Foundations Exam 3 (Grief and End of Life)

Grief

The feelings or reactions than an individual has to a loss in their life

Uncomplicated grief

Healthy grieving

-Loss of a loved one, relationship, identity, security, autonomy, health, career, dreams / expectations, etc.

-Unique and individualized experiences

-Sadness, guilt, yearning, anger, and regret

-Lessens as intensity of feelings decrease -> accepts loss -> peace and closure

Anticipatory grief

-Experienced before the loss of someone or something

-Terminal illness, worsening state of health, imminent death

-Sadness, grief, worry, fear, anxiety, anger, and helplessness

Prolonged grief

-Intense and function impairing grief that persists beyond expected cultural and developmental norms

-More than 6 months for children and adolescents

-More than 12 months for adults

-Unable to accept the death of a loved one and are preoccupied with thoughts of the deceased person

-Guilt, anger, difficulty participating in ADLs and recreation events and social isolation

Disenfranchised grief

-Mourning a loss that is not socially recognized or supported

-Individuals are left to grieve alone and in silence

-Depression, unstable emotions, social isolation, insomnia, and low self esteem

ex: suicide, loss of a loved one responsible for mass violence

Psychological response to grief

-Disbelief

-Fixation

-Trouble concentrating

-Hallucinations

Physiological response to grief

-Chest tightness/heaviness

-Nausea

-Dizziness

-Headache

-Muscle weakness

-Tiredness

Behavior response to grief

-Difficulty falling asleep

-Loss of interest

-Becoming short tempered and hostile

Factors affecting grief

-Cause

-Age

-Role within family

-Socioeconomic factors

-Culture

-Spirituality

-Prior loss

Grief in infants and toddlers

-React to the emotions and stress experienced by their caregivers

-Increased irritability, crying, clinginess, and anxiety

Grief in preschool age children

-Perceive death as temporary and reversible

-Increased irritability, tantrums, and changes in eating, sleeping, and toileting habits

Grief in school aged children

-Understand the finality of death and recognize its impact

-Sad, anxious, withdrawn, angry, aggressive, and problems at school

Grief in adolescents

-Cognitive understanding of death, but may still have difficulty processing their feelings

-Peer support, social withdraw, distractions, and high risk activities

Grief in adults

-Full understanding of death and hold memories of the deceased

-Anxiety, anger, depression and mood changes

-Chest tightness, lightheadedness, fatigue, and nausea

Kubler-Ross's five stages of grief

1) Denial (avoidance, confusion, shock)

2) Anger (frustration, irritation)

3) Depression (overwhelmed, helplessness, hostility)

4) Bargaining (struggle to find meaning, reaching out to others)

5) Acceptance (exploring options, new plan in place, moving on)

Worden's four tasks of grieving

1) Accept the reality of the loss

2) Experience the pain of grief

3) Adjust to an environment without the deceased

4) Find an enduring connection while embarking on a new life

Know how to apply these

Accept the reality of the loss

Facing and reorganizing ones thoughts regarding the loss, nature of it, and the changed reality

Experience the pain of grief

Opportunity and environment to recognize and articulate their feelings of pain, anger, and sadness

Adjust to an environment without the deceased

Adapt and redefine oneself by developing a new identity to navigate life

Find an enduring connection while embarking on a new life

Comprehend the meaning and loss of the loss, find new purpose, and redirect emotional energy towards new connections

Bereavement

Period of time in which a person experiences grief and mourning after a loss

Mourning

-Expression of grief in public

-Religious beliefs, ethnic background, and cultural customs

Individual experiences of loss and death

Manifestations:

-crying spells

-trouble sleeping

-altered eating patterns

-mood swings

Logistics:

-finances

-funeral plans

Loss of child:

-parents lose a sense of self / caregiver role

Loss of parent:

-reflects the parent child relationship before the death

Loss due to suicide:

-shame, guilt, rejection

Pet:

-provide companionship and acceptance

-allow the full grieving process

Recognizing personal grief for patients / families

-Anxiety

-Difficulty sleeping

-Headaches

-Joint pain

-Verbalize and process feelings of grief

Compassion fatigue

-Cumulative stress that develops from the desire to help those who are suffering combined with the inability to relieve that suffering

-Difficulty focusing, feeling nervous, anxiety

-Disruptive behavior with coworkers and difficulty developing therapeutic nurse patient relationships

