Chapter 30

Dying, Death & Grieving

Hospice

• Care begins after treatment of the disease or condition is stopped, when it is clear that survival is not possible

• Multidisciplinary team approach that focuses on patient care and symptom reducton rather than on a cure

• Navigate Questions, concerns and decisions faced by those who ar dying and includes caring for the family

• Routine: provided at the individual’s residences

• Continuous Home Care: 8-24 hours a day to manage pain and acute medical symptoms in terminally ill patients

• Inpatient Respite Care: temporary relief to patient’s primary caregiver; provided in hospitals, hospice facilities, or long-term care facilities with 24 hour nurse presence

• General Inpatient: pain control or other acute symptom management that cannot easily be provided in other settings; hospitals, hospice facilities, nursing facilities with 24 hours nursing care

Palliative Care

• Patient & family centered care that optimizes quality of life anticipating, rpeventing and treating suffering

• Addresses physical, intellectual, emotional, social and spiritual needs

• Promote patient autonomy, access to information, and choice

• Palliative care can begin at the time of diagnosis and continue throughout the treatment of the illness — specialized medical and nursing care for people living with serious illness

Stages of Grief

1. Denial & Isolation: denial is a brief reactions where the patient is in disbelief or shock about the situation; buffer between receiving shocking news and allowing for thoughts to regroup

2. Anger: pessimistic, unahppy, anger is often projected unpredictably onto others

3. Bargaining: patient attempts to deal with overwhelmign feelings of vulnerability and helplessness; secretly make deals with a higher power to prolong life

4. Depression: no longer avoid a sense of great loos; feel guilty; sadness; Prepartory Phase: patients preparing themselves for their final separation from this world; Reactive Phase: unrealistic guilt or shame patients may feel about their illness

5. Acceptance: not happiness, but a quiet peacefulness in the end of life, resting, free of pain and struggle, solitude, times of silence

Artificial Nutrition & Hydration

• Medical intervention not a comfort measure

• Not a component of basic care for people who are actively dying

• Does not generally benefit people who are dying — can induce edema, pulmonary congestion, ascites, n/v

• Unwillingess or inability to eat/drink is caused by impending death of the patient

Euthanasia

• Act of putting someone to death; someone other than the patient commits an action with the intent of ending the patient’s life

• Sometimes called mercy killing

• Voluntary: requested by the patient and is typically performed when a person is suffering from a terminal illness and is in great pain

• Passive: omission of acts that would keep a patient alive who is unable to participate in decision making — discontinuing a med or not performing life-saving procedure

• Involuntary: actively ending the life of a person who is able to perform consent, typically by injection of a lethal drug — homicide

Legally Assisted Death

• Someone else makes the means of death available, but does not act as the direct agent of death

• state dependent laws about the legality of legally assissted death

• Typically allows it for terminally ill patients with a life expectancy of no more than 6 months to request medication from a licensed prescriber that is taken to hasten death

Patient-Self Determination Act (PSDA)

• Healthcare facilities provide clearly written information for every patient, including legal rights to make healthcare decisions, especially the right to accept or refuse treatment

• Right to advance directives

Advance Directives

• Patients have a right to provide directions for clinicians to follow in the event of serious illness

• Preferences for the types and amount of medical care desired

• Comes into effect should physical or metnal incapacitation prevent the patient from making healthcare decisions

Durable Power of Attorney for Healthcare

• Designation of a person to act as the patient’s medical decision maker

• Patient must be competent when making the appointment and must also be competent to revoke the power

• Individuals do not have to be terminally ill or incompetent to allow the empowered individual to act on their behalf

Living Will

• A personal statemnt of how and where one wishes to die

• Guidance / instructions for making healthcare decisions

• activated only when the person is terminally ill and incapacitated, and a competent patient may alter a living will at any time

• Question of whether an incompetent person can change a living will is addressed on a state-by-state basis

Provider/Physician Orders for Life-Sustaining Treatment (POLST)

• AKA Medical orders for life-sustaining treatment (MOLST)

• Full Code: all life-saving measures are initiated; chest compressions, defibrillation, and intubation

• Do Not Resuscitate (DNR): cardiopulmonary resuscitation will not be initiated in the event of cardiopulmonary arrest

• Do Not Resuscitate- Comfort Care Arrest (DNR-CAA): permits the use of all life-saving measures prior to cardiopulmonary arrest; only comfort care is provided after the cessation of heartbeats and respiration — includes airway suctioning, oxygen administration, positioning, and pain medications

• Do Not Resuscitate- Comfort Care Only (DNR-COO): care focuses on providing patin-free quality of life and comfort free of invasive procedures and incubation; generally reserved for people with a terminal illness, short life expectancy or little chance of surviving cardiopulmonary resusciation

Anticipatory Grief

• After a life-threatening diagnosis has been received or curative efforts are stopped

• AKA anticipatory mouning

• Future loss is being mourned in the present

• People ackowledge the importance of the dying person, adjust their lives to accommodate the intervening time, and foresee how their futures will be altered by the loss

Grieving

Normal & complex process in response to loss

Bereavement

Period of grieving after a death

Mourning

Things people do to cope with grief

• Viewing hours, funerals, and bereavement groups

• Not everyone mourns

• Length of time, degree and ritual for moutning are often typically determined by cultural, religious and familial factors

Persistent Complex Bereavement Disorder

• not yet an official disorder, but proposed to account for and address prolonged grieving

• condition for further study

• better understand the nature and clinical course of grief that becomes unshakeable, may be debilitating to relationships, impair occupational and academic performance, and significantly impact day-to-day functioning

• Individuals whose acute grief period persists beyond 12 months in adutls and 6 months in children

• Suicidal ideation and disinterest in living make thsi type of bereavement particularly dangerous

Disenfranchised Grief

• Experiencing an intense loss that is not congruent with a socially recognized relationship

• Lover, a divorced spouse, a cargervier, and abortion, pets

• Grief felt by healthcare workers over the loss of a patient

• No opportunity to publicly grieve the loss or expressing grief is viewed as unacceptable