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)