Nursing Taylor Chapter 42: Loss, Grief, and Dying

Needs of Dying Patients

*Physiologic needs*: physical needs, such as hygiene, pain control, nutritional needs *Psychological needs*: patient needs control over fear of the unknown, pain, separation, leaving loved ones, loss of dignity, loss of control, unfinished business, isolation *Needs for intimacy*: patient needs ways to be physically intimate that meets needs of both partners *Spiritual needs*: patient needs meaning + purpose, love + relatedness, forgiveness + hope

Providing Postmortem Care

- *Care of the body* - *Care of the family* - Discharging legal responsibilities - Death certificate issued and signed - Labeling body - Reviewing organ donation arrangements, if any - Care of other patients

Physician Order for Life- Sustaining Treatment (POLST) Form

- A medical order indicating a patient's wishes regarding treatments commonly used in a medical crisis - Because it is a medical order it must be completed and signed by a health care professional and cannot be filled out by a patient - In some states such as Maryland they are called Medical Orders for Life-Sustaining Treatment (MOLST) Forms - Always remain with the patient regardless of weather the patient is int eh hospital, at home or on a long term care facility

Dysfunctional Grief

- Abnormal or distorted grief. - A person may have trouble expressing feelings of loss or may deny them. - *Unresolved grief* - describes a state of bereavement that extends over a lengthy or denied grief reaction. - *Inhibited grief* - when a person suppresses feelings of grief and may instead manifest somatic symptoms, such as abdominal pain or heart palpitations.

Special Orders

- Allow natural death, do-not-resuscitate, or no-code Orders - Terminal weaning - Voluntary cessation of eating and drinking - Active and passive euthanasia - Palliative sedation

Terminal Illness

- An illness in which death is expected within a limited period of time - Physician's responsibility: deciding What, When and How the patient should be told - Cultural influences may dictate how much information is desired and which family members are to be informed. (in traditional Asian families, the patient's family is told the diagnosis and prognosis, not the patient)

Grief

- An internal emotional reaction to loss - Occurs by separation or by death - Normal expressions of grief: . * physical (crying, headaches, difficulty sleeping, fatigue), . * emotional (feelings of sadness and yearning), . * social (feeling detached from others and isolating oneself from social contact), . * spiritual (questioning the reason for our loss, the purpose of pain and suffering, the purpose of life and the meaning of death).

Good Death allows a person to die in one's own terms, relatively free of pain, and with dignity

- Control of symptoms - Preparation for death - Opportunity to have a sense of completion of one's life - A good relationship to health care professionals - The care of the dying patient should be guided by the values and preferences of the individual patient. - Independence and dignity are central issues for many dying patients. - Palliative care - Should focus on the relief of symptoms and should use both pharmacologic and nonpharmacologic means - Adequate funding for research on the optimal care of dying patients is essential to improving end-of-life care

Factors Affecting Grief and Dying

- Developmental considerations - Family - Socioeconomic factors - Cultural, gender, and religious influences - Cause of 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 - Decreased level of consciousness or agitated delirum

Developing a Trusting Nurse-Patient Relationship

- Explain the patient's condition and treatment. - Teach self-care and promoting self-esteem. - Teach family members to assist in care. - Meet the needs of the dying patient. - Meet family needs.

Hospice Care

- Hospice care is premised on the fact that dying is a normal process. - Symptoms are treated aggressively in order to preserve comfort. - Type of end-of-life care for persons with limited life expectancy, often in the home.

Advance Directives

- Indicate who will make decisions for the patient in case the patient is unable. - Indicate the kind of medical treatment the patient wants or doesn't want. - Indicate how comfortable the patient wants to be. - Indicate how the patient wants to be treated by others. - Indicate what the patient wants loved ones to know.

