Exam 14 - Loss, Grief, Death,

Historical Overview of Dying and Death

• Before the 1950s, most individuals died at home with family assistance.
• From the 1950s to the 1980s, death primarily occurred in institutions using life-prolonging technology.
• Diagnosis-related groups (DRGs) introduced in the early 1980s shifted the trend, with hospitals primarily admitting patients at risk for complications or needing post-surgical recovery.
• Hospices gained recognition as health care delivery systems in the 1970s.
• Grief therapy continues to evolve, adapting to various theories on grief and loss.
• The Oregon Death With Dignity Act (1997) allows terminally ill residents to end their lives via voluntary self-administration of prescribed medications.
• Similar laws have been enacted in Washington, Vermont, California, Colorado, the District of Columbia, and Hawaii since then.
• Montana's Supreme Court, while not endorsing a specific act, has not ruled against physicians prescribing medications for voluntary, self-administered lethal administrations.

The Eight Domains of Palliative Care

• The National Consensus Project for Quality Palliative Care (2013) established eight core domains: structure and process of care, physical aspects, psychological and psychiatric aspects, social aspects, spiritual, religious, and existential aspects, cultural aspects, care of the patient at the end of life, and ethical and legal aspects.
• Structure and process of care involve an interdisciplinary assessment to develop individualized care plans.
• Physical aspects focus on pain and symptom control, and alleviation of suffering.
• Psychological and psychiatric aspects encompass managing stress, coping mechanisms, grieving processes, and addressing mental health conditions.

Types of Loss

• Losses can be obvious, such as the death of a loved one, divorce, or job loss.
• Less obvious losses include those triggered by illness, aging, disabilities, and changes in schools, jobs, or neighborhoods.
• Actual losses, like a mastectomy, are easily identifiable.
• Perceived losses, like a loss of confidence or a birth outcome contrary to expectations, are less readily apparent.
• Maturational losses occur with normal life transitions, such as leaving childhood dreams behind, teenage romantic breakups, or leaving home for college or marriage.
• Situational losses arise from specific external events, like the sudden death of a loved one or job loss.

Grief

• Grief is a subjective response to actual or anticipated loss, involving thoughts, feelings, and behaviors.
• It is a process, not an episode, and can sometimes be lifelong.
• It has a useful function in helping individuals resolve hurt and rebuild their lives.
• Successful grieving involves accepting the loss, experiencing the pain of grief, adjusting to the absence of the lost person/object, and reinvesting emotional energy in new relationships.
• Nurses play a role in assisting patients and families through these tasks.
• Unresolved grief, characterized by incomplete relationships and health problems, can occur if these tasks are not completed.

Grief Attacks

• Grief attacks are involuntary and unexpected reappearances of emotions and behaviors associated with grief.
• They can be triggered by various stimuli, like scents, places, foods, dates, clothing, or people.
• Memories of the deceased may also trigger an attack, spontaneously or in response to external cues like hearing of a similar death or reading a related story.
• The pain of loss typically persists even after a loved one's death.

Nurses' Grief

• Nurses caring for the terminally ill and bereaved often develop heightened empathy for their patients.
• However, nurses' own grief experiences can complicate their role, especially when caring for dying patients.
• Nurses should not allow their own grief to overshadow patient and family care.
• Bereavement overload, resulting from experiencing multiple losses without adequate processing, can lead to frustration, anger, guilt, sadness, helplessness, anxiety, depression, and feelings of overwhelm.
• Unrelieved grief and stress can negatively affect well-being and care for others.
• Lack of peer support and work-related rewards can contribute to burnout.

Stages of Grief and Dying

• There is no single "right" way to grieve.
• Stages of grief are tools to anticipate patients and families' needs and plan interventions to help them understand and manage their grief.
• Knowledge of these developmental stages can help nurses comprehend patients' responses to life-threatening situations and grief reactions after loss.

Complicated Grief

• Bereavement is a state of significant physical, emotional, and social risk.
• Unresolved grief, also known as complicated grief, is a delayed or exaggerated response to loss.
• It occurs when individuals become stuck in grief, experience depression, are unable to express emotions, lack support, or face unresolved past losses.
• Suffering a loss that stirs up past unresolved losses can lead to difficulty coping.
• Individuals with complicated grief may struggle to trust the grieving process and believe they cannot work through their loss.
• Untreated complicated grief can lead to chronic distress and impaired functioning.

