1. Chapter 25 Loss, Death, and Palliative Care
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Chapter 25 Loss, Death, and Palliative Care

2. Objectives 1. Differentiate the meanings of the terms loss and grief.
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Objectives
1. Differentiate the meanings of the terms loss and grief.
2. Explain the different types of grief and the dynamics of the grieving process.
3. Explain the characteristics required of the nurse to be able to intervene effectively in grief and bereavement.
4. Identify and discuss the needs of the dying.
5. Propose palliative measures when comfort is the goal of care.
6. Explain the role and responsibility of the nurse in advance directives.
7. Explain the difference between passive and active euthanasia.

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Grieving Process
First period of the grieving process exhibits the physical and psychological manifestations of acute grief; that is, when grief is first felt.
Middle period of the grieving process exhibits despair or depression, which affects the day-to-day functioning of a person.
Final phase of the grieving process is the period during which the person learns to adjust to life in a new way.
Process is not a rigid structure.
Pattern of grief is not always predictable.

4. Loss Response Model Person is in a state of disequilibrium.
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Loss Response Model
Person is in a state of disequilibrium.
Grieving family members search for meaning.
Loss becomes real as the person repeats the story.
Change is accepted.

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Types of Grief
In older adults, the reaction to grief may be mistaken for another condition such a dementia.
Types of grief include:
Anticipatory
Acute
Chronic
Disenfranchised

6. Factors Affecting Coping with Loss
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Factors Affecting Coping with Loss
Those at risk for adverse affects of grief include:
Older spouses
Life partners
Intense grief may cause a temporary decrease in cognitive function, such as dementia.

7. Coping Those who effectively cope: Those who ineffectively cope:
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Coping
Those who effectively cope:
Maintain composure.
Use good judgment.
Are optimistic without denying the loss.
Those who ineffectively cope:
Are more rigid and pessimistic.
Are demanding.
Have emotional extremes.
Live alone, socialize little, and have few close friends.
May have history of mental illness.
May have guilt.

8. Implications for Gerontological Nursing and Healthy Aging
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Implications for Gerontological Nursing and Healthy Aging
Nurses support those who are grieving.
Working with grieving older adults is part of a normal workday for the gerontological nurse.
Assessment determines whether the client is effectively coping.
Interventions assist the individual in attaining healthy adjustments.
Nurses use the skills of therapeutic communication.

9. Countercoping The client copes and the nurse countercopes.
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Countercoping
The client copes and the nurse countercopes.
Strategies of countercoping include:
Clarification and control
Collaboration
Direct relief
Cooling off

10. Dying, Death, and Palliative Care
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Dying, Death, and Palliative Care
Death is not the problem; dying is the work.
Dealing with dying reflects one’s own culture.
Older adult death seems normative.
If the dying process is long or painful, then death is viewed as a relief.

11. Conceptual Models Dr. Elizabeth Kübler-Ross’ stages of dying are:
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Conceptual Models
Dr. Elizabeth Kübler-Ross’ stages of dying are:
Denial
Anger
Bargaining
Depression
Acceptance
All of these stages are emotional reactions to dying.

12. Living-Dying Interval
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Living-Dying Interval
Dying begins at the moment called “crisis knowledge of death” and ends at the moment of physiological death.
The living-dying interval is the time between these two points.
The chronological timeframe depends on the remissions and exacerbations in the diagnosis of a terminal illness.
Dying may take days, weeks, months, or years.

13. Dying Time Crisis intervention is most effective at this point.
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Dying Time
Crisis intervention is most effective at this point.
Anticipatory grieving may occur.
Most time is spent in the chronic phase.
Life can still be lived because it does go on, despite the anticipated end.
Terminal phase is when the speed of physical dying is accelerated, and the person no longer has the energy to maintain the activities of everyday life.

14. Responses to Death The person who is dying may:
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Responses to Death
The person who is dying may:
Withdraw from outside work.
Engage in coded communication.
Give away cherished items.
Urgently contact friends and family.
In some cultures, these actions occur during a period termed, death watch.

15. Responsibilities of the Nurse during the Dying Period
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Responsibilities of the Nurse during the Dying Period
Provides safe care to the person and family.
Meets the needs of the dying person.
Uses the six C’s approach:
Care
Control
Composure
Communication
Continuity
Closure

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Role Toward Family
Family members need support and help from the nurse to meet their needs in response to a family loss.
Nurses are appreciated if they:
Keep the family members informed.
Ask how family members are doing and offer support.
Offer comfort when a family member cries and often cries as well.
Brings food.
Knows family members’ names.
Brings a bed to the dying client’s room for a family member.
Holds the hand of a family member.
Advises family members to hold the hand of the dying person during the dying process.
Calls a chaplain when needed.
Stays after their shift duties are over.

17. Dying and the Nurse Death of a client is not a failure of the nurse.
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Dying and the Nurse
Death of a client is not a failure of the nurse.
Nurses provide safe comfort to the dying and gentle care to the family.
Nurses must know the grieving process.
Nurses must have coping skills such as meaning making and the ability to disengage.
Nurses must be comfortable with their own lives.

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Palliative Care
Nurses care for older adults with irreversible and progressive conditions (Alzheimer disease, Parkinson disease).
Is the time during which the client does not want any more treatment.
Focus is on care and comfort versus cure.
Hospice care is an option.

19. Nurses Role in Palliative Care
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Nurses Role in Palliative Care
Staff nurse giving direct care
Nursing coordinator implementing the plan of the interdisciplinary team
Nursing executive officer being responsible for clinical care
Nurse advocating for humane care for the person who is dying and his or her family

20. Decision Making at the End of Life
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Decision Making at the End of Life
Causes legal, ethical, medical, and personal concerns.
As a result of technologies, the line between living and dying is blurred.
Advanced directives include:
Living wills
Durable powers of attorney for health
Medical powers of attorney

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Euthanasia
Is the client’s right to refuse life-sustaining medical measures.
Terms associated with euthanasia include:
Physician-assisted death
Physician-assisted suicide
Physician helping the client during the dying process
Passive and active euthanasia

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References
Touhy, T.A., & Jett, K.F. (2014). Ebersole and Hess' Gerontological Nursing & Healthy Aging (4th ed.). St. Louis, Elsevier. Touhy & Jett Powerpoint