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Chapter 17: Loss, Grief, & Dying

Terms in this set (36)

What Are the Main Points in This Chapter?
-How people cope with loss directly affects their healing and well-being.

-Loss may be actual or perceived, physical or psychological, external or internal.

-Grief is the physical, psychological, and spiritual response to loss.

-People do not move neatly from one stage of grief or dying to the next; there is constant movement and overlap between and among them.

-Factors that affect the grieving process include the significance and circumstance of the loss, the timeliness of the death, the bereaved support system, spiritual beliefs, cultural values, the person's developmental stage, and conflicts existing at the time of death.

-Patients experience loss of independence, body image, self-esteem, and so on, when they are ill and/or hospitalized. Recognizing these as losses, you can assist the patient with the grieving process, thus promoting physical, emotional, and spiritual healing.

-The Uniform Determination of Death Act states that death has occurred when "an individual . . . has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brainstem. . . ."

-Palliative care focuses on providing comfort care and symptom relief, without further efforts to stop the disease process or prevent death.

-Hospice care is a movement and an approach to allow terminally ill persons to face death with dignity and surrounded by the comfort of their home and family.

-Healthcare providers are responsible for educating staff and patients about advance directives.

-A do not attempt resuscitation (DNAR) or allow natural death (AND) order is a specific order to not perform cardiopulmonary resuscitation.

-Nurses should be aware of what is involved with assisted suicide and euthanasia. You should think ahead about what your response might be if a patient wants to discuss these topics. You may find the American Nurses Association (ANA) position statement on the nurses' roles and responsibilities in end-of-life care helpful.

-An autopsy is a medical examination of the body to determine the cause of death.

-When a patient is dying or has
experienced a loss, you should perform a thorough, holistic assessment.

-Most grief is normal, not dysfunctional; you should not diagnose Complicated Grieving for every person who is grieving a loss.

-You can facilitate grief work by validating feelings ("It's normal to feel that way") and providing an opportunity and encouragement to talk about the lost person or object.

-Active dying usually occurs over a 10- to 14-day period, although it can take as little as 24 hours. During the final 4 to 48 hours, failure of body systems results in death.

-When the patient is very near death, focus on relieving physical symptoms and emotional distress. If he can communicate, ask about immediate concerns, such as, "Who do you want in the room right now?"

-At the moment of death, do not interrupt or intrude upon the family; give them as much time as they need to say good-bye to their loved one. Express your sympathy.

-Care of the body includes making it presentable for the family, carefully placing identification tags, and arranging to have the body sent to the morgue.

-The death certificate must be signed by the person who legally pronounced the death (usually a physician).

-It is normal for the nurse to feel grief when a patient dies.
What types of losses commonly occur in our lives?
Answer:
Losses occur whenever there is change or growth. Some examples include developmental changes, moving, marriage, divorce, surgery, death of significant others, job loss, and retirement. Losses are actual, perceived, physical, and psychological.
What are the main tasks of the grieving process?
Answer:
According to Worden, there are four stages of the grieving process:
1. Acknowledging the loss
2. Feeling the emotions and pain
3. Adjusting to the environment without the loved one
4. Investing emotional energy into something or someone else
What factors affect the grieving process?
Answer:
The meaning of the loss is the most significant factor indicating the way a person will grieve. Some other factors include the following:
Number of previous losses
Person's coping mechanisms
Circumstances of the loss
Timeliness of the loss
Developmental stage of the grieving person
Person's spiritual/cultural supports
What are advance directives?
Answer:
Advance directives are legal documents that identify what a person would want or not want relative to his healthcare in the event that he is incapacitated or unable to make that decision. This is done through a "living will" that contains written instructions of the type and extent of life saving measures the person wants undertaken. The durable power of attorney for healthcare allows the person to identify the person entrusted to make medical decisions.
What is the ANA's position on assisted suicide?
Answer:
The ANA's position is that the nurse should not participate in assisted suicide because such an act is a violation of the Code for Nurses and the ethical traditions of the profession.
What assessments should you make for your terminally ill patient and his or her family?
Answer:
When a patient is dying or has experienced a loss, you must carefully assess the patient and significant others for common grief reactions. Other important areas to assess include knowledge base, history of loss, coping patterns and abilities, meaning of the loss/illness, support systems, cultural and spiritual needs, and physical status.
List three nursing diagnosis labels you might consider when dying or grieving is the primary problem.
Answer:
Any of the following labels would be appropriate answers:
Grieving
Complicated Grieving
Ineffective Denial
Hopelessness
Powerlessness
Caregiver Role Strain
Chronic Sorrow
Spiritual Distress
List three nursing diagnosis labels that might occur as a result of dying or grieving.
Answer:
Any of the following labels would be appropriate answers:
Situational or Chronic Low Self-Esteem
Anxiety
Death Anxiety (or Fear)
Decisional Conflict
Deficient Knowledge
Disturbed Sensory Perception
Fatigue
Imbalanced Nutrition: Less Than Body Requirements
Impaired Comfort
Spiritual Distress
Self-Care Deficit (specify)
Describe four ways to facilitate the grief work of a grieving or dying person.
Answer:
Any four of the following ways are appropriate answers for facilitating grief work of patients:

