Loss, Grief, and Dying - Exam #4

Although the dying process is unique to each person, there are similar phases and experiences that people go through. List in order these phases of the active dying stage of a person dying of a serious illness. -Diminished respirations and changes in breathing pattern - increased energy and mental awareness - decreased circulatory function - withdrawal from others - death

- EARLY STAGES - Withdrawal from others - decreased circulatory function *accompanied by pallor and fatigue HOURS OR DAYS BEFORE DEATH: - Increased energy and mental awareness FINAL STAGES: - diminished respirations and changes in breathing pattern - death

Suzie, the nurse performing the grief and loss assessment on Philip, feels very uncomfortable asking personal questions. What could be some reasons for this response? Select all that apply. Fear of expressing emotion Unresolved personal grief issues Caring too much Fear of her own mortality Relating too much to his situation

Fear of expressing emotion Unresolved personal grief issues Caring too much Fear of her own mortality Relating too much to his situation

A year after Emma's death, Philip is still unable to return to work. His mother has moved in to care for the twins and Philip feels depressed and withdrawn. What type of grief is Philip experiencing? Chronic grief Masked grief Delayed grief Disenfranchised grief Anticipatory grief

Chronic grief Masked grief Delayed grief Disenfranchised grief Anticipatory grief

Which condition is the result of loss of higher cerebral function? Coma Brain death Anticipatory grief Persistent vegetative state

Coma Brain death Anticipatory grief Persistent vegetative state (occurs when all higher cerebral function is lost, including all awareness of the persons environment)

How should a nurse behave in the presence of a client who is dying? Communicate as though the client can still hear and understand everything being said. Converse about the client to family members in the client's presence, since the client is unresponsive. Avoid speaking altogether when providing care for a dying client. Speak in a very loud voice, since dying clients experience hearing loss.

Communicate as though the client can still hear and understand everything being said. Converse about the client to family members in the client's presence, since the client is unresponsive. Avoid speaking altogether when providing care for a dying client. Speak in a very loud voice, since dying clients experience hearing loss.

A nurse is caring for a client who is in the dying process. He has been ill and bedridden for over a year. His wife has previously been showing signs of grief and loss, but she is now behaving in a detached manner. The nurse knows this is which type of grief reaction? Complicated grief Chronic grief Anticipatory grief Delayed grief

Complicated grief Chronic grief Anticipatory grief Delayed grief

When Alexia was 17 years old, she lost her mother. She put all her energy into caring for her three younger siblings. Two years after her mom's death, a casual acquaintance was killed in a car accident. She tells the nurse, "I had a harder time with that than I did with my mom's death." What could Alexia be experiencing? Delayed grief Chronic grief Disenfranchised grief Masked grief

Delayed grief Chronic grief Disenfranchised grief Masked grief

Describe the Kubler Ross stages of grief (SLO 4, 5) pg 340

Denial, Anger, Bargaining, Depression, Acceptance

Which are effective ways of working through grief? Select all that apply. Recalling memories Trying to find distractions Facilitating life review Bibliotherapy Expressing feelings

Recalling memories Trying to find distractions Facilitating life review Bibliotherapy Expressing feelings

Which are appropriate questions a nurse could ask to help establish a client's goals at end of life? Select all that apply. "What is your pain goal, on a scale of 0-10?" "Whom would you like to have in the room with you?" "What would you do to prevent dying?" "Is there anything you would still like to do?" "Why do you think you got this illness?"

"What is your pain goal, on a scale of 0-10?" "Whom would you like to have in the room with you?" "What would you do to prevent dying?" "Is there anything you would still like to do?" "Why do you think you got this illness?"

