Chapter 36 The Experience of Loss, Death, and Grief

 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

 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)

 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.

 Kübler-Ross’ Stages of Dying (DABDA): Denial Anger Bargaining Depression Acceptance

 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

 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

 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

 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

Human developmentPersonal relationships Nature of lossCoping strategies

 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

Assessment Nursing Diagnosis Planning Implementation Evaluation

 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

 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

 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.

 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

 Federal and state laws apply to certain events after death.  Documentation  Organ and tissue donation  Autopsy  Postmortem care

 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?

 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

 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.