LOSS, GRIEF, DYING

Hospice Care

"Hospitality" • Palliative Care vs Hospice • Team Approach to Care • Focus: Quality of Life

Evaluation

*Evaluating effectiveness of nursing care is difficult *Criteria for evaluation is based on goals *If outcomes not achieved-explore reason why

Factors that Influence Grief

Age Significance of the loss Culture Spiritual beliefs Gender Socioeconomic status Support systems Cause of loss or death

Mourning

Behavior after the death of a significant other, which varies among cultures

Postmortem Care

Changes in body tissues Coroner's cases

Meeting the Physiological Needs of the Dying

Hygiene Controlling pain Relieving respiratory difficulties Assisting with movement Nutrition Hydration Elimination

Care of Body After Family Viewing

Leave client ID band in place Body wrapped in shroud Handle body with dignity!

Evaluation

Listening to client's report of feeling in control of the environment surrounding death Observing client's relationship with significant others Listening to client's thoughts on powerlessness and hopelessness

Planning: Goals for Dying Clients

Maintaining physiological & psychological comfort Achieving a dignified & peaceful death, which includes maintaining personal control & accepting declining health status Dying Person's Bill of Rights is a useful guide

Implementation

Minimize loneliness, fear & depression Maintain the client's sense of security, self-confidence, dignity & self worth Help client accept loss Provide physical comfort

Planning

Promote Trust- show empathy & respect Assist in Labeling Feelings- help client to identify feelings Encourage- review of relationship with the deceased, participation in grief counseling & usual spiritual practices Offer Support and Reassurance- redirect emotional energy

Impementation

Provide Physical Comfort maintain privacy and dignity explore personal values Communicate Effectively listen attentively utilize paraphrasing, reflecting and summarizing

Postmortem Terminology

Rigor mortis - the stiffening of the body 2-4 hours after death Algor mortis-is the gradual decrease of body temperature after death Livor mortis-discoloration of skin in the lowermost dependent areas of body

dysfunctional grief

dysfunctional grief: Grief that falls outside normal parameters; may manifest as absence of, delayed, exaggerated, or prolonged grief

Support Groups

*Grief Recovery Institute: http://www.grief-recovery.com *Partnership for Caring: America's voice for the dying: http://www.partnershipforcaring.org *AARP: End -of -Life Issues: http://www.aarp.org/endoflife *Compassionate Friends: Death of a child, sibling or grandchild: http://www.compassionatefriends.org *Promoting Excellence in End-of-Life Care: http://www.promotingexcellence.org *Palliative Care Nursing: http://palliativecarenursing.net

Death Related Religious and Cultural Practices

*Help people to cope *Beliefs and attitudes about death *Beliefs about body preparation *Death related rituals

Spiritual Support

*Not all clients have a specific religious faith, but most have a need for meaning in their lives, especially with a terminal illness *Nurses need to attend to the client's spiritual care -direct intervention or arranging for access to individuals who can *Be aware of your own comfort level, do not impose your personal beliefs on another *Communication skills important -develops trust & sense of caring *Specific interventions-prayer, facilitating expressions of feeling, meditation, reading & discussion with clergy or spiritual adviser

Family Support

*Provide support to family *Nurse as teacher *Encourage family involvement with care *Okay for family to encourage client to die

Providing Emotional Support

*Use silence and personal presence *Acknowledge grief *Offer choices that promote autonomy *Community Resources *Suggest additional resources

Types of Grief Responses

Abbreviated Grief: Brief but genuinely felt Anticipatory Grief: Experienced in advance of the event Disenfranchised Grief: Grief that cannot be acknowledged to others Complicated Grief: Unhealthy or pathologic

End of Life Care Issues

Advanced Health Care Directives Living Will-client's dying wishes for treatment Durable Power of Attorney for Healthcare Health Care Proxy-who can speak for the client when unable to express their wishes Physician Orders for Life-Sustaining Treatment (POLST)-signed by both client or health care decision maker and PCP

End of Life Care Issues

Assisted suicide Euthanasia Do-not-resuscitate orders (NO CODE) Comfort Measures Only Terminal weaning Death certificate Organ donation Autopsy

Organ Donation

CORE Organs suitable for donation include: heart kidney pancreas lungs liver intestines

Attitudes of Nurses

Changing subject Offering false reassurance Denying what's happening Blocking discussion Being distant/aloof Making client feel dependent

