DEATH & DYING GRIEF & LOSS

Loss -Occurs when a valued person, object, or situation is changed Types of Losses -actual loss -perceived loss -anticipatory loss Actual 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– for example Physical loss-loss of an arm from a car accident Psychological 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.

Grief or Grieving- Grief is the Emotional Reaction to Loss Mourning- a period of acceptance of loss and grief during which the person learns to deal with the loss Bereavement- a state of grieving during which a person goes through a 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)

Engels: 6 Stages of the Grief Reaction Shock and Disbelief Developing Awareness Restitution Resolving the Loss Idealization Outcome Shock and disbelief , “no not me” Developing awareness “why me” crying, anger, feeling empty Restitution – funeral services and rituals surrounding loss Resolving the loss- dealing with the void left by loss.. Idealization- Exaggeration of good qualities of the person or object lost Outcome- acceptance

When I must leave you for a little while Please do not grieve and shed wild tears And hug your sorrow to you through the years But start out bravely with a gallant smile; Reach out your hand in comfort and in cheer And I in turn will comfort you and hold you near; And never, never be afraid to die, For I am waiting for you in the sky!

Stages of the Grief and Loss/ Death & Dying Process Denial Anger Bargaining Depression Acceptance Kubler- 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 person DENIAL 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.

Five Principles of Palliative Care (Hospice Care) respect the goals, likes and choices of the dying patient look after medical, emotional, social, and spiritual needs of the dying person support the needs of the family members help the patient gain access to needed healthcare providers and appropriate settings build ways to provide excellent end of life care Medical, emotional, social, and spiritual needs- focus on making sure there comfortable, not left alone Supports 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 gov

Ethical and Legal Dimensions -managed death -legalized physician assisted suicide physician- administered lethal injections create ethical dilemmas patients look to nurses for information, advice and support

Advanced Directives Living Wills- provide specific instructions about the kinds of health care that should be provided or foregone in a particular situation Durable Power of Attorney- appoints an agent the person trusts to make decisions in the event of the appointing person’s subsequent incapacity

Factors That Influence Death and Dying Developmental Family Socioeconomic Cultural Religious Cause of Death Developmental- 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).

Nursing 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 about how you are coping What is helping you get through this? Assessing- determine the adequacy of the patient’s and family’s 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 expectations Coping objective see if family and pt are using effective coping strategies. Resources- assess adequacy of the human financial and spiritual resources avail.

Nursing Process Planning- the patient and family will: demonstrate freedom in expressing feelings identify and use effective coping strategies accept need for help as appropriate make healthcare decisions reflecting personal values and goals

Nursing Process Implementing- the family the nurse’s aim is to care for the dying patient and their families as well as to promote health and prevent illness in the family Nursing Diagnoses impaired adjustment r/t newly diagnosed terminal illness caregiver role strain r/t hospital discharged dying pt because of inadequate insurance. dysfunctional grieving r/t inability to accept death of infant

Nursing Interventions Monitor anxiety Monitor changes in mood/affect Communicate willingness to discuss death Encourage patient and family to share feelings about death Monitor pain Facilitate obtaining spiritual support for patient and family Include the family in care decisions and activities as desired

Nursing Process Evaluating does the plan of nursing care for the dying patient meet the outcome of a comfortable, dignified death? do family members resolve their grief after a suitable time of mourning and resume meaningful life roles and activities?

Question #1 A referral for bereavement resources to enhance care Interventions for a pt in isolation and inner thought Assessment skills to determine fear and anxiety Therapeutic skills to enhance communication A 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 implement: D therapeutic skills to enhance communication

Question #2 A 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 should Encourage her to refuse the test Inform the MD of her statement Educate her on the test’ s benefits Educate her on the procedure b. Inform the MD of the statements