Supportive Care During the Dying and Grieving Process

• Nurses use a holistic approach to provide compassionate care, encompassing physical, emotional, intellectual, sociocultural, and spiritual aspects.
• Physical assessment includes evaluating sleeping patterns, body image, ADLs, mobility, overall health, medication use, and pain.
• Interventions should focus on energy conservation, pain-reduction techniques, comfort measures, sleep promotion, and increasing self-esteem.
• Emotional assessment involves assessing anxiety, guilt, anger, and acceptance levels in both patients and families.
• Nurses should accept and support patients' and families' feelings, providing encouragement, offering permission to die, and aiding in saying goodbye.
• Intellectual assessment includes evaluation of patients' and families' educational levels, knowledge, abilities, and expectations about death.
• Nurses should provide education to patients and families, keeping them informed about procedures, changing conditions, and hospital policies.
• Sociocultural assessment evaluates patients' and families' support systems and determines the level of family involvement in care.
• Nurses must be sensitive to individual family preferences and not assume their willingness to participate in hands-on care.
• Nurses encourage family members to provide support for one another and recognize their value as resources in the dying process.
• When caring for home-based patients, ensuring families are adequately prepared for care and providing support through hospice services is crucial.
• Identify and encourage the patient's most supportive person to participate in their network and care planning.
• Spiritual assessment involves exploring patients' philosophies of life, spirituality, and religious resources.
• Nurses should avoid judging or interpreting patients' spiritual views and create a safe space for discussing spiritual concerns.
• Hope is essential for coping with loss and illness.
• Nurses should assist patients and families in identifying and accessing appropriate sources of hope.

Nursing Process in Loss and Grief

• Licensed Practical Nurses (LPNs)/Licensed Vocational Nurses (LVNs) participate in care planning, review and revise plans, follow prioritization guidelines, and use care pathways/maps to guide and review care for patients experiencing loss.
• Data collection involves assessing the meaning of loss for both the patient and their family or significant others.
• Nurses should not judge patients' grief reactions but focus on understanding their individual responses.
• Culture and ethnicity significantly influence the interpretation and expression of loss.
• Patient problem identification involves analyzing behavioral patterns, actual or potential losses, and data related to the loss.
• Nurses should consider multiple possible patient problem statements and address the relevant context or related factor.
• For example, dysfunctional grief stemming from loss of physical function requires different interventions than dysfunctional grief caused by job loss.
• Attending to all complex problems simultaneously is not feasible.### Nursing Interventions for Grieving Patients
• Prioritize interventions based on the patient's most pressing needs, constantly reevaluating as their condition changes.
• Focus on addressing grief before other issues, as unresolved grief can negatively impact other health concerns.
• Involve family and friends, clergy, support groups, and legal consultants to provide comprehensive support.

Outcomes and Planning for Grief Care

• Set goals addressing the patient's physical, emotional, developmental, and spiritual needs.
• Examples of goals:
  • Patient actively participates in grief work.
  • Patient verbalizes finding meaning in life.
• Incorporate external resources into the plan of care, such as legal aid or counseling services.

Implementation of Grief Care

• Recognize the value of family members as resources and assist them in supporting the dying patient.
• Focus on enabling the patient to achieve optimal physical and emotional functioning, even in the face of significant loss.
• Use various techniques and interventions to help patients cope effectively with stress and make decisions about their care.

Evaluation of Grief Care

• Evaluate the achievement of goals through observation, patient self-reports, and assessments.
• Examples of evaluative measures:
  • Patient discusses loss with significant others.
  • Patient demonstrates progress in dealing with the stages of grief.
  • Patient indicates finding peace through meditation.
• Foster a trusting relationship with the patient and family.

Special Supportive Care

• Perinatal Death:

  • Provide support for grieving parents and family members, allowing them to grieve adequately.
  • Encourage parents to see, touch, and hold the infant to process their loss.
  • Support cultural rituals surrounding the infant's death.
  • Provide mementos and resources to help parents cope.

