COPING WITH LOSS DEATH AND GRIEVING.doc

8/10/2019 COPING WITH LOSS DEATH AND GRIEVING.doc

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COPING WITH LOSS, DEATH AND GRIEVING

LOSS

INTRODUCTION

Loss is a part of life cycle. All people eperie!ce i! t"e for# ofc"a!$e, $ro%t" a!& tra!sitio!. O'r loss (e$i!s at (irt" )"a*i!$ to lea*et"e %ar#t" + sec'rity of t"e %o#( a!& e!& %it" t"e 'lti#ate loss,t"e &eat" of self. T"e eperie!ce of loss is pai!f'l, fri$"te!i!$ a!&lo!ely a!& it tri$$ers a! array of e#otio!al respo!se. People #ay*acillate (et%ee! &e!ial, s"oc-, &is(elief, a!$er, i!ertia, i!te!seyear!i!$, lo!eli!ess, sa&!ess loss of co!trol, &epressio! a!& spirit'al

&espair. I! a&&itio! to !or#al losses associate& %it" lifecycle sta$es t"ereare pote!tial losses of "ealt", a (o&y part, self i#a$e, self estee# a!&e*e! o!es life. W"e! t"ere are p"ysical "ealt" pro(le#s s'c" as&ia(etes, AIDS, car&iac co!&itio!s, GI &isor&ers, &isa(ilities a!&!e'rolo$ical i#pair#e!ts te!& to respo!& to t"ese ill!ess %it" a $rief.

DEFINITION OF LOSS

Loss ca! (e &e/!e& as t"e '!&esire& c"a!$e or re#o*al of a *al'e&o(0ect, perso! or sit'atio!

TYPES OF LOSSES

Necessary losses

It is a! i!te$ral part of eac" perso!s life. Necessary lossesare so#et"i!$ !at'ral a!& positi*e .E $1 $ro%i!$ 'p process. We&e*elop i!&epe!&e!ce fro# o'r pare!ts, start a!& lea*e sc"ool,c"a!$e frie!&s, (e$i! career a!& for# relatio!s"ips. T"ese lossesare replace& (y so#et"i!$ &i2ere!t a!& (etter.

Actual losses T"e loss of a!y perso! or o(0ect t"at ca! !o lo!$er (e felt,

"ear&, -!o%! or eperie!ce& (y t"e i!&i*i&'al. E $1 loss of a (o&ypart, c"il& relatio!s"ip, or role at %or-.

Perceived losses

A!y loss t"at is '!i3'ely &e/!e& (y t"e $rie*i!$ clie!t, #ay(e less o(*io's to ot"ers. T"ey are easily o*er loo-e& a!&

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#is'!&erstoo&, yet t"e pro$ress of $rief follo%s t"e sa#ese3'e!ci!$ a!& pro$ressio! as act'al losses. E $ 1loss of co!/&e!ceor presti$e.

Maturational losses

A!y c"a!$e i! t"e &e*elop#e!t process t"at is !or#allyepecte& &'ri!$ a life ti#e. It is a part of !or#al life tra!sitio!, ('tfeels "elp a perso! to cope %it" t"e c"a!$e.

Situational losses

It i!cl'&es a!y s'&&e! '!pre&icta(le eter!al e*e!ts. Ofte!t"is type of loss i!cl'&es #'ltiple losses rat"er t"a! a si!$le losss'c" as a'to#o(ile acci&e!t t"at lea*es a &ri*er paralyse&, '!a(leto ret'r! to %or- a!& $rie*i!$ o*er t"e loss of a passe!$er i! t"eacci&e!t

Loss of external objects

Ete!& of $rie*i!$ &epe!&s o! o(0ects *al'e, se!ti#e!tattac"e& to it a!& its 'sef'l!ess .E $1 loss ,#isplace#e!t,&eterioratio!, &estr'ctio! (y !at'ral ca'ses

Loss of known environment

Lo!eli!ess or !e% '!fa#iliar e!*iro!#e!t t"reate!s selfestee# a!& #a-es $rie*i!$ &i4c'lt. E $1 #o*i!$ fro# a!ei$"(or"oo&, "ospitali5atio!, a !e% 0o( etc.

Loss of signicant others Loss of a fa#ily #e#(er, frie!&, tr'ste& !'rse or a!i#alco#pa!io!.

Loss of life

Loss of life creates $rief for t"ose left (e"i!&. Perso! faci!$&eat" ofte! fears pai!, loss of co!trol, a!& &epe!&e!cy o! ot"ers. E$1 &eat" of a fa#ily #e#(er, frie!& or o%! &eat".

GRIE6Grief is t"e p"ysical ,psyc"olo$ical + spirit'al respo!se to loss. It is

#a!ifeste& i! a *ariety of %ays t"at are '!i3'e to a! i!&i*i&'al a!&(ase& o! perso!al eperie!ces, c'lt'ral epectatio!s a!& spirit'al(eliefs. 7o'r!i!$ is t"e psyc"olo$ical process t"ro'$" %"ic" t"ei!&i*i&'al passes o! to s'ccessf'l a&aptatio! to t"e loss of a *al'e&o(0ect. 8erea*e#e!t i!cl'&es $rief a!& #o'r!i!$9t"e i!!er feeli!$ a!&o't%ar& reactio!s of t"e s'r*i*or. T"e ti#e of $rie*i!$ &epe!&s o! t"esi$!i/ca!ce of t"e loss, t"e le!$t" of ti#e t"e perso! %as -!o%! a!&

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lo*e&, t"e a!ticipatio! of or preparatio! for t"e loss, t"e perso!se#otio!al sta(ility a!& copi!$ a(ility. So#e people resort to a('se ofprescriptio! #e&icatio!s, ille$al &r'$s or alco"ol if t"ey /!& it &i4c'ltto cope %it" t"e loss, t"e $rief process is t"e! co#plicate& (y t"e 'seof a&&icti*e s'(sta!ces.

TYPES OF GRIEF

Normal grief

It co!sists of !or#al feeli!$s, (e"a*iors a!& reactio! to loss.T"is !or#al $rief respo!se to a loss ca! pro*e, "elpi!$ o!e to #at'rea!& &e*elop as a perso!. It i!cl'&es rese!t#e!t, sorro%, a!$er, cryi!$,lo!eli!ess a!& te#porary %it" &ra%l fro# acti*ities.

Anticiatory grief

T"e process of &ise!$a$i!$ or letti!$ $o t"at occ'rs (efore a!act'al loss of &eat" "as occ'rre& .E $1 o!ce a fa#ily recei*es ater#i!al &ia$!osis, t"ey (e$i! t"e process of sayi!$ $oo& (ye a!&co#pleti!$ t"e life a2airs. W"e! t"e act'al process of &yei!$ isete!&e& for a lo!$ ti#e, perso!s i! t"e clie!t fa#ily #ay "a*e fe%sy!&ro#es of $rief o!ce &eat" occ'rs.

!omlicated grief

W"e! t"e perso! "as &i4c'lty i! pro$ressi!$ t"ro'$" t"e!or#al process of $rie*i!$, (erea*e#e!t (eco#e co#plicate&. I!t"ese cases (erea*e#e!t appears to $o %ro!$ a!& loss !e*er resol*es.T"is ca! t"reate! t"e perso!s relatio!s"ip %it" ot"ers. Co#plicate&$rief i!cl'&es

ac"ro!ic $rief9(e$i!s as !or#al $rief ('t co!ti!'es lo!$ ter#, %it"little resol'tio! of feeli!$s a!& i!a(ility to re0oi! !or#al life

(&elaye& $rief9 a $rief t"at is p't of '!til a later ti#e

cea$$erate& $rief

as-e& $rief9occ'rs %"e! t"e perso! is $rie*i!$ ('t epressi!$ t"e$rief t"ro'$" ot"er types of (e"a*iors. e $1 a #a! %"ose %ife "as &ieay (e$i! &ri!-i!$ "ea*ily

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"isenfranchised grief

Perso! eperie!ces $rief %"e! a loss is eperie!ce& a!& ca!!ot(e ope!ly ac-!o%le&$e&, socially sa!ctio!e& or p'(licly s"are&. E $1loss of part!er fro# AIDS, c"il& eperie!ci!$ &eat" of step pare!t

FACTORS INFLUENCING LOSS AND GRIEF

#uman develoment

Perso! of &i2eri!$ a$es a!& sta$es of &e*elop#e!t %ill &isplay

&i2ere!t a!& '!i3'e sy#pto#s of $rief. E $1 to&&lers are '!a(le to'!&ersta!& loss or &eat", ('t t"ey %ill feel $reat a!iety o*er loss ofo(0ects a!& separatio! fro# pare!ts

Psychological ersectives of loss and grief

A$e, $e!&er, stat's, race, spirit'ality, reli$io's (eliefs, i!tellect,ac"ie*e#e!t, self epressio! a!& c'lt'ral opport'!ity are t"e (asis fora! i!&i*i&'al to &e/!e a!& 3'alify t"e &e/!itio! of life or &eat".