1. Help grieving and dying persons express feelings by:
-Encouraging questions and responding to them within a reasonable time
-Sitting by the head of the bed and not appearing rushed
-Encouraging the patient or family member to continue expressing feelings either verbally or nonverbally
-Expecting and accepting a wide range of feelings, including anger, fear, and loneliness.
-Asking, "How would you like me to help?" "What do you need?"
-Making sure that everyone on the healthcare team understands and follows the care plan
-Asking yourself what you would do if this were your family member
-Not comparing another person's loss to your own experience (e.g., avoid comments such as "I know how you feel"; instead, try "Tell me how you feel")

2. Assist them in recalling memories, for example, by going through photo albums with them and asking questions about the people in the pictures. Also look for objects of sentiment (e.g., a family heirloom) in the environment and have the dying or bereaved person share their significance.

3. Assist them finding meaning in their lives or their past by helping them talk about it. Facilitating life review is one technique to help the patient and family recognize the unique contributions this person has made to family, friends, and society. You can begin by asking about the various aspects of the patient's life, commenting on pictures in the room, or picking up on verbal cues that are expressed.

4. Suggest bibliotherapy and counseling.

5. Provide grief education. Explain the stages of grief and point out that it takes months or even years to resolve. Explain that grief may become more intense on the anniversary of the death (or other loss) and on significant dates (e.g., birthdays). After the death of a loved one, family members may need support for several months. Direct them to educational resources on Web sites, in printed material, and at community forums (e.g., many churches and hospices have groups that meet regularly). Become informed about counseling services and support groups in your community, and refer families to them as needed. (Note: This content is found in Volume 1 under the heading, Providing Grief Education.)

6. Help them to normalize their grief. Recall that once the bereaved person accepts that the loss is real, their feelings may be so intense that they may wonder if they are losing their sanity. The grieving person may be fatigued from not sleeping, may be disoriented or unable to concentrate, and may be concerned about what such symptoms mean. Reassure the person that such responses are expected and that there is no single "right" way to grieve (Egan & Arnold, 2003; Holtslander & McMillan, 2011). Also assure them that although the grief process takes time, their symptoms won't last forever.

7. Increase your self-awareness: your attitudes and feelings regarding death and dying.
List two specific interventions, in addition to facilitating grief work, for helping grieving families.
Answer:
In addition to interventions for facilitating grief work (preceding), any two of the following interventions are appropriate answers:

-Encourage family members to help care for the patient, if they are able. This helps meet their need to be useful, as well as promoting family ties and making the patient more comfortable. If they are not physically or emotionally able to provide care, accept that. For family members who are able to help with care, provide instruction and supervision.
-Encourage family members to ask questions, listen actively to client and family concerns, and help them solve problems when needed.
-Follow up with other healthcare team members promptly when the family has questions that are outside your scope of practice.
-Encourage the family to visit the hospital chapel and talk with a chaplain or to speak with their own spiritual adviser.
-Provide anticipatory guidance to the family regarding the stages of loss and grief, so that they will know what to expect after their loved one dies.
-Acknowledge feelings of the family and the loss they are experiencing. (Many family members begin the grieving process before the loved one dies.)
-Help the family members to explore past coping mechanisms and reinforce successful past coping mechanisms.
-Remind family members and significant others to take care of themselves. Many need "permission" to go eat or to go home and rest. If the patient is near death and family and friends do not want to leave the patient's side, make them as comfortable as possible. Provide comfortable chairs, coffee, and snacks (according to organizational policy), and be alert for other needs they may have. Watching a loved one die is a very difficult experience. A sensitive, caring nurse can make it a little easier.
-Teach the family what to expect with regard to medications, treatments, and signs of approaching death. If family members know what is normal, they will be less likely to panic or fear the inevitable. As physical signs of death become apparent, keep the family informed. You may say something like, "Her blood pressure is becoming difficult to hear. That is one of the signs that she is closer to death."
-Reassure families of patients who become withdrawn near the time of death that this does not mean the patient is rejecting them, but only that his body is conserving energy and that he has come to terms with dying.
-When approaching death is apparent, ask family members directly, "Do you want to be present while he is dying?" Tell them what to expect, if they do not know.
-At the moment of death, do not interrupt or intrude upon the family. Wait quietly and observe. -Give them as much time as they need. When they move away from the body or have said last goodbyes, then it is time to assess and report the lack of vital signs. Be accepting of their behavior at this time, no matter how strange it may seem to you. -A family might want to take a picture, or the spouse may lie down beside the deceased person.
Describe six nursing interventions to use in meeting the physiological needs of a dying person.
Answer:
Any six of the following interventions would be appropriate:

