Download Chapter 30 The Experience of Loss, Death, and Grief

Chapter 36
The Experience of
Loss, Death, and Grief
Scientific Knowledge Base: Types of Loss
Developing a personal understanding of your own feeling
about grief and death will help you better serve your patients.
• Necessary Loss: A part of life. These cause us to undergo
some type of change. (Job change, moving, friendships)
• Maturational loss: are a type of necessary loss and
include those changes that occur across the life
span.(Mother’s sense of loss when child goes to
kindergarten)
• Situational loss: sudden and unpredictable (Physical
injury, loss of function, income, dreams or life goals)
Scientific Knowledge Base: Grief
• Grief = An emotional response to a loss, manifested in ways
unique to an individual based on personal experiences,
cultural expectations, and spiritual beliefs.
Theories of Grief and
Mourning
• Kübler-Ross’ Stages of Dying:
Denial
Anger
Bargaining
Depression
Acceptance
Denial
Anger
Bargaining
Depression
Acceptance
Advance Directives
• Advance Directive: A document or verbal statement in which an
individual states choices for medical treatment or designates who
should make treatment choices if the individual should lose decision
making capacity.
• Durable Power Of Attorney for Health Care: An advance directive
in which an individual names someone else (the "agent" or "proxy")
to make health care decisions for him/her.
• Living Will: A written and signed declaration instructing an
individual's physician to withhold or withdraw certain death
delaying procedures (including artificially supplied nutrition and
hydration) when the individual is in a terminal condition and unable
to communicate his/her wishes.
10
DNR
•Do Not Resuscitate (DNR): an explicit order that
requests the withholding of any one or endotracheal
intubation and initiation of ventilatory support, 2) chest
compressions, 3) electrical countershock, 4) external
cardiac pacing, and 5) bolus administration of inotropes,
vasopressors or antiarrhythmics. A DNR order does not
limit or restrict the use of any other medical treatment,
diagnosis or intervention prior to cardiopulmonary or
respiratory arrest.
•MUST have a new order with each admission!
11
Dying Process Assessment
•
•
•
•
•
•
•
Increased periods of sleeping/unresponsiveness
Coolness and color changes in extremities, nose, fingers
Bowel or bladder incontinence
Decreased urine output; dark-colored urine
Restlessness or disorientation
Decreased intake of food or fluids; inability to swallow
Congestion/increased pulmonary secretions; noisy respirations
(death rattle)
• Altered breathing (apnea, labored or irregular breathing, CheyneStokes pattern)
• Decreased muscle tone, relaxed jaw muscles, sagging mouth
• Weakness and fatigue
Palliative Care
• Palliative care focuses on the prevention, relief, reduction, or
soothing of symptoms of disease or disorders throughout the
entire course of an illness, including care of the dying and
bereavement follow-up for the family.
• The primary goal of palliative care is to help patients and families
achieve the best possible quality of life
Hospice Care
• Hospice care is a philosophy and a model for the care of terminally
ill patients and their families.
• Patients accepted into a hospice program usually have less than 6
to 12 months to live.
• Hospice services are available in home, hospital, extended care, or
nursing home settings.
Hospice Care
• To be eligible for home hospice services, a patient must have a
family caregiver to provide care when the patient is no longer able
to function alone.
• Aides for hygienic needs
• Nurse to coordinate and manage symptoms relief
• As the patient’s death comes closer, the hospice team provide
intensive support to the patient and family.
Promoting Comfort in the Terminally ill Patient
Pain
Multiple causes
Pain relief measures
Skin
Any source of skin irritation increases
discomfort.
Provide skin care; apply lotion
to skin; dry, clean bed linens
Mucous
membrane
discomfort
Mouth breathing or dehydration
leads to dry MM; tongue and lips
become dry or chapped.
Provide oral care, including
tongue, q 2-4 hrs. Apply lip
balm; apply topical analgesics
to oral lesions
Corneal
irritation
Blinking reflexes diminish near death,
causing drying of the cornea
Apply artificial tears to reduce
corneal drying.
