Spirituality & Loss/Death/Grief Notes

First Stage: Denial and Isolation

- "No not me, it cannot be true" - Usually influenced by delivery person/method - Throughout illness - Functions as initial buffer - Allows patient to collect him/herself - Usually temporary - Be aware of your feelings

Third stage: Bargaining

- "Now don't forget I have another child" - Maybe if I ask nicely - Helpful for brief periods of time - An attempt to postpone death - Sets self-imposed goal - Usually made with God and kept a secret - May be associated with quiet guilt - Don't brush such remarks aside

Second Stage: Anger

- "Oh yes it is me" - Anger, rage, envy, resentment replaces denial - When denial cannot be maintained - Often difficult to cope with - Displaced in all directions (mostly to closest ones. Nurses often more of a target) - Try to place yourself in the patient's position (how would you feel?)

Hospice

- Aggressive pain and symptom management and quality of life - Patient has terminal diagnosis - Prognosis 6 months or less - Not seeking curative treatment - Hospice is not a place, but a concept of care based on the promise that when medical science can no longer add days to life, more life can be added to each day.

Palliative Care

- Aggressive pain and symptom management and quality of life - Patient may or may not have terminal diagnosis - May still be seeking curative treatments - Focuses on the prevention, relief, reduction, or soothing of symptoms of the disease or disorder throughout the entire course of an illness. - Primary goal is to help patients and families achieve the best possible quality of life.

Diagnosis

- Anticipatory grieving - Compromised family coping - Death anxiety - Fear - Impaired comfort - Ineffective denial - Grieving - Complicated grieving - Risk for complicated grieving - Hopelessness - Pain (acute or chronic) - Risk for loneliness - Spiritual distress - Readiness for enhanced spiritual well-being

Diagnosis Use NANDA-I approved list

- Anxiety - Ineffective coping - Fear - Complicated grieving - Hopelessness, powerlessness - Readiness for enhanced spiritual well-being - Spiritual distress

Critical Thinking

- Apply knowledge, experience, standards, and attitudes - Personal experience in caring for patients in spiritual distress is valuable when helping patients select coping options - Each person has a unique spirituality - The Joint Commission requires health organizations to provide for pastoral care

Assess patient's viewpoints

- Ask direct questions - What do you observe - Observe what they have with them. Is it a religious object or a spiritual object? - EX: "I noticed a bible on your bedside table. Is that something that is important to your faith?"

Planning pt. 2

- Care plans for the dying patient focus on - Comfort - Preserving dignity and quality of life - Providing family members with emotional, social, and spiritual support - Give priority to a patient's most urgent physical or psychological needs while also considering his or her expectations and priorities.

Death: Medical Criteria

- Cessation of breathing - No response to deep painful stimuli - Lack of reflexes (such as the gag or corneal reflex) and spontaneous movement - Flat encephalogram (brain waves)

Components of a Good Death

- Control of symptoms - Preparation for death - Opportunity to have a sense of completion of one's life - Good relationship with health care professionals

Assessment pt 2

- Conversations about the meaning of loss to a patient often lead to other important areas of assessment: - Knowledge base - Expectations/perceptions - Patient's coping style - The nature of family relationships - Social support systems - The nature of the loss - Cultural and spiritual beliefs - Life goals - Family grief patterns - Self-care - Sources of hope

Factors Influencing Spirituality

- Developmental level (age) - Family/background Formal religion - Type of illness- acute, chronic, terminal (timeline is given) - People tend to cling to spirituality if they know death is imminent - Near-Death experience (NDE)- people who have an experience aren't afraid and have a meaning in life - Psychological phenomenon close to clinical death or recovered after declared death

Clinical Signs of Impending Death

- Difficulty talking or swallowing - Nausea, flatus, abdominal distention - Urinary and/or bowel incontinence or constipation - Loss of movement, sensation, and reflexes - Decreasing body temperature, with cold or clammy skin - Weak, slow, or irregular pulse - Decreasing blood pressure - Noisy, irregular, or Cheyne-Stokes respirations - Restlessness and/or agitation - Cooling, mottling, and cyanosis of the extremities and dependent areas

