Grief, Old Age, Loss
Older Adults
Introduction
- In the US age 65 is considered an “older adult”
o How people feel at each age is individual
- Gerontology: scientific study of aging and its affects; focuses on the aging population
- Ageism: discrimination against older adults because of age
- Nurse must acknowledge their thoughts and beliefs on the aging population to care for this population properly- myths and stereotypes
- Most older adults live on their own- only 4% in long term care settings
Variability
- Wide range of functional ability
- physiological, cognitive and psychosocial health
- functionality
- chronic conditions add to complexity of care
- do not assume that all older adults have signs, symptoms, or behaviors representing disease
Assessing Needs of Older Adults
- older interview techniques
o sit or stand at eye level, in front of patient in full view
o face the older adult while speaking
o speak clearly
o provide diffuse, bright, nonglare light
o encourage the older adults to their assistive devices
- nursing assessment to ensure an age-specific approach
o actively engage older adults and provide adequate time
- age specific approach
o tailoring the nursing assessment to an older person
- sensory changes may affect data gathering; provide culturally competent care
Physiological Changes by System
- integumentary
o loss of elasticity with fat loss
- respiratory
o decreased cough reflex and cilia
- cardiovascular
o loss vessel elasticity and lower cardiac output
- gastrointestinal
o decrease saliva, decreased peristalsis, and intestinal motility
- musculoskeletal
o decreased mass and strength and decalcification of bones
- neurological
o degeneration of nerve cells
- sensory
o eyes: presbyopia, difficulty from light to dark, yellowing of lens, and altered color perception
o ears: loss of high frequency tones, earwax
o taste: often diminished, fewer taste buds
o smell: often diminished
o touch: decreased skin receptors
o proprioception: decreased awareness of body position space
- genitourinary
o male: prostate fewer nephrons and decrease bladder capacity enlargement
o female: reduced sphincter tone
- endocrine
o alterations in hormone response
- immune system
o T-cell function decreases and core temp is lowered
Functional Changes
- Performance of ADLs is a sensitive indicator of health or illness
Cognitive Disorders
- Delirium
o Sudden abrupt- short durations less than one month
o Short- fluctuations more symptoms at night
o Usually reversible when treat the cause
o Caused by systemic infections, sensory deprivation unfamiliar surroundings, sleep deprivation, electrolyte imbalances, medications
- Depression
o Typically worse in the morning but fluctuates
o Last at least 6 weeks
o Selective disorientation- patchy memory
o Disturbed sleep- wake cycle
o Decreased affect (decrease expression), mood changes, preoccupation with personal thoughts, poor hygiene, self-neglect
- Dementia
o Generalized impairment of intellectual functioning that interferes with social and occupational functioning
o Frequent “near miss” answers, struggles with tests, effort to find the correct reply
Nursing Management of Dementia
- Nursing management of older adults with any form of dementia always considers the safety, physical, and psychosocial needs of the older adult and the family
- Use all your senses to get attention and help with ADL
o Give clear instructions and use senses
o Modify the environment- family and surrounding familiar
o Stay in their world
o Keep safe
Principles of Nursing Care of Cognitive Impairment
- Maximize safety
- Gauge activity and stimulation provide wandering cues with pictures etc.
- Remove cause of wandering- thirst, toileting, etc.
