1. Loss, Grief, the Dying Patient, and Palliative Care
Chapter 15
Loss, Grief, the Dying Patient, and Palliative Care

2. Chapter 15
Lesson 15.1

3. Learning Objectives Theory
Describe stages of grief and dying, and associated behaviors and feelings
Discuss hospice care
Identify three common fears a patient is likely to experience when dying

4. Learning Objectives Clinical Practice
Identify ways to support or instill hope in the terminally ill patient and his family
Demonstrate compassionate therapeutic communication techniques with a terminally ill patient and/or his family

5. Loss, Grief, and Death
Person’s reaction to loss influenced by importance of what was lost and culture in which person was raised
Death is a universally shared event
All cultures have beliefs and rituals to explain and cope with death
Nurses must provide the best care for the dying patient
Ask students to share cultural words or phrases to express death and dying, i.e., “passed on” and “ready to board the glory train,” etc. Some may be humorous and it may be worthwhile to explore common methods of coping, including humor.
Ask students to share a personal experience with death and dying in their particular culture.
Discuss the common culture surrounding death and dying in the United States.
Ask students to share any personal challenges in caring for the dying.

6. Loss To no longer possess or have an object, person, or situation
Can be physical
Loss of a limb or body function
Psychosocial
Loss of a loved one
Only the person experiencing the loss can define the value of the loss
When do people usually experience their first loss, whether it is the loss of a grandparent, great-grandparent, a pet, or even when a friend moves away?
How is value assigned to a loss?

7. Grief
The total emotional feeling of pain and distress that a person experiences as a reaction to loss
Grieving process
Occurs over time
Person adapts and moves through pain and associated symptoms toward recovery or acceptance
Bereavement
The state of having suffered a loss by death
Grieving person may experience physical and emotional symptoms
Persons who are dying, as well as their loved ones, experience loss and grief when faced with a terminal diagnosis.
What physical and emotional symptoms may be seen with bereavement?

8. Grief Anticipatory grieving Dysfunctional grieving Prolonged grieving
May occur before the loss actually happens
Dysfunctional grieving
Falls outside normal responses
Prolonged grieving
Person seems trapped in a stage, unable to progress
What is the usual time frame for grieving?
Visible absence of grieving may be viewed by others as a good adjustment, but it often results in later psychosomatic illness.

9. Symptoms of Grief Depression, sadness
Fatigue, apathy, lack of interest
Sleep alterations
Loss of appetite
Change in sexual interest
Anxiety, shortness of breath
Feeling helpless, restless, angry, irritable
Not everyone experiences these symptoms.
Symptoms are not experienced in any particular order.
Ask the students to share interventions to support an individual experiencing these various symptoms.

10. Symptoms of Grief Forgetfulness, tendency to make mistakes
Confusion, disorientation
Symptoms of the same illness the deceased suffered
Seeing loved one’s presence, hearing loved one’s voice
Ned to tell and retell things about the loved one
What other symptoms may be experienced?
What if none of these symptoms are evident?
What is the best way to cope with an individual who insists that he or she continues to see and converse with the deceased?

11. Stages of Grief Disbelief, yearning, anger, depression, and acceptance
Peak within 6 months after the loss
Nurse should reevaluate and create additional nursing plans for patients who continue to score high in these areas after 6 months
You can assist persons who are grieving by accepting their feelings and behaviors and validating their loss.
How can you validate the loss of a grieving person?
Quiet presence, a warm caring concern for the person's well-being, and the ability to listen to the person speak about his pain and loss are supportive

12. The nurse provides caring and comfort to the patient who experiences grief.

13. The Nature of Death
Absence of heartbeat and breathing (historic, widely accepted definition of death until 1960s)
Brain death/biologic death
Since 1970s
The stopping of integrated functioning of the person as a whole
Each death experience is unique
The absence of a heartbeat and breathing is still the standard for today in numerous health care settings.
Allow the family and friends time and privacy to say goodbye.
Send home personal belongings with the family.

14. End-of-Life Care Consider the terminally ill patient’s preferences
Try to maintain functional capacity and relieve discomfort
Control patient’s pain
Be aware of advance directives and durable powers of attorney
Make the patient feel safe and secure
The patient will have ample opportunity to finish business with loved ones
How should the nurse assess a terminally ill patient’s preferences?
How should the nurse care for a terminally ill patient who, although capable of doing so, refuses to get out of bed and feed himself?
Pain medication may be given at higher doses due to increased intensity and duration of pain.
Remind students where to find the advance directives and durable power of attorney.

15. End-of-Life Standards
Opportunities provided to spend final moments with people important to the patient
Families will have opportunity to discuss the patients imminent death with the staff
Family provided private time with the patient
Family will be provided time to carry out cultural customs regarding the body after death
Use open-ended therapeutic conversation with the patient to encourage verbalization.
Patient may need to be encouraged to “finish business.”
The nurse may suggest referral to clergy or social worker. Check with the family.
Cultural customs may require some discussion and preparation prior to death. This should be handled with sensitivity.

