2Loss, Grief, Dying Class Objectives The nursing student will learn:nurses role in loss, grief, death and dyingemotional reactions to lossEngles stages of griefKubler-Ross Grief and Death Reactionslegal and ethic dilemmas with death and dyingto create a nursing care plan for a death and dying patient.
3Loss Occurs when a valued person, object, or situation is changed Actual LossPerceived lossAnticipated lossPhysical lossPsychological lossActual loss can be recognized by others including the person sustaining the loss, ex: a person losing a limb, spouse, valued object, job etc.Perceived loss- felt by the person but is intangible to others EX:(loss of your youth, financial dependence.Anticipatory loss- the person displays loss and grief behaviors for loss that has yet to take place. EX: families with terminally ill patients and serves to lessen the impact of actual loss- ex.Physical lossloss of an arm from a car accident Physical lossPsychological loss- caused by an altered self image and the inability to return to his or her occupation. A person who is scared by has not lost a limb may suffer from perceived and psychological loss of self image.
4Grief or Grieving-Grief is the Emotional Reaction to Loss Mourning-period of acceptance of loss and grief during which the person learns to deal with the loss.Bereavement- state of grieving during which a person goes through grief reaction.Grief occurs with loss caused by separation as well as with loss caused by death. (Many people who divorce experience grief, loss of a body part a job, a house or a pet.)Bereavement- when a person neglects their own health to an extreme.Mourning person- char. By a return to normal living habits.(refers to Engel’s 6 stages of grief reaction)
5Engels 6 Stages of Grief Reaction Shock and disbeliefDeveloping awarenessRestitutionResolving the lossIdealizationOutcomeShock and disbelief , “no not me”Developing awareness “why me” crying, anger, feeling emptyRestitution – funeral services and rituals surrounding loss cultural influences come in to play here talk about funeralsResolving the loss- dealing with the void left by loss.Idealization- Exaggeration of good qualities of the person or object lostOutcome- acceptance
6Kubler-Ross Grief and Death Reactions Denial and isolationAngerBargainingDepressionAcceptanceKubler- Ross is considered the “pioneer” in the study of grief and death reactions.More important than the stages of any grief reaction is the idea that grief is a process and it varies person to personDENIAL and isolation- pt. Denies that he or she will die. “thy made a mistake in the dx, maybe they mixed my records with someone else.Anger- the pt expresses rage and hostility in the anger stage and adopts a “why me” attitude, I quit smoking and I watched what I ate, Why did this happen to me?”Bargaining- the pt tries to barter for more time. If I can just make it to my son’s graduation I will be satisfied. Just let me live until then” This is the stage wills are made, personal affairs are taken care of, final trips.”Depression- period of grief before death. Characterized by crying and not speaking. “I waited all these years to see my daughter get married. AN d now I may not see my daughter get married. I may not be her to walk her down the aisle.I can’t bear the though to not being there.”Acceptance- pt feels tranquil. She or he has accepted death and is prepared to die. “I’ve tied up all the loose ends- made my will , arrangements for my daughter to live with her grandparents. No I can go in peace.Dysfunctional when person is not able to resume normal life. Unresolved or inhibited. IE peggy’s concerns for allison after jesse died no expression. Talk about people grieve in different ways
7Five Principles of Palliative Care- (Hospice care) Respects the goals, likes and choices of the dying pt.Looks after medical, emotional, social, and spiritual needs of the dying personSupports the needs of the family membersHelps pt gain access to needed healthcare providers and appropriate settingsBuilds ways to provide excellent end of life careMedical, emotional, social, and spiritual needs- focus on making sure there comfortable, not left aloneSupports the needs of the family members- helping with responsibilities of a care giving and supporting them through grief.Builds ways to provide excellent end of life care- through education of care providers, appropriate health policies, adequate funding from insurers and govPage 879 box 33-2
8Ethical and Legal Dimensions Managed death,Legalized physician assisted suicide,Physician administered lethal injections (aid in dying) – create ethical dilemmas.Patients look to nursing for information, advice and support.“bill of rights page 877 box 33-1 “
9The nurse patient relationship is key to helping patient’s grieve
10Advanced DirectivesLiving wills- provide specific instructions about the kinds of health care that should be provided or foregone in a particular situationDurable power of attorney- appoints and agent the person trusts to make decisions in the event of the appointing person’s subsequent incapacity.
12Do not resuscitate or No code orders What is the difference between a DNR or a No code orderandComfort measures only order?DNR Prevents the improper cardiopulmonary resuscitation which is designed to prevent unexpected death.The order means simply that there are no attempts made to resuscitate.Comfort measures only-goal of tx is to comfort pt. Allow dignified death and that further life sustaining efforts are not taken.
13Factors that influence Grief and Dying DevelopmentalFamilySocioeconomicCulturalReligiousCause of DeathDevelopmental- death of a parent can retard a child’s development.Children may not understand death but their sense of loss is great.Family- roles with in the family are identified, for ex. The oldest child may feel the need to be strong.Socioeconomic- if one has no health or life insurance or pension , the family can experience the loss of the person as well as the economic loss. This may result into loss of house, community, and support system.Cultural influences-Western culture grief is private matter that is only shared with family.Religion- May play an important role is expression of grief and provide comfort.Cause of Death- sudden, disease (AIDS), accidental death, death from war, violent deaths, suicides).
