death and dying
TRANSCRIPT
THE CONCEPT OF LOSS
NURSING GOALS:
1. TO PROMOTE GOOD/ PLEASANT DYING THROUGH COMPASSIONATE, PALLIATIVE CARE
2. FACILITATE COPING WITH DISABILITY AND DEATH
LOSS- is a change in a person’s situation that reduces the probability of
achieving goals- is when a person is without something he formerly possessed- is an actual or potential situation is which a valued object, person or the
like is inaccessible or changed so that it is no longer perceived as valuable
- occurs when a valued person/ object/ situation is changed or made inaccessible, diminished or removed
- is inevitable and inescapable – no one is exempt
CATEGORIES OF LOSS
1.) SELF LOSS a. Loss of psychologic self - includes the loss of self esteem or personal identity
b. Loss of sociocultural self - includes the loss of language, association, and the meaning of one’s cultural heritage-influence of other cultures
c. Loss of physical self - the extent, duration, and viability of the loss will influence how the individual responds to loss- loss of a limb or a part of the body
d. Loss of spiritual self - loss of hope, values, beliefs- without hope, despair sets in and the patient gives up
2.) EXTERNAL LOSS- includes the loss of objects, possessions, loved ones- loss can occur through separation, moving, promotion, or death
a. Actual loss - can be recognized by others and the person sustaining the loss - e.g. loss of a limb, spouse, valued object ( money or job)
b. Perceived loss - felt by a person but intangible to others- e.g. loss of youth, financial independence, valued environment- physical and psychological loss are directly related to actual or perceived loss
c. Maturational loss - is experienced as a result of natural developmental processes- e.g. loss that the 1st child flees when the new sibling is born; loss that a stay at home parent feels when the child starts school
d. Situational loss - experienced as a result of an unpredictable event- an event that did not allow a plan to happen- e.g. traumatic injury, disease, death, natural disaster
e. Anticipatory loss - type of loss experienced before the loss really occurs- a person displays loss and grief behaviors for a loss that has yet to take place- serves to lessen the impact of the actual loss- e.g. families of patient with serious and life threatening illness
FACTORS INFLUENCING LOSS EXPERIENCE
1. Childhood experiences - can impact the way one perceives and reacts to a loss- how parents handle losses can influence the child’s view of
losing something or someone
2. Significance assigned to the loss - related to objective and subjective value of the object
3. Physical and Emotional state - depends on the time of the loss which can have significant influence of one’s response
4. Accumulated loss experience - can impact how a person responds to a current loss especially if there are unresolved losser
- has the greatest impact
5. View loss as crisis - can be helpful to understand how a person experiencing the loss perceives his ability to cope
6. Viability - can have a (+) or (-) effect
7. Duration and Timing - depends on the degree of goal disruption that results from the time spent in resolving the loss
8. Abruptness and suddenness of the loss - more difficult to cope because of the lack of time to preprare
9. Financial impact - the longer and more extensive the loss the greater the expenses usually involved
10. Availability of resources - both internal (ability to cope with challenges from the loss) and external (support from family and friends)
11. Cultures
12. Relationship with the lost person
DYING- an integral part of life- it is as natural and predictable as being born- universal and individually unique event of human experience- occurs suddenly as a result of an accident, injury, pathologic
crisis and after a prolonged experience of debilitating illness
- it is the process of coming to an end
DEATH- permanent cessation of all vital functions - the end of human life- it is an event (moment of death) and a state (that of being dead)
CONCEPTS AND PRINCIPLES OF DEATH & DYING
1. Person may suspect or knows that he is dying
2. Make the client feel that they are not alone – lessen fear of death
3. Living life to the fullest in their own way
4. Life review
5. Facing death is individualized
REACTIONS TO DEATH AND DYING THROUGHOUT LIFE CYCLE
Developmental Stage Coping Reaction Nursing Implications
I. INFANCY TO TODDLER (0-1 yo)
- no concept of death- impossible to comprehend absence of life-egocentricity (self-centered, selfish)- vague separation of fact and fantasy- the dead still exists --- “Grandpa is dead. He went to heaven.”
