Grief, Loss, and End of Life (UTD) PDF

WEEK 6 GRIEF, LOSS and END of LIFE COPYRIGHT This presentation and all its content is copyright and is owned by Durham College or its Licensors (2022). © Durham College or its licensor LEARNING OBJECTIVES Define the concepts of loss, bereavement and grief,...

WEEK 6 GRIEF, LOSS and END of LIFE COPYRIGHT This presentation and all its content is copyright and is owned by Durham College or its Licensors (2022). © Durham College or its licensor LEARNING OBJECTIVES Define the concepts of loss, bereavement and grief, and explore their associated theories. List strategies to provide support for the family, friends and caregivers of a dying patient Explore legal issues related to dying such as MAID, informed consent, competency, advance directives and substitute decision making Describe physiological changes that occur when death is imminent, and the nursing interventions used to provide care and comfort at the end of life. © Durham College or its licensor ACTIVITY Write down one I worry about how to support a patient and question / concern you their family if I am have about caring for sad and upset as well. someone who is dying… © Durham College or its licensor WEEK 6.2 GRIEF & LOSS LOSS, GRIEF & DEATH Loss, death, dying and grief are inevitable and universal aspects of human life. Loss and grief are experienced throughout life, through the loss of dreams, positions, relationships, health and death. When does a person experience Loss? Loss & grief can be experienced by both the patient and their loved ones. A nurse plays an important role in helping patients work through loss & grief and in supporting family and loved ones through the bereavement period. © Durham College or its licensor LOSS Loss is an experience of losing someone or something. This can be an experience we have throughout life, or at the end of life. We may lose our health, a valued possession, a significant relationship or our lives. One person's loss of life is another person's loss of a significant relationship. What is the nurses’ role in caring for people experiencing loss? © Durham College or its licensor GRIEF Grief is an individual's emotional response to a loss. There is no one way to respond to grieve, everyone will respond differently. Mourning and bereavement are terms that are often used synonymously. Both are active and evolving processes of incorporating the loss into one's life. May include rituals and behaviours that assist in this process. Mourning and bereavement are highly influenced by culture and social norm. These norms indicate appropriate behaviours regarding the response to loss and the ways in which we cope with loss. © Durham College or its licensor FACTORS INFLUENCING GRIEF & LOSS Human Development – individuals of different ages and stages of development Psychosocial Perspectives – Personal Experiences shape coping Socioeconomic Status – feel more burden from a loss when financial, educational or occupational resources are lacking Personal relationships – when loss involves a loved one, the quality and meaning of the relationship are critical in understanding the survivor’s grief experience Nature of Loss – ability to manage grief depends on the meaning of the loss and the situation surrounding the loss Culture and ethnicity – Canada is multicultural, so the nurse needs © Durham College or its licensor to anticipate many cultural contexts and responses to loss, death and MODELS OF GRIEF THE GRIEVING PROCESS Many models of grieving have been developed since the 1970's. These models influence what health care providers and society have been taught about grief. The majority of models developed aim to describe the grieving process as it relates to death, however it is well accepted that these models can also be applied to any loss that is considered meaningful or significant. © Durham College or its licensor THE GRIEVING PROCESS Models of grief recognizes similar physical and psychological manifestations and share similar phases. Acute Grief (Beginning) is experienced when the loss first happens. Consider the emotions experienced during this time. Despair Grief (Middle) may present as despair or depression and can affect the person's day-to-day functioning and interactions. Adjustment Grief (End) occurs when the person learns to adjust to new life in a new way without the person or object of the loss The grieving process is not rigid and that a perfectly predictable process is not always the individual experience. © Durham College or its licensor KUBLER ROSS Denial - the individual acts as though nothing has happened, and may not believe that the loss has occurred Anger - occurs when the individual resists the loss and frequently will strike or act out at the people around them Bargaining - an individual postpones the awareness of their new reality by thinking they can make a deal so the loss can be prevented Depression - the individual is hit with the full impact of the loss and its significance. During this phase, they may withdraw from their community or support system Acceptance - the individual accepts the loss and begins to look forward towards a future It is important to remember that there is no time limit on these © Durham College or its licensor PATTISON’S LIVING-DYING INTERVAL Pattison's Living-Dying Interval refers to the time between the "crisis knowledge of death", where one learns they are going to die, and the point of death, when the person ceases living. The time in between these two points is referred to as the living-dying