Death & Dying, Grief & Loss

1. Death & Dying, Grief & Loss Chapter 30 NRS_105/320_Collings

2. Loss & Grief • Experienced throughout the lifespan • Grief behavior is shaped by values, culture but grief itself is universal • All Change involves some loss • Nurses deal with patients’ and their own grief and loss • Grief is a normal response to loss • Grief behaviors vary over time and among individuals, families, and cultures NRS_105/320_Collings

3. Terms • Situational loss • Sudden, unexpected, external • Loss of person, object, limb, function, role… • Maturational loss • Part of life transition • Help develop coping skills • Anticipatory Grieving • Before an expected event [e.g. terminal pt] NRS_105/320_Collings

4. Terms • Palliative Care • Control of symptoms throughout an illness including bereavement care for family • Hospice Care • Final stage of Palliative Care • Patient & family with terminal diagnosis • Client- and family- centered NRS_105/320_Collings

5. More Terms • Normal [uncomplicated] grief • Anger, disbelief, yearning, depression, acceptance • Time to ‘recovery’ varies – 6 months • Complicated [dysfunctional] grief • Persists >6months AND interrupts life • May follow sudden death, death of child • Disenfranchised [unsupported] Grief • relationship not socially accepted • Same as any other grief + less support NRS_105/320_Collings

6. Factors Influencing Grief & Loss • Age/ Development • Children – understanding and behaviors depends on developmental stage • Young Adults – experience maturational loss • Midlife – more maturational losses • Older – prior experiences may help coping • Meaning of loss or person • Affects the grief response & support NRS_105/320_Collings

7. Factors Influencing Grief & Loss • Coping Mechanisms/ Strategies • People use what has worked before • May need new strategies • Suggest expressing positive feelings • Culture • Influences acceptable expression of grief • Rituals around death • Who is included as ‘family’ NRS_105/320_Collings

8. Factors Influencing Grief & Loss • Spiritual Belief • Influences end-of-life care • Rituals around death • Belief about afterlife • Hope • Ability to see life as having meaning • Important for nurses NRS_105/320_Collings

9. Nursing Process • Know yourself • Own your own beliefs, do not push them • Take care of your self • Respect others’ beliefs • Listen • Don’t take negative behaviors personally • Involve pt. and family in planning NRS_105/320_Collings

10. Assessment • Establish relationship first • Assess factors like coping style, meaning of loss, beliefs about death, support • Use open-ended questions • Observe verbal & nonverbal responses • Summarize and validate • May need to talk to pt, family separately NRS_105/320_Collings

11. Assessment • Assess understanding of treatment options • End-of life & after death • Encourage family involvement • Assess need for education • Assess other possible causes of symptoms/ behaviors • Loss of appetite R/T grief or disease? NRS_105/320_Collings

12. Nursing Diagnosis • May address the loss directly OR effects • Hopelessness R/T loss of child AEB social isolation and inability to maintain employment • Nutrition: less than body requirements R/T decreased appetite and motivation 2* to grief over loss of child NRS_105/320_Collings

13. Implementation Focus: • Facilitate healthy coping, growth • For families • For patient • Enhance quality of life • Alleviate symptoms • Promote dignity • Prevent complications NRS_105/320_Collings

14. Interventions • Therapeutic communication • Active listening • Silence • Acceptance • Attitude: you can not fix emotions! • Provide information, referrals NRS_105/320_Collings

15. Interventions • Symptom Management • Ongoing assessments • Pain management, effects of medications • Effects of immobility • Hydration and comfort • Skin & hygiene • Elimination • Oxygenation • Level of consciousness NRS_105/320_Collings

16. Comfort Care • Comfort • Pain relief, N/V, Constipation, fatigue, anxiety • Skincare • May include linens, Foley, lotion, mouth care • Nutrition • Small, preferred foods • Respiratory • O2, position, meds • Stay available/ with patient NRS_105/320_Collings

17. Bereavement Support • Involve pt/family in decisions • Provide space & time for grief & mourning • Educate about choices • end-of-life care • Postmortem options & requirements • Encourage clear communication • Answer questions, reinforce info NRS_105/320_Collings

18. Physical aspects of dying • Symptoms may confuse family • E.g. loss of appetite, SOB, withdrawal • May also provide help anticipating time of death/ imminence BUT may varies – no guaranteed timetable • Focus is on relief of symptoms, education of family, maintaining dignity, following wishes and cultural rituals NRS_105/320_Collings

19. Loss of Energy • Physical Weakness / Lack of Energy / Loss of Interest in Everyday Things • Search for meaning; self-examination • Caregivers can help by: • assisting with ADL’s • Listening, promoting dignity • Providing comfort, symptom control • Preventing injury NRS_105/320_Collings

