6. Loss, Death, and Grief

CASE STUDY: •Mrs. Kelly is 79 years old and is in end-stage heart disease secondary to diabetes mellitus. Her mobility has declined greatly because of shortness of breath, poor food intake, decreased strength, and lack of oxygen. She takes pain medication for severe back and joint pain and has trouble with constipation. •She is now in the intensive care unit for chest pain and congestive heart failure. •Mrs. Kelly no longer wants to be hospitalized for her medical conditions, and she wants to go home to die. Mrs. Kelly is being evaluated for home hospice care and will temporarily receive home care. •While being evaluated for home hospice, Mrs. Kelly becomes more disorientated. She is unable to swallow anything without choking. The healthcare provider suggests inserting a nasogastric feeding tube to provide nutrition. • Mr. Kelly reminds the healthcare provider that Mrs. Kelly's living will excludes feeding tubes and that they have never shared this with their daughter •Which response demonstrates that the nurse understands the underlying premise of a living will when the patients wishes are in opposition to the proposed plan? 1. "We will honor Mrs. Kelly's directives in her living will" 2. "Are you sure that this is what you really want for Mrs. Kelly" 3. "Your healthcare provider wants to do all he can to preserve life" 4. " Your daughter might not agree with your decision"

1. "We will honor Mrs. Kelly's directives in her living will"

•Jennifer notices the next day that Mrs Kelly's vital signs are : pulse 50 and thread, respirations 10 and shallow, BP 70/30, Glasgow coma scale 3 •What other physical symptom should the nurse anticipate? 1.Hyperreflexia in legs and arms 2.Increased urinary output 3.Mottling of hands and feet 4.Head turned away from light

3.

•Mrs. Kelly lives with her husband of 54 years. Her daughter, Lilly, lives near her parents and visits them every day. Lilly does not agree with the plan to begin hospice care. She cannot accept her mother's plan to "give up." •Mr. Kelly does not understand hospice and is not sure if he will be a good caregiver. •Nurse Jennifer will be caring for the Kelly family as she learns how to give care in the home. Before Jennifer meets the Kelly family for the first time, she reviews the information essential for making a thorough assessment. Jennifer worries that she will be asked questions for which she has no answer. She feels more comfortable talking about heart disease than about end-of-life decisions and care •Jennifer will ensure that Mrs. Kelly's pain is well managed before asking about her other priorities for care. Jennifer knows that many families have never given end-of-life care, so she plans to provide teaching for their priority concerns. •Jennifer asks Mr. Kelly and Lilly about any changes they see in Mrs. Kelly. They report that Mrs. Kelly has less activity tolerance, that she is able to rest with oxygen in place, and that Mrs. Kelly's family asks about her pain before Mrs. Kelly states it. •Jennifer observes family members' caregiving and level of comfort and involvement. She notes that after 1 week, Mrs. Kelly's family is more at ease with caregiving activities. •Lilly tells Jennifer she feels helpless and doesn't know what to do to make her mother comfortable. She asks Jennifer if it would be alright if a massage therapist came in and gently massaged her mothers limbs and back •How should the nurse respond to Lilly's request? 1. Ask her what purpose she thinks the massage will serve 2. Inform Lilly that she must produce the therapists credentials 3. Tell Lilly that massage therapists are welcome in hospice 4. Share with Lilly that she uses alternative therapies herself.

3. Tell Lilly that massage therapists are welcome in hospice

1. You are caring for a patient who is depressed because their only child has gone away to college. The nurse will assess this type of loss as A. actual B. perceived C. situational D. maturational

D. Maturational

2. As a first-year nursing student, you are assigned to care for a dying patient. To best prepare you for this assignment, you will want to A. complete a course on death and dying. B. control your emotions about death and dying. C. compare this experience to the death of a family member. D. develop a personal understanding of your own feelings about grief and death.

D. develop a personal understanding of your own feelings about grief and death.

What will help you better serve your patients?

Developing a personal understanding of your own feelings about grief and death •Be familiar with commonly experienced responses to loss -self reflection- how did we cope with it? realize how they feel -let patient grieve/ talk to you about it uninterrupted -be comfortable being around grieving/ dying patients

8 factors influencing loss and grief: 8

Human development Personal relationships Nature of loss Coping strategies Socioeconomic status- cant afford to take off work to grieve Culture and ethnicity Spiritual and religious beliefs Hope

Types of grief 4

Normal Anticipatory Disenfranchised (Ambiguous loss) Complicated

•Maturational loss-

a form of necessary loss, experienced as a result of natural development. Can be positive (i.e., first child experiences new sibling, stay at home mom & only child going to school.

Ambiguous loss

a type of disenfranchised GRIEF-PERSON WHO IS LOST IS PHYSICALLY PRESENT BUT NOT PHYSCHOLOGICALLY AVAILABLE dementia, Alzheimer's, brain injury, coma,

Types of loss 6

actual loss perceived loss physical/psychological loss necessary loss maturational loss situational loss

Ethical decisions at the end-of-life _______, __________, or _________

complicate grief, create family divisions or increase family uncertainty at the time of death.