interval. © Durham College or its licensor PATTISON’S LIVING-DYING INTERVAL The point of crisis moment is followed by an acute crisis phase, which is a time of peak anxiety and stress. The next phase is the chronic living-dying phase, where the person is forced to resume normalacy of living, with the knowledge that they are dying. The terminal phase occurs when the person knows that death is imminent, and the speed of physical dying is accelerated. During this time the person is preparing to die by saying goodbye to loved ones, friends and making plans for the end of life. In the chronic living-dying phase, Pattison identified two key concepts: Integrated dying vs. disintegrated dying. Integrated dying is when each new crisis experienced in this phase is dealt with effectively and the quality of life of the person is preserved. Disintegrated dying is experienced when one crisis ebbs into the next without any effective resolution, thus compromising the persons quality of life. © Durham College or its licensor TYPES OF GRIEF  TYPES OF GRIEF ANTICIPATORY GRIEF A response to a loss before it occurs Behaviours may include preoccupation with the loss, unusually detailed planning, or a sudden change in attitude toward the thing, part or person Sociological Death – to be lost premature withdrawal of others from the dying person Psychological death – withdrawal of the dying person for others or environment © Durham College or its licensor  It is important to remember that grieving takes an enormous amount of physical and emotional energy and can be especially difficult for older adults. Intense emotions may appear as confusion, depression or preoccupation with thoughts of the deceased. Those anticipating the loss, many find themselves becoming irritable, hostile or impatient as a result of the unknown. As nurses, we can help those experiencing anticipatory grief by facilitating communication. This has been shown to improve bereavement outcomes. © Durham College or its licensor  TYPES OF GRIEF - ACUTE GRIEF Is a crisis with somatic and psychological symptoms of distress occurring in waves lasting various periods of time May include feelings of self-blame or guilt and manifest as hostility or anger towards friends or depression or withdrawal Difficult to accomplish ADL’s and daily living (meet responsibilities) Acute signs eventually diminish © Durham College or its licensor  PERSISTENT GRIEF Lingering Grief OR Shadow Grief – resurfaces from time to time but does not persist Pathological Grief Persists AKA: Impaired, dysfunctional or maladaptive grief Begins with normal grief responses but adjustment is blocked, memories resist being reframed. Recurrent acute grief over and over Signs may include irrational and excessive anger, insomnia, depression Loved ones dealing with suicide Often requires professional intervention © Durham College or its licensor PERSISTENT OR COMPLICATED GRIEF A person often experiences persistent grief on significant dates or events such as birthdays and anniversaries. This is anticipated and is quite normal, as long as it does not linger, and the person does not become overwhelmed by the loss. When this does happen, this is referred to as complicated grief. Complicated grief begins a normal grieving trajectory but then the process becomes blocked and the person is unable to adjust to the new reality without the person or object of loss. Often the person will experience the loss over and over again, lasting for months or years after the initial loss. Signs of complicated grief include: a preoccupation with the loss, avoiding reminders of the loss, feeling as though others are untrustworthy or do not understand, bitterness, anger, numbness, anhedonia, shock and depression. This type of grief requires psychological intervention by a professional who is experience in grief counselling. © Durham College or its licensor  DISENFRANCHISED GRIEF Is an experience of the person whose loss cannot be openly acknowledged or publically mourned e.g.: hidden or secret relationships , extramarital affairs, losses not deemed worthy like a loss of a pet © Durham College or its licensor DISENFRANCHISED GRIEF The grief is deemed socially unacceptable or the persons rights as a bereaved person is not recognized. Disenfranchised grief often results from a hidden or secret relationship, losses deemed less worthy (eg: loss of a pet), or stigmatized deaths such as suicide. The person does not have a socially recognized right to be perceived as a bereaved person. A common theme with disenfranchised grief is that persons close to the grieving person do not know about the loss or do not understand the full meaning of the loss to that person. Examples: Secret relationships Stigmatized deaths (HIV/AIDS, suicide) When death is considered a blessing (dementia) © Durham College or its licensor VIDEO © Durham College or its licensor WEEK 6.3 NEEDS OF THE DYING PATIENT AND FAMILY END OF LIFE End of life care includes“the services that may be needed by dying persons and their family or friends in the last year of life, as well as bereavement services following death.” © Durham College or its licensor A GOOD DEATH The responsibility of the nurse is to work with the interprofessional team to provide safe conduct as the dying and their families navigate through unknown waters to a good and appropriate death. A good death is: Free from avoidable distress and suffering for patient, family and caregivers; in general accord with patient’s and family’s wishes; and Reasonably consistent with