Transcript No Slide Title

Unit II
Death, Loss, End of Life
Death, Loss and End of Life
Care
 Loss – actual or potential situation in
which something valued is changed, no
longer available or gone
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Actual
Perceived
Anticipatory
Grief
 Response to experience of loss
 Bereavement – subjective response
experience by surviving loved ones after
death
 Mourning – behavioral response through
which grief is eventually resolved or
altered
Types of Grief
 Anticipatory Grief
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Grief before loss
Patient, family, professionals
Children have unique needs
Normal Grief (Uncomplicated)
 Normal feelings, behaviors and reactions
to loss
 Physical, emotional, cognitive and
behavioral reactions
Dysfunctional grief
 Unresolved grief - extended length and severity
May result from:
ambivalence towards lost person, perceived need to
be brave or in control, endurance of multiples losses,
extremely high emotional value invested in lost
person (helps bereaved avoid reality of loss,
uncertainty about loss (“missing in action”), lack of
support systems
 Inhibited grief - normal symptoms of grief
suppressed
Complicated Grief
 Fails to grieve
 Avoids visiting gravesite or participate in memorial
 Recurrently symptomatic on anniversary of death
 Persistent guilt, low self-esteem
 Continues to search for lost person
 May consider suicide
 Minor events trigger grief
 Unable to discuss the deceased with composure
 Physical symptoms similar to the deceased
 Relationships with others worsen (Kozier, 1034)
Stages and Tasks of Grief
 Denial
 Anger
 Bargaining
 Depression
 Acceptance
Factors Influencing the Grief
Process
 Survivor personality, coping
 History of substance abuse
 Relationship to deceased
 Spiritual beliefs
 Type of death
Grief Assessment
 Begins at time of admission or diagnosis
 Ongoing to detect complicated grief
Grief Assessment Includes
 Type of grief
 Reactions
 Stages and tasks
 Influencing factors, general health
Children’s Grief
 Based on developmental stages
 Can be normal or complicated
 Symptoms unique to children
Grief Interventions…
 Presence
 Identify support systems
 Access bereavement specialists
 Identify and express feelings
 Special attention to disenfranchised grief
 Public and private rituals
 Spiritual care
Completion of the Grieving
Process
 No one can predict completion
 Grief work is never completely finished
 Healing occurs when the pain is less
Death and Dying
Communication
Communication
•Crucial to palliative care
•Terminal illness is a family
experience
Communication
•Imparting necessary information
so that individuals may make
informed decisions
•Requires interdisciplinary
collaboration
Communication Process
•Patient/Family Expectations
•be honest
•non abandonment
•elicit values and goals
•team communication
•take time to listen
Communication
•Provides for informed choices
•Offers support
•Allows verbalization of fears
Communication
•How much patient/family want to
know
•Initiate family meetings
•Base communication with children
on developmental age
Attentive Listening
•Encourage them to talk
•Be silent
•Be non-judgmental
•Avoid misunderstandings
Attentive Listening (cont.)
•Don’t change the subject
•Encourage reminiscing
Factors Influencing
Communication
•Patient/Family
•family systems
•financial/educational
•physical limitations
•coping/grief
Factors Influencing
Communication (cont.)
•Health care professionals
•communication barriers (e.g.
fear of own mortality, fear of
not knowing, lack of
understanding culture)
Breaking Bad News
•Nurses reinforce news provided by
physicians
•Steps:
•plan what to say
•establish rapport
Steps (cont.)
•set aside time/turn off pager
•control the environment
•find out what they know/want to
know
•use simple language
•be sensitive/respectful
Adaptive and Maladaptive
Responses
•Cultural mores dictate what is
adaptive or maladaptive
Team Communication
•Intra team communication is vital
•Should occur frequently
•Documentation is key
•Conflict is expected
Death and Dying:
Symptom
Management
Symptom Management
Introduction
•There are many physical and
psychological symptoms common
at the end of life
•Ongoing assessment and
evaluation of interventions is
needed
•Requires interdisciplinary
teamwork
Introduction (cont.)
•Reimbursement concerns
•Limit diagnostic tests
Symptoms and Suffering
•Symptoms create suffering and
distress. Psychosocial intervention
is key to complement
pharmacologic strategies
Physiologic Changes/
Symptoms
•Pain
•Dyspnea / Apnea
•Anorexia and Cachexia
•Weakness & Fatigue
•Mental Status Changes
•Hypotension / Renal Failure
•Incontinence
•Anxiety
•Depression
Key Nursing Roles
•Patient advocacy
•Assessment
•Pharm tx
•Non-Rx tx
•Pt/family teaching
Anxiety
•Subjective feeling of apprehension
•Often without specific cause
•Categories of mild, moderate,
severe
Depression
•Ranges from sadness to suicidal
•Often unrecognized and
under treated
•Occurs in 25-77% of terminally ill
•Distinguish normal vs. abnormal
Assessment of Depression
•Situational factors
•Previous psychiatric history
•Other factors (e.g. lack of
support system, pain)
Example Questions for
Depression Assessment
•How have your spirits been lately?
•What do you see in your future?
•What is the biggest problem you
are facing?
Suicide Assessment
•Do you think life isn’t worth
living?
•Have you thought about how you
would kill yourself?
Conclusion
•Multiple symptoms common
•Coordination of care with
physicians and others
•Use drug and nondrug treatment
•Patient/family teaching and
support
Care Following Death
•Preparing the family
•Care after death
•Evaluate circumstances
•Organ donor procedures
Care Following Death (cont.)
•Removal of tubes, equipment
•Bathing and dressing the body
•Positioning the body
•Respect cultural preferences
Care Following Death (cont.)
•Removal of the body
•Rigor mortis 2-4 hrs after death
•Embalming
Care Following Death (cont.)
•Assistance with calls, notifications
•Destroying medications
•Assisting with arrangements
•Initiating bereavement support
Death of Children
•Encourage parents to hold child
•Siblings
•Encourage verbalization
Conclusion
•Care of the patient and family at
the time of death entails unique
concerns, best provided by an
interdisciplinary team
Bereavement Interventions . . .
 Plan of care
• Attitude
• Cultural practices
• What to say
• Anticipatory grief
. . . Bereavement Interventions
 Provide presence
 Active listening, touch, reassurance
 Decrease sense of loss
 Use bereavement services
Bereavement Interventions for
Children and Parents
 Recognize developmental stage
 Refer to support groups
The Nurse: Death Anxiety,
Cumulative Loss, Grief
 Death anxiety
 Defenses
 Personal death awareness
Cumulative Loss
 Succession of losses common to nurses
 May not have time to resolve losses
before another loss occurs
Stages of Adaptation
 Nurses new to working with the dying
need support
 Stages of adaptation (Harper)
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Intellectualization
Emotional survival
Depression
Emotional arrival
Deep compassion
Factors Influencing the
Nurse’s Adaptation
 Professional training
 Personal death history
 Life changes
 Support system
System of Support (Vachon)
 Balance
 Assessing formal / informal support
systems
 Instructor support
 Spiritual support
 Self care and support
Support for the Nurse
•Ask for help
•Verbalize
•Post clinical debriefing
Conclusion
 Loss, grief and bereavement assess with
ongoing intervention
 Nurses must recognize and respond to
their own grief
 Interdisciplinary care