a. avoid admonishing behaviorsb. stress that person will only
return in thoughtc. consistent staff assignment
II. TODDLER ( 1-3 yo) -coping reactions 1. Crankiness 2. Crying 3. Clingy- according to parents’ emotional state- greatest threats: PAIRS P – painful intrusive procedures A – altered rituals I – immobilization R – regression S – separation- persists on visiting the dead- anxiety- talks about the deceased as if nothing happened
a. avoid admonishing behaviorsb. stress that person will only
return in thoughtc. consistent staff assignment
III. PRESCHOOLER (3-6 yo)
- preoperational thought- magical thinking: “the dead lives underground”- consequence: guilt, shame, punishment- psychosexual development has a heavy influence – focus
primarily on opposite sex parent- God is viewed as a male human- heaven, hell and holy spirit considered frightening- meaning of death : death is sleep and sleep is death; recognize
physical death as temporary and reversible- coping reactions: 1. Giggling 3. Attracting attention 2. Joking 4. Regression- greatest fear: parental separation- unusual activities
a. explain that the soul goes to heaven
b. the more outward the grief, the less significant is the loss
c. ceremonies: tell child what to expect, give choices
d. hold and reassuree. explain that death is final: no breathing no eating no awakening
IV. SCHOOLER (6-12 yo) - concrete operations – thinks logically; deals best with actual objects and people but can relate concepts & compare events; develops an awareness and understanding; daydream of other people’s feelings and point of view
- coping reactions: 1. nightmares 2. rituals 3. daydreaming- fears: darkness and being alone- better understanding to casualty- prone to self reference (privacy and
understanding)- death is final (5-9 yo): best can be
avoided; possibility of life after death
- understands own mortality (9-12 yo): death is reversible but beginning to see its finality; personification of death, naturalistic and physiologic explanation
a. allow to achieve independenceb. anticipatory explanationsc. explain what is happening and what
can be done(be realistic)
V. ADOLESCENTS (13-17 yo) - formal operations- abstract- death: religious and philosophical terms- adult approach with remnants of magical
thinking- life is fragile but feels immortal- inevitable, universal, permanent- rejects death- coping reactions: 1. maturational crisis 2. body image is more important 3. alienate self from fears 4. fears lingering death 5. talks about loss 6. silent and withdrawn 7. undisturbed by events 8. extremely angry, lack of fulfillment
of adult roles 9. idealistic view of the world:
horrified and angry over practical matters, fear of the unknown, funeral rites
- Adolescents’ response to grief: D – despair, depression, denial W – withdrawn A – anger and aggression R – repression F – frustration S – silence - other risky behaviors: Independence vs. dependence Development vs. deterioration
- answer honestly, be direct- respect privacy- allow self-control and independence- structure hospital admission
- acceptance and non-judgmental attitude- role model
- allow ventilation of feelings
VI. YOUNG ADULTS (18-30 yo) - coping reactions: 1. rage 2. disappointment 3. frustration- unwelcome intrusion
a. patient group support
VII. MIDDLE ADULTS (30-60 yo) - unmet goals- threat to emotional integrity- concern: consequence of own death and
that of others- pain
VIII. LATE ADULTS (60 and above) - philosophic rationalization: Life is over When time runs out- new life- rest and peaceful reflection- fear: 1. prolonged illness 2. freedom from pain 3. reunion
a. religious belief for comfortb. help prepare for own deathc. reminiscingd. care and comforte. be present at death
SUMMARY OF COPING BEHAVIORS:
a.THE GRIEVING CHILD
PRE-SCHOOLER (2-5)R – regressionE – express little concernS – separation fearT – temporary state
EARLY SCHOOLER (6-9)C – cry A – anxious oftenB – better understanding of deathG – grasp is unclear: cause and effect
LATE SCHOOLER (9-12)D – distancing and day dreamingR – realistic viewA – afraid to leave homeG – grades are poorS – separation anxiety
ADOLESCENTS – substance abuseA – angry and aggressionD – drastic behavior
b. THE GRIEVING ADULT
18-35 yo – influenced by religious and cultural beliefs (priest/ minister)
45-65 yo – accepts own mortality Encounters death of parents Experiences death - anxiety
GRIEVING PROCESS
- is the process of psychological, social, and somatic reaction to a perceived loss (emotional reaction to a loss)
- is said to be a natural reaction often expected to any kind of loss- is the total response to the emotional experience of the loss and is
manifested in thoughts, feelings and behaviors.- a normal subjective emotional response to loss, essential for good
mental, and physical health- better termed as “STATES” since grief is dynamic
GRIEF
- a mental suffering - sharp sorrow- painful- subjective and individualized- follow loss- accompanies mourning
DISENFRANCHISED GRIEF- is briefly over a loss that is not or cannot be acknowledged openly,
mourned publicly or socially supported
3 Categories of circumstances that can result in disenfranchised grief1. a relationship has no legitimacy2. the loss itself is not recognized3. the griever is note recognized
MOURNING- is the period of acceptance of loss and grief during which the
person learns to deal with the loss- characterized by a return to more normal living habits
BEREAVEMENT- is the state of grieving during which a person goes through grief
reactions (state of having suffered a loss)- bereaved people often neglect their health to an extreme
General Characteristics of Grief Stagesa. reactions to grief and dying are similarb. stages of reactions overlap an vary among individuals
Normal Grief Reactions1. denial2. sadness3. anger4. fear5. anxiety
Symptoms of GriefPhysically drainedEmotionally out of controlNo appetiteProne to diseaseEasy fatigabilityNeglect work, physical appearance, personal hygieneLoudnessGuilt – a person who is guilty cannot move onLack of interestZombie effect – existing without lifeThinking is unclearForgetfulCry continuouslySighingLack of interest in sex and alterations in libido
FACTORS THAT AFFECT GRIEF AND DYING
1. Age - the younger the individual is, the lesser the easier the grief- children do not understand death on same levels as adults do- death of parent can retard a child’s development – regression- Nursing implication: prepare oneself for inevitable death
2. Family role - death of child – devastating to the family- loss of a spouse – protect the children- loss of parent – eldest sibling feels the need to be strong and therefore may not grieve
openly- Nursing implication: Give time to talk and be listened to Allow family to enough time to accept reality of the situation Allow family to express themselves in non-judgmental way
3. Socioeconomic factors (economic loss) - bereaved family suffer more if there is no life insurance- loss of home, support system especially if death of spouse may lead to down income
4. Cultural influences/ culture - varies from culture to culture, person to person- e.g. male: expected to be emotionally supportive Female: expected to be weak and needs support- in western culture families, grief is a private matter, shared by the family only but
others may display emotion.
5. Religious influences/ religion - faith and religious practices play important role in expression of grief and provide comfort and solace to the person experiencing the loss.
