4Values, Morals, & EthicsValues: 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 familyValues 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.
5Values 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 valuesOnce 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
6Watson (1981) outlined 4 important values of nursing: 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 serviceBelief in the dignity and worth of each personCommitment to educationAutonomy
7Nurses 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”
8This acceptance and nonjudgmental approach requires nurses to be aware of their own values and how they influence behaviorValues about life, health, illness, death.
9Morals and EthicsMorals: 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 group norms
10Morals and EthicsEthics 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)
11Morals and EthicsIn 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 acceptedDifferences in values and decisions put people into direct conflict.
12Morals and Ethics (resolving conflicts) Be constructive (rather than destructive) in the methods you choose to work toward resolving the differencesListen carefully without interruptionsSeek clarification using gentle questioningRespect cultural differencesBe attentive to body languageExplain the context of your point of view and try to picture the other person’s expective of what you are saying
13Comparison of morals and ethics Formal responding process used to determine right conductProfessionally and publicly statedInquiry or study of principles and valuesProcess of questioning, and perhaps changing, one’s moralsSpeaks to relationships between human beingsMoralsPrinciples and rules of right conductPrivate, and personalCommitment to principles and values is usually defended in daily lifePertain to an individual‘s character
14Moral distressWhen 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.
15Basic ethical concepts RightsAutonomyBeneficence and NonmaleficenceJusticeFidelityVeracityThe standard of best interest
16Basic ethical concepts Rights Rights form the basis of most professional codes and legal judgmentsSelf-determination rightsRights and cultural relativismRights of the unbornRights of privacy and confidentiality
17Basic ethical concepts Autonomy Involves the right of self-determination, independence, and freedom.It refers to the right to make one’s own decisionsRespect for autonomy means that nurses recognize the individual’s uniqueness, the right to be what that person is, and the right to choose personal goalsNurses 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
18Basic ethical concepts Autonomy Respect for people also means treating others with considerationIn 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
19Basic 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 clearA client may be at risk of harm during a nursing intervention that is intended to be helpful (e.g. medication)
20Basic ethical concepts Justice Is often referred to as fairnessNurses frequently face decisions in which a sense of justice should prevail (succeed)E.g. busy unit, new admission
21Basic ethical concepts Fidelity Means to be faithful to agreements and responsibilities one has undertakenNurses have responsibilities to clients, employers, government, society, the profession, and themselvesCircumstances often affect which responsibilities take precedence at a particular time
22Basic ethical concepts Verasity Refers to telling the truthAs 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?
23Basic 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
24Nursing Codes of Ethics Nurses have four fundamental responsibilities: to promote health, to prevent illness, to restore health, and alleviate suffering.Nurses and peopleNurses and practiceNurses and the professionNurses and the co-workers
25DEATHMosby’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.
26The 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:DenialAngerBargainingDepressionAcceptance
271. DenialOn 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.
282. AngerPatients 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.
293. BargainingThe 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.
304. DepressionThe 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.
315. AcceptanceThe 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).
33SpiritualityReligion 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.
34Existential 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
35Management 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.
36Symptom 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)
37PAINThe 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 painUse of medicationsUse of nonpharmacologic methods
38Deal 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.
39Deal with…. Living Wills Prepared while patient has decisional capacityDescribes 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
40The Nursing ApproachNurses 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.
41Death & 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.
42The Nursing ApproachThe person who deals with the dying patient must commit (Schwartz and Karasu, 1997) to:Deal with mental anguish and fear of deathTry to respond appropriately to patient’s needs by listening carefully to the complaints andBe fully prepared to accept their own counter transferences, as doubts, guilt and damage to their narcissism are encountered.
43The 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.
44The Nursing ApproachMany nurses are not well prepared to deal with death and dyingNonmalignant or chronic conditions, (such as cardio-respiratory disease) are usually treated with acute care focusNurses are frustrated by giving futile treatmentsLack 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
45Definition 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)
46WHO Definition (Continued): Affirm life and regard dying as a normal processNeither hasten nor postpone deathProvide relief from pain and other distressing symptomsIntegrate psychological and spiritual aspects of careOffer a support system to help patients live as actively as possible up to deathUse a team approach to address the needs of patients and their familiesOffer a support system to help the family cope during the illness and their own bereavement
47HospiceA 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.
48Why is Palliative Care Important to Nurses? Death and dying are too rarely discussedCommunication among patients, their families, and health care providers is often lackingThere 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
49Palliative VS. Hospice Care (ANA-ELNEC) No hospitalizationFocus on comfort vs. cureNo invasive proceduresHospice org’s. provide medical,nursing,nurse assistants,chaplain,social worker24 hr support pt & familyBereavement services
50Nursing Interventions Encourage discussion of “end- of-life “Decisions re: type of careAdvance directivesEuthanasia - Active vs. passive.
