Test #4: End of Life Care

depression

●Overwhelmingly saddened by the inability to change the situation ●Reality sets in and the loss of the loved one or thing is deeply felt ●Patient feels numbness and a sense of immense loss, mourns the loss ●Wonders if it is worth continuing in life alone ●Some patients might withdraw, not wanting to be around others as they try to deal with the loss ●It is natural and appropriate to have feelings of depression during the grieving process

types of loss causing grief: necessary loss

a loss related to a change that is part of the cycle of life and is anticipated but still can be intensely felt. This type of loss can be replaced by something different or better (relinquishing our dreams of ideal relationships for the human reality of imperfect connections) no one is perfect don't expect perfection loss of impossible expectations

a nurse is not allowed to ______________ about organ donations

A nurse is not allowed to begin a dialogue about organ or tissue donation with the patient or a family member. Only health care professionals who have completed a course provided or endorsed by an organ procurement organization (OPO) are permitted to initiate the request of the patient or surrogate.

a nurse is providing postmortem care select all that apply Document where the body is being moved .Document the date and time of death .Ensure the client's belongings are accounted for .Place an identification tag on a minimum of one area of the client's body Include the name of anyone notified in the medical record is correct.

Document where the body is being moved is correct. The nurse should document where the body is being moved, such as to a funeral home .Include the name of anyone notified in the medical record is correct. The nurse should document the name of anyone notified of the client's death in the medical record .Document the date and time of death is correct. The nurse should document the date and time of the client's death .Ensure the client's belongings are accounted for is correct. The nurse should ensure the client's belongings are accounted for. Place an identification tag on a minimum of one area of the client's body is incorrect. The nurse should place an identification tag on a minimum of two areas of the client's body, such as a toe, arm, or outside of the body bag.

wordens four task of grieving

Four tasks a mourner completes to avoid the risk of developing complications of grief 1.To accept the reality of the loss 2.Experience the pain of grief 3.Adjust to an environment with the deceased not there 4.Resume one's life while still having a healthy and enduring connection with the deceased

the dual process model: restoration

Grief processing involves coping with other losses that come with the death of a loved one (secondary loses) and rebuilding one's life without the loved one

what occurs in each case of disenfranchised grief

In each case, a relationship has been lost as well as the griever's ability to grieve in public and receive the social support that assists in the grieving process

physical loss versus psychological loss: physical

Injuries, removal of an organ or body part, loss of function *After removal of prostate gland, a man may feel both physical and psychological loss of sexuality

A caregiver asks a nurse about the client's noisy respirations what information should the nurse include select all that apply They can be an indication of approaching death Deep suctioning is effective in removing trapped secretions Turning the client's head to the side can assist with drainage Medications can be administered to help dry up the secretions The client is unable to clear the secretions themselves

MY ANSWER They can be an indication of approaching death is correct. Noisy respirations are caused by retention of secretions in the respiratory tract, also known as "death rattle" and Cheyne-Stokes respirations. Deep suctioning is effective in removing trapped secretions is incorrect. A moist washcloth and oral suctioning can be used to remove secretions from the client's mouth .Turning the client's head to the side can assist with drainage is correct. Turning the client's head to the side can assist with drainage of the secretions from the throat and lungs. Medications can be administered to help dry up the secretions is correct. Medications such as oral atropine drops or scopolamine patches are used to assist with drying up the oral secretions. The client is unable to clear the secretions themselves is correct. The accumulation of secretions in the lungs and throat causes congestion and a "rattling" sound as the secretions become trapped. The sound of "rattling" caused the family members to become upset. The nurse should tell the family that this is not an indication that the client is experiencing any discomfort.

organ tissue donation

Organ and tissue donation is voluntary; the donor must give authorization before death, or a surrogate can give permission when the patient has not previously consented.

"actively dying" or "imminent death"

Physiological changes at the end of life follow a familiar pattern of signs and symptoms. The terminal phase of a patient's life is characteristically referred to as "actively dying" or "imminent death" *Assess patients frequently for status and need for comfort measures

priority interventions or actions: interventions to prevent abandonment and isolation