GRIEF AND THE FAMILY
1. DENIAL-initially support and then strive to increase the development of awareness
2. ISOLATION- listen and spend designated time consistently with the family personally- offer the person and the family opportunity to express their emotions-reflect on past losses and acknowledge loss behavior
3. DEPRESSION- begin with simple problem solving and move towards acceptance- enhance self worth through positive reinforcement- identify the level of depression and indication of suicidal behavior or ideas-be consistent and establish regular time to speak with the person and family
4. ANGER- allow for crying to replace their energy- listen and communicate-encourage concern, support from significant others as well as professional support
5. GUILT- listen and communicate- allow crying- promote more direct expression of feelings- explore methods to resolve grief
6. FEAR- help the person and family recognize the feelings- explain that this will help cope with life - explore the person’s and family’s attitudes about loss, death etc
7. REJECTION- allow for verbal expression of this feeling state to diminish the emotional strain- recognize that the expression of anger may create for rejection of self to significant others
STAGES OF PARENTAL GRIEF
1. SHOCK- disbelief, confusion, restlessness
2. DEPRESSION- months of emotional numbness- preoccupation with thoughts of the deceased- consult doctor for antidepressants
3. ANXIETY- Loneliness- Communication breakdown- Sleep disturbance
4. HOSTILITY- accuses mate- anger with God – God is uncompassionate- expresses anger in improper manner
5. GUILT- angry at child for dying- anger and guilt feed on each other (will to die)
6. RECONCILIATION- increased energy & sleep restoration, physical healing, forgetting, searching for meaning & hope
7. RELIEF- painlessness, strengthens marriage- improves parenting skills & closer sibling bond
Effects of grief in the family
1. Worsening marital tensionGender roles: husband is the provider, wife is the nurturer
2. Sexual intimacy affected
Caring for the couple:a. familiarize with grieving processb. counselingc. wife’s behavior is not a form of rejectiond. husband is trying to be stronge. open communicationf. never judge how a family chooses to mourn
Impact on surviving children (family therapy)a. daddy does not want to play ball anymoreb. child is unable to verbalize sadness, fear of deathc. attention seeker, somatic complaints, suicide
DIFFERENT SIGNS OF IMPENDING DEATH
A. Clinical Death1. function stops2. apnea3. patient will go into coma
B. Biologic Death1. organs cease to function2. no PR, RR3. brain and heart stops
C. Cerebral Death1. affects the cerebrum2. irreversibly unconscious
D. Brain Death1. cerebral panecrosis (extensive tissue death)
E. Social Death1. the time when the physician pronounces death
DIFFERENT CLINICAL SIGNS OF DEATH
1. Loss of muscle tone- incontinence- dysphagia- dysphasia- loss of gag reflex- decreased GI motility, inspite incontinence- decreased body movement
2. Decreased circulation- skin becomes cyanotic- cold and clammy feet, hands, ears, nose
3. Changes in v/s – everything goes down- breathing is shallow, irregular, abnormally slow, does mouth
breathing causing dry mucous membrane and lips to crack- eyes: pupils dilate, doll’s eye- swallowing and yawning until the last breath
4. Flat ECG
GRIEF ACCORDING TO DIFFERENT THEORISTS
A.KUBLER-ROSS – taught that the health care community, that having open discussions about life and death issues did not harm patients
STAGEDEFINITION EXAMPLE NURSING
RESPONSIBILITIESRATIONALE
1.) Denial - temporary defense
mechanism
Patient uses denial to protect himself against the anguish and despair of his situation; refuse to believe that loss is happening.
An adoptive coping mechanism to delay the pain and shock until the patient is better able to deal with the reality.
Patient is unready to deal with practical problems.
“No, not me!”
“Hindi kaya nagkamali ang doctor sa aking diagnosis?”
Support patient denial. Patient needs time before facing death
Do not force acceptance of truth
It serves as protective function; patient needs time before facing death.
2.) Anger and Rage These feelings are projected on to family are care givers who are able to continue with life and activities.
“Why me?”
“Bakit ako? Sa milyo-milyong tao ako pa ang natamaan ng cancer.”
Help patient understand that anger is a normal response to feelings of loss and powerlessness created by the impending death.
Provide structure and continuity in patient’s care – this increases patient’s feelings of security.
The nurse should not take anger personally or label patient as ungrateful or uncooperative. It will isolate patient and family further and increase guilt and anxiety.
3.) Bargaining An attempt to postpone dying until certain tasks are completed.
These requests are usually made to God and provide a way for the patient to deal with the situation in small increment.
“If only…’
“Hinihingi ko sa Diyos na mabigyan pa ako ng anim na taon, makita ko man lang anak ko makagraduate.”
Nurse needs to listen attentively, encourage patient to talk. Talking can relieve guilt and irrational fears.
In some situations, it is advisable to refer the patient to member of the clergy.
Be patient and allow expression of feelings and support realistic and positive hope.
4.) Depression Occurs when the patient realizes that he is about to lose many things.
E.g. family, job, control and life itself.
“What’s the use” – this realization produces profound sadness and depression.
“Wala akong gana sa lahat ng Gawain. Para saan pa ang pag-aayos ng sarili.”
Do not avoid the patient. - - Patient has the reason to be sad and must be allowed to express sadness. This time the patient needs a listening ear and support from the nurse.
Don’t try to cheer the patient up. Communicate nonverbally.- sitting quietly with patient and
not expecting conversation; conveying caring by touch; being with the patient in silence is very important because it increases self worth.
Insincere reassurance/ encouragement of unrealistic hopes should be avoided.
5.) Acceptance Comes when the patient acknowledges and recognizes that death is inevitable. Time of peace and contentment.
- the patient accepts it after having gone through the other stages; he may become increasing detached and show readiness to go.
