1. Unit II Death, Loss, End of Life

2. Death, Loss and End of Life Care  Loss – actual or potential situation in which something valued is changed, no longer available or gone Actual Perceived Anticipatory

3. Grief  Response to experience of loss  Bereavement – subjective response experience by surviving loved ones after death  Mourning – behavioral response through which grief is eventually resolved or altered

4. Types of Grief  Anticipatory Grief Grief before loss Patient, family, professionals Children have unique needs

5. Normal Grief (Uncomplicated)  Normal feelings, behaviors and reactions to loss  Physical, emotional, cognitive and behavioral reactions

6. Dysfunctional grief  Unresolved grief - extended length and severity May result from: ambivalence towards lost person, perceived need to be brave or in control, endurance of multiples losses, extremely high emotional value invested in lost person (helps bereaved avoid reality of loss, uncertainty about loss (“missing in action”), lack of support systems  Inhibited grief - normal symptoms of grief suppressed

7. Complicated Grief  Fails to grieve  Avoids visiting gravesite or participate in memorial  Recurrently symptomatic on anniversary of death  Persistent guilt, low self-esteem  Continues to search for lost person  May consider suicide  Minor events trigger grief  Unable to discuss the deceased with composure  Physical symptoms similar to the deceased  Relationships with others worsen (Kozier, 1034)

8. Stages and Tasks of Grief  Denial  Anger  Bargaining  Depression  Acceptance

9. Factors Influencing the Grief Process  Survivor personality, coping  History of substance abuse  Relationship to deceased  Spiritual beliefs  Type of death

10. Grief Assessment  Begins at time of admission or diagnosis  Ongoing to detect complicated grief

11. Grief Assessment Includes  Type of grief  Reactions  Stages and tasks  Influencing factors, general health

12. Children’s Grief  Based on developmental stages  Can be normal or complicated  Symptoms unique to children

13. Grief Interventions…  Presence  Identify support systems  Access bereavement specialists  Identify and express feelings  Special attention to disenfranchised grief  Public and private rituals  Spiritual care

14. Completion of the Grieving Process  No one can predict completion  Grief work is never completely finished  Healing occurs when the pain is less

15. Death and Dying Communication

16. Communication Crucial to palliative care Terminal illness is a family experience

17. Communication Imparting necessary information so that individuals may make informed decisions Requires interdisciplinary collaboration

18. Communication Process Patient/Family Expectations be honest non abandonment elicit values and goals team communication take time to listen

19. Communication Provides for informed choices Offers support Allows verbalization of fears

20. Communication How much patient/family want to know Initiate family meetings Base communication with children on developmental age

21. Attentive Listening Encourage them to talk Be silent Be non-judgmental Avoid misunderstandings

22. Attentive Listening (cont.) Don’t change the subject Encourage reminiscing

23. Factors Influencing Communication Patient/Family family systems financial/educational physical limitations coping/grief

24. Factors Influencing Communication (cont.) Health care professionals communication barriers (e.g. fear of own mortality, fear of not knowing, lack of understanding culture)

25. Breaking Bad News Nurses reinforce news provided by physicians Steps: plan what to say establish rapport

26. Steps (cont.) set aside time/turn off pager control the environment find out what they know/want to know use simple language be sensitive/respectful

27. Adaptive and Maladaptive Responses Cultural mores dictate what is adaptive or maladaptive

28. Team Communication Intra team communication is vital Should occur frequently Documentation is key Conflict is expected

29. Death and Dying: Symptom Management

30. Symptom Management Introduction There are many physical and psychological symptoms common at the end of life Ongoing assessment and evaluation of interventions is needed Requires interdisciplinary teamwork

31. Introduction (cont.) Reimbursement concerns Limit diagnostic tests

32. Symptoms and Suffering Symptoms create suffering and distress. Psychosocial intervention is key to complement pharmacologic strategies

33. Physiologic Changes/ Symptoms Pain Dyspnea / Apnea Anorexia and Cachexia Weakness & Fatigue Mental Status Changes Hypotension / Renal Failure Incontinence Anxiety Depression

34. Key Nursing Roles Patient advocacy Assessment Pharm tx Non-Rx tx Pt/family teaching

35. Anxiety Subjective feeling of apprehension Often without specific cause Categories of mild, moderate, severe

36. Depression Ranges from sadness to suicidal Often unrecognized and under treated Occurs in 25-77% of terminally ill Distinguish normal vs. abnormal

37. Assessment of Depression Situational factors Previous psychiatric history Other factors (e.g. lack of support system, pain)

38. Example Questions for Depression Assessment How have your spirits been lately? What do you see in your future? What is the biggest problem you are facing?

39. Suicide Assessment Do you think life isn’t worth living? Have you thought about how you would kill yourself?

40. Conclusion Multiple symptoms common Coordination of care with physicians and others Use drug and nondrug treatment Patient/family teaching and support

41. Care Following Death Preparing the family Care after death Evaluate circumstances Organ donor procedures

42. Care Following Death (cont.) Removal of tubes, equipment Bathing and dressing the body Positioning the body Respect cultural preferences

43. Care Following Death (cont.) Removal of the body Rigor mortis 2-4 hrs after death Embalming

44. Care Following Death (cont.) Assistance with calls, notifications Destroying medications Assisting with arrangements Initiating bereavement support

45. Death of Children Encourage parents to hold child Siblings Encourage verbalization

46. Conclusion Care of the patient and family at the time of death entails unique concerns, best provided by an interdisciplinary team

47. Bereavement Interventions...  Plan of care Attitude Cultural practices What to say Anticipatory grief

48. ... Bereavement Interventions  Provide presence  Active listening, touch, reassurance  Decrease sense of loss  Use bereavement services

49. Bereavement Interventions for Children and Parents  Recognize developmental stage  Refer to support groups

50. The Nurse: Death Anxiety, Cumulative Loss, Grief  Death anxiety  Defenses  Personal death awareness

51. Cumulative Loss  Succession of losses common to nurses  May not have time to resolve losses before another loss occurs

52. Stages of Adaptation  Nurses new to working with the dying need support  Stages of adaptation (Harper) Intellectualization Emotional survival Depression Emotional arrival Deep compassion

53. Factors Influencing the Nurse’s Adaptation  Professional training  Personal death history  Life changes  Support system

54. System of Support (Vachon)  Balance  Assessing formal / informal support systems  Instructor support  Spiritual support  Self care and support

55. Support for the Nurse Ask for help Verbalize Post clinical debriefing

56. Conclusion  Loss, grief and bereavement assess with ongoing intervention  Nurses must recognize and respond to their own grief  Interdisciplinary care