Palliative Care

- Involves taking care of the whole person- body, mind, spirit, heart and soul - Views dying as something natural and personal - The goal is to give patients with life threatening illnesses the best quality of life they can have by the aggressive management of symptoms

Passive Euthanasia

- Is defined as withdrawing medical treatment with the intention of causing the patient's death - *NOT DOING* SOMETHING to a patient's *life*

Active Euthanasia

- Is taking active steps to cause a patient's death - *DOING* SOMETHING to a patient's *die*

Postmortem *Care of the Family*

- Listen to family's expressions of grief, loss, and helplessness. - Offer solace and support by being an attentive listener. - Arrange for family members to view body. - In the case of sudden death, provide a private place for family to begin grieving. - It is appropriate for the nurse to attend the funeral and make a follow-up visit to the family.

Postmortem *Care of the Body*

- Prepare the body for discharge. - Place the body in anatomic position, replace dressings, and remove tubes (unless there is an autopsy scheduled). - Place identification tags on the body. - Follow local law if patient died of communicable disease.

Grief Cycle Models and their stages

- are not discrete; - pricess varies from person to person; - duration of stages may range from hours to months; - grieving persons may go through the stages at varying rates, go back and forth between stages, or skip stages; - *children* do not understand death on the same level as adults, but their sense of loss is just as great; they need to go through the same grief reactions as adults; death of a parent or another significant person can delay a child's development.

Medical Criteria used to certify a death

- cessation of breathing, - no response to deep painful stimuli, - lack of reflexes (such as the gag or corneal reflex) and spontaneous movement

*Kubler-Ross* 5 Stages of Grief

1.) *Denial + Isolation* - "No!" the individual believes the diagnosis is somehow mistaken and clings to a false reality that they prefer 2.) *Anger* - "Why me?" the individual recognized the denial cannot continue so they become frustrated, especially ate individuals close to them; they believe what is happening to them is unfair and look for someone to blame 3.) *Bargaining* - "Just let me live long enough to attend my son's marriage" the individual attempt to avoid grief by looking for hope; they believe that they can negotiate an extended life in exchange for a reformed lifestyle 4.) *Depression* - "preparatory grief" the individual is in despair over the recognition of their mortality; they may become silent, refuse visitors and spend their time mourning 5.) *Acceptance* - "Now I can go" - quiet expectation; no longer struggle against death but make their peace with it - the individual embraces mortality or inevitable future, or that of a loved one; the individual dying may precede the survivors in this state and their emotions will stabilize

*Engel*'s 6 Stages of Grief

1.) *Shock + Disbelief* are defined as refusal to accept the loss, followed by a stunned response. "I can't believe my mother died of breast cancer. She was never seriously ill in her life" 2.) *Developing Awareness* is physical and emotional responces such as anger, feeling empty, and crying. "Every time I think of my mother I can't help but cry" 3.) *Restitution* involves the rituals surrounding the loss. "I've been attending mass every morning to pray for my mother's soul to help me get over her death" 4.) *Resolving the Loss* involves dealing with the void left by the loss. "I know I won't be having Sunday Dinner with my mother anymore, maybe I can cook my husband, my mama biscuits, on Sundays" 5.) *Idealization* is the exaggeration of the good qualities the person or object had, followed by acceptance of the loss. "My mother was the best, and she will lost in our memory such a person" 6.) *Outcome* involves dealing with the loss as a common life occurrence. "I miss my mother, but at least now I can accept her death and try to get on with my life"

*Advance Directives* VS POLST (Box 42-3) - for anyone 18 and older - provides instructions for *future* treatment - does not guide Emergency Medical Personnel = guides inpatient treatment decision when made available

Advance Directives VS *POLST* (Box 42-3) - for persons woth serious illnes any age - privides medical orders for *current* treatment - guides actions by Emergency Medical Personnel when made available = guides inpatient treatment decision when made available

Durable Power of Attorney

An agent the person trusts to make decisions in the event of subsequent incapacity

Uniform Definition of Death Act (1981)

An individual is dead, if there has sustained either 1. irreversible cessation of all functions of circulatory and respiratory functions OR 2. irreversible cessation of all functions of the entire brain, including the brain stem

A graduate nurse enters a client's room and finds the client unresponsive, not breathing, and without a carotid pulse. The graduate nurse is aware that the client has mentioned that he does not wish to be resuscitated, but there is no DNR order on the client's chart. What is the nurse's best action?

