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Chapter 36 The Experience of Loss, Death, and Grief
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Developing a personal understanding of your own feeling about grief and death will help you better serve your patients. Actual losses Necessary losses Maturational losses Situational losses Perceived losses
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Grief = An emotional response to a loss, manifested in ways unique to an individual based on personal experiences, cultural expectations, and spiritual beliefs. Normal (uncomplicated) Complicated: exaggerated, delayed, masked Anticipatory Disenfranchised (aka marginal or unsupported)
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When caring for patients who have experienced a loss, facilitate the grief process by helping survivors feel the loss, express it, and move through their grief. Loss comes in many forms based on the values and priorities learned within a person’s sphere of influence. The type and perception of the loss influence how a person experiences grief.
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Kübler-Ross’ Stages of Dying (DABDA): Denial Anger Bargaining Depression Acceptance
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Numbing Protects the person from the full impact of loss Yearning and seeking Tearing, sobbing, and acute distress Disorganization and despair Person examines loss and expresses anger Reorganization Person begins to accept change, new role or skills
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Task I: Accept the reality of the loss Task II: Experience the pain of grief Task III: Adjust to a world in which the deceased is missing Task IV: Emotionally relocate the deceased and move on with life
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Rando’s “R” Process Model: grief as a series of processes instead of stages or tasks Recognizing the loss, reacting to the pain of separation, reminiscing, relinquishing old attachments, and readjusting to life after loss Reminiscence is an important activity in grief and mourning. Dual process model: moving back and forth between loss-oriented and restoration- oriented activities Post modern grief theories
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End-of-Life Nursing Consortium (ELNEC) American Nurses Association (ANA) Hospice and Palliative Care Nurses Association American Society of Pain Management Nurses American Association of Critical Care Nurses
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Human developmentPersonal relationships Nature of lossCoping strategies
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Listen carefully to the patient’s perceptions. Use culture-specific understanding. Use Professional Standards: Nursing Code of Ethics Dying Person’s Bill of Rights ANA Scope and Standards of Hospice and Palliative Nursing Use Clinical Standards: American Society of Pain Management Nurses’ Guidelines
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Assessment Nursing Diagnosis Planning Implementation Evaluation
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Conversations about the meaning of loss to a patient often lead to other important areas of assessment: Patient’s coping style The nature of family relationships Social support systems The nature of the loss Cultural and spiritual beliefs Life goals Family grief patterns Self-care Sources of hope
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Anticipatory grieving Compromised family coping Death anxiety Fear Impaired comfort Ineffective denial Grieving Complicated grieving Risk for complicated grieving Hopelessness Pain (acute or chronic) Risk for loneliness Spiritual distress Readiness for enhanced spiritual well-being
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Care plans for the dying patient focus on Comfort Preserving dignity and quality of life Providing family members with emotional, social, and spiritual support Give priority to a patient’s most urgent physical or psychological needs while also considering his or her expectations and priorities.
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Providing palliative care in acute and restorative settings Providing hospice care Using therapeutic communication Providing psychosocial care Managing symptoms Promoting dignity and self-esteem Ensuring a comfortable and peaceful environment Promoting spiritual comfort and hope Protecting against abandonment and isolation Supporting the grieving family Assisting with end-of-life decision making Facilitating mourning
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Federal and state laws apply to certain events after death. Documentation Organ and tissue donation Autopsy Postmortem care
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Questions to help validate achievement of patient goals and expectations: What is the most important thing I can do for you at this time? Are your needs being addressed in a timely manner? Are you getting the care for which you hoped? Would you like me to help you in a different way? Do you have a specific request that I have not met?
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Federal and state laws require institutions to: Request organ or tissue donation Perform an autopsy Certify and document the occurrence of a death Provide safe and appropriate postmortem care
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You cannot give fully engaged, compassionate care to others when you feel depleted or do not feel cared for yourself. Frequent, intense, or prolonged exposure to grief and loss places nurses at risk for developing compassion fatigue. Being a professional includes caring for yourself physically and emotionally. To avoid the extremes of becoming overly involved in patients’ suffering or detaching from them, nurses develop self-care strategies to maintain balance.
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