Transcript HG060-003.50_Hospice Care

Hospice Care
for
C.N.A.s
Prepared by Ellen Williams, CAHPN
for
Capitol Community College
Objectives
At the end of the course learner will be able to:
• Discuss hospice philosophy and care
• Discuss importance of communication and IDT in hospice
care
• State the role of C.N.A. in pain control
• State the role of C.N.A. in dyspnea
• Discuss nearing death awareness
• State the role of the C.N.A. at time of death
• Discuss the importance of self care
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Dying Well
• Deeply personal experience
• Natural part of life
• Growth opportunity
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Dying Well
• Manage needs of patient and family
– Physical
– Emotional
– Spiritual
• Goals
– Symptoms well controlled
– Be at peace
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Fears That Arise When Thinking of Own or Family Death
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Being alone
Having discomfort
Loosing control
Loosing loved ones/ life without him/her
Life had no meaning
Unknown
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History of Healthcare in Dying
• No treatment--death at home
• Focus on treatment of disease--death is
failure
• Death in hospitals, institution
• Medical technology has limits
• Hospice movement
• Education and training
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Hospice Care and
Philosophy
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Goals in Hospice
• Quality of life
• Symptom control
• Openness and honesty in dealing with dying
process
• Support for patient and family
• Focus on patient and family goals
• Peaceful death
• Allow natural death
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Overview of Hospice Philosophy
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Interdisciplinary team
Pt and family as unit of care
Across many settings
Pt and family as unit of care
Quality of life
Aggressive symptom control
Cancer
Non cancer illness
Let nature take its course
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Hospice Interdisciplinary Team
• Nursing
– CNA’s
• Counseling
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Social work
Spiritual
Bereavement
Dietary
• Volunteers
• Medical director
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Symptom Control
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Pain
Difficulty breathing
Cough
Respiratory congestion
Nausea and vomiting
Nutrition and hydration
Anxiety
Delirium
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Hospice Medicare Benefit
• Available for anyone who has Medicare A
• Covers hospice services
• Covers medicine and equipment related to
terminal condition
• Levels of care
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Routine
Inpatient
Continuous care
Respite
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Cancer
• People who are not responding to treatment
• People who choose not to have treatment
• People who are not candidates for treatment
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Non-Cancer Illnesses
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Non-Cancer Illnesses for which Hospice may be Appropriate
• Acute Cerecute Cerebrovascular Accident (CVA) – Commonly
referred to as a ‘stroke’ when patient has severe deficits.
• Autoimmune Deficiency Syndrome (AIDS) – Caused by a virus,
which attacks the body’s immune system and leaves the patient
susceptible to many life-threatening diseases including bacterial
infections and cancers.
• Amyotrophic Lateral Sclerosis (ALS) – This is also called Lou
Gehrig’s disease. Cause unknown, but the disease is characterized by
an advancing degeneration of portions of the nervous system, causing
weakness and progressive loss of function.
• Alzheimer’s Dementia – Caused by degeneration of the brain cells.
The disease is progressive, with the rate of progression varying widely
among individuals. In the final stages the patient frequently
discontinues eating and drinking.
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Non-Cancer Illnesses ... (continued)
• Cardiac Disease – This group includes many diseases of the heart that
may be life threatening, such as congestive heart failure and
cardiomyopathy. Fluids may accumulate in the tissues, generating
swelling (edema) or in the lungs producing congestion and difficulty
breathing.
• Chronic Obstructive Pulmonary Disease (COPD) – This includes
several diseases on the lungs, characterized by obstruction of the tiny
air passages or air sacs in the lungs. Breathing becomes difficult and
patients frequently require oxygen.
• Debility Syndrome – or Failure To Thrive. Patients without one
specific diagnosis that is considered terminal, but with multiple
diagnoses contributing to a general system failure.
• Kidney Disease – Kidneys are not functioning correctly. Patient
chooses to stop dialysis or not start.
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Non-Cancer Illnesses ... (continued)
• Liver Disease – Diseases may include cirrhosis, hepatitis or vascular
disorders of the liver. Patients with end stage liver disease may become
confused then lapse into a coma due to accumulations of toxins in the
blood. Cirrhosis is caused by many different things, not necessarily
alcohol.
• Multiple Sclerosis - Multiple Sclerosis is a progressive disease in
which nerve fibers of the brain and spinal cord lose their myelin cover.