“Yes, it is me.”
“Malapit na akong mamatay. Do not give me anymore oxygen – the time has come to be with my creator. I am ready to go don’t delay me.”
Direct activities toward maintaining the patient’s self worth and ensuring that patient is not alone.
Encourage the patient to participate as much as possible in his or her treatment program.
Spend time with patient and convey caring. It can relieve patient’s feelings of loneliness or fear.
Suggest for a visit of a priest – last sacrament (SOS)
B.JOHN HARVEY (1998)
1. Shock, outcry denial2. Intrusion of thoughts, distractions and obsessive review of the loss3. Confiding in others as a way to emote and to cognitively restructure an
account of the loss
C.RODEBAUGH, SCHWINDT & VALENTINE (1999)
1. Reeling – the person feels shock, disbelief or denial2 . Feeling – the person experiences anguish, guilt, profound sadness, anger,
lack of concentration3 . Dealing – the person begins to adapt to the loss by engaging in support
groups, grief therapy, reading and spiritual guidance.4. Healing – the person integrates the loss as part of life acute anguish lessens.
D. WORDEN’S BASIC TASK OF GRIEF AND MOURNING (1990)
1. to accept the reality of the loss2. to experience the pain of grief or loss3. to adjust to an environment in which the deceased is missing4. to withdraw emotional energy and reinvent it in other relation
E. LINDEMANN’S 3 BASIC TASK OF GRIEF (1944)1. Emancipation - stress2. Readjustment – struggles, bear pain of separation3. Reinvestment – grief work, successful mourning
F. RANDO’S 7 TASK OF DYING (1992)1. Preserving emotional balance.2. Preserving self image3. Preparing for the future4. Pain and symptom control5. Managing stress6. Managing relationship with caregivers.7. Managing relationship with significant others (SO)
Rando’s prerequisite for working with the dying1. A personal confrontation with death in the sense of having
started to come to quits with one’s own mortality.2. An understanding of the grief process and an appreciation for the
total experience of the dying patient. 3. Effective listening skills and the ability to appropriately respond
non-verbally as well as verbally.4. A commitment to giving part of oneself to the dying person and
working with families after death when appropriate.5. A knowledge of one’s own personal limits, knowing when there is to get away from
death and now to avoid burnout.6. Appreciation of the total experience.
G. GEORGE ENGEL1. SHOCK AND DISBELIEF
- refusal to accept loss- stunned feelings- intellectual acceptance but emotional denial
2. DEVELOPING AWARENESS- reality of loss begins to penetrate awareness- anger may be directed at hospital nurses etc- crying and self blame
3. RESTITUTION- rituals of mourning
4. RESOLVING THE LOSS- attempts to deal with painful void- still unable to accept new love object to replace lost person- may accept more dependent relationship with support- thinks over and talks about memories of the dead person
5. IDEALIZATION- is the exaggeration of the good qualities that the person or object had followed by acceptance of the loss and develops a lessened need to focus on it.- produces image of dead persons that is almost devoid of undesirable features.- represses all negative and hostile feelings towards the deceased- unconsciously internalizes admired qualities of the deceased- reinvest feelings in others
6. OUTCOME- the final resolution of the grief process including dealing with loss as a common life occurrence- behavior influenced by several factors:
a. importance of the lost object as source of supportb. degree of dependence on relationshipc. degree of ambivalence toward the deceasedd. number and nature of other relationshipse. number and nature of previous grief experience
H. JOHN BOULBY
1. Numbness and Protest- anger directed at deceased for having died- unacknowledged loss
2. Disequilibrium- preoccupation- intense weeping- anger- ambivalence- guilt
3. Disorganization and Despair- depression sits in, unable to make decisions, lack of confidence- fear- aimless- restless- somatic complaints- 2H - helplessness and hopelessness
4. Reorganization- achieving stability and sense of reintegration- reinvestment- acceptance- reminiscing
DYSFUNCTIONAL GRIEVING - when the person cannot move on with normal activities- does not allow a person to adjust to situation - state in which an individual or group experiences prolonged
unresolved grief and engage in detrimental activities
ABBREVIATED GRIEF- is brief but genuinely felt
ANTICIPATED GRIEF- is experienced in advance of the event- occurs before the actual loss
UNHEALTHY GRIEF- is pathologic, dysfunctional grief
FACTORS CONTRIBUTING TO DYSFUNCTIONAL GRIEFa. prior to traumatic loss in childhoodb. circumstances of the present lossc. family or cultural barriers
TYPES OF DYSFUNCTIONAL GRIEF
a. Unresolved grief- is prolonged in terms of length and severity- bereaved has difficulty accepting/ expressing grief - denies the loss
b. Inhibited grief- suppressed symptoms/ reactions
FACTORS LEADING TO DYSFUNCTIONAL GRIEVING1. client fails to grieve following death of a loved one – does not cry, absent himself at the funeral2. the client becomes recurrently symptomatic on the anniversary of the loss, during holidays esp Xmas 3. the client avoids visiting the grave & refuses to participate in religious memorial services of a loved
one4. the client develops persistent guilt and lowered self esteem5. even after prolonged period, the client continues to search for the lost person6. the client is unable to discuss the deceased with equanimity even after a long period of time7. the client experiences physical symptoms similar to those of the person
who died after the normal period of grief8. client’s relationships with friends and relatives worsen following the death
FACTORS THAT CONTRIBUTE TO UNRESOLVED GRIEF AFTER DEATH
1. ambivalence towards the lost person- intense feelings of both love and hate- the bereaved is often fears discovering unacceptable negative
feelings
2. a perceived need to be brave and in control- fear of losing control in front of others
3. endurance of multiple losses
4. extremely high emotional value inverted in the dead person- failure to grieve in this instance helps the bereaved avoid the
reality of the loss
5. uncertainty about the loss- e.g. when a loved one is missing in action
6. lack of support persons
7. subjection to socially unacceptable loss that cannot be spoken about- e.g. suicide, abortion, giving up child for adoption
TYPES OF DYSFUNCTIONAL GRIEVING Possible complicated outcomes of grief.