clinical, cultural, and ethical standards (RNAO BPG) © Durham College or its licensor WEISMANS 6 C’S Care Control Individuals who are at the end of life require Composure specialized care to meet Communication their physical, emotional and spiritual needs. Continuity Weisman identified a 6 C Closure approach to caring for the needs of the dying. © Durham College or its licensor  CARE People who are dying deserve the best care and expert management of symptoms and support Treatment of physical symptoms Medical Needs are met Conservation of Energy Treatment of psychological pain When emotional needs are not met the total pain experience is intensified. Medication alone cannot relieve pain © Durham College or its licensor  CONTROL Proceeding along the living-dying interval clients can feel that control over one’s life has been lost. Loss of identity, independence, and control of bodily functions…. May lead to feelings of shame, humiliation and being a burden. Return control Provide the patient as much control as possible Provide effective nursing care for symptom control Provide continuity of care as the palliative care team directs total patient care. © Durham College or its licensor  COMPOSURE For many people dying is an emotional activity both for the dying and those around him or her… including modulating emotional extremes Can use countercoping techniques “Weisman” The client copes, the nurse countercopes Clarification and control - nurse can help client cope with loss by helping him confront the loss, by getting or receiving information, considering alternatives and finding a way to make grief manageable Collaboration - nurse can collaborate by encouraging the griever to share stories with others and repeat stories as often as is necessary as he talks it out. Directed relief - helpful during acute grief. Catharsis may be helpful. Nurse encourages griever to cry, act feelings out Cooling off - griever is encouraged to temporarily avoid active mourning through diversions. © Durham College or its licensor  COMMUNICATION Nurse has the responsibility to make sure that the dying person has an opportunity for the communication he or she desires Glaser and Strauss (1963) identified four types: 1. Closed awareness - is referred to as secret keeping. In this situation, everyone (health care providers, friends & family) are all aware that the patient is dying, but the patient either does not know or keeps it as secret as well. Although this was more common decades ago, current legislation related to patient's right means it occurs less often. Occasionally it still occurs frequently based on cultural values, where closed awareness is expected. 2. Suspected awareness - The person suspects that they are dying, but it is not discussed and is not confirmed. If the patient questions it, they often do in an indirect way, or the subject is avoided by others. © Durham College or its licensor  3. Mutual Pretense - This form of communication results in a situation where everyone is pretending the person is not dying. Despite everyone knowing the patient has a terminal illness, no one talks about it, and everyone hides their feelings. This does not allow for any expression of grief. 4. Open Awareness - This form of communication promotes openly acknowledging the eventual death. Open awareness encourages the patient, family and friends to discuss and ask questions, and allows all involved to become resigned to the fact that the person is dying. This form of communication allows for people to grieve with the person rather than for the person. This is the ideal form of communication and nurses should encourage it whenever possible. © Durham College or its licensor  CONTINUITY Equates to preserving as normal a life as possible while dying and transcending the present by leaving a legacy of the future Legacy Work: Establishing legacies contributes to the continuity of their life after death Memories and / or rituals that will live on in the minds of others Videos; Trusts; Assigning personal items; sharing or writing of stories, establishing an endowment or trust, passing down values, giving key possessions to loved ones etc... Establishing legacies contributes to the continuity of the person's life after their death © Durham College or its licensor  CLOSURE Need for closure corresponds to an opportunity for reconciliation and transcendence. Reminiscence is one way of putting one’s life in order. Closure may mean coming to terms with their spiritual selves (Diety) © Durham College or its licensor CLOSURE The need for closure allows for the opportunity to reconcile important relationships while the person is still alive. This may involve resolving conflicts, giving up possessions, making final arrangements and saying goodbye. If a person's physical symptoms and pain are not well managed, this can interfere with the person's desire to reconcile and find closure. Nurses need to provide the time and privacy for self-reflection as well as the opportunity for the dying patient to talk about the meaning of their lives and death. It means resolving conflicts, giving up possessions and making final goodbyes. If pain and other symptoms are not well controlled – it may interfere with this reminiscing and reconciliation – making these interventions and important priority for nursing. © Durham College or its licensor SUPPORTING FAMILIES Families and friends are often with the patient in their last days and moments. Nurses provide emotional support to the patients loved ones What do I say? How to help