Ethics and Values, The Experience of Loss, Death, and Grief, Stress and

Coping

Nursing ethics

Nursing ethics is a branch of applied ethics that concerns itself with activities in the field of nursing. Nursing ethics shares many principles with medical ethics, such as beneficence, non-maleficence and respect for autonomy. It can be distinguished by its emphasis on relationships, human dignity and collaborative care

The nature of nursing means that nursing ethics tends to examine the ethics of caring rather than 'curing' by exploring the relationship between the nurse and the person in care. arly work to define ethics in nursing focused more on the virtues that would make a good nurse, rather than looking at what conduct is necessary to respect the person in the nurse's care. However, recently, the ethics of nursing has also shifted more towards the nurse's obligation to respect the human rights of the patient and this is reflected in a number of professional codes for nurses.

Nursing Code of Ethics Provision 1 

The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.

Provision 2 The nurse's primary commitment is to the patient, whether an individual, family, group, or community.

Provision 3 The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.

Provision 4 The nurse is responsible and accountable for individual nuring practice and determines the appropriate delegation of tasks consistent with the nurse's obligation to provide optimum patient care. 

Provision 5The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.

Provision 6The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provisiobn of quality health care and consistent with the values of the profession through individual and collective action.

Provision 7The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development.

Provision 8The nurse collaborates with other health professionals and the public in promoting community, national and international efforts to meet health needs.

Provision 9The profession of nursing value, for maintaining the integrity of the prosession and its practice, and for shaping social policy.

How to Deal With a Patient's Death First, it is important to acknowledge the death - you may find

it helpful to share your feelings with colleagues, friends and family.

You may also find it helpful, to some degree, to share feelings of loss with members of the family of the deceased. Of course, it is important to realise that the grief of the family must take precedence, but sometimes family members can gain a great deal of comfort from sharing experiences with someone who has been involved with the care of their relative.

Too often in medicine we do not acknowledge events such as this, and our own feelings get lost because we then become involved with new cases and new situations.

Loss, Grief and DeathPeople are complex, biopsychosocial

beings. When they become ill, undergo diagnosis for altered health states, experience a loss, or progress into the end stage of life, their responses are the result of the complex interaction of biopsychosocial changes that occur. Because we live in a culture marked by dramatically different responses to the experiences of loss and grief, nurses often feel inadequate in planning interventions to facilitate grief management and the healing process.

Loss

The concept of loss can be defined in several ways. The following definitions have been selected to familiarize the student with the concept of loss:

Change in status of a significant object Any change in an individual's situation that reduces the

probability of achieving implicit or explicit goals An actual or potential situation in which a valued object,

person, or other aspect is inaccessible or changed so that it is no longer perceived as valuable

A condition whereby an individual experiences deprivation of, or complete lack of, something that was previously present

Types of Loss

A loss may occur suddenly (eg, death of a child due to an auto accident) or gradually (eg, loss of a leg due to the progression of peripheral vascular disease). It may be predictable or occur unexpectedly. Loss has been referred to as actual (the loss has occurred or is occurring), perceived (the loss is recognized only by the client and usually involves an ideal or fantasy), anticipatory (the client is aware that a loss will occur), temporary, or permanent

For example..

“A 65-year-old married woman with the history of end stage renal disease is told by her physician that she has approximately 12 months to live. She may experience several losses that affect not only her, but also her husband and family members, as her illness gradually progresses.”

The losses may include a predictable decline in her physical condition, a perceived alteration in her relationship with her husband and family, and a permanent role change within the family unit as she anticipates the progression of her illness and actual loss of life.

Examples of Losses Identified by Student NursesLoss of spouse, friend, and companion.

The client was a 67-year-old woman admitted to the psychiatric hospital for treatment of depression following the death of her husband. During a group discussion that focused on losses, the client stated that she had been married for 47 years and had never been alone. She described her deceased husband as her best friend and constant companion. The client told the student and group that she felt better after expressing her feelings about her losses

Loss of physiologic function, social role, and independence because of kidney failure. A 49-year-old woman was admitted to the hospital for improper functioning of a shunt in her left forearm. She was depressed and asked that no visitors be permitted in her private room. She shared feelings of loneliness, helplessness, and hopelessness with the student nurse as she described the impact of kidney failure and frequent dialysis treatment on her lifestyle. Once an outgoing, independent person, she was housebound because of her physical condition and presented what her kidneys were doing to her.

