Death & Dying, Grief & Loss Chapter 30 NRS_105/320_Collings

Death & Dying, Grief & Death & Dying, Grief & LossLoss

Chapter 30Chapter 30

NRS_105/320_CollingsNRS_105/320_Collings

Loss & GriefLoss & Grief

• Experienced throughout the lifespan• Grief behavior is shaped by values, culture but

grief itself is universal• All Change involves some loss• Nurses deal with patients’ and their own grief

and loss• Grief is a normal response to loss• Grief behaviors vary over time and among

individuals, families, and cultures


TermsTerms

• Situational loss– Sudden, unexpected, external– Loss of person, object, limb, function, role…

• Maturational loss– Part of life transition – Help develop coping skills

• Anticipatory Grieving– Before an expected event [e.g. terminal pt]


TermsTerms

• Palliative Care– Control of symptoms throughout an illness

including bereavement care for family

• Hospice Care– Final stage of Palliative Care– Patient & family with terminal diagnosis– Client- and family- centered


More TermsMore Terms• Normal [uncomplicated] grief

– Anger, disbelief, yearning, depression, acceptance

– Time to ‘recovery’ varies – 6 months

• Complicated [dysfunctional] grief– Persists >6months AND interrupts life– May follow sudden death, death of child

• Disenfranchised [unsupported] Grief – relationship not socially accepted– Same as any other grief + less support


Factors Influencing Grief & LossFactors Influencing Grief & Loss

• Age/ Development– Children – understanding and behaviors

depends on developmental stage– Young Adults – experience maturational loss– Midlife – more maturational losses– Older – prior experiences may help coping

• Meaning of loss or person– Affects the grief response & support



• Coping Mechanisms/ Strategies– People use what has worked before– May need new strategies– Suggest expressing positive feelings

• Culture– Influences acceptable expression of grief– Rituals around death– Who is included as ‘family’



• Spiritual Belief – Influences end-of-life care– Rituals around death– Belief about afterlife

• Hope– Ability to see life as having meaning– Important for nurses


Nursing ProcessNursing Process

• Know yourself– Own your own beliefs, do not push them– Take care of your self

• Respect others’ beliefs

• Listen

• Don’t take negative behaviors personally

• Involve pt. and family in planning


AssessmentAssessment

• Establish relationship first

• Assess factors like coping style, meaning of loss, beliefs about death, support

• Use open-ended questions

• Observe verbal & nonverbal responses

• Summarize and validate

• May need to talk to pt, family separately


AssessmentAssessment

• Assess understanding of treatment options– End-of life & after death

• Encourage family involvement– Assess need for education

• Assess other possible causes of symptoms/ behaviors– Loss of appetite R/T grief or disease?


Nursing DiagnosisNursing Diagnosis

• May address the loss directly OR effects

– Hopelessness R/T loss of child AEB social isolation and inability to maintain employment

– Nutrition: less than body requirements R/T decreased appetite and motivation 2* to grief over loss of child


ImplementationImplementation

Focus:

• Facilitate healthy coping, growth– For families– For patient

• Enhance quality of life– Alleviate symptoms – Promote dignity– Prevent complications


InterventionsInterventions

• Therapeutic communication– Active listening– Silence– Acceptance– Attitude: you can not fix emotions!– Provide information, referrals


InterventionsInterventions

• Symptom Management– Ongoing assessments– Pain management, effects of medications– Effects of immobility– Hydration and comfort– Skin & hygiene– Elimination– Oxygenation– Level of consciousness


Comfort CareComfort Care• Comfort

– Pain relief, N/V, Constipation, fatigue, anxiety

• Skin care– May include linens, Foley, lotion, mouth care

• Nutrition– Small, preferred foods

• Respiratory– O2, position, meds

• Stay available/ with patient


Bereavement SupportBereavement Support

• Involve pt/family in decisions

• Provide space & time for grief & mourning

• Educate about choices – end-of-life care– Postmortem options & requirements

• Encourage clear communication

• Answer questions, reinforce info


Physical aspects of dyingPhysical aspects of dying

• Symptoms may confuse family– E.g. loss of appetite, SOB, withdrawal

• May also provide help anticipating time of death/ imminence BUT may varies – no guaranteed timetable

• Focus is on relief of symptoms, education of family, maintaining dignity, following wishes and cultural rituals


Loss of EnergyLoss of Energy

• Physical Weakness / Lack of Energy / Loss of Interest in Everyday Things– Search for meaning; self-examination

• Caregivers can help by:– assisting with ADL’s– Listening, promoting dignity– Providing comfort, symptom control– Preventing injury


