Transcript Διαφάνεια 1

End of Life AND Death:
The Nursing Approach
Tallinn, 12/2012
Maria Tsironi,MD
Assoc. Professor
Dept of Nursing
University of Peloponnese
SPARTA, GREECE
Nightingale’s Model
for Nursing Practice
Values, Morals, & Ethics
• Values: are freely chosen, enduring beliefs or
attitudes about the worth of a person, object,
idea, or action (e.g. freedom, family, honesty,
hard work)
• Values frequently derive from a person’s
cultural, ethnic, and religious background;
from societal traditions; and from the values
held by peer group and family
• Values form a basic for Behaviour “purposive
Behaviour”; The purposive behavior is based
on a person’s decisions/choices, and these
decisions/choices are based on the person’s
underlying values.
• Values are learned and are greatly
influenced by a person’s sociocultural
environment (e.g. demonstrate honesty,
folk healer, observation and experience)
• People need societal values to feel
accepted, and they need personal values
to produce a sense of individuality.
• Professional values often reflect and
expand on personal values
• Once a person becomes aware of his/her
values, they become an internal control for
behavior, thus, a person’s real values are
manifested in consistent pattern of
behavior
• Nurses acquire these values
during socialization into
nursing – from codes of ethics,
nursing experiences, teachers,
and peers.
• Watson (1981) outlined 4
important values of nursing:
– Strong commitment to service
– Belief in the dignity and worth of
each person
– Commitment to education
– Autonomy
• Nurses need to understand their
own values related to moral matters
and to use ethical reasoning to
determine and explain their moral
positions.
• Moral principles are also important,
otherwise, they may give emotional
responses which often are not
helpful.
• Although nurses can not and should
not ignore or deny their own and the
profession’s values, they need to be
able to accept a client’s values and
beliefs rather than assume their own
are the “right ones”
This acceptance and nonjudgmental
approach requires nurses to be aware of
their own values and how they influence
behavior
• Values about life, health, illness, death.
Morals and Ethics
• Morals: is similar to ethics and
many people use the two wards
interchangeably (closely associated
with the concept of ethics)
• Derived from the Latin “mores”,
means custom or habit.
• Morality: usually refers to an
individual’s personal standards of
what is right and wrong in conduct,
character, and attitude.
• Morals: are based on religious
beliefs and social influence and
9
group norms
Morals and Ethics
• Ethics is a branch of philosophy (the study
of beliefs and assumptions) referred to as
moral philosophy.
Derived from the Greek word “ethos” which
means customs, habitual usage, conduct
and character.
• Ethics: usually refers to the practices,
beliefs, and standards of behavior of a
particular group such as nurses. It also
refers to the method of inquiry that assists
people to understood the morality of human
behavior (study of morality)
10
Morals and Ethics
• In both, we describe the behavior we
observe as good, right, desirable,
honorable, fitting or proper or we might
describe the behavior as bad, wrong,
improper, irresponsible, or evil.
• There are times when a differences in
values and decisions can be accepted
• Differences in values and decisions put
people into direct conflict.
11
Morals and Ethics (resolving conflicts)
• Be constructive (rather than destructive) in
the methods you choose to work toward
resolving the differences
– Listen carefully without interruptions
– Seek clarification using gentle questioning
– Respect cultural differences
– Be attentive to body language
– Explain the context of your point of view and
try to picture the other person’s expective of
what you are saying
12
Comparison of morals and ethics
Morals
• Principles and rules of
right conduct
•
• Private, and personal
•
• Commitment to
principles and values is
usually defended in
daily life
• Pertain to an
individual‘s character
•
•
•
Ethics
Formal responding process
used to determine right
conduct
Professionally and publicly
stated
Inquiry or study of
principles and values
Process of questioning,
and perhaps changing,
one’s morals
Speaks to relationships
between human beings
Moral distress
• When the nurses are unable to follow their
moral beliefs because of institutional or
other restriction.
• The distress occurs when the nurse
violates a personal moral value and fails to
fulfill perceived responsibility.