1. Persevering, unusually intense or distorted occurrences of normal grief symptoms.
- delayed or prolonged grief- alternation in relationships in
relationships with friends and relatives
2. Syndromes of depression, distortions, and problems.
- hostility against specific person somehow connected with the death
- phobias about illness or death
3. Diagnosable mental or physical disorder.
- agitated depression, insomnia and feeling of worthlessness
4. Suicide
RISK FACTORS OF OCCURRENCE OF DYSFUNCTIONAL GRIEVING
1. Sudden unanticipated death especially when it is traumatic, violent.
2. Ambivalence, marked dependence or co-dependence in the relationship with the deceased
3. Perceived lack of social support
4. Liabilities of the mourners.
5. Loss of a child.
6. Perception of the death or suffering preventable.
CHANGES THAT OCCUR WHILE APPROACHING DEATH AND AFTER DEATH
A. Facial appearance, sight, speech, and hearing
- facial muscle relaxes, cheeks become flaccid, facial structure changes to distress; frowns
- pale ashy skin, sunken gazing eyes- sight gradually fails, eyes remain half open or gazing (cover or
wet eyes with NSS to prevent drying- pupils are fixed, do not react to light- speech becomes difficult, confused and finally impossible- hearing is retained being the last sense to be lost
B. Skin and Musculo-Skeletal System - muscles relax, patient is increasingly losing capability to move- lips lose reflexes, sensation, ability to move following death,
muscles become fixated- Rigor Mortis – stiffening of the body few hours following death;
starts from the jaw and progressing down the body- immediately following death movements of the body occur- as death approaches, skin becomes pale, cool with excessive or
profuse perspiration (diaphoresis)- increased or uncontrolled temperature – the thermoregulating
center fails.- following death, body cools rapidly initially then gradually
reaches environment temperature- Clinically dead – RR and HR stops - Biologically alive – patient remains alive for a period of 3-4
minutes after the heart ceased to beat. Once grace period passes, biologic death occurs, resuscitation is useless; brain is severely damaged.
C. Respiratory System - breathing patter will change and becomes irregular (Cheyne Stokes), rapid and shallow or very slow
- 10-30 seconds period of no breathing (apnea) while asleep
D. Central Nervous System - the patient will spend more and more time sleeping and at times difficult to arouse (results from the body’s slowing metabolism
- reflexes are gradually lost- there is restlessness – owing to need of oxygen because
the blood circulation is slowing- consciousness is lost and reflexes are absent
E. Circulatory System - changes occur due to alteration in temperature, RR, PR as circulatory system gradually fails
- rapid irregular PR progresses to death- following death (Postmortem Hypostasis) bruise-like
reddish or bluish discoloration
F. Gastrointestinal & Genitourinary Systems
- n/v, weight loss is common- impaction, urine retention, distention, bladder and bowel
incontinence maybe present- decreasing peristalsis prevents stomach from emptying
intestinal contents; stomach distends- impaction occurs due to lack of energy needed to
evacuate bowel- incontinence is due to relaxation of anal and bladder
sphincters.
NURSING PROCESS IN DEATH AND DYINGAssessment of Patient and Family experiencing loss/ dying and death
O’Toole’s Phases of Living-Dying and related tasks1. The living with illness phase – at the time the illness was 1st diagnosed2. The active dying phase3. The time of death4. The follow-up of bereavement phase
The Living with illness phase (key tasks of patient and family at their phase)1. The need to obtain and gain understanding and information regarding the illness process –
include information about medical and nursing treatment and what to expect and what the patient and family need to do.
2. The need for assistance and information about limitation imposed by the illness and what resources are available to assist them.
3. A period of adjustment as family members develop new roles.4. The patient and family need to develop trusting relationship with their caregivers.5. The need for assistance in maintaining hope while dealing with the reality with the disease
process and the implication of the threat to life. 6. The family’s needs to develop strategies to meet the needs of the ill person to retain as much
control over his or her life as possible.7. The patient and family need to discover coping patterns that will assist in limiting their
awareness of the impact of losses and conserve energy so that living can continue8. The need to maintain and/or restore relationships with significant persons, the need to tie up
loose ends9. The time to some degree to recognize and resolve unfinished business10. The caregivers need to develop a system that permits them to care for themselves and
continue living fully as possible
Patient/ Family tasks of the active dying phase
1. if the patient is cared for at home, the caregivers will need instructions on the care of the terminally ill
2. the family caregiver needs to regulate emotions to attend to personal needs, the dying person’s needs and the family system needs
3. the patient and family will experience the pain of separation as the patient begins to withdraw
4. the need to remain sufficiently engaged to provide care, comfort and presence to the dying person and other family member
5. the time of completion of significant issues of reconciliation and forgiveness
6. as far as possible, the time to accept or recognize the earth life is ending
7. the need for some form of acknowledgment of the bonds of the dying person to those who remain and some formalization of the creation of memories.