• Pediatric Death:

  • Be aware of how children understand death and provide honest information in language they can understand.
  • Reassure children they will be cared for and not abandoned.
  • Offer support and guidance to grieving family members.
  • Consider supportive group therapy for survivors.

• Suicide:

  • Recognize the unique grief experiences of survivors, including guilt, shame, and social isolation.
  • Provide support and understanding to survivors, acknowledging their pain.
  • Refer survivors to grief counselors.

• Gerontological Death:

  • Treat older adults as individuals, assessing their needs like any person facing a terminal illness.
  • Encourage participation in self-care and decision-making regarding treatments.
    • Offer support to grieving family members.

• Sudden or Unexpected Death:

  • Provide extensive support to families struggling with a sudden, unexpected, or violent loss.
  • Acknowledge their need to understand the cause of death.
  • Provide grief therapy and referral to support groups.

Issues Related to Dying and Death

• Euthanasia:

  • Understand the differences between active and passive euthanasia.
  • Recognize the ethically complex issues surrounding euthanasia.
  • Be aware of societal attitudes toward euthanasia.

• Do Not Resuscitate (DNR) Order:

  • Emphasize the importance of patient and family involvement in DNR decisions.
  • Ensure clear communication about patient's condition and treatment options.
  • Understand the implications of DNR orders and specific restrictions.
  • Maintain accurate documentation of DNR orders and discussions.
  • Familiarize yourself with your institution's policies and procedures regarding DNR orders.

• Advance Directives:

  • Understand the two main types of advance directives: living wills and durable powers of attorney for health care.
  • Support patients in creating and implementing these directives.

Organ Donations

• Organ donation is a vital option for individuals with end-stage organ failure.
• Understand the scarcity of organ donations and the need to maximize organ recovery.
• Be aware of the different mechanisms of death, including brain death, and their implications for organ viability.
• Collaborate with organ procurement organizations (OPOs) and transplant team.
• Provide emotional support to donor families.

Organ Donation: An Overview

• The National Organ Transplant Act of 1984 established the Organ Procurement and Transplantation Network (OPTN), managed by the United Network for Organ Sharing (UNOS), to oversee organ donation and transplantation in the United States.

• UNOS maintains a national registry for organ sharing and matching, while the Health Care Financing Administration certifies Organ Procurement Organizations (OPOs).

• There are 58 nonprofit OPOs dedicated to organ donation services, covering the United States, Puerto Rico, and Bermuda.

• Hospitals receiving Medicare or Medicaid reimbursement must report impending deaths to the local OPO.

• Hospitals have clinical criteria (triggers) for identifying potential organ donors, including a Glasgow Coma Scale score less than 5, stroke, anoxia, and brain trauma.

Types of Organ Donation

• Living Donor:

  • Healthy individuals can donate organs like a kidney, a lung or liver lobe, part of the pancreas, or a segment of the intestine.
  • Must be a clinical match with the recipient and have no psychosocial contraindications.
  • Don't need to be related to the recipient.

• Brain Death:

  • Patients may donate after being declared brain dead, with consent from themselves (via donor designation) or a legal representative.
  • Requires thorough communication between healthcare providers, OPO staff, and family members.

• Circulatory Death:

  • Organ donation after circulatory death occurs after withdrawal of life-sustaining therapies and subsequent asystole (absence of heartbeat) within a specific timeframe.

Categories of Organ Donors

• Standard Criteria Donor:

  • Under 50 years old
  • Declared brain dead from traumatic injuries or stroke
  • Can donate kidneys, pancreas, liver, intestine, heart, lungs, tissues

• Deceased, Heart-Beating Donors:

  • Declared brain dead due to nonsurvivable head injuries or neurological events
  • Can donate kidneys, pancreas, liver, intestine, heart, lungs, and tissues including abdominal wall, face, penis, uterus, and upper limb.

• Donation after Circulatory Death:

  • Donation following withdrawal of life support and asystole.
  • Can donate kidneys, liver, and lungs.

• Living Donor:

  • A healthy individual donates an organ or part of an organ.
  • May be related or unrelated to the recipient.
  • Can donate kidneys, one or two liver lobes, a lung or part of a lung, part of a pancreas, part of the intestine.

• Nondirected/Altruistic Living Donor:

  • Donates an organ to a stranger.
  • Most common donation is a kidney, liver lobe donation is rare.

