Grief, Loss and End of Life Care - Week 6 - Durham College

GR I E F, L OSS and E N D of L IF E WEEK 6 COPYR I GH T This and all its content is copyright and is owned by Durham College or its Licensors (2022). © D urham C ollege or its licensors 20 22 L E AR N I N G OJ BE CT IV E S Define the...

GR I E F, L OSS and E N D of L IF E WEEK 6 COPYR I GH T This and all its content is copyright and is owned by Durham College or its Licensors (2022). © D urham C ollege or its licensors 20 22 L E AR N I N G OJ BE CT IV E S 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. © D urham C ollege or its licensors 20 22 ACT IV IT Y I worryabout how to support a Write down one question / patient and their family if I concern you have about caring am sad and upset as well. for someone who is dying… © D urham C ollege or its licensors 20 22 GR I E F & L OSS W EEK 6. 2 L OSS, GR I E F & DE AT H Loss, death, dying and grief are inevitable and universal aspects of human life. 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. © D urham C ollege or its licensors 20 22 L OSS 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? © D urham C ollege or its licensors 20 22 GR I E F 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. © D urham C ollege or its licensors 20 22 FACT OR S I N F L U E N CI N G GR I E F & L OSS 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 to anticipate many cultural contexts and responses to loss, death and bereavement. © D urham C ollege or its licensors 20 22 M ODE L S OF GR I E F W EEK 6. 2 T H E GR I E V I N G PR OCE SS 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. © D urham C ollege or its licensors 20 22 KU BL E R R OSS 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 phases and many people do not experience them sequentially. © D urham C ollege or its licensors 20 22  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. © D urham C ollege or its licensors 20 22 T YPE S OF GR I E F W EEK 6. 2  T YPE S OF GR I E F AN T I CI PAT ORY GR I E F 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 to be lost Sociological Death – premature withdrawal of others from the dying person Psychological death – withdrawal of the dying person for others or environment © D urham C ollege or its licensors 20 22  T YPE S OF GR I E F - ACUT E GR I E F 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 © D urham C ollege or its licensors 20 22  PE R SI ST E N T GR I E F 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 © D urham C ollege or its licensors 20 22  DI SE N F R AN CH I SE D GR I E F 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 © D urham C ollege or its licensors 20 22 V I DE O © D urham C ollege or its licensors 20 22 W EEK 6. 3 N E E DS OF T H E DYI N G PAT I E N T AN D FAM I LY E N D OF L I F E 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.” © D urham C ollege or its licensors 20 22 A GOOD DE AT H 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) © D urham C ollege or its licensors 20 22 W E I SM AN S 6 C’S Care Control Individuals who are at the end of life require specialized care to meet their Composure physical, emotional and spiritual needs. Communication Weisman identified a 6 C approach to Continuity caring for the needs of the dying. Closure © D urham C ollege or its licensors 20 22 CAR E 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 © D urham C ollege or its licensors 20 22 CON T R OL 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. © D urham C ollege or its licensors 20 22 COM POSU R E Many Cultures 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 1. Clarification and control 2. Collaboration 3. Directed relief 4. Cooling off © D urham C ollege or its licensors 20 22  COM M U N I CAT I ON 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 2. Suspected awareness 3. Mutual pretense 4. Open awareness © D urham C ollege or its licensors 20 22 CON T I N U IT Y 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; © D urham C ollege or its licensors 20 22  CL OSU R E 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 with Jesus, God, Allah or Buddha © D urham C ollege or its licensors 20 22 SU PPORT I N G FAM I L I E S 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 © D urham C ollege or its licensors 20 22 W EEK 6. 