More Ethical and Legal issues

- Do Not Resuscitate (DNR) - Allow Natural Death (AND) - Comfort Measures Only - Euthanasia

Supportive healing relationship

- EX: patient asks, "Am I going to die?" Nurse says, "I don't know; doing everything we can to help you with this process" or if you know they will die "Things aren't looking too good" explain what is happening, say we are fighting for you, maybe encourage them to call their family. - Mobilize hope. - Provide interpretation of suffering that is acceptable to patient. - EX: if a patient says "Why me? Why am I suffering like this?" you must choose the most therapeutic response for that patient. But remember, you don't have the magic words. Establishing presence and physically being there for support are more important. - Help patient use resources (pastoral care).

Assessment

- Establish trusting relationship - Assess patient's viewpoints - Utilize spiritual assessment tools:

Barriers to Quality of Care at End of Life

- Failure to acknowledge limits of medicine - Lack of training for healthcare providers - Hospice/palliative care poorly understood - Denial of death

Constitutions of Good Quality Care at the End of Life

- For Healthcare Team—Providing symptom management and discussing emotional aspects of the disease - For Patients - Achieving a sense of control, attaining spiritual peace, succeeding in having finances in order, strengthening relationships with loved ones, believing their life had meaning

Ethical and Legal Issues Advance Directive

- For anyone 18 and older - Provides instructions for future treatment - Appoints a Health Care Representative - Does not guide Emergency Medical Personnel - Guides inpatient treatment decisions when made available

Physician Order for Life-Sustaining Treatment (POLST) Form

- For persons with serious illness—at any age - Provides medical orders for current treatment - Guides actions by Emergency Medical Personnel when made available - Guides inpatient treatment decisions when made available

Planning

- Goals: Spiritual care plan includes realistic and individualized goals with relevant outcomes - Setting priorities: patient identifies what is important - Collaboration: in hospital setting, pastoral care is a valuable resource

Factors influencing loss and grief

- Human development - Personal relationships - Nature of loss (was it sudden or expected?) - Coping strategies - Socioeconomic status - Culture and ethnicity - Spiritual and religious beliefs - Hope

Preparatory Depression (loss will happen soon)

- Impending loss - Do not reassure - Allow to express sorrow (to reach acceptance) - Usually in silence - Physical expression-touch, hug, stroking of hair - Just a silent sitting together goes a long way

Critical Thinking pt. 2

- Listen carefully to the patient's perceptions. - Use culture-specific understanding. - Use Clinical Standards: American Society of Pain Management Nurses' Guidelines

Grief Normal

- Looks different for everyone, hard to define - Grief can occur with loss by separation or death - Divorce, loss of body part, job, house, pet

Scientific Knowledge

- Mind, body, and spirit are interrelated - Physical and psychological well-being results from beliefs and expectations - Beliefs and convictions are powerful resources for healing

Spirituality Common to all people:

- Need for meaning and purpose - Need for love and relatedness - Need for forgiveness

Spirituality

- Nightingale- it was a force that provided energy needed to promote a healthy hospital environment - Defined as an awareness of one's inner self and a sense of connection to a higher being, nature, or some purpose greater than oneself - Important in helping patients achieve balance needed to maintain health and well-being

Use Professional Standards:

- Nursing Code of Ethics - Dying Person's Bill of Rights - ANA Scope and Standards of Hospice and Palliative Nursing

Reactive Depression (loss that happened)

- Past loss (e.g. body part) - Loss of role/ability to provide - Can reassure "look at the bright side"

Expressions of grief:

- Physical→ crying, headaches, difficulty sleeping, fatigue - Emotional→ sadness and yearning - Social→ detached from others , social isolation - Spiritual→ questioning- the reason for your loss, the purpose of pain and suffering, the purpose of life and the meaning of death