• Parkinson’s Disease - a slowly progressive neurological disorder
characterized by resting tremor, shuffling gait, stooped posture, rolling
motions of the fingers, drooling and muscle weakness, sometimes with
emotional instability.
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Dementia
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Dependent with dressing
Dependent with bathing
Unable to ambulate independently
Incontinent of bowel and bladder
Unable to speak more than six words
meaningfully
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Dementia
At least one of the following medical complications:
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Aspiration pneumonia
Recurrent fever despite antibiotic treatment
Upper respiratory infection
Urinary tract infection
Weight loss of 10 % in six months or less
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Goals of Care
• To provide care that matches the resident’s and
family’s goals and values
• To guide everyday clinical decisions and actions
• To make sure we use healthcare resources
wisely
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C.N.A. Roles
• Listening to residents and families and helping them to
identify and express their goals, values, and wishes
• Communicating goals, values, and wishes to other team
members
• Encouraging residents and families to discuss their goals
and wishes with other hospice interdisciplinary team
members (e.g, MD, spiritual care counselor, social
worker, nurse)
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Goals of Medical Therapies
• Care
• Control
• Comfort/palliation
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Decisions at the End of Life
Should I continue with treatments aimed at
curing my disease or condition?
or
Should the focus of my medical care be on
keeping me comfortable?
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Decisions at the End of Life
If my condition gets worse or I develop a
medical problem:
Do I want to be transferred to a hospital?
or
Do I want to be cared for at the nursing
home or my home or my child’s?
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Decisions at the End of Life
• If I can no longer make decisions for
myself, who should make the decisions for
me?
• What decisions do I need to make to get my
affairs in order?
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Decisions at the End of Life
If I needed machines and other medical
treatments to stay alive:
Would I want to receive those therapies?
or
Do I want nature to take its course?
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Treatment Options
Decision makers need to understand risks/benefits and
probable outcomes of therapy:
• CPR/mechanical ventilation
• Kidney dialysis
• Diagnostic tests
• Hospitalization
• Antibiotics
• Blood transfusions
• Tube feeding/intravenous fluids
• Pain management and comfort care
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Exploring Values and Beliefs
• Who should speak for me?
• What makes my life worth living?
• What are personal and spiritual beliefs that
influence decisions?
• Hope for recovery?
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Advance care planning,
informed consent,
and
medical decision making are
Processes
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Ideally, identifying goals of care
occurs
before a major change
in resident status or a medical crisis
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Ideally, the Resident is Able to Make Decisions
• Understands the information given
• Thinks clearly about treatment options
• Can communicate decisions
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Residents Who Might Not be Able to Make Decisions
• Those with advanced dementia
• Who have had strokes that decrease
their ability to understand or to speak
• Who are in a coma
• Who have a serious mental disease
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Don’t Assume a Resident is Unable to Make Good
Decisions Because:
• They are strange or odd
• They don’t speak your language
• They are not well educated
• They are physically handicapped
• They are deaf
• They disagree with their family or the health
care team
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Advance Directives
• Are written instructions (directives) to a
health care provider before (advance) the
need for medical treatment
• Ensure that your wishes are followed in the
event that a future accident or illness makes
it impossible for you to communicate your
wishes
• In an AD, you can refuse or consent to future
treatment
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Types of Advance Directives
• Living will (health care directive)
• Durable power of attorney for health care
(health care proxy)
• No code/do not resuscitate (DNR)
• Anatomical gifts - tissue/organ/body
donation
• Do not hospitalize (DNH)
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Purposes of Advance Directives
• To help a person maintain autonomy after he
or she can no longer make decisions; helps
ensure that person’s wishes are honored
• Provides guidance to family and caregivers
about type and goals of care
• Can decrease family and caregiver distress
about decision making
• Can decrease conflict around EOL decision
making
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Who Can Make Decisions if the Resident isn’t Capable?