Which scenario puts a person at highest risk for experiencing complicated grief? Age over 65 Deep spiritual belief Several losses in a short period of time Strong significance attached to the loss

Age over 65 Deep spiritual belief Several losses in a short period of time Strong significance attached to the loss

Compare and contrast the different types of loss (SLO 5) Page 338 -Actual vs Perceived Loss: -Physical Loss vs Psychological Loss: -External vs Internal Loss: -Loss of Aspects of Self: -Environmental Loss: -Loss of Significant Relationships:

Actual Versus Perceived Loss. ■ Actual loss includes the death of a loved one (or relationship), theft, deterioration, destruction, and natural disaster. The loss can be identified by others, not just by the person experiencing it (e.g., hair loss during chemotherapy). ■ Perceived loss is internal; it is identified only by the person experiencing it (e.g., a woman diagnosed with a sexually transmitted infection may perceive herself as having lost her purity). Physical Loss Versus Psychological Loss. ■ Physical loss includes (1) injuries (e.g., when a limb is amputated), (2) removal of an organ (e.g., hysterectomy), and (3) loss of function (e.g., loss of mobility). ■ Psychological losses challenge our belief system. Also known as perceived losses, they are commonly seen in the areas of sexuality, control, fairness, meaning, and trust. ■ Some losses may be mixed. For example, after removal of a prostate gland, a man may feel both the physical and psychological loss of sexuality. External Versus Internal Loss. ■ External losses are actual losses of objects that are important to the person because of their cost or sentimental value (e.g., jewelry, a home). These losses can be brought about by theft, destruction, or disasters such as floods and fire. ■ Internal loss is another term for perceived or psychological loss. Loss of Aspects of Self: These losses include physical losses such as body organs, limbs, body functions, and/or body disfigurement. Psychological and perceived losses in this category include aspects of one's personality, developmental change (as in the aging process), loss of hopes and dreams, and loss of faith. Environmental Loss involves a change in the familiar, even if the change is perceived as positive. Examples include moving to a new home, getting a new job, and going to college. These losses can be perceived or actual. Loss of Significant Relationships includes, but is not limited to, actual loss of spouses, siblings, family members, or significant others through death, divorce, or separation (e.g., military deployment).

Fred just found out his wife was killed in a car accident. He visits his priest and says, "I told God that I would go to church every day for the rest of my life if He would just bring my wife back." What stage of dying and grief is Fred experiencing? Anger Bargaining Depression Denial

Anger Bargaining Depression Denial

After Philip gets over the initial shock of the situation, which Kübler-Ross stage of grief is he most likely to experience next? Denial Anger Bargaining Depression Acceptance

Denial Anger Bargaining Depression Acceptance

Which are stages of grief as defined by Elisabeth Kübler-Ross? Select all that apply. Depression Acceptance Fear Denial Frustration

Depression Acceptance Fear Denial Frustration (Denial, Anger, Bargaining, Depression, Acceptance)

As the family discusses with the healthcare team the possibility of removing Emma from life support, what questions should be considered before a decision is made? Select all that apply. Does Emma have an advance directive? What do Emma's parents want? Who is the healthcare proxy? Who will raise the children? What would Emma want?

Does Emma have an advance directive? What do Emma's parents want? Who is the healthcare proxy? Who will raise the children? What would Emma want?

Emma's care is transferred to hospice and the family prepares for her eventual death. What advantages would this provide? Select all that apply. Emma will receive holistic care. Visitation from family and friends will be unlimited. Support for Philip will be available. The twins will be able to stay with their mom. Support groups will continue after Emma dies.

Emma will receive holistic care. Visitation from family and friends will be unlimited. Support for Philip will be available. The twins will be able to stay with their mom. Support groups will continue after Emma dies.

Differentiate end of life care, hospice care, and palliative care (SLO 5)

End of life care includes three situations: the patient has a fatal condition; death is likely with the next exacerbation of disease; the patient acknowledges the seriousness of the situation. End of life care includes palliative care and hospice care, which are similar in that both may involve caring for dying patients, and neither focus on cure. There are subtle differences. Palliative Care: When patients reach a stage in their illness in which a cure is no longer possible, or when they refuse further treatment, they may be eligible to receive "comfort care" - meaning that no further efforts will be made to stop the disease process or prevent the patient from dying. However, the patient will receive treatment to minimize unpleasant symptoms (nausea, pain). It is aggressively planned comfort care. (addresses end of life concerns that include supporting families and caregivers, promoting continuing of care, ensuing respect for persons, addressing emotional and spiritual concerns, managing symptoms, an ensuring informed decision making. A patient does not have to be "actively" dying to receive this care. Kayla, "focuses on providing comfort care and symptom relief, without further efforts to stop the disease process or prevent death," Hospice Care Focuses on holistic care of patients who are dying or debilitated and not expected to improve. Unlike Palliative Care, for a pt to be eligible for hospice insurance benefits, a provider must certify that the patient is likely to die within 6 months. Kayla, "a movement and an approach to allow terminally ill person to face death with dignity and surrounded by the comfort of their home and family,"

