Loss, Grief, the Dying Patient, and Palliative Care Ch. 15
Terms in this set (59)
is to no longer possess or have an object, person, or situation.
is the total emotional feeling of pain and distress that a person experiences as a reaction to loss
occurs over a period of time
is the state of having suffered a loss by death
grieving that begins before the loss occurs
when it falls outside normal responses (grieving)
used since 1970's; the permanent stopping of integrated functioning of the person as a whole as evidenced by the absence of EEG waves
is a philosophy of care for the dying and their families; provided in small clinics, houses, or the patients or patients family's own home.
the study of death
Kubler- Ross's stages of coping with death (stages of grief)
denial- "No not me." The person can't believe the diagnosis or prognosis. It serves as a buffer to protect the patient from an uncomfortable & painful situation.
anger- "Why me?" The person looks for a cause or fixes blame. Dr.s and nurses are often the target of displaced anger, as well as family and God.
bargaining- "If I'm good then I get a reward." The wish is for extension of life, or later for relief of pain, & the person knows from past experiences that "good behavior" is rewarded.
depression- "It's hopeless" There is a sense of great loss, of the impending loss of being. People mourn losing family, possessions, responsibilities, and all they value.
acceptance-"I'm ready." The pain is gone, struggle is over, the patient has found peace. There is a withdrawal from every day activities and interest. Verbal communication is less important, and touch and presence are most important.
(The stages overlap as with the grieving process, the patient may move back and forth or even skip stages. In some cases the patient "gets stuck" in one stage & not move through to acceptance.)
is an inner positive life force, a feeling that what is desired is possible. Open ended questions such as "What are you hoping for from this admission?" or "What are you hoping for today?" can allow patients to talk about their needs.
is focused on identifying symptoms that cause the pt distress and adequately treating those symptoms
is the relief of symptoms when cure is no longer possible, and treatment is provided solely for comfort
transcutaneous electrical nerve stimulation
chronic obstructive lung disease: will have problems with ineffective airway clearance
Renal impairment (opioid to use)
morphine, hydrocodone, oxycodone,methadone, fentanyl
renal impairment ( do not use opioid)
codeine, meperidine, propoxyphene
respirations that gradually become shallower and are followed by periods of apnea
is to say goodbye to those people or things that are important.
spells out pt's wishes for health care at that time when they may be unable to indicate their choice. Also indicate a patient's choices about end-of-life decisions such as DNR orders and artificial hydration or tube feeding.
durable power of attorney for health care
is a legal document that appoints a person
health care proxy
chosen by the pt to carry out his wishes as expressed in an advance directive
is the act of ending another person's life to end suffering, with (voluntary) or without (involuntary) consent. " mercy killing "
occurs when a pt chooses to die by refusing treatment that might prolong life. An example would be withholding artificial feeding or parental (IV) fluid when the patient is unable to take them orally. It would also include not treating pneumonia with antibiotics.
is generally defined as administering drug or treatment to end the pt's life ( not legal or permissible in usa )
is distinguished from active euthanasia. It is making available to patients the means to end their life (such as weapons or drugs) with knowledge that suicide is their intent.
is a person with legal authority to determine cause of death. Any deaths that occur under suspicious circumstances are investigated by the corner. These include; deaths from injury, accident, murder, or suicide. Any death within 24hrs. after admission to the hospital, during surgery, or death of a person who hasn't been under a physician's care is reported to a coroner.
is an examination of the body, organs, and tissues to determine the cause of death.
It is when the heart stops that death is said to have occurred, unless the person is on a ventilator. When a patient is being mechanically ventilated, brain death must be established to determine death.
sheet used to wrap body after death
rigidity of muscles that occurs after death
A persons reaction to loss is influenced by
the importance of what was lost and culture in which the person is raised.
In all cultures & religion there are ________ & _________ to explain and cope with death, loss & grief.
beliefs and rituals
Examples of physical loss
amputation of leg, or inability to speak or walk after a stroke
Examples of psychosocial loss
Disfiguring surgery or scarring from burns may result in altered self-image & emotional problems.