• Increased-Risk Donor:

  • Donation involves risk of disease transmission based on the recipient's critical condition.
  • Patient and family must consent to accept an organ from an increased-risk donor.
  • Includes people who have:
    • Had sex with someone who has HIV, HBV, or HCV.
    • Been in jail, prison, or a juvenile correctional facility for over 72 hours.
    • Injected drugs intravenously.
    • Been newly diagnosed or treated for syphilis, gonorrhea, Chlamydia, or genital ulcers.

• Expanded Criteria Donor:

  • Deceased donor over 50 years old with either high blood pressure, creatinine ≥1.5 mg/dL, or death from stroke.
  • All donors over 60 years old.
  • Can donate kidneys, liver, heart, pancreas, lungs, and intestines.

• Hepatitis C Core Antibody–Positive Donor:

  • A donor with a positive test for hepatitis C core antibody.
  • May have been successfully treated for hepatitis C or had prior exposure.
  • Active hepatitis C prevents donation.
  • Can donate kidneys, liver, heart, and lungs.

Living Donor Kidney Paired Exchange Donation

• Criteria for Living Donor:

  • At least 18 years old and willing to donate.
  • Good physical and mental health.
  • Well informed about risks and benefits.
  • Have a good support system.
  • Able to take time off from work or school for diagnostic workup.
  • Able to take time off from work or school after surgery.
  • Be free from certain medical conditions (including diabetes, cancer, kidney and heart disease, hepatitis C, HIV)
  • Have a body mass index less than 35.
  • No drug or alcohol problems.

• OPTN Policies for Living Donor:

  • Requires a living donor advocate independent of the transplant team to avoid conflicts of interest.
  • Evaluates motivation to ensure no coercion or financial incentives are present.
  • Age is flexible, gender and race are not factors, and blood type must be compatible with the intended recipient.
  • After evaluation, the transplant team coordinates the donation.

• Kidney Paired Exchange Donation:

  • Allows individuals with compatible living donors who cannot donate to their intended recipients due to incompatibility to participate.
  • UNOS works with transplant centers to match donors and recipients.
  • The OPTN coordinates the exchange.

Brain Dead Donor

• Definition of Brain Death:

  • Complete and irreversible cessation of function in the brain and brainstem.
  • Determined according to neurological criteria.

• Evaluation of Brain Death:

  • Involves clinical evaluation, neurodiagnostic studies, and ensuring cardiopulmonary function and end-organ perfusion are maintained artificially.
  • Brain death diagnosis is by physical examination, usually by a neurologist or neurosurgeon.
    • Includes these steps:
      • Prerequisites for clinical evaluation.
      • Clinical evaluation (neurological assessment).
      • Neurodiagnostic testing: electroencephalogram, cerebral angiography, or radionuclide cerebral perfusion scan.
      • Identification of potential confounding factors.

• Conditions for Pronouncing Death by Neurological criteria:

  • Documented cause of catastrophic brain injury (metabolic or structural).
  • Elimination of reversible causes for depressed neurological examination.
  • Clinical evaluation consistent with brain death, including carbon dioxide unresponsiveness at the brainstem documented by apnea testing.
  • Clinically appropriate neurodiagnostic testing within a brain death protocol consistent with brain death.

• OPO Contact and Consent:

  • Federal and state laws require physicians to contact the OPO following a brain death determination.
  • The OPO is usually contacted before brain death declaration, and consent for organ donation is obtained from the family after a discussion with the patient's primary healthcare team.

Organ Donation after Circulatory Death (DCD)

• Criteria:

  • Patient has an illness with no expected recovery.
  • Does not meet brain death criteria.
  • Relies on life support (like mechanical ventilation, vasoactive medications, inotropic medications).

• Process:

  • The OPO is contacted when the family discusses or decides to withdraw life support.
  • The OPO coordinator conducts clinical and respiratory drive assessments.
  • The decision to withdraw life support is independent of the donation decision.
  • Legal next of kin must consent to organ donation.

Care of the Family

• Special Needs:

  • Families of organ donors need support after making the decision to donate and the death of their loved one.
  • Advocacy, honesty, and empathy build trust with the family.