Grief Grief is a normal, appropriate

emotional response to an external and consciously recognized loss. It is usually time-limited and subsides gradually.

The grief process is all-consuming, having a physical, social, spiritual, and psychological impact on an individual that may impair daily functioning. Feelings vary in intensity, tasks do not necessarily follow a particular pattern, and the time spent in the grieving process varies considerably from weeks to years.

Precipitating Factors of Grief

Death in family Separation Divorce Physical Illness Work failure disappointments

Nursing Interventions:

Assess; specific loss, meaning of loss, coping skills, support persons.

Accept the client; do not respond personally to the client. Support adaptive responses; allow to express feelings Support defense mechanism – reassure client that denial and

wanting to be alone is normal. Help find constructive outlets of anger. Do not take clients

hostility personally. Do no retaliate. Monitor for self destructive behaviors Help express feelings: Ask how they feel Meet needs Allow as much decision making as possible to maintain dignity by

giving choices and alternatives.

Death is defined as:

"cessation of heart- lung function, or of whole brain function, or of higher brain function.

"either irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain, including the brain stem" - (The President's Commission for the study of Ethical problems in Medicine and Biomedical and Behavioral Research, US, 1983).

Responses to dying and death lthough each person reacts to the knowledge of impending death or to loss

in his or her own way, there are similarities in the psychosocial responses to the situation.

Kubler-Ross' (1969) theory of the stages of grief when an individual is dying has gained wide acceptance in nursing and other disciplines.

The stages of dying, much like the stages of grief, may overlap, and the duration of any stage may range from as little as a few hours to as long as months. The process vary from person to person.

Some people may be in one stage for such a short time that it seems as if they skipped that stage. Some times the person returns to a previous stage

According to Kubler- Ross, the five stages of dying are: Denial Anger Bargaining Depression Acceptance

They are videly known in the acronym 'DABDA'.

Denial On being told that one is dying, there

is an initial reaction of shock.

The patient may appear dazed at first and may then refuse to believe the diagnosis or deny that anything is wrong.

Some patients never pass beyond this stage and may go from doctor to doctor until they find one who

supports their position.

Anger Patients become frustrated,

irritable and angry that they are sick.

A common response is,” Why me? ”

They may become angry at God, their fate, a friend, or a family member.

The anger may be displaced onto the hospital staff or the doctors who are blamed for the illness.

Bargaining The patient may attempt to negotiate

with physicians, friends or even God, that in return for a cure, the person will fulfill one or many promises, such as giving to charity or reaffirm an earlier faith in God.

DepressionThe patient shows clinical signs of

depression- withdrawal, psychomotor retardation, sleep disturbances, hopelessness and possibly suicidal ideation.

The depression may be a reaction to the effects of the illness on his or her life or it may be in anticipation of the approaching

death.

Physical signs of dying Dying is a different experience for everyone involved. Confusion – about time, place, and identity of loved ones; visions of

people and places that are not present A decreased need for food and drink, as well as loss of appetite Drowsiness – an increased need for sleep and unresponsiveness Withdrawal and decreased socialization Loss of bowel or bladder control – caused by relaxing muscles in the

pelvic area Skin becomes cool to the touch Rattling or gurgling sounds while breathing or breathing that is irregular

and shallow, decreased number of breaths per minute, or breathing that switches between rapid and slow

Involuntary movements (called myoclonus), changes in heart rate, and loss of reflexes in the legs and arms also mean that the end of life is near

Changes in body after death: Rigor Mortis: body becomes

stiff within 4 hours after death as a result of decreased ATP production. ATP keeps muscles soft and supple.

Algor Mortis: Temperature decreases by a few degrees each hour. The skin loses its elasticity and will tear easily.