51Assessment 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.
52Physiological Needs of the Dying Client Respirations.Fluids and nutrition.Mouth, eyes, and nose.Mobility.Skin care.Elimination.Comfort.Physical environment.
53Signs 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.
54Legal Aspects Following Death Autopsy (examination of the body after death by pathologist to ascertain cause of death).Organ Donation.
55ChallengesNurses may be confused and frustrated about what the DNR order meansHow far do you go with invasive treatments?Patients must be given realistic expectations of prognosis and treatment outcomesWhat 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
56Implications 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?”
57End of Life Discussions: Break bad news sensitivelyProvide information as the patient wishesPermit expression of emotionClarify concerns and problemsInvolve patient and family in making decisions about treatmentSet realistic goalsProvide appropriate medical, psychological, and social care, and promote continuity of care
58Nursing Students Need To Know: Pain and symptom managementGrief, loss and bereavement issuesCommunication skillsCultural considerationsEthical and legal issuesQuality end-of-life careStandards of practice for sound clinical judgment in pain managementAcute, chronic, and end-of-life pain issuesAssurance that nurses are supported for providing appropriate pain management
60LossAny situation —actual, potential, or perceived —wherein a valued object or person is changed or is no longer accessible to the individual.
61Types of Loss Actual (loss of someone or some thing). Perceived (felt by an individual but not tangible to others, e.g. loss of self-esteem).Physical (loss of part or aspect of the body).Psychological (emotional loss, e.g. a woman’s feelings after menopause).
62Categories of Loss Loss of External Object. Loss of Familiar Environment.Loss of Aspect of Self (Physiological or Psychological).Loss of Significant Other.
63Grief“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.”
64GriefA series of intense physical and psychological responses that occur following a loss.A normal, necessary, and adaptive response to a loss.
65Mourning & 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.
66Theories of the Grieving Process Leading theoretical models describinggrieving have been devised by:Erich LindemannGeorge L. EngleJohn BowlbyWilliam Worden
67Lindemann 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.
68Engle 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).
69Bowlby Theory Four Stages of Mourning Numbness. Yearning and searching.Disorganization and despair.Reorganization.
70Worden 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.
71Types of GriefUncomplicated (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).
72Types of GriefAnticipatory grief ->premature detachment = sociological death; premature withdrawal of a person =psychological deathAcute grief - a crisis. - person feels physically sick & is emotionally distressed - preoccupied with the loss->functional disruption - intense for first 3 monthsChronic grief - may temporarily inhibit activities; intermittent pain of grief -exacerbated on anniversary dates.Pathological chronic grief - c/b excessive & irrational anger, insomnia, major depression
73Factors Affecting Loss and Grief Developmental Stage.Religious and cultural beliefs.Relationship with the lost object.Cause of death.
74Nursing Care of the Grieving Client Five-part model:Assessment.Nursing Diagnosis.Planning/Outcome Identification.Implementation.Evaluation.
75Loss, Grief & End of Life Care Worden’s Model “grieving process series of evolving tasks”Acceptance stage -person accepts of reality of lossWorking stage - person works through physical & emotional painAdjustment stage - person adjusts to a change in environmentRelocation of loss - person is able to emotionally move on with life
76Loss , Grief & End of lifeJett’s Loss Response Model - incorporates a systems approachLoss-> stage of disequilibriumSearch for meaning of lossStory of loss is told repeatedly(this helps in the grieving process)Adaptation & accommodation of new roles
77Implications for nursing care Goal- to attain healthy adjustment to the loss ; to reestablish equilibriumInterventions -Gently establish rapportOffer reasonable hope /emotional supportOffer support for functional disruptionProvide information about the disease that may help person to process the loss.Allow/encourage grievers to inform othersFacilitate elder to reorganize their lifeGuide & encourage the reframing of memories
78Needs of the Dying & their Families The “6 C’s Approach to caring for the dying & their families -Care - best possible careControl - active participant in own careComposure -within the realm of one’s cultureCommunication- 4 types of communication identified (Closed awareness,suspected awareness,mutual pretense;open awarenessContinuity - establish legaciesClosure - corresponds with reconciliation & transcendence
79Care of the FamilyInforming 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.
80Nurse’s Self-CareDealing 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.
81Signs 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.
82Coping 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.
83"Every suffering has meaning" Man's search for meaning- V.E Frankl
84and always remember Carpe diem You are invited for your ERASMUS Program inThe Dept. of Nursing, University of Pelponnese Sparta,Greece (http://sparti.uop.gr/~nosil)and always remember Carpe diemmeaning ENJOY EVERY DAY