Ch.17-Loss, Grief, and Dying

What is hospice care?

Holistic care of dying patients

What is the physical versus psychological loss category?

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. They are commonly seen in the areas of sexuality, control, fairness, meaning, and trust. Some losses may be mixed.

What is grief?

Physical, psychological, and spiritual responses to a loss

What is the timeliness of death factor affecting grief?

The death of a child or a young person is almost universally more difficult to accept than the death of an older person. In addition to loss of the person, there is a sense of unfairness because of the loss of potential—of what the child might have become or achieved. You may hear someone ask, "Why was her life cut short?" or state, "He had so much going for him, but God didn't give him a chance."

What occurs during the "1 to 3 months prior to death" physiological stage of 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 may be protective. The resulting ketosis can diminish pain and increase the person's sense of well-being.

What is whole-brain death?

The irreversible cessation of all functions of the brain, including the brain stem. Spontaneous respirations cannot continue once the brain stem stops functioning; however, the heart may continue to beat until it becomes oxygen starved from cessation of respirations.

What is heart-lung death?

The irreversible cessation of spontaneous respirations and circulation

What are the physiological stages of dying?

-1 to 3 months prior to death -1 to 2 weeks prior to death -Days to hours prior to death -Moments prior to death

What are the general issues for most end of life care patients?

-Supporting families and caregivers -Ensuring continuity of care -Ensuring respect for persons -Ensuring informed decision making -Attending to emotional and spiritual concerns -Supporting function and survival duration -Managing symptoms (e.g. pain, dyspnea, depression)

A young womans fiancé died in a car accident one month prior to their wedding day. Since his death, she has become sexually promiscuous. What type of grief, if any, is the woman displaying? A. Chronic B. Disenfranchised C. Masked D. No grief

C. Masked The woman is expressing her grief through maladaptive behavior to mask her grief. There has only been a short period of time since her fiancés death.

What are the different categories of the complicated type of grief?

Chronic, masked, and delayed

What is the unresolved conflict factor affecting grief?

Conflict existing at the time of death: A conflict left unresolved may cause prolonged grief.

The student nurse has earned "A's" in all of her prerequisite courses. For the first exam in a nursing course, she earns a "D" and now feels that she may not be smart enough to become a nurse. What type of "Loss" is the student experiencing? a. actual loss b. external loss c. physical loss d. perceived loss

D.perceived loss The students perception of herself as "not smart" is internal. Unless she chooses to share her grade with others, it cannot be "seen". This is not a "physical" loss

What is the developmental stage of the bereaved factor affecting grief?

Developmental stages are also an important factor in grieving. Grief can affect the healthy development of life stages, and in turn, the person's stage of development can affect the grieving process.

Who are the four major theorists about the stages of grief?

Engel, Bowlby,Rando, and Worden

What facilitates grief?

Expressing feelings, recalling memories, finding memories

What is the circumstances of the loss factor affecting grief?

If the circumstances of the loss leave the bereaved feeling guilty or responsible, his or her healing process may be impeded.

What is the previous loss factor affecting grief?

If the person has sustained more than one loss in a short period of time, the grieving process can become more complicated.

What is a DNR/ AND order?

an order to not attempt resuscitation of the patient in the event of a cardiac or respiratory failure. The ANA recommends "allow natural death" (AND).

What is the chronic complicated type of grief?

begins as normal grief but continues long term, with little resolution of feelings and inability to rejoin normal life.

What did Worden believe about the stages of grief?

described the tasks a grieving person must achieve. They progress from an initial numbness or denial through experiencing and working through pain and grief and eventually moving on with life.

What is the anticipatory type of grief?

experienced before a loss occurs. The potential negative outcome of anticipatory grief is that the survivor may detach from a dying person too early in the dying process, leaving the person without emotional support during that period. This does not always happen, of course.

What is the disenfranchised type of grief?

experienced in connection with a loss that is not socially supported or acknowledged by the usual rites or ceremonies. Disenfranchised grief may be experienced by a man whose wife has had a miscarriage, a mistress whose lover dies, or a bereaved partner in a homosexual relationship not recognized by the families. In each of these instances, the bereaved person lacks the communal support that is helpful in grieving.

What is the delayed complicated type of grief?

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.").

Hospice care is based on two key premises:

(1) the quality of life is as important as the length of life, and (2) those who are terminally ill should be allowed to face death with dignity and surrounded by the comfort of their homes and families. Thus, hospice providers consider helping family members an essential part of their role.

What do you do to care of the dying person?

-Meeting physiological needs -Meeting psychological needs -Addressing spiritual needs -Addressing cultural needs

What are the different types of grief?

-Uncomplicated -Complicated -Disenfranchised -Anticipatory

What are the two types of end of life care?

Palliative care and hospice care

What is the uncomplicated type of grief?