Self care from experiencing grief for patients

-Self reflection and self evaluation

-Physical, psychological, spiritual, financial, and relational areas of growth

-Employee assistance programs

Assess grief

-Patient

-Family / caregiver

-Type of grief

-Phase of grief

Diagnose grief

-acute anxiety

-altered health maintence

-caregiver fatigue

-denial

-depression

-fear

-grief

-risk for self harm

-risk for social isolation

Plan an outcome for grief

-Verbalize and express feelings of grief

-Asking for help and support as needed

-Reliable support system

-Learn and utilize effective coping strategies

-Prevent disenfranchised grief and prolonged grief disorder

Interventions to support healthy grieiving

Physiological:

-promote patient's independence until unable to do so

-teach family members to assist in care

Psychological:

-meaningful, un-interupted communication

-do not give false reassurance

-explain patients condition and treatment

-teach self care

-provide caregiver support

Intimacy:

-share emotions and stories

-fear of hurting a loved one

Spiritual:

-pastoral care referral

-feel that their life had meaning

Evaluate grief

-Trusting nurse patient and nurse family relationship

-Feelings of grief acknowledged and shared

-Reliable support system

-Appropriate use of resources

-Effective use of coping strategies

-Health grieving process

Terminal illness

-Death is expected within a certain period of time

-Provider is responsible for what, when, and how the patient is told

-Right to consent to or refuse treatment

Full code

All life saving resuscitation measures if a patient's heart stops or they stop breathing

Do not resuscitate (DNR)

No attempts are made to resuscitate a patient whose breathing or heart stops

(same as allow natural death)

Do not intubate

No intubation, compressions and medications allowed

Allow natural death

No attempt to intervene or resuscitate

Hospice care

-Individual has 6 months or less to live

-No curative treatments or intervention

Admission criteria of hospice care

-PCP and hospice provider officially state the individual is terminally ill (less than 6 months)

-Individual must agree to symptom management and stop curative treatments

-Signed statement confirming their choice of hospice care in place of other benefits to treat their illness

Terms of hospice care

-Home, skilled nursing, inpatient hospice, or hospital

-Can stop hospice care at any time

-Can be recertified by hospice provider if they live beyond 6 months

Goals of hospice care

Involved: nursing, providers, social workers, spiritual leaders, volunteers, therapies

-Medical, physical, spiritual, and psychosocial care

-Focus on comfort, dignity, and quality of life rather than delaying the dying process

Care of the family / caregivers with loved ones on hospice

Up to 12 months after death of the individual

Education:

-dying process

-timeline

-what can be expected

-how to keep the individual comfortable

Hands on care:

-medication administration

-ADLs

-equipment

-supplies

Emotional support:

-active listening

-coping strategies

-support groups

Palliative care

-Aggressive symptom management for chronic or life threatening illnesses while maintaining the highest level of quality of life possible for the individual and family / caregivers

-Life expectancy does not play a role

ex: heart disease, renal failure, respiratory failure, parkinsons, alzheimers

Terms of palliative care

-Curative treatments still included in the plan of care

-No time constraints

-Holistic approach

Benefits of palliative care

-Improved quality of life

-Reduce hospital stays

-Improve patient / family satisfaction

Respite care

-Short term break for primary caregivers

-Up to 5 days

End of life options

Comfort measures:

-what life sustaining interventions does the patient want?

Terminal weaning:

-gradual withdrawal of mechanical ventilation

-family education

Voluntary cessation of eating and drinking:

-foregoing life sustaining treatment vs. form of suicide

-patient competency (has to be competent)

Palliative sedation:

-medications to limit patient's awareness of intractable suffering

Legal definition of death

-Irreversible cessation of all functions of circulatory and respiratory functions

-Irreversible cessation of all functions of the entire brain, including the brainstem

Medical definition of death

-Cessation of breathing

-No response to deep painful stimuli

-Lack of reflexes and spontaneous movement

-Flat EEG

"Good death"

Patient:

-death on your own terms

-relatively free of pain and discomfort

-sense of completion

-dignity

Healthcare provider:

-patient centered

-control symptoms

-consistent with patients values and preferences

-consider evolving physical, emotional, social, and spiritual needs

Assess for physiologic changes of death: neuro

-Difficulty talking or swallowing

-Loss of movement, sensation, and reflexes

-Restlessness or agitation

-Hallucinations

Assess for physiologic changes of death: cardiac

-Weak, slow, irregular pulse

-Decreasing blood pressure

Assess for physiologic changes of death: respiratory

-Dyspnea

-Cheyne stokes respirations (within 3 days of impending death)