-Encourage the patient to be as independent as possible, so that she will maintain a sense of control. Monitor the patient's energy level. If she tires easily or lacks the energy for self-care, you should provide this care.
-Maintain skin integrity by turning the patient frequently, providing massage to increase circulation, assessing for increased diaphoresis and/or incontinence, and maintaining adequate nutrition. During the final hours of life, the goal of these activities changes from preserving skin integrity to providing comfort. Realize that during this time, even excellent skin care may not prevent skin breakdown.
-If the patient is comatose or unconscious, provide special care for the eyes so they do not become too dry. Many agencies use a form of artificial tears for this purpose.
-If the patient is not able to take fluids, prevent dryness and cracking of lips and mucous membranes by wetting the lips and mouth frequently with cool water or a prepared product for this (there is some evidence that glycerin swabs dry the mucous membranes and should not be used). You may provide artificial hydration unless the patient has an advance directive requesting "No artificial hydration per nasogastric or IV route." However, IV fluids can cause edema, nausea, and even pain in a patient who is actively dying.
-Dying patients may experience constipation, urinary retention, and incontinence. Pads are helpful, but change them frequently to prevent skin breakdown and, near the end, to promote comfort. Administer laxatives for constipation, and catheterize the patient if he is unable to void and the bladder becomes distended.
-If a "death rattle" occurs from accumulated secretions and if it is distressing to the family, turn the patient on his side and elevate the head of the bed. Antispasmodic and anticholinergic medications may also be administered.
-Provide adequate pain control. This can be a major issue for patients and caregivers. Refer to Chapter 31 for more information about pain management. In fact, dying patients are often more concerned about the pain and loss of control than about dying.
-Provide education as necessary to dispel the myths about pain medication (e.g., addiction, overdose). Effective pain control medications exist and can be administered by various routes.
Assure patient and family that analgesics will not be addictive in this situation.
-Respect the patient's informed decision to refuse pain medications. For example, a patient may prefer to endure pain rather than to be sleepy and not alert when his family is at the bedside.
-Follow the pain protocol to ensure that pain is controlled.
-To ensure pain control, administer pain medication on a regular schedule instead of waiting until the patient asks (prn).
-Teach and perform nonpharmacological pain relief measures when you judge that they can be helpful. These measures might include meditation, heat/cold therapies, massage, distraction, imagery, deep breathing, and herbal-scented lotions. It may be soothing to play soft music, add "white noise," or turn off the television.
-Patients who are near death may moan or grunt as they breathe; this does not necessarily indicate pain. Be sure that families understand this.
-Provide medication for other symptoms, such as nausea.
The patient is usually able to hear even after he can no longer respond to sounds and other stimuli, so continue to talk to him as if he can hear. Do not talk about him to others in his presence.
Describe six nursing interventions to use in meeting the psychological needs of a dying person.
Answer:
Patients experience many emotions at end of life, including anger, sadness, depression, fear, relief, loneliness, and grief. At this time, communication and support are most helpful. Discussing concerns and issues is a viable means of coping. The following interventions are important, and any six would be appropriate answers:

-Answer all questions honestly.
-Explain procedures that are being done.
-Realize that the patient may feel she is losing control. Help the person to acknowledge what she does have control over. Include the patient in care decisions as much as she is able to participate.
-Attend to social needs: Relationships are a priority at this time. Some patients may simply need to keep the bonds with family members and friends intact. For other patients, this may be a time to reestablish or mend relationships.
-Early in the dying process, finances may be a concern and may place an additional burden on the family. The patient may feel she is a burden to care for. As you assess these needs, it will be important to know the sources of support to assist the patient and family.
-Be aware of sexual needs and suggest ways a couple can be close and affectionate at this time. Some people may feel it is not right to have sexual feelings when the person they love is dying. Others may be afraid of harming the patient if they are sexually intimate. Provide realistic information about these issues. Expressions of sexuality may change as a person becomes closer to death.
-Some people seem to wait to die until after a significant date (birthday, anniversary, etc.) has passed. Others wait for family to gather; others wait until loved ones leave so they will not upset the family by dying while they are there.
What should be the focus of your interventions when the patient is very near death?
Answer:
When the patient is very near death, focus on relieving symptoms (e.g., pain, nausea) and emotional distress.
--If the person can communicate, ask about immediate concerns (Pitorak, 2003):
-"Are you in pain?"
-"Are you comfortable?"
-"What are you afraid of now?"
-"What can we do to help you go peacefully?"
-"Who do you want in the room with you right now?"
--If the patient asks whether he is dying, be honest.
--If the patient cannot communicate, ask the family, who may know what the patient would want.
--When the patient is very near death, it may be helpful to say something like "Your family will be fine" rather than "It is okay for you to go now."
Why is it important to position the body with a pillow under the head and shoulders soon after death?
Answer:
To prevent discoloration from blood settling in these areas, which would be upsetting to the family.
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