8. the dying person’s needs for assurance that he or she will be remembered
Tasks at the time of death
1. Assessment of the need and wish of the family to be present at the time of death
2. The patient should not be left alone at the time of death3. Assessment of who the patient/ family wanted to be
present, such as clergy, other family members or friends
4. The family’s need for information about what to expect at the time of death
5. The family’s needs for assistance in notifying the appropriate person about the death such as the funeral home.
6. The family’s need for permission to remain alone with the patient’s body after death.
Family Tasks after death
1. If the patient died at home, the family needs assistance with the preparation of the body.
2. They may need assistance in arranging funeral/ memorial rituals meaningful to them and the deceased.
3. They may want and need encouragement to use this period to reminisce about the “good days”.
DATA ANALYSIS: NURSING DIAGNOSIS
Diagnostic Title Possible Etiologies
1. Anxiety - Financial insecurity, fear of own death, loneliness- Threat to self concept, change in health status/ socioeconomic status/ role functioning and threat
to death
2. Role Performance Altered - Changes in social involvement due to life – threatening illness
3. Hopelessness - Failing physical condition, abandonment
4. Denial - Threat to life
5. Powerlessness - Health care environment, illness-related regimen
6. Grieving, Anticipating - Potential loss of significant person/ object/ body part
7. Social Interaction, Impaired - Poor communication skills, self concept disturbance, absence of significant others, altered thought processes
8. Social Isolation - Alteration in physical appearance, state of wellness or altered mental status
9. Grieving, Dysfunctional - Actual or perceived object loss- Lack of family support
Needs of the Dying Patient and their corresponding Nursing Interventions throughout the Living-Dying Continuum
PHYSICAL NEEDS
MOUTH a. Remove dentures – they obstruct breathing, contributes to n/vb. Lubricate patient’s lips – mouth and lips become dry due to elevated
temperature
EYE a. When vision fails communicate more with speech and touchb. Keep room comfortably illuminated, prevent shining light to patient’s eye –
because patient’s eyes are glazed and dryc. If eyes are open during the terminal stage, protect them with NSS and eye
pads.
SKIN a. Back rubs to promote circulationb. Frequent turning of patient gently – prone to bedsores due to lack of adequate
adipose tissues to cushion bony prominences.c. Continue ROM exercises gentlyd. Always keep skin dry from diaphoresis
NUTRITION a. Administration of IVF as ordered to replace fluid loss during n/v and diaphoresis
b. NGT feeding
Needs of the Dying Patient and their corresponding Nursing Interventions throughout the Living-Dying Continuum
PHYSICAL NEEDS
ELIMINATION a. Laxativeb. Manual removal of impacted stoolc. Irritation may occur due to incontinence – skin care and application of
soothing ointment around anus and perineum d. For urinary retention – catheterization may be necessary and care of cathetere. Measure I and O
POSITIONING & AIRWAY
a. Elevate head part for easier breathingb. Oxygen therapyc. If patient is unconscious, flat on bed with head turned to the sides to facilitate
drainage of mucus from the mouth and throatd. Suction secretions gently
SAFETY a. Protect patient from harm: - put side rails up - precaution on use of hot water bag - NGT insertion for tube feeding to prevent aspiration
REST
Needs of the Dying Patient and their corresponding Nursing Interventions throughout the Living-Dying Continuum
EMOTIONAL NEEDS
Grieving is the
normal respons
e to loss
a. Show kindness, thoughtfulness, gentlenessb. Be sensitive to their needs through sensitive listening, caring, touch, empathy,
and soothing presencec. Love can be expressed through kind, compassionate care of patient
SPIRITUAL NEEDS
Asking the Clergy to visit
a. The lost leg of earthly journey of the patient should be characterized by peace with God, with other people and himself.
BODY CHANGES AFTER DEATHA. LIVOR MORTIS
- discoloration of the skin after death due to the cessation of blood circulation- cyanotic skin, gravitational pooling- dependent lividity- RBC hemolysis or breakdown releasing hgb which discolors surrounding tissues- onset: 30 minutes- peak: 6 hours
B. RIGOR MORTIS - is the stiffening of the body due to chemical changes, contracted muscles and
joint immobility- etiology: lack of ATP (adenosine triphosphate) - onset: 2-4 hours- care following rigor mortis:
1. position body2. place dentures3. close eyes and mouth
C. ALGOR MORTIS- gradual decrease of body temperature after death- blood circulation stops – hypothalamic functions stops- RBC hemolysis – BT falls about 1ºC (1.8ºF) until it reaches room temperature- blood circulation stops- decreased skin elasticity- tissue softens- bacterial fermentation eventually resulting to liquefaction
POST MORTEM CARE
1. Position body:a. Close eyelids and mouthb. Put back denturesc. Remove all attachmentsd. Clean the body – bath or “labar”e. Lysol bath for some patients
2. Make a list of valuables for endorsement and place in a bag3. Make the environment as clean and as pleasant as possible4. Make the body appear natural and comfortable5. Remove all equipment and supplies from the bedside6. Remove soiled linens so the room is free from odors7. Place the body in supine position, arms at sides and palms down8. Place one pillow under the head and shoulders to prevent blood from discoloring the face9. Place absorbent pads under the buttocks to take up any feces and urine released because of