• Moral distress represent practical, rather
than ethical dilemmas.
Basic ethical concepts
1. Rights
2. Autonomy
3. Beneficence and
Nonmaleficence
4. Justice
5. Fidelity
6. Veracity
7. The standard of best interest
Basic ethical concepts
Rights
•
Rights form the basis of most
professional codes and legal
judgments
–
Self-determination rights
–
Rights and cultural relativism
–
Rights of the unborn
–
Rights of privacy and confidentiality
Basic ethical concepts
Autonomy
•
•
•
•
Involves the right of self-determination,
independence, and freedom.
It refers to the right to make one’s own
decisions
Respect for autonomy means that nurses
recognize the individual’s uniqueness,
the right to be what that person is, and
the right to choose personal goals
Nurses who follow the principle of
autonomy respect a client's right to make
decisions even when those choices
seem not to be in the client’s best interest
Basic ethical concepts
Autonomy
•
•
•
Respect for people also means
treating others with consideration
In the clinical setting, this principle
is violated when a nurse disregards
client's subjective accounts of their
symptoms (e.g. pain)
Patients should give informed
consent before tests and
procedures are carried out
Basic ethical concepts
Beneficence and Nonmaleficence
Beneficence: means “doing good”
•
Nurses should implement actions that benefit
clients and their support persons. However, in an
increasing technologic health care system, doing
good can also pose a risk of doing harm (e.g.
intensive exercise program).
Nonmaleficence: means the duty to do no harm.
•
This is the basic of most codes of nursing ethics.
•
Harm can mean deliberate harm, risk of harm, and
unintentional harm.
•
In nursing, intentional harm is always
unacceptable.
•
The risk of harm is not always clear
•
A client may be at risk of harm during a nursing
intervention that is intended to be helpful (e.g.
medication)
Basic ethical concepts
Justice
•
•
•
Is often referred to as
fairness
Nurses frequently face
decisions in which a sense
of justice should prevail
(succeed)
E.g. busy unit, new
admission
Basic ethical concepts
Fidelity
•
•
•
Means to be faithful to
agreements and responsibilities
one has undertaken
Nurses have responsibilities to
clients, employers, government,
society, the profession, and
themselves
Circumstances often affect
which responsibilities take
precedence at a particular time
Basic ethical concepts
Verasity
•
•
•
•
Refers to telling the truth
As a nurse should I tell the
truth when it is known that
doing so will cause harm?
Does tell a lie when it is
known that the lie will relieve
anxiety and fear?
Should I lie to dying people?
Basic ethical concepts
The standard of best interest
•
Applied when a decision must be made
about a patient’s health care and the patient
is unable to make an informed decision
Nursing Codes of Ethics
• Nurses have four fundamental
responsibilities: to promote health,
to prevent illness, to restore
health, and alleviate suffering.
– Nurses and people
– Nurses and practice
– Nurses and the profession
– Nurses and the co-workers
DEATH
• Mosby’s medical, Nursing & Allied Health
Dictionary
“ Death is: The cessation of life as indicated
by the absence of activity in the brain and
central nervous system, the cardiovascular
system, and the respiratory system as
observed and declared by a physician”.
• BUT the style in which a person dies is
very individual, just as their life was.
• The stages of dying, much like the stages of grief, may
overlap, and the duration of any stage may range from
as little as a few hours to as long as months. The
process vary from person to person.
• Some people may be in one stage for such a short time
that it seems as if they skipped that stage. Some times
the person returns to a previous stage. According to
Kubler- Ross, the five stages of dying are:
–
–
–
–
–
Denial
Anger
Bargaining
Depression
Acceptance
1. Denial
• On being told that one is dying, there is an
initial reaction of shock.
• The patient may appear dazed at first and
may then refuse to believe the diagnosis
or deny that anything is wrong.
• Some patients never pass beyond this
stage and may go from doctor to doctor
until they find one who supports their
position.
2. Anger
• Patients become frustrated, irritable and
angry that they are sick.
