminal Illness Illness in which death is expected MD decides what, when and how px should be told RN, clergy, other health care professionals may be
involved in discussing px’s condition w/ him or her Breaking the “bad news”:
Sit face-to-face in a private place Ask how much is already known Ask how much is wanted to be known Give info in “small chunks” and ask if understood Let reactions come Summarize, ask questions, set a new appointment
Impact on Patient Pxs pick up nonverbal cues Pxs should be allowed to go through grieving process Competent pxs may refuse or consent to any or all
treatments Should know rights
Impact on Family Family should participate in planning px care Healthcare personnel should be available for
discussion and to offer support Family may want to participate in planning memorial
services
Palliative Care Taking care of the whole person – body, mind, spirit,
heart and soul Dying – natural and personal GOAL – best quality of life by aggressive mgmt of
symptoms Also called “Hospice Care”
Hospice Care standard of care for terminally ill cancer clients Symptom control Pain management Providing comfort and dignity 24 hour – 7 day coverage Services given based on client’sneed not on ability to pay
Ethical and Legal Dimensions Patients w/ legal and moral right to consent to and refuse
any and all indicated therapies Common law right of self determination and
constitutionally supported right to privacy Nurse identifies and supports legally valid decision
maker; clarifies goal of treatment; advocate for patient and family; documents end of life care preferences, written record of communication, wills, durable power of attorney for healthcare, medical advance directive
Advance Directives Allow indv to state in advance their choices would be for
healthcare LIVING WILLS – specific instructions about kinds of
healthcare that should be provided or foregone in specific situations
DURABLE POWER OF ATTORNEY – appoints an agent to make decisions in the event of subsequent incapacity
Self-Determination Act of 1990 – requires all hospitals to inform their patients about advance directives
Do-Not-Resuscitate or No-Code Orders DNR or No code – no attempts are to be made to
resuscitate a px who stops breathing or whose heart stops breathing
Standard of care still obligates healthcare professionals to attempt resuscitation if px stops breathing or his heart stops
Nurses should clarify patient’s code status if probable results of resuscitation are negligible or has reason to believe that patient would not want to be resuscitated
Comfort measures only and other Special Orders Comfort-measures-only order - Comfortable, dignified
death and life sustaining measures not indicated Do-not-hospitalize order – patient s in nursing homes and
residential settings who have elected not to be hospitalized for further aggressive treatment
Nurses should be familiar with pertinent federal and state laws and institutional policy as well as forms to indicate preferences of patients on end-of-life-care
Other Ethical and Legal Issues Terminal Weaning - Gradual withdrawal of mechanical
ventilation from a patient with terminal illness or an irreversible condition with a poor prognosis
Assisted Suicide – Making lethal combination of drugs available to patient wishing to die
Active Euthanasia - administering lethal injection at the patient’s request
Passive Euthanasia – allow disease to progress naturally to death***ANA – assisting in suicide and participating in active euthanasia – violation of Nurses’ Code
Death Certificate – US law reqt; prepared for each px; RN should ensure physician signed the certificate
Organ Donation – fill out an organ donation card; RN reviews options and provide consent forms to interested clients
Autopsy – examination of organs and tissues of body after death; MD obtains permission; RN may assist in explaining reasons for autopsy
Good Dying “Last Acts Project” – focuses on improving care for dying
patients 8 key elements of end-of-life-care
State advance directive policies- living will, power of atty.
Location of death Hospice use Hospital end-of-life services Care in ICU Pain among nursing home residents State pain policies Palliative care certified physicians and nurses
6 Major Components of a Good Death Pain and symptoms management Clear decision making Preparation for death Completion Contributing to others Affirmation of the whole person
FACTORS THAT AFFECT GRIEF AND DYING
Age family relationships socioeconomic position
cultural and religious influences person’s reaction to and expression of grief Cause of death
Nurse as Role Model Nurses need to take time to analyze their own
feelings about death before they can effectively help others with terminal illness
Grief after patient death is natural ; nurse should address personal health needs
NURSING PROCESS FOR GRIEVING FAMILIES
Assessing Adequacy of knowledge Realism of expectations Adequacy of coping strategies Adequacy of resources Physical response
Diagnosing Impaired adjustment Caregiver role strain Decisional conflict Ineffective coping Ineffective denial Anticipatory grieving Dysfunctional grieving Hopelessness Ineffective Therapeutic Regimen Management
Implementing Developing a Trusting Nurse-Patient Relationship Explaining the Patient’s Condition and Treatment Teaching Self-Care and Promoting Self-Esteem Teaching Family Members to Assist in Care Meeting the Needs of Dying Patients Meeting Family Needs Providing Postmortem Care
Evaluating• Plan of nursing care is effective if patients meet the
outcome of a comfortable, dignified death and family members resolve their grief after a suitable time of mourning and resume meaningful life roles and activities
Post Mortem Care Body Care after death
Make the body appear natural Remove all equipment and supplies from the bedside Place the body in supine position (arms at the sides,
palms down) Place one pillow under head to prevent face
discoloration Close eyelids, insert dentures and close the mouth Wash soiled parts of the body Watch out feces and urine discharge Remove all jewelry and place in a safe storage Allow Significant Other to view the patient’s body Apply 3 ID tags (wrist, ankle and over the shroud) Wrap the body in a shroud Bring the body to the morgue for cryonics (cooling)