• Communication:

  • Encourage family communication, be honest about the patient's prognosis, explain condition and terms (like brain death), and acknowledge cultural, ethnic, and religious beliefs.

Evaluation of Potential Organ Donor

• OPO Coordinator's Role:

  • Conducts a physical assessment, medical and social history, and various laboratory tests.

• Increased Risk Donor:

  • Documented risk of disease transmission: IV drug use, incarceration, high-risk sexual behaviors, poor historian.

• Standard Criteria Donor:

  • Younger than 50 years old with no significant comorbidities.

• Expanded Criteria Donor:

  • Older than 60 years old or older than 50 with high blood pressure, creatinine ≥1.5 mg/dL, or death from stroke.

Fraudulent Methods of Treatment

• Suspicion:
  • Be wary of treatments that do not offer informed consent or lack approval from federal agencies.

Dying Patient: Communication

• Therapeutic Communication:

  • Express respect, offer realistic hope, and provide support.
  • Ensure verbal and nonverbal communication match.
  • Don't offer false reassurance.
  • Pay attention to verbal and nonverbal cues.
  • Accept the patient's wishes if they prefer not to communicate.
  • Use attending behavior (eye contact, attentive body language, verbal acknowledgement).

• Empowering Patients and Families:

  • Participate in the final act of living.
  • Continuous assessment, communication, and skilled care.

Supporting the Dying Patient

• A skilled professional can guide the patient toward a peaceful and comfortable dying experience.
• Depending on the patient's needs and wishes, resources like clergy or chaplain services can be summoned for spiritual support.
• Assistance may be required with religious rituals, such as prayer or reading scripture; if uncomfortable, ask another nurse or contact chaplain services.
• Nontraditional therapies can be supported if they offer hope and do no harm.
• The nurse's role is to explain realistic options while maintaining hope for the patient.
• The attitude of both the nurse and patient impacts the perceived success or failure of a dying experience.

Assisting the Patient in Saying Goodbye

• Assisting terminally ill patients with saying goodbye to loved ones is essential.
• Patients must say goodbye, either verbally, nonverbally, concretely, or symbolically.
• Family members also need to process the impending departure and complete unfinished business to help them through the grieving process.
• The nurse plays a crucial role in supporting both the dying person and the family during this process.
• A private and comfortable environment should be provided for these goodbyes.
• To facilitate saying goodbye, encourage patients to talk to their loved ones as if they were going to be separated for a long time.
• Encourage expression of feelings and thoughts they want their loved ones to know in their absence.
• Encourage creative tasks like writing poems, letters, or recordings to provide feelings of control and purpose during their final days.

Palliative Care

• Palliative care focuses on preventing, relieving, reducing, or soothing symptoms of disease or disorders without aiming for a cure.
• It allows for informed choices, improved symptom management, and closure for patients.
• The nurse's role in palliative care includes:
  • Relieving pain and distressing symptoms.
  • Affirming life and acknowledging death as a natural process.
  • Neither hastening nor postponing death.
  • Integrating psychological and spiritual aspects of patient care.
  • Providing a support system to help patients live actively until death.
  • Offering support to families during the patient's illness and bereavement.
  • Using a team approach to address patient and family needs.
  • Enhancing quality of life and potentially influencing the course of illness.
• Palliative care operates as a philosophy of total care suitable for patients of any age and diagnosis, not solely in the final months of life.
• An interdisciplinary team provides care, including nurses, social workers, pastoral care professionals, therapists, and pharmacists.
• The ultimate goal is to ensure a "good death" free from avoidable pain and suffering, consistent with the patient's and family's wishes and ethical standards.

Physical Care

• The nurse assists patients with their physical needs, including nutrition, elimination, and cleanliness.
• Keeping the patient clean, dry, well-groomed, and comfortable helps maintain self-esteem and prevents skin deterioration.
• Nurses provide care in facilities or the patient's home.
• Adjustments to the environment to increase comfort and safety are crucial, using side rails for safety and assistance with positioning.