• A common response is,” Why me? ”
• They may become angry at God, their fate,
a friend, or a family member.
• The anger may be displaced onto the
hospital staff or the doctors who are
blamed for the illness.
3. Bargaining
• The patient may attempt to negotiate with
physicians, friends or even God, that in
return for a cure, the person will fulfill one
or many promises, such as giving to
charity or reaffirm an earlier faith in God.
4. Depression
• The patient shows clinical signs of
depression- withdrawal, psychomotor
retardation, sleep disturbances,
hopelessness and possibly suicidal
ideation.
• The depression may be a reaction to the
effects of the illness on his or her life or it
may be in anticipation of the approaching
death.
5. Acceptance
• The patient realizes that death is inevitable and
accepts the universality of the experience.
• Under ideal circumstances, the patient is
courageous and is able to talk about his or her
death as he or she faces the unknown.
• People with strong religious beliefs and those
who are convinced of a life after death can find
comfort in these beliefs (Zisook & Downs, 1989).
MANAGING DEATH ANXIETY
Spirituality
Religion is a prime source of strength and sustenance to many people
when they are dealing with death. Different religious theories explain
the inevitability and even necessity of death from different
perspectives,i.e.
• In The Bible death has been viewed as “Blessed are the dead who
die in the Lord from now on…….that they may rest from their labors,
and their works follow them (Revelations, ch. 14, verse 13)”.
• Islamic belief says- death as the begining of eternal life. Every
individual will be questioned about his deeds in this life and he will
be awarded Heaven or Hell based on His judgement.
• According to the Gita, soul is not destructible but immortal. It says
that death of the body is certain and irrelevant but eternal Self or the
universal Self is immortal, therefore there should be no grief over
what is inevitable, even necessary.
Existential Approaches in
Management of Death Anxiety
• Death anxiety is inversely proportional to life satisfaction (Yalom,
1980).
• When an individual is living authentically, anxiety and fear of death
decrease (Richard, 2000).
• Recognition of death plays a significant role in psychotherapy, for it
can be the factor that helps us transform a stale mode of living into a
more authentic one (Yalom, 1980). Confronting this realization
produces anxiety.
• Frankl (1969) also contends that people can face pain, guilt, despair
and death in their confrontation, challenge their despair and thus
triumph. It also postulates that a distinctly human characteristic is
the struggle for a sense of significance and purpose in life.
Existential therapy provides the conceptual framework for helping the
client challenge the meaning in his or her life
Management of dying patient
The 7 C (Cassen,1991)
• Concern: Empathy, compassion, and involvement are essential.
• Competence: Skill and knowledge can be as reassuring as warmth
and concern.
• Communication: Allow patients to speak their minds and get to
know them.
• Children: If children want to visit the dying, it is generally advisable;
they bring consolation to dying patients.
• Cohesion: Family cohesion reassures both the patient and family.
• Cheerfulness: A gentle, appropriate sense of humor can be
palliative; a somber or anxious demeanor should be avoided.
• Consistency: Continuing, persistent attention is highly valued by
patients who often fear that they are a burden and will be
abandoned; consistent physician involvement mitigates these fears.
Symptom Management
• Assessment of the severity of the symptoms.
• Evaluation for the underlying cause.
• Addressing the social, emotional and spiritual
aspects of the symptom.
• Discussing the treatment options with the patient
and family.
• Using therapies designed as around the clock
interventions for chronic symptoms.
• Reevaluating the control of the symptom
periodically.
(Dial, 1999)
PAIN
The major focus of most dying patients is
the avoidance of pain. Controlling pain in
terminally ill patients requires attention to
the following:
• Potential etiology of pain
• Use of medications
• Use of nonpharmacologic methods
Deal with….
• Euthanasia
Greek words meaning “easy death”.
Euthanasia is an act by which the causative agent of
death is administered by another with the intent to
end life.
Killing an innocent person, even at his or her request is
not ethical.
“Code for Nurses (1985) and the ANA position
statement (1994) states that the nurse should not
participate in euthanasia but be vigilant advocates for
the delivery of dignified and human care.
