Chapter 10 Loss, Grief, Dying, and Death Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Loss, Grief, Dying, and Death An aspect of self no longer available to a person Death Cessation of life Grief Pattern of physical and emotional responses to bereavement Grief Work Adaptation process of mourning a loss Mortality The condition of being subject to death Describe grief. Describe grief work.

Changes in Health Care Related to Dying and Death Before the1950s, it was common for patients to die at home in their own beds with assistance from family. From the 1950s to 1980s, the health care system became highly mechanized and dying occurred mostly in institutions. By the early 1980s, when diagnosis related groups (DRGs) came into play, this trend changed. Currently, the recuperating or terminally ill patient is often discharged to home, a convalescent home, or a nursing home. How have death and dying practices changed over the past 50 years?

Historical Overview 1960s 1970s 1980s Pioneers in death and dying theory, such as Kübler-Ross and Glassner and Strauss, produced works that stimulated the health care industry to research topics about death and dying. 1970s Hospices became recognized as health care delivery systems. 1980s Grief therapy was introduced when Benoliel and Martocchio added new insights into the needs and care of the dying patient.

Loss Not all losses are obvious or immediate. Obvious losses Death of a loved one Divorce Breakup of a relationship Loss of a job Not-so-obvious losses Illness Aging Changing schools, jobs, or neighborhoods What is the difference between obvious loss and not-so-obvious loss?

Loss Losses may be actual or perceived. Actual loss is easily identified. A woman who has a mastectomy Perceived loss is less obvious. Loss of confidence A women who hopes to give birth to a female child delivers a male child instead Perceived losses are easily overlooked or misunderstood, yet the process of grief involved is the same as an actual loss. Describe the differences between actual and perceived losses.

Loss Maturational Loss Loss resulting from normal life transitions Loss of childhood dreams, the loss felt in adolescents when a romance fails, loss felt when leaving family home for college or marriage and establishing a home of one’s own As an individual ages, they experience menopause and loss of hair, teeth, hearing, sight, and “youth.” Apply maturational loss to different stages in a person’s life.

Loss Situational Loss Personal Loss A loss occurring suddenly in response to a specific external event Sudden death of a loved one, or the unemployed person who suffers low self-esteem Personal Loss Any loss that requires adaptation through the grieving process Loss occurring when something or someone can no longer be seen, felt, heard, known, or experienced; individuals respond to loss differently Explain the difference between situational and personal loss.

Grief and Grieving Grief Bereavement Mourning The subjective response of emotional pain to actual or anticipated loss The total process of reacting and responding to the losses in one’s life Bereavement A common depressed reaction to the death of a loved one Mourning A reaction activated by a person to assist in overcoming a great personal loss What are the differences among grief, bereavement, and/or mourning?

Grief and Grieving Morbidity An illness or an abnormal condition or quality Both physical and mental morbidity after significant loss Increased incidence of divorce after the loss of a child or after a partner loses a body part or function How can the term “morbidity” be used to describe different situations?

Grief and Grieving Tasks of Grief to Facilitate Healthy Adjustment to Loss Accepting the reality of the loss Experiencing the pain of grief Adjusting to an environment that no longer includes the lost person, the object, or the aspect of self Reinvesting emotional energy into new relationships These tasks are not sequential; may work on all four tasks simultaneously, or only one or two may be priorities How do the tasks of grief assist a person in dealing with loss? How can a person experience all tasks at once?

Grief and Grieving Nurse’s Role Assess for grieving behaviors. Recognize the influence of grief on behavior. Provide empathetic support. How can a nurse assist a person in dealing with grief? What does the term “empathetic support” mean?

Figure 10-1 (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) Nurses assist family members in finding resources to help with the grieving process.

Grief and Grieving Anticipatory Grief This type of grief is to expect, await, or prepare oneself for the loss of a family member or significant other It is somewhat easier to cope with loss if it is expected. Having time for anticipation does not necessarily ease the pain of loss. Emotions expressed at this time can make the loss less conflicted. In what situations might a person be experiencing anticipatory grief?