Prevent fear of dying alone ●Answer call lights in a timely manner and make frequent contact ●Allow family to stay overnight ●Determine where the patient is most comfortable (room close to nurse's station) ●If patient at home, move patient bed to a central location rather than isolated bedroom ●Keep patient informed of any procedures and times

example of NURSE technique for communication

Provide support for the patient and family as they cope with grief and loss Assists in demonstrating empathy and building a relationship with the patient and family

common grief reactions

Shock •Anger •Anxiety •Numbness •Denial •Guilt •Sadness •Relief (if death is expected) •Depression *The age of the person experiencing the grief will influence the grief response

grief across the lifespan: age related considerations: pre-school age children

age related children usually perceive death as temporary and reversible. Their tendency to magical thinking may lead the, to think they caused a person's death with their thoughts. Preschool age children may display their grief through increased irritability, tantrums, and changes in sleeping, eating, or toileting habits

grief across the lifespan: age-related considerations: adolescents

adolescents have an adult understanding of death, but they may have difficulty with processing their feelings of grief. they may turn to high-risk behaviors to distract themselves from their emotions. They may turn to their peers for support or withdraw socially

grief across the lifespan: age related considerations: adults

adults have a full understanding of death hold memories of the deceased. While grieving, the adult may experience anxiety, anger, depression, and rapid mood changes. There can additionally be physical manifestation of grief such as chest tightness, lightheadedness, fatigue, and nausea

types of loss causing grief: maturational or developmental loss

any loss normally expected due to developmental processes of life; associated with normal life transitions, (child leaving the home)

types of loss causing grief: acutal loss

any loss of a valued person, item, or status (loss of a job) that others can recognize

types of loss causing grief: situational loss

any unanticipated loss by an external event (family losing home due to hurricane)

types of loss causing grief: perceived loss

anything patients define as loss but that is not obvious or verifiable to others (loss of youth, financial independence)

anticipatory grief

grief experienced before the loss of someone or something; arises when loss is expected "letting go" of an object or person before the loss; as in a terminal illness -individuals have the opportunity to start the grieving process before the actual loss patients can also experience when they face a looming crisis or end of life

physical loss versus psychological loss: psychological

challenges our belief system and can be caused by an altered self-image *After removal of prostate gland, a man may feel both physical and psychological loss of sexuality

types of loss causing grief: anticipatory loss

expected before the loss happens

grief across the lifespan: age related considerations: infants or toddlers

infants or toddler is typically unable to understand the concept of death. However, they can react to the emotions and stress experienced by their caregivers. Infanta and toddlers often display increased irritability and crying behavior. They may appear anxious or clingy and not sleep or eat as usual

common findings of anticipatory grief

sadness anger loneliness guilt anxiety fear fatigue poor concentration

grief across the lifespan: age related considerations: school-age children

school age children usually can understand that death is final. They may display an increased level of concern about the well being of themselves and others around them when grieving. School age children mat display feelings of sadness and increased anxiety or become withdrawn. They may demonstrate increased levels of anger and aggressive behaviors

according to ATI IIn order to receive hospice you must have a______________ ______

terminal illness

mourning

the outward expression of grief in public can be affected by religious beliefs, ethnic backgrounds, or cultural customs -religious spiritual rituals can help with the death and grieving process -cultural customs provide guidelines on expressing the grief experience

grief

the pain experienced after significant loss of someone or something that is loved and the way it impacts to psychosocial and physical well-being experienced with many types of los

bereavement

the period of time in which a person experiences grief and mourning after a loss

symptoms of normal grief

○Chest pain ○Palpitations ○Headaches ○Nausea ○Changes in sleep patterns ○fatigue

the dual process model: loss-orientated

○Grief is conveyed through intense thoughts and feelings - sadness, longing for the person who died, feeling it is unfair they are no longer alive

disenfranchised grief can occur as a result of loss being:

○Unrecognized as significant (loss of pet, miscarriage) ○Unrecognized relationship (extramarital affair, non-heteronormative relationship) ○Unrecognized griever (young child)

acceptance

●Acknowledgement what is happening and plans for the future by moving forward -The spouse, child, who is never coming back -The job that they will never return to ●It is the point at which the person still feels the pain of the loss but realizes that all will eventually be well ●Some days will be better than others, with a higher number of good days than bad ●Person begins to connect with friends again and make new friendships ●Realization that nothing will take place of the loss, but that life goes on

hospice vs palliative

●All hospice care is palliative in that it focuses on controlling distressing symptoms, but not all palliative care includes hospice ●Palliative Care - is any treatment intended to control pain or other distressing symptoms ●In the context of hospice, palliative care focuses on quality of life rather than curing the disease

priority interventions or actions: emotional care

●Allow for privacy of patient and family ●Ensure comfortable and peaceful environment ●Provide support and advocacy ●Encourage family to communicate with the patient using verbalization and touch to relate with the patient ●Encourage patient and family to discuss fears at end-of-life, including pain, loneliness, and remorse ●Provide active listening and emotional support ●Use therapeutic communication (NURSE) mnemonic: name, understand, respect, support, explore

