bellringer: yesterday, we dealt with our own feelings about death & dying. today, we will talk...
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Bellringer:Yesterday, we dealt with our own
feelings about death & dying. Today, we will talk about the emotional changes of a patient through the process.
How do YOUR beliefs about death/dying affect the care that you give a patient through the dying process?
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Emotional Changes of a patient through end of life
care Jackilyn Malone,
RN, BSN Montgomery
County ATC
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DeathCessation of heart & lung
function OR
Cessation of whole brain function
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Terminal IllnessA disease that cannot be
cured and will result in death
Time frame??◦Days,◦Months◦Years
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Reactions to DiagnosisHelplessnessFear
◦Pain, separation from family, unknown
AnxietyLoss of independence/controlUnprepared/unfinished
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Five StagesElizabeth Kubler-Ross
◦Psychiatrist◦Encouraged hospice care◦1969— “On Death & Dying” ◦Believed there are five stages of
grief in the dying process◦Not necessarily linear
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1. Denial2. Anger3. Bargaining4. Depression5. Acceptance
DABDA
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Stage 1: DenialUsually the first stage when
newly diagnosedInitial reaction of shockDazed at first, then refusal to
believeMay seek second, third, fourth
medical opinion“This can’t be happening.” “Must
be some mistake”
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Stage 1: DenialTips for the Health Care Provider
(HCP)◦Listen to the patient without
confirming or denying the diagnosis
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Stage 2: AngerNo longer denies deathFrustrated, angry, irritable, bitterMay blame self and/or others,
God“Why me?”
Bad habits may begin◦Drinking, smoking, speeding
“Why follow rules and take care of myself if I’m going to die?”
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Stage 2: AngerTips for the HCP:
◦Understand that displaced anger is not a personal attack.
◦Try to be understanding
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Stage 3: BargainingUsually occurs when patient
accepts death but wants more time to live
Turns to religions, bargains with God
“If you let me live long enough to see my grandson graduate college, I’ll donate everything I have to charity.”
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Stage 3: BargainingTips for HCP
◦Just listen
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Stage 4: DepressionOccurs when patient realizes
death is coming and they no longer have control
Clinical s/s:◦Withdrawal◦Sleep changes◦Hopelessness/crying◦Decreased appetite◦Possible suicidal ideation
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Stage 4: DepressionTips for the HCP
◦Depression is okay and normal◦Listen◦Use comforting touch◦Offer encouragement
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Stage 5: AcceptanceNormally, this is the final stageRealizes death is inevitable and
accepts itMay be able to talk about death,
tries to comfort family & friendsIf religious, may be comforted by
beliefs of afterlifeMay complete unfinished
business◦Make amends, pay off loans
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Stage 5: AcceptanceTips for HCP
◦Listen◦Encourage
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Five StagesNot always linearCan jump back and forth, skip
stagesMay or may not go through all
fiveOne stage may be more intense
than othersEvery patient will be different
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Tips for HCPsLISTENTalk as neededProvide religious support as
requestedSupport familyIdentify appropriate resourcesAvoid statements such as:
“It’s God’s will,” “Everything happens for a reason,” “Everything will be ok”
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ActivityI will divide students into groups
with sticksI will give each group a packet of
scenariosRead through the scenarios and
then decide what stage of grief the patient is in.
The first one, we will do together as a class
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Break timeTake a 5 minute break
◦Get water◦Use restroom◦Stretch legs
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Death AnxietyPatients experience some degree
of anxiety when dyingDifferent for each patient
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Managing Death AnxietySpirituality/Religion
◦Solely up to patient◦HCP can ask the patient if they want
clergy but must respect their wishes regardless
◦Encourage them in their wishes and pursuits
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Managing Death AnxietyCreative Outlets
◦Art◦Music◦Scrapbooks◦Writing◦Videos◦Quilts
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Managing Death AnxietyMany people are now making
videos for their loved ones◦Gives them a chance to say what
they want to say about life’s milestones
◦http://www.cnn.com/2013/12/22/us/iowa-wife-dying-wish/
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Traits for HCP to showConcern
◦Empathy, compassion, involvementCompetence-skill & knowledge =
reassuranceCommunication-know when to
listen and when to talkCohesion-family & medical
personnel on same page
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Traits for HCP to showCheerfulness-gentle, not
obnoxious; light humor okay if a regular part of rapport with patient
Consistency
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A Dying Patient’s Bill of Last RightsThe Right to be in control.
◦Grant me the right to make as many decisions as possible regarding my care. Please do not take choices from me. Let me make my own decisions
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A Dying Patient’s Bill of Last RightsThe right to have a sense of
purpose. ◦I have lost my job. I can no longer
fulfill my role in my family. Please help me find some sense of purpose in my last days
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A Dying Patient’s Bill of Last RightsThe right to reminisce
◦There has been pleasure in my life, moments of pride, moments of love. Please give me some time to recollect those moments. And please listen to my recollections.
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A Dying Patient’s Bill of Last RightsThe right to be angry and sad
◦It is difficult to leave behind all my attachments and all that I love. Please allow me the opportunity to be angry and sad.
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A Dying Patient’s Bill of Last RightsThe right to hear the truth.
◦If you withhold the truth from me, you treat me as if I am no longer living. I am still living, and I need to know the truth about my life. Please help me find that truth.
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A Dying Patient’s Bill of Last RightsThe right to be in denial.
◦If I hear the truth and choose not to accept it, that is my right.
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A Dying Patient’s Bill of Last RightsThe right to have respected
spirituality◦Whether I am questioning or
affirming, doubting or praising, I sometimes need you ear, a non-judging ear. Please let my spirit travel its own journey, without judging its direction.
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A Dying Patient’s Bill of Last RightsThe Right to touch and be
touched◦Sometimes I need distance. Yet
sometimes I have a strong need to be close. When I want to reach out, please come to me and hold me as I hold you.
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A Dying Patient’s Bill of Last RightsThe Right to Laugh
◦People often—far too often– come to me wearing masks of seriousness. Although I am dying, I still need to laugh. Please laugh with me and help others to laugh as well.
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A Dying Patient’s Bill of Last RightsHonor these rights. One day you,
too, will want the same rights.
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Exit slipWhat character trait do you
possess that you feel will help a dying patient?