Socio economic status

It i!:'e!ces a perso!s a(ility to o(tai! optio!s a!& 'se s'pport#ec"a!is#s %"e! copi!$ %it" loss. Ge!erally a! i!&i*i&'al feel$reater ('r&e! fro# a loss %"e! t"ere is a lac- of /!a!cial,e&'catio!al or occ'patio!al reso'rces T"ese clie!ts re3'ire referral toco##'!ity social ser*ice a$e!cies t"at ca! pro*i&e !ee&e& reso'rces.

Personal relationshis

W"e! t"e loss i!*ol*es a lo*e& o!e, t"e 3'ality a!& #ea!i!$ ofrelatio!s"ip are critical i! '!&ersta!&i!$ a perso!s $rief eperie!ce. It

is sai& t"at to lose yo'r pare!ts is to lose yo'r past, to lose yo'rspo'se is to lose yo'r prese!t a!& to lose yo'r c"il& is to lose yo'rf't're. W"e! t"e relatio!s"ip (et%ee! t%o perso!s "as (ee! *eryclose, it %ill (e *ery &i4c'lt for t"e o!e left (e"i!& to cope

Nature of loss

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T"e a(ility to resol*e $rief &epe!&s o! t"e #ea!i!$ of t"e lossa!& t"e sit'atio! s'rro'!&i!$ t"e loss. T"e *isi(ility of t"e lossi!:'e!ces t"e s'pport a perso! recei*es.E $1 T"e loss of "o#e fro# a tor!a&o %ill (ri!$ s'pport fro# t"eco##'!ity, %"ere as a pri*ate loss of a! i#porta!t possessio! #ay

(ri!$ less s'pport fro# ot"ers

Amount of suort for the bereaved

People %it" #ore e#otio!al a!& psyc"olo$ical s'pporttypically "a*e less co#plicate& $rief

!ulture and ethinicity

I!terpretatio! of t"e loss a!& t"e epressio! of t"e $rief arisefro# c'lt'ral (ac-$ro'!& a!& fa#ily practices. Critical co#po!e!ts ofc'lt're are t"eir (asic core (elief syste#s t"at t"ey ca! a!& ofte! &o"ol& to.

Siritual beliefs

I!&i*i&'als spirit'ality i!:'e!ces t"eir a(ility to cope %it"loss. Clie!ts %it" a stro!$ i!terco!!ecte&!ess %it" a "i$"er po%erare a(le to face &eat" %it" relati*ely #i!i#al &isco#fort.

STAGES OF GRIEVING

MODEL OF SUCCESSFUL GRIEVING : ENGEL(1964)

E!$el ); %as a#o!$ t"e /rst to &e/!e sta$es of $rief. E!$els sista$es are1

$% Shock and disbelief%

S"oc- a!& &is(elief are 's'ally &e/!e& as ref'sal to accept t"e fact

of loss, follo%e& (y a st'!!e& or !'#( respo!se

&% "eveloing awareness.

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De*elopi!$ a%are!ess is c"aracteri5e& (y p"ysical a!& e#otio!al

respo!ses s'c" as a!$er, feeli!$ e#pty a!& cryi!$.

'% (estitution%

Restit'tio! i!*ol*es t"e rit'als s'rro'!&i!$ t"e loss %it" &eat"? it

i!cl'&es reli$io's, c'lt'ral or social epressio!s of #o'r!i!$, s'c" as

f'!eral ser*ices.

)% (esolving the loss%

It i!*ol*es &eali!$ %it" t"e *oi& left (y t"e loss.

*% +deali,ation.

I&eali5atio! is t"e ea$$eratio! of t"e $oo& 3'alities t"at t"e perso! or

o(0ect "a&, follo%e& (y accepta!ce of t"e loss a!& a lesse!e& !ee& to

foc's o! it.

-% .utcome

O'tco#e t"e /!al resol'tio! of t"e $rief process i!cl'&es &eali!$ %it"

t"e loss as a co##o! life occ'rre!ce.

STAGES OF GRIEVING : KUBLER ROSS (1975)

De!ial A!$er

8ar$ai!i!$

Depressio!

Accepta!ce

.

"enial

De!ial is 's'ally o!ly a te#porary &efe!ce for t"e i!&i*i&'al.E.$.9@I feel

/!e, @t"is ca!!ot (e "appe!i!$, !ot to #e

Anger

O!ce i! t"e seco!& sta$e, t"e i!&i*i&'al reco$!ises t"e &e!ial ca!!ot

co!ti!'e. 8eca'se of a!$er t"e perso! is *ery &i4c'lt to care for &'e

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to #isplace& feeli!$s.E.$.1%"y #eB Its !ot fair, @"o% ca! t"is

"appe!i!$ to #eB

/argaining

T"e t"ir& sta$e i!*ol*es t"e "ope t"at t"e i!&i*i&'al ca! so#e"o%

postpo!e or &elay &eat".E.$.1I '!&ersta!& I %ill &ie, ('t if I co'l& 0'st

"a*e #ore ti#e....

"eression

I! t"is sta$e t"e perso! (e$i!s to '!&ersta!& t"e certai!ty of &eat".

8eca'se of t"is t"e i!&i*i&'al #ay (eco#e sile!t, ref'se *isitors a!&

spe!& #'c" of t"e ti#e cryi!$ a!& $rie*i!$.E.$.1I #iss #y lo*e& o!e,

%"y $o o!B

Accetance

T"e /!al sta$e co#es %it" peace a!& '!&ersta!&i!$ of &eat" t"at is

approac"i!$. Ge!erally, t"e perso! i! t"is sta$e %a!ts to (e left alo!e.T"is sta$e "as also (ee! &escri(e& as t"e e!& of t"e &yi!$

str'$$le.E.$.1I ca!t /$"t it, I #ay as %ell prepare for itT"ese sta$es

are !ot !ecessarily se3'e!tial sta$es. People ca! #o*e fro# o!e sta$e

to a!ot"er a!& t"e! (ac- a$ai! or s-ip a sta$e as t"ey atte#pt to &eal

%it" t"e loss.

MARTOCCIO!S STAGES OF GRIEVING7artocc"io prese!te& /*e cl'ster of $rief to i!cl'&e

;. S"oc- a!& &is(elief.. ear!i!$ a!& protest.. A!$'is", &isor$a!i5atio! a!& &espair.>. I&e!ti/catio! of (erea*e#e!t98erea*e#e!t is a! i!&i*i&'al

e#otio!al respo!se to t"e loss of a si$!i/ca!t perso!.

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RANDO!S STAGES OF GRIEF

;. A*oi&a!ce. Co!fro!tatio!. Acco##o&atio!

A*oi&a!ce9i!cl'&es respo!ses s'c" as s"oc-, &e!iel, a!$er +

(ar$ai!i!$. Co!fro!tatio!9t"e p"ase &'ri!$ %"ic" t"e perso! act'ally faces

t"e loss. It is a *ery e#otio!al + 'psetti!$ ti#e. T"is is %"e! t"e

perso! feels t"e $rief #ost ac'tely

Acco##o&atio!9t"e perso! (e$i!s to li*e %it" t"e loss, feel

(etter + res'#e so#e ro'ti!e acti*itiesRa!&os sta$es are -!o%! as t"e si Rs of $rie*i!$. T"ey are

Reco$!isi!$ t"e loss)a%are!ess Reacti!$ to t"e separatio!)feel t"e e#otio!s Recollecti!$ #e#ories of t"e &ecease&)re#e#(eri!$,

relie*i!$ Reli!$'is"i!$ t"e ol& attac"#e!ts)!e% %ays of li*i!$

%it"o't t"e &ecease&

Rea&0'sti!$ to t"e !e% e!*iro!#e!t)!e% copi!$ s-ills Rei!*esti!$ self)e!er$y o!ce t'r!e& i!%ar& o! $rief to (e

foc'sse& o't%ar&

STAGES OF BEREAVEMENT: BO"LBY(1961)

ProtestDisor$a!i5atio!Reor$a!i5atio!