(List is in order of priority)
• Appointed guardian
• DPOA - HC
• Patient's spouse
• Adult (18+ years) children
• Patient’s parents
• Adult brothers and sisters
• If none of the above, guardian may be appointed
RCW 7.70.065
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Communication in Hospice
• Staff
• Patient
• Family
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Basic Principles of Communication
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One cannot not communicate
Communication is a two way activity
Much communication is nonverbal
Actions and words are perceived by the
receiver based on own personal experiences
• Listening is one of the most important parts of
EOL communication
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Communicating with Staff
• Hospice IDT important in exploring all
aspects
• Need to update one another with patient and
family issues
• Each patient has individual needs
• Update nurse as you find new information or
needs
• Update individual care plans
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Co-Workers
• Update them on new concerns with patient or
family or care needs
• Report how the day is going
• There may be emotional upheavings
• Report what has helped
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How to Address Your Patients
• Ask what they want to be called
• Find if they have a nickname they want used
• Many folks find “honey” and “sweetie”
insulting
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Cultural Influences
• One’s rules for communication (is touching
OK?)
• How emotions are expressed
• One’s view of illness and death
• How the family makes decisions and who the
sick person wants to speak for him or her
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Life Experiences
• People often die how they have lived
• People who have not trusted much most likely
still will not trust
• People who have been demanding will
probably continue to be demanding
• People who have been fairly happy will
probably still be somewhat pleasant
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Some Challenges in Communication in Hospice
• Society's denial of death -- how openly
families will talk about approaching death
• Patient and family’s fears and emotions
• Dementia and severe illnesses where patients
are not able to talk about their wishes
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Caregiver Challenges
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Not sure of what to say
Not having “the answers”
Fear of showing own emotions
Fear of making a mistake which might upset
the family or patient
• One’s own fear of dying
• Having trouble with patient or family
reactions
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Family Emotions
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Fear
Guilt
Hopelessness
Helplessness
Anger
Sadness
Relief
Ambivalence
Acceptance
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Tips on How to Respond
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Remove yourself from the situation
Ask yourself : what am I feeling? Anger? Fear?
How are you showing these feelings?
Are they affecting your care?
Talk with other team members
Make a plan to deal with the conflict with the team
Use “I” statements: ”I feel uncomfortable when you
raise your voice”
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When Communicating With Someone Who Is Upset
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Stay calm
Do not raise your voice
Treat them with respect
Do not argue or touch the person
Answer questions or if you do not know, find
someone who can
Let the person vent but do not let them abuse you
Remember anger is normal part of grieving process
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Concepts in EOL Communication
• Being present is most important
• Use active listening
• Allow the patient and family let you know
what is important to them
• Encourage life review
• Listen to all tell their story
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Working With Hospice Families
• Legitimize their feelings: “I would feel that
way, too”
• Normalize feelings: “Many families feel this
way when going through this transition time”
• Be aware of your own personal opinions:
– Do not bring your own agenda into any discussion
– Ask yourself: Who wants this?
– Our expectations may not be met-- allow patients
their own agenda
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Keep Questions to a Minimum
• Only ask necessary questions
• Respect privacy of both patient and family
• If you need to ask a sensitive question, explain
why it is important
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Hope at EOL
• Self: accepting and moving beyond current
suffering
• Rational: setting goals and keeping control
• Relational: being connected to others
• Spiritual: being connected to God or
something larger than self
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Professional Relationships
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Are different from personal relationships
Are one way
Stick to agency rules
Are confidential but not secret
Do not continue outside of work
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Common Mis-Assumptions
• It’s the other person’s fault/problem when
communication is poor
• The other person can always change the way
they are
• It works to treat everyone the same way
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Communication Don’t’s
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Use “should” or “ought”
Give advice or offer solutions
Argue and/or repeat your point
Make dramatic comments
Judge, criticize, or place blame
Threaten
Interrupt
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Communication Don’t’s
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(continued)
Make light of patient’s problems
Feed into patient’s problems
Promise extra care “this time”
Talk about other patients or families
Talk about your own problems
Dwell on the past
Ask for their help
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Communication Do’s
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Be consistent
Be kind
Follow agency policies
Set clear boundaries
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Keys to Good People Skills
• Self-awareness
• Thinking about and taking into account
someone else: “walk a mile in their shoes”
• Know your purpose; be aware of what you are
trying to accomplish
• Avoid making the other person wrong
• Change your approach if the one you are using
is not working
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Techniques
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Smile
Open eyes
Steady even rhythm
Give patient and family choice
Explain what you will do
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Techniques (continued)
• Listen
• Repeat back what you understand the
person to have said
• Find common ground
• Honor diversity
• Be as specific as possible
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The Basic Principles
• Focus on the situation, issue, or behavior, not
the person
• Help to maintain the self-confidence and selfesteem of others
• Maintain constructive relationships
• Take initiative to make things better
• Lead by example
Zenger Miller, Inc
1994
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Points to Remember
• Remember why you are there
• Be aware of your own reactions and how they
impact how you are coming across
• Be respectful
• Know that how you communicate makes a
difference
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Emotional Issues
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Emotional Issues
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Deal with anxiety about terminal illness
Unfinished business
Long term planning for self and family
Family issues: “Did I do enough?”
