Unit II Death, Loss, End of Life

Death, Loss and End of Life Care  Loss – actual or potential situation in which something valued is changed, no longer available or gone Actual Perceived Anticipatory

Grief  Response to experience of loss  Bereavement – subjective response experience by surviving loved ones after death  Mourning – behavioral response through which grief is eventually resolved or altered

Types of Grief  Anticipatory Grief Grief before loss Patient, family, professionals Children have unique needs

Normal Grief (Uncomplicated)  Normal feelings, behaviors and reactions to loss  Physical, emotional, cognitive and behavioral reactions

Dysfunctional grief  Unresolved grief - extended length and severity May result from: ambivalence towards lost person, perceived need to be brave or in control, endurance of multiples losses, extremely high emotional value invested in lost person (helps bereaved avoid reality of loss, uncertainty about loss (“missing in action”), lack of support systems  Inhibited grief - normal symptoms of grief suppressed

Complicated Grief  Fails to grieve  Avoids visiting gravesite or participate in memorial  Recurrently symptomatic on anniversary of death  Persistent guilt, low self-esteem  Continues to search for lost person  May consider suicide  Minor events trigger grief  Unable to discuss the deceased with composure  Physical symptoms similar to the deceased  Relationships with others worsen (Kozier, 1034)

Stages and Tasks of Grief  Denial  Anger  Bargaining  Depression  Acceptance

Factors Influencing the Grief Process  Survivor personality, coping  History of substance abuse  Relationship to deceased  Spiritual beliefs  Type of death

Grief Assessment  Begins at time of admission or diagnosis  Ongoing to detect complicated grief

Grief Assessment Includes  Type of grief  Reactions  Stages and tasks  Influencing factors, general health

Children’s Grief  Based on developmental stages  Can be normal or complicated  Symptoms unique to children

Grief Interventions…  Presence  Identify support systems  Access bereavement specialists  Identify and express feelings  Special attention to disenfranchised grief  Public and private rituals  Spiritual care

Completion of the Grieving Process  No one can predict completion  Grief work is never completely finished  Healing occurs when the pain is less

Death and Dying Communication

Communication Crucial to palliative care Terminal illness is a family experience

Communication Imparting necessary information so that individuals may make informed decisions Requires interdisciplinary collaboration

Communication Process Patient/Family Expectations be honest non abandonment elicit values and goals team communication take time to listen

Communication Provides for informed choices Offers support Allows verbalization of fears

Communication How much patient/family want to know Initiate family meetings Base communication with children on developmental age

Attentive Listening Encourage them to talk Be silent Be non-judgmental Avoid misunderstandings

Attentive Listening (cont.) Don’t change the subject Encourage reminiscing

Factors Influencing Communication Patient/Family family systems financial/educational physical limitations coping/grief

Factors Influencing Communication (cont.) Health care professionals communication barriers (e.g. fear of own mortality, fear of not knowing, lack of understanding culture)

Breaking Bad News Nurses reinforce news provided by physicians Steps: plan what to say establish rapport

Steps (cont.) set aside time/turn off pager control the environment find out what they know/want to know use simple language be sensitive/respectful

Adaptive and Maladaptive Responses Cultural mores dictate what is adaptive or maladaptive

Team Communication Intra team communication is vital Should occur frequently Documentation is key Conflict is expected

Death and Dying: Symptom Management

Symptom Management Introduction There are many physical and psychological symptoms common at the end of life Ongoing assessment and evaluation of interventions is needed Requires interdisciplinary teamwork

Introduction (cont.) Reimbursement concerns Limit diagnostic tests

Symptoms and Suffering Symptoms create suffering and distress. Psychosocial intervention is key to complement pharmacologic strategies

Physiologic Changes/ Symptoms Pain Dyspnea / Apnea Anorexia and Cachexia Weakness & Fatigue Mental Status Changes Hypotension / Renal Failure Incontinence Anxiety Depression

Key Nursing Roles Patient advocacy Assessment Pharm tx Non-Rx tx Pt/family teaching

Anxiety Subjective feeling of apprehension Often without specific cause Categories of mild, moderate, severe

Depression Ranges from sadness to suicidal Often unrecognized and under treated Occurs in 25-77% of terminally ill Distinguish normal vs. abnormal

Assessment of Depression Situational factors Previous psychiatric history Other factors (e.g. lack of support system, pain)

Example Questions for Depression Assessment How have your spirits been lately? What do you see in your future? What is the biggest problem you are facing?

Suicide Assessment Do you think life isn’t worth living? Have you thought about how you would kill yourself?

Conclusion Multiple symptoms common Coordination of care with physicians and others Use drug and nondrug treatment Patient/family teaching and support

Care Following Death Preparing the family Care after death Evaluate circumstances Organ donor procedures

Care Following Death (cont.) Removal of tubes, equipment Bathing and dressing the body Positioning the body Respect cultural preferences

Care Following Death (cont.) Removal of the body Rigor mortis 2-4 hrs after death Embalming

Care Following Death (cont.) Assistance with calls, notifications Destroying medications Assisting with arrangements Initiating bereavement support

Death of Children Encourage parents to hold child Siblings Encourage verbalization

Conclusion Care of the patient and family at the time of death entails unique concerns, best provided by an interdisciplinary team

Bereavement Interventions...  Plan of care Attitude Cultural practices What to say Anticipatory grief

... Bereavement Interventions  Provide presence  Active listening, touch, reassurance  Decrease sense of loss  Use bereavement services

Bereavement Interventions for Children and Parents  Recognize developmental stage  Refer to support groups

The Nurse: Death Anxiety, Cumulative Loss, Grief  Death anxiety  Defenses  Personal death awareness

Cumulative Loss  Succession of losses common to nurses  May not have time to resolve losses before another loss occurs

Stages of Adaptation  Nurses new to working with the dying need support  Stages of adaptation (Harper) Intellectualization Emotional survival Depression Emotional arrival Deep compassion

Factors Influencing the Nurse’s Adaptation  Professional training  Personal death history  Life changes  Support system

System of Support (Vachon)  Balance  Assessing formal / informal support systems  Instructor support  Spiritual support  Self care and support

Support for the Nurse Ask for help Verbalize Post clinical debriefing

Conclusion  Loss, grief and bereavement assess with ongoing intervention  Nurses must recognize and respond to their own grief  Interdisciplinary care