20. Withdrawal • Withdrawal from Family and Friends / Increased Sleepiness / Coma • ‘entertaining’ visitors may exhaust dying Caregivers can: • be there without making demands • Be aware that the person can likely still hear even if in a coma-like state • Advocate for the patient’s stated wishes NRS_105/320_Collings

21. Loss of Appetite • As the body begins to shut down, need for food decreases • Caregivers can: • Offer small favorite foods • Respect the person’s wishes if food is refused • Educate others about the process • Providing food often makes the caregiver/family feel better; it is OK to offer NRS_105/320_Collings

22. Difficulty Swallowing • As body , muscles weaken, swallowing may become more difficult – may cause choking • Reverse diet [Regular – soft – liquid] • Small amounts [2-5 ml] to test swallowing • Caregivers can: • Provide mouth care frequently • Adapt foods, positioning for safety and palatability • Crush meds in jam or yoghurt NRS_105/320_Collings

23. Confusion • May come and go • May be caused by O2 changes [perfusion] • Caregivers can: • Use familiar sounds [music], sights, tactile sensations to comfort, reorient • Recognize that this may be a pleasant or frightening time • Refrain from arguing, denying the person’s ‘reality’ NRS_105/320_Collings

24. Restlessness • May be intermittent, can be R/T pain, nausea, full bladder etc. OR confusion May also signal nearness of death • Caregivers can: • Assess for physical symptoms, safety risks • May be a spiritual crisis – unresolved [access spiritual counselor, pray] • Use music, touch, aromatherapy NRS_105/320_Collings

25. Elimination • As weakness increases, person may become incontinent, diaphoretic • Caregivers can: • Maintain dignity • Place a Foley for comfort • Keep skin clean and dry • Administer pain meds before bathing as needed NRS_105/320_Collings

26. Circulation • Temperature control mechanisms start to fail, circulation withdraws to center • May cause cool skin or sweating • Extremities become bluish, mottled, cool • Caregivers can: • Follow person’s wishes R/T blankets • Prevent shivering to conserve energy • Turn less frequently – for comfort, SOB NRS_105/320_Collings

27. Breathing • SOB not uncommon; • O2 for comfort, fan; position semi-fowlers • Change in breathing signals active dying • Exhalation longer than inhalation • Irregular breathing [Cheyne-Stokes] • Shallow, rapid respiration followed by apnea • RR 30-50 not uncommon • Often Indicates days to hours until death • ‘Death Rattle’ [secretions in throat R/T lack of swallow] may be disconcerting NRS_105/320_Collings

28. Spurt of Energy • Some dying people ‘rally’ and become more alert, energetic, shortly before death • Caregivers can: • Use this time to attend to unfinished business, say goodbye, give person ‘permission to go’ • Involve spiritual guides, chaplain, family members • Often followed by unconsousness and then death NRS_105/320_Collings

29. Signs of Imminent Death • Eyes have glassy fixed stare with large pupils • Pasty grey, or blue grayish color present especially on lips, hands and feet • Hands and feet can be cold • Pooled blood in dependent areas causes bruised appearance • Jaw open, breathing through mouth very rapid or very slow (often with rattle) with pauses of 20-50 seconds between breaths [Cheyne-Stokes] • Unresponsive to voice or pain • Caregivers can: maintain calm, quiet atmosphere, perform pre-death rituals NRS_105/320_Collings

30. After Death Care • Specifics depend on facility, legal needs • If autopsy case, leave all tubes • Document everything • Donation – required to discuss • May offend some • Autopsy • Cases of sudden death, unattended, < 24 hrs • Maintain dignity, respect culture NRS_105/320_Collings

31. After Death Care • Documentation • Autopsy? Donation? • Family to be included? Special ritual? • Bathe body, clean up room • Allow family, others to say goodbye • Personal belongings to family • ID and transport per policy • Self-care NRS_105/320_Collings

32. Evaluation • Were client goals met at time of death? • Family goals? • Goal not met: pt expired with infection… - OK • Look for expressions of hope, + coping NRS_105/320_Collings

33. Caring for yourself • All nurses experience grief & loss • Need balance, rituals, people for support • Change of scenery • Assess yourself • Ask for help – and accept help • Find meaning in Nursing • Practice self-care NRS_105/320_Collings

34. Final thought "Be wise. Treat yourself, your mind, sympathetically, with loving kindness. If you are gentle with yourself, you will become gentle with others." - Lama Thubten Yeshe NRS_105/320_Collings

35. A Good Death • http://www.learner.org/vod/vod_window.html?pid=1279 • Type / copy http://www.learner.org/resources/series108.html into browser if blocked, then click on ‘A Good Death’ • Other good videos [streaming] on site NRS_105/320_Collings