Financial issues
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Dealing With Emotional Issues
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Listening is important
Realize family patterns cannot be changed
Allow patient and family to talk about feelings
Feelings may change from day-to-day or hourto-hour
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Pain
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Pain Definitions
• “an unpleasant sensory or emotional
experience” -- IASP
• “anything the patient says it is” -- Margo
McCaffrey
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Pain Versus Suffering
• Pain can be on many levels
• Most people think it is only physical
• When emotional or spiritual pain is involved,
this often becomes suffering
• Sometimes the physical pain needs to be
controlled for the patient to get to this level
• All the members of the hospice IDT become
involved and are important
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Common Types of Pain
• Arthritis
• Nerve related -- diabetic neuropathy, after
shingles, phantom pain after amputation
• Constipation
• Cancer pain
• Injury related
• After surgery
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Acute and Persistent Pain
• Acute
– Sudden onset
– After injury or surgery
– Usually improves with healing
• Persistent
– Slow onset or follows acute
– Cause may not be known
– Goal: keep function and quality of life
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Myths About Pain in the Elderly
• Natural part of growing old
• Older folks are less sensitive to pain
• If one does not report pain, they are not
experiencing it
• If one is sleeping, they are not experiencing
pain
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Issues With Addiction
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Tolerance
The body becomes used to certain doses of
medicine and needs higher doses to
relieve pain
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Physical Dependence
• Body has withdrawal symptoms if medicine is
stopped abruptly
• This occurs with many pain medicines, as well
as antidepressants and steroids
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Addiction
• Biological and emotional illness
• Loss of control over drug use
• Continued use despite harm to self and others
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Pseudo-Addiction
• Occurs with under-treatment of pain
• May appear like addiction, but behaviors
stop when pain is relived
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Common Words Used to Describe Pain
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Discomfort
Sore
Ache
Heavy
Crampy
Burning
Pressure
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Intensity
1 2 3 4 5 6 7
Mild
Moderate
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Severe
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C.N.A. Role in Pain
• Observe for discomfort and report it and get
help for patient
• Observe for changes after treatment-- Does it
get better? Is patient having new confusion?
• Administer non drug treatments, exercise,
ROM, as directed by nurse
• If patient uses heating pad or ice, check skin for
redness or burns.
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Things to Observe
• What seems to make patient more
uncomfortable?
• What helps to make it better?
• Is there a pattern (when you transfer? when you
roll him/her in bed)?
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Screening for Pain
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Always ask if the patient is uncomfortable or hurts or
aches
Believe The Patient!
Remember pain is whatever the person says it is,
occurring whenever and wherever the person says it
does
People have different coping patterns and may not
always look like you think a person with pain should
look like
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Screening for Pain
(continued)
• Patients may display any of the following either
at rest or while being moved:
– Sleeping a lot of the time or having difficulty
sleeping
– Coping with pain by using behaviors such as
watching TV, humor, conversation, listening to
music and guided imagery
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Pain in Cognitive
Impairment
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Pain in Cognitive Impairment
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Many folks can still report discomfort
Need extra time
Look for changes in behavior
Look for facial expressions
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Pain in Cognitive Impairment
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Observe
– Facial expressions
• Grimacing
• Frowning
• Wrinkling of the brow (forehead)
– Verbal expressions
• Moaning
• Groaning
• Crying out
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Pain in Cognitive Impairment
• Movements
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Restlessness
Fidgeting
Pacing
Rocking back and forth
Wringing hands
Clenching fists
Rubbing or protecting the place that hurts
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Pain in Cognitive Impairment
• Changes in
– Eating or sleeping
– Usual behaviors (for example a very vocal patient
becomes quiet or a very quiet patient becomes very
vocal)
– Activity level or resisting activity or movement
– Tone of vocalization
• Withdrawal from family, friends
• Noisy, labored breathing
• Looking scared, worried or troubled
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Cognitively Impairment Pain
• If you notice any of the above behaviors
– Check for hunger, thirst, incontinence, positioning
issues, hot or cold issues, over-stimulation
– If none of the above helps, notify nurse of behaviors
as possible pain behaviors
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Dyspnea
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Dyspnea Definition
• Respiratory distress
• A feeling of air hunger
• Breathlessness
• Can’t catch breath
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Causes of Dyspnea
• Pneumonia
• COPD
• Tumors
• Anemia
• Ascites
• Panic
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Symptoms of Dyspnea
• Rapid respiratory rate
• Using accessory muscles
• Sweating
• Being anxious
• Gasping
• Flaring nostrils
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C.N.A. Role in Dyspnea
• Listen
– Report feelings of breathlessness
– Report inability to catch breath
• Observe