Planning

Client Knowledge-client's understanding of implications of loss Self care abilities- skill in caring for self. Current coping-what's their stage in grieving process. Current manifestations of grief process-adaptive or maladaptive s/s Role expectations- client's perception of need to return to work or family roles Family Knowledge- family members perception of loss Support people's availability & skills- how sensitive are support persons to grieving client. Role expectations- family's perception of client's need to return to work & family roles Community Resources- knowledge & availability of local support groups & resources for grief assistance

States of Awareness

Closed awareness- client not aware of impending death Mutual pretense-all involved know the prognosis but do not talk about it Open awareness- all involved know about impending death and feel comfortable discussing it

Concept of Comfort

Comfort has been defined by some as "giving strength or hope" to those in need and "easing the grief or trouble of" others (Merriam-Webster, 2003). In 2003, Katharine Kolcaba, stated comfort is "the immediate experience of being strengthened by having needs for relief, ease, and transcendence met in four contexts (physical, psychospiritual, sociocultural, and environmental); much more than the absence of pain." Clients achieve relief when their needs are met. Physical comfort is related to bodily sensations and homeostatic mechanisms. Psychospiritual comfort is related to individual awareness of oneself and one's relationship to a higher being. Sociocultural comfort is related to family and societal relationships. Environmental comfort is related to the external surroundings. Increased comfort, reduced stress, and a healing environment are linked to increased client satisfaction and shorter hospital stays. Providing a healing environment in which stressors are reduced through adequate comfort measures allows clients to maintain normal vital signs, receive adequate sleep-rest and nutrition and feel a sense of control over their healing process. I. Definition A. Physiology Review II. Alterations to Comfort A. Concepts Related to Comfort 1. Pain 2. End-of-life care 3. Sleep and Rest Disorders B. Genetic Considerations and Non-modifiable Risk Factors 1. Gender 2. Environment and support system III. Prevention IV. Nursing Process A. Nursing assessment B. Lifespan and Cultural Considerations 1. Ethnic and cultural values 2. Developmental stage C. Clinical Manifestations D. Caring Interventions and Therapies 1. Independent implementation 2. Psychosocial well-being 3. Relaxation therapy 4. Sleep hygiene 5. Pharmacological therapies a. Pain b. Sleep 6. Collaborative Plan a. Diagnostic tests/studies b. Non-pharmacological therapies c. Complementary and Alternative Medicine d. Cultural and Religious Considerations e. Across the Lifespan 7. Evaluation

KUBLER-ROSS STAGES OF GRIEF

DENIAL- person denies reality of situation Nursing Response: support but do not reinforce the denial ANGER- family or client may direct anger at staff Nursing Response: help client understand anger is a normal response to feelings of loss and powerlessness BARGAINING- bargains to avoid loss Nursing Response: listen to client, encourage talking to help relieve guilt & irrational fear, offer spiritual support if appropriate DEPRESSION- grieves over what has happened & what cannot be, may talk freely or withdrawal Nursing Response: allow client to express sadness, sit quietly, non-verbally convey caring with touch ACCEPTANCE- comes to terms with the loss Nursing Response: help family/friends understand client's decreased need to socialize

Loss

Experience of parting with an object, person, belief, or relationship that one values and the sadness that follows the loss requires a reorganization of one or more aspects of the person's life

hospice

Family-focused health service that provides care for terminally ill patients

Grief, Bereavement and Mourning

Grief: Normal response to the emotional experience related to loss Bereavement: Subjective response experienced by surviving loved ones Mourning: Behavioral process through which grief is eventually resolved or altered

Defining Characteristics for Nursing Diagnosis

Grieving Fear Hopelessness Powerlessness

Nursing Diagnosis

Grieving: a normal complex process Complicated/Risk for Complicated Grieving: experience of distress accompanying bereavement fails to follow normal expectations Interrupted Family Processes: loss has negative affect on family roles and interactions Risk-Prone Health Behavior: difficulty placing loss in appropriate perspective Risk for Loneliness: loss of relationships with others

STAGES OF GRIEVING

Kubler Ross's Stages of Grieving Denial, Anger, Bargaining, Depression, Acceptance (table 43-1 Kozier) Engel's Stages of Grieving Shock & disbelief, Developing awareness, Restitution, Resolving the loss, Idealization, Outcome (table 43-2 Kozier) Sander's Phases of Bereavement Shock, Awareness of loss, Conservation/withdrawal, Healing, Renewal (table 43-3 Kozier) Martocchio's Clusters of Grief Shock & disbelief, Yearning & protest, Anguish, Disorganization, Despair

Signs of Impending Death

Loss of muscle tone Slowing circulation Changes in respiratory status Sensory impairment ***(LAST TO GO!)

What is Loss?