(Normal) grief is the natural response to a loss. The bereaved person experiences the feelings, behaviors, and cognitions that are expected in light of his or her culture, social status, and relationship to the lost person or object. The emotions are intense but gradually diminish over time (several months to several years). Some emotions will always be present, but the intensity will change.

What are the different categories of categorizing loss?

-Actual versus perceived loss -Physical versus psychological loss -External versus internal loss -Loss of aspects of self -Environmental loss -Loss of significant relationships

What are the legal and ethical considerations?

-Advanced directive -Do not resuscitate (DNR)/allow natural death (AND) -Assisted suicide -Euthanasia -Autopsy -Organ donation

What are the psychological stages of dying?

-Denial -Isolation -Anger -Bargaining -Depression -Acceptance

What is included in expressing feelings?

-Encourage questions, and respond to them within a reasonable time. -Sit beside the head of the bed; do not appear rushed. -When you observe the patient or family member expressing feelings, either verbally or nonverbally, encourage him or her to continue. -Expect and accept a wide range of feelings, including anger, fear, and loneliness. -Ask, "How would you like me to help?" "What do you need?" -Be sure that everyone on the healthcare team understands and follows the care plan. -Ask yourself what you would do if this were your family member. -Do not compare another person's loss to your own experience. For example, avoid comments such as, "I know how you feel." Instead, say, "Tell me how you feel."

What is included in finding meaning?

-Facilitating life review is one technique to help the patient and/or family recognize the unique contributions this person has made to family, friends, and society. -Begin by asking about the various aspects of the patient's life, commenting on pictures in the room, or picking up on verbal cues that are expressed.

When you study the Kübler-Ross stages, it important to understand that dying people:

-May not go through every stage -May not go through the stages in a linear fashion, but rather in random order -Do not necessarily complete one stage and move on to the next -may experience two or three stages simultaneously -Remember that it is not the nurse's responsibility to move people on to the next stage so that everyone dies accepting death. It is our responsibility to accept and support people "where they are" and help them to verbalize their feelings. We need to understand patients, not change them.

What is included in recalling memories?

-One way to encourage recall is to go through photo albums with them and ask questions about the people in the pictures. Also look for objects of sentiment (e.g., a family heirloom) in the environment and ask the dying or bereaved person to share their significance.

What should you do as a nurse to encourage therapeutic communication?

-Perfect your listening skills -Encourage and accept expression of feelings -Reassure it is not wrong to feel anger, relief, or other "unacceptable" feelings -Respond to nonverbal cues with touch and eye contact -Increase your self awareness -Continue to communicate, even in case of coma

What are the factors affecting grief?

-Significance of loss -Support system -Unresolved conflict -Circumstances of the loss -Previous loss -Spiritual/cultural beliefs and practices -Timeliness of death -Developmental stage of the bereaved

What occurs when addressing the cultural needs when caring for the dying patient?

-Some cultures may emphasize keeping emotions more subdued and limiting expressions of grief to private settings, whereas others gauge the value of the deceased by the amount of wailing and crying. -Blacks and Hispanics may be reluctant to withdraw life-sustaining treatment or to use a hospice, whereas Arab Muslims may be reluctant to prolong life unnecessarily (Duffy, Jackson, Schim, et al., 2006; Health Care Chaplaincy, 2013).

What occurs during the "1 to 2 weeks prior to death" physiological stage of dying?

A host of physical changes indicates the body is beginning to lose its ability to maintain itself.

According to William Worden, which task in the grieving process takes longest to achieve? A. Accepting that the loved one is gone B. Experiencing the pain from the loss C. Adjusting to the environment without the deceased D. Investing emotional energy

A. Accepted the loved one is gone Worden described the tasks a grieving person must achieve. They progress from an initial numbness or denial through experiencing and working through pain and grief and eventually moving on with life. Shock with disbelief is not a Worden task.

What is the actual versus perceived loss category?

Actual loss includes the death of a loved one (or relationship), theft, deterioration, destruction, and natural disaster. Actual loss can be identified by others, not just by the person experiencing it (e.g., hair loss during chemotherapy). In contrast, perceived loss is internal; it is identified only by the person experiencing it.

What occurs with meeting the psychological needs when caring for the dying person?

Everyone involved with the patient should know exactly what the patient and the family have been told. Most patients want to know their prognosis as soon as possible so that they can put personal affairs in order, share their feelings with family members, and come to terms with their life and death.

What is the external versus internal loss category?

External losses are actual losses of objects that are important to the person because of their cost or sentimental value (e.g., jewelry, pets, 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

What is dying?

Historically defined as the cessation of the flow of vital bodily fluids

What occurs during the " days to hours prior to death" physiological stage of dying?

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. 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 (Pitorak, 2003). Fatigue is common.

What occurs with meeting the physical needs when caring for the dying person?

