MH 1D Grief and Loss

Advanced Directives and End-of-Life Care

  • Advanced directives:

    • Living wills: declaration of end-of-life care goals and wishes, especially concerning life-saving measures (tube feedings, mechanical ventilation, resuscitation) when the individual cannot make decisions.
    • Medical Power of Attorney: A healthcare proxy who makes medical decisions for the patient when they are unable to do so; limited to healthcare settings.
    • Out-of-hospital DNR: written orders documenting an individual's desire for no life-sustaining therapies.

  • Important Note: If a patient states they are DNR but there's no documentation, healthcare providers are obligated to initiate life-saving measures.

Patient Self-Determination Act

  • Resulted from the Cruzan case: Nancy Cruzan experienced anoxia for 15 minutes after a car accident on 01/11/1983. After resuscitation but with no advanced directives, her parents fought a legal battle to remove her feeding tube.

  • She was ejected 35 feet from the vehicle into a field and experienced approximately fifteen minutes of anoxia; anoxia means no oxygen before she was resuscitated.

  • Her heartbeat was restored, with no advanced directives in place, her parents fought the legal battle to remove her feeding tube and allow her to die, which occurred on 12/26/1990.

  • The Act requires federally funded nursing homes and hospitals to:

    • Provide patients and families the chance to complete advanced directives.
    • Provide information and education on advanced directives.
    • Include advanced directive forms in medical records.
    • Ask all patients about advanced directives upon admission.

Performance Scales

  • Palliative Performance Scale: Validates a patient's ability to function and determines how to move forward toward the end of life and about goals and conversations with family.
  • Karnovsky Performance Scale: Assesses a patient's functional status to carry out ADLs (Activities of Daily Living).
  • Functional Assessment Staging Test (FAST): Tracks the progression of Alzheimer's disease.
  • Eastern California Oncology Group (ECOG) Performance Scale: Assesses how a patient’s disease is progressing and how it affects ADLs to determine appropriate treatment and prognosis.

Clinical Signs of Dying

  • Weeks Remaining:

    • Decreased socialization.
    • Mental status changes.
    • Decreased oral intake.
    • Fatigue.
    • Being bedbound with potential for skin breakdown.
    • Decline in functional status.

  • Days Remaining:

    • May or may not be urinating as much.
    • Little to no response to auditory or visual stimuli.
    • Terminal secretions (death rattle)
    • Mottling (skin color changes).
    • Rally day (temporary increase in alertness and conversation).
    • Temperature fluctuations and increased heart rate.
    • Near-death awareness experiences.

  • Hours Remaining:

    • Cooling and increased mottling of extremities.
    • Bradycardia.
    • Terminal secretions.
    • Prolonged periods of apnea.
    • Cyanosis.
    • Waxy pale appearance.
    • Obtunded state.

Loss, Grief, and Bereavement

  • Losses are experienced in many situations, not just death or terminal illness (e.g., hysterectomy, oxygen dependency, handicapped child, amputation, diabetes, stroke, heart attack, hypertension, knee injury).
  • Loss: thoughts, feelings, beliefs, behaviors based on the perceived relationship to the person or object that is lost.
  • Grief: expression or reaction to loss.
  • Bereavement: the process of healing or coping with the loss.

Types of Grief

  • Normal Grief: Reaching acceptance within six months of the loss.
  • Anticipatory Grief: Often seen with terminal illness.
  • Complicated Grief: profound grief past six months.
    • Risk factors: dependency on the deceased, unexpected death at a young age, lack of social support, pre-existing mental health issues.
    • Protective factors: spiritual or religious beliefs, sense of personal well-being, sense of financial control, no additional or concurrent loss.

Types of Complicated Grief

  • Delayed or inhibited grief.
  • Distorted or exaggerated grief.
  • Chronic or prolonged intense grief reactions (longer than six months).
  • Disenfranchised grief: occurs with a loss that is not socially acceptable or publicly shared (e.g., suicide, abortion).