End of Life Care & Grief PDF

1 End of Life Care & Greif Hospice Care Medical and psychosocial care services that focus on comfort and support at end-of-life Provided when treatment will no longer cure or control the illness Interprofessional team approach + voluntee...

1 End of Life Care & Greif Hospice Care Medical and psychosocial care services that focus on comfort and support at end-of-life Provided when treatment will no longer cure or control the illness Interprofessional team approach + volunteer services Multiple settings - client home, hospital, extended care facility, inpatient hospice center Focus on comfort, dignity, and personal growth as client faces death Client’s readiness to discontinue treatments should be discussed Eligibility criteria: ○ Official statement from the provider that client is terminally ill Life expectancy of less than 6 months ○ Client must agree with palliative(comfort) measures as opposed to curing illness ○ Client signs a statement that they are choosing hospice care in place of other benefits to treat their illness May stop services at any time Supported services are provided for up to 13 months following the death of client & have volunteers to help Care of the family Caregiver and family members play a vital role with the health care team Education and support necessary ○ Understanding what they can do, what to expect as conditions deteriorate ○ Emotional support of fears, anxiety, doubts Hospice nurses assist in meeting client’s daily care needs Provide supplies, equipment, medications needed Respite care ( Brief break for primary caregivers ) ○ Can last for hours, days, or weeks ○ May request client to be admitted to facility for up to 5 days Palliative care Holistic care approach that is focused on the management of symptoms for a chronic or severe medical illness for clients approaching end-of-life Concentrated on lessening the client’s distress Combination of curative treatments and comfort Ex disease: advanced stages of cancer, heart failure, renal failure, alzheimer’s/parkinson’s disease Goal: to improve quality of life, reduce time in hospital, improve satisfaction Any client is eligible with life-limiting disease, regardless of life expectancy or prognosis Services are unrestricted by time (no specific timeframe) Palliative care - can receive at any stage of disease - Occur at same time as curative treatment Optimize comfort - reduce stress - Provide emotional and spiritual support - Relieve symptoms Hospice care - prognosis of 6 months or less - Cannot be utilizing curative treatment  2 Physiological Changes and Interventions Breathing & Respirations ○ Shortness of breath (dyspnea) ○ Secretion build up (“death rattle”), Cheyne-Stokes respirations ○ Treatment: O2, opioids (morphine), benzodiazepines ○ Comfort measures: medications, positioning (turn to side), relaxation techniques, oral suctioning Pain ○ Source: nerve injury, organ stretched/compressed, bone pain ○ Nurses have ethical responsibility to alleviate pain and suffering ○ Combination approach is recommended: administration of scheduled and/or PRN medications, and nonpharmacologic interventions, interprofessional approaches ○ Three step: NSAIDs < codeine or tramadol < morphine Temperature ○ Regulation diminishes ○ Periods of increased and decreased temperature ○ Blankets, hot and cold compresses, warm sponge baths, environmental change (fan), antipyretic medications ○ Mottling: cool to touch, purple, gray, pale, or reddish marbling Indication of impending death, begins in the feet and moves up Due to decreased perfusion Provide warm blanket Vision & hearing ○ May experience hallucinations ○ Avoid denial of sensation, provide support and reassurance ○ Clients can hear in deep comatose state ○ Ensure client safety and prevent injury End of Life Goals Preventing Social Isolation ○ Causes loneliness ○ Increases suffering ○ Encourage face to face connections or other platforms ○ Have visitors come at time when pain is controlled so client is comfortable Maintain Dignity & Sense of Control ○ Manage client manifestations ○ Advocate independence, privacy, listen ○ Provide care with optimistic attitude ○ Address spiritual & everyday concerns ○ Ask for input about how they desire to be cared for Spirituality ○ Offers an approach to coping with impending death ○ Provides hope for life after death ○ Ask client of they desire spiritual care ○ Accommodate religious beliefs and rituals: contact religious leaders and followers Good Death; Definition of “dying well” is different for every client ○ Aspects are unique to each individual: pain management, planning for death, clear decision making ○ Avoid personal views of what constitutes a “good death”  3 Role Of the Nurse: Pastoral Care Referral Offers spiritual care to people of all religions and religious group Role: ○ Assess spiritual needs ○ Collaborate with members of hospice team to provide support to client & family ○ Ensure religious and spiritual needs are met Role of the Nurse: Diversity Considerations Acknowledges client’s perspectives, experience, and values Understand religious and cultural differences about impending death ○ Opioids seen as addictive and