Promoting Comfort in the Terminally ill Patient
Nausea
Medications, pain or decreased
intestinal blood flow with
impending death
Antiemetics; discontinue meds
or foods that cause nausea;
provide oral care q 2-4 hrs;
offer clear liquid diet and ice
chips; avoid acid foods
Constipation
Opioids, medications and
immobility slow peristalsis.
Use a stimulant laxative with
opioids. Dietary alterations as
preferred; increase fluid intake
Diarrhea
Disease processes, treatment or
medications, and GI infections
Assess for fecal impaction,
Confer with HCP to change
meds; protect skin with
moisture barrier
Promoting Comfort in the Terminally ill Patient
Urinary incontinence
Progressive disease and
decreased level of
consciousness
Protect skin from irritation
or breakdown by
maintaining dry linens and
clothing.
Use catheter or condom
catheter for comfort or
prevention of skin
problems.
Altered nutrition
Medications, depression,
decreased activity, and
decreased blood flow to GI
tract; nausea
Offer small portions of
patient-preferred foods. Do
not force food on patient.
Promoting Comfort in the Terminally ill Patient
Ineffective breathing
Patterns (dyspnea, SOB)
Anxiety; fever; pain
increased oxygen demand;
disease process; anemia
Position for comfort;
provide O2;use fan for air
movement;
Noisy breathing
“death rattle”
Noisy breathing is the
sound of secretions moving
in the airway during
inspiratory and expiratory
phases caused by thick
secretions, decreased
muscle tone, swallow and
cough
HOB up, Turn from side to
side, stop oral intake; avoid
suctioning because of
discomfort and
ineffectiveness.
Anticholinergic meds are
sometimes helpful.
Dehydration
Patient less willing to
maintain oral intake
Give mouth care q 2-4
hours; keep lips and tongue
moist
Care after Death
• Federal and state laws require institutions to develop policies and
procedures for certain events that occur after death.
•
•
•
•
Requesting organ or tissue donation
Performing autopsy
Certifying and documenting the occurrence of a death
Providing safe and appropriate postmortem care
Care of the Body after Death
• In your collaborative groups read about the rituals of dying from
the various cultures:
•
•
•
•
•
•
•
•
African-American
Chinese
Hispanic/Latino
Native American
Islamic
Buddhists
Hindu
Jewish
(Hint: See table 36-10 )
Care of the Body after Death
• Identify the patient with 2 identifiers
• Provide sensitive and dignified nursing care to the patient and
family.
• Elevate the HOB as soon as possible after death to prevent discoloration of
the face
• Collect ordered specimens
• Ask if the family wishes to participate in preparation of the body
• Remove all equipment, tubes, indwelling lines
• Cleanse the body thoroughly
Care of the Body after Death
• Provide sensitive and dignified nursing care to the patient and
family.
• Cover body with clean sheet, place head on a pillow and leave arms
outside covers if possible.
• Close eyes by gently holding them shut
• Ensure dentures are in mouth to maintain facial shape
• Cover any signs of body trauma
• Prepare and clean the room, deodorize room if needed, and lower
lights
Care of the Body after Death
• Provide sensitive and dignified nursing care to the patient and
family.
• Offer family members the options to view the body and ask if they want
your or other support persons to accompany them.
• Encourage grievers to say good-bye
• Provide privacy and an unrushed atmosphere.
• Determine which personal belongings stay with the body. Document time,
date, description of the items taken and who received them.
Care of the Body after Death
• Provide sensitive and dignified nursing care to the patient and
family.
• Apply identifying name tags and shroud before transporting the body.
• Maintain privacy and dignity when transporting the body to another
location; cover the body or stretcher with a clean sheet.
Nurse’s Presence
Importance of Nurses’ Self-Care
• 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.
Importance of Nurses’ Self-Care (cont’d)