Chapter%2014%20Loss%20-%20Grief%20-%20Dying

Chapter 14: Loss, Grief, Dying

Professor Constantino

  • COVID 19

What Is Loss?

  • Definition: Loss is described as an undesired change or removal of a valued object, person, or situation.

Categorizing Loss

  • Types of Loss:
    • Actual versus perceived loss: An actual loss is tangible (e.g., a loved one), while perceived loss is subjective and might not be physically apparent (e.g., loss of self-esteem).
    • Physical versus psychological loss: Physical loss involves tangible objects or people, whereas psychological loss affects mental or emotional well-being.
    • External versus internal loss: External loss is related to losses outside oneself, while internal loss pertains to losing aspects of oneself.
    • Loss of aspects of self: This involves losing parts of one’s identity, such as roles or abilities.
    • Environmental loss: Change or loss of a familiar environment or setting.
    • Loss of significant relationships: Losing someone who played a critical role in one’s life (e.g., death of a partner).

What Is Grief?

  • Grief: Grief encompasses the physical, psychological, and spiritual responses to a loss.
  • Mourning: Action associated with grief, a process to express and cope with loss.
  • Bereavement: The period of mourning and adjustment that follows a loss.

Types of Grief

  • Types of Grief:
    • Uncomplicated grief: Normal mourning process.
    • Complicated grief: Prolonged or intensified grief that disrupts daily functioning.
    • Chronic grief: Persistent grief that does not resolve.
    • Masked grief: Grief experienced in ways that are not openly acknowledged.
    • Delayed grief: A postponement of the grief response.
    • Disenfranchised grief: Grief that is not openly acknowledged or socially supported.
    • Anticipatory grief: Grief that occurs before an impending loss, such as in terminal illness situations.

How Is Death Defined?

  • Higher-brain death: Refers to a state where the brainstem may function to sustain cardiac and respiratory activity, but purposive responses and cephalic reflexes are absent. An EEG shows no activity.
  • Uniform Law of Commission: Redefines death as the "irreversible cessation of all functioning of brain, including brainstem" as determined by reasonable medical standards.
  • Uniform Determination of Death Act (1981): Expanded the definition to include the "irreversible cessation of circulation and respiratory functions." Medical professionals assess brainstem activity through several tests:
    • Pupils fixed & unresponsive to light
    • No corneal reflex
    • Absence of vestibulo-ocular reflexes

Coma & Persistent Vegetative State

  • Coma: A prolonged state of deep unconsciousness lasting days or years, where the patient cannot be aroused and may have decreased brainstem reflexes.
  • Persistent vegetative state: A condition where higher cerebral functions are lost, leading to unresponsive behavior to the environment, with no cognition or affective functions.

Physiological Stages of Dying

  1. 1 to 3 months prior to death
  2. 1 to 2 weeks prior to death
  3. Days to hours prior to death
  4. Moments prior to death

Psychological Stages of Dying

  • 5 stages by Dr. Elizabeth Kübler-Ross:

    1. Denial: "Not me," a state of shock where the individual cannot believe the situation.
    2. Anger: "Why me?" Responses manifest as anger towards self, others, or the situation.
    3. Bargaining: A phase where individuals try to negotiate for more time or for a different outcome (often involves a higher power).
    4. Depression: A state of profound sadness in response to the loss and anticipated future losses.
    5. Acceptance: Coming to terms with the loss, which does not necessarily mean wanting the loss; it signifies an end to fighting it.

  • Important to note:

    • Nurses should not push patients through stages but support them in their current stage.
    • Stages may not be linear; individuals may not progress through each stage in an orderly fashion or may experience multiple stages simultaneously.

Stage Defining Characteristics

  • Denial:

    • Expressions: "Not me," "This cannot be happening," "I don’t believe it."
    • Function: Allows psychological preparation for accepting news.

  • Anger:

    • Expressions: "Why me?" or "Why is this happening?"
    • Manifestation: Can be overt or subtle; directed towards "safe" individuals.