relaxation of the sphincter muscle10 Provide clean gown, brush/ comb the hair11. Allow the family to view the patient’s body12. Apply ID tags, one to the ankle and one to the wrist13. Wrap the body in shroud or white linen apply another ID tag to the outside of the shroud14. Bring the body to the morgue for cooling (cyanosis)
Note:*** While the patient is dying, listen to what they are saying and maintain confidentiality*** Pray with him and call for the clergy*** Reassure family to lessen grieving
PROCEDURAL ACTIVITIES THAT MUST BE COMPLETED AT THE TIME OF CLIENT’S DEATH
1. Pronouncement of death
2. Death Certificate – it documents the time and cause of death
3. Request for post mortem examination (autopsy) – with written consent from next of kin if required by law
4. Request for organ or tissue donation – if client is medically judged to be a suitable donor
5. Determination of funeral home – the family selects the mortician to embalm or cremate
DEVELOPMENTAL IMPACT OF LOSS AND DEATH
Age Developmental Stage Concept of Death Impact of Loss
0 - 1 ½ years Trust vs. Mistrust Self centered and center of the world Separation
1 ½ - 3 Autonomy vs. Shame and Doubt
Unable to think correctly about abstract concept
Disappearance
3 – 5 Initiative vs. Guilt Very temporary Fear of not being loved
5 – 12 Industry vs. Inferiority Concrete and logical (thinks logically about its causes)
Punishment for not measuring up to expectations
Threat of bodily harm
13 – 18 Identity vs. Role Confusion Poor orientationAbstract thinking
Threat to independenceSigns of being different from
peers
Young adult 18-25 Intimacy vs. Isolation Abstract Description of lifestyleSeparation
Adulthood 25 – 45 Generativity vs. Stagnation Abstract philosophies Description of lifestyle
Maturity 45 - death
Integrity vs. Despair New life, rest and peaceful reflection SeparationPart of life cycle
PHASES OF LIFE THREATENING ILLNESS
1. PREDIAGNOSTIC PHASE- the client recognizes symptoms and risk factors of illness- the client recognizes some element of risk and selects
strategies to cope with this perceived threat
2. ACUTE PHASE- the client faces a diagnosis of life threatening illness- the client now must make a series of decisions
3. CHRONIC PHASE- the client is struggling with the disease and its treatment- this period is punctuated by a series of illness-related crisis
4. TERMINAL PHASE- the disease has progressed to a point in which death is
inevitable
EXPECTED OUTCOME - remembering the loved one without emotional pain and reinvesting emotional energy in life so that the capacity to move is not lost.
BENEFICIAL WAYS IN WHICH DEATH AFFECTS OUR PERCEPTION OF LIFE
1. it gives us an appreciation for living
2. it gives us sense of real existence, individual existence
3. it gives us meaning to courage and integrity, allowing us to express our conviction effectively
4. it provides us with the strength to make major decisions
5. it shows us the importance of ego-transcending achievements
6. it allows us to see our achievements as being significant
THE GRIEVING PERSON MUST ACCOMPLISH THE FOLLOWING TASKS:
1. face the pain – acknowledging the loss and its impact in changing roles
2. permit the emotional expression of the full range of feeling – talking about the reality of loss
3. achieve emancipation from bondage to the deceased (beginning to incorporate the reality of the loss
4. adjust to an altered environment
5. renew or form new relationships
6. be able to live with memories
CARE FOR NURSE CARE GIVER
a. nurses who work w/ the terminally ill and with bereaved person develop a heightened empathy and identification with their patients
b. nurses take emotional grief and form bonds that demand grief responsec. nurses are susceptible to all the emotion of grief: frustration, sadness, guilt,
anxiety, depression, helplessness, anger
DIFFERENT ROADBLOCKS TO NURSES GRIEVING
1. Social negation of the loss and isolation from support – the nurse is left alone to grieve or to go on as if nothing important has occurred.
2. Professionalism: nurses are expected to be strong3. Ambivalence and feelings of guilt toward the dead person, can result if the
nurse had mixed feelings about the patient – if the patient was a difficult person to care for, the nurse may even feel a sense of relief when death occurs.
4. Nurses often have a need to be in control or may suppress their feelings 5. Multiple losses can be overwhelming6. Old, unresolved losses suffered by the nurse can be reawakened.
STRATEGIES FOR NURSES’ SURVIVAL – NURSES’ RESPONSIBILITIES TO TAKE STEPS TO CARE FOR THEMSELVES
1. Take regular meals or time-outs from the patient care area and consider rotating out of high-stress nursing area.
2. Identify specific patients that are most difficult, so that they can be anticipated and counteracted.
3. Acknowledge physical needs as key factor in stress reduction.4. Integrate decompression routines into daily life. Before leaving the work
area, take moment to review the day and set it aside before going alone.
5. Engage in life affirming activities e.g. spend time with lively healthy children6. View losses as an opportunity to re-evaluate and grow.7. Avoid the rescuer or “savior complex”: recognize limits.8. Recognize the need for support and do not hesitate to ask for it.9. Say “I choose” rather than “I should”10. Develop the skills of setting limits and feeling ok about saying “no”.11. Laugh and play in the face of tragedy without guilt.12. Seek consultation on a regular basis.
NURSES’ BLOCKS TO A HELPING RELATIONSHIP
1. unwillingness to share the dying experience.