PATTERNS OF LIVING "ILE DYEING : MARTOCCIO(19#$

;. Pea- a!& *alleys or perio&s of "ope a!& &epressio!1 Despite"opef'l ti#es t"ere is still a! o*erall #o*e#e!t to%ar& &ecli!ea!& &eat"

. Desce!&i!$ platea's1 T"is &escri(es a &o%!%ar& tre!& %it"pro$ressi*e &e(ilitatio! a!& e*e!t'ally &eat"

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. Do%!%ar& slope %it" p"ysiolo$ical para#eters i!&icati!$ t"at&eat" is i##i!e!t. Ofte! o(ser*e& i! critical care '!its %"erepeople a!& fa#ilies "a*e !o ti#e to prepare for &eat"

>. Last patter! is a &o%!%ar& sla!t t"at re*eals a crisis e*e!t, s'c"as se*ere cere(ral "e#orr"a$e %it" al#ost !o "ope of reco*ery.

Ofte! t"e patie!t i! t"is patter! is (ei!$ #ai!tai!e& o! lifes'pport syste#s

"ILLIAM "ORDEN!S TEORY

His t"eory &escri(es t"e tas-s a $rie*i!$ perso! #'st ac"ie*e.T"ese i!cl'&es t"e follo%i!$1

;. (eali,ing that loved one is gone0 i! t"e "o'rs + &ays after asi$!i/ca!t loss, t"e $rie*i!$ perso! typically feels !'#( a!&'!a(le to accept t"e fact of t"e loss. T"is !'#(!ess is t"o'$"t to

(e a! "elpf'l for# of &e!ial. So t"e tas- of reali5i!$ t"at lo*e&o!e or o(0ect is $o!e #ay ta-e se*eral &ays, i! case of s'&&e!&eat" it ta-es se*eral %ee-s to ac"ie*e.

. 1xeriencing the ain0o!ce t"e $rie*i!$ perso! "as accepte&t"e reality of t"e loss, t"e feeli!$ a!& e#otio!s t"at s'rface arei!te!se a!& ca! c"a!$e rapi&ly. T"is #a-es t"e perso! feel o'tof co!trol. People i! t"is sta$e #ay say t"at t"ey feel as if t"eyare $oi!$ cra5y. T"is is t"e lo!$est p"ase of $rie*i!$

. Adjusting to the environment without the deceased0t"is #ea!sperfor#i!$ acti*ities alo!e ,s'c" as $oi!$ for %al- or s"oppi!$,t"at %ere o!ce s"are& or ta-i!$ o! roles a!& respo!si(ilities t"att"e &ecease& pre*io'sly "el&. O!ce t"e perso! "as esta(lis"e&t"e !e% patter! "e feels satisfactio! a!& i!crease& self estee#

>. Adjusting to the environment without the deceased1 i!itially alle!er$y is foc'se& o! t"e &ecease&1 t"i!-i!$ a(o't t"e perso!,tal-i!$ a(o't "er, reli*i!$ #e#ories a!& so o!. Co!ce!tratio! is&i4c'lt, so t"e $rie*i!$ perso! /!&s it "ar& to e!$a$e i!acti*ities s'c" as rea&i!$. W"e! t"e perso!s e!er$y (e$i!s to

:o% to%ar& ot"ers or to &i2ere!t or for#er i!terest, t"e "eali!$process is i! pro$ress.

DEAT AND DYING

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Deat" is t"e 'lti#ate loss.T"e &yei!$ perso! 'lti#atelyfaces

t"e loss of p"ysical co!trol a!& f'!ctio!, i!&epe!&e!ce, relatio!s"ips,

possi(ilities a!& 'lti#ately life itself.

DEFINITION

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"eart stops (eati!$.

STANDARDS OF DEAT DETERMINATION

)a A perso! is &ea& %"e!, accor&i!$ to or&i!ary sta!&ar&s of #e&ical

practice, t"ere is irre*ersi(le cessatio! of t"e perso!s spo!ta!eo's

respiratory a!& circ'latory f'!ctio!s. )Patie!t is p'lse less, ap!oeic a!&

'!respo!si*e to *er(al sti#'li for a perio& of at least #i!'tes.

)( If arti/cial #ea!s of s'pport precl'&e a &eter#i!atio! t"at a

perso!s spo!ta!eo's respiratory a!& circ'latory f'!ctio!s "a*e

cease&, t"e perso! is &ea& %"e!, i! t"e a!!o'!ce& opi!io! of a

p"ysicia!, accor&i!$ to or&i!ary sta!&ar&s of #e&ical practice, t"ere is

irre*ersi(le cessatio! of all spo!ta!eo's (rai! f'!ctio!. Deat" occ'rs

%"e! t"e rele*a!t f'!ctio!s cease.

NEEDS OF TE DYING PATIENT

D*+,- &/0,!0 2+33 /+-0

6ro# A#erica! Jo'r!al of !'rsi!$, K);


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I "a*e t"e ri$"t !ot to (e &ecei*e&. I "a*e t"e ri$"t to "a*e "elp fro# a!& for #y fa#ily i! accepti!$

#y &eat". I "a*e t"e ri$"t to &ie i! peace a!& &i$!ity. I "a*e t"e ri$"t to retai! #y i!&i*i&'ality a!& !ot (e 0'&$e& (y

#y &ecisio!s, %"ic" #ay (e co!trary to t"e (eliefs of ot"ers. I "a*e t"e ri$"t to &isc'ss a!& e!lar$e #y reli$io's or spirit'al

eperie!ces, re$ar&less of %"at t"ey #ea! to ot"ers. I "a*e t"e ri$"t to epect t"at t"e sa!ctity of t"e "'#a! (o&y

%ill (e respecte& after &eat". I "a*e t"e ri$"t to (e care& for (y cari!$, se!siti*e,

-!o%le&$ea(le people %"o %ill atte#pt to '!&ersta!& #y !ee&s

a!& %ill (e a(le to $ai! so#e satisfactio! i! "elpi!$ face #y

&eat".

CLINICAL MANIFESTATIONS AT TE END OF LIFE

Deat" occ'rs %"e! all *ital or$a!s a!& syste#s cease to f'!ctio!. As

&eat" approac"es, #eta(olis# is re&'ce& a!& t"e (o&y $ra&'ally

slo%s &o%! '!til all f'!ctio! e!&s. Ge!erally respiratio! ceases /rst,

a!& t"e! "eart stops (eati!$ %it"i! a fe% #i!'tes. T"e #a!ifestatio!i! &etail i!cl'&es p"ysical a!& psyc"olo$ical #a!ifestatio!s.

PYSICAL MANIFESTATIONS

SENSOR SSTE7

Heari!$ 9 's'ally last se!se to &isappear

To'c" 9 &ecrease& se!satio!

9 &ecrease& perceptio! of to'c" a!& pai!

Taste 9 &ecrease& %it" &isease pro$ress.

S#ell 9 &ecrease& %it" &isease pro$ress.

Si$"t 9(l'rri!$ of *isio!

9(li!- re:e a(se!t

9eyeli&s re#ai! "alf ope!

INTEG7ENTAR SSTE7

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9Col& cla##y s-i!

9cya!oses o! !ose, !ail (e&s

9@%a li-e s-i! %"e! *ery !ear to &eat".

RESPIRATOR SSTE7

9I!crease& respiratory rate

9c"ey!e stro-e respiratio! )alter!ati!$ perio&s of ap!oea, &eep

a!& rapi& (reat"i!$

9irre$'lar (reat"i!$ $ra&'ally slo%i!$ &o%! to ter#i!al $asps

)$'ppy (reat"i!$

9!oisy %et so'!&i!$ )&eat" rattle

RINAR SSTE7

9Gra&'al &ecrease i! 'ri!ary o'tp't

9'ri!ary i!co!ti!e!ce or '!a(le to 'ri!ate

GASTROINTESTINAL SSTE7

9Acc'#'latio! of $as

9&iste!sio! a!& !a'sea

9loss of sp"i!cter co!trol

9possi(le cessatio! of GI f'!ctio!

9(o%el #o*e#e!t #ay occ'r (efore i##i!e!t &eat" or at t"eti#e of &eat".