Grief and Grieving Sudden death of someone who is not “supposed to” die is the most difficult grief to bear. Parents and siblings are often wracked by powerful and personal emotions of guilt, denial, and anger, as well as sorrow. Blame and guilt can destroy a family just when family members need each other most. Why might a person experience guilt or anger when a person has died?

Grief and Grieving Nurse’s Grief Nurse must come to grips with Understanding the grief process Appreciating the experience of the dying patient Using effective listening skills Acknowledging personal limits Knowing when there is a need to get away and take care of the self Why is it important for nurses to manage their grief? Why does a nurse need to set personal boundaries?

Nurses benefit from support of colleagues during their time of loss. Figure 10-2 (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) Nurses benefit from support of colleagues during their time of loss.

Grief and Grieving Bereavement Overload Burnout The initial loss was compounded with an additional loss before resolution of the initial loss When nurses experience multiple losses and fail to adequately process them Burnout The stresses exceed the rewards of the job and the individual nurse lacks the support of peers How does bereavement overload affect a nurse? How does burnout occur?

Grief and Grieving Stages of Grief and Dying Kübler-Ross stages of grieving/dying 1. Denial and isolation 2. Anger 3. Bargaining 4. Depression 5. Acceptance Describe each of Kübler-Ross’s stages of grieving/dying.

Kubler –Ross Stages of Grief

Grief and Grieving Stages of Grief and Dying Mustachio's manifestations of grief and bereavement Shock and disbelief Yearning and protest Anguish, disorganization, and despair Identification in bereavement Reorganization and restitution How is Mustachio’s “Manifestations of Grief and Bereavement” similar to Kübler-Ross’s stages of grieving and dying? How are they different?

Grief and Grieving Unresolved, Dysfunctional Grief Bereavement is a state of great risk physically, as well as emotionally and socially. Unresolved grief There have been some disturbances of the normal progress toward resolution. Dysfunctional grieving There is a delayed or exaggerated response to a perceived, actual, or potential loss. Give an example of unresolved grief. Give an example of dysfunctional grieving.

Grief and Grieving Unresolved, Dysfunctional Grief Dysfunctional grief occurs when an individual Gets “stuck” in the grief process and becomes depressed Is unable to express feelings Cannot find anyone in daily life who acts as the listener he or she needs Suffers a loss that stirs up other, unresolved losses Lacks the reassurance and support to trust the grief process and fails to believe that he or she can work through the loss

Grief and Grieving Signs, Symptoms, and Behaviors of Dysfunctional Grieving Acquisition of symptoms belonging to the last illness of the deceased Alteration in relationships with friends and relatives Lasting loss of patterns of social interaction Actions detrimental to one’s social and economic well-being Agitated depression with tension, insomnia, feelings of worthlessness, bitter self-accusation, obvious needs for punishment, and even suicidal tendencies How might a nurse or family member deal with another who is suffering from dysfunctional grieving?

Grief and Grieving Signs, Symptoms, and Behaviors of Dysfunctional Grieving (continued) A feeling that the death occurred yesterday, even though the loss took place months or years ago Unwillingness to move the possessions of the deceased after a reasonable amount to time Inability to discuss the deceased without crying, particularly more that 1 year after the loss Radical changes in lifestyle Exclusion of friends, family members, or activities associated with the deceased How might a family member deal with the individual who is unwilling to discuss his/her grief?

Grief and Grieving Supportive Care during the Dying and Grieving Process Assessment To give compassionate nursing care and support to the family and patient during the grieving and dying process, the nurse should consider the five aspects of human functioning: Physical Emotional Intellectual Sociocultural Spiritual How will the nurse utilize the assessment information obtained regarding the five aspects of human functioning?

Grief and Grieving Supportive Care during the Dying and Grieving Process Physical assessment Sleeping patterns Body image Activities of daily living (ADLs); mobility General health Medications Pain Basic needs: nutrition, elimination, oxygenation, activity, rest, sleep, and safety

Grief and Grieving Supportive Care during the Dying and Grieving Process Emotional assessment Patient’s and family’s anxiety level, guilt, anger, level of acceptance, and identification Major fears: abandonment, loss of control, pain and discomfort, and the unknown How might the nurse address the emotional issues obtained during his/her emotional assessment of an individual?