end of life nurses roles

●Assess patient's ○religious and spiritual preferences ○end-of-life wishes including advance directive and durable power of attorney ○other legal and ethical wishes, including withdrawal of treatment, organ and tissue donation ●Listen carefully to the patient's perceptions ●Use culture-specific understanding ●Use Professional Standards ○Nursing Code of Ethics ○Dying Person's Bill of Rights ○ANA Scope and Standards of Hospice and Palliative Nursing ●Use Clinical Standards: American Society of Pain Management Nurses' Guidelines

bargaining

●Attempting to avoid grief through the act of negotiating ●Bargaining with a higher power by making a promise to do something in exchange for a different, better outcome ○"I promise I will be a better person if you let this person live." ●Guilt is commonly experienced ○"If only I answered that call, maybe they would still be alive."

common findings: prolonged grief

●Behavior is marked by a persistent need to find the deceased person ●Preoccupation with thoughts of the deceased person ●Feelings of guilt (self-blame), lowered self-esteem, anger, and difficulty participating in new and different activities ●Detachment from friends and family resulting in isolation and loneliness ●Somatic complaints persist for an extended period of time

end of life care

●Care and management of the patient and caregivers facing end-of-life care issues with the outcome of providing a "good death." ●A good death is free from avoidable suffering for patients and families in consideration with their preferences and consistent with practice standards ●This generally includes pain management, planning for death, closure at the end of life, clear decision making, able to contribute to others

priority intervention or actions: additional support for grieving family

●Determine family members' desire to provide physical care and maintain awareness of signs of caregiver fatigue ●Educate on physical changes to expect as patient moves closer to death ●Allow family to express their feelings

postmortem care: postmortem procedures

●Follow agency policies for postmortem care ●Close patient's eyes, replace dentures as needed ●Remove IV tubing, catheters, and dressings (check hospital policy if autopsy is being performed) ●Wash patient and redress (check hospital policy if autopsy is being performed) ●Place pads under the patient, place a pillow under head, and position patient for family viewing ●When transporting the patient to the morgue, follow agency policy and ensure patient identification, cover or use special bed for transfer

grief experience

●Grief is defined as the reaction to either real or perceived loss and the way it impacts psychosocial and physical well-being ●Grief is the body's way of healing after one has suffered a loss ●Grief can also be triggered by other experiences considered painful or traumatic to the patient ●Most people will experience grief after a loss for several months to a year ●Normal grief experience is different for everyone ●Typically lessens over time as the feelings of intensity decrease and the person experiencing the grief simultaneously moves forward in their acceptance of loss ●Some patients will follow a different path leading to chronic and debilitating grief

disenfranchised grief

●Grief r/t a relationship that does not coincide with what is considered by society to be a recognized or justified loss ●The loss is seen to be shameful or socially uncomfortable by society and not worthy of grief (suicide and abortion) ●Social support not provided to the grieving individual and they grieve alone in silence

palliative and hospice care

●Holistic care provided throughout the lifespan for patients experiencing severe medical illness and particularly for patients approaching end of life. ●Goal - improve quality of life for the patient, the family and caregivers. ●Initially concentrated on lessening client suffering at end of life ○but current best practice dictates it be implemented earlier in the course of life-threatening health events. ●Palliative care is different from hospice care, as palliative care is provided while the client is still engaging in curative treatment methods.

Kübler-Ross Model: Grief Theory

●Identifies five stages an individual experiences during the grieving process 1.Denial 2.Anger 3.Bargaining 4.Depression 5.Acceptance ●The stages are NOT sequential ●Not everyone goes through all of of the stages or in a prescribed order

normal grief

●Normal Grief (uncomplicated grief), caused by the loss of a loved one through death or the ending of a relationship ○Emotions can be negative (anger, resentment, withdrawal, hopelessness, and guilt) but should change to some acceptance by 6 months after the loss

nurse reactions

●Nurses may experience grief after a patient's death ●Reactions differ among nurses in expressing grief and is affected by the clinical circumstances of the client's death as well as personal factors specific to the nurse ●Because reactions differ, each nurse needs to be aware of and manage their grief ●Compassion fatigue can be experienced ○Caused by the cumulative stress that develops from the desire to help those who are suffering ○Leads to feelings of professional uselessness and self-blame