someone who is losing their loved? Presence is important © Durham College or its licensor SUPPORTING FAMILIES One study identified what families most appreciated in their nurse. The simplicity of what they appreciated may surprise you. Study showed what families want: Kept me informed Put an arm around me when I cried Brought me food Knew my name Cried with me Provided a bed so I could stay over Told me to hold my husbands hand Let me take care of my husband Got the chaplain for me © Durham College or its licensor WEEK 6.4 LEGAL CONCEPTS AT END OF LIFE ADVANCED CARE PLANNING Advanced care planning involves planning ahead for a time when a person is not capable of making their own decisions about their health and the care they want to receive. Advanced Care Planning involves: Choosing a Substitute Decision Maker (POA/SDM) Communicating your wishes to your POA/SDM The role of the POA/SDM is to make decisions for the incapable person based on their wishes or in the best interest of the incapable person, if their wishes were not made know to the SDM. © Durham College or its licensor ADVANCED DIRECTIVE Legal document containing written instructions regarding the type of medical interventions a person wants implemented in the event they are unable to express your wishes. Voluntary process Having written instructions for your loved ones to enact, can ease the pressure in an otherwise very difficult time Discuss wishes / plans with the physician © Durham College or its licensor SUBSTITUTE DECISION MAKER Substitute Decision Maker A person who can legally make health care decisions on your behalf if you are not able to Act on your wishes or in your best interest If unable to choose a SDM, the law lists in order the person who will be appointed your SDM If 2 SDMs are appointed and cannot agree, the Office of the Public Guardian & Trustee (OPGT) will make © Durham College or its licensors 2022 MAID MEDICAL ASSISTANCE IN DYING Medical Assistance in Dying (MAiD) became legal in Canada on June 17th 2016 and was revised on March 17, 2021. Under the Criminal Code, there are two ways in which MAiD can be performed in Canada. Practitioner-Assisted MAiD Defined as when "a Nurse Practitioner (NP) or Physician provides assistance by administering a medication to a patient, at their request, that causes their death" Patient Self-Administered An NP or Physician prescribes or provides a medication to a patient, at their request, so that they may self-administer the medication, and in doing so, cause their own death“ © Durham College or its licensor MEDICAL ASSISTANCE IN DYING Eligibility includes:: At least 18 years old Grievous and irremediable medical condition Capable of making their own health-related decisions Request assistance voluntarily Provide informed consent Be informed of other options Eligible to receive health services in Canada Currently MAiD excludes cases where the only underlying condition is a mental illness © Durham College or its licensor MEDICAL ASSISTANCE IN DYING Safeguards include: A written request (with limitations on who can witness the request) A second opinion A waiting period before the request is fulfilled Patient is allowed to withdraw request at any time The patient is informed of all other available means to relieve suffering Communication strategies are maximized to ensure understanding and to communicate decisions Expressed consent just prior to MAiD procedure Communication that prescribing physicians and nurse practitioners must have with pharmacists © Durham College or its licensor NURSES ROLE IN MAID An RN or RPN's role in MAiD is limited to: Support the patient and the interprofessional team May provide education and support to the patient & family May insert an IV they know will be used to administer the medicine that will cause death May act as an independent witness. © Durham College or its licensor IMPORTANT LEGAL NOTE According to the Criminal Code of Canada: An RN or RPN must NEVER administer a medication intended to cause the death of the patient. This is the sole responsibility of a Nurse Practitioner or Physician. In addition, nurses who are educating patients regarding MAiD must ensure they do not encourage or pressure a patient to choose MAiD. Violation of either of these acts is considered a criminal offence © Durham College or its licensor CONSCIENTIOUS OBJECTION The CNO and the law recognizes a nurses "freedom of conscience. It is allowable for a nurse to engage in conscientious objection. If a nurse conscientiously objects, then they must: Hand over care of the patient to another nurse who will meet the patient's health care needs. If there is a lag in time between the nurse identifying the need to conscientiously object, and the time another nurse can be identified to take over care, the first nurse needs to provide all care, with the exception of any care related to the MAiD procedure. © Durham College or its licensor WEEK 6.5 END OF LIFE CARE END OF LIFE CARE There are several settings where a patient can choose to die. Hospice Palliative Care Settings Hospital Home or Long Term Care Patients should receive high quality care with a focus on pain and symptom management © Durham College or its licensor END OF LIFE CARE When a patient is nearing their death, there are several settings where a patient can choose to die. Regardless of the setting, the care provided should be of the utmost quality of care, with a focus on pain and symptom management, as opposed to heroics and measures intended to extend life. This section will review the