ch 43 loss, grief, & dying

Learning Objective 3. Compare and contrast the five emotional stages of dying defined by Kübler-Ross. • Understand that Kübler-Ross (1969), considered a pioneer in the study of grief and death reactions, defined five stages of reaction similar to Engel's: (1) denial and isolation, (2) anger, (3) bargaining, (4) depression, and (5) acceptance.

Denial and isolation Anger Bargaining Depression Acceptance

maturational loss

Result of natural development (loss of status)

Learning Objective 1. Explain the concepts of loss and grieving, including types of loss and grief reactions. • Describe the types of loss that occur when a valued person, object, or situation is changed and its value is diminished or removed. Be sure your students can define actual loss, perceived loss, physical loss, psychological loss, maturational loss, situational loss, and anticipatory loss.

actual loss perceived loss physical loss psychological loss maturational loss situational loss anticipatory loss

psychological loss

altered self-image

physical loss

body part or function

actual loss

can be recognized by others and the person sustaining the loss

active euthanasia

clinician acts directly to cause death

factors that affect grief and dying

developmental considerations family socioeconomics culture, gender, religious influences cause of death

palliative care

involves taking care of the whole person-body, mind, spirit, heart, soul

anticipatory loss

loss that is yet to come (terminally ill patient)

assisted suicide

making available the means to commit suicide (Oregon, Vermont, Washington, California, & with court approval, Montana)

situational loss

result of unpredictable event (injury or disaster)

grief

´Emotional reaction to loss §separation §death ´Bereavement- state of grieving §Person may neglect health and require care ´Mourning- Is the action and expressions of that grief. §Period of acceptance of loss and grief where person learns to deal with the loss

• Review the stages of grief according to Engel. Ask student volunteers to discuss their own reaction to a loss. Reinforce the concept that more important than the actual stages of any given grief reaction is the idea that grief is a process and that it varies from person to person. (Refer to Promoting Health 43-1.)

´Engel - (1964)was one of the first to define stages: 1.Shock and disbelief- 'not me' 2.Developing awareness- anger, crying, 'why me' 3.Restitution- rituals of loss based on culture, religion 4.Resolving the loss- dealing with void from loss 5.Idealization- exaggerating good qualities of person or object lost 6.Outcome- final resolution of loss

ethical and legal dimensions for nurses

´Legal foundations for patient freedom to choose: 'right of self-determination' and Constitutional 'right to privacy' ´2 kinds of Advanced Directives: 1.Living Wills- Specific instructions 2.Durable Power of Attorney for Healthcare-Appoints a person to make decisions ´Combination Directives Box 43-3 P. 1692-1693 §Who- will make care decisions, §What- kind of medical treatment §Comfort- How comfortable I want to be §How treated §Family info to be shared ´DNR, No Code, Comfort Measures Only ´Terminal Weaning- gradual withdrawal. Patient may have spontaneous breathing from hours-days once withdrawn. Family needs to be prepared for this. ´Comfort Measures Only order: -Patient or surrogates may request. This indicates that the goal of treatment is a comfortable, dignified death and that further life sustaining measures are no longer indicated.

good death:

Allows Person to die on their Own Terms Home or hospital Free of pain and with dignity Free of avoidable distress and suffering Emotional support for patient and family Treated with respect Sense of completion of ones Life Good relationship with healthcare professionals

Learning Objective 2. Describe the 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 and dependent areas

euthanasia

'good dying'

• Review the definition of death.

A person who 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 is dead.

perceived loss

experienced by the person but intangible to others

passive euthanasia

withdrawing medical treatment with the intent to cause death