7SCLOSMELETAL SSTE7

9Gra&'al loss of a(ility to #o*e

9loss of $a$ re:e

9sa$$i!$ of 0a% res'lts i! loss of facial #'scle to!e, &ysp"a$ia,

&i4c'lty i! spea-i!$

CADIOVASCLAR SSTE7

9I!crease& "eart rate1 later slo%i!$

9irre$'lar r"yt"#s

9&ecrease& (loo& press're

9%ea-e!i!$ of p'lse

PSYCOSOCIAL MANIFESTATIONS

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A *ariety of feeli!$s a!& e#otio!s a2ect t"e &yi!$ patie!ts at t"e e!&

of life care. T"ey are

Altere& &ecisio! #a-i!$ 6ear of lo!eli!ess

fear of pai! Helpless!ess Restless!ess A!iety I#pe!&i!$ &oo# Visio! li-e eperie!ces Grief

ASPECTS OF END OF LIFE CARE

T"e i#porta!t aspects of e!& of life care i!*ol*es

i. Palliati*e careii. Preparatio! at t"e e!& of life careiii. A&*a!ce& &irecti*esi*. !&ersta!&i!$ CPR a!& DNR*. Care &'ri!$ t"e /!al &ays

*i. Hospice care

1. PALLIATIVE CARE

DE6INITION

T"e palliati*e care #ea!s ta-i!$ care of t"e %"ole perso!9

(o&y, #i!& a!& spirit, "eart a!& so'l. Palliati*e care is so#eti#es

calle& "ospice care. To&ay, &octors are a(le to c're #a!y people

&ia$!ose& %it" ca!cer. If a c're is !ot possi(le, so#e people recei*e

treat#e!t to #a!a$e t"e sy#pto#s a!& si&e e2ects of ca!cer a!& its

treat#e!t. T"is type of treat#e!t is calle& palliati*e care.

PRPOSES

Treati!$ pai! a!& all ot"er p"ysical sy#pto#s ca'se& (y &iseasea!& its treat#e!ts.

A&&ressi!$ a perso!s spirit'al !ee&s a!& co!cer!s. A&&ressi!$ a!& treati!$ a perso!s psyc"osocial !ee&s s'c" as

copi!$ %it" c"a!$es i! (o&y i#a$e a!& &epressio!.

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Pro*i&i!$ s'pport for t"e patie!ts fa#ily, frie!&s a!& care

$i*ers.

PRINCIPLES O6 PALLIATIVE CARE

I. palliati*e care respects t"e $oals, li-es, a!& c"oices of t"e &yi!$

perso! a!& "is or "er lo*e& o!es..."elpi!$ t"e# to '!&ersta!&

t"e ill!ess a!& %"at ca! (e epecte& fro# it, a!& to /$'re o't

%"at is #ost i#porta!t &'ri!$ t"e ti#e.II. Palliati*e care loo-s after t"e #e&ical, e#otio!al, social a!&

spirit'al !ee&s of t"e &yi!$ perso! %it" a foc's o! #a-i!$ s're

"e or s"e is co#forta(le, !ot left alo!e, a!& a(le to loo- (ac- o!

"is or "er life a!& /!& peace.III. Palliati*e care s'pports t"e !ee& of fa#ily #e#(ers, "elpi!$

t"e# %it" t"e respo!si(ilities of care $i*i!$ a!& e*e! s'pporti!$

t"e# as t"ey $rie*e.IV. Palliati*e care "elps to $ai! access to !ee&e& "ealt" care

pro*i&ers a!& appropriate care setti!$s i!*ol*i!$ *ario's -i!&s of

trai!e& pro*i&ers i! &i2ere!t setti!$s, tailore& to t"e !ee&s of t"e

patie!t a!& "is or "er fa#ily.V. Palliati*e care ('il&s a %ay to pro*i&e ecelle!t care at t"e e!&

of life t"ro'$" e&'catio! of care pro*i&ers, appropriate "ealt"

policies, a!& a&e3'ate f'!&i!$ fro# i!s'res a!& t"e $o*er!#e!t.

THE PALLIATIVE CARE TEA7

Se*eral "ealt" care professio!als #ay participate as part of a tea# to

$i*e palliati*e care. T"e tea# #e#(ers i!cl'&es,

DOCTOR1 T"e &octor ser*es as t"e "ealt" care tea# lea&er,

#a-es treat#e!t pla!s a!& &eci&es o! #e&icatio! a!& &osi!$

a!& #ay co!s'lt %it" ot"er &octors, s'c" as pai! specialist or a

ra&iatio! o!colo$ist.

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NRSES1 T"e !'rse $i*es &irect care to t"e patie!t a!& "elps

%it" #a!a$i!$ pla! a!& ot"er si&e e2ects of ca!cer a!& its

treat#e!t. T"e !'rse also acts as a laiso! %it" t"e rest of t"e

"ealt" care tea# #e#(ers. 6or people i! "o#e "ospice

pro$ra##e, !'rses *isit t"e# at "o#e se*eral ti#es a %ee- a!&

so#eti#es #ore t"a! o!ce a &ay. SOCIAL WORMER1 A social %or-er #ay "elp %it" /!a!cial iss'es?

arra!$e fa#ily #eeti!$s a!& "elps %it" &isc"ar$e fro# "o#e or

"ospice care. SPIRITAL ADVISORS1 A c"aplai! or ot"er spirit'al a&*isors

co'!sel t"e patie!t a!& fa#ily #e#(ers o! reli$io's a!&

spirit'al #atters. DIETITIAN1 A &ieticia! "elps t"e patie!t a!& fa#ily #e#(ers to

pla! "ealt"y #eals a!& a&&resses !'tritio!al co!cer!s. PHSIOTHERAPIST1 A p"ysiot"erapist "elps t"e patie!t to

#ai!tai! #o*e#e!t a!& "elps %"e! t"e patie!t "as &i4c'lty i!

#o*i!$ aro'!&, a!& also a&&resses social co!cer!s at "o#e. GRIE6 AND 8EREAVE7ENT CO.ORDINATOR1 T"is professio!al

co'!sels t"e patie!t a!& fa#ily #e#(ers a!& "elp %it" pla!!i!$

a!& #e#orial ser*ices.

PALLIATIVE CARE SETTINGS

As t"e !ee&s of e*ery fa#ily a!& fa#ily #e#(er *ary, a!& as

&i2ere!t care setti!$s prese!t. palliati*e care is pro*i&e& i! "o#e a!&

"ospital also.

I, & 0+'3 0&+,-0

Despite t"e eco!o#ic a!& "'#a! costs associate& %it" &eat"

i! t"e "ospital setti!$s, as #a!y as of all &eat"s occ'r i! t"e ac'tecare setti!$s. It is clear t"at #a!y patie!ts %ill co!ti!'e to opt for

"ospital care or &efa'lt %ill /!& t"e#sel*es i! "ospital setti!$s at t"e

e!& of life care. I!creasi!$ly, "ospitals are co!&'cti!$ syste# %i&e

assess#e!ts of e!& of life care practices a!& o'tco#es a!& are

&e*elopi!$ i!!o*ati*e #o&els for &eli*eri!$ "i$" 3'ality, perso!

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17/33

ce!tre& care to t"e patie!ts approac"i!$ t"e e!& of life. Hospitals cite

co!si&era(le /!a!cial (arriers to pro*i&i!$ "i$" 3'ality palliati*e care

i! ac'te care setti!$s. P'(lic policy c"a!$es "a*e (ee! calle& for t"at

%o'l& pro*i&e rei#('rse#e!t to "ospitals for care &eli*ere& *ia

&esi$!ate& "ospital %i&e palliati*e care (e&s, cl'stere& palliati*e care

'!its or palliati*e care co!s'ltatio! ser*ices i! ac'te care setti!$s.

I, & & '/& 0&+,-0

W"ere e*er t"e patie!t #ay 'lti#ately &ie, t"ey are li-ely to

spe!& #ost of t"eir last year of life i! t"eir o%! "o#e (ei!$ care& for

(y close fa#ily #e#(ers. W"e! t"e patie!t a!& t"e fa#ilys "opes are

foc'sse& o! allo%i!$ t"e patie!t to &ie i! "is or "er o%! "o#e ,t"e

!'rses !ee& to (e ac'tely se!siti*e to t"e s"ifti!$ !ee&s of t"e cari!$

fa#ily. S'pport fro# palliati*e care cli!ical !'rse specialists s'c" as

7ac#illa! !'rses a!&or accessi!$ t"e 7arie c'rie !'rsi!$ ser*ice to

pro*i&e ete!&e& perio&s of care i! t"e "o#e, ofte! o*er!i$"t ,ca!

pro*i&e cr'cial s'pport to t"e fa#ily, per"aps a*oi&i!$ late crisis

aissio! to "ospital &'e to care $i*er strai!. 6or people i! "o#e

"ospice pro$ra##e, !'rses *isit t"e# at "o#e se*eral ti#es a %ee-

a!& so#eti#es #ore t"a! o!ce a &ay.