Only the person experiencing the loss can define the value of the loss- you must?
put aside your own values regarding loss & accept the patient's meaning of loss.
A person who is grieving may experience physical and emotional symptoms such as;
crying, fatigue, changes in appetite, sleep disturbance, loneliness, sadness, change in sexual interest, anxiety, SOB , chest pains, rapid heartbeat, feeling helpless, anger, guilty, confused.
The 5 grief indicators - denial, anger, bargaining, depression, acceptance- peak within ?
6 months after the loss.
The validate the loss is to
reassure the grieving person that the loss was important and understood.
Examples of validating a person's loss
Quiet presence, a warm caring concern for the person's well being, and the ability to listen to the person speak about the pain & loss
is an event marked in different ways. The absence of heartbeat & breathing was and is historic & widely accepted definition of death.
Cultural views about disclosure
Many people feel they have the right to know if they are dying, and nurses often do not like it if the fact is hidden from the patient. However, cultural factors need to be considered. For example, Mexican American's and Korean's are less likely to want to be told if they have a terminal illness. They also feel the family, not the patient should make decisions about life-sustaining treatments. These belief's need to be considered before speaking to a patient about terminal prognosis.
Standard of care for the terminally ill
1) You must consider their preferences, personality, and lifestyle when planning care.
2) Every effort is made to maintain functional capacity and relieve discomfort thru the control of symptoms, regardless of the expected length of time until death.
3) Pain control is a major goal of treatment
4) The pt's preferences and intentions regarding health care as set out in an advance direct , or durable power of attorney for health care, will take precedent as far as the law will allow.
5) Patient should feel secure and safe with care provided & with the level of communication regarding care.
6) Patient will hv ample opportunities to finish business with loved ones and say goodbyes.
7) Opportunities will be provided for the dying patient to spend final moments In a personally meaningful way with ppl who are important to them.
8) Family and significant others will hv opportunities to discuss patients imminent death and their emotional needs with staff.
9) Family and significant other will be provided private time before and after death as desired.
10) Family members will be allowed to perform rituals and carry out cultural customs regarding body after death.
Rights of the dying patient
Be treated as a person until death.
Caring human contact
Have pain controlled
Cleanliness and comfort
Maintain a sense of hope
Participate in his care or the planning of it
Respectful, caring medical & nursing attention
Continue of care and caregivers
Info about his condition and impending death
Honest answers & ?'s
Explore and change religious beliefs
Maintain individuality and express emotions w/o being judged
Make amends with others and settle personal business
Say goodbyes in private or with assistance of nurse
Assistance for significant others with the grief process
Withdraw from social contact if desired
Die at home
Die with dignity
Respectful treatment for the body after death
The hospice philosophy is based on the
acceptance of death as a natural part of life and emphasizes the quality of remaining life
is concerned with treating symptoms, providing comfort measures, and promoting the best quality of life possible day by remaining day. Requires a specialized body of knowledge & skills that can be difficult to learn since it isn't focused on "cure".
Nursing Assessment (Data collection)
A baseline assessment & continuing data collection are essential to identify the problems and needs of the patient and his family. AT NO TIME SHOULD THE PATIENT BE PUSHED TO DISCUSS SOMETHING HE IS OBVIOUSLY AVOIDING.
An assessment of the patients PHYSICAL conditions would include
such measures as weight (with attention to usual weight), mobility and the ability to perform ADL'S, weakness or energy level, appetite (nausea, indigestion, gas), bowel and bladder function, and respiratory function. Special attention should be paid to assessing pain: location, nature, and what relieves it or makes it worse..
An assessment of the patient's EMOTIONAL condition can often be observed during
interaction, and symptoms such as anxiety, agitation, confusion, or depression may be obvious. Validating your observation allows patient to speak about his feelings.
An assessment of the patient's SPIRITUAL condition can begin
with questions about the patients religious affiliations and whether he would like to meet with a spiritual advisor.
Common problems of the dying patient and nursing management
Anticipatory Guidance- Anticipating the death assists in preparing the family and patient by giving them guidance about physical changes, symptoms and complications that may arise. Also aids the patient and family in deciding about possible hospice care.