16. Rights of the Dying Patient
A person who is dying has the right to:
Be treated as a person until death
Caring human contact
Have pain controlled
Cleanliness and comfort
Maintain a sense of hope
Participate in his care or the planning of it
Respectful, caring medical and nursing attention
Discuss how staff commonly fear “killing the patient” or expediting death by turning a patient, administering pain medication, etc.
Continually assess for nonverbal cues to suggest pain or anxiety.
If prognosis is terminal or grave, what is the role of providing hope?

17. Rights of the Dying Patient
A person who is dying has the right to:
Continuity of care and caregivers
Information about his condition and impending death
Honest answers to questions
Explore and change religious beliefs
Maintain individuality and express emotions freely without being judged
It may be difficult and uncomfortable to provide honest answers.
A change in religious belief and practice on the part of the patient may be shocking and distressing to the family.
What are some examples of “personal business”?
Provide optimum privacy without isolating the patient and family.

18. Rights of the Dying Patient
A person who is dying has the right to:
Make amends and settle personal business
Say goodbye to family and significant others in private
Assistance for significant others with the grief process
Withdraw from social contact if desired
Die at home in familiar surroundings
Die with dignity
Respectful treatment of the body after death
What if the patient wishes to die at home, but the family refuses?
What does it mean to “die with dignity”?
What are some examples of respectful and disrespectful treatment of the body after death?

19. Hospice and Palliative Care
Philosophy of caring for dying and their families
Started in England in the 1960s
Based on accepting death as natural part of life; emphasis is on the quality of remaining life
Focused on treating symptoms, providing comfort measures, and promoting best quality of life possible
What is palliative care? (symptom relief with comfort as the only goal)

20. The hospice nurse assists the family in saying goodbye to the dying patient.

21. Stages of Coping with Death (Kübler-Ross)
Denial
Anger
Bargaining
Depression
Acceptance
People move back and forth between the stages, sometimes getting stuck in one of them
A patient can become “stuck” in one stage and not achieve acceptance.
Some consider the acceptance stage unrealistic, whereas others consider it an appropriate expectation.
How do these stages compare and contrast to stages of grieving?
The dying patient may experience relapses between stages.
After a death of a loved one, survivors may experience relapses at vulnerable times, i.e., holidays, anniversary of the diagnosis, or the date of death.

22. Emotions Seen in the Dying Process
Fear of dying
Fear of the unknown
Guilt
Hope
Despair
Humor
Individual’s reaction to death may be consistent with the way he coped with difficulties in the past
It is important to assess and determine what is unknown.
Once the unknown is identified, devise and implement appropriate nursing interventions.
Assess the sources of guilt and despair.
What are some therapeutic methods to foster hope and humor, without raising unrealistic expectations?

23. Hope and the Dying Process
An inner positive life force
A feeling that what is desired is possible
Takes many forms and changes as patient declines
At first there is hope for cure
Then a hope that treatment will be possible
Next a hope for the prolonging of life
Finally hope for a peaceful death
What open-ended questions can you ask that may help patients to talk about their needs?
You can always be supportive of hope by recognizing and affirming the wish the patient is expressing.

24. Chapter 15
Lesson 15.2

25. Learning Objectives Theory
Identify four expected symptoms related to metabolic changes at end-of-life stages
List the common signs of impending death
Explain difference between the patient's right to refuse treatment and assisted suicide
Explain how the Code for Nurses provides nursing guidelines regarding patient’s right to refuse treatment, euthanasia, and assisted suicide

26. Learning Objectives Clinical Practice
Describe one nursing intervention that can be implemented in a hospital or a nursing home for each of the following: pain, nausea, dyspnea, anxiety, constipation, incontinence, thirst, and anorexia
Explain reason for completing an advance directive to a terminally ill patient and what “health care proxy” and “DNR” mean
Prepare to provide information regarding organ or tissue donation in response to family questions
Prepare to perform postmortem care

27. Nursing and the Dying Process
Comfort care
Identifying symptoms that cause the patient distress and adequately treating those symptoms
Palliation
Relief of symptoms when cure is no longer possible, and treatment is provided solely for comfort
The application of the nursing process to care of the dying patient uses skills and knowledge from physical, emotional, social, and spiritual contexts.
How can beginning students and new graduates address their fear of saying the wrong thing to the dying patient or family?
Listening skills, observation, and use of nonverbal communication, touch, and presence all contribute to the patient's sense of acceptance.

28. Assessment (Data Collection)
Baseline assessment and continuing data collection essential to identify the problems and needs of the patient and family
Pay special attention to assessing pain: location, nature, what makes it better or worse
Emotional condition
Can often be observed during the interaction
Anxiety, agitation, confusion, depression may be obvious
Spiritual assessment can begin with questions about the patient's religious affiliation, and whether he would like to meet with a spiritual advisor.

29. Nursing Diagnoses Activity intolerance Death anxiety Fear
Anticipatory grieving
Imbalanced nutrition: less than body requirements
Risk for loneliness
Pain
Impaired physical mobility
Fatigue
Impaired skin integrity
Deficient knowledge
Self-care deficit
Nursing diagnoses for the dying patient will be varied, depending on the disease process.
Certain nursing diagnoses are common at some point to most dying patients.