PALLIATIVE SEDATION AT THE END O6 LI6E

Alt"o'$" palliati*e se&atio! re#ai!s co!tro*ersial, it is

o2ere& i! so#e setti!$s to patie!ts %"o are close to &eat" or %"o

"a*e sy#pto#s t"at &o !ot respo!& to co!*e!tio!al p"ar#acolo$ic or

!o! p"ar#acolo$ical approac"es. T"e palliati*e se&atio! to relie*e

sy#pto#s, !ot to "aste! &eat" it is #ost co##o!ly 'se& %"e! t"e

patie!t e"i(its i!tracta(le pai!, &ysp!oea, sei5'res or &eliri'#. 8efore

i#ple#e!ti!$ palliati*e se&atio!, t"e "ealt" care tea# s"o'l& asses

for t"e prese!ce of '!&erlyi!$ a!& treata(le ca'ses of s'2eri!$ s'c"

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as &epressio! or spirit'al pai!. 6i!ally t"e patie!t a!& fa#ily s"o'l& (e

f'lly i!for#e& a(o't t"e 'se of t"is treat#e!t.

E$1 I!f'sio! of (e!5o&ia5epi!e or (ar(it'rates i! &oses a&e3'ate to

i!&'ce sleep a!& eli#i!ate si$!s of &isco#fort.

O!ce se&atio! "as (ee! i!&'ce&, t"e !'rse s"o'l& co!ti!'e

to co#fort to t"e patie!t, #o!itor t"e p"ysiolo$ical e2ect of t"e

se&atio!, s'pport t"e fa#ily are a!& e!s're t"e co##'!icatio! %it"i!

t"e "ealt" tea# a!& (et%ee! t"e tea# a!& t"e fa#ily.

$. PREPARATION AT TE END OF LIFE CARE

Despite t"e &octors (est e2orts a!& "ar& %or-, &isease

treat#e!t so#eti#es stops %or-i!$ a!& a c're or lo!$er ter#

re#issio! is !o lo!$er possi(le. T"is sta$e of ill!ess is calle& a&*a!ce&,

ter#i!al or e!& sta$e. T"is sta$e i!cl'&es,

GRIEVING OR LOSSES

Lear!i!$ t"at perso!s ill!ess "as (eco#e ter#i!al ca! (ri!$

a(o't i!te!se feeli!$s of a!$er, fear $rief, re$ret a!& ot"er

stro!$ e#otio!s.

Tal-i!$ a(o't feeli!$s a!& co!cer!s %it" fa#ily, frie!&s a!&care$i*ers ca! "elp (ri!$ yo' co#fort.

It is !or#al to $rie*e a!& #o'r! t"e loss of yo'r a(ilities, t"e

lo*e& o!es yo' %ill lea*e (e"i!&, a!& t"e &ays yo' %ill !ot "a*e.

GETTING A66AIRS IN ORDER

Setti!$ yo'r a2airs i!cl'&e locati!$ a!& or$a!i5i!$ i#porta!t

le$al a!& /!a!cial &oc'#e!ts, s'c" as %ill, #arria$e a!& (irt"certi/cates, social sec'rity car&, i!s'ra!ce policies, (a!-

state#e!ts a!& i!*est#e!t s'##aries. So#e people also /!& it "elpf'l to pla! so#e aspects of t"eir

o%! f'!eral. T"is ca! (e &o!e %it" set of %ritte! i!str'ctio!s or

tal-i!$ to fa#ily or close frie!&s a(o't yo'r %is"es.

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As %e approac" t"e e!& of yo'r life t"ere #ay (e certai! t"i!$s

yo' %is" to acco#plis" i! t"e ti#e yo' "a*e left. T"ese tas-s

ca! "elp to (ri!$ a se!se of #ea!i!$ a!& co#pletio! to yo'r life,

a!& #ay ra!$e fro# f'l/lli!$ a lifelo!$ &rea# to #ore si#ple

eperie!ces s'c" as rerea&i!$ a fa*o'rite (oo- or spe!&i!$ ti#e

%it" t"ose %"o are i#porta!t to yo'.

REVIEWING OR LI6E

It is o!ly !at'ral to %a!t to lea*e a le$acy? e*i&e!ce t"at yo'r

life #attere& a!& t"at yo' #a&e a &i2ere!ce i! t"e %orl&. Ta-e ti#e to re:ect o! a!& cele(rate t"e e*e!ts i! yo'r life9t"e

t"i!$s yo' "a*e acco#plis"e&, t"e people yo' "a*e lo*e&, t"e

i!&i*i&'als a!& e*e!ts t"at "a*e s"ape& yo'. Tal-i!$ a(o't or recor&i!$ yo'r %is"es a!& &rea#s for lo*e&

o!es i! t"e f't're ca! "elp ease re$rets a(o't "a*i!$ to lea*e

t"e#, a!& "elp t"e# feel co!!ecte& to yo' at i#porta!t ti#es

t"ro'$"o't t"eir li*es.

RELIGION AND SIRITALIT

T"e spirit'ality is a -ey co#po!e!t of co#pre"e!si*e !'rsi!$

for ter#i!ally ill patie!ts a!& t"eir fa#ilies. I!cl'&e co'!selli!$ to

patie!t a!& fa#ily #e#(ers. Spirit'al !ee&s &o !ot !ecessarily e3'ate

to reli$io!. A perso! #ay (e of !o partic'lar fait" ('t "a*e a &eep

spirit'ality. So#e patie!ts #ay c"oose to p'rs'e a spirit'al pat" so#e

#ay !ot. So t"eir i!&i*i&'al !ee&s to (e respecte&. T"e patie!ts a!&

fa#ilys prefere!ces relate& to spirit'al $'i&a!ce or pastoral care

ser*ices s"o'l& (e !ote&.

E$1 Gi*i!$ a!oi!t#e!t.

6or so#e, or$a!ise& reli$io! is a ce!tral part of life a!& t"e

s'pport of fait" a!& cler$y #e#(ers are a! i#porta!t so'rce of

co#fort at t"e e!& of life. 6or ot"ers, spirit'al co#fort #ay lie i! a

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20/33

se!se of co!!ectio! to !at're or people. W"at #atters is /!&i!$ s'c"

co#fort, co#pletio!, peace %"ic" %ill s'stai! "ope a!& #ea!i!$.

4. ADVANCED DIRECTIVES

I! ;


21/33

treat#e!t &irecti*e or &irecti*e to p"ysicia!s a!& fa#ily. A li*i!$ %ill

ca! i!cl'&e t"e state#e!ts a(o't

W"et"er clie!t %a!t t"e #e&ical tea# to 'se car&iop'l#o!ary

res'scitatio!)CPR a!& or arti/cial life s'pport s'c" as

#ec"a!ical *e!tilator, if (reat"i!$ or "eart stops. W"et"er yo' %a!t to recei*e a fee&i!$ t'(e, if yo' ca!!ot (e fe&

ot"er%iseB W"et"er clie!t %a!t certai! proce&'res s'c" as &ialysis.

DRA8LE POWER O6 ATTORNE 6OR HEA LTH CARE

It is a le$al &oc'#e!t t"ro'$" %"ic" t"e si$!er appoi!ts a!&

a't"ori5es a!ot"er i!&i*i&'al to #a-e &ecisio!s o! "is or "er (e"alf

%"e! "es"e is !o lo!$er a(le to spea- for "i#"erself. T"e perso!s

appoi!t is ofte! referre& to as "eat" care proy, a$e!t or attor!ey i!9

fact a!& "as a't"ority o!ly o*er #e&ical &ecisio!s, !ot ot"er #atters

s'c" as /!a!ces. T"is is also -!o%! as a "ealt" care po%er of attor!ey

or a proy &irecti*e. A!y co#pete!t a&'lt, a$e #ore t"a!;Fyrs or ol&er

ca! (e a "ealt" care a$e!t. O!ce yo' c"oose a "ealt" care a$e!t yo'

ca! still #a-e yo'r o%! &ecisio!s a(o't yo'r #e&ical care1 yo'r "ealt"

care a$e!t %ill o!ly #a-e &ecisio!s o!ce yo' are '!a(le to &o so.O!ce yo' #a-e a! a&*a!ce &irecti*e, yo' ca! c"a!$e it if !ee&e&.