  • Bargaining:

    • Expressions: "If only I can live until…" or "Yes, but…"
    • Commonly religious in sentiment, asking for a reprieve for specific events.

  • Depression:

    • Definition: A state of sadness that shouldn't be confused with clinical depression; linked to current and cumulative losses.

  • Acceptance:

    • Definition: Not a desiring of death, but recognizing the reality of loss and ceasing the struggle against it; may appear emotionally flat.

End-of-Life Care

  • Palliative care: Designed for holistic comfort, addressing the emotional, spiritual, and physical needs of the patient. General principles include:

    • Supporting families and caregivers.
    • Ensuring continuity of care and respect for persons.
    • Ensuring informed decision-making.
    • Managing symptoms, which include pain and emotional issues.

  • Hospice care: Focus on the quality of life rather than the length of life, emphasizing dignity in dying surrounded by family in familiar settings.

Legal and Ethical Considerations

  • Advance directives: Legal documents that outline preferences for medical care.
  • Do Not Resuscitate (DNR)/Allow Natural Death (AND): Orders that prevent resuscitation efforts.
  • Assisted suicide: Provision of means for a patient to end their own life, restricted for nurses according to ANA Code of Ethics.
  • Euthanasia: The deliberate ending of a person's life to alleviate suffering. It can be categorized into:
    • Active euthanasia: Direct action taken.
    • Passive euthanasia: Allowing death through inaction.
  • Autopsy: Medical examination of a body post-death to determine the cause of death, requiring permissions in most cases.
  • Organ donation: Legal implications are tied to the consent of the deceased or their family for organ retrieval post-mortem.

Sample: DNR

  • DO NOT RESUSCITATE orders (DNR): Descriptions and steps for documenting DNR orders. It mandates no resuscitative measures in case of cardiac or respiratory arrest.
  • Documentation needs: Signature of the attending physician and verification every seven days.

Assessment for Terminally Ill Patient & Family

  • Knowledge base: Consideration of history of loss, coping mechanisms, and support systems.
  • Physical and cultural assessment: Encouragement for communication about the patient’s wishes for burial and other arrangements after death.
  • Organ donation discussions: Important to explore if applicable based on the patient's condition.

Diagnosis for Terminally Ill Patient and Family

  • Normal grief versus dysfunctional grief:
    • Loss and grieving viewed as the problem versus loss and grieving as the etiology when they negatively impact other areas of function.
  • Examples of nursing diagnoses linked to grief:
    • Situational/Chronic Low Self-Esteem, Anxiety, Death Anxiety, Decisional Conflict, and Deficient Knowledge.

Planning Outcomes/Evaluation

  • Standardized Outcomes (NOC):

    • Open communication among patients and healthcare providers.
    • Effective pain relief and symptom management.
    • Utilization of available resources for coping.
    • Exercising control in care management.

  • Standardized Interventions (NIC):

    • Important nursing interventions include therapeutic communication, helping with grief work, and guidance to families during care of dying patients.

Nursing Outcomes

  • Grief Resolution: Patients progress through stages of grief, seek support, and express future expectations positively.
  • Facilitation of Grief Work: Through counseling, spiritual support, and community sources.
  • Therapeutic Communication: Essential elements include active listening, expression of feelings, and emotional support for families.

Barriers to End-of-Life Communication

  • Fears surrounding mortality, personal grief, lack of experience, and fear of relationships.
  • Cultural insensitivity and emotional distance from patients hinder communication.

Facilitating Grief

  • Methods include expressing feelings, recalling memories, and finding meaning.
  • Bibliotherapy: Using literature to help individuals process grief.

Helping Families of Dying Patients

  • Encouraging family involvement in care.
  • Providing emotional support and guidance through anticipatory grief.
  • Discussing what to expect and facilitating family well-being during the grieving process.

Care of the Dying Person

  • Meeting the physiological, psychological, spiritual, and cultural needs of the patient is essential for holistic care.

Providing Postmortem Care

  • Responsibilities include body care adhering to agency policy and culture, arranging for transportation of the body, and caring for