Which types of loss describe loss of something tangible? Select all that apply. External loss Physical loss Loss of relationship Perceived loss Environmental loss

External loss (the loss of something of sentimental or monetary value) Physical loss Loss of relationship Perceived loss Environmental loss

The healthcare providers said that Emma has experienced brain death. What does that mean for her physical functions? Select all that apply. Her heart is beating without artificial means. Breathing requires a ventilator. Cognitive functioning is intact. A pacemaker has been placed to keep her heart beating. She can grimace and cry.

Her heart is beating without artificial means. Breathing requires a ventilator. Cognitive functioning is intact. A pacemaker has been placed to keep her heart beating. She can grimace and cry. (Heart-lung death is defined by the irreversible cessation of blood flow and breathing. Evaluating brain death is a little more complicated. The level of brain function varies depending on the involvement of the brain stem. If there is brainstem involvement, the body cannot sustain normal functions such as temperature control and breathing without artificial means. A higher-brain death involves the impairment of cognitive functioning, consciousness, memory, and reasoning, placing a person in a persistent vegetative state).

Philip and Emma are a young married couple expecting twins. They have spent years trying to conceive and were finally able to do so with artificial insemination. Both babies, a boy and a girl, were born small but healthy. The night after delivery, Emma suffers a significant brain hemorrhage and is placed on life support. In the next few days, her family is told she is brain dead and only being kept alive by the machines. They are asked to consider withdrawing life support, allowing her to die.What factors will impact Philip's grieving process? Select all that apply. His attachment to his wife Support of family and friends Previous experiences with loss Cost of the hospitalization Spiritual beliefs

His attachment to his wife Support of family and friends Previous experiences with loss Cost of the hospitalization Spiritual beliefs

The decision is made to withdraw life support from Emma and she is changed to "DNAR" status. What does this designation mean for the healthcare team? If she stops breathing, she will be given oxygen. If she cardiac arrests, no action will be taken. Cardiopulmonary resuscitation may be initiated. The family will decide what actions will be taken. She will be transferred to hospice care.

If she stops breathing, she will be given oxygen. If she cardiac arrests, no action will be taken. Cardiopulmonary resuscitation may be initiated. The family will decide what actions will be taken. She will be transferred to hospice care.

Which of the following may cause grief and loss? Select all that apply. Loss of a pet Inability to have children Demotion of a job position Losing a political office Amputation of a toe

Loss of a pet Inability to have children Demotion of a job position Losing a political office Amputation of a toe

Philip's mom convinces him to seek assistance from his family practitioner for his behavior changes. What should the nurse include in the assessment of grief and loss? Select all that apply. Nutritional intake and weight Emotional feelings of helplessness and depression Behaviors of forgetfulness and crying Changes in sleep patterns Willingness to become more socially active

Nutritional intake and weight Emotional feelings of helplessness and depression Behaviors of forgetfulness and crying Changes in sleep patterns Willingness to become more socially active

Create a timeline of the dying process, including the physiological signs and symptoms common to each stage (SLO 2, 3, 4)