importance of nurses self care

●Nurses, like patients need to verbalize and process their own feelings of grief ●Nurses need to take time to care for themselves and make self-care a priority ●Being 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 ●Nurses can use coping strategies (with consideration of professional boundaries) ○Going to a patient's funeral ○Communicating in writing to the family ○Attending debriefing sessions with colleagues ○Using stress management techniques ○Talking with a professional counselor

anger

●Patient directs anger toward the self, others, a deity, objects, or current circumstances ●Trying to adjust to the loss; feeling severe emotional distress ●Thinks, "why me?" and "it's not fair." may experience spiritual distress and question belief in their God(s), higher power ●Anger provides a means of releasing emotional discomfort ●Blaming of others for the loss can occur; targeted at loved ones and close friends ●After loss, many people feel abandoned and left alone; anger connects the patient to reality ●Anger is necessary and a healthy stage of grief and will eventually dissolve ●The more anger is felt, the faster the person will heal

denial

●Patient has difficulty believing in an expected or actual loss ●Done to lessen the pain of the loss; feelings of numbness and shock ●The mind is trying to adjust to the loss of someone or something; letting in only as much as it can handle ●The patient is trying to understand what has happened and deal with feelings of losing someone or something ●The patient reflects on and relives the time spent with the person and questions how life can move forward without the person ●The body's way of slowing things down and giving time to adjust to the loss so the patient will not become emotionally overwhelmed

common findings of disenfranchised grief

●Patients can experience depression, unstable emotions, social isolation, physical symptoms, insomnia, and low self-esteem

prolonged grief (complicated grief)

●Patients who are unable to accept the death of a loved one ●Grief that lasts longer than 6 months; can be so significant that it affects the patient's ability to function ●Manifestations of grief are more severe can result in depression or exacerbate a preexisting disorder ●Can develop suicide ideation

priority interventions or actions: physical care

●Provide pain management ●Elevate head of bed, suction as needed, provide oxygen ●Provide oral and other hygiene measures as tolerated ●Keep perineal area clean and change pads frequently ●Provide rest as needed ●Allow or restrict visitors to meet the needs of the patient ●Provide anti-emetics as needed ●Manage adverse effects of medications ●Reposition patient to maintain airway patency and comfort ●Maintain the integrity of skin and mucous membranes ●Provide caring touch (hold the patient's hand) ●Encourage the patient to perform ADL's as able and willing to do so ●If appropriate encourage the use of relaxation techniques (guided imagery and music)

postmortem care: care of the body

●Provide respectful and compassionate care while attending to the desires of the patient and family based on cultural, spiritual, and social practices ●The provider certifies the death by pronouncing the time and documenting therapies used, and actions taken prior to death ●Elevate the patients head to prevent facial discoloration by raising HOB

the nurses role in organ/tissue donation

●Provide support and education to family members as decisions are being made ●Review organ donation arrangements, if any ●Use private areas for any family discussions concerning donation ●Maintain ventilator and cardiovascular support for vital organ retrieval ●Autopsy concerns- answer family members' questions and support their choices; obtain permission if needed, check hospital policy

the dual process model

●Suggests that the process of grieving "oscillates" (shifts back and forth) between two types of responses: loss oriented and restoration grief ●Does not put emphasis on confronting your feelings ●Restoration activities help the patient cope

hospice care

●The administration of medical care to support the patient who has a terminal illness, so they can live the last days of their life as best as they can ○Focus is on improving quality of life rather than merely prolonging its length, and on preserving dignity (by being respectful and caring) for the patient in death ●Provided when treatment will no longer cure or control the illness. ●Originally offered only to clients diagnosed with terminal cancer but has grown to include any client with a life-limiting illness. ●Interprofessional, holistic care that treats the whole person, including caregivers and family members. ●Admission into hospice care is dependent upon the client meeting specific criteria in addition to having a health care provider make a diagnosis of a life expectancy of fewer than six months.

manifestations of approaching death

●↓ LOC loss of consiousness ●Pupils no longer reactive to light ●Muscle relaxation of the face ●Hearing is NOT diminished ●Incontinence of bowel and/or bladder ●↓ urine output ●Loss of movement, sensation, and reflexes ●Cool extremities, with cold or clammy skin ●Perspiration ●Weak, slow, or irregular pulse ●Decreasing BP ●Noisy respirations (death rattle) and and alternating deep and rapid breathing (Cheyne Stokes respirations) ●Mucus collecting in large airways ●Restlessness and/or agitation ●Inability to swallow ●Mottling and cyanosis of the extremities and dependent areas