30. Planning
Giving the patient control is a first priority at a time when it seems that he has no control
Planning should be a team effort, with all members of the team aware of the patient’s goals and needs
What rules may need to be relaxed for the patient who is dying?

31. Implementation Interventions should be implemented for:
Anticipatory guidance
End-stage symptom management
Pain control
Constipation, diarrhea
Anorexia, nausea, vomiting
Dehydration
Dyspnea
Death rattle
A truly compassionate nurse studies and learns about pain management and applies those principles in daily practice.
There is no concern for addiction or of reaching a safety or effectiveness limit when narcotics are increased in response to pain.
It is more important to listen than to talk.

32. Implementation Interventions should be implemented for: Delirium
Impaired skin integrity
Weakness, fatigue, decreased ability to perform activities of daily Living
Anxiety, depression, agitation
Spiritual distress, fear of meaninglessness
Discuss appropriate assessments and interventions. What are pharmacological and nonpharmacological interventions?
What are examples of noninvasive interventions to relieve these symptoms?
What are examples of therapeutic communication to decrease fear and anxiety, as well as perception of symptoms?

33. Physical Signs of Impending Death
Physically weaker
Spends more time sleeping
Body functions slow
Appetite decreases
Urine output decreases; urine more concentrated
Edema of the extremities or over the sacrum
Pulse increases and becomes weak or thready
Blood pressure declines
Skin of the extremities mottled, cool, and dusky
Respirations become shallow and irregular
Moistening the patient's lips and mouth, and providing oral hygiene, will be more comforting than "pushing" food or fluids.
Often at the time of death, a "death rattle" is heard, which occurs when the patient can no longer clear the throat of normal secretions.
Cheyne-Stokes respirations may be noted: respirations that gradually become shallower and are followed by periods of apnea (no breathing).

34. Psychosocial and Spiritual Aspects of Dying
As individuals approach death, their spiritual needs take on greater importance
Do not impose your religious beliefs on dying patient and family; instead assist patients to find comfort and support in their own belief systems
Be aware of remarks you make in the presence of unresponsive patients because they DO hear
To die with closure is to say goodbye to those people and things that are important.
It may also involve saying "I'm sorry, forgive me," "I forgive you," and "I love you."
Dying patients may exhibit confusion and disorientation.
Assurance that it is "okay to go" and that family members will take care of each other may ease dying individuals' anxiety about leaving their responsibilities.

35. Advance Directives
Spells out patients’ wishes for health care when they may be unable to indicate their choice
Durable power of attorney for health care
A legal document that appoints a person (health care proxy) chosen by the patient to carry out his wishes as expressed in an advance directive
Patients determine under which situations they would agree to do-not-resuscitate (DNR) orders.
Their choices regarding artificial feeding and fluids, ventilators, and administration of antibiotics are documented.
Nurses must be active in keeping up to date on legal decisions regarding these issues, and continue to learn and apply new nursing theory and procedures regarding end-of-life care.
They must also deal with their own feelings and values regarding patient choices to seek life-prolonging or death-seeking treatment.

36. Euthanasia
Ending another person’s life to end suffering, with (voluntary) or without (involuntary) his consent
Passive euthanasia
Patient chooses to die by refusing treatment
Active euthanasia
Administering a drug or treatment to kill the patient
Not legal or permissible
Assisted suicide
Making available means to end patients’ life (such as a weapon or drug), knowing that suicide is their intent
Honoring the refusal of life-prolonging treatment of a patient with a terminal illness is legally and ethically permissible.
Both active euthanasia and assisted suicide are considered to be a violation of the American Nurses Association's Code for Nurses.
Which state passed a law legalizing assisted suicide?

37. Adequate Pain Control
Nurses advocates for compassionate end-of-life care
Cornerstones of end-of-life care that can eliminate the need for a person to choose euthanasia or suicide
Knowledgeable and skillful symptom management
Relief of suffering
Promise of presence, of not abandoning the patient
Why are physicians reluctant to prescribe large enough doses of pain medication for the dying patient?

38. Organ and Tissue Donation
Organs that can be transplanted:
Kidneys, livers, hearts, and lungs
Tissues that can be transplanted:
Corneas, bone, and skin
Physicians usually request organ donation from family members, but nurse may be in a position to answer questions the family raises about organ donation
Organs such as hearts, lungs, and livers can only be obtained from a person who is on mechanical ventilation and has suffered brain death.
Other tissues can be removed for several hours after death, such as after a massive heart attack or stroke.
How can a person become an organ and/or tissue donor?

39. Postmortem (After Death) Care
Nurse is responsible for postmortem care
The body is prepared for the family to say their goodbyes and for removal to the morgue or undertaker
Return patient’s belongings to the family
Provide a private quiet place for the family to begin the grieving process until they are able to leave
In a hospital or nursing home, a physician is usually designated as the person responsible for pronouncing the death.
When a patient dies at home, the pronouncement of death may be delegated to an undertaker, registered nurse, or coroner.