4 L E GAL CON CE PT AT E N D OF L I F E ADVAN CE D CAR E PL AN N I N G Advanced care planning involves planning ahead for a time when a person is not capable of making your own decisions about your health and the care you 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 there wishes were not made know to the SDM. © D urham C ollege or its licensors 20 22 ADVAN CE D DI R E CT IV E 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 © D urham C ollege or its licensors 20 22 POA / SDM Power of Attorney An assigned person who is legally allowed to make decisions on the incapable persons behalf regarding their personal care POA becomes very important if there are multiple people assigned as the Substitute decision maker POA is the ultimate decision maker when conflict exists Substitute Decision Maker Assigned when the patient has not legally decided on a POA Law provides a hierarchy of individuals who can be assigned a SDM © ©DD urham urham C C ollege ollege or or its its licensors licensors 20 20 22 22 M AI D M E DI CAL ASSI STAN CE I N DYI N G 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“ The law has identified eligibility criteria and safeguards that must be adhered to. © D urham C ollege or its licensors 20 22 M E DI CAL ASSI STAN CE I N DYI N G 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 © D urham C ollege or its licensors 20 22 M E DI CAL ASSI STAN CE I N DYI N G 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 Format for the completion of a death certificate © D urham C ollege or its licensors 20 22 N U R SE S R OL E I N M AI D 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. © D urham C ollege or its licensors 20 22 I M PORTAN T L E GAL N OT E 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 © D urham C ollege or its licensors 20 22 CON SCI E N T I OU S OBJ E CT I ON 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. The nurse must not disclose their objection to the patient © D urham C ollege or its licensors 20 22 W EEK 6. 5 E N D OF L I F E CAR E E N D OF L I F E CAR E 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 © D urham C ollege or its licensors 20 22 H OSPI CE PAL L IAT IV E CAR E 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 © D urham C ollege or its licensors 20 22 H OSPI CE PAL L IAT IV E CAR E 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 patient 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" © D urham C ollege or its licensors 20 22 H OSPI CE PAL L IAT IV E CAR E 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. © D urham C ollege or its licensors 20 22 H OSPI CE PAL L IAT IV E 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. Address physical, 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 © D urham C ollege or its licensors 20 22 N U R SI N G I M PL I CAT I ON S 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 Nursingtextbook (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 © D urham C ollege or its licensors 20 22 ADV I CE F OR FAM I L I E S & CAR E GIV E R S Signs and Symptoms Supporting Patients Sleeping May sleep for longer periods Keep conversations to periods of alertness May tire easily Avoid over stimulation Restlessness May grab & pull at bed linens or clothes Hold the patients hand and speak in a calm voice May refer to people who have died in the past If distressed may need meds Do not correct them if they are not distressed Confusion & Fatigue, pain and spread of disease may cause Speak in a calm, reassuring voice Forgetfulness (Delirium) symptoms Re-orient them These symptoms can be caused by side effects of Remember the client is not doing this on purpose, medications and changes in body chemistry avoid arguing with them Immobility & Involuntary Occasional muscle twitches, involuntary Keep client clean and dry Movements movements, changes in heart rate, loss of reflexes Place pad under the patient Loss of bladder and bowel control © D urham C ollege or its licensors 20 22 ADV I CE F OR FAM I L I E S & CAR E GIV E R S Signs and Symptoms Supporting Patients Skin Changes Blue or purple mottling on arms, legs and underneath is No need for extra blankets. This can cause related to poor circulation distress. Use a mohair or light weight blanket Skin will feel cool to the touch, client does not feel cool Never use a heating pad or water bottle Changes in Shortness of breath Sometimes oxygen is used to provide symptom relief, Breathing Noisy breathing and gurgling due to small amounts of not routinely required saliva collecting at the back of the throat There is strong evidence to support the use of oral, Irregular, shallow breathing, may have periods of apnea parenteral or rectal opiods for the management of dyspnea. 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 life Turn the patients head towards a light source Eyes may feel very dry Leave soft indirect lights on in the room Use artificial tears © D urham C ollege or its licensors 20 22 ADV I CE F OR FAM I L I E S & CAR E GIV E R S Signs and Symptoms Supporting Patients Mouth Care & Difficulty Muscle weakness may cause swallowing Do not force the client to eat or drink as it may cause Swallowing problems as illness progresses aspiration pneumonia and infection May take small amounts if they show interest in eating Ice chips and good mouth care are important Pain Patients with malignancies often Assess & treat pain frequently experience severe pain Effective narcotic use (narcotics are effective in pain management strategy) Quality & frequency of doses needs to be titrated to the intensity and duration of pain National Initiative for the Care of the Elderly, n.d © D urham C ollege or its licensors 20 22 R E F L E CT I ON 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? © D urham C ollege or its licensors 20 22