Loss, Grief, and End-of-Life Care 13 Loss, Grief, and End-of-Life Care

Learning Outcomes Define loss, grief, and death. Explain the stages of loss with commonly experienced emotional responses for each stage. Discuss factors that influence responses to loss.

Learning Outcomes Discuss legal and ethical issues of dying, including advance directives, living wills, do-not-resuscitate orders, and euthanasia. Explain the philosophy and services of hospice and palliative care.

Learning Outcomes Assess physiologic changes as a client nears end of life and of death. Use the nursing process to collect data and provide interventions for the client who is experiencing loss or is at the end of life.

Loss Valued object, person, body part, or situation is lost or changed Can no longer be seen, felt, heard, known, or experienced May be temporary or permanent, complete or partial May be subjective, physical, symbolic May be as painful as death

Grief Emotional response to loss and its accompanying changes Internal process used to work through response to loss Mourning - actions or expressions of the bereaved Bereavement – the way grief is processed

Death Irreversible cessation of circulatory and respiratory functions or cessation of all functions of the entire brain (24 hours or more) Lack of responsiveness Lack of movement or breathing Lack of reflexes Flat EEG Inevitable - may be accidental, result of terminal illness, or purposeful An immensely difficult loss for dying person and loved ones

Kubler-Ross’s Stages of Death and Dying Denial -Shock and disbelief Anger -Resists the loss Bargaining -Attempts to delay reality of the loss Depression - Prepares for impending loss by working through struggle of separation Acceptance -Comes to terms with the loss and resumes activities

Factors that Interfere with Successful Grieving Perceived inability to share the loss Lack of social recognition of the loss Ambivalent relationships prior to the loss Traumatic circumstances of the loss →Need good support system to combat feelings of loneliness and isolation

Spirituality Spiritual beliefs provide comfort, help to find meaning in loss Principles, values, personal philosophy, and meaning of life brought to question Nursing support : trusting relationship and listening to the client

Rituals of Mourning Dictated by culture Funeral ceremony serves needs of bereaved Symbolically express triumph over death Deny fear of death Adaptation to the loss Triumph over death

Nurse’s Response to Client’s Loss Need to analyze own feelings and values (see page 302) Conscious or unconscious reactions influence the outcome of interventions - avoid “blunting” of feelings Self-reflection helps to approach interactions more objectively

End-of-Life Care Client’s wishes about death should be respected

End-of-Life Care Principles of hospice care People live until the moment they die Care until death may be offered by a variety of health care providers Care is coordinated, sensitive to diversity, offered around the clock Incorporates physical, psychologic, social, and spiritual concerns of the client and client’s family

End-of-Life Care “Dying persons and their families have individual cultural beliefs and values. The quality of care during the end stage of life greatly contributes to peaceful and dignified death and provides support to family members in dealing with their loss and grieving process.” (ICN)

Legal and Ethical Issues Advanced Directives: Legal documents, plan for health care and/or financial affairs in the event of incapacity Durable power of attorney for health care; proxy Living will – wishes for life sustaining treatment DNRs: Physicians order, based on wishes of the client/family No CPR for respiratory or cardiac arrest Comfort measures only order; Goal: comfortable, dignified death

Legal and Ethical Issues Euthanasia (“good death”, painless, gentle) Killing that is prompted by some humanitarian motive “slow code” = malpractice Voluntary Euthanasia Involuntary Euthanasia Competent client and physician make decision together Without client consent Turn off ventilators, cease hydration or feeding tubes “Mercy killing” Administering medications that would inhibit cardiac or respiratory functions

Settings for End-of-Life Care Hospice - Palliative rather than curative (model of care) Initiated for clients as they near the end of life Emphasizes quality of life Client and family are included in plan of care Provides support for a dignified and peaceful death Palliative Care - improving the quality of life, relief of physical, mental, and spiritual distress Involves single person or interdisciplinary team Outcomes of care are interventions to manage current manifestations of illness and to prevent new manifestations ex. N/V, pain, anxiety, confusion

Physiologic Changes in the Dying Client Weakness and fatigue - ↑ risk for ulcers, joint pain Anorexia/↓ food intake – sense of well being, gag reflex Fluid and electrolyte imbalances Hypotension/renal failure – oliguria, ↑HR, ↓BP, cyanosis Neurologic dysfunction - ↓LOC, agitated delirium Respiratory changes – Cheyne-Stokes Bowel/Bladder incontinence - loss of sphincter control Pain – most feared *(See Box 13-3)

Postmortem Care Document time of death Notify physician Assist family Remove jewelry and give to family Complete required paperwork (Box 13-4, p. 305)

Nurse’s Grief Crying with family is expression of empathy and caring Sharing grief with the family Reflect on responses to own losses Obtain support from peers Obtain counseling as needed

Nursing Care of Clients Assess physical, emotional, cultural, and spiritual needs Provide comfort Provide anticipatory grieving interventions Explore death anxiety with the client Evaluate if client has a comfortable and dignified death Teach client care to family

It’s NCLEX time!!! No sleeping… Or…