Loss, Grief, and End-of-Life Care - PDF Notes

N230 Week Thirteen: Loss, Grief, & End-of-Life Care 1 Resources: ATI Engage Fundamentals: 1. Grief module (located in Psychosocial Concepts for Nursing Practice); complete all 4 tabs included in the lesson 2. End-of Life Care module (loca...

N230 Week Thirteen: Loss, Grief, & End-of-Life Care 1 Resources: ATI Engage Fundamentals: 1. Grief module (located in Psychosocial Concepts for Nursing Practice); complete all 4 tabs included in the lesson 2. End-of Life Care module (located in Physiological Concepts for Nursing Practice); complete all 4 tabs included in the lesson. Related chapters in ATI book: 1. Chapter 35 - Cultural & Spiritual Nursing Care (pp. 193-202) 2. Chapter 36 - Grief, Loss, & Palliative Care (pp. 203-208) Objectives: 1. Identify Kubler-Ross’ stages of grief. 2. Differentiate between palliative care and hospice care. 3. Explain nursing interventions relevant to patients and families experiencing loss, grief, and death. 4. Describe physical care of the deceased (post-mortem care). Loss: Something of value (people, places, objects, situations) is changed in a way that it is diminished or absent Subjective experience – meaning of loss can only be determined by the one affected by it Actual – tangible loss that can be easily recognized by others Perceived – Experienced by someone but intangible to others Reactions to loss: iii is o Physical: tightness in chest, fatigue, sleep disturbances, changes in appetite o Emotional: numbness, sadness, guilt, anxiety, depression, anger, less patient or tolerant o Cognitive: forgetfulness, preoccupation with the loss, inability to concentrate or retain information, disorganized o Behavioral: crying, insomnia, restlessness, withdrawal, irritability, apathy, impaired work performance Grief: Internal emotional response to loss Process varies for each person Physically and emotionally exhausting May last a lifetime Healthy response to loss: some acceptance within 6 months et cancer Anticipatory grieving: experiencing grief before the loss happens Mourning: outward actions and expressions of loss o Affected by cultural norms, traditions, religious beliefs, personality Complicated grief (AKA dysfunctional grief): o Unable to progress through stages of grief o Distressing symptoms at least 6 months after loss shoy set o Threatens physical and emotional health 9 o Includes: Chronic/unresolved: bereavement for extended period that does not diminish over time Inhibited: suppresses feelings of grief; may have somatic manifestations Exaggerated: overwhelmed by grief & unable to function in daily life Disenfranchised grief: loss that is not validated or recognized schoolsay ter o Loss happens but cannot be openly shared by grieving person o Society doesn’t know how to deal with the loss N230 Week Thirteen: Loss, Grief, & End-of-Life Care 2 Kübler-Ross Stages of Grief Length & sequence of stages vary for each person Help to understand feelings and emotions common at each stage  adapt interventions to that stage 1. Denial: Difficulty believing a terminal diagnosis or loss o Temporary defense to assist in coping process i o Encourage patient to share fears and concerns “Tell me how you are coping with this new information about your illness” 9 2. Anger: Feelings of anger, rage, or hostility directed at other people or things o Can be isolating o Treat patient with respect and allow the patient to express feelings of anger a 3. Bargaining: Tries to negotiate for more time or a cure is o “If I can just do this, then I will be ready” u o “I will get my life together if I can just live longer” o Be supportive of bargaining expressions → helps patients to process loss 4. Depression: Overwhelmingly sad about inability to change situation o Understanding of the certainty of loss o Encourage expressions of sadness 5. Acceptance: Acknowledges reality of what is happening and make plans for the future o Patient may withdraw from loved ones family may feel rejected o Encourage family and loved ones to continue to remain present Factors affecting grief Age littlekids Health status Cognitive status dementiapt Relationships Coping skills Concurrent stressors otherthings in life Supports religion Socioeconomics Type of loss naturalcauses ussuicide Religion & spirituality Culture Culture Culturally congruent care: use of “culturally based knowledge in sensitive, creative, safe, and meaningful ways to promote the health and well-being” (Yoost, p. 385) First step in cultural competence is self-assessment: need to know and understand personal beliefs, attitudes, values, biases & practices Cultural competence depends on understanding interaction of multiple cultures: o Nurse culture o Health care culture know99 o Patient culture N230 Week Thirteen: Loss, Grief, & End-of-Life Care 3 Spirituality & religion Spirituality – expression of meaning and purpose of life Religion – structure for understanding spirituality, involves rituals as part of a faith community Spiritual care – interaction between nurse and patient to promote patient’s spiritual health First requires compassionate & caring environment so patient feels comfortable expressing spiritual needs Spiritual care meat diet o Recognize patient cues o Be present: active listening o Initiate connections with others – family, clergy o Facilitate religious rituals o Avoid sharing personal beliefs that conflict with those of the patient Nursing diagnoses Grieving Complicated grieving Death anxiety Caregiver role strain Spiritual distress End of life nursing care Areas of knowledge & skill needed to provide high-quality end-of-life care: o Scientific/clinical knowwhy o Interpersonal talk tofam o Ethical/professional Advance directives: legal documents that allow people to communicate their wishes about medical care they want at the end of life o Health Care Power of Attorney: Appoints person who will make health care decisions if patient is unable to o Living will: Indicates treatment options that a person does/does not want if they are unable to make the decision POLST: Physician Orders (for) Life-Sustaining Treatment eroy o Physician order indicating patient’s wishes 5 o Standardized medical form per state law o Form valid in multiple settings and stays with patient o Can be revoked by patient at any time o PA POLST: CPR status, medical interventions, antibiotics, artificially administered nutrition Facility orders iii o Do Not Resuscitate (DNR) – “no code” o Do Not Intubate (DNI) o Type of DNR: Comfort measures only o If patient does not have DNR order, “full code”  staff obligated to attempt resuscitation N230 Week Thirteen: Loss, Grief, & End-of-Life Care 4 Palliative care: Holistic care for patients with Hospice care: Comfort and supportive care for incurable disease patients with life expectancy ≤ 6 months Goal: best quality of life Goal: symptom control and quality of life Focus: aggressive management of Focus: supporting peaceful and dignified distressing symptoms death May include curative treatments (efforts to Does not include curative treatment prolong life) Family centered: provides care for family Support system to help patients live as during illness and bereavement care after actively as possible death Interdisciplinary team all cancer chemo Provided in homes, long-term care, hospital, hospice facilities Ethical considerations Pncisicyqs.sitedeexAls o Medical Aid in Dying – ANA summarized position: “While nurses are still ethically prohibited from administering aid-in-dying medication, ANA now advises nurses to remain objective when patients are exploring this end-of-life option. Nurses have an ethical duty to be knowledgeable about this evolving issue and have the right to conscientiously object to being involved in the aid-in-dying process.” Full statement here. o Active euthanasia o Passive euthanasia msn.tumat.mn “Good death” Death that allows a person to die with dignity on their own terms, relatively free of pain and sufferingwhatis important to them Consistent with clinical, cultural, & ethical standards Includes symptom control, preparation for death, & good relationship with health care providers Recognizes evolving physical, emotional, spiritual, and social needs of patients and families Goal of nursing: o Promote peaceful death through compassionate care o Facilitate patient and family’s coping with disability and death Talking about dying Do not avoid the topic Listen: verbalization of loss important for grieving Ask questions to explore feelings Do not provide false reassurance youneverknow Tears are ok Nonverbal expressions Rubback Nursing assessments Family relationships - functional family is better prepared to deal with stressors that occur during time of loss Caregiver – often neglect their own needs aretheytaking careof themselves Physical assessment of dying patient N230 Week Thirteen: Loss, Grief, & End-of-Life Care 5 End-of-life symptoms: 11 a Itpicture Weakness, fatigue Drowsiness, sleeping more, less responsive Restlessness, agitation Decrease in oral intake noappetite Trouble swallowing Elimination changes: constipation, diarrhea, incontinence Signs of impending death 24arhus Decreased urine output Cold, mottled extremities Decreased BP misin HR – increased/decreased Breathing changes, periods of apneachanestokesBreathing Respiratory congestion: “death rattle” usursing 98 s Teaching: Progression of disease and dying process – simple answers Measures to control symptoms and maintain quality of life Right to consent and/or refuse any treatment Encourage family involvement to degree desired iii Help family to make time to eat, sleep, personal care ite Demonstrate talking and touching dying person until unresponsive End-of-life care: “comfort measures only” Basic nursing care provided with high level of compassion and caring o Hygiene o Oral care o Turning & repositioning until theend o Relaxing environment: decrease stimuli, play music Symptom control o Pain o Oxygen 2 3L o Nausea, vomiting o Respiratory secretions deathrattle o Agitationsheepcalm Use non-oral routes for med administration (SL, patches, IV, suppositories) Definition of death Uniform Definition of Death Act – death is either: o Irreversible cessation of all functions of circulatory and respiratory functions o Irreversible cessation of all functions of the entire brain, including brain stem State law & facility policies determine who pronounces death o Absence of pupil response o Absence of pulse2(palpation/auscultation) iii situation o Absence of respiration3(observation/auscultation) for 1 min N230 Week Thirteen: Loss, Grief, & End-of-Life Care 6 Postmortem care: Prepare room & body for family Allow family time to be with body Ask if any cultural or religious rituals Offer spiritual advisor Give personal belongings to familyweddingBand Notification (state law & facility policy): o Coroner o Organ/tissue donation o Funeral home Body should be treated with same respect and dignity given during life Clean body Remove tubes (unless autopsy indicated) Place body in normal anatomic position: supine, head on one pillow, arms at sides with palms down, close eyes, insert dentures Absorbent pad under buttocks & identification tags on body for transfer Support for family: Appropriate for nurse to attend funeral, follow-up visit, or call to family Let family know things patient shared with you that would bring comfort imreadytogo Grief in nursing: Grief after a patient death is normal Allow grief process to happen instead of pushing it away Discuss feelings with a co-worker, supervisor, friend Identify coping strategies and find help to replace maladaptive coping mechanisms Accept the mixed emotions Remember that each individual grieves differently Self-evaluation: Exploring and reflecting on beliefs concerning life & death  understanding and acceptance of death as part of life In order to communicate effectively and convey care, acceptance, and respect for patients and families who are experiencing death, loss, and grief, the nurse must be aware of one’s own fears, feelings, responses, and reactions to death and dying Verbalizing feelings to others helps to process own reactions to grieving process