- Use all your senses to get attention and help with ADLs
- Learning needs=learn at a slower rate
Health Promotion and Maintenance- Social Isolation, Cognitive Impairment, Retirement stress, Relocation
- Touch: provides sensory stimulation, induces relaxation, provides physical and emotional comfort, orients the person to reality, shows warmth, and communicates interest
- Reality orientation: communication technique that makes an older adult more aware of time, place, and person
- Validation therapy: reality orientation insists that the confused older adult with your statements of time, place, and person
- Reminiscence: recalling the past; uses the recollection of the past to bring meaning and understanding to the present and to resolve current conflicts; it helps with coping
Grief
Normal Loss and Grief
- Loss: absence of something or someone that a person has formed an attachment to; it can include people, places, and things
o Each person responds to loss differently
- Grief: the emotional response to a loss
o It is individualized and deeply personal feelings and responses that an individual makes to real, perceived or anticipated loss
- Normal grief, also known as uncomplicated grief, is caused by the loss of a loved one, through death or the ending of a relationship
o Most people will experience grief after a loss or several months to a year
Grief
- Complicated grief now prolonged grief disorder a person has a prolonged or significantly difficult time moving forward after a loss
o Chronic grief, delayed grief, exaggerated grief, masked grief, and prolonged grief disorder
- Anticipatory grief: occurs before the actual loss of grief occurs
- Ambiguous loss: type of disenfranchised grief when the lost person is physically present but is no psychologically available
- Disenfranchised grief: occurs when a relationship to a decreased person is not socially sanctioned and cannot be openly acknowledged or publicly shared
Grief in Older Adults
- Responses are related to the individuals experiences
- Pain
o Undertreated in older adults
o Side effects of medications and toxicity can occur
- Relieving depression and maintaining physical function and therapeutic goals for older adults
- Little evidence that grief is different because someone is older
o Responses are likely related to the nature of the loss experience and individual differences
Types of Loss
- Actual losses: a loss when a person can no longer feel, hear, or know a person or object
- Necessary losses: part of life theses can cause us to undergo some type of change when the loss occurs it is sometimes replaces with something different or better
- Maturational losses: a type of necessary loss and include those changes that occur across the life span
- Situational loss: sudden and unpredictable
- Perceived loss: defined by the person experiencing the loss; it is a less obvious loss to others but is real to that person
- Death is the ultimate loss and is part of the continuum of life
Theories of Grief and Mourning; Kubler-Ross Stages of Death and Dying
- Survivors move back and forth through a series of stages many times and may extend over a long period of time
- Denial: not able to accept the loss, helps to protect the individual
o Avoidance, confusion, elation shock, fear
- Anger: resistance and anger with God or others
o Frustration irritation, anxiety
- Bargaining: try to prevent the event from happening; making promises
o Struggling to find meaning, reaching out to others telling one’s story
- Depression: overwhelming sadness, hopelessness, and loneliness
o Overwhelmed, helplessness, hostility, flight
- Acceptance: incorporate the loss into life; move forward\
o Exploring options, new plan in place moving on
Individual Response to Grief- Adulthood
- Common reactions: depression, anxiety anger, rapid changes in mood, shock, numbness or doubt
- Physical reactions: tightness in the chest similar to heart attack, upset stomach, lightheadedness, and fatigue
- Looking for behaviors
o Hallucinations
o Dreams about the deceases person continue to exist
o “observing” the deceased person on the road
o Other illusions and misconceptions
Cultural Influences of Grief
- Every culture has its own beliefs, values, behaviors, traditions and rituals
- Asking appropriate questions and being curious and nonjudgmental will help build cultural intelligence and move nurses toward cultural competence
Spiritual Influences of Grief
- Religious/spiritual rituals can help a person who is grieving deal with death and te grieving process
- Practices involving the use of religion and spirituality have produced better client outcomes a post-bereavement
- It is essential for nurses who are caring for persons who are grieving to acknowledge and be sensitive to the differing beliefs among the various religions to ensure the delivery of patient-centered care
Nurses Caring for those Experiencing Grief
- Nurses may encounter many challenges in providing support to those who are experiencing grief and loss when a client dies
