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Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Chapter 36 The Experience of Loss, Death, and Grief
2Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Scientific Knowledge Base: Types of Loss Developing a personal understanding of your own feeling about grief and death will help you better serve your patients. Actual losses Necessary losses Maturational losses Situational losses Perceived losses
3Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study Mrs. Kelly is 79 years old and is in end-stage heart disease secondary to diabetes mellitus. Her mobility has declined greatly because of shortness of breath, poor food intake, decreased strength, and lack of oxygen. She takes pain medication for severe back and joint pain and has trouble with constipation. She is now in the intensive care unit for chest pain and congestive heart failure. Mrs. Kelly no longer wants to be hospitalized for her medical conditions, and she wants to go home to die. Mrs. Kelly is being evaluated for home hospice care and will temporarily receive home care.
4Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Scientific Knowledge Base: Grief Grief = An emotional response to a loss, manifested in ways unique to an individual based on personal experiences, cultural expectations, and spiritual beliefs. Normal (uncomplicated) Complicated: exaggerated, delayed, masked Anticipatory Disenfranchised (aka marginal or unsupported)
5Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Grieving When caring for patients who have experienced a loss, facilitate the grief process by helping survivors feel the loss, express it, and move through their grief. Loss comes in many forms based on the values and priorities learned within a person’s sphere of influence. The type and perception of the loss influence how a person experiences grief.
6Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d) Mrs. Kelly lives with her husband of 54 years. Her daughter, Lilly, lives near her parents and visits them every day. Lilly does not agree with the plan to begin hospice care. She cannot accept her mother's plan to “give up.” Mr. Kelly does not understand hospice and is not sure if he will be a good caregiver.
7Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Quick Quiz! 1. You are caring for a patient who is depressed because the only child has gone away to college. The nurse will assess this type of depression as A. Actual loss. B. Perceived loss. C. Situational loss. D. Maturational loss.
8Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Theories of Grief and Mourning Kübler-Ross’ Stages of Dying (DABDA): Denial Anger Bargaining Depression Acceptance
9Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Bowlby’s Attachment Theory Numbing Protects the person from the full impact of loss Yearning and seeking Tearing, sobbing, and acute distress Disorganization and despair Person examines loss and expresses anger Reorganization Person begins to accept change, new role or skills
10Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d) Nursing student Jennifer Brown will be caring for the Kelly family as she learns how to give care in the home. Before Jennifer meets the Kelly family for the first time, she reviews the information essential for making a thorough assessment. Jennifer worries that she will be asked questions for which she has no answer. She feels more comfortable talking about heart disease than about end-of-life decisions and care.
11Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Worden’s Grief Tasks Model Task I: Accept the reality of the loss Task II: Experience the pain of grief Task III: Adjust to a world in which the deceased is missing Task IV: Emotionally relocate the deceased and move on with life
12Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Additional Grief Theories Rando’s “R” Process Model: grief as a series of processes instead of stages or tasks Recognizing the loss, reacting to the pain of separation, reminiscing, relinquishing old attachments, and readjusting to life after loss Reminiscence is an important activity in grief and mourning. Dual process model: moving back and forth between loss-oriented and restoration- oriented activities Post modern grief theories
13Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Knowledge Base End-of-Life Nursing Consortium (ELNEC) American Nurses Association (ANA) Hospice and Palliative Care Nurses Association American Society of Pain Management Nurses American Association of Critical Care Nurses
14Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Factors Influencing Loss and Grief Human developmentPersonal relationships Nature of lossCoping strategies
15Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Factors Influencing Loss and Grief (cont’d)
16Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Critical Thinking Listen carefully to the patient’s perceptions. Use culture-specific understanding. Use Professional Standards: Nursing Code of Ethics Dying Person’s Bill of Rights ANA Scope and Standards of Hospice and Palliative Nursing Use Clinical Standards: American Society of Pain Management Nurses’ Guidelines
17Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Process and Grief Assessment Nursing Diagnosis Planning Implementation Evaluation
18Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Assessment Conversations about the meaning of loss to a patient often lead to other important areas of assessment: Patient’s coping style The nature of family relationships Social support systems The nature of the loss Cultural and spiritual beliefs Life goals Family grief patterns Self-care Sources of hope
19Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Diagnosis Anticipatory grieving Compromised family coping Death anxiety Fear Impaired comfort Ineffective denial Grieving Complicated grieving Risk for complicated grieving Hopelessness Pain (acute or chronic) Risk for loneliness Spiritual distress Readiness for enhanced spiritual well- being
20Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Planning Care plans for the dying patient focus on Comfort Preserving dignity and quality of life Providing family members with emotional, social, and spiritual support Give priority to a patient’s most urgent physical or psychological needs while also considering his or her expectations and priorities.
21Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d) Jennifer will ensure that Mrs. Kelly's pain is well managed before asking about her other priorities for care. Jennifer knows that many families have never given end-of-life care, so she plans to provide teaching for their priority concerns.
22Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nurse’s Presence
23Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Implementation: Health Promotion Providing palliative care in acute and restorative settings Providing hospice care Using therapeutic communication Providing psychosocial care Managing symptoms Promoting dignity and self-esteem Ensuring a comfortable and peaceful environment Promoting spiritual comfort and hope Protecting against abandonment and isolation Supporting the grieving family Assisting with end-of-life decision making Facilitating mourning
24Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d) InterventionRationale Involve the Kelly family in a discussion about symptom recognition and management. Even with poor prognosis, social supports and prompt symptom relief improve quality of life. Offer the Kelly family a chance to ask questions. Clarifying expectations better prepares individuals to face changes. Explain that setting easily achievable goals helps give hope. Restructuring goals to be more short term and achievable helps to give hope.
25Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Implementation: Care After Death Federal and state laws apply to certain events after death. Documentation Organ and tissue donation Autopsy Postmortem care
26Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Evaluation Questions to help validate achievement of patient goals and expectations: What is the most important thing I can do for you at this time? Are your needs being addressed in a timely manner? Are you getting the care for which you hoped? Would you like me to help you in a different way? Do you have a specific request that I have not met?
27Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Quick Quiz! 2. As a first-year nursing student, you are assigned to care for a dying patient. To best prepare you for this assignment, you will want to A. Complete a course on death and dying. B. Control your emotions about death and dying. C. Compare this experience to the death of a family member. D. Develop a personal understanding of your own feelings about grief and death.
28Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d) Jennifer asks Mr. Kelly and Lilly about any changes they see in Mrs. Kelly. They report that Mrs. Kelly has less activity tolerance, that she is able to rest with oxygen in place, and that Mrs. Kelly’s family asks about her pain before Mrs. Kelly states it. Jennifer observes family members’ caregiving and level of comfort and involvement. She notes that after 1 week, Mrs. Kelly’s family is more at ease with caregiving activities.
29Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d) Jennifer asks Mrs. Kelly to describe her feelings after sharing stories and life review with family. After 2 weeks Jennifer notices that the Kelly family has begun to look forward to sharing these stories, and they are becoming at ease with Mrs. Kelly’s decision and their role in palliative care.
30Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Care After Death Federal and state laws require institutions to: Request organ or tissue donation Perform an autopsy Certify and document the occurrence of a death Provide safe and appropriate postmortem care
31Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Importance of Nurses’ Self-Care You cannot give fully engaged, compassionate care to others when you feel depleted or do not feel cared for yourself. Frequent, intense, or prolonged exposure to grief and loss places nurses at risk for developing compassion fatigue. Being a professional includes caring for yourself physically and emotionally. To avoid the extremes of becoming overly involved in patients’ suffering or detaching from them, nurses develop self-care strategies to maintain balance.
32Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Importance of Nurses’ Self-Care (cont’d)
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