euthanasia (painless killing) Provide a certified interpreter Assess cultural needs Role Of the Nurse: Postmortem Care Physical care performed after the client has died to prepare for viewing, autopsy, or release to funeral home Document date & time of death, name of who was notified, location of belongings, where body was moved Follow institution’s policy: provide privacy, wash the body, removal of invasive devices, place client in clean gown, place absorbent pad under perineal area, apply clean cover sheet, place minimum of two identification tags (toe, outside of body bag), ensure belongings are accounted for Family care: be respectful, allow religious/cultural traditions Preparing the Body for Viewing Ask the family whether they want to be included in preparation of the body Maintain privacy Remove all tubes Remove all personal belongings to be given to family Cleanse and align body in supine position with pillow under head, arms with palms of hand down outside of the sheet, eyes closed Apply fresh linens with absorbent pads Brush or comb hair Remove excess supplies, soiled linens, and equipment from room Dim the lights and minimize noise Provide quiet/private/clean environment to be with body Role of the Nurse: Organ/ Tissue Donation Make referral to organ procurement organization (OPO) when client or surrogate requests to initiate organ/tissue donation & discuss options Surrogate can give permission when the client has not previously consented to organ or tissue donation Support client and family who are considering organ donation Refer to and facilitate meeting with organ procurement coordinator (OPC) to discuss options Assist family who are dealing with a challenging decision  4 Grief The suffer experienced after significant loss, usually the death of a beloved person” ○ Losses that trigger grief include divorce, loss of a job, loss of a friendship, loss of financial stability, miscarriage Normal process of loss Can include both emotional and physical manifestations Accompanied by physiological stress Normal Grief Uncomplicated grief Lasts several months to a year Caused by death of loved one or ending of a relationship or other experiences Sadness, guilt, anger, regret Grief typically lessens over time Anticipatory Grief Grief experienced before loss of someone or something Loss is expected Loved one is still living but death is imminent Suffering from a terminal illness or chronic disease May be experienced by the dying person themselves Sadness, anger, loneliness, guilt, anxiety, fear, fatigue, poor concentration Prolonged grief disorder Complicated grief Experience by those who are unable to accept the death of the loved one > 6 months in adolescents and children, > 1 year for adults Preoccupied with thoughts of loved one Guilt (self-blame), anger, difficulty participating in new and different activities Hard recovery with isolation Assess for potential for self-harm Disenfranchised Grief Related to a relationship that does not coincide with what is considered a socially justified loss Loss is not regarded as worthy of grief – social support is not provided to the grieving individual Loss of unrecognized as significant (pet or miscarriage), unrecognized relationship (extramarital affair), suicide Left to grieve alone, in silence Depression, unstable emotions, social isolation, insomnia, low self-esteem Kubler-Ross Five Stages Of Grieving The five stages are not sequential & can go back and forth between stages or don't go through all stages 5 Stages ○ Denial: refuses to believe reality, an attempt to lessen pain and shock, body’s way of giving time to adjust ○ Anger: tries to adjust to the loss and feels severe emotional distress ○ Bargaining: tries a different approach in attempt to relieve or minimize the pain, making promise to do something in exchange for a different and/or better outcome ○ Depression: reality sets in, loss is deeply felt, mourns the loss, may withdraw from others  5 ○ Acceptance: still feels pain but realizes all will eventually be well, acknowledges the new reality that life goes on Dual Process Model of Grief Suggest that grieving process shifts back and forth between two types of responses Concentrating on one process too much can be detrimental Loss-oriented - Grief is conveyed through intense thoughts and feelings (sad & unfair ) Restoration-oriented - Coping with loss and rebuilding one’s life without the loved one Client may feel tired of focusing on feeling sad, then will switch to focus on new roles and responsibilities Worden’s Four Tasks of Grieving Mourner completes these tasks to avoid the risk of developing complicated grief Accept The reality of the loss ○ Overcoming denial of loss ○ Accepting loss of move forward Experience the pain of grief ○ Be aware of emotions ○ Coping handled with resources and support ○ Feelings are dealt with and not suppressed Adjust to an environment without the deceased ○ Get used to living without loved one being around ○ Have to realize that moving on is not a betrayal ○ Have to reestablish themselves and rearrange life Find a connection while embarking on new life ○ Stay connected to loss of one (memories) while moving forward ○ Rather than focusing on what they have lost, focus on what they had Individual Experience of Loss and Death Bereavement: The period of time which a person experiences grief and mourning after a loss Mourning: Act of expressing grief in public; affected by religious beliefs, ethnic background, cultural customs Manifestations: Most clients have decline in manifestations after 6 months ○ Disbelief, anger, crying spells, difficulty sleeping, changes in food intake, decreased work productivity 6 causes of Bereavement and Mourning 1. Loss of child 2. Loss of parent 3. Loss of spouse or partner 4. Loss due to suicide 5. Loss of pet 6. Miscarriage 4 factors affecting grief Circumstance of death Deceased person’s age Customs, religious, spiritual beliefs Prior experiences with loss  6 Age Related Considerations Infants & Toddlers (~ 3 yo) ○ Do not understand the concept of death, unable to express what they are feeling ○ Can sense distress in adults and react to emotions and stress experience by the caregiver ○ Irritability, changes in eating or sleeping patterns, increased crying Preschoolers ○ Perceive death as temporary and reversible ○ May think they are to blame for a person’s death (magical thinking) ○ Some may appear unaffected due to a child’s inability to understand death ○ May look for a person who has died ○ Common reactions: trouble sleeping, anxiety, irritability, increased tantrums, toileting problems, changes in eating Middle School-Aged Childhood (8 to 12 yo) ○ Understand that death is everlasting/final ○ Has increased fears related to death (self and others) ○ May hold back their feelings ○ Reactions: anger, sadness, anxiety, aggressive behavior, appearing withdrawn, trouble in school Adolescence (12 to 20 yo) ○ Have a complete understanding of death ○ May have feelings of “no one understands me” ○ May have difficulty explaining feelings which leads to high-risk behavior ○ May either rely more on friends vs detach themselves from others (social withdrawal) Adulthood ○ Occurrence of death among loved ones increases ○ Manifestations: depression, anxiety, anger, shock, numbness, mood changes, tightness of chest, (similar to heart attack), upset stomach, lightheadedness, fatigue, dreams of the deceased person Managing Health Care Member Grief Bond will usually develop with client and intensifies the nurse’s feelings of loss Grieving nurses may display: Anger, irritation, unhappiness, sleeplessness, exhaustion, depression difficulty staying focused Avoid Compassion Fatigue ○ Cumulative stress that develops from the desire to help those who are suffering ○ May lead to self-blame or professional uselessness Strategies to cope (Self-care) ○ Exercising ○ Eating well balanced meals ○ Reflective journaling ○ Taking time for oneself ○ Practice meditation or yoga ○ Join religious group ○ Be present with family, friends ○ Adequate rest  7 Cultural/Spiritual Influences on Grief How people and communities demonstrate grief differs among cultures One’s culture serves as the foundation for the grieving person’s action Rituals help communicate grief and prepare for the loss of a loved one ○ Expression of grief (silently or loudly), expected length of the grieving process, how family members act during the mourning phase, how to clean or dress body, who handles body, whether the body is cremated or buried Religious traditions can provide comfort during the grieving process and produce better outcomes post bereavement Culture may define expected family roles ○ When to remarry, oldest son becomes head of household Asking appropriate questions and being non judgemental is best practice toward cultural competence Assisting In Experiencing Grief and Loss First task is to develop a relationship with clients and families as they cope Assess for indications/manifestations of grief and loss Encourage to share their psychological and physical feelings Actively listen, do not criticize, be truthful/open/honest, empathic NURSE: techniques is a therapeutic communication skill used when discussing emotional subjects Name: identify what they person stated, identity the emotion expressed Understand: Demonstrated understanding by recognizing the clients feelings and providing opportunities to elaborate on those feelings Respect: voice your respect for the client under these circumstance Support: inform the client that you are available to them Explore: ask an opened Ed question to extend the conversation and provide more detailed expression for clients feeling Nursing Process Assess whether the client or family is experiencing grief ○ Manifestations of grief, ask about support system Use clinical judgment to make decision about actual or potential health problem related to the grieving process Develop a plan of care with client specific goals and outcome Carry out the treatment plan ○ Therapeutic communication skills to facilitate the verbalization of feelings ○ Provide non judgemental and trusting environment ○ Educate effective coping strategies ○ Provide guidance and available resources ○ Highlight strengths and progress to client and family Evaluate the expected outcomes: Ability to express feelings, successful use of coping strategies