- To ensure they are capable of delivering the best care for those experiencing grief and loss, nurses need to remain emotionally balanced while caring for clients and families experiencing grief and loss
Nurses Self-Care when Caring for Grief
- Individual nurse needs to be aware of and manage their grief
- Dealing with death is a normal part of being a nurse but that doesn’t make it painless
- death of a client can be one of the most difficult experiences in a nurses career
- recognizing personal grief
o nurses need to find a place that is supportive of their feelings and where they can heal. Keeping emotions to oneself and not dealing with them can cause nurses to be less effective in providing care for their clients
o need to verbalize and process feeling of grief as part of this healing, they need to set aside time for themselves and make taking care of themselves a priority
- American Nurses Association’s Code of Ethics states that nurses have a duty to take care of themselves as they do others (including health and safety), preserve competence, protect their character and dignity, and continue personal and professional growth
o Self care relieves stress associated with being a nurse
o Restores ability to be compassionate and empathic
o Promotes safety and higher quality care
- Compassion fatigue: cumulative stress that develops from the desire to help those whoa re suffering combined with the inability to relive that suffering, which results in a feeling of professional uselessness and self-blame
- Common manifestations:
o Difficulty with focus
o Feeling nervous
o Anxiety
o Disruptive behavior with coworkers
o Problems connections with clients
Assisting Clients and Families with Grief and Loss
- Assess for grief and loss
- Encourage them to share psychological and physical feeling
- Encourage them to be truthful, open and honest
- Use active listening techniques and provide and environment free of criticism
- NURSE technique
NURSE Technique
- Family states: this is overpowering
o Name: “This is overpowering”; identify what the person stated a moment age., the nurse identifying the emotion expressed by the client
o Understand: “There is a lot happening right now. What can I do to assist you?”; the nurse demonstrates understanding by recognizing the clients feelings and providing an opportunity for the client to discuss those feelings
o Respect: “I’m very impressed with your ability to manage everything.”; voice your respect for the client under these circumstances
o Support: “I’m her all day for you,”; inform the client that you are available to them
o Explore: “What is the most difficult aspect?”; asking an open-ended question will extend the conversation and provide a more detailed expressions of the clients feelings and beliefs
- The goal is for those involved in the grieving process to verbalize their feelings and have a reliable support system
End-of-Life-Care
Hospice Care
- Hospice care
o Provision of medical and psychosocial care to support clients who have a terminal illness so as to allow them to live the last days of their life as best as they can and for as long they can
o Care is provided when treatment will no longer cure or control the illness
o Focus then becomes providing for comfort, dignity and personal growth as the client faces death
- Asked to select someone to be their primary caregiver
- Primary caregiver is usually a family member or a close friend
Hospice Care: Admission Criteria
- Admission into hospice care depends on the client meeting specific criteria in addition to having the primary care provider making diagnosis of a life expectancy of 6 months
- The Centers for Medicine and Medicaid Services has developed specific criteria that must be met for a client to be eligible for hospice service
o A hospice provider and the primary care provider must officially state the client is terminally ill
o The client must agree to palliative as opposed to curing their illness
o The client is requires to sign a statement that they are choosing hospice care in place of other benefits to treat the disease
Interprofessional/Holistic Care
- Modern hospice care is provided by an interdisciplinary team, consisting of providers, nurses, assistive personnel, social workers, spiritual leaders, and other healthcare professional services necessary to meet client needs
- The team allows for holistic care and considerations within the dying experience
- Respite care support for family/caregivers
- Aromatherapy and therapeutic tough
- Provide supportive services for a period of up to 13 months following the death of the client for those individuals identified as family and in the primary caregiver role
Care of the Family: Respite Care
- Respite care provides a brief break for primary caregivers
Palliative Care
- Palliative care is defined as holistic care provided for clients throughout the lifespan who are experiencing a severe medical illness, and particularly for clients approaching end-of-life
- The goal is to improve the quality of life for the client as well as for the family and caregivers
- Palliative care has been shown to improve a clients quality of life, reduce time in the hospital, and improve client satisfaction