2. forgetting the emotional experience of the dying: fear loneliness, abandonment
3. irritation and hostility to the dying’s frequent calls
4. failure to seek support
5. elephant communication
6. use of technical language or social chitchat
LEGALITIES RELATED TO DEATH
BILL OF RIGHTS OF THE DYING PATIENTI have the right …
1. to be treated as a living human being until I die2. to maintain a sense of hopefulness3. to be cared for by those who can maintain a sense of hopefulness4. to express my feelings and emotions and my approaching death in my own way5. to participate in decisions concerning my care6. to expect continuing medical and nursing attention eventhough cure goals must be
changed to comfort goals7. not to die alone8. to be free from pain – give placebo9. to have my questions answered honestly10. not be deceived11. to have help from and for my family in accepting my death12. to die in peace and dignity13. to retain my individuality and not be judged by my decisions which may be contrary
to the beliefs of others14. to discuss and enlarge my religious and spiritual experience regardless of what
they mean to others15. to expect that the sanctity of the human body will be respected after death16. to be cared fro by caring, sensitive, knowledgeable people who attempt to
understand my needs and will be able to gain some satisfaction in helping me face my death
The nurses’ role in legal issues related to death is prescribed by the laws of the region and the policies of the health care institution (e.g. NGT, ET)
1. ADVANCE HEALTH CARE DIRECTIVES-include a variety of legal documents that allow persons to specify aspect of
care to receive should they become unable to make or communicate their preferences
2 Typesa. Living will
- provides specific instructions about what medical treatment the client chooses to omit or refuse (e.g. ventilatory support)
b. Health care proxy
- a durable power of attorney for health care- a notarized or witnessed statement appointing someone else to manage health care treatment decisions when the client is unable to do so.
2. AUTOPSY- an examination of the body after death to determine the exact cause of
death- the organs and tissues of the body are examined- consent is necessary by the decedent (before death) or the next of kin- after autopsy, hospitals cannot retain any tissue or organ without the permission of the person who consented the autopsy
3. CERTIFICATION OF DEATH- pronouncement must be performed by a physician- usually signed by the attending physician and filed with the local
health or other government office- the family is usually given a copy to use for legal matters such as
insurance claims
4. DO NOT RESUSCITATE ORDER (DNR) OR NO CODE- for clients who are in terminal stage, irreversible illness & expected death- a written order is generally written when the client or proxy has
expressed the wish for no resuscitation in the event of a respiratory or cardiac arrest
5. EUTHANASIA- act of painless putting to death persons suffering from incurable or
distressing disease
6. ORGAN DONATION- people 18 years or older with sound mind may make a gift of all or any part of their own bodies for the following purposes:
a. medical or dental educationb. research and advancement of medical/ dental sciencec. therapy of transplantation
*** card is usually carried by the person who signed it
DEATH-RELATED RELIGIOUS AND CULTURAL PRACTICES- various cultural and religious traditions and practices associa-ted with death, dying
and grieving process help an individual cope with those experiences- nurses are often present through the dying process and at the moment of death so knowledge of the client’s religious and cultural heritage help nurses provide individualized care to client’s and their families
1. Many cultures prefer a peaceful death at home rather than in the hospital
2. Members of some ethnic group may request that health professionals do not reveal the prognosis to dying client because they believe that the person’s last days should be free of worry. Other cultures prefer that a family member (preferable male) be told the diagnosis so that the client will be tactfully informed by the designated family member in gradually or not at all. Nurses all need to determine whom to call, and when as the impending death draws near
BELIEFS AND ATTITUDES- Autopsy may be prohibited, opposed, discouraged by Eastern Orthodox, Muslims,
Jehovah’s Witness and Orthodox Jesus- Organ donation is prohibited by the Jehovah’s Witness and Muslims- Cremation is discouraged and opposed by Mormons, Eastern Orthodox, Islamic and Jewish
faiths- Hindus prefer cremation and cast ashes in a holy river- Christians use medical means to prolong life and the Jewish faith generally opposes
prolonging life after irreversible brain damage- Buddhists permit euthanasia
*** Nurses need to be knowledgeable about the client’s death-related rituals such as last rites, chanting at bedside and the like.
RECOGNIZING DEATH SIGNS
Traditional signs of Death ----- cessation of apical pulse, respiration and BP – referred as heart-
lung death
Cerebral death or Brain death – occurs when the higher brain center or the cerebral cortex is irreversibly destroyed
1968 WORLD MEDICAL ASSEMBLY Adopted the following guidelines for physicians as indication of death:1. total lack of response to external stimuli2. no muscular movement especially breathing3. no reflexes4. flat encephalogram (brain waves)
Care of the body- the body of the deceased needs to be treated in a way that respects the
sanctity of the human body- nursing care includes maintaining privacy and preventing damage to the
body
SPECIAL CONSIDERATION WITH PEDIATRIC CLIENT*** Dying infants or newborn should be baptized using emergency
baptism
Nurses role in facilitating healthy grieving:
1. CREATING MEMORY- the greatest gift that nurses can give to grieving families is the gift of
memory- through simple gestures nurses can create an environment that
facilitates bonding and provide tangible keepsakes that will comfort families for a lifetime
2. QUIET TIME- all parents deserve the opportunity to have quiet time alone with their
infants to promote quality family time
3. HOLDING THE INFANT- strongly encourage bereaved parents to see and hold their child
regardless of the physical deformity or malformation present- the nurse should also encourage parents to seethe entire body by
unwrapping blankets and pointing out the positive features of the
child.
4. NAMING THE CHILD
- parents may be reluctant to use a chosen name for a baby who has
died, encourage them to do so.- the name will identify that child as a person, a little person to be
remembered and loved as integral part of the family
5. PROVIDING KEEPSAKE
- following the infant’ s death, tangible memories provide the greatest
source of comfort for parents- helpful keepsakes may include birth certificates, foot prints, crib
card, name bracelet, cord clamp, unwashed diaper, infant’s
hat, blanket, ultrasound, fetal heart strip, photos, video tapes and pedia book
- a memory book is a nice way to organize these keepsakes