Death & Dying PDF

Chapter 13 End of Life Care Objectives ► Identify stages of grief ► State ways the nurse can help the dying patient and family through the grief process ► List objectives of a hospice program ► Identify local resources  GROUP QUESTIONS 1. What is LOSS 2. Give examples of how one...

Chapter 13 End of Life Care Objectives ► Identify stages of grief ► State ways the nurse can help the dying patient and family through the grief process ► List objectives of a hospice program ► Identify local resources  GROUP QUESTIONS 1. What is LOSS 2. Give examples of how one experiences LOSS 3. What is GRIEF 4. What are the 5 stages of GRIEF (Kubler-Ross) 4. What are ADVANCED DIRECTIVES 5. What is a LIVING WILL 6. What is POWER OF ATTORNEY 7. What is PALLATIVE CARE Loss Any potential, actual, or perceived situation when valued object or person is changed or is not accessible to the individual Maturational and Situational Loss ► Maturational ► Occurs as person moves from one developmental stage to another ► Situational ► Occurs in response to external events generally beyond person’s control Major Categories of Loss ► Loss of: ► Significant other ► Aspect of self ► External object ► Familiar environment Grief ► Highly individualized experience (life experiences, support system, resources) ► Series of intense psychological responses occurring after loss ► Inner emotional response to loss, exhibited in many ways ► Necessary, normal, natural, and adaptive responses Nursing Care ► Stay with grief-stricken client in moments of need: provides emotional support and may help the client feel the nurse will be available to respond during fture needs  Stages of Grief ► Elizabeth Kübler-Ross identified clients’ and families’ five stages of dying: ► Denial ► Anger ► Bargaining ► Depression ► Acceptance Individual grief.. Own order…own timeline Denial= People usually go into SHOCK after receiving bad news!! Anger = directed at others..spouse..HCP Bargaining = negotiate with God/higher power ► Depression = crying, sadness ► Acceptance = accept death Stages of Grief ► Shock ► May last days to one month or more ► Person may describe feeling emotional numbness ► Reality ► Painful experience that begins when person consciously realizes full meaning of loss Types of Grief ► Uncomplicated ► Normally follows fairly predictable significant loss ► Anticipatory ► Occurs before expected loss (continued) Types of Grief ► Dysfunctional ► Intense, persistent pattern that does not result in reconciliation of feelings ► Disenfranchised ► Not openly acknowledged, socially sanctioned, or publicly shared Factors Affecting Loss and Grief ► Developmental stage ► Religious and cultural beliefs ► Relationship with lost object ► Cause of death Nursing Care of the Grieving Client: Assessment ► Nurses must: ► Determine personal meaning of loss ► Encourage clients to experience feelings ► Assess person’s progress through grieving process Diagnosis ► Dysfunctional grieving ► Anticipatory grieving Planning and Outcome Identification ► Some expected goals for person experiencing grief: ► Accept loss ► Verbalize feelings of grief ► Share grief with significant others ► Renew activities and relationships Implementation ► Nurses should: ► Spend time listening ► Demonstrate acceptance ► Exhibit nonjudgmental, accepting attitude ► Provide reassurance, support, and counseling resources Evaluation ► Nurses usually do not have opportunity to know when bereaved family completes its grief work ► Foundation: ► Goals mutually established with client and family ► Nurses should teach that resolution of loss is process of life-long adjustment Death ► Last stage of life ► Each person dies unique death ► Nurses must understand ethical and legal issues surrounding dying and death ► Nurses must come to terms with own mortality and feelings about death to provide comfort to clients and families  Legal Considerations ► Advance directive ► Written instruction of client wishes ► DO NOT RESUSCITATE, NO INTUBATION, MEDICATIONS ONLY ► Patient Self-Determination Act (PSDA) provides legal means for people to specify circumstances under which life-sustaining measures should or should not be rendered POWER OF ATTORNEY ► Competent adults has the right to direct their own medical health ► Once client NO LONGER capable of making own decisions = DURABLE POWER OF ATTORNEY (continued) Ethical Considerations ► Death can be fraught with ethical dilemmas ► Ethics committees in many health care agencies deal with end-of-life issues ► One of the most difficult dilemmas: ► Determining difference between killing and allowing to die by withholding life-sustaining treatment  End of Life Care ► Focus on meeting physical and psychosocial needs of client and family ► Attend to: ► Control of symptoms ► Identification of needs ► Promotion of interaction ► Facilitation of peaceful death ► DYING WITH DIGNITY ► CARING BEHAVIORS from Nurses  Palliative Care ► End of Life Care ► Relief of symptoms ► Goal: ► Assure quality of life ► Meet clients physical needs ► Meet clients psychosocial needs FEAR OF DYING ► Stay with