- Palliative care vs. hospice care
o Palliative care differs from hospice care in that palliative care can be provided while the client is still receiving curative treatment
Physiological Changes and Interventions
- Breathing and respirations
- Dyspnea: the sensation of difficult or labored breathing
- Oxygen therapy: used to relieve and provide psychological support for the family
- When death is imminent, comfort measures such as positioning, using a fan to facilitate air movement, reducing exertion, and relaxation techniques are used
- Anxiolytics such as benzodiazepines may be used to help with breathing- medications
- Death rattle: sound produced as a result of an accumulation of secretions in the lung and the throat, leading to congestion; secretions become trapped as the client is unable to clear the secretions
o Death rattle can upset family members
o Indication of death approaching within hours or days
o Turning the clients heat can help with drainage from the throat and lungs
o Medications- oral atropine drops or scopolamine patches can dry up secretions
o Moist washcloth and oral suctioning can help to eliminate secretions in the mouth
o Deep suctioning is not effective removing secretions pooled in the lungs
o Interventions
- Cheyne-stokes respirations: breathing pattern of cycles that begin with rapid, shallow breaths increase to deep breaths, ending with period of apnea
o Usually occurs within 3 days of impending death
o Respirations become irregular
o Fluctuating between several quick breaths followed by periods of apnea
o Fans can be used to blow lightly in the direction of the client
o Educate family that this pattern of breathings is typical and expected
o Interventions
Physiological Changes and Interventions
- Pain
o Pharmacologic treatment of pain includes the use of both nonopioids and opioids
o Palliative care guidelines suggest that a 3 step ladder be used when administering these pain management medications
o Nonpharmacologic interventions in managing pain: diversion, relaxation, imagery, massage therapy, breathing exercises, music therapy, spiritual practices, changes of lighting or noise, repositioning, heat and cold therapy
- Temperature
o As the client nears death, the nervous system’s ability to regulate body temperature diminishes, causing the client to experience episodes of both increased and decreased temperature
o Interventions to manage body temperature
§ Hot or cold compress
§ Warm sponge baths
§ Hypothermia blankets
§ Adjusting environmental temperature
§ Using a fan
§ Antipyretic medications: acetaminophen, ibuprofen, naproxen, aspirin
- Mottling
o The upper and lower extremities become cool to the touch, accompanied by purple or reddish marbling of the skin
o Expected and ordinary physical change that occurs hours or days before death
o That is a result of the hearts inability to pump blood effectively, leading to decreased blood perfusion throughout the body
o Mottling often begins in the feet and moves up the legs
o It is an indication of impending death
o The client does not feel any discomfort from mottling but may feel cold
o Interventions: provide warm blankets
- Hallucinations (visions and hearing)
o Sensation that something is there when it is not, including hearing and seeing those who have already died
o Can include all the senses
o Hear voices or see an item or person unseen by others
o Interventions
§ Avoid contradicting what the client believes to be true
§ Denying the occurrence of hallucinations can cause distress and aggravate the client who is actively dying
§ As clients can hear even if they are in a deep comatose state, talk to them and provide reassurance
§ If the family is at the bedside, provide support and reassurance, as they may become unsettles when the client experiences hallucinations
§ Ensuring the client safety and preventing client injury
Assessment- Physical Changes Hours or Days Before Death
- Increased periods of sleeping/unresponsiveness
- Coolness and color changes in extremities, nose, fingers
- Bowel or bladder incontinence
- Decreased urine output, dark colored urine
- Restlessness, confusion or disorientation
- Decreased intake of food or fluids, inability to swallow
- Congestion/increased pulmonary secretions
- Altered breathing (apnea, labored or irregular breathing)- death rattle from secretions
- Decreased muscle tone, relaxed jaw muscles, sagging mouth
- Weakness/fatigue
Preventing Social Isolation
- Social isolation refers to inadequate contact or relationships with people
- Services can be provided through home visits, the telephone, or the internet
- In-person face-to-face connections will be the most beneficial to the client, but other methods of facilitating social support include social media platforms and texting to help the client who is actively dying to stay in touch with friends and family
Maintaining Dignity and Sense of Control
- The American Nurses Association’s Code of Ethics for Nurses state, “The nurse practices with compassion and respect for the inherent dignity, worth and unique attributes of every person.”