Deal with….
• Living Wills
Prepared while patient has decisional capacity
Describes patient preferences in the event they
become incapable of making decisions or
communicating decisions.
Usually describes what type of life prolonging
procedures the patient would or would not want
and circumstances under which they would want
these procedures carried out, withheld, or
withdrawn
The Nursing Approach
• Nurses are very committed to life and health.
• The dying patient is a contradiction to a nurse's
commitment. Occasionally people in the medical
field react to the dying person as if they
represent a failure in their care, or their skills.
Although there is really nothing a human being can
do to stop the destiny/ process of another
human being.
We can help the dying patient and their
families in their final hours with our
education and compassion.
Death & Ethical Considerations
• Death is often fraught with ethical
dilemmas.
• Many health care agencies have ethics
committees to develop and implement
policies to deal with end-of-life issues.
• Important distinctions must be made
between pain relief and euthanasia.
The Nursing Approach
The person who deals with the dying patient must
commit (Schwartz and Karasu, 1997) to:
• Deal with mental anguish and fear of death
• Try to respond appropriately to patient’s needs
by listening carefully to the complaints and
• Be fully prepared to accept their own counter
transferences, as doubts, guilt and damage to
their narcissism are encountered.
The Nursing Approach
• Developing a sense of control and efficacy.
• Encouraging peer groups for families coping
with bereavement.
• Developing increased resourcefulness in dealing
with death related situations.
• Recognizing that a moderate level of death
anxiety is acceptable.
• Improving our understanding of pain and
suffering will also improve communication and
effective interactions.
The Nursing Approach
• Many nurses are not well prepared to deal
with death and dying
• Nonmalignant or chronic conditions, (such as
cardio-respiratory disease) are usually
treated with acute care focus
• Nurses are frustrated by giving futile
treatments
• Lack of a palliative care plan may mean
patient is less likely to have a “good death”
• Palliative care vs. hospice care is not well
understood
Definition of Palliative Care:
• An approach that improves the quality of life of
patients and their families facing the problems
associated with life-threatening illness, through
the prevention and relief of suffering by means
of early identification and impeccable
assessment and treatment of pain and other
problems, physical, psychosocial, and spiritual
---World Health Organization (2004)
WHO Definition (Continued):
• Affirm life and regard dying as a normal process
• Neither hasten nor postpone death
• Provide relief from pain and other distressing
symptoms
• Integrate psychological and spiritual aspects of care
• Offer a support system to help patients live as actively
as possible up to death
• Use a team approach to address the needs of patients
and their families
• Offer a support system to help the family cope during
the illness and their own bereavement
Hospice
• A type of care for the terminally ill,
founded on the concept of allowing
individuals to die with dignity,
surrounded by those who love them.
• Clients enter hospice care when
aggressive medical treatment is no
longer an option or when client refuses
further medical intervention.
Why is Palliative Care Important
to Nurses?
• Death and dying are too rarely discussed
– Communication among patients, their families,
and health care providers is often lacking
• There is a need for better end-of-life care
-Nurses have the most intimate and
continuous contact with patients and families
during that phase of life
Palliative VS. Hospice Care
(ANA-ELNEC)
• No hospitalization
• Focus on comfort vs.
cure
• No invasive
procedures
• Hospice org’s. provide
medical,nursing,nurse
assistants,chaplain,
social worker
24 hr support pt & family
Bereavement services
Nursing Interventions
•
•
•
•
Encourage discussion of “end- of-life “
Decisions re: type of care
Advance directives
Euthanasia - Active vs. passive.
Assessment of the Dying Client
• Client and family goals and expectations.
• Client’s awareness of terminal nature of
the illness.
• Availability of support systems.
• Current stage of dying.
• History of previous positive coping skills.
• Client perception of unfinished business
to be completed.
Physiological Needs of the
Dying Client
•
•
•
•
•
•
•
•
Respirations.
Fluids and nutrition.
Mouth, eyes, and nose.
Mobility.