-Retention of secretions (death rattle hours to days before impending death)

Assess for physiologic changes of death: pain

-Nerve injury

-Organ being stretched / compressed

-Bone pain

Assess for physiologic changes of death: temperature

-Decreased ability to regulate body's temperature

-Cool extremities -> mottling

-Core -> fever

Assess for physiologic changes of death: GI / GU

-Nausea, flatus, abdominal distention

-Incontinence or constipation

Assess for physiologic changes of death: musculoskeletal / skin

-Loss of movement

-Cooling, mottling, cyanosis

Nursing process: diagnose

-Acute pain

-Altered breathing pattern

-Coping impairment

-Death anxiety

-Denial

-Fear

-Impaired comfort

-Knowledge deficiency

-Spiritual distress

Outcomes for end of life

-Demonstrate freedom to express feelings, needs, fears, and concerns

-Make and document healthcare decisions to end of life that reflect personal values and wishes

-Individual will experience a dignified and comfortable death

-Accept the need for help as appropriate and use available resources

-Sufficient pain relief to interact meaningfully with loved ones

-Loved ones will resolve grief after a suitable period of mourning

Advance directive

-18 or older

-Two parts -> living will and durable power of attorney for health care

-Instructions for FUTURE treatment (impatient only)

-Does NOT guide emergency medical personnel

-Guides INPATIENT treatment decision when made available

Physician order for life sustaining treatment (POLST)

-Person with serious illness, ANY AGE

-Provides medical orders for CURRENT treatment

-Guides actions by emergency medical personnel when made available

-Guides impatient treatment decisions when made available

Interventions for psychological needs: prevent social isolation

-Support groups

-Volunteer visits

Interventions for psychological needs: maintain dignity and sense an control

-Maintain sense of self

-Promptly manage the individuals symptoms

-Advocate for independence, privacy, and social assistance

-Compassionate and empathetic care with a positive attitude

Interventions for psychological needs: pastoral care referral

-Religious and / or spiritual support aligned with the clients beliefs and preferences

-Seek meaning, emotional peace, and acceptance

-Facilitate visits from spiritual / religious leaders

-Perform religious ceremonies

Interventions for psychological needs: diversity considerations

-Talk about impending death

-Pain control and opioids

-Use of an interpreter

-Roles of family members / loved ones during the dying process

-How the body is handled after death

-Beliefs about the afterlife

Interventions for breathing

Dyspnea:

-morphine, oxygen, benzodiazepines

Cheyne - Stokes:

position a fan to blow lightly towards individual

Secretions:

turn head to the side, position on side, suctioning, scopolamine patch, oral atropine drops

-Positioning, reducing, exertion, and relaxation techniques

Interventions for vision and hearing

-Focus on safety and preventing injury

-Hallucinations -> provide comforting and safe environment

-Reassure family / caregiver

Interventions for temperature

-Medications (antipyretics)

Nonpharmacological:

-hot / cold compresses

-warm baths

-hypothermia blankets

-fans

Interventions for pain

Non opioids:

-NSAIDs

-acetaminophen

-steriods

-numbing agents

Opioids:

-morphine

-fentanyl

Nonpharmacological:

-distraction

-relaxation exercises

-massage

-music therapy

-spiritual practices

-repositioning

-heat / cold

Postmortem interventions

Caring for the body:

-cool room

-normal anatomical position

-clean the body

-change soiled dressings

-lines, drains, and tubes (no removal for autopsy)

-identification tag and body bag

Caring for the family:

-viewing the body

-private location

-patient belongings

Caring for other patients:

-ask nursing team for help

Role of nurse: legal consiterations

Post death checklist:

-documentation

-notify provider

-notify corner

-notify funeral home

Death certificate:

-signatures of a clinician, pathologist, and coroner

Organ donation:

-individual choice vs. family decision

-organ procurement coordinator

-united network for organ sharing

Autopsy:

-consent

-required: accident, suicide, homicide, illegal therapeutic practice

Interventions to cope with patient deaths

-"Pause" after a patient's death

-Debrief with the healthcare team

-Explore your own feelings

-Take time to express your emotions

-Be honest about maladaptive coping strategies

-Go through the grieving process

-Employee assistance programs