C"a!$es ca! #a&e as lo!$ as yo' still "a*e or re$ai! yo'r a(ility to

#a-e &ecisio!s a!& s"o'l& !otify "ealt" care tea# if a!y c"a!$es

#a&e.

4. UNDERSTANDING CPR AND DNR

CPR is a co#(i!atio! of c"est co#pressio!s a!& resc'e

(reat"i!$ t"at is $i*e! to a perso! i! car&iac arrest. W"e! a perso!

$oes to car&iac arrest, t"e "eart stops p'#pi!$ (loo& t"ro'$"

(o&y.CPR ca! te#porarily "elp a s#all a#o'!t of (loo& :o% to t"e

"eart a!& (rai! '!til t"e "eart (e$i!s (eati!$ a$ai!.CPR #ay i!cl'&e

t"e follo%i!$1

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7a!'al c"est co#pressio!.

De/(rillatio!

Gi*i!$ &r'$s to sti#'late t"e "eart

7o't" to #o't" (reat"i!$

I!sertio! of a! arti/cial air%ay

A DNR or&er is a type of a&*a!ce &irecti*e a!& it is t"e

%ritte! p"ysicia!s or&er i!str'cti!$ "ealt" care pro*i&ers !ot to

atte#pt CPR a!& it is ofte! re3'este& (y patie!t a!& fa#ily. A Q!o co&e

Qor DNR or&er allo%s t"e perso! to &ie %it" co#fort #eas'res o!ly a!&

%it"o't t"e i!terfere!ce of t"e tec"!olo$y. A !e% ter# (ei!$ 'se& to

replace Q!o co&e or DNR is t"e ter# allo%e& !at'ral &eat" )AND.t"is

ter# #ore acc'rately co!*eys %"at act'ally "appe!s. It is alsoso#eti#es referre& to as Qco#fort co&e stat's, #ea!i!$ t"at all

co#fort #eas'res associate& %it" pai! co!trol a!& sy#pto#

#a!a$e#e!t are carrie& o't. Ho%e*er, t"e !at'ral p"ysiolo$ical

pro$ressio! to &eat" is !ot &elaye& or i!terr'pte&. !li-e ot"er

a&*a!ce &irecti*es t"at are %ritte! a!& si$!e& (y t"e i!&i*i&'al, a DNR

or&er #'st (e co#plete& a!& si$!e& (y &octor or ot"er "ealt" care

pro*i&er, s'c" as "ospice !'rse practio!er. O!ce co#plete& it s"o'l&

(e a&&e& to t"e #e&ical recor&.

I&eally, &ecisio!s a(o't e!& of life care s"o'l& (e #a&e early

i! t"e care process (efore t"ere is a !ee& for t"e#. If %ait '!til a crisis

occ'rs, it #ay (e too late for co##'!icate yo'r %is"es a(o't a DNR

or&er or ot"er a&*a!ce &irecti*es. Ho%e*er, #a!y p"ysicia!s are

rel'cta!t to %rite t"ese or&ers, especially %"e! t"is iss'e is a so'rce of

co!:ict (et%ee! t"e patie!t a!& fa#ily or (et%ee! i!&i*i&'al fa#ily

#e#(ers.

5. CARE DURING FINAL DAYS

If treat#e!t is !o lo!$er a(le to slo% or "alt t"e $ro%t" of

t"e &isease, t"e &isease &e*elops %"at is -!o%! as a&*a!ce& or e!&

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sta$e. Treat#e!t for e!& sta$e foc'ses o! -eepi!$ t"e perso!

co#forta(le a!& free of pai! as "e or s"e approac"es t"e e!& of life.

E*e! if a c're or lo!$ ter# re#issio! is !o lo!$er possi(le, t"e perso!

still "as t"e c"oices for care. So#e people &eci&e to stop acti*e

treat#e!ts )e.$.1 c"e#ot"erapy,ot"er people #ay recei*e a&&itio!al

#e&ical treat#e!ts a!& to co!ti!'e (ot" palliati*e a!& acti*e care a!&

#a!y of t"e# &eci&e to e!ter "ospice care. Care &'ri!$ /!al &ays

i!cl'&e,

P/+%+,- /

Co#fort #eas'res &'ri!$ t"e e!& of life i!cl'&es,

se foa# c's"io!s to #a-e (e&s a!& c"airs #ore co#forta(le

a!& "elp t"e patie!t to c"a!$e positio!s fre3'e!tly a!& c"a!$e

t"e (e& li!e!s as !ecessary. Ele*ate t"e patie!ts "ea& or t'r! t"e patie!t o! "is or "er si&e

to "elp #a-e (reat"i!$ easier. se (la!-ets to "elp -eep t"e perso! %ar# + $e!tly r'( t"e

perso!s "a!&, feet or soa- t"e "a!&s a!& feet i! %ar# %ater. A $e!tle #assa$e ca! (e co#forti!$ a!& ca! "elp %it" (loo&

circ'latio! a!& &ry s-i!. se a lotio! %it"o't alco"ol, %"ic"

te!&s to f'rt"er &ry s-i!. O2er sips of li3'i& t"ro'$" a stra% or fro# a spoo! to "elp to

-eep t"e #o't" #oist. Glyceri!e s%a(s a!& lip (al# also "elp

%it" &ry #o't" a!& lips.

C,/33+,- '+,

Co!trolli!$ pai! is a! i#porta!t part of &yi!$ co#forta(ly a!&

peacef'lly.

Ai!ister #e&icatio!s aro'!& t"e cloc- i! a ti#ely #a!!er a!&

o! a re$'lar (asis to pro*i&e co!sta!t relief rat"er t"a! %aiti!$

'!til t"e pai! is '!(eara(le. Co!ce!trate& #orp"i!e sol'tio! ca! (e *ery e2ecti*e (y

&eli*ere& (y t"e s'(li!$'al ro'te.

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I! case of '!co!trolle& pai!, palliati*e se&atio!.

R&0&+,- 8,'3 +0&0

T"e !'rse !ee&s to (e a%are of %is"es of patie!t a!& fa#ily

#e#(ers. 6or ea#ple, so#e people !eari!$ t"e e!& of life c"oose !ot

to recei*e arti/cial life s'pport )e$? *e!tilators, fee&i!$ t'(es etc, a!&

#ay re3'est a DNR or&er. Care $i*ers a!& ot"ers %"o care a(o't t"e

perso! #ay !ot al%ays a$ree %it" t"e &ecisio!s o'tli!e& i! a! a&*a!ce

&irecti*e. Ho%e*er, "a*i!$ a patie!ts /!al %is"es respecte& a!&

follo%e& is a! i#porta!t !ee& for people %it" a! a&*a!ce& ill!ess.

6. OSPICE CARE

Hospice is !ot a place ('t a co!cept of care t"at pro*i&es

co#passio!, co!cer!, a!& s'pport for &yi!$. Hospice a!& palliati*e

care are fre3'e!tly 'se& i!terc"a!$ea(ly. Hospice eists to pro*i&e

s'pport a!& care for perso! i! t"e last p"ases of t"e i!c'ra(le &iseases

so t"at t"ey #i$"t li*e as f'lly a!& as co#forta(le as possi(le. Hospice

care pro$ra##es pro*i&e #'lti&iscipli!ary care at t"e e!& of life %it"

e#p"asis o! sy#pto# #a!a$e#e!t, a&*a!ce care pla!!i!$, spirit'al

care, fa#ily s'pport, i!cl'&i!$ (erea*e#e!t.

Hospice care is $e!erally pro*i&e& i! t"e "o#e, %it"

i!patie!t care reser*e& for ac'te pai! #a!a$e#e!t or respite care for

fa#ilies or care $i*ers i! !ee& of a (rea-. Ho#e care is pro*i&e& o! a

part ti#e, i!ter#itte!t, o! call, re$'larly sc"e&'le& or co!ti!'o's (asis

.Hospice care ser*ices are a*aila(le >"rs a &ay a!& K &ays a %ee- to

pro*i&e "elp to patie!ts a!& fa#ilies i! t"eir "o#es. T"e i!patie!t

"ospice setti!$s "a*e (ee! &ei!stit'tio!alise& to #a-e t"e at#osp"ere

as relae& a!& "o#eli-e as possi(le.

