Grief and Loss (Class 24)

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Spirituality

Spirituality

An awareness of one’s inner self and a sense of connection to a higher being, nature, or some purpose greater than oneself.

Religion

Organized, institution-related practice that is commonly associated with particular beliefs. Has a specific system of practice associated with a particular deomination, sect, or form of worship.

Self Transcendence

A sense of authentically connecting to one’s inner self. Positive force. Allows people to have new experiences and develop new perspectives that are beyond ordinary physical boundaries. Ex. Holding a newborn with awe.

Connectedness

Being interpersonally connected with oneself, interpersonally connected with others and the environment, and transpersonally connected with God or an unseen higher power. Through this, patients move beyond the stressors of everyday life and find comfort, faith, hope, and empowerment.

Faith

Allows people to have firm beliefs despite lack of physical evidence and enables people to believe in and establish transpersonal connections. Exists without religious beliefs.

Hope

Has several meanings, which vary on the basis of how it’s being experiences; it usually refers to an energizing source that has an orientation to future goals and outcomes.

Spiritual Wellbeing

Feelings of contentment coming from the inner self and has been shown to be related to quality of life. Four Dimensions:

• Interpersonal relationships

• Connectedness with God

• Meaning and purpose of one’s own life

• Sense of unity with the environment

Spiritual Distress

A disruption in the life principle that pervades a person’s entire being and transcends the person’s biologic and psychosocial nature. Causes people to question their identities and to feel doubt, lose faith, feel alone, or abandoned.

Prescence

“Being with” a patient, rather than just “doing for” a patient. Ex. Supporting their emotional needs and listening to them.

Spiritual Health

Involves finding a balance between one’s values, goals, and beliefs and one’s relationships within the self and with others.

FICA Spiritual Assessment Tool

F= Faith or Belief

I= Importance and Influence

C= Community

A= Address (interventions to address)

Faith (Assessment Questions)

• Do you consider yourself spiritual or religious?

• Do you have spiritual beliefs that help you cope with stress?

• What gives your life meaning?

Importance and Influence (Assessment Questions)

• What importance does your faith or belief have in your life?

• On a scale of 0 (not important) to 5 (very important), how would you rate the importance of faith/belief in your life?

• Have your beliefs influenced you in how you handle stress?

• What role do your beliefs play in your healthcare decision making?

Community (Assessment Questions)

• Are you a part of a spiritual of religious community?

• Is this of support to you and how?

• Is there a group of people you really love or who are important to you?

Address in Care (Assessment Questions)

• Ho would you like your healthcare provider to use this information about your spirituality as they care for you?

Actual Loss

Occurs when a person can no longer feel, see, or know a person or object. Ex. Loss of a job or death of a family member. (Tangible Loss)

Perceived Loss

The person experiencing the loss and is less obvious to other people. Ex. Rejection from a friend.

Necessary Loss

Losses that are normal and expected. Every person experiences them. Ex. a child having separation anxiety from a parent on their first day of school.

Maturational Loss

A form of necessary loss; includes all normally expected life changes across the lifespan.

Situational Loss

A type of unnecessary loss. Sudden, unpredictable external events. Ex. An automobile accident leaving a patient as a paraplegic.

Ambiguous Loss

A type of disenfranchised grief, can occur when the person who is lost is physically present but not psychologically available (Ex. Dementia) or the person is gone (Ex. kidnapping) but the grieving person maintains an ongoing attachment. Particularly difficult because of the lack of finality.

Grief

A person’s response to the loss. Not a state but a process.

Bereavement

Refers to the time of sadness after a person experiences a significant loss through death. (Occurs during grief and mourning)

Mourning

All the ways in which an individual outwardly expresses grief and the behaviors taken to manage grief. (External Response)

Normal Grief

A common and universal reaction characterized and by complex emotional, cognitive, social, physical, behavioral, and spiritual responses to loss and death, Normal feelings include disbelief, yearning, anger, and depression.

Anticipatory Grief

Occurs before the actual loss or death occurs, especially in situation of prolonged/predicted loss. Ex. Dementia

True

True or False: A family member dealing with anticipatory grief may feel a sense of relief when their family members passes.

Disenfranchised Grief

When their relationship with the deceases person is not socially sanctioned, cannot be shared opening, or seems of lesser significance. Ex. The death of an Ex-Spouse.

Complicated Grief

Prolonged or significantly difficult time moving forward after a loss.

Chronic Grief

Normal grief response but extended time frame. Can include years to decades of intense grieving.

Exaggerated Grief

Exhibit self-destructive or maladaptive behavior, obsessions, or psychiatric disorders. Suicide is a high risk for these patients.

Delayed Grief

Usually delayed or postponed because the loss is so overwhelming that the person must avoid the full realization. Triggered by a second loss.

Masked Grief

Survivor is not aware hat their behaviors that interfere with normal functioning are as a result of a loss. Ex. Insomnia, rashes, heartburn.