•Necessary Loss-

life changes are normal, expected and often positive-change always involves a necessary loss-most necessary losses are relaced by something different or better

•Physical/psychological loss-

loss of a body part, altered self image

•Stages of grief- 5

not always linear Denial Anger Bargaining Depression Acceptance

•Actual loss-

occurs when person can no longer feel, hear, see or know a person or object. Can also be loss of body part, loss of job

End of life care can be complicated due to:

sophisticated life support technologies and multiple treatment options

Normal grief:

uncomplicated, go through the motions, acceptance is goal. Person gets to the point where they are okay.

•Perceived loss-

uniquely defined by the person experiencing the loss, intangible to others -youth, relationship with friend

•Situational loss-

unpredictable loss (i.e., traumatic injury, disease, death

Complicated grief (4 types)

• chronic- extends for a longer period • exaggerated- often exhibits self-destructive or maladaptive behavior • delayed- avoiding the full realization of the loss •Masked- interferes with normal functioning (headaches/ not sleeping)

•Asses the terminally ill patient and family wishes for end of life care and after death during assessment:

•Be present •Use active listening, silence, therapeutic touch •Use open, honest communication •Ask open-ended questions

Anticipatory grief

•Before the actual loss or death occurs-impending death (family member transferred to hospice,

Post Mortem Care

•Care of a body after death •Ensure request for organ tissue donations and /or autopsy is complete •Understand cultural aspects of care

Post Mortem care of the body can be delegated:

•Elevate head of bed •Collect any needed specimens •Ask if family would like to participate •Notify spiritual advisor, bereavement counselor •Remove all tubes and indwelling lines •Bathe body •Position body for family viewing •After family have left prepare body in shroud

•Organizations that assist in end-of-life care 4 (how much meds to give?)

•End-of-Life Nursing Consortium (ELNEC) •American Nurses Association (ANA) •American Society of Pain Management Nurses •American Association of Critical Care Nurses

Signs of impending death include: 8

•Increased periods of sleeping/unresponsiveness •Mottling-circulatory changes •Bowel and bladder incontinence •Restlessnes, confusion •Picking, reaching •Altered breathing pattern •Congestion/increased pulmonary secretions •Decreased urinary output

Theories of Grief and Mourning

•Knowledge of grieving theories assists you in how to help a grieving person •Support the complexity and individuality of grief responses

•Advanced Directives allow pt. to state in advance choices for health care in certain situations. Two types:

•Living will (ex: do not want any artificial tubes) •Durable Power of Attorney (sign over when in sound mind- give someone power to make end of life decisions) State in advance

•DNR and No Code Orders

•No attempt to resuscitate in the event of cardio-pulmonary arrest •Nurses must be aware of pt. code status family might have conflicting views / opinions about family member

•Disenfranchised Grief

•Not socially sanctioned-cannot be shared openly -celebrity dies and youre sad, even though you didnt know them

•Palliative Care focus

•Not solely for the dying •Primary goal is achieving best quality of life. •Appropriate for any age, any advanced or chronic illness, any time, any setting. Can be used in conjunction with curative treatments achieving the best quality of life, reduce pain, make comfortable if given bad news/ have incurable disease

•Professional standards to consider when helping patient deal with loss 3

•Nursing code of Ethics •Dying persons bill of rights** •ANA scope and standards of Hospice and Palliative Nursing

Define loss

•Occurs when a valued person, object or situation is changed or made inaccessible so that the value is diminished or removed •Each person responds to loss differently •Previous experience of loss effects response to new loss

Promoting Comfort with Symptom Management of:

•Pain •Skin discomfort •Secretions •Nausea •Ineffective breathing patterns •Anxiety •Constipation •Cheilosis and stomatitis

Implementation: Health Promotion

•Use therapeutic communication (Helps earn trust- )Use open-ended questions •Provide psychological care •Promote dignity and self-esteem •Assist with end-of-life decision making (Support and educate patients and families as they identify, contemplate, and decide the best journey to the end of life) •Facilitate mourning (Provide bereavement care) •Care after death (Ensure respect for the body) •Promote spiritual comfort and hope •Maintain a comfortable and peaceful environment •Protect against abandonment and isolation •Support the grieving family •Manage symptoms

Hospice-

•a philosophy of care for terminally ill patients with less than 6 months to live •Care at home, hospital, nursing home, in patient hospice setting •Individualized care at the end of life •Manage pain, provide comfort •Life saving treatments stopped •Patient goals are mutually set

Define grief:

•is a normal but bewildering cluster of ordinary human emotions arising in response to a significant loss, intensified and complicated by the relationship to the person or the object lost. -human emotions in response to loss