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Death & Dying, Grief & Loss Chapter 30 NRS_105/320_Collings Loss & Grief • Experienced throughout the lifespan • Grief behavior is shaped by values, culture but grief itself is universal • All Change involves some loss • Nurses deal with patients’ and their own grief and loss • Grief is a normal response to loss • Grief behaviors vary over time and among individuals, families, and cultures NRS_105/320_Collings Terms • Situational loss – Sudden, unexpected, external – Loss of person, object, limb, function, role… • Maturational loss – Part of life transition – Help develop coping skills • Anticipatory Grieving – Before an expected event [e.g. terminal pt] NRS_105/320_Collings Terms • Palliative Care – Control of symptoms throughout an illness including bereavement care for family • Hospice Care – Final stage of Palliative Care – Patient & family with terminal diagnosis – Client- and family- centered NRS_105/320_Collings More Terms • Normal [uncomplicated] grief – Anger, disbelief, yearning, depression, acceptance – Time to ‘recovery’ varies – 6 months • Complicated [dysfunctional] grief – Persists >6months AND interrupts life – May follow sudden death, death of child • Disenfranchised [unsupported] Grief – relationship not socially accepted – Same as any other grief + less support NRS_105/320_Collings Factors Influencing Grief & Loss • Age/ Development – Children – understanding and behaviors depends on developmental stage – Young Adults – experience maturational loss – Midlife – more maturational losses – Older – prior experiences may help coping • Meaning of loss or person – Affects the grief response & support NRS_105/320_Collings Factors Influencing Grief & Loss • Coping Mechanisms/ Strategies – People use what has worked before – May need new strategies – Suggest expressing positive feelings • Culture – Influences acceptable expression of grief – Rituals around death – Who is included as ‘family’ NRS_105/320_Collings Factors Influencing Grief & Loss • Spiritual Belief – Influences end-of-life care – Rituals around death – Belief about afterlife • Hope – Ability to see life as having meaning – Important for nurses NRS_105/320_Collings Nursing Process • Know yourself – Own your own beliefs, do not push them – Take care of your self • • • • Respect others’ beliefs Listen Don’t take negative behaviors personally Involve pt. and family in planning NRS_105/320_Collings Assessment • Establish relationship first • Assess factors like coping style, meaning of loss, beliefs about death, support • Use open-ended questions • Observe verbal & nonverbal responses • Summarize and validate • May need to talk to pt, family separately NRS_105/320_Collings Assessment • Assess understanding of treatment options – End-of life & after death • Encourage family involvement – Assess need for education • Assess other possible causes of symptoms/ behaviors – Loss of appetite R/T grief or disease? NRS_105/320_Collings Nursing Diagnosis • May address the loss directly OR effects – Hopelessness R/T loss of child AEB social isolation and inability to maintain employment – Nutrition: less than body requirements R/T decreased appetite and motivation 2* to grief over loss of child NRS_105/320_Collings Implementation Focus: • Facilitate healthy coping, growth – For families – For patient • Enhance quality of life – Alleviate symptoms – Promote dignity – Prevent complications NRS_105/320_Collings Interventions • Therapeutic communication – Active listening – Silence – Acceptance – Attitude: you can not fix emotions! – Provide information, referrals NRS_105/320_Collings Interventions • Symptom Management – Ongoing assessments – Pain management, effects of medications – Effects of immobility – Hydration and comfort – Skin & hygiene – Elimination – Oxygenation – Level of consciousness NRS_105/320_Collings Comfort Care • Comfort – Pain relief, N/V, Constipation, fatigue, anxiety • Skin care – May include linens, Foley, lotion, mouth care • Nutrition – Small, preferred foods • Respiratory – O2, position, meds • Stay available/ with patient NRS_105/320_Collings Bereavement Support • Involve pt/family in decisions • Provide space & time for grief & mourning • Educate about choices – end-of-life care – Postmortem options & requirements • Encourage clear communication • Answer questions, reinforce info NRS_105/320_Collings Physical aspects of dying • Symptoms may confuse family – E.g. loss of appetite, SOB, withdrawal • May also provide help anticipating time of death/ imminence BUT may varies – no guaranteed timetable • Focus is on relief of symptoms, education of family, maintaining dignity, following wishes and cultural rituals NRS_105/320_Collings Loss of Energy • Physical Weakness / Lack of Energy / Loss of Interest in Everyday Things – Search for meaning; self-examination • Caregivers can help by: – assisting with ADL’s – Listening, promoting dignity – Providing comfort, symptom control – Preventing injury NRS_105/320_Collings Withdrawal • Withdrawal from Family and Friends / Increased Sleepiness / Coma – ‘entertaining’ visitors may exhaust dying Caregivers can: – be there without making demands – Be aware that the person can likely still hear even if in a coma-like state – Advocate for the patient’s stated wishes NRS_105/320_Collings Loss of Appetite • As the body begins to shut down, need for food decreases • Caregivers can: – Offer small favorite foods – Respect the person’s wishes if food is refused – Educate others about the process • Providing food often makes the caregiver/family feel better; it is OK to offer NRS_105/320_Collings Difficulty Swallowing • As body , muscles weaken, swallowing may become more difficult – may cause choking – Reverse diet [Regular – soft – liquid] – Small amounts [2-5 ml] to test swallowing – Caregivers can: • Provide mouth care frequently • Adapt foods, positioning for safety and palatability • Crush meds in jam or yoghurt NRS_105/320_Collings Confusion • May come and go • May be caused by O2 changes [perfusion] • Caregivers can: – Use familiar sounds [music], sights, tactile sensations to comfort, reorient – Recognize that this may be a pleasant or frightening time – Refrain from arguing, denying the person’s ‘reality’ NRS_105/320_Collings Restlessness • May be intermittent, can be R/T pain, nausea, full bladder etc. OR confusion May also signal nearness of death • Caregivers can: – Assess for physical symptoms, safety risks – May be a spiritual crisis – unresolved [access spiritual counselor, pray] – Use music, touch, aromatherapy NRS_105/320_Collings Elimination • As weakness increases, person may become incontinent, diaphoretic • Caregivers can: – Maintain dignity – Place a Foley for comfort – Keep skin clean and dry – Administer pain meds before bathing as needed NRS_105/320_Collings Circulation • Temperature control mechanisms start to fail, circulation withdraws to center – May cause cool skin or sweating • Extremities become bluish, mottled, cool • Caregivers can: – Follow person’s wishes R/T blankets – Prevent shivering to conserve energy – Turn less frequently – for comfort, SOB NRS_105/320_Collings Breathing • SOB not uncommon; – O2 for comfort, fan; position semi-fowlers • Change in breathing signals active dying – Exhalation longer than inhalation – Irregular breathing [Cheyne-Stokes] • Shallow, rapid respiration followed by apnea • RR 30-50 not uncommon – Often Indicates days to hours until death – ‘Death Rattle’ [secretions in throat R/T lack of swallow] may be disconcerting NRS_105/320_Collings Spurt of Energy • Some dying people ‘rally’ and become more alert, energetic, shortly before death – Caregivers can: • Use this time to attend to unfinished business, say goodbye, give person ‘permission to go’ • Involve spiritual guides, chaplain, family members – Often followed by unconsousness and then death NRS_105/320_Collings Signs of Imminent Death • Eyes have glassy fixed stare with large pupils • Pasty grey, or blue grayish color present especially on lips, hands and feet – Hands and feet can be cold – Pooled blood in dependent areas causes bruised appearance • Jaw open, breathing through mouth very rapid or very slow (often with rattle) with pauses of 20-50 seconds between breaths [Cheyne-Stokes] • Unresponsive to voice or pain • Caregivers can: maintain calm, quiet atmosphere, perform pre-death rituals NRS_105/320_Collings After Death Care • • • • Specifics depend on facility, legal needs If autopsy case, leave all tubes Document everything Donation – required to discuss – May offend some – Autopsy • Cases of sudden death, unattended, < 24 hrs • Maintain dignity, respect culture NRS_105/320_Collings After Death Care • Documentation – Autopsy? Donation? • • • • • • Family to be included? Special ritual? Bathe body, clean up room Allow family, others to say goodbye Personal belongings to family ID and transport per policy Self-care NRS_105/320_Collings Evaluation • Were client goals met at time of death? • Family goals? • Goal not met: pt expired with infection… - OK • Look for expressions of hope, + coping NRS_105/320_Collings Caring for yourself • • • • • • • All nurses experience grief & loss Need balance, rituals, people for support Change of scenery Assess yourself Ask for help – and accept help Find meaning in Nursing Practice self-care NRS_105/320_Collings Final thought "Be wise. Treat yourself, your mind, sympathetically, with loving kindness. If you are gentle with yourself, you will become gentle with others." - Lama Thubten Yeshe NRS_105/320_Collings A Good Death • http://www.learner.org/vod/vod_window.ht ml?pid=1279 • Type / copy http://www.learner.org/resources/series10 8.html into browser if blocked, then click on ‘A Good Death’ • Other good videos [streaming] on site NRS_105/320_Collings