Transcript Death & Dying, Grief & Loss

Death & Dying, Grief &
Loss
Chapter 30
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Loss & Grief
• Experienced throughout the lifespan
• Grief behavior is shaped by values, culture but
grief itself is universal
• All Change involves some loss
• Nurses deal with patients’ and their own grief
and loss
• Grief is a normal response to loss
• Grief behaviors vary over time and among
individuals, families, and cultures
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Terms
• Situational loss
– Sudden, unexpected, external
– Loss of person, object, limb, function, role…
• Maturational loss
– Part of life transition
– Help develop coping skills
• Anticipatory Grieving
– Before an expected event [e.g. terminal pt]
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Terms
• Palliative Care
– Control of symptoms throughout an illness
including bereavement care for family
• Hospice Care
– Final stage of Palliative Care
– Patient & family with terminal diagnosis
– Client- and family- centered
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More Terms
• Normal [uncomplicated] grief
– Anger, disbelief, yearning, depression,
acceptance
– Time to ‘recovery’ varies – 6 months
• Complicated [dysfunctional] grief
– Persists >6months AND interrupts life
– May follow sudden death, death of child
• Disenfranchised [unsupported] Grief
– relationship not socially accepted
– Same as any other grief + less support
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Factors Influencing Grief & Loss
• Age/ Development
– Children – understanding and behaviors
depends on developmental stage
– Young Adults – experience maturational loss
– Midlife – more maturational losses
– Older – prior experiences may help coping
• Meaning of loss or person
– Affects the grief response & support
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Factors Influencing Grief & Loss
• Coping Mechanisms/ Strategies
– People use what has worked before
– May need new strategies
– Suggest expressing positive feelings
• Culture
– Influences acceptable expression of grief
– Rituals around death
– Who is included as ‘family’
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Factors Influencing Grief & Loss
• Spiritual Belief
– Influences end-of-life care
– Rituals around death
– Belief about afterlife
• Hope
– Ability to see life as having meaning
– Important for nurses
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Nursing Process
• Know yourself
– Own your own beliefs, do not push them
– Take care of your self
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Respect others’ beliefs
Listen
Don’t take negative behaviors personally
Involve pt. and family in planning
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Assessment
• Establish relationship first
• Assess factors like coping style, meaning
of loss, beliefs about death, support
• Use open-ended questions
• Observe verbal & nonverbal responses
• Summarize and validate
• May need to talk to pt, family separately
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Assessment
• Assess understanding of treatment options
– End-of life & after death
• Encourage family involvement
– Assess need for education
• Assess other possible causes of
symptoms/ behaviors
– Loss of appetite R/T grief or disease?
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Nursing Diagnosis
• May address the loss directly OR effects
– Hopelessness R/T loss of child AEB social
isolation and inability to maintain employment
– Nutrition: less than body requirements R/T
decreased appetite and motivation 2* to grief
over loss of child
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Implementation
Focus:
• Facilitate healthy coping, growth
– For families
– For patient
• Enhance quality of life
– Alleviate symptoms
– Promote dignity
– Prevent complications
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Interventions
• Therapeutic communication
– Active listening
– Silence
– Acceptance
– Attitude: you can not fix emotions!
