Unit II Death, Loss, End of Life

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Unit II Death, Loss, End of
Life
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Death, Loss and End of Life Care

• Loss actual or potential situation in which
  something valued is changed, no longer available
  or gone
• Actual
• Perceived
• Anticipatory

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Grief

• Response to experience of loss
• Bereavement subjective response experience by
  surviving loved ones after death
• Mourning behavioral response through
• which grief is eventually resolved or altered

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Types of Grief

• Anticipatory Grief
• Grief before loss
• Patient, family, professionals
• Children have unique needs

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Normal Grief (Uncomplicated)

• Normal feelings, behaviors and reactions to loss
• Physical, emotional, cognitive and behavioral
  reactions

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Dysfunctional grief

• Unresolved grief - extended length and severity
• May result from
• ambivalence towards lost person, perceived
  need to be brave or in control, endurance of
  multiples losses, extremely high emotional value
  invested in lost person (helps bereaved avoid
  reality of loss, uncertainty about loss (missing
  in action), lack of support systems
• Inhibited grief - normal symptoms of grief
  suppressed

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Complicated Grief

• Fails to grieve
• Avoids visiting gravesite or participate in
  memorial
• Recurrently symptomatic on anniversary of death
• Persistent guilt, low self-esteem
• Continues to search for lost person
• May consider suicide
• Minor events trigger grief
• Unable to discuss the deceased with composure
• Physical symptoms similar to the deceased
• Relationships with others worsen (Kozier, 1034)

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Stages and Tasks of Grief

• Denial
• Anger
• Bargaining
• Depression
• Acceptance

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Factors Influencing the Grief Process

• Survivor personality, coping
• History of substance abuse
• Relationship to deceased
• Spiritual beliefs
• Type of death

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Grief Assessment

• Begins at time of admission or diagnosis
• Ongoing to detect complicated grief

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Grief Assessment Includes

• Type of grief
• Reactions
• Stages and tasks
• Influencing factors, general health

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Childrens Grief

• Based on developmental stages
• Can be normal or complicated
• Symptoms unique to children

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Grief Interventions

• Presence
• Identify support systems
• Access bereavement specialists
• Identify and express feelings
• Special attention to disenfranchised grief
• Public and private rituals
• Spiritual care

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Completion of the Grieving Process

• No one can predict completion
• Grief work is never completely finished
• Healing occurs when the pain is less

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Death and DyingCommunication
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Communication

• Crucial to palliative care
• Terminal illness is a family
• experience

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Communication

• Imparting necessary information
• so that individuals may make
• informed decisions
• Requires interdisciplinary
• collaboration

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Communication Process

• Patient/Family Expectations
• be honest
• non abandonment
• elicit values and goals
• team communication
• take time to listen

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Communication

• Provides for informed choices
• Offers support
• Allows verbalization of fears

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Communication

• How much patient/family want to
• know
• Initiate family meetings
• Base communication with children
• on developmental age

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Attentive Listening

• Encourage them to talk
• Be silent
• Be non-judgmental
• Avoid misunderstandings

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Attentive Listening (cont.)

• Dont change the subject
• Encourage reminiscing

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Factors Influencing Communication

• Patient/Family
• family systems
• financial/educational
• physical limitations
• coping/grief

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Factors Influencing Communication (cont.)

• Health care professionals
• communication barriers (e.g.
• fear of own mortality, fear of
• not knowing, lack of
• understanding culture)

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Breaking Bad News

• Nurses reinforce news provided by
• physicians
• Steps
• plan what to say
• establish rapport

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Steps (cont.)

• set aside time/turn off pager
• control the environment
• find out what they know/want to
• know
• use simple language
• be sensitive/respectful

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Adaptive and Maladaptive
Responses

• Cultural mores dictate what is
• adaptive or maladaptive

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Team Communication

• Intra team communication is vital
• Should occur frequently
• Documentation is key
• Conflict is expected

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Death and DyingSymptom Management
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Symptom Management Introduction

• There are many physical and
• psychological symptoms common
• at the end of life
• Ongoing assessment and
• evaluation of interventions is
• needed
• Requires interdisciplinary
• teamwork

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Introduction (cont.)

• Reimbursement concerns
• Limit diagnostic tests

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Symptoms and Suffering

• Symptoms create suffering and
• distress. Psychosocial intervention
• is key to complement
• pharmacologic strategies

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Physiologic Changes/ Symptoms

• Pain
• Dyspnea / Apnea
• Anorexia and Cachexia
• Weakness Fatigue
• Mental Status Changes
• Hypotension / Renal Failure
• Incontinence
• Anxiety
• Depression

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Key Nursing Roles

• Patient advocacy
• Assessment
• Pharm tx
• Non-Rx tx
• Pt/family teaching

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Anxiety

• Subjective feeling of apprehension
• Often without specific cause
• Categories of mild, moderate,
• severe

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Depression

• Ranges from sadness to suicidal
• Often unrecognized and
• under treated
• Occurs in 25-77 of terminally ill
• Distinguish normal vs. abnormal

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Assessment of Depression

• Situational factors
• Previous psychiatric history
• Other factors (e.g. lack of support system, pain)

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Example Questions for Depression Assessment

• How have your spirits been lately?
• What do you see in your future?
• What is the biggest problem you
• are facing?

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Suicide Assessment

• Do you think life isnt worth
• living?
• Have you thought about how you
• would kill yourself?

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Conclusion

• Multiple symptoms common
• Coordination of care with
• physicians and others
• Use drug and nondrug treatment
• Patient/family teaching and
• support

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Care Following Death

• Preparing the family
• Care after death
• Evaluate circumstances
• Organ donor procedures

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Care Following Death (cont.)

• Removal of tubes, equipment
• Bathing and dressing the body
• Positioning the body
• Respect cultural preferences

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Care Following Death (cont.)

• Removal of the body
• Rigor mortis 2-4 hrs after death
• Embalming

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Care Following Death (cont.)

• Assistance with calls, notifications
• Destroying medications
• Assisting with arrangements
• Initiating bereavement support

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Death of Children

• Encourage parents to hold child
• Siblings
• Encourage verbalization

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Conclusion

• Care of the patient and family at
• the time of death entails unique
• concerns, best provided by an
• interdisciplinary team

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Bereavement Interventions . . .

• Plan of care
• Attitude
• Cultural practices
• What to say
• Anticipatory grief

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. . . Bereavement Interventions

• Provide presence
• Active listening, touch, reassurance
• Decrease sense of loss
• Use bereavement services

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Bereavement Interventions for Children and Parents

• Recognize developmental stage
• Refer to support groups

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The Nurse Death Anxiety, Cumulative Loss, Grief

• Death anxiety
• Defenses
• Personal death awareness

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Cumulative Loss

• Succession of losses common to nurses
• May not have time to resolve losses before
  another loss occurs

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Stages of Adaptation

• Nurses new to working with the dying need support
• Stages of adaptation (Harper)
• Intellectualization
• Emotional survival
• Depression
• Emotional arrival
• Deep compassion

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Factors Influencing the Nurses Adaptation

• Professional training
• Personal death history
• Life changes
• Support system

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System of Support (Vachon)

• Balance
• Assessing formal / informal support systems
• Instructor support
• Spiritual support
• Self care and support

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Support for the Nurse

• Ask for help
• Verbalize
• Post clinical debriefing

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Conclusion

• Loss, grief and bereavement assess with ongoing
  intervention
• Nurses must recognize and respond to their own
  grief
• Interdisciplinary care