Grief and Grieving Supportive Care during the Dying and Grieving Process Intellectual assessment Evaluation of the patient’s and family’s educational level, their knowledge and abilities, and expectations they have in regard to how and when death will occur Why is an intellectual assessment important? How will this information assist the nurse in his/her delivery of care?

Grief and Grieving Supportive Care during the Dying and Grieving Process Social assessment Assessment of the patient’s and family’s support systems is valuable. Ascertain whether family members desire to assist in the patient’s daily care. Never assume they do; many do, others do not. When families choose to take the patient home for care, be sure that they are well-prepared before discharge for what they need to know and do. Who might the nurse consult to assist with the social assessment? Why is a social assessment necessary?

Grief and Grieving Supportive Care during the Dying and Grieving Process Spiritual assessment Assess the spiritual dimension by gaining insight into the patient’s philosophy of life, religious resources, and how the rituals of the particular faith group have significance in dealing with his or her death. Why would the nurse perform a spiritual assessment? How will he/she utilize this information?

Special Supportive Care Perinatal Death The death of a child before, during, or shortly after birth Often viewed as one of the most devastating losses that can occur in a family When possible, the parents should see, touch, and hold the infant, so that the reality of the situation can be faced and resolution of the grief can occur. Why is it beneficial for parents to touch, see, and hold their infant after death? What actions by the nurse facilitate this process?

Special Supportive Care Pediatric Death Nurses should be aware of how children view or understand death, both for themselves and for others. They need to be told the truth in language they can understand and be allowed to share fears, feelings, and opinions. Parents may express hostility and anger toward health care providers, a higher power, or the world in general. Why should nurses understand how a child views death? How might a nurse handle a parent who is displaying anger toward the nurse?

Special Supportive Care Suicide Survivors of a person who has committed suicide suffer all the emotions of grief, in addition to profound guilt or shame. Survivors fear rejection and lack of social and religious support. Survivors are at risk for suicide themselves, and a grief counselor may be helpful. What signs should the nurse be aware of which indicate a person might be suicidal?

Special Supportive Care Gerontologic Death The older patient must be treated as an individual, and the nurse should assess the patient’s needs in the same way as for any patient facing a terminal illness. Families who suffer the loss of an older person may accept the death but nonetheless must experience the grieving process.

Special Supportive Care Sudden or Unexpected Death Accident, homicide, and sudden illness are difficult to cope with. There is “unfinished business,” such as things left unsaid or undone. There can be an obsessive need to understand or know why this has happened. How might the nurse assist an individual who has experienced an incident of sudden death?

Issues Related to Dying and Death Euthanasia Active euthanasia An action deliberately taken with the purpose of shortening life to end suffering or to carry out the wishes of a terminally ill patient Passive euthanasia Permitting the death of a patient that takes the form of withholding treatment that might extend life, such as medication, life-support systems, or feeding tubes What is the difference between euthanasia and passive-euthanasia? Provide examples of both.

Issues Related to Dying and Death Do Not Resuscitate (DNR) Patients and families should control any decisions relative to any conditions that withhold or withdraw treatment. DNR decision should be a joint decision of the patient, family, and health care providers. DNR means only not to resuscitate; it does not mean to withhold any other care. All DNR orders and the discussion with the patient and family should be thoroughly documented in the patient’s chart.

Issues Related to Dying and Death Advance Directives Signed and witnessed documents providing specific instructions for health care treatment in the event that a person is unable to make those decisions personally at the time they are needed Living wills Written documents that direct treatment in accordance with patient’s wishes in the event of a terminal illness or condition Durable powers of attorney Designates an agent, a surrogate, or a proxy to make health care decisions on patient’s behalf In what situations is a living will appropriate? In what situations is a durable power of attorney necessary?

