1. Loss, Grief, and End-of-Life Care13
Loss, Grief, and End-of-Life Care

2. 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.

3. 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.

4. 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.

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

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

14. 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

15. 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)

16. 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

17. 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

18. 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

19. 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)

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

21. 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

22. 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

23. It’s NCLEX time!!!
No sleeping…
Or…