– Rapid respiratory rate
– Periods of apnea (no breathing) of up to 40 seconds
– Respiratory congestion
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C.N.A. Role in Dyspnea
• Report to nurse
• Raise head of bed
• Raise arms on pillows
• Some patients prefer to lean forward over table
• Cool cloths
• Fan if patient desires
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Nausea and Vomiting
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Nausea and Vomiting
• People can be nauseous without vomiting and
still feel miserable
• If patient vomits, save it for nurse or
approximate amount and color
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Possible Causes of Nausea and Vomiting
• Constipation
• Obstruction
• Medication side effects
• Coughing
• Tumors
• Overeating
• Emotional response
• Pain
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C.N.A. Role in Nausea and Vomiting
• Report to nurse
• Remove food
• Offer liquids, if authorized by nurse
• Start with ice chips or sips of water
• Avoid acid juices (such as cranberry, grape,
apple)
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C.N.A. Role in Nausea and Vomiting
• Cool cloths to head
• Wash patients face and hands
• Change clothes
• Clean floor or linen if needed
• Quiet calm environment
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Anxiety
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Anxiety/Agitation
• Anxiety
– Feeling worried, apprehensive or uneasy, especially
about the future
• Agitation
– Very restless with increased mental and physical
activity
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Possible Causes of Anxiety/Agitation
• Medication side effects
• Chemical changes in the body
• Family concerns
• Financial concerns
• Fears of the unknown
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C.N.A. Role in Anxiety/Agitation
• Listen
– Reports of anxiety or worry
– Feeling heart is pounding hard
• Observe
– Increased agitation
– Increased respiratory rate
– Patient wanting you to stay all the time
• Report any of the above to the nurse
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How to Help in Anxiety
• Listen compassionately
• Stay with the person
• Hold their hand or touch their shoulder (gentle
touch)
• Decreased stimulation (turn off TV, lights)
• Try to move away from noisy folks
• Reassure patient he/she is safe
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Anorexia
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Anorexia/Cachexia
• Anorexia -- loss of appetite
• Cachexia -- muscle wasting and weight loss
• Observe changes in eating patterns or
swallowing
• Measure weights
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Possible causes of Anorexia/Cachexia
• Medications
• Difficulty swallowing
• Loosing muscle ability
• Depression
• Constipation
• Obstruction
• Mouth sores
• Dentures not fitting
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C.N.A. Role in Anorexia
• Think about your own beliefs about tube
feelings (but don’t share them)
• Assure family they are not starving patient
• Provide small frequent snacks or sips, at patient
desire
• Use thickeners, if ordered
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Ways to Help in Anorexia
• Support patient/family decisions
• Remind family that decreased appetite occurs
often at end of life
• Provide good mouth care every two hours
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Nearing Death
Awareness
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Nearing Death Awareness
• A special knowledge about the process of dying
that some patients experience
• The attempt of dying people to describe what
they are experiencing
• It may be an attempt to request something the
person needs for a peaceful death
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Signs of Nearing Death Awareness
• Appearance of confusion
• Seeing and/or speaking to those already dead or spiritual
beings
• Talking about seeing other places of light, peace, or
beauty
• Uses symbolic language – talks of journeys, luggage,
standing in line
• Going home
• May begin to ask for people with whom they need
closure
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How to Help in Nearing Death Awareness
• Report observations to the Interdisciplinary Team
• Listen carefully to the person and affirm their
communication
• Ask gentle questions if the person is expressing a need
• Involve the family in this experience and support them –
assure them that this is not confusion but is a significant
change in condition
• Explore with family possible meaning
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Impending Death
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Symptoms of Impending Death
• Sleep more
• Withdraw from people or have little to say
• Eat or drink less
• Have trouble swallowing
• Become more confused
• Lose control of bowel and bladder
• May have burst of energy
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Symptoms of Impending Death
• Have moist breathing or sound congested
• Have changes in the pattern of breathing such as apnea
then several quick, deep breaths
• Have blurred vision
• Have less pain
• Have cool feeling hands and arms or feet and legs
• Turn blue around nose, mouth, fingers, toes
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C.N.A. Role in Impending Death
• Allow the patient to sleep as much as they wish
• Moisten the patient’s mouth with a toothette
• Continue to talk clearly to the patient;
remember that the patient may be able to hear
even when not able to respond
• Keep a light on in the room, as the patient
cannot see well and may be scared by darkness
and shadows
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Ways to Help in Impending Death
• Play the patient’s favorite music softly
• Encourage visitors to talk directly to the patient
and tell the patient who they are
• Keep things calm around the patient
• Model touching and being near the patient for
loved ones
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C.N.A. Role At Death
• Notify the nurse
• Support the family, if present
• Ask if there is any thing special that needs to
happen in their religion
• Allow family time alone, if patient is
incontinent or drooling offer to clean this, or
help family to do so
• Follow your agency protocol for post mortem
care
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Discussion
• What stresses do you experience in doing postmortem care?
