Ch 37 The experience of Loss, Death, and Grief

Stages of Dying

1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance

Rando's "R" Process Model

1: recognizing the loss 2: reacting to the pain of separation 3: reminiscing 4: relinquishing old attachments 5: readjusting to life after loss 6: Reminiscence of the relationship by mentally or verbally anecdotally reliving and remembering the person and past experiences

Necessary Loss

> Most necessary losses eventually are replaced by something different or better. >The death of a loved one, divorce, or loss of independence changes life forever and often significantly disrupts a person physical, psychological, and spiritual health. *Maturational and situational losses

Attachment Theory (Bowlby)

> Numbing- protects person from full impact of loss >Yearning and Searching- emotional outbursts, acute distress >Disorganization and Despair- endless examination of how and why the loss occurred. Anger toward people who seem responsible for the loss >Reorganization-Accepts the change, assumes unfamiliar roles, acquire new skills, build new relationships and begins to separate himself or herself from the lost relationship without feeling that the or she is lessening in importance

Assessment of Loss, Death, and Grieving

> Assess meaning of loss for the patient > Observe behaviors and other symptoms indicative of grief response > Note quality and extent of patient's family support

Loss

> Can be tangible things such as body part or function, relationship, or possession. > They can also be intangible such as loss of self-esteem, confidence, or a dream. >Illness can also be a source of loss (e.g. change in job, family role, income level, and overall quality of life.

Nursing Diagnosis

> Compromised Family Coping > Death Anxiety > Grieving > Complicated Grieving > Risk for Complicated Grieving > Hopelessness >Pain (Acute or chronic) > Spiritual Distress

Planning

> Goals and Outcomes- based on nursing diagnosis > Setting Priorities- encourage patient to share priorities for care, give priority to ta patient's most urgent physical or psychological needs, maintain an ongoing assessment to revise the plan of care according to the patient needs and preferences > Teamwork and Collaboration

Implementation

> Health Promotion- focusing on coping and optimizing health > Palliative Care- primary goal is to help patients and families achieve the best possible quality of life > Hospice care- care of terminally ill patients, manage pain, provide comfort , ensure quality of life, adheres to the patient's wishes

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

In designing plans of care, use professional standards include:

> Nursing code of ethics >the dying person's bill of rights >ANA Scope and Standards of Hospice and Palliative Nursing Practice >American Society of Pain Management Nurses'

Trajectories of Bereavement (Bonanno)

>Common grief >Chronic grief >Chronic depression >Depression followed by improvement >Resilience

Nursing education Programs that support end of life care

>End-of -Life Nursing Education Consortium >Hospice >Palliative Care Nurses Association >American Nurses Association >American Association of Critical Care Nurses >American Society of Pain Management nurses

The Self-Determination Act 1990

>Every patient has a legal right to make medical decisions. Nurse and other health care providers are starting these conversations earlier but there is more work to do. You have the opportunity to advocate for patients and the high quality of care deserved at the end of life.

Factors Influencing Grief and Loss

>Human Development >Personal Relationships >Nature of Loss >Coping Strategies >Socioeconomic Status >Culture >Spiritual and Religious Beliefs

A Dying Person's Bill of Rights

>I have the right to be treated as a living human until I die. >I have the right to maintain a sense of hopefulness, however changing its focus may be. >I have the right to be cared for by those who can maintain a sense of hopefulness, however changing this may be. >I have the right to express my feelings and emotions about my approaching death in my own way. >I have the right to participate in decisions concerning my care. >I have the right to expect continuing medical and nursing attention even though "cure" goals must be changed to "comfort" goals. >I have the right to not die alone. >I have the right to be free of pain. >I have the right to have my questions answered honestly. >I have the right to retain my individuality and not be judged for my decisions, which may be contrary to the belief of others. >I have the right to expect that the sanctity of the human body will be respected after death. >I have the right to be cared for by caring, sensitive, knowledgeable people who will attempt to understand my needs and will be able to gain some satisfaction in helping me face my death.

Dual Process Model

>Loss oriented activities -grief work, dwelling on the loss, breaking connections with the deceased person, and resisting activities to move past grief >Restoration Oriented activities attending to life changes, finding new roles or relationships, coping with finances, and participating in distractions, which provide balance to the loss-oriented state

Maturational Loss

>Loss, usually of an aspect of self, resulting from the normal changes of growth and development. >Ex: toddler experiences separation anxiety from mom when starting preschool.

Grief Variables

>Patient's Coping Style >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

masked grief

>Sometimes a grieving person behaves in ways that interfere with normal functioning but is unaware that the disruptive behavior is a result of the loss and ineffective grief resolution

Grief reactions

>Withdrawn behavior >headaches >upset stomach >decreased ability to concentrate Potential Cause: 1. Anxiety 2. gastrointestinal disturbances 3. medication side effects 4. impaired memory

complicated grief

>a person has a prolonged or significantly difficult time moving forward after a loss >has trouble accepting the death and trusting others; and/or feels excessively bitter

ambiguous grief

>a type of disenfranchised grief that occurs when the lost person is physically present but not psychologically available such as with severe dementia or severe brain injury >e.g. after a kidnapping, prisoner of war or when there is no body found

bereavement

>encompasses both grief and mourning and includes the emotional responses and outward behaviors of a person experiencing loss

situational loss

>experienced as a result of an unpredictable event, including traumatic injury, disease, death, or national disaster

actual loss

>occurs when a person can no longer feel, hear, see, or know a person or object >Ex: Loss of a body part, death of a family member, or loss of a job.

Mourning

>the outward, social expressions of grief and the behavior associated with loss

Critical thinking nurse integrates:

>theory >Prior experience >appreciation of subjective experiences >self-knowledge to respond to the patient's emotions with patience and understanding .

Perceived Loss

>uniquely defined by the person experiencing the loss and is less obvious to other people >Ex: Come ppl perceive rejection by a friend to be a loss

delayed grief

A type of grief which is suppressed and or postponed is

Grief Tasks Model Worden (2008)

Accepts the reality of the loss Experiences the pain of grief Adjusts to a world in which the deceased is missing. Emotionally relocates the deceased and moves on with life

You are caring for a patient who is depressed because the only child has gone away to college. The nurse will assess this type of depression as: A. Actual Loss B. Perceived loss C. Situational Loss D. Maturational loss

D. Maturational Loss

As a first year nursing student, you are assigned to a dying patient. To best prepare you for this assignment, you will want to:

Develop a personal understanding of your own feelings about grief and death

Normal (Type of Grief)

Uncomplicated and is a common and universal reaction characterized by complex emotional, cognitive, social physical, behavioral, and spiritual responses to loss and death.

disenfranchised grief

When their relationship to the deceased person is not socially sanctioned, cannot be shared openly, or seems of lesser significance.

anticipatory grief

before the actual loss or death occurs

chronic grief

excessive in duration and never comes to a satisfactory conclusion

exaggerated grief

often exhibits self-destructive or maladaptive behavior, obsessions, or psychiatric disorders. Suicide is a risk for these people.