Assessments and Interventions

• Care of the dying patient has many facets, with love and affection, pain control, and preservation of dignity being most crucial.
• The nurse provides meticulous care to address physical needs and alleviate suffering.
• The goal is to help patients accept death as a reality of life and die with dignity and self-esteem.
• Preventing abandonment by family, friends, and caregivers is essential.
• Consider the No One Dies Alone program, which provides compassionate companions for dying patients.
• Assess for impending death through observations such as:
  • Extreme fatigue, appearing comatose, or unresponsive.
  • Restlessness, picking at bed linens, decreased oxygenation.
  • Discoloration of arms and legs due to impaired circulation.
  • Changes in vital signs including slow, weak pulse, lowered blood pressure, and abnormal respirations.
  • Mouth breathing leading to dry mucous membranes.
  • Detached look in the eyes.
  • Diminished sensory and motor function.
  • Dilated and fixed pupils, Cheyne-Stokes respirations, weak pulse, and falling blood pressure.
  • Diminished peripheral circulation, cool and clammy skin, diaphoresis.
  • Noisy respirations due to mucus in the throat (death rattle).
  • A period of peace may precede the moment of death.
• Signs of death include unresponsiveness, lack of movement and breathing, no reflexes, flat encephalogram, absence of pulse, and cessation of respirations.

Inquest

• An inquest is a legal inquiry into the cause or manner of death, usually conducted when a death is accidental.
• The inquest is conducted by a coroner or medical examiner, who are public officials investigating the cause of death.
• Agency policy dictates who is responsible for reporting deaths to the coroner or medical examiner.

Postmortem Care

• The healthcare provider certifies the death in the medical record, noting the time and any therapies or actions taken.
• Permission for an autopsy may be requested from the family, especially in cases of unusual death.
• The nurse often provides postmortem care to the patient's body after death.
• Postmortem care prioritizes dignity and sensitivity.
• Immediate measures for organ donation are taken if requested.
• State laws and institutional policies should be adhered to.
• The body should be prepared with dignity and comfort:
  • Remove supplies and equipment from sight.
  • Remove, clamp, or cut tubes within 1 inch of the skin and tape in place.
  • Clear away soiled linen and use deodorizer to eliminate odors.
  • Place the body supine with arms at the sides, palms down or across the abdomen.
  • Prevent facial discoloration by placing a pillow or towel under the head.
  • Gently hold the eyelids closed for a few seconds, or use a moistened cotton ball.
  • Insert dentures to maintain facial features.
  • Use a rolled-up towel under the chin to keep the mouth closed.
  • Document any valuables and secure them for the family.
• Offer the family the opportunity to view the body.
• Assist grieving family members by providing emotional support and contacting other support services.

Documentation

• Document all care provided objectively, completely, legibly, and accurately.
• Make frequent entries as death approaches, including signs of impending death.
• Record who was present at the time of death.
• Continue documentation until the final entry, stating the body's transfer location and recipient.

Grieving Family

• Nurses provide caring and compassionate attention to grieving family members and significant others.
• Contact someone to be with the family if they are alone at the time of death.
• Express sympathy and offer comfort through touch, if appropriate.
• Answer questions and encourage viewing, touching, and talking to the deceased.
• Remain nonjudgmental as family members express emotions like anger, guilt, or unfairness.
• Assist with notification of the mortician and organ donation procurement if applicable.
• Informing others can be an emotional burden for family members, so the nurse's presence and assistance is vital.
• Direct families to support groups and referral agencies to expand their social network, reduce isolation, and promote relatedness.
• Grief work helps individuals cope with loss by:
  • Adapting to life without a loved one.
  • Accepting the reality of the loss.
  • Reinvesting in life while maintaining a connection to the deceased.
  • Managing the emotional pain of the loss.

Resolution of Grief

• Resolution of grief has begun when an individual or family can complete the following tasks:
  • Engage in positive interactions with others.
  • Participate in support groups.
  • Set and work towards goals.
  • Discuss the meaning of the loss and its impact on their life.
• It takes time and support for individuals to work through grief.
• Months or years may pass before they begin resolving grief and experiencing less emotional pain.
• The intensity of grief depends on the energy invested in the relationship with the deceased.

Explore the significant changes in the care of dying patients in the United States from the 1950s to the 1980s. This quiz covers various important aspects, including laws, nursing roles, and theories related to death and dying. Test your knowledge on the evolution of end-of-life care and the support systems in place for terminally ill patients.