One to Three Months Before Death The dying person begins to withdraw from the world and people. Sleep increases; it becomes difficult for the body to digest food, especially meats; and appetite and food intake decrease. Liquids are preferred. Anorexia and the resulting ketosis may be protective, as they can diminish pain and increase the person's sense of well-being. One to Two Weeks Before Death A host of physical changes indicates the body is beginning to lose its ability to maintain itself. Cardiovascular deterioration brings reduced blood pressure, changes in pulse and skin color (e.g., a yellowish pallor), and extreme pallor of the extremities. Temperature fluctuates and perspiration increases. Respiratory rate may increase or decrease; during sleep, the dying person may experience brief periods of apnea. Congestion may cause a rattling sound and/or a nonproductive cough. Days to Hours Before Death Often a surge of energy brings mental clarity and a desire to eat and talk with family members. However, as death approaches, patients tend to become dehydrated and have difficulty swallowing, which results in decreased blood volume. The tissues of the tongue and soft palate sag, and the gag reflex declines, so secretions accumulate in the oropharynx and/or bronchi. Often the mucous membranes become dry and tacky and lips become cracked. Dehydration during the last hours of dying is thought not to cause distress and perhaps to stimulate endorphin release (Emanuel, Ferris, von Gunten, et al., 2015; McGinley, 2014). ■ Respirations—Breathing may be shallow, rapid, or irregular: Periods of apnea may lengthen to 10 to 30 seconds before breathing resumes. ■ Congestion causes a "death rattle" that can be quite loud. ■ Cheyne-Stokes respirations may occur. This is a cyclic pattern consisting of a 10- to 60-second period of apnea and then a gradual increase in depth and rate of respirations. Respirations gradually become slow and shallow, and then the cycle begins again with apnea. ■ Peripheral circulation decreases, and the person perspires and feels "clammy." ■ Blood pressure decreases; pulse may be hard to detect. ■ Extremities become cool and mottled; the underside of the body may be much darker. ■ Decreased circulation also results in reduced kidney function and decreased urinary output. ■ Elimination—As peristalsis slows, the patient may retain feces. Urine output decreases and urine often becomes more concentrated and foul smelling. Sphincters relax, and bowel and bladder incontinence can occur. ■ Muscles throughout the body relax, causing the face to "droop." ■ Vision blurs; the eyes may be open or partially open but unseeing. Instead, the patient may see things that are not visible to others. ■ Cognition—In the final hours of life, many patients become restless and agitated. This response may be caused by medications, liver failure, cerebral hypoxia, renal failure, stool impaction, distended bladder, increased pain, or unresolved emotional or spiritual issues. Near to the time of death, some people unexpectedly become more coherent and energized for a time. Others become less communicative, quiet, and withdrawn (Emanuel, Ferris, von Gunten, et al., 2015; Scott, 2016). Fatigue is common. Moments Before Death The dying person does not respond to touch or sound and cannot be awakened. Typically, there is a short series of long-spaced breaths before breathing ceases entirely and the heart stops beating (National Caregiver Library, n.d.; Scott, 2016).

A nurse is caring for a 22-year-old who has lost his or her leg due to a motor vehicle crash. The client is very withdrawn and is not interested in pursuing physical therapy. The client says, "What's the point? I will never have a normal life now." The nurse knows the client is experiencing which type of loss? Perceived loss Environmental loss External loss Physical loss

Perceived loss Environmental loss External loss Physical loss

Which healthcare team members are involved in hospice care? Select all that apply. Phlebotomists Therapists Dietitians Social workers Clergy

Phlebotomists Therapists Dietitians Social workers Clergy

Identify the role of the nurse in post-mortem care and the care of the grieving client (SLO 1, 5)

Postmortem care includes care of the patient's body after death and fulfilling any legal obligations, such as arranging transportation to the morgue or funeral home and determining the disposition of the patient's belongings. You will follow agency policies and respect cultural and spiritual preferences, along with the care that is commonly provided. In most states, the provider must pronounce death; in some areas, however, a coroner or a nurse may also perform this task. Other roles: Providing grief eduction; Help children deal with loss (pg 360); taking care of yourself.

Which are the main premises of hospice care? Select all that apply. Quality of life is as important as the length of life. All illnesses should be treated aggressively. Lifesaving measures should always be implemented, even if the illness is not curable. Those who are terminally ill should be allowed to face death with dignity surrounded by family and loved ones. No efforts will be made to treat or reduce symptoms of illness.

Quality of life is as important as the length of life. All illnesses should be treated aggressively. Lifesaving measures should always be implemented, even if the illness is not curable. Those who are terminally ill should be allowed to face death with dignity surrounded by family and loved ones. No efforts will be made to treat or reduce symptoms of illness.

Which factor most strongly affects the intensity of one's grief after a loss? The coping skills of the person experiencing the loss The meaning the person attaches to the loss The length of the relationship with the person lost Support systems available after the loss

The coping skills of the person experiencing the loss The meaning the person attaches to the loss The length of the relationship with the person lost Support systems available after the loss

In states where assisted suicide is legal, what is the role of the nurse? The nurse assists with the process. The nurse monitors vital signs throughout. The nurse does not participate in any way. The nurse provides education to the client and family about assisted suicide.