Loss: When a valued person, object or situation is changed or made inaccessible Actual loss Perceived loss Physical loss Psychological loss Anticipatory loss

Nursing Assessment in Grieving

Nursing History- previous losses, past coping Assessment of Personal Coping Resources- beliefs Physical Assessment- general health status

anticipatory grief

Pattern of psychological and physiologic responses a person makes to the impending loss (real or imagined) of a significant person, object, belief, or relationship

Preparation of the Body for Family

Place body in supine position Place one pillow under the head and shoulders Close the eyelids and the mouth Wash any soiled/bloody areas Place pad beneath buttocks Place a clean gown on client Cover with clean linens

grief

Psychological and physiologic response after the loss of a significant person, object, belief, or relationship

NANDA Nursing Diagnoses

Risk for Caregiver Role Strain-responsibilities for providing physical, economic, psychological & social support to a dying person causes extreme stress for the provider. Interrupted Family Processes- unable to meet physical, emotional or spiritual needs of family members.

Palliative care

Specialized care for people with serious illness that emphasizes symptom management and improved quality of life

Definitions of Death

Traditional clinical signs of death included cessation of the apical pulse, respirations and blood pressure (isoelectric=flat line) (EEG-electroenchaphalogram)- measuring brain waves Hypothermia can mimic brain death since coldness preserves and warms body up Today, identifying death more difficult Cerebral Death

Forms of Complicated Grief

Unresolved or Chronic Grief: Grief extended in length and severity Inhibited Grief: Normal symptoms of grief are suppressed Delayed Grief: Feelings are purposely or subconsciously suppressed Exaggerated Grief: Participating in dangerous activities to lessen the pain

Techniques to Prevent Burn-Out

Use stress reduction techniques Proper eating & exercise routines Regular sleep Recognize effects of stressors b4 burnout sets Spend time with family & friends Accept support from colleagues Humor in the workplace

NCLEX #3 The shift changed while the nursing staff was waiting for the adult children of a deceased client to arrive. The oncoming nurse has never met the family. Which of the following greetings is most appropriate? a. "I'm very sorry for your loss." b. "I'll take you in to view the body." c. "I didn't know your father but I am sure he was a wonderful person." d. "How long will you want to stay with your father?"

a. "I'm very sorry for your loss."

The dying client and family have many interrelated psychosocial and physical care needs. Which ones can the nurse manage with the client and family (select all that apply)? a. Anxiety b. Fear of pain c. The dying process d. Care being provided e. Anger toward the nurse f. Feeling powerless and hopeless

a. Anxiety b. Fear of pain c. The dying process d. Care being provided e. Anger toward the nurse f. Feeling powerless and hopeless

The children caregivers of an older client whose death is imminent have not left the bedside for the past 36 hours. In the nurse's assessment of the family, what findings indicate the potential for an abnormal grief reaction to occur (select all that apply)? a. Family cannot express their feelings to one another. b. Dying client is becoming more restless and agitated. c. A family member is going through a difficult divorce. d. Family talks with and reassures the client at frequent intervals. e. Siblings who were estranged from each other have now reunited.

a. Family cannot express their feelings to one another. c. A family member is going through a difficult divorce

A terminally ill man tells the nurse, "I have never believed there is a God or an afterlife, but now it is too terrible to imagine that I will not exist. Why was I here in the first place?" What does this comment help the nurse recognize about the client's needs? a. He is experiencing spiritual distress. b. This man most likely will not have a peaceful death. c. He needs to be reassured that his feelings are normal. d. This client should be referred to a clergyman for a discussion of his beliefs.

a. He is experiencing spiritual distress.

A 20 year-old client with a massive head injury is on life support, including a ventilator to maintain respirations. What three criteria for brain death are necessary to discontinue life support? a. apnea b. coma c. absent brainstem reflexes

a. coma b. apnea c. absent brainstem reflexes

The home health nurse visits a 40-year-old client with metastatic breast cancer who is receiving palliative care. The client is experiencing pain at a level of 7 (0-10 point scale). In prioritizing activities for the visit, what should the nurse do first? a. Auscultate for breath sounds. b. Administer PRN pain medication. c. Check pressure points for skin breakdown. d. Ask family about client's food and fluid intake.

b. Administer PRN pain medication.