End-Stage Symptom Management- Expected symptoms such as pain, GI distress, dyspnea, fatigue, cough, death rattle, and delirium, that are related to metabolic changes at the end of life. Nurse must be able to alleviate them or help explain them to the patient and family.
Pain Control- Many terminally ill patients unnecessarily die with uncontrolled pain. It's the 1st fear of the patients regarding dying. The patient may fear becoming an addict, or tht the meds will not work when he needs them for minimal pain. Another fear nurses have is that the pain meds will result in hastening the patient's death by depressing respirations. A TRULY COMPATIONATE NURSE STUDIES AND LEARNS ABOUT PAIN MANAGEMENT AND APPLIES THOSE PRINCIPLES IN DAILY PRACTICE. REGULARLY SCHEDULED PAIN MEDS W/PRN BACKUP FOR BREAKTHROUGH PAIN IS 1 OF THE MOST EFFECTIVE METHODS OF CONTROLLING PAIN.
Constipation, Diarrhea- predictable for patients receiving opiates, experiencing decreased fluid intake & mobility, and hving certain abdominal diseases.
Anorexia, Nausea, Vomiting- Anorexia may be due to nausea, drug side effects, disease process, or slowing down that occurs naturally in dying process.
Dehydration- Patients spend more time sleeping. Researches show that dehydration results in less distress and pain, hydration doesn't improve comfort.
Dyspnea- Seen early in the dying process in certain lung and heart disorders, and shortly before death. Suctioning not effective in clearing airway but meds decrease secretion and ease breathing. Oxygen may provide comfort.
Death rattle- Noisy respirations are heard when patient can no longer clear throat.
Delirium- Patients may experience hallucinations and/or altered mental status.
Impaired Skin Integrity- Weight loss, decreased nutrition, incontinence, and inactivity all contribute to skin breakdown.
Weakness, fatigue, decreased ADL- The dying patient is not going to get stronger or better; he gets weaker and weaker, not because lying in bed, but because he is dying.
Anxiety, depression, Agitation- May be treated with appropriate drugs with good effects. Listen and use good therapeutic communication skills to allow patient to express fear, feelings and needs, and convey nonjudgmental acceptance.
Spiritual Distress, Fear of Meaninglessness- Each person needs to feel that his life had meaning, and this is the essence of the spiritual nature of the dying process.
Evaluation- is based on the specific expected outcomes written for the patient.
Nonchemical approach to pain relief may include
visualization and guided imagery, relaxation and breathing exercises, massage, music therapy, mediation, religious healing, biofeedback, hypnosis or self hypnosis, use of transcutaneous electrical nerve stimulation (TENS), and hydrotherapy.
Physical signs of impending death
Body functions slow, appetite decreases, and the patient may refuse favorite foods and later fluids. Moistening the lips and mouth and provide oral care will be more comforting than "pushing" food or fluids. Urine output decreases and urine becomes more concentrated. Edema may be present in L/E or over the sacrum area. Vital signs change as death approaches. Pulse increases and becomes weaker or thready. BP declines, and skin becomes mottled, cool, and dusky. Respirations becomes shallow and irregular. Death rattles may occur. Cheyne-stokes respirations may be noted. Body temp may rise and patient may be hot or cold. Blankets should be used.
Rather then imposing your own religious beliefs on dying patients and family, you should assist patients to find
comfort and support in their own belief system.
Honoring the refusal of life-prolonging treatment of a patient with a terminal illness is
legally and ethically permissible.
Organs and tissue that can be donated
Kidney, livers, hearts, and lungs.
corneas, bone, and skin
Nurses assist the grieving person through
validation of loss, teaching of adaptive coping skills, and caring support
Therapeutic communication techniques that are extremely useful in dealing with the person who is experiencing loss include;
active listening, avoiding clichés, and attention to nonverbal communication
The nursing process identifies the
physical, emotional, social, and spiritual aspect of the dying patient's care and provides a comprehensive team approach.