Grief and End-of-Life Care Quiz

Grief, Loss, and End of Life

• Grief is an individual's emotional response to a loss.
• There is no one way to respond to grief; everyone's experience varies.
• Mourning and bereavement are often used synonymously.
• Both are active processes of incorporating loss into one's life.
• Rituals and behaviours may assist with this process.
• Cultural and social norms influence mourning and bereavement.

Learning Objectives

• Define loss, bereavement, and grief, and explore their associated theories.
• List strategies to support families, friends, and caregivers of a dying patient.
• Explore legal issues related to dying, including MAID, informed consent, competency, advance directives, and substitute decision-making.
• Describe physiological changes during imminent death and nursing interventions for end-of-life care.

Activity

• Write down one question or concern about caring for someone who is dying.
• Example concern: Worrying about supporting a patient and family if the caregiver is also experiencing sadness and upset.

Loss

• Loss is an experience of losing someone or something.
• Loss can occur throughout life, or at the end of life.
• Persons may lose health, a valued possession, a significant relationship, or their lives.
• One person's loss of life is another person's loss of a significant relationship.
• Nurses play a vital role in supporting patients and families through loss and grief.

Grief

• Grief is an individual's emotional response to a loss.
• Mourning and bereavement are often used synonymously.
• Both are ongoing, active processes of incorporating loss into one's life.
• Processes may include rituals and behaviors to assist.
• Cultural and social norms significantly influence the experience of grief.

Factors Influencing Grief and Loss

• Human development (age and life stage) shape the experience.
• Psychosocial perspectives and personal experiences influence coping mechanisms.
• Socioeconomic status can increase the burden of loss when resources are limited.
• Personal relationships, especially loss of loved ones, deeply impact the experience of grief.
• The nature of the loss (e.g. sudden or expected) impacts the grieving process.
• Culture and ethnicity affect grief responses due to the multicultural nature of Canada.

Models of Grief

• Grief models acknowledge common physical and psychological manifestations and phases across individuals.
• Acute Grief: Experienced when the loss first occurs, focusing on initial emotions.
• Despair Grief: Often presented as sadness or depression, affecting daily functioning and interactions.
• Adjustment Grief: The stage where an individual learns to adapt to change and rebuild their life without the lost person or object.
• Grief processes are not fixed; the experience is not always linear and predictable.

Kubler-Ross Model

• Stages of grief experienced by individuals dealing with loss: denial, anger, bargaining, depression, and acceptance.
• The stages are not rigid. Some people may not experience all the stages.
• The timeline for the stages is not set in stone.

Pattison's Living-Dying Interval

• The time between the initial "crisis knowledge" of impending death and the point of death.

Types of Grief

• Anticipatory Grief: Grief experienced before the loss occurs, characterized by worry and pre-occupation with the loss.
• Sociological Death: Premature withdrawal from the dying person by others.
• Psychological Death: Withdrawal of the dying person from others.
• Acute Grief: A crisis presenting somatic and psychological symptoms fluctuating over time, that includes negativity, hostility, and or difficulty doing daily activities.
• Persistent Grief: Recurring grief responses that do not diminish with time.
• Disenfranchised Grief: When a loss cannot be outwardly acknowledged or publicly mourned, such as hidden relationships or losses deemed unimportant.

Needs of the Dying Patient and Family

• End-of-life care encompasses services for the last year of a patients life and bereavement services following the patients death.

A Good Death

• Nurses work with the interprofessional team to support patients and their families through end-of-life.
• A "good death" is free of avoidable distress.
• A "good death" is consistent with patient and family's wishes.
• A "good death" is consistent with clinical, cultural, and ethical standards.

Weisman's 6Cs

• Individuals at the end of life require specialized care addressing their physical, emotional, and spiritual needs.
• Six areas considered to care for the needs of the dying that include: Care, Control, Composure, Communication, Continuity, and Closure.

Care

• People who are dying need the best symptom management.
• Medical needs must be addressed to provide comfort to patients.
• Treatment of symptoms and conserving energy are crucial elements of good care.
• Pain needs treatment that addresses all emotional and psychological elements of pain, not only physical elements.

Control

• Patients at the end of their lives may lose control.
• Nurses should facilitate as much control as possible in their care. This includes providing care to support symptom control and total care for patients as directed by the palliative team.

Composure

• Many cultures incorporate emotional expression and support during periods of illness and death.
• Tools can be utilized to support clients having emotional extremes.

Communication

• Nurses have the responsibility to encourage communication with the dying person.
• Different types exist (closed awareness, suspected awareness, mutual pretense, and open awareness).

Continuity

• Maintaining a sense of continuity for dying persons is important, preserving an awareness of legacy and memory of the life they have lived.
• Leaving a legacy or establishing rituals or memories can offer a sense of continuity.

Closure

• Closure provides opportunities for reconciliation and transcendence that can allow for the process of acceptance and closure.
• Reminiscence can be helpful in putting a life in order.

Supporting Families

• Families and friends are often present during a person's last days and moments.
• Nurses provide emotional support to ensure patient's loved ones are met with comfort.

Legal Concepts at End of Life

• Advanced Care Planning: The process of planning ahead for decisions and care that might need to occur when the individual is unable to decide for themselves.
  • Choosing a Substitute Decision Maker (SDM) and communicating wishes.
  • SDM role is to act in the best interest of the incapable person based on the incapable person's wishes.
• Advanced Directive: A legal document containing written instructions to direct healthcare if the individual is unable to make choices.
  • Discussing advance directives and wishes with a physician. This could be a helpful option.
  • Having written instructions can ease pressure at crucial times.
• POA/SDM: An assigned decision maker granted the legal ability in Canada to make decisions on the incapable person's behalf. The law provides a hierarchy of who can be assigned as a SDM should the incapable person not have chosen a SDM.
  • Determining the appropriate assigned SDM.
  • Determining the individuals in the hierarchy in case the incapable person doesn't choose.
• MAID (Medical Assistance in Dying): A legal process for individuals in Canada.
  • Two types of MAID: Practitioner-Assisted and Patient Self-Administered.
    • Requirements include: eligibility criteria (18+, grievous, etc.); specific written requests; waiting periods; withdrawing options; ensuring the patient is informed of other options; and other safeguards.
    • RN/RPN role is limited; safeguarding that they are not administering the potentially fatal medication.
• Conscientious Objection: The right to refuse to participate in any medical procedures with which a nurse has a belief conflict with their values or conscience. If refusing, the nurse must transfer care to another nurse qualified to handle the care in question.

End-of-Life Care

• Various settings for end-of-life care: Hospice, hospital, home, and long-term care.
• Patients require quality care that addresses pain, symptoms, and other practical and psychosocial, spiritual needs, including the family.
• Canada's preference for end-of-life care at home, though not always possible.
• Hospice palliative care is an approach to care and a philosophy of care that aims to improve the quality of patient and family's life during a patient's illness, death, and bereavement.

Nursing Implications

• Nursing care for dying patients may last days or months.
• Nurses need competency for dying patients and their families.
• Review of resources, including the Canadian Fundamentals of Nursing, are vital.

Advice for Families and Caregivers

• Provides specific signs or symptoms related to end-of-life and support options.

Reflection

• Reflect on personal values and beliefs related to death and dying.
• Consider how you would prefer to receive care during your own death and the death of a loved one, including the needs of your loved ones and expectations surrounding death.
• Determine how you will treat others during similar personal or family experiences.