C/+&/+' / 0+& '/&

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Aissio! to a "ospice care pro$ra##e "as t%o criteria

.6irst t"e patie!t #'st &esire t"e ser*ices? seco!&, a p"ysicia! #'st

certify t"at t"e patie!t "as = #o!t"s or less to li*e. Hospice ca! "elp

(y foc'ssi!$ o! i!&i*i&'als !ee& a!& $oals. Hospice care allo%s a

perso! to approac" t"e e!& of life %it" co!/&e!ce, co#fort, peace a!&

&i$!ity.

C'/+,- '33+'+& '/& ',% 0+& '/&

Alt"o'$" t"e ter# palliati*e care a!& "ospice care are

so#eti#es 'se& i!terc"a!$ea(ly, t"ey "a*e sli$"tly &i2ere!t

#ea!i!$s. Palliati*e care applies to e*ery steps of ca!cer process.

Palliati*e care is t"e fra#e %or- for "ospice care. Palliati*e care starts

#'c" earlier i! a &isease process %"ere as "ospice is tra&itio!ally is

li#ite& to t"e pro0ecte& last si #o!t"s of life.

T& 0+& &'

6or "ospice to (e s'ccessf'l i! ac"ie*i!$ its $oals, it

re3'ires a &isc'ssio! a#o!$ patie!t, His or "er care $i*ers a!& a

*ariety of #e&ical, !'rsi!$ a!& ot"er "ealt" care professio!als. T"e

#e#(ers i!cl'&e

A &octor %"o ser*es as t"e #e&ical &irector of t"e tea#. N'rses %"o pro*i&e &irect care a!& case #a!a$e#e!t. Ho#e "ealt" ai&es i!cl'&i!$ (at" ai&s to assist %it" (asic !ee&s. Social %or-ers. C"aplai!s a!& pastoral care co'!sellors P"ysical, occ'patio!al a!& re"a(ilitatio! t"erapists. Dieticia!s Trai!e& "ospice *ol'!teers 8erea*e#e!t co'!sellors

7ost "ospice care is pro*i&e& i! patie!ts o%! "o#e, also careo'tsi&e t"e "o#e. Also 7e&icare "ospice (e!e/ts are also a*aila(le. It

is a fe&eral "ealt" i!s'ra!ce pro$ra##e for people of a$e =yrs a!&

ol&er, so#e &isa(le& people '!&er =yrs a!& people of all a$es %it"

e!& sta$e re!al &iseases.

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NURSING MANAGEMENT: END OF LIFE CARE

6OR PAIN

Pai! #ay (e a #a0or sy#pto# associate& %it" ter#i!al ill!ess

a!& t"e o!e of t"e #ost feare&. Pai! ca! (e ac'te or c"ro!ic.

N/0+,- I,&/&,+,0

Asses t"e pai! t"oro'$"ly a!& &eter#i!e t"e 3'ality, i!te!sity,

locatio!, a!& co!tri('ti!$ factors. 7i!i#i5e possi(le irrita!ts s'c" as s-i! irritatio!s fro# %et!ess,

"eat or col& a!& press're.

Ai!ister #e&icatio!s aro'!& t"e cloc- i! a ti#ely #a!!er a!&o! a re$'lar (asis to pro*i&e co!sta!t relief rat"er t"a! %aiti!$

'!til t"e pai! is '!(eara(le. Pro*i&e co#ple#e!tary a!& alter!ati*e t"erapies s'c" as

#assa$e, ac'press're, t"erape'tic to'c" relaatio! tec"!i3'es

as !ee&e&. E*al'ate t"e e2ecti*e!ess of pai! relief #eas'res fre3'e!tly to

e!s're t"at t"e patie!t is o! correct a&e3'ate &r'$ re$i#e!. Do !ot &elay or &e!y pai! relief #eas'res to a ter#i!ally ill

patie!t.

6OR DSPHAGIA

It #ay occ'r (eca'se of etre#e %ea-!ess a!& c"a!$es i! le*el

of co!scio's!ess.

N/0+,- I,&/&,+,0

I&e!tify t"e least i!*asi*e alter!ati*e ro'tes of ai!istratio! for

&r'$s !ee&e& for sy#pto# #a!a$e#e!t. S'ctio! orally as !ee&e&.

6OR DEHDRATION

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7ay occ'r &'ri!$ t"e last &ays of life. As t"e &eat" approac"es,

patie!t te!& to ta-e i! less foo& a!& :'i&.

N/0+,- I,&/&,+,0

Asses t"e co!&itio! of #'co's #e#(ra!e fre3'e!tly to pre*e!t

ecessi*e &ry!ess, %"ic" ca! lea& to &isco#fort. 7ai!tai! co#plete, re$'lar oral care to pro*i&e for co#fort a!&

"y&ratio! of t"e #'co's #e#(ra!es. Do !ot force t"e patie!t to eat or &ri!-. E!co'ra$e t"e co!s'#ptio! of ice c"ips a!& sips of :'i&s or 'se

#oist clot"es to pro*i&e #oist're to t"e #o't". Apply l'(rica!t to t"e lips a!& oral #'co's #e#(ra!e as

!ee&e&.

Reass're fa#ily t"at cessatio! of foo& a!& :'i& i!ta-e is !at'ralpart of t"e processes of &yi!$.

6OR DSPNEA

Acco#pa!ie& (y fear of s'2ocatio! a!& a!iety or '!&erlyi!$

&isease process ca! eacer(ate &ysp!oea. Co'$"i!$ a!&

epectorati!$ secretio!s (eco#e &i4c'lt.N/0+,- +,&/&,+,0

Assess respiratory stat's re$'larly. Ele*ate t"e "ea& a!&or positio! o! si&e to i#pro*e c"est

epa!sio!. se a fa! or air co!&itio!er to facilitate #o*e#e!t of cool air. Ai!ister s'pple#e!tal oy$e! as or&ere&. Ai!ister &r'$s as prescri(e&. S'ctio! as !ee&e& to re#o*e acc'#'latio! o #'c's fro# t"e

air%ays. S'ctio!i!$ is 'se& ca'tio'sly i! ter#i!al p"ase.

6OR WEAMNESS AND 6ATIGE

It is epecte& at t"e e!& of life. 7eta(olic &e#a!&s relate& to

&isease process co!tri('te to %ea-!ess a!& fati$'e.

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N/0+,- +,&/&,+,0

Assess t"e patie!ts tolera!ce for acti*ities. Ti#e !'rsi!$ i!ter*e!tio!s to co!ser*e e!er$y. Assist t"e patie!t to i&e!tify a!& co#plete &esire& acti*ities. Pro*i&e fre3'e!t rest perio&s.

6OR SMIN 8REAMDOWN

S-i! i!te$rity is &i4c'lt to #ai!tai! at t"e e!& of life. I##o(ility,

'ri!ary a!& (o%el i!co!ti!e!ce, &ry s-i!, !'tritio!al &e/cits, a!ae#ia,

frictio! a!& s"eari!$ forces lea& to a "i$" ris- for s-i! (rea-&o%!. As

&eat" approac", circ'latio! to t"e etre#ities &ecreases a!& t"ey

(eco#e cool #ottle& a!& cya!otic.

N/0+,- +,&/&,+,0 Assess t"e s-i! for t"e si$!s of (rea- &o%!. I#ple#e!t protocols to pre*e!t s-i! (rea-&o%! (y co!trolli!$

&rai!a$e a!& -eepi!$ t"e s-i! a!& a!y %o'!& areas clea!. 6ollo% appropriate !'rsi!$ #a!a$e#e!t protocol for a patie!t

%"o is i##o(ile. se (la!-ets to co*er for %ar#t"? !e*er apply "eat. Pre*e!t t"e e2ects of s"eari!$ forces.

6OR I7PAIRED 8OWEL PATTERNS

Co!stipatio! ca! (e ca'se& (y i##o(ility, 'se of opioi&s, lac- of

/(res i! t"e &iet a!& &e"y&ratio!. Also &iarr"oea #ay occ'r as

#'ssels rela or fro# a faecal i#pactio! relate& 'se of opioi&s a!&

i##o(ility.

N/0+,- +,&/&,+,0

Assess (o%el f'!ctio!. Assess for a!& re#o*e faecal i#pactio!s.

E!co'ra$e #o*e#e!t a!& p"ysical acti*ities as tolerate&. E!co'ra$e /(re i! t"e &iet if appropriate. E!co'ra$e :'i&s if appropriate. se stool softe!ers, s'ppositories, laati*es or e!e#a if or&ere&.