A 67-year-old woman was recently diagnosed with inoperable pancreatic cancer. Before the diagnosis she was very active in her neighborhood association. Her husband is concerned because his wife is staying at home and missing her usual community activities. Which common end of life psychological manifestation is she most likely demonstrating? a. Peacefulness b. Decreased socialization c. Decreased decision making d. Anxiety about unfinished business

b. Decreased socialization

While caring for his dying wife, the husband states that his wife is a devout Roman Catholic but he is a Baptist. Who is considered the most reliable source for spiritual preferences concerning end of life care for the dying wife? a. A priest b. Dying wife c. Hospice staff d. Husband of dying wife

b. Dying wife

NCLEX #5 A client's family tells the nurse that their culture does not permit a dead person to be left alone before burial. Hospital policy states that the body should be taken to the morgue until the funeral director can come for the body. How would the nurse best manage this situation? a. Gently explain the policy to the family and then implement it. b. Inquire of the nursing supervisor how an exception to the policy could be made. c. Call the client's primary care provider for advice. d. Move the deceased to an empty room and assign an aide to stay with the body. 5

b. Inquire of the nursing supervisor how an exception to the policy could be made.

A client with end-stage liver failure tells the nurse, "If I can just live to see my first grandchild who is expected in 5 months, then I can die happy." The nurse recognizes that the client is demonstrating which stage of grieving? a. Prolonged grief disorder b. Kubler-Ross's stage of bargaining c. Kubler-Ross's stage of depression d. The new normal stage of the Grief Wheel

b. Kubler-Ross's stage of bargaining

A client is receiving care to manage symptoms of a terminal illness when the disease no longer responds to treatment. What is this type of care known as? a. Terminal care b. Palliative care c. Hospice care d. Supportive care

b. Palliative care

A terminally ill client is unresponsive and has cold, clammy skin with mottling on the extremities. The client's husband and two grown children are arguing at the bedside about where the client's funeral should be held. What should the nurse do first? a. Ask the family members to leave the room if they are going to argue. b. Take the family members aside and explain that the client may be able to hear them. c. Tell the family members that this decision is premature because the client has not yet died. d. Remind the family that this should be the client's decision and to ask her if she regains consciousness.

b. Take the family members aside and explain that the client may be able to hear them.

NCLEX #2 Kubler-Ross's five successive stages of death and dying are: a. Anger, bargaining, denial, depression, acceptance b. Denial, anger, depression, bargaining, acceptance c. Denial, anger, bargaining, depression, acceptance d. Bargaining, denial, anger, depression, acceptance

c. Denial, anger, bargaining, depression, acceptance

NCLEX #1 Nurses and other health care providers often have difficulty helping a terminally ill client through the necessary stages leading to acceptance of death. Which of the following strategies is most helpful to the nurse in achieving this goal? a. Taking psychology courses related to gerontology b. Reading books and other literature on the subject of thanatology c. Reflecting on the significance of death d. Reviewing varying cultural beliefs and practices related to death

c. Reflecting on the significance of death

NCLEX #4 Which of the following symptoms is the best indicator of imminent death? a. Increased blood pressure b. Decreased muscle tone c. Slow, weak pulse d. Normal respirations

c. Slow, weak pulse

The family attorney informed a client's adult children and wife that the client did not have an advance directive after he suffered a serious stroke. Who is responsible for making the decision about end of life measures when the client cannot communicate his or her specific wishes? a. Notary and attorney b. Physician and family c. Wife and adult children d. Physician and nursing staff

c. Wife and adult children

A deathly ill client from a culture different than the nurse's is admitted. Which question is appropriate to help the nurse provide culturally competent care? a. "If you die, will you want an autopsy?" b. "Are you interested in learning about palliative or hospice care?" c. "Do you have any preferences for what happens if you are dying?" d. "Tell me about your expectations of care during this hospitalization."

d. "Tell me about your expectations of care during this hospitalization."

End-of-life palliative nursing care involves a. constant assessment for changes in physiologic functioning. b. administering large doses of analgesics to keep the client sedated. c. providing as little physical care as possible to prevent disturbing the client. d. Encouraging the patient and family members to verbalize their feelings of sadness, loss and forgiveness.

d. Encouraging the patient and family members to verbalize their feelings of sadness, loss and forgiveness.

The primary purpose of hospice is to a. allow clients to die at home. b. provide better quality of care than the family can. c. coordinate care for dying clients and their families. d. provide comfort and support for dying clients and their families.

d. provide comfort and support for dying clients and their families.

Death & Dying

death: Cessation of heart-lung function, or of whole-brain function, or of higher-brain function dying: End-of-life process in which the lungs become less efficient for gas diffusion and oxygenation, the heart and blood vessels become inadequate to maintain circulation and to perfuse tissues, and the brain ceases to regulate vital centers

Facilitating Grief Work

★Explore and respect client and family ★Teach client and family what to expect ★Encourage client to express and share feelings ★Teach family members to encourage expression of grief ★Encourage client to resume activities