Livor Mortis: Dependant parts of body become discolored. The patient will likely be lying on their back, their backside being the 'dependant' body part. The discoloration is a result of blood pooling, as the hemoglobin breaks down.

Hospice and palliative care Hospice is a specialized program that addresses the needs of

the catastrophically ill and their loved ones particularly accepte in US and West.

A team approach is provided in hospice that may involve physicians, nurses, social workers, clergy, home health aids, volunteers, therapists and family caregivers.

Hospice workers can help a dying person manage pain, provide medical services and offer family support through every stage of the process, from diagnosis to bereavement.

Components of hospice care programme include the following: Client and family as the unit of care Co-ordinated home care with access to available inpatient and nursing

home beds Control of symptoms(physical, sociological, psychological and spiritual) Physician directed services Provision of an interdisciplinary care team of physicians, nurses,

spiritual advisers, social workers and counselors. Medical and nursing services available at all times Bereavement follow up after a client's death Use of trained volunteers for frequent visitation and respite support Acceptance into the programme on the basis of health care needs rather

than the ability to pay

Palliative Care Palliative care is the active total care of patients whose disease is not

responsive to curative treatment (World Health Organization). The relief of suffering is one of the central goals of palliative care in

terminal illnesses. Control of pain, of other symptoms and of psychological, social and

spiritual problems is paramount. The goal of palliative care is the achievement of the best possible quality

of life for patients and their families. Palliative care is a special care, which affirms life and regards dying as a

normal process, neither hastens nor postpones death, provides relief from pain and other distressing symptoms, integrates the psychological and spiritual aspects of patient care and offers a support system to help patients live as actively as possible until death and helps the family cope during the patient’s illness and in their own bereavement.

Palliative care is based on five major principles It respects the goals, likes and choices of the dying person. It looks after the medical emotional, social and spiritual needs of the dying

person. It supports the needs of the family members. It helps gain access to needed health care providers and appropriate care

settings. It builds ways to provide excellent care at the end of life

Identify the sources of stress

Stress management starts with identifying the sources of stress in your life. This isn’t as easy as it sounds. Your true sources of stress aren’t always obvious, and it’s all too easy to overlook your own stress-inducing thoughts, feelings, and behaviors. Sure, you may know that you’re constantly worried about work deadlines. But maybe it’s your procrastination, rather than the actual job demands, that leads to deadline stress.

To identify your true sources of stress, look closely at

your habits, attitude, and excuses: Do you explain away stress as temporary (“I just have a

million things going on right now”) even though you can’t remember the last time you took a breather?

Do you define stress as an integral part of your work or home life (“Things are always crazy around here”) or as a part of your personality (“I have a lot of nervous energy, that’s all”).

Do you blame your stress on other people or outside events, or view it as entirely normal and unexceptional?

Stress management strategy #1: Avoid unnecessary stress Learn how to say “no” – Know your limits and stick to them. Whether in your

personal or professional life, refuse to accept added responsibilities when you’re close to reaching them. Taking on more than you can handle is a surefire recipe for stress.

Avoid people who stress you out – If someone consistently causes stress in your life and you can’t turn the relationship around, limit the amount of time you spend with that person or end the relationship entirely.

Take control of your environment – If the evening news makes you anxious, turn the TV off. If traffic’s got you tense, take a longer but less-traveled route. If going to the market is an unpleasant chore, do your grocery shopping online.

Avoid hot-button topics – If you get upset over religion or politics, cross them off your conversation list. If you repeatedly argue about the same subject with the same people, stop bringing it up or excuse yourself when it’s the topic of discussion.

Pare down your to-do list – Analyze your schedule, responsibilities, and daily tasks. If you’ve got too much on your plate, distinguish between the “shoulds” and the “musts.” Drop tasks that aren’t truly necessary to the bottom of the list or eliminate them entirely.

Stress management strategy #2: Alter the situation Reframe problems. Try to view stressful situations from a more

positive perspective. Rather than fuming about a traffic jam, look at it as an opportunity to pause and regroup, listen to your favorite radio station, or enjoy some alone time.

