10 Loss Grief and Dying

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<p>Loss, Grief and DyingLoss when something of value is changed or made inaccessible so that its value is diminished or removed</p> <p> Abnormal or Distorted</p> <p>Unresolved trouble expressing feelings; denies feelings Unresolved extends over a long period Inhibited suppresses feelings but presents somatic symptoms</p> <p>Actual Loss recognized by others E.g.: loss of a limb</p> <p>Perceived Loss intangible to others E.g.: loss of youth Physical Loss Psychological loss E.g.: diminished body image</p> <p>Interventions in Grieving Interpersonal skills to demonstrate empathy Encourage verbalization Respond to inquiries honestly Promote grief work through each stage of grieving Appropriate referrals</p> <p>Maturational Loss result of natural development E.g.: kids growing up Situational Loss result of an unpredictable event</p> <p>Alert about patient who is moving through grief work</p> <p>Death and Dying Death </p> <p>E.g.: trauma, accident, death, natural disasterAnticipatory loss feeling the loss before it happens; E.g.: mourning for the terminally ill</p> <p>Heart-Lung Death irreversible cessation ofspontaneous respiration and circulation functions of the entire brain</p> <p>Grief emotional reaction to a loss</p> <p>Whole brain death irreversible cessation of allbrain functions, cognitive functions Signs of impending death: Inability to swallow Pitting edema Decreased GIT &amp; UT activity Bowel &amp; bladder incontinence Loss of motion, sensation &amp; reflexes Elevated temperature but cold &amp; clammy skin; cyanosis Low BP Noisy/irregular respiration Cheyne-Stokes respiration</p> <p>Bereavement state of grieving w/ grief reaction May neglect health to extremes Mourning period of acceptance of a loss Return to normal habits</p> <p>Higher Brain death irreversible loss of all higher</p> <p>Grief Reactions Engel (1964)</p> <p> Kubler- Ross (1969)</p> <p>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 Denial and isolation Anger Bargaining Depression Acceptance</p> <p> Stages of Grief &amp; 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</p> <p>Abbreviated short but genuine Anticipatory before actual loss</p> <p>Dying Persons Bill of Rights I 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</p> <p>Dysfunctional Grief</p> <p>Infancy to 5 years old prescho ol</p> <p>NO clear concept of Death It is Reversible, temporary sleep</p> <p> Common law right of self determination and constitutionally supported right to privacy</p> <p>- death is permanent -may believe that he is responsible -death is a punishment 5 to 9 Understands DEATH is FINAL years but can be AVOIDED 9-12 Death is INEVITABLE years Understands own mortality 12-18 Fears a lingering Death 18-45 Attitude is influenced by religion 45-65 Experiences peak of death anxiety 65 and Death as multiple meanings Terminal Illness Illness in which death is expected MD decides what, when and how px should be told</p> <p>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</p> <p>Advance Directives Allow indv to state in advance their choices would be for healthcare</p> <p>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</p> <p>RN, clergy, other health care professionals may be involved in discussing pxs 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</p> <p>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</p> <p>Nurses should clarify patients code status if probable results of resuscitation are negligible or has reason to believe that patient would not want to be resuscitated</p> <p>Comfort measures only and other Special Orders Comfort-measures-only order - Comfortable, dignified death and life sustaining measures not indicated</p> <p>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</p> <p>Healthcare personnel should be available for</p> <p>Other Ethical and Legal Issues</p> <p>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 clientsneed not on ability to pay Ethical and Legal Dimensions</p> <p>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 patients 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</p> <p>Patients w/ legal and moral right to consent to and refuse any and all indicated therapies</p> <p>Good Dying Last Acts Project focuses on improving care for dying patients</p> <p> 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</p> <p>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</p> <p>Age family relationships socioeconomic position cultural and religious influences</p> <p>persons 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</p> <p>Grief after patient death is natural ; nurse should address personal health needs</p> <p>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 Patients 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</p> <p> Wrap the body in a shroud Bring the body to the morgue for cryonics (cooling)</p> <p>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</p> <p>Allow Significant Other to view the patients body</p> <p> Apply 3 ID tags (wrist, ankle and over the shroud)</p>