Kubler Ross Stages of Grieving

• Denial

• Anger

• Bargaining

• Depression

• Acceptance

False

True or False: Once a patient passes a stage of grief they will not revisit that stage again.

Denial

The person cannot accept the fact of the loss. It is a form of psychological protection from a loss that the person cannot yet bear.

Anger

The person expresses resistance or intense anger at God, other people, or the situation

Bargaining

The person cushions and postpones awareness of the loss by truing to prevent it from happening.

Depression

The person realizes the full impact of the loss.

Acceptance

The person incorporates the loss into life.

Factors Influencing Grief

• Age and stage of development

• Significance of loss

• Culture

• Spiritual and religious beliefs

• Socioeconomic status

• Gender

Age and Stage of Development (Factor)

• Toddlers cannot understand loss or death but often feel anxiety over loss or separation

• Young adults experience many developmental losses related to their evolving future

• In older adults, the aging process leads to expected developmental losses

Significance of Loss (Factor)

• Quality and meaning of the lost relationship influence the grief response.

Culture (Factor)

• Patients and families draw on the social and spiritual practices of their cultures to find comfort, expression, and meaning in the experience.

Spiritual and Religious Beliefs (Factor)

• A person’s faith often influences the response to an illness, treatment, advanced life support options, autopsy, organ donation, and what happens to the body and spiritual beliefs to obtain comfort and seek understanding at times of loss.

Socioeconomic Status (Factor)

• An individual with limited finances may be unable to take time off work to attend a funeral or may be unable to travel to visit a dying family member.

• Changing roles, needs to work several jobs to make ends meet, and dose not find time to initiate self-care or grieve the loss.

Gender (Factor)

• Men are socially expected to “act strong” and women can “be more emotional”

Heart/Lung Death

Cessation of the apical pulse, heart rate, and BP.

Cerebral/Higher Brain Death

Permanent loss of cerebral/brainstem function: no responsiveness, no cephalic reflexes, apnea.

Advanced Directives

Written documents that provide info about the patient’s wishes and designated spokesperson (MPOA)

Living Wills

Details a person’s wishes to avoid, limit, or withhold medical intervention.

Medical Power of Attorney (MPOA)

If the patient is unable to communicate or is incapacitated, this allows the agent to make all healthcare decisions.

Do Not Resuscitate (DNR)

A written medical order that documents a patient’s wishes about resuscitation and the patient’s desire to avoid CPR.

Allow Natural Death (AND)

Preferred term over DNR

Euthanasia

The deliberate act of hastening death. Not legal federally and deemed inconsistent with the values of nursing by the ANA.

Hospice Care

• Individuals that have 6 months or less to live

• Care focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life.

• No curative treatment is offered (Ex. Chemotherapy will end)

• Life-sustaining medication is granted (Ex. BP meds)

• Strives to meet a patient and family’s physical, psychological, social, and spiritual needs.

Palliative Care

• Starts as soon as possible when a chronic or terminal disease starts creating difficult-to-manage symptoms.

• Focuses on the prevention, relief, reduction, or soothing of symptoms of disease or disorders through the entire course of an illness.

• Appropriate for patients of any age, with any diagnosis, at any time, and in any setting.

• Can still receive curative treatment.

Terminal/Palliative Sedation

Giving medications to intentionally produce sedation to relieve distressing symptoms in a patient who is imminently dying.

True

True or False: All hospice is palliative care, but not all palliative care is hospice.

Physical Changes Preceding Death

• Increased periods of sleeping/unresponsiveness

• Circulatory changes with coolness and color changes in extremities, nose, fingers (cyanosis, pallor, mottling)

• Bowel or bladder incontinence

• Decreased urine output, dark-colored urine.

• Restlessness, confusion, disorientation

• Decreased intake of food or fluids; inability to swallow

• Congestion/increased pulmonary secretions; noisy respirations (death rattle)

• Altered breathing (Apnea, labored or irregular breathing, Cheyne-Stokes pattern)

• Decreased muscle tone, relaxed jaw muscles, sagging mouth

• Weakness and fatigue

Cheyne-Stokes Respiration

A pattern of breathing characterized by alternative periods of apnea and deep, rapid breathing.

True

True or False: When respirations cease, the heart stops beating within a few minutes.

Death

• Occurs when all vital organs and body systems cease to function.

• Irreversible cessation of cardiovascular, respiratory, and brain function.

Reflex Assessments for Brain Death

• Pupillary reflex

• Corneal reflex

• Gag reflex

• Cough reflex

• Oculocephalic reflex (doll’s eye reflex)

Postmortem Care Examples

• Follow all religious care and customs

• Put head of the bed all the way down

• Turn temperature down in room

• Place body in a normal, comfortable position

• Remove medical equipment (Ex. IVs) from the patient unless the patient is scheduled for autopsy

• Call organ donation hotline within one hour of death whether the patient is or is not a donor.

• Have doctor call time of death and document

• Identify the patient using two identifiers