Restorative and continuing care

- Prayer - Meditation - Supportive grief work

Fourth stage: Depression

- Reactive Depression (loss that happened) - Preparatory Depression (loss will happen soon)

spiritual assessment tools:

- SWB (Spiritual Well-Being Scale) - HOPE - FICA

Spiritual Health

- Spiritual health represents a balance - Spiritual health matures with increasing awareness of meaning, purpose, and life values - Spiritual beliefs changes as patients grow and develop

Acute care

- Support systems - Diet therapies - Supporting rituals

Spirituality Now

- Technological cure oriented model (technology helps us prolong life)

Fifth stage: Acceptance

- The final rest before the long journey - Neither depressed nor angry about "fate" - Time to process - Progressed through previous stages - Should not be mistaken for a happy stage - Almost void of feelings - Circle of interest diminishes - Be intentionally present

Kubler-Ross Stages of Grief/Dying

- These stages are protective mechanisms from the identity of loss - Someone may not go through all these stages. It is not linear (no particular order)

Evaluation

- This involves an increased or restored sense of connectedness - Did patient identify spiritual beliefs that give meaning and purpose to everyday life? - Does patient have a healthy acceptance of current situation? Did patient express peaceful acceptance of limitations and failings? - Successful outcomes: patient develops an increased or restored sense of connectedness w/ family; maintains, renews, or reformed a sense of purpose in life; and exhibits confidence and trust in a supreme being or power

Implementation

- This is based on phase of care - Health promotion - Acute care - Restorative and continuing care - Implementation → Spiritual Distress

Implementation pt 2

- Using therapeutic communication - Managing symptoms - Promoting dignity and self-esteem - Ensuring a comfortable and peaceful environment - Promoting spiritual comfort and hope - Protecting against abandonment and isolation - Supporting the grieving family - Providing palliative care in acute and restorative settings - Assisting with end-of-life decision making - Providing hospice care - Facilitating mourning

Evaluation Questions to help validate achievement of patient goals and expectations:

- What is the most important thing I can do for you at this time? - Are your needs being addressed in a timely manner? - Are you getting the care for which you hoped? - Would you like me to help you in a different way? - Do you have a specific request that I have not met?

Grieving

- When caring for patients who have experienced a loss, facilitate the grief process by helping survivors feel the loss, express it, and move through their grief. - Loss comes in many forms based on the values and priorities learned within a person's sphere of influence. - The type and perception of the loss influence how a person experiences grief.

Self-care for the Nurse

- You cannot give fully engaged, compassionate care to others when you feel depleted or do not feel cared for yourself. - Frequent, intense, or prolonged exposure to grief and loss places nurses at risk for developing compassion fatigue. - Being a professional includes caring for yourself physically and emotionally. - To avoid the extremes of becoming overly involved in patients' suffering or detaching from them, nurses develop self-care strategies to maintain balance

Mourning

- actions and expressions of grief, including the symbols and ceremonies that make up outward expression of grief - Actions and expressions which is the process we incorporate the experience into our lives

Connectedness

- ask about the patient's ability to express a sense of relatedness to something greater than self - Ask "Are your beliefs important to you?"

Actual loss

- can be recognized by others EX: loss of a limb, a child, a valued object such as money, and a job

Situational loss

- experienced as a result of an unpredictable event - EX: lost your leg d/t accident; stroke

Maturational loss

- experienced as a result of natural developmental process - EX: dropping your child off at kindergarten; first born gets a sibling

RELIGIOUS CARE

- helping patients maintain faithfulness to their belief system and worship practices - EX: calling the chaplain, praying with the patient if comfortable/within hospital policy/patient requests it, etc.

SPIRITUAL CARE

- helping people identify meaning and purpose in life, look beyond the present, and maintain personal relations as well as a relationship with a higher being or life force - EX: listening to spiritual feelings/needs, providing support and hope, etc.