6OR RINAR INCONTINENCE

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It #ay res'lt fro# &isease pro$ressio! or c"a!$es i! t"e le*el of

co!scio's!ess. As &eat" (eco#es i##i!e!t, t"e pere!!ial #'ssels

rela.

N/0+,- +,&/&,+,0

Assess 'ri!ary f'!ctio!. se a(sor(e!t pa&s for 'ri!ary i!co!ti!e!ce. 6ollo% t"e appropriate !'rsi!$ protocol for t"e co!si&eratio! for

t"e 'se of i!&%elli!$ or eter!al cat"eters. 6ollo% appropriate !'rsi!$ #a!a$e#e!t to pre*e!t s-i!

irritatio!s a!& (rea-&o%! fro# 'ri!ary i!co!ti!e!ce.

6OR ANOREA, NASEA+VO7ITTING

Ca'se& (y co#plicatio!s of t"e &isease process or &r'$s.

Co!stipatio!, i#pactio!, (o%el o(str'ctio! ca! also ca'se a!oreia,

!a'sea a!& *o#iti!$.

N/0+,- +,&/&,+,0

Asses t"e patie!t for co#plai!ts of !a'sea a!& *o#iti!$.

Asses possi(le co!tri('ti!$ factors of !a'sea a!& *o#iti!$. Ha*e fa#ily #e#(ers to pro*i&e patie!ts fa*o'rite foo&s. Disc'ss #o&i/catio! to t"e &r'$ re$i#e! %it" t"e &octor. Pro*i&e a!tie#etic (efore #eals if or&ere&. O2er a!& pro*i&e fre3'e!t #eals %it" s#all portio!s of fa*o'rite

foo&s. Pro*i&e fre3'e!t #o't" care, especially after *o#iti!$.

PSCHOSOCIAL CAREA *ariety of feeli!$s a!& e#otio!s a2ect t"e &yi!$ patie!t a!&

fa#ily at t"e e!& of life. 7ost patie!ts a!& fa#ilies str'$$le %it" a

ter#i!al &ia$!osis a!& t"e reali5atio! t"at t"ere is !o c're. Ti#e #ay

(e !ee&e& to process t"e i#pe!&i!$ &eat" a!& for#'late e#otio!al

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respo!ses. T"e patie!t a!& fa#ily feel o*er%"el#e&, fearf'l, po%erless

a!& fati$'e&.

N/0+,- +,&/&,+,0

Asses t"e psyc"olo$ical stat's of t"e patie!t. Co!*erse as if t"e patie!t is alert, 'si!$ soft *oice a!& $e!tle

to'c". E!co'ra$e t"e fa#ily to tal- %it" a!& reass're t"e &yi!$ perso!. E!co'ra$e *isit (y appropriate spirit'al care pro*i&er, c"aplai! or

fa#ily #e#(ers. Pro*i&e a roo# t"at is 3'iet, %ell li$"te&, a!& fa#iliar to re&'ce

t"e e2ects of &eliri'#, a!iety.

Reorie!t t"e &yi!$ perso! to t"e perso!, place, %it" eac"e!co'!ter.

Stay p"ysically close to t"e fri$"te!e& patie!t Reass're i! a cal#, soft *oice %it" to'c" a!& slo% stro-es of t"e

s-i!. E!co'ra$e fa#ily #e#(ers to participate i! t"e care of t"e

patie!t. Ta-e %it" co!s'lta!t a!& arra!$e for co'!selli!$. Do!t allo% t"e patie!t to (e alo!e, -eep "i# e!$a$e& %it" so#e

%or-.

LEGAL AND ETICAL ISSUES AFFECTING END OF LIFE

CARE

Patie!ts a!& fa#ilies str'$$le %it" #a!y &ecisio!s &'ri!$ t"e

ter#i!al ill!ess a!& &yi!$ eperie!ce. 7a!y people &eci&e t"at t"e

o'tco#es relate& to t"eir care s"o'l& (e (ase& o! t"eir o%! %is"es.

7'ltiple treat#e!t optio!s a!& sop"isticate& life s'pport tec"!olo$ies

#ay #a-e it &i4c'lt to &ra% t"e li!e (et%ee! pro#oti!$ life a!&

!ee&lessly prolo!$i!$ t"e &yi!$ process. Patie!ts "a*e a le$ally a!&

#orally protecte& ri$"t to co!se!t to a!& ref'se a!y a!& all i!&icate&

#e&ical t"erapies.

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);.ORGAN AND TISSE DONATON

Perso!s %"o are le$ally co#pete!t #ay c"oose or$a! &o!atio!.

A!y (o&y part or t"e e!tire (o&y #ay (e &o!ate&. T"e &ecisio! to

&o!ate or$a!s or to pro*i&e a!ato#ic $ifts #ay (e #a&e (y perso!

(efore &eat" a!& fa#ily per#issio! #'st (e o(tai!e& at t"e ti#e of

&o!atio!. 8ot" or$a! a!& tiss'e &o!atio! follo% speci/c le$al

$'i&eli!es. Le$al re3'ire#e!ts a!& facility policies for or$a! or tiss'e

&o!atio! #'st (e follo%e&. T"e p"ysicia! #'st (e !oti/e& i##e&iately

%"e! or$a! &o!atio! is i!te!&e& (eca'se so#e tiss'es #'st (e 'se&

%it"i! "o'rs after &eat".

).TER7INAL WEANING

Ter#i!al %ea!i!$ is t"e $ra&'al %it"&ra%al of #ec"a!ical

*e!tilatio! fro# a patie!t %it" a ter#i!al ill!ess or a! irre*ersi(le

co!&itio! %it" a poor &ia$!osis. I! so#e cases ,a co#pete!t patie!ts

&eci&e t"at t"ey %is" t"eir *e!tilator s'pport e!&e&? #ore ofte!, t"e

s'rro$ate &ecisio! #a-ers for a! i!co#pete!t patie!t &eter#i!e t"at

co!ti!'e& *e!tilator s'pport is f'tile. A !'rses role i! ter#i!al %ea!i!$is to participate i! t"e &ecisio! #a-i!$ process (y o2eri!$ "elpf'l

i!for#atio! a(o't t"e (e!e/ts a!& ('r&e! of co!ti!'e& *e!tilatio! a!&

&escriptio! of %"at to epect if ter#i!al %ea!i!$ is i!itiate&. S'pport

t"e patie!ts fa#ily a!& #a!a$i!$ se&atio! a!& a!al$esia are critical

!'rsi!$ respo!si(ilities.

).ETHANASIA

E't"a!asia literally #ea!s @$oo& &yi!$.It is t"e &eli(erate

e!&i!$ of t"e life of perso! s'2eri!$ fro# a! i!c'ra(le &isease.

E't"a!asia #ay (e co!&'cte& passi*ely, !o! acti*ely, or acti*ely.

E't"a!asia #ay (e co!&'cte& %it" co!se!t )*ol'!tary e't"a!asia or

%it"o't co!se!t )i!*ol'!tary.i!*ol'!tary e't"a!asia is co!&'cte&

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%"ere a! i!&i*i&'al #a-es a &ecisio! for ot"er perso! i!capa(le of

&oi!$ so. Passive euthanasia e!tails t"e %it""ol&i!$ of co##o!

treat#e!ts s'c" as a!ti(iotics, c"e#ot"erapy i! ca!cer or s'r$ery or

t"e &istri('tio! of #e&icatio! s'c" as #orp"i!e to relie*e pai!,

-!o%i!$ t"at it #ay also res'lt i! &eat". Passi*e e't"a!asia is #ost

accepte& for# a!& it is a co##o! practice. Non active euthanasia

e!tails t"e %it"&ra%i!$ of life s'pport. Active euthanasia e!tails t"e

'se of let"al i!0ectio! or car(o! #o!oi&e t"at forces to -ill a!& %as

&ee#e& (ot" i##oral a!& ille$al. I! t"is t"e cli!icia! acts &irectly to

ca'se t"e &eat" of t"e patie!t. Also i! assisted suicide, t"e cli!icia!

pro*i&es t"e #ea!s t"e patie!t 'se& to ca'se "er o%! &eat" )e.$.

pro*i&es a prescriptio! for a let"al &ose of (ar(it'rates.

I! ;


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;. MOIER, 8, ETAL. )F.DEATH AND DING. 23N"AM1N4ALS .2

N3(S+N56 P(.!1SS AN" P(A!4+!1S )FTH ED., PP.;

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