various palliative care and hospice options, and discuss the expert nursing care required to ensure a patient has as peaceful a death as possible. © Durham College or its licensor HOSPICE PALLIATIVE CARE Majority of Canadians would prefer to die at home, however this is not always possible Regardless of setting, there are 4 components of end of life care: 1.Universal access to psychosocial, spiritual and physical care for all dying persons 2.Care coordination by a care coordinator or case manager 3.Access to a broad range of basic and advanced care services such as palliative and hospice care 4.End of life care in all settings, wherever a dying person resides © Durham College or its licensor HOSPICE PALLIATIVE CARE Hospice palliative care is both an approach to care and a philosophy of care. The World Health Organization (2017) defines palliative care as "an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual" © Durham College or its licensor HOSPICE PALLIATIVE CARE Changes the focus of care from cure to comfort & quantity of life to quality of life. The nurses’ role is pain and symptom management and in supporting the patient and family A palliative care approach to care increases as the possibility of cure decreases, and then continues in the care of the family as they transition into bereavement. © Durham College or its licensor HOSPICE PALLIATIVE CAR The Canadian Hospice Palliative Care Association (CHPCA) goals for care: Aim to relieve suffering and improve the quality of living and dying. Strives to help patients and families: 1. Addressphysical, psychological, social, spiritual and practical issues, and their associated expectations, needs, hopes and fears; 2. Prepare for and manage self-determined life closure and the dying process; and 3. Cope with loss and grief during the illness and bereavement Aims to do the following: 1. Treat all active issues 2. Prevent new ones from occurring 3. Promote opportunities for meaningful and valuable experiences, personal and spiritual growth and self-actualization © Durham College or its licensor NURSING IMPLICATIONS Nursing care for patients who are dying may last days or months. Nurses need to be competent in the care of those who are dying and their families. Please review Table 25-4 in your Canadian Fundamentals of Nursing textbook (pg. 448). This chart reviews how nurses can provide comfort to terminally ill patients. It addresses many of the symptoms patients experience and how nurses can help. This is testable material © Durham College or its licensor ADVICE FOR FAMILIES & CAREGIVERS Signs and Symptoms Supporting Patients Sleeping May sleep for longer periods Keep conversations to periods of May tire easily alertness Avoid over stimulation Restlessness May grab & pull at bed linens or Hold the patients hand and speak in a clothes calm voice May refer to people who have died in If distressed may need meds the past Do not correct them if they are not distressed Confusion & Fatigue, pain and spread of disease Speak in a calm, reassuring voice Forgetfulness may cause symptoms Re-orient them (Delirium) These symptoms can be caused by Remember the client is not doing this side effects of medications and on purpose, avoid arguing with them changes in body chemistry Immobility & Occasional muscle twitches, Keep client clean and dry Involuntary involuntary movements, changes in Place pad under the patient Movements heart rate, loss of reflexes © Durham College or its licensor Loss of bladder and bowel control ADVICE FOR FAMILIES & CAREGIVERS Signs and Symptoms Supporting Patients Skin Blue or purple mottling on arms, legs No need for extra blankets. This can Changes and underneath is related to poor cause distress. Use a mohair or light circulation weight blanket Skin will feel cool to the touch, client Never use a heating pad or water does not feel cool bottle Changes in Shortness of breath Sometimes oxygen is used to provide Breathing Noisy breathing and gurgling due to symptom relief, not routinely required small amounts of saliva collecting at the There is strong evidence to support the back of the throat use of oral, parenteral or rectal opiods Irregular, shallow breathing, may have for the management of dyspnea. periods of apnea Noise is very distressing A combination of pharmacological and non-pharmacological interventions can be used for managing respiratory secretions Eye Care Vision is often reduced towards end of Turn the patients head towards a light life source © Durham College or its licensor Eyes may feel very dry Leave soft indirect lights on in the ADVICE FOR FAMILIES & CAREGIVERS Signs and Symptoms Supporting Patients Mouth Care & Muscle weakness may cause Do not force the client to eat or drink Difficulty swallowing problems as as it may cause aspiration pneumonia Swallowing illness progresses and infection May take small amounts if they show interest in eating Ice chips and good mouth care are important Pain Patients with malignancies Assess & treat pain frequently often experience severe pain Effective narcotic use (narcotics are effective in pain management strategy) Quality National & frequency of doses Initiative for theneeds Care ofto the be titrated to the intensity andElderly, n.d duration of pain © Durham College or its licensor REFLECTION Reflect on your own personal values and beliefs about death and dying. How would you want to be supported during the death of a loved one or even your own death. How would you want to be treated? How will you treat others? © Durham College or its licensor