Look at the big picture. Take perspective of the stressful situation. Ask yourself how important it will be in the long run. Will it matter in a month? A year? Is it really worth getting upset over? If the answer is no, focus your time and energy elsewhere.

Adjust your standards. Perfectionism is a major source of avoidable stress. Stop setting yourself up for failure by demanding perfection. Set reasonable standards for yourself and others, and learn to be okay with “good enough.”

Focus on the positive. When stress is getting you down, take a moment to reflect on all the things you appreciate in your life, including your own positive qualities and gifts. This simple strategy can help you keep things in perspective.

Stress management strategy #3: Adapt to the stressor Reframe problems. Try to view stressful situations from a more positive

perspective. Rather than fuming about a traffic jam, look at it as an opportunity to pause and regroup, listen to your favorite radio station, or enjoy some alone time.

Look at the big picture. Take perspective of the stressful situation. Ask yourself how important it will be in the long run. Will it matter in a month? A year? Is it really worth getting upset over? If the answer is no, focus your time and energy elsewhere.

Adjust your standards. Perfectionism is a major source of avoidable stress. Stop setting yourself up for failure by demanding perfection. Set reasonable standards for yourself and others, and learn to be okay with “good enough.”

Focus on the positive. When stress is getting you down, take a moment to reflect on all the things you appreciate in your life, including your own positive qualities and gifts. This simple strategy can help you keep things in perspective.

Stress management strategy #4: Accept the things you can’t change Don’t try to control the uncontrollable. Many things in life are beyond

our control— particularly the behavior of other people. Rather than stressing out over them, focus on the things you can control such as the way you choose to react to problems.

Look for the upside. As the saying goes, “What doesn’t kill us makes us stronger.” When facing major challenges, try to look at them as opportunities for personal growth. If your own poor choices contributed to a stressful situation, reflect on them and learn from your mistakes.

Share your feelings. Talk to a trusted friend or make an appointment with a therapist. Expressing what you’re going through can be very cathartic, even if there’s nothing you can do to alter the stressful situation.

Learn to forgive. Accept the fact that we live in an imperfect world and that people make mistakes. Let go of anger and resentments. Free yourself from negative energy by forgiving and moving on.

Stress management strategy #5: Make time for fun and relaxation Set aside relaxation time. Include rest and relaxation in your daily

schedule. Don’t allow other obligations to encroach. This is your time to take a break from all responsibilities and recharge your batteries.

Connect with others. Spend time with positive people who enhance your life. A strong support system will buffer you from the negative effects of stress.

Do something you enjoy every day. Make time for leisure activities that bring you joy, whether it be stargazing, playing the piano, or working on your bike.

Keep your sense of humor. This includes the ability to laugh at yourself. The act of laughing helps your body fight stress in a number of ways.

Stress management strategy #6: Adopt a healthy lifestyle Exercise regularly. Physical activity plays a key role in reducing and

preventing the effects of stress. Make time for at least 30 minutes of exercise, three times per week. Nothing beats aerobic exercise for releasing pent-up stress and tension.

Eat a healthy diet. Well-nourished bodies are better prepared to cope with stress, so be mindful of what you eat. Start your day right with breakfast, and keep your energy up and your mind clear with balanced, nutritious meals throughout the day.

Reduce caffeine and sugar. The temporary "highs" caffeine and sugar provide often end in with a crash in mood and energy. By reducing the amount of coffee, soft drinks, chocolate, and sugar snacks in your diet, you’ll feel more relaxed and you’ll sleep better.

Avoid alcohol, cigarettes, and drugs. Self-medicating with alcohol or drugs may provide an easy escape from stress, but the relief is only temporary. Don’t avoid or mask the issue at hand; deal with problems head on and with a clear mind.

Get enough sleep. Adequate sleep fuels your mind, as well as your body. Feeling tired will increase your stress because it may cause you to think irrationally.

Healthy ways to relax and recharge Go for a walk. Spend time in nature. Call a good friend. Sweat out tension with a good workout. Write in your journal. Take a long bath. Light scented candles. Savor a warm cup of coffee or tea. Play with a pet. Work in your garden. Get a massage. Curl up with a good book. Listen to music. Watch a comedy.