– Provide information, referrals
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Interventions
• Symptom Management
– Ongoing assessments
– Pain management, effects of medications
– Effects of immobility
– Hydration and comfort
– Skin & hygiene
– Elimination
– Oxygenation
– Level of consciousness
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Comfort Care
• Comfort
– Pain relief, N/V, Constipation, fatigue, anxiety
• Skin care
– May include linens, Foley, lotion, mouth care
• Nutrition
– Small, preferred foods
• Respiratory
– O2, position, meds
• Stay available/ with patient
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Bereavement Support
• Involve pt/family in decisions
• Provide space & time for grief & mourning
• Educate about choices
– end-of-life care
– Postmortem options & requirements
• Encourage clear communication
• Answer questions, reinforce info
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Physical aspects of dying
• Symptoms may confuse family
– E.g. loss of appetite, SOB, withdrawal
• May also provide help anticipating time of
death/ imminence BUT may varies – no
guaranteed timetable
• Focus is on relief of symptoms, education
of family, maintaining dignity, following
wishes and cultural rituals
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Loss of Energy
• Physical Weakness / Lack of Energy /
Loss of Interest in Everyday Things
– Search for meaning; self-examination
• Caregivers can help by:
– assisting with ADL’s
– Listening, promoting dignity
– Providing comfort, symptom control
– Preventing injury
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Withdrawal
• Withdrawal from Family and Friends /
Increased Sleepiness / Coma
– ‘entertaining’ visitors may exhaust dying
Caregivers can:
– be there without making demands
– Be aware that the person can likely still hear
even if in a coma-like state
– Advocate for the patient’s stated wishes
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Loss of Appetite
• As the body begins to shut down, need for
food decreases
• Caregivers can:
– Offer small favorite foods
– Respect the person’s wishes if food is refused
– Educate others about the process
• Providing food often makes the
caregiver/family feel better; it is OK to offer
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Difficulty Swallowing
• As body , muscles weaken, swallowing
may become more difficult – may cause
choking
– Reverse diet [Regular – soft – liquid]
– Small amounts [2-5 ml] to test swallowing
– Caregivers can:
• Provide mouth care frequently
• Adapt foods, positioning for safety and palatability
• Crush meds in jam or yoghurt
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Confusion
• May come and go
• May be caused by O2 changes [perfusion]
• Caregivers can:
– Use familiar sounds [music], sights, tactile
sensations to comfort, reorient
– Recognize that this may be a pleasant or
frightening time
– Refrain from arguing, denying the person’s
‘reality’
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Restlessness
• May be intermittent, can be R/T pain,
nausea, full bladder etc. OR confusion
May also signal nearness of death
• Caregivers can:
– Assess for physical symptoms, safety risks
– May be a spiritual crisis – unresolved [access
spiritual counselor, pray]
– Use music, touch, aromatherapy
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Elimination
• As weakness increases, person may
become incontinent, diaphoretic
• Caregivers can:
– Maintain dignity
– Place a Foley for comfort
– Keep skin clean and dry
– Administer pain meds before bathing as
needed
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Circulation
• Temperature control mechanisms start to
fail, circulation withdraws to center
– May cause cool skin or sweating
• Extremities become bluish, mottled, cool
• Caregivers can:
– Follow person’s wishes R/T blankets
– Prevent shivering to conserve energy
– Turn less frequently – for comfort, SOB
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Breathing
• SOB not uncommon;
– O2 for comfort, fan; position semi-fowlers
• Change in breathing signals active dying
– Exhalation longer than inhalation
– Irregular breathing [Cheyne-Stokes]
• Shallow, rapid respiration followed by apnea
• RR 30-50 not uncommon
– Often Indicates days to hours until death
– ‘Death Rattle’ [secretions in throat R/T lack of
swallow] may be disconcerting
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Spurt of Energy
• Some dying people ‘rally’ and become
more alert, energetic, shortly before death
– Caregivers can:
• Use this time to attend to unfinished business, say
goodbye, give person ‘permission to go’
• Involve spiritual guides, chaplain, family members
– Often followed by unconsousness and then
death
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Signs of Imminent Death
• Eyes have glassy fixed stare with large pupils
• Pasty grey, or blue grayish color present especially on
lips, hands and feet
– Hands and feet can be cold
– Pooled blood in dependent areas causes bruised appearance
• Jaw open, breathing through mouth very rapid or very
slow (often with rattle) with pauses of 20-50 seconds
between breaths [Cheyne-Stokes]
• Unresponsive to voice or pain
• Caregivers can: maintain calm, quiet atmosphere,
perform pre-death rituals
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After Death Care
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Specifics depend on facility, legal needs
If autopsy case, leave all tubes
Document everything
Donation – required to discuss
– May offend some
– Autopsy
• Cases of sudden death, unattended, < 24 hrs
• Maintain dignity, respect culture
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After Death Care
• Documentation
– Autopsy? Donation?
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Family to be included? Special ritual?
Bathe body, clean up room
Allow family, others to say goodbye
Personal belongings to family
ID and transport per policy
Self-care
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Evaluation
• Were client goals met at time of death?
• Family goals?
• Goal not met: pt expired with infection…
- OK
• Look for expressions of hope, + coping
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Caring for yourself
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All nurses experience grief & loss
Need balance, rituals, people for support
Change of scenery
Assess yourself
Ask for help – and accept help
Find meaning in Nursing
Practice self-care
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Final thought
"Be wise. Treat yourself, your mind,
sympathetically, with loving kindness. If
you are gentle with yourself, you will
become gentle with others." - Lama Thubten Yeshe
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A Good Death
• http://www.learner.org/vod/vod_window.ht
ml?pid=1279
• Type / copy
http://www.learner.org/resources/series10
8.html into browser if blocked, then click
on ‘A Good Death’
• Other good videos [streaming] on site
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