WithdrawalWithdrawal

• Withdrawal from Family and Friends / Increased Sleepiness / Coma– ‘entertaining’ visitors may exhaust dying

Caregivers can:– be there without making demands– Be aware that the person can likely still hear

even if in a coma-like state– Advocate for the patient’s stated wishes


Loss of AppetiteLoss of Appetite

• As the body begins to shut down, need for food decreases

• Caregivers can:– Offer small favorite foods– Respect the person’s wishes if food is refused– Educate others about the process

• Providing food often makes the caregiver/family feel better; it is OK to offer


Difficulty Swallowing Difficulty Swallowing

• As body , muscles weaken, swallowing may become more difficult – may cause choking– Reverse diet [Regular – soft – liquid]– Small amounts [2-5 ml] to test swallowing– Caregivers can:

• Provide mouth care frequently• Adapt foods, positioning for safety and palatability• Crush meds in jam or yoghurt


ConfusionConfusion

• May come and go

• May be caused by O2 changes [perfusion]

• Caregivers can:– Use familiar sounds [music], sights, tactile

sensations to comfort, reorient– Recognize that this may be a pleasant or

frightening time– Refrain from arguing, denying the person’s

‘reality’


RestlessnessRestlessness

• May be intermittent, can be R/T pain, nausea, full bladder etc. OR confusion May also signal nearness of death

• Caregivers can:– Assess for physical symptoms, safety risks– May be a spiritual crisis – unresolved [access

spiritual counselor, pray]– Use music, touch, aromatherapy


EliminationElimination

• As weakness increases, person may become incontinent, diaphoretic

• Caregivers can:– Maintain dignity– Place a Foley for comfort– Keep skin clean and dry– Administer pain meds before bathing as

needed


CirculationCirculation

• Temperature control mechanisms start to fail, circulation withdraws to center– May cause cool skin or sweating

• Extremities become bluish, mottled, cool

• Caregivers can:– Follow person’s wishes R/T blankets– Prevent shivering to conserve energy– Turn less frequently – for comfort, SOB


BreathingBreathing• SOB not uncommon;

– O2 for comfort, fan; position semi-fowlers

• Change in breathing signals active dying– Exhalation longer than inhalation– Irregular breathing [Cheyne-Stokes]

• Shallow, rapid respiration followed by apnea• RR 30-50 not uncommon

– Often Indicates days to hours until death

– ‘Death Rattle’ [secretions in throat R/T lack of swallow] may be disconcerting


Spurt of EnergySpurt of Energy

• Some dying people ‘rally’ and become more alert, energetic, shortly before death– Caregivers can:

• Use this time to attend to unfinished business, say goodbye, give person ‘permission to go’

• Involve spiritual guides, chaplain, family members

– Often followed by unconsousness and then death


• Eyes have glassy fixed stare with large pupils• Pasty grey, or blue grayish color present especially on lips, hands and feet

– Hands and feet can be cold – Pooled blood in dependent areas causes bruised appearance

• Jaw open, breathing through mouth very rapid or very slow (often with rattle) with pauses of 20-50 seconds between breaths [Cheyne-Stokes]

• Unresponsive to voice or pain • Caregivers can: maintain calm, quiet atmosphere, perform pre-death rituals

•


Signs of Imminent DeathSigns of Imminent Death

After Death CareAfter Death Care

• Specifics depend on facility, legal needs

• If autopsy case, leave all tubes

• Document everything

• Donation – required to discuss– May offend some– Autopsy

• Cases of sudden death, unattended, < 24 hrs

• Maintain dignity, respect culture


After Death CareAfter Death Care• Documentation

– Autopsy? Donation?

• Family to be included? Special ritual?

• Bathe body, clean up room

• Allow family, others to say goodbye

• Personal belongings to family

• ID and transport per policy

• Self-care


EvaluationEvaluation

• Were client goals met at time of death?

• Family goals?

• Goal not met: pt expired with infection… - OK

• Look for expressions of hope, + coping


Caring for yourselfCaring for yourself

• All nurses experience grief & loss

• Need balance, rituals, people for support

• Change of scenery

• Assess yourself

• Ask for help – and accept help

• Find meaning in Nursing

• Practice self-care


Final thoughtFinal thought

"Be wise. Treat yourself, your mind, sympathetically, with loving kindness. If you are gentle with yourself, you will become gentle with others." - Lama Thubten Yeshe


A Good DeathA Good Death

• http://www.learner.org/vod/vod_window.html?pid=1279

• Type / copy http://www.learner.org/resources/series108.html into browser if blocked, then click on ‘A Good Death’

• Other good videos [streaming] on site


Documents

Death & Dying, Grief & Loss Chapter 30 NRS_105/320_Collings