14Nursing Process Questions to ask What have you been told about your condition?Have you had any previous experience with this condition or death of a loved one?Tell me a little bit about how you are copingWhat is helping you get through this?Assessing- determine the adequacy of the pt’s and families, knowledge, perceptions, coping strategies and resources.Knowledge- Objective is to id. Whether or not the knowledge of the pt and family possess will allow them to make informed decisions.Perceptions- object is to discover if pt and fx have unrealistic expectationsCoping objective see if family and pt are using effective coping strategies.Resources- assess adequacy of the human financial and spiritual resources avail.Cultural influences
15Nursing Diagnoses Impaired adjustment Caregiver role strain Decisional conflictIneffective copingIneffective denialAnticipatory grievingDysfunctional grievingHopelessnessIneffective management of therapeutic regimemProblem or etiology can be lossPage 891 in text
16Planning expected outcomes The pt and family will achieve:Demonstrate freedom in expressing feelingsIdentify and use effective coping strategies.Accept need for help as appropriateMake healthcare decisions reflecting personal values and goals.Must have trusting relationshipNeeds of both patient and family are psychological, physiological and spiritual. Sexual needs alsoMay feel sexual needs are inappropriate. Choice between both. Can be a form of expression of love, caring acceptance.Hospice role.Accept beliefs of others role is to provide comfort. Not to change or convert
17ImplementingThe nurses aim is to care for the dying pts and their families and promote health and preventing illness of the familyNursing DiagnosisImpaired adjustment r/t newly diagnosed terminal illnessCaregiver role strain r/t hospital discharged dying pt because of inadequate insurance.Dysfunctional grieving r/t inability to accept death of infant no grief resolution.
18Nursing interventions Monitor patient for anxietyMonitor mood changesCommunicate willingness to discuss deathEncourage pt and family to share feelings about deathMonitor painFacilitate obtaining spiritual support for pt and familyInclude the family in care decisions and activities as desired.
19EvaluatingThe plan of nursing care for dying pts. meets the outcome of a comfortable, dignified death and family members resolve their grief after a suitable time of mourning and resume meaningful life roles and activities.
21Clinical Signs of Impending Death Muscle weaknessRespiratory changesCheyne-StokesDeath RattleSensory changesCirculatory changesMuscles. Difficulty with speech, swallowing, movement, incontinence, jaw sagsRespiratory. Cheyne stokes. Alternating deep/shallow breathing with temporary apnea. Death rattle is noisy due to increases secretions. Breathing becomes through mouth vs nose.Sensory vision blurrs, taste and smell declineCirculatory mottling, cyanosis in extremities, cold skin decreased b/p, slow pulse, poor or decreases sensation.
22Postmortem Care Nursing prepares the body for viewing Identification Who to notifyJewelry and valuablesDentures, glasses, prostheticsIn hospital. Leave on bracelet for id. Clean the body and area for family viewing. Remove tubes, IVs, cover and position straighten room.Notify Life center for organ donationHospice if involved.CoronerFamilyPhysicianWho pronounces?Care of the family offer a cup of coffee/teaCare of roommate or other patients.Family gone place body in schroud and tag on the ankle transport to morgue or wait for funeral home to pick it up.
23QuestionA nurse is caring for a pt who is dying of terminal cancer. While assessing the pt. for signs of impending death, the nurse should observe the pt for:Elevated B/PCheyne-Stokes respirationsElevated pulse rateFlushed skin
24Question #1A nurse caring for a 15 y/o pt with terminal CA has assessed that the pt. is very quiet and has not expressed his feelings. The nurse will need to implementA referral for bereavement resources to enhance careInterventions for a pt in isolation and inner thoughtAssessment skills to determine fear and anxietyTherapeutic skills to enhance communicationD therapeutic skills to enhance communication
25Question #2A pt who has ovarian CA with metastasis to the liver complains of increased pain and dysphasia. A physician orders a barium enema. The patient states, “I don’t want this test. What should I do?” The nurse shouldA inform her to refuse the testInform the MD of her statementsEducate her on the test’s benefitsEducate her on the procedureb. Inform the MD of the statements
26Question #3A 39 y/o pt who is apparently dead is brought to the hospital by ambulance. A concerned neighbor found the pt alone in the apartment in this condition. The tentative cause of death is suicide. Even though the family has refuse an autopsy, an autopsy can be ordered by theA families MDCounty courtCity policy deptCounty coroner.Count coroner
27Question #4You overhear a patient state, “If you make me well, God, I will try to be a better person.” You know that this type of statement is one of the stages of grieving known asAngerBargainingDenialDepressionBargaining
28Question #5The process of viewing the body after death best supports which of the following statements?Provides the resolution of the death experience for most familiesIncreases anxiety levelsAllows family members an avenue of escape from the truthSupports the family members’ decision for a DNR