client, don’t leave client alone esp if frightened of dying ► Stay with them until family arrives (continued) Hospice ► Care for terminally ill ► When aggressive treatment no longer option or client refuses further care ► Often in home or hospice setting without technology to prolong dying ► Interdisciplinary program  Nursing Management During End-of-Life Care 1. PAIN 2. DYSPNEA 3. ANOREXIA 4. WEAKNESS/FATIGUE 5. CONSTIPATION 6. NAUSEA & VOMITING 7. DELIRUM *Refer to Table 13-6 Nursing Care of the Dying Client: Assessment ► Client and family goals and expectations ► Client’s awareness that illness is terminal ► Identification of support systems ► Client’s stage of dying ► History of positive coping skills ► Client perception of unfinished business to be completed Dying Person https://www.youtube.com/watch?v=xfDtMWm0yUU Diagnosis ► Powerlessness ► Hopelessness ► Death anxiety Planning and Outcome Identification ► Goals of nursing care are same as goals developed for all clients unable to meet own needs ► Treat dying client as unique person worthy of respect ► Many dying do not fear death, but are anxious about painful death or dying alone (continued) Planning and Outcome Identification ► Schedule time to spend with client ► Identify areas of concern and make appropriate referrals ► Protect and promote self-esteem and self-worth ► Balance client’s need for independence with need for assistance (continued) Planning and Outcome Identification ► Meet physiological needs ► Respect confidentiality ► Provide factual information ► Offer to contact clergy or spiritual leader Implementation ► Communicate caring to client and family ► Holding client’s or family member’s hand and saying “I will not leave you” is powerful way to show caring Physiological Needs ► Respirations ► Skin care ► Fluids and nutrition ► Elimination ► Mouth, eyes, and nose ► Comfort ► Mobility ► Physical environment (continued) Physiological Needs ► Nurses can humanize dying person’s environment ► For many clients, important to maintain well-groomed appearance ► Advise people purchasing clothing for client to select loose-fitting, washable items with few fasteners Spiritual Needs ► Use touch ► Play music ► Pray with client ► Communicate empathy ► Contact clergy, if requested ► At client’s request, read religious literature aloud Support for the Family ► Nurses must remember that: ► Family rules and coping mechanisms may not always coincide with staff values and beliefs ► Client’s and family’s wishes must be respected to extent possible ► Relationship with family does not always end with client’s death Learning Needs ► Treatment regimen and information about physical condition ► Anticipation of medical crisis ► Inexperience with personal threat of death ► Unfamiliarity with what to do in case of emergency outside hospital Impending Death ► Lungs cannot provide adequate gas diffusion ► Heart and blood vessels unable to maintain adequate tissue perfusion ► Brain ceases to regulate vital centers ► Cheyne-Stokes respirations and “death rattles” occur Physical Signs of Death ► Absence of heartbeat (Apical) ► Cessation of respirations ► Mottling of skin ► Eyelids remaining slightly open ► Jaw relaxation and slight opening of mouth (continued) Physical Signs of Death ► No response to name, touch, or environmental sound ► Eyes fixed on certain spot ► No eye-blinking in response to touch or air movement over eyes ► Release of bowel and bladder contents Care after Death ► Treat body with respect ► Post Mortem Care: ► Bathe, leave naked or clean gown (policy) ► Remove dressings and tubes (NOT IF CORONERS CASE) ► Place body with head elevated (small roll under chin) ► Place dentures in denture cup ► Send with body, Comb hair Legal Aspects ► Physician is responsible for certifying death ► In most states ► Autopsy ► Examination of body after death to determine cause ► Organ donation requires sensitivity and compassion from health care team Care of the Family ► Offer information about viewing body ► Contact support people ► Help family with decisions regarding transportation, funeral home, and removal of deceased’s belongings ► Provide coffee, tissues, and light snacks to show sensitivity to family and friends Nurse’s Self-Care ► Many nurses confronted with death and loss daily ► Nurses at particular risk for experiencing negative effects from caring for dying clients ► Shadow grief ► Unresolved sadness ► May lead to burnout Symptoms of Shadow Grief ► Loss of energy, spark, joy, or meaning ► Detachment from surroundings ► Powerlessness ► Increased smoking or drinking ► Unusual forgetfulness ► Constant criticism of others (continued) Symptoms of Shadow Grief ► Consistent inability to get work done ► Uncontrolled outbursts of anger ► Perception of clients and their families as objects ► Surrendering of hobbies or interests Ways to Cope with Grief ► Take time to cry with and for clients ► Run, walk, bicycle, or play tennis ► Ask colleagues to help with tasks ► Connect to place of worship and pray ► Look for joy in work and laugh ► Create caring circle of friends ► Listen to music