Physiological needs during this time include mobility, oxygenation, safety, nutrition, fluids, elimination, personal hygiene, and control of pain and symptoms (nausea, vomiting).

What did Rando believe about the stages of grief?

Rando stands for Recognizing the loss (awareness); Reacting to the separation (feeling the emotions); Recollecting memories of the deceased (remembering, reliving); Relinquishing the old attachment (new ways of living without the deceased); Readjusting to the new environment (new coping skills); Reinvesting self (energy once turned inward on grief begins to be focused outward again).

What is the spiritual/cultural beliefs and practices factor affecting grief?

Spirituality and religious beliefs can help or hinder the grieving process. Most cultures engage in rituals (e.g., funerals) that help the bereaved begin the grieving process by openly expressing their emotions and pain. Some cultures may emphasize keeping emotions more subdued and limiting expressions of grief to private settings.

What is higher-brain death?

The brain stem can still be functioning, so both respiratory and cardiac activity may continue even though the person does not make purposive responses to external stimuli, cephalic reflexes are absent, and the electroencephalogram shows no activity.

What is the significance of the loss factor affecting grief?

The meaning the person has attached to the person or object lost will be different for each person. The more attachment to the relationship or object, the more difficult is the grieving.

What occurs when addressing the spiritual needs when caring for the dying person?

The person may be looking for forgiveness and/or acceptance or be reaching out to feel connected. Ways to address this need include (but are not limited to) empathetic listening, contacting pastoral care or clergy if the patient asks for this service, special rituals, praying with the patient, music, meditation, or special readings.

What is loss?

The undesired change or removal of a valued object, person, or situation

What is the loss of aspects of self category?

This includes 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.

What is the loss of significant relationships category?

This includes, but is not limited to, actual loss of spouses, siblings, family members, or significant others through death, divorce, or separation

What is the environmental loss category?

This 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.

What is the uniform determination of death act?

This provides a highly reliable means of declaring death for respirator-maintained bodies—loss of brain stem function.

What are advanced directives?

a group of instructions (written or oral) stating a person's wishes regarding his or her healthcare if he or she were incapacitated or unable to make that decision. An ordinary power of attorney does not give another person the right to make healthcare decisions for the patient; only a durable power of attorney for healthcare decisions can do that.

What is an autopsy?

a medical examination of the body to determine the cause of death that involves removals of the organs and extractions of tissue samples. Autopsies have also provided relevant data about disease processes and causes. It requires signed permission from the next of kin, except in cases in which autopsy is required by law (e.g., deaths that are suspicious or unwitnessed).

What is palliative care?

aggressively planned, holistic comfort care.

What is the complicated type of grief?

distinguished from uncomplicated grief by length of time and intensity of emotion. The person's responses are maladaptive, dysfunctional, unusually prolonged, or overwhelming. Complicated grief results when the grieving process has been impeded for some reason (e.g., something keeps the person "stuck" in the grief process

What did Bowlby believe about the stages of grief?

drawing on attachment theory, suggested that grief occurs when the bereaved learn that the object of their attachment is lost.

What does end of life care provide?

individualized, comprehensive, holistic care to meet patient and family needs predicated on goals of care from the time of diagnosis, through death, and into the bereavement period

What is assisted suicide?

making available that which is needed for the patient to end his or her own life (e.g., pharmacological agents or weapons). The patient is physically capable of ending his or her own life, has expressed the intention to do so, and has turned to the healthcare provider merely to supply the means. "The ANA (2013) prohibits nurses' participation in assisted suicide and euthanasia because these acts are in direct violation of the Code of Ethics for Nurses with Interpretive Statements (2001), the ethical traditions and goals of the profession, and its covenant with society. Nurses have an obligation to provide humane, comprehensive, and compassionate care that respects the rights of patients but upholds the standards of the profession in the presence of chronic, debilitating illness and at end-of-life."

What is the masked complicated type of grief?

occurs when the person is grieving but expressing the grief through other types of behavior.

What did Engel believe about the stages of grief?

that uncomplicated grief has a clear onset and a predictable course, modified mainly by the abruptness and significance of the loss and the preparedness of the bereaved person. Uncomplicated grief is universal and does not require treatment.

What is the support system factor affecting grief?

the amount of support for the bereaved: People with more emotional and psychosocial support typically have less complicated grief.

What is the historical definition of death?

the cessation of the flow of vital bodily fluids

What is euthanasia?

the deliberate ending of a life of someone suffering from a terminal or incurable illness. Active euthanasia occurs as a result of a direct action (e.g., giving an overdose of medication). Passive euthanasia occurs as a result of a lack of action (e.g., withholding medications or food necessary to sustain life).

What occurs during the "moments prior to death" physiological stage of dying?

§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 (Karnes, 1995; National Caregiver Library, n.d.).