Call a code and begin resuscitating the client. Explanation: If there is no DNR order to the contrary, the standard of care obligates professionals to attempt resuscitation if a client stops breathing or his or her heart stops. It is important for nurses to clarify a client's code status if the nurse has reason to believe a client would not want to be resuscitated. Slow-codes are never good practice, and the nurse could be charged with negligence in the event of a slow-code and resultant client death.

Situational loss

Experienced as a result of an unpredictable event: traumatic injury, disease , death, or national disaster

Maturational loss

Experienced as a result of natural developmental processes

Comfort Measures Only Order

Indicates that the goal of treatment is a comfortable, dignified death and that further life sustaining measures are no longer indicated

Euthanasia

Literally means "good death"

Physiological loss

Loss that affects a person's self-image

Palliative Sedation

Lowering of patient consciousness using medication for the purpose of limiting patient awareness of suffering that is intractable and intolerable

Anticipatory loss

Occurs when a person displays loss and grief behaviors for a loss that has yet to take place. Often seen in the families of patients with serious and life threatening illnesses and may lessen the effect of the actual loss of a family member.

Do Not Hospitalize Order

Often used for patients in long term care and other residential settings who have elected not to be hospitalized for further aggressive treatment.

*Palliative Care* VS *Hospice Care*

PC may be given *at any time* during a client's illness, from diagnosis to end of life. PC is appropriate across the spectrum of disease and illness. HC, which, in effect, are a type of insurance benefit, focus on relieving symptoms and supporting clients with a *life expectancy of 6 months or less*, and their families. HC focuses on the needs of the dying.

Living Will

Provide specific instructions about the kinds of healthcare that should be provided for foregone in particular situations

Terminal Weaning

The gradual withdraw of mechanical ventilation from a patient with a terminal illness or an irreversible condition with a poor prognosis

Hospise and Palliative Care Nurses Assosiation (1986)

The nation's lagest ond oldest professional organization is dedicated to promoting excellence in palliative nursing care.

Do Not Resuscitate (DNR) order

an order specifying that there be no attempt to resuscitate a patient in the event of cardiopulmonary arrest

Allow Natural Death (AND) order or Do Not Intubate (DNI) order

an order that no attempts are to be made to resuscitate a patient who stops breathing or whose heart stops beating

MOURNING

is the actions and expressions of that grief, including the symbols and ceremonies that make up the outward expressions of grief

Perceived loss

loss tangible ONLY to the person sustaining it ex. loss of financial independance / youth

Actual / Physical loss

loss tangible to both the person sustaining the loss and to others ex. life, limb, an object, person, pet, or job

Loss

occurs when a valued person, object, or situation is changed or becomes inaccessible such that its value is diminished or removed

BEREAVED

state of grieving from loss of a loved one

Focused Nurse Assessment for those *experiencing loss, grief, and dying*

to determinate the adequacy of the client's and family's *knowledge, perceptions, coping strategies, and resources*: - adequacy of knowledge base ("describe your condition"), - perceptions ("previous experience with death of someone you loved"), - adequacy of resources ("community resources"), - adequacy of coping ("those around you coping").

Focused Nurse Assessment regarding *realism of expectations and perception of condition*

to determinate whether the client and family have *unrealistic expectations or misperceptions* about the diagnosis, prognosis: - Have you had any previous experiences with this condition or with the death of someone you love? - What are your expectations in this case? - How do you see the next few weeks (days) playing out? - What are your fears, hopes, concerns, worries? - What good do you think might be happening in the midst of all this?

Sentinel Event

unexpected occurence involving death or serious physical or psychological injury or their risk