• Discuss cultural or religious concerns around
care, both personal and concerns you have
observed.
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Spiritual Issues
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Spirituality
• Different from religion
• Wide possibilities, but very specific and
personal for individuals
• What gives meaning to one's life
• Where one turns to feel strength
• What brings joy to one’s life
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Life Review
• Finding meaning
– Encourage patient to remember life both good and
bad
– Helps to emphasize the uniqueness of each life
• Helps to build a connection
• Brings joy and humor and sadness
• Can lessen physical and emotional pain
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Life Review With Dementia
• Family and friends can add input
• Singing
• Pictures
• Memories if you’ve worked with someone for a
while
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Significance of Death in Patient’s Belief System
• Each religion has ways of dealing with death
• Folks not connected to a religion have own
thoughts about death
• Certain rituals may be important in folks lives
• Do NOT try to change patient to your religion
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How to Identify Spiritual Distress
• Definition: an uncomfortable experience of
spiritual or existential struggle within which
there is potential for growth
• Helpful to know
– Fears
– Hopes and expectations
– Unfinished business
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Fears of Dying Person
• Lack of meaning or incomplete life
• Loss of control
• Loss of personal identity
• Loss of relationships
• What happens after death
• The unknown
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More Fears
• Loneliness
• Being a burden
• The dying process
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Will it be painful?
How long will it take?
Will I be abandoned?
Will I lose my dignity?
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Hopes and Expectations
• To get well and be productive again
• To die with dignity, surrounded by caring
people
• To be able to keep some control
• To mange pain
• To express needs and feelings openly
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Unfinished Business
• Seeing a loved one who is far away
• Taking one last trip to ….
• Completing an unfinished project
• Providing for loved ones
• Forgiving
• Being forgiven
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C.N.A. Role in Spiritual Distress
• Listen supportively
• Stay with someone—being present
• Life review
• Encourage use of spiritual strengths
• Referral to spiritual caregiver
• Report to nurse
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Role of Spiritual Counselor in Hospice
• Consistent presence
• To help with seeing meaning in one’s life
• Encourage reconciliation with estranged ones
• Support in death
• Help with services
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Role of Spiritual Counselor in Hospice
• Consistent presence
• To help with seeing meaning in one’s life
• Encourage reconciliation with estranged ones
• Support in death
• Help with services
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Self Care
Stress: Definition
State of bodily or mental tension resulting
from factors that tend to alter
an existent equilibrium
Merriam-Webster online dictionary
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Factors Which Affect Stress
• Emotional issues
• Role overload
• Role conflict
• Issues of power and control
• Team conflicts
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Physical Signs of Stress
• Increased BP, HR, reaction time
• Indigestion
• Weight gain or loss
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Psychological Signs of Stress
• Excitement or fear
• Sadness, depression, apprehension
• Poor sleep, fatigue
• Negative attitude
• Increased smoking, alcohol or drug use
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Long Term Stress
• Multiple grief and losses
• Compassion fatigue
• Burnout
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Stress Management
• Assertive communication
• Conflict management
• Lifestyle management
• Forming personal philosophy
• Self-renewal
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Self-care is not . . .