Skin care.
Elimination.
Comfort.
Physical environment.
Signs of Impending Death
• Lungs become unable to provide adequate gas
diffusion.
• Heart and blood vessels become unable to maintain
adequate tissue perfusion.
• The brain ceases to regulate vital centers.
• Cheyne-Stokes respirations (irregular breathing) and
“death rattle” (noisy respirations caused by secretions
accumulating in larynx and trachea) signal imminence
of death.
Legal Aspects Following Death
• Autopsy (examination of the body after
death by pathologist to ascertain cause of
death).
• Organ Donation.
Challenges
• Nurses may be confused and frustrated about
what the DNR order means
– How far do you go with invasive
treatments?
• Patients must be given realistic expectations
of prognosis and treatment outcomes
– What are the patient’s current desires and
wishes/advance directives?
• Acute care and critical care areas may not be
conducive to palliative care/comfort care
Implications for nursing care
• Assessment
“tell me about recent events in your life”
Look for concurrent stressors
“what spiritual beliefs do you hold in relation to
death?”
End of Life Discussions:
•
•
•
•
•
Break bad news sensitively
Provide information as the patient wishes
Permit expression of emotion
Clarify concerns and problems
Involve patient and family in making
decisions about treatment
• Set realistic goals
• Provide appropriate medical, psychological,
and social care, and promote continuity of
care
Nursing Students Need To
Know:
• Pain and symptom
management
• Grief, loss and
bereavement issues
• Communication skills
• Cultural considerations
• Ethical and legal issues
• Quality end-of-life care
• Standards of practice
for sound clinical
judgment in pain
management
• Acute, chronic, and
end-of-life pain issues
• Assurance that nurses
are supported for
providing appropriate
pain management
LOSS AND GRIEF
Loss
• Any situation —actual, potential, or
perceived —wherein a valued object or
person is changed or is no longer
accessible to the individual.
Types of Loss
• Actual (loss of someone or some thing).
• Perceived (felt by an individual but not
tangible to others, e.g. loss of selfesteem).
• Physical (loss of part or aspect of the
body).
• Psychological (emotional loss, e.g. a
woman’s feelings after menopause).
Categories of Loss
• Loss of External Object.
• Loss of Familiar Environment.
• Loss of Aspect of Self (Physiological or
Psychological).
• Loss of Significant Other.
Grief
“Grief is the individual’s response to a loss
and mourning is an active and evolving
process that includes those behaviors
used to incorporate the loss experience
into one’s life after the loss.”
Grief
• A series of intense physical and
psychological responses that occur
following a loss.
• A normal, necessary, and adaptive
response to a loss.
Mourning & Bereavement
• Mourning is the period of time during
which grief is expressed and resolution
and integration of loss occur.
• Bereavement is the period of grief
following the death of a loved one.
Theories of the Grieving
Process
Leading theoretical models describing
grieving have been devised by:
•
•
•
•
Erich Lindemann
George L. Engle
John Bowlby
William Worden
Lindemann Theory
Erich Lindemann coined the phrase grief
work and described typical grief reactions:
• Somatic distress.
• Preoccupation with the image of the
deceased.
• Guilt.
• Hostile reactions.
• Loss of patterns of conduct.
Engle Theory
• Three Stages of Mourning
– Stage I: Shock and Disbelief (disorientation,
helplessness, denial).
– Stage II: Developing Awareness (guilt, sadness,
isolation, anger and hostility).
– Stage III: Restitution and Resolution (bodily
symptoms, idealization of the deceased, beginning of
coming to terms with loss, establishment of new
social patterns and relationships).
Bowlby Theory
• Four Stages of Mourning
–
–
–
–
Numbness.
Yearning and searching.
Disorganization and despair.
Reorganization.
Worden Theory
Four Tasks to Deal with Loss Successfully
–
–
–
–
Accept the fact that the loss is real.
Experience the emotional pain of grief.
Adjust to an environment without the deceased.
Reinvest the emotional energy once directed at
the deceased into another relationship.