Issues Related to Dying and Death Organ Donations Legally competent people are free to donate their bodies or organs for medical use. In most states (National Organ Transplantation Act), required request laws stipulate that at the time of a person’s death, a qualified health care provider must ask family members to consider organ or tissue donation. The Uniform Anatomical Gifts Act addresses many problems of organ donation and stipulates that the physician who certifies death shall not be involved in removal or transplantation of organs. Why would it be a problem if the physician who certifies the death also is involved in the removal of donated organs?

Issues Related to Dying and Death Rights of Dying Patients Death with dignity is the goal in caring for the dying patient. “The Dying Person’s Bill of Rights” is honored at hospitals and other health care agencies and is posted in prominent areas. Fraudulent Methods of Treatment Often patient and family seek unconventional methods of treatment to prolong the patient’s life. Treatments that are misrepresented, whether by concealment or nondisclosure of facts, for the purpose of inducing another to use the product are fraudulent. Why is it important to observe the deceased’s rights? What types of treatment might be considered fraudulent to the dying person?

The Dying Patient Communicating with the Dying Patient Therapeutic communication expresses respect for the patient, maintains realistic hope, and offers appropriate reassurance and support. Careful attention to what the patient expresses verbally and nonverbally is required. If patients do not wish to communicate at a particular time, they need to know that this is acceptable and will be respected. Why is communication important with the dying patient? Other than verbal communication, how might a nurse communicate with the dying patient?

The Dying Patient Assisting the Patient in Saying Goodbye This may be expressed in verbal, nonverbal, concrete, and symbolic ways. Provide a private, comfortable environment. They should be encouraged to express those feelings and thoughts they would most want their loved ones to know in their absence. How might the nurse assist the family in saying goodbye to the deceased?

The Dying Patient Physical Care Provide adequate nutrition and maintain elimination patterns. Keep the patient clean, dry, well-groomed, odor-free, and comfortable; provides the patient with feelings of self-esteem and self-worth. Adjusting the environment to increase comfort and safety is paramount.

The Dying Patient Palliative Care According the the World Health Organization, when health care providers deliver palliative care, they do the following: Provide relief from pain and other distressing symptoms Affirm life and regard dying as a normal process Neither hasten nor postpone death Integrate psychological and spiritual aspects of patient care What does the term “palliative care” mean? In what situations would this be utilized?

The Dying Patient Palliative Care (continued) Offer a support system to help patients live as actively as possible until death Offer a support system to help families cope during the patient's illness and their own bereavement Enhance the quality of life How does palliative care enhance a dying person’s life?

The Dying Patient Assessments and Interventions for the Dying Patient Most crucial needs are control of pain, preservation of dignity and self-worth, and love and affection. Assessing for impending death Restlessness Discoloration of arms and legs Changes in vital signs: slow, weak, and thready pulse; lowered blood pressure; rapid, shallow, irregular, or abnormally slow respirations What is occurring when the patient’s arms and legs become discolored?

The Dying Patient Assessments and Interventions for the Dying Patient As death becomes imminent Pupils dilated and fixed Cheyne-Stokes respirations Pulse weaker and more rapid Blood pressure continues to fall Skin cool and clammy Profuse diaphoresis Death rattle: noisy respirations What is occurring when the patient’s skin becomes cool and clammy?

The Dying Patient Clinical Signs of Death Unreceptivity and unresponsiveness No movement or breathing No reflexes Flat encephalogram Absence of apical pulse Cessation of respirations Give examples of unresponsiveness. What is a flat encephalogram?

The Dying Patient Postmortem Care This is care of the patient’s body after death. The body should be cared for as soon as possible after death to prevent tissue damage or disfigurement. Offer the family the opportunity to view the body. Before the family views the body, prepare it and the room to minimize the stress of the experience. The body should be made to look as natural and comfortable as possible. Why is it important to perform postmortem care?

The Dying Patient Special Considerations for Children Documentation The child’s developmental level determines the amount and type of detailed information that should be discussed with the child. Documentation It must be objective, complete, legible, and accurate. It should be frequent and include the signs of impending death as they occur. The last entry should state where and to whom the body was transferred. How can the nurse assist children during the death of a loved one? How would a nurse document the death of a patient?