Spiritual Distress

- impaired ability to experience and integrate meaning/purpose in life through connectedness w/ self, others, art, music, literature, nature and or a power greater than oneself - EX: feeling abandoned by God, questioning the meaning of life, questioning or sudden doubt in one's beliefs

Perceived loss

- is felt by person but intangible to others - Not recognized by others - EX: youth, financial independence, or a valued environment Physical loss versus psychological loss

Anticipatory loss

- loss has not yet taken place - EX: cancer

Religion

- organized set of beliefs that can include spiritual practices (form of worship) - Belief in a superhuman power/creator. More commonly has a set of organized beliefs and practices that are followed usually in a community or group. - Catholic, Christian, Buddhist, Hindi, Muslim

Spirituality:

- pertains to a person's relationship with a higher power - More personal and individualized. Deals with a sense of peace and purpose. Spirituality is other than religion. - Belief that the divine is within all of us. Spirituality is a person's connection and purpose.

Bereavement

- state of grieving from loss of a loved one - Period after the loss

The Nursing Intervention Classification (NIC) nurse recommendations: 1-7

1. Observe client for self-esteem, self-worth, feelings of futility, or hopelessness. 2. Monitor client's support systems. 3. Be physically present and available to help client determine religious and spiritual needs. 4. Provide protected quiet time for meditation, prayer and relaxation. 5. Help client make a list of important and unimportant values. 6. Ask how to be most helpful, then actively listen, and seek clarification. 7. If client is comfortable with touch, hold client's hand or place hand gently on arm. Touch makes nonverbal communication more personal.

The Nursing Intervention Classification (NIC) nurse recommendations: 8-13

8. Help client develop and accomplish short-term goals and tasks. 9. Help client find a reason for living and be available for support. 10. Listen to client's feelings about death. Be non-judgmental and allow time for grieving. 11. Help client develop skills to deal with illness or lifestyle changes. Include client in planning of care. 12. Provide appropriate religious materials, artifacts or music as requested. 13. Provide privacy for client to pray with others or to be read to by members of own faith.

Health promotion

Establishing presence—involves giving attention, answering questions, having an encouraging attitude, and expressing a sense of trust; "being with" rather than "doing for"

Care after Death

Federal and state laws apply to certain events after death. - Documentation - Organ and tissue donation - Autopsy - Postmortem care

HOPE

H: Sources of Hope, meaning, comfort, strength, peace, love, and connection O: Organized religion P: Personal spirituality and practice E: Effects on medical care and end-of-life issue

Spirituality History

In early societies, many concepts of health and illness were linked with spirituality. Many of early nursing beginnings were tied to a form of religion

Spirituality 20th century

Medicine & nursing grew apart from spirituality as the focus shifted to biological and behavioral sciences

Types of grief

Normal, anticipatory, grieving

Care: Religious VS Spiritual

Patients benefit from both types of care

The Joint Commission requires health organizations to provide for pastoral care

Upon admission, ask the patient about their religion and let them know about services available

Grief

an internal emotional reaction to a loss, manifested in ways unique to an individual based on personal experiences, cultural expectations, and spiritual beliefs.

Life & self-responsibility

ask about a patient's understanding of illness limitations or threats and how the patient will adjust - Also assess life satisfaction

Faith/belief

ask about a religious source of guidance

Culture

ask about faith and belief systems to understand culture and spirituality relationships

Ritual and practice

ask about life practices used to assist in structure and support during difficult times

Fellowship and community

ask about support networks

Vocation

ask whether illness or hospitalization has altered spiritual expression

Faith

belief in something without proof

Spiritual well-being

exists when a person's universal spiritual needs are met

Spiritual Well-Being Scale

has 20 items that assess the individuals view of life and relationship with higher power

Psychological needs

patient needs control over fear of the unknown, pain, separation, leaving loved ones, loss of dignity, loss of control, unfinished business, isolation

Spiritual needs

patient needs meaning and purpose, love and relatedness, forgiveness and hope

Needs for intimacy

patient needs ways to be physically intimate that meets needs of both partners

Physiologic needs

physical needs, such as hygiene, pain control, nutritional needs