• An emergency response plan
• About acting selfishly
• About doing more
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Self-care is not . . .
• An emergency response plan
• About acting selfishly
• About doing more
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Self-care is taking the time
to be a human being,
as well as human doing
from PERT Education Program
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Grief and Bereavement
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Grief and Bereavement
• Patient
• Family
• Professional
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Patient Grief
• Dealing with loss issues
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Loss of employment
Loss of social network
Loss of function
Loss of independence
• Anticipatory grief
– Loss of family
– Loss of self or transition
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Normal Grief
• Human reaction to loss
• May include
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Experiencing the pain of loss
Accepting reality of loss
Adjusting to life without loved one
Bring up previous losses
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Early Stages of Grief
• Experiencing the pain
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Stomach “tied in knots”
Shock and disbelief
Numbness
Agitation
Nausea
Panic
Hearing or seeing the deceased loved one
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Emerging Awareness of Grief
Adjusting to new life
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Fear
Guilt
Anger
Crying spells
Trouble concentrating
Withdrawal from friends and family
Mood swings
Change in sleep and appetite
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Complicated Grief
• Absence of expected grief
– Stoicism
– Total denial
• Prolonged grief (many years)
• Excessive fear, anger or guilt
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Complicated Grief
• Risk factors
– Poor support systems
– Multiple losses and stresses
– Ambivalent relationship between deceased and
bereaved
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Role of C.N.A.
• Support family by telling them grieving is
normal
• Using non-verbal communication
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Smile
Touch
Hug
Quiet listening
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Things Not to Say
• “I know how you feel”
• “This was God’s plan”
• “God needed (deceased) in heaven”
• “You’ll get over it”
• “You shouldn’t feel that way”
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Some Things to Say
• “I’m so sorry”
• “Tell me about (your loved one)”
• “What is this like for you?”
• “What I remember most about him/her is…”
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Other Ways to Help
• Provide space for grieving
• Allow family time alone with the body
• Send a card or note to bereaved
• Attend the services
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Family Grief
• Loss issues
– Present
– Past
• Role changes
• Financial issues
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Professional Grief
• Shock and denial can happen
• Each staff member will react differently
• Each has personal and cultural beliefs about
death
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Facts About Loss and Grief
• Every loss has an accompanying grief
• Grief is a process
• Loss, like stress, can accumulate
• We all grieve differently
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Symptoms of Grief
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Disorganization
Depression
Anxiety
Sadness
Frustration
Anger
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Insomnia
Appetite changes
Tightness in throat
Restlessness
Irritability
Hostility
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Symptoms of Grief
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Disorganization
Depression
Anxiety
Sadness
Frustration
Anger
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Insomnia
Appetite changes
Tightness in throat
Restlessness
Irritability
Hostility
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Myths About Grief
Myth
– Only family members
grieve
– Grief is an emotional
reaction
– Grieving means letting
go of the deceased
– Grievers are best left
alone
Reality
– All who are attached
grieve
– Grief is manifested in
many ways
– We never fully detach
from those who have
died
– Grievers need
opportunities to share
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Facts About High Loss Work
• Workers who experience frequent losses at
their work site will experience grief responses
• Professional grief is different from personal
grief
• Familiarity with death does not make it easier
to accept loss
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Difference Between Professional and Personal Grief
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Professional caregivers are distant mourners
Professional losses accumulate
Effects of grief are hidden and often delayed
Professional grief is a significant cause of
burnout
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Coping Methods
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Maintaining control
Overwork
Realism with hope
Apathy (burnout)
Guilt
Letting go
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Bereavement Overload
• Warning signs:
– Increased irritability, anxiety, being forgetful;
having trouble meeting work demands that weren’t
previously a problem
– Cynicism, resentment, procrastinating, loss of
interest in social plans
– Fatigue, sadness, depression, digestive problems,
hopelessness.
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Things That Help
• Talking
– Talk about your feelings and your losses and good
memories
– Find a buddy who shares your values and
understands why you feel the way you do
• Rituals
– Attend memorial services
– Develop personal rituals of remembrance to honor
the memories of the lives that you touched, and that
touched you
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Things That Help
• Spirituality
– Find and focus on your core beliefs
– May be your religion, or other more individual
beliefs
• Physical activity
– Even though you may be doing physically
exhausting work, it doesn’t leave you feeling
energized
– Look for activities that leave you with a tired-happy
feeling, especially things outdoors in nature
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