The Grieving Family Support Resolution of Grief The needs of the grieving family and significant others should be met by a caring, compassionate health care provider. Resolution of Grief Begins when the grieving person can complete the following tasks Have positive interactions, participate in support groups, establish goals and work to achieve them, discuss the meaning of the loss and its effect How might the nurse provide support for the family?

Chapter 38 End-of-Life Care

Terminal Illness and Care Terminal illness: recovery from the condition is beyond reasonable expectations Stages of dying Denial: psychological defense mechanism; refusal to believe certain information; helps to cope with reality of death

Terminal Illness and Care (cont’d) Stages of dying (cont’d) Anger: emotional response to feeling victimized; occurs because there is no way to retaliate against fate Bargaining: psychological mechanism to delay the inevitable Depression: sad mood; realization that death will come sooner rather than later

Terminal Illness and Care (cont’d) Stages of dying (cont’d) Acceptance: attitude of complacency that occurs after clients have dealt with their losses Promoting acceptance: nurses can help client to pass from one stage to another by providing emotional support and supporting client’s choice regarding terminal care

Stages of Dying

Terminal Illness and Care (cont’d) Promoting acceptance (cont’d) Emotional support: part of missing nursing care; more necessary for dying clients Arrangements for care: respecting the rights of dying clients

Helping Dying Clients Cope

Terminal Illness and Care (cont’d) Arrangements for care (cont’d) Home care Respite care: relief for the caregiver by a surrogate Hospice care Eligibility for hospice care: 6 months or less to live

Question Is the following statement true or false? In home care, the focus of support may shift back and forth from the client to the caregiver.

Answer True. In home care, the focus of support may shift back and forth from the client to the caregiver.

Terminal Illness and Care (cont’d) Arrangements for care (cont’d) Hospice care (cont’d) Hospice services: clients receive care in their own homes; multidisciplinary team of hospice professionals and volunteer support are provided

Medicare Home Hospice Benefits

Terminal Illness and Care (cont’d) Arrangements for care (cont’d) Terminating hospice care Residential care: form of intermediate care Acute care: sophisticated technology and labor-intensive treatment

Terminal Illness and Care (cont’d) Providing terminal care Hydration: maintenance of adequate fluid volume Nourishment: tube feeding and parenteral nutrition Elimination: catheterization; enemas or suppositories; skin care

Terminal Illness and Care (cont’d) Providing terminal care (cont’d) Hygiene: clean, well groomed, and free of unpleasant odors Positioning: promote comfort and circulation Comfort: keep clients free from pain

Terminal Illness and Care (cont’d) Family involvement: maintain family bonds to help coping with future grief Approaching death: decrease and ultimate cessation of function Multiple organ failure: two or more organs cease to function Family notification: family should be aware of approaching death

Signs of Multiple Organ Failure

Terminal Illness and Care (cont’d) Family notification (cont’d) Meeting relatives to promote smooth transition Discussing organ donation Confirming death: determined on the basis that breathing and circulation have ceased

Age Criteria for Organ Donation

Terminal Illness and Care (cont’d) Confirming death (cont’d) Brain death: irreversible loss of function of the brain Death certificate Permission for autopsy: examination of organs and tissues of human body after death

Terminal Illness and Care (cont’d) Performing postmortem care: Cleaning and preparing the body to enhance its appearance during viewing at the funeral home Proper identification Releasing the body to mortuary personnel

Grieving Process of feeling acute sorrow over a loss Pathologic grief: dysfunctional grief; refusing to accept the client’s death Resolution of grief: time taken for mourning; ability to talk about the dead person; controlling emotions

General Gerontologic Considerations Understand that the dying older client is a living person who may want to maintain the same interpersonal relationships as someone who is not dying Encouraging older clients, who have experienced the death of a close friend or family member, to express feelings associated with grieving is important

General Gerontologic Considerations (cont’d) Reading obituaries can be an effective coping mechanism in helping to develop a peaceful and accepting attitude toward death