Types of Grief
• Uncomplicated (a grief reaction that normally
follows a significant loss).
• Dysfunctional (intense grief that does not result
in reconciliation of feelings).
• Anticipatory (occurrence of grief work before
loss actually occurs).
• Disenfranchised (grief that is not openly
acknowledged, socially sanctioned, or publicly
shared, e.g. grief over the loss of a pet).
Types of Grief
• Anticipatory grief ->premature detachment =
sociological death; premature withdrawal of a
person =psychological death
• Acute grief - a crisis. - person feels physically
sick & is emotionally distressed - preoccupied
with the loss->functional disruption - intense
for first 3 months
• Chronic grief - may temporarily inhibit
activities; intermittent pain of grief exacerbated on anniversary dates.
• Pathological chronic grief - c/b excessive &
irrational anger, insomnia, major depression
Factors Affecting Loss and Grief
•
•
•
•
Developmental Stage.
Religious and cultural beliefs.
Relationship with the lost object.
Cause of death.
Nursing Care of the Grieving
Client
Five-part model:
• Assessment.
• Nursing Diagnosis.
• Planning/Outcome Identification.
• Implementation.
• Evaluation.
Loss, Grief & End of Life Care
• Worden’s Model 2003- “grieving process series
of evolving tasks”
• Acceptance stage -person accepts of reality of
loss
• Working stage - person works through physical
& emotional pain
• Adjustment stage - person adjusts to a change
in environment
• Relocation of loss - person is able to emotionally
move on with life
Loss , Grief & End of life
• Jett’s Loss Response Model - incorporates a
systems approach
• Loss-> stage of disequilibrium
• Search for meaning of loss
• Story of loss is told repeatedly
(this helps in the grieving process)
• Adaptation & accommodation of new roles
Implications for nursing care
• Goal- to attain healthy adjustment to the loss ;
to reestablish equilibrium
• Interventions  Gently establish rapport
 Offer reasonable hope /emotional support
 Offer support for functional disruption
 Provide information about the disease that
may help person to process the loss.
 Allow/encourage grievers to inform others
 Facilitate elder to reorganize their life
 Guide & encourage the reframing of
memories
Needs of the Dying & their
Families
• The “6 C’s Approach to caring for the dying &
their families • Care - best possible care
• Control - active participant in own care
• Composure -within the realm of one’s culture
• Communication- 4 types of communication
identified (Closed awareness,suspected
awareness,mutual pretense;open awareness
• Continuity - establish legacies
• Closure - corresponds with reconciliation &
transcendence
Care of the Family
• Informing the family as to the
circumstances of the death.
• Providing information about viewing the
body.
• Offering to contact support people.
• Sometimes assisting in decision making
regarding a funeral home and removal
of the dead person’s belongings.
Nurse’s Self-Care
• Dealing with dying clients is stressful.
Nurses must face their grief.
• Unresolved grief is called shadow grief.
Nurses often carry shadow grief which, if
not released, can cause illness and
burnout.
Signs of Shadow Grief
• Loss of energy, spark,
joy, and meaning in life.
• A feeling of being
powerless to make a
difference.
• Increased smoking or
drinking.
• Unusual forgetfulness.
• Constant criticism
directed at others.
• Constant inability to get
work done.
• Uncontrolled outbursts of
anger.
• Perception of clients and
their families as objects.
• Surrender of hobbies or
interests.
Coping with Shadow Grief
• Take time to cry with and
for clients.
• Get physical: run, walk,
bicycle, play tennis.
• Ask colleagues to help
with tasks; avoid being
“Supernurse.”
• Connect to place of
worship; pray.
• Look for joy in work.
Laughter is a great
healer.
• Create a caring circle of
friends.
• Listen to music.
"Every suffering has meaning"
Man's search for meaning- V.E Frankl
You are invited
for your ERASMUS Program in
The Dept. of Nursing, University of Pelponnese Sparta,Greece
(http://sparti.uop.gr/~nosil)
and always remember
Carpe diem
meaning ENJOY EVERY DAY