The nurse assists with the process. The nurse monitors vital signs throughout. The nurse does not participate in any way. *The ANA has established that the assisted suicide violates the ethical principal of nonmaleficence and prohibits nurses participation. The nurse provides education to the client and family about assisted suicide.

What actions should the nurse take if he or she begins to have feelings of grief while caring for dying clients? The nurse should remind himself or herself that he or she is a professional and suppress these feelings. Transfer to another type of care with less exposure to dying clients. Acknowledge the grief and speak with coworkers who have similar job responsibilities. Take a leave of absence until the grief subsides.

The nurse should remind himself or herself that he or she is a professional and suppress these feelings. Transfer to another type of care with less exposure to dying clients. Acknowledge the grief and speak with coworkers who have similar job responsibilities. Take a leave of absence until the grief subsides.

What is the goal of palliative care? To aggressively treat a serious illness To work collaboratively to cure an illness To provide comfort care to those whose illnesses are no longer curable Respecting the client's decision to not perform heroic lifesaving efforts

To aggressively treat a serious illness To work collaboratively to cure an illness To provide comfort care to those whose illnesses are no longer curable Respecting the client's decision to not perform heroic lifesaving efforts

Compare and contrast the different types of grief (SLO 3)

Uncomplicated Grief (Normal/Functional Grief) is the natural response to a loss of a person or object. The bereaved person may experience a range of feelings, behaviors, and cognitions related to the loss. Emotions are initially intense, but gradually diminish over time (several months to several years). The recognition and meaning of the loss will always be present, but the intensity of the responses will lessen. Dysfunctional (Complicated Grief) also known as prolonged acute grief, is characterized by intensity of emotion and length of time. The person's responses are maladaptive, dysfunctional, unusually prolonged, or overwhelming (Pies, Shear, & Zisook, 2014). For example, the bereaved may become severely depressed, violent, or suicidal; a "workaholic"; socially isolated; or demonstrate addictive behavior. After several years the person may still be experiencing as much pain and disruption as in the first months after the loss. Chronic grief, masked grief, and delayed grief are all examples of dysfunctional (complicated) grief: ■ Chronic grief begins as normal grief but continues long term, with little resolution of feelings and inability to rejoin normal life. ■ Masked grief occurs when the person is grieving but expressing the grief through other types of behavior. For example, a man whose wife has died may begin drinking heavily, or a couple who lost a child start to argue more intensely with each other. They may not recognize this change in behavior as a part of their grief response. ■ Delayed grief is grief that is put off until a later time (e.g., "I'll think about it later; right now, I'm busy trying to keep a roof over our heads and care for my children"). In each of these instances, the bereaved person lacks the familial or communal support that is helpful in grieving. Disenfranchised Grief is experienced in connection with a loss that is not socially supported or acknowledged by the usual rites or ceremonies. Some examples include the unplanned termination of a child's foster placement or a mistress whose lover dies (Degroot & Vik, 2017; Valentine, Bauld, & Walter, 2016). In each of these instances, the bereaved person lacks the familial or communal support that is helpful in grieving. Anticipatory Grief is experienced before a loss occurs. A wife caring for her husband through a long illness may grieve as she sees the vibrant man she once knew change before her eyes as she anticipates his death. Family members experience anticipatory grief as they watch the mental capacity diminish in a loved one with Alzheimer's disease and realize that the person they once knew is becoming progressively removed from them. Potential negative outcomes of anticipatory grief are that the survivor may detach from a dying person too early in the dying process, leaving him without emotional support, or it may prolong the grief of the survivor.

Define death according to The Uniform Determination of Death Act (SLO 5) pg 344

was adopted in 1981 to further clarify (see Box 17-1) and expand the previous definition to include the "irreversible cessation of circulation and respiratory functions" based on acceptable medical standards. Providers use several methods to assess for functioning of the brainstem (e.g., pupils fixed and unresponsive to light, no corneal reflex, absence of vestibulo-ocular reflexes).