- Dignity is regarded as an everyday necessity that is essential to the well-being of all clients
- Ways to support clients dignity by managing clinical manifestations
o Pain and respiratory issues
o Advocating independence
o Advocating private and social assistance
o Providing care with an optimistic attitude
o Listening
o Providing correct information
o Demonstrating caring and empathy
o Spiritual needs met
o Educated understanding the general timeline of death/dying
Dying Person Bill of Rights
- Right to die with dignity
- Right to be free of pain
- Right for honest answers
- Right to participate in decisions
- Right to express feelings
- Right to be cared for by knowledge people
- Treated as a living person
- Right to be in control
- Right to maintain sense of hopelessness
- Right to be cared for by those who maintain a sense of hopefulness
- Right to sense of purpose
- Right to express my feelings and emotions
- Right to participate in care decisions
- Right to continued treatment
- Right my body respected after death
- Right to be cared for by caring sensitive, knowledgeable people who will understand my needs and help face death
- Right to die alone
- Right to be free of pain
- Right to have respected spirituality
- Right to have honest answers
- Right to have honest answers
- Right to not be dcieved
- Right to have help from family in accepting death
- Right to die in peace and dignity
- Right to not bed judges for my decisions
- Right to discuss religion/spirituality whatever they means to others
Dying Person Care
- Use culture-specific understanding/developmental stage for appropriate care
- Use professional standards
o Nursing Code of Ethics
o Dying Person Bill of Rights
o ANA Scope and Standards of Hospice and Palliative Nursing
- Use clinical standards
Spirituality
- Religion is based on specific beliefs and values that are shared within a community in the worship of a higher power
- Spirituality speaks to a person’s existence, centered on the significance and purpose of life
- Spirituality can offer clients an approach to coping with impending death, as it provides hope for life after death
- Providing spiritual care is a part of the nurse’s role in delivering holistic, client-centered care
- Before offering spiritual care, asking clients if they desire spiritual care is essential
- Nonreligious spiritual care should be offered to those clients who do not identify religious beliefs with spirituality
Pastoral Care Referral
- The nurse’s role is to collaborate with other members of the hospice care team to provide support for the client, family, and caregivers
- The nurse’s role to address the client’s spiritual needs by working with the team to ensure the client’s religious or spiritual needs are met
Cultural Considerations
- Nurses knowledgeable about the distinctions of culture are more effective in managing a clients pain and assisting the family in adjusting to the dying process
- Before a nurse discusses a poor prognosis with a client and family, it is essential to understand the beliefs and culture of the individual
Postmortem Care
- Physical care performed after the client has died; included washing the body, accounting for the clients possessions, removing invasive devices, and placing identification tags on the body
- Confirm certified time of death
- Determine if autopsy/organ donation
- Identify patient with two identifiers
- Elevate HOB to prevent discoloration of the face
- Collect ordered specimens
- Ask family if they want to participate in care
- Ask if special body prep
- Remove tubes if no autopsy
- Cleanse the body
- Cover with clean sheet, close eyes, leave denture in mouth
- Clean the environment
- Offer family support
- Provide privacy for family
- Know what items will stay with the body
- Apply body tags
- Documentation
Implementation: Care After Death
- Autopsy: a surgical dissection of the body after death to determine the exact cause and circumstances of death or to discover the pathway of disease
- Lay may require that an autopsy be performed when death is result of foul play, homicide, suicide, or accidental causes, or death that occurs within 24 hours of hospital admission
- Usually MD suggests, RN supports
Organ/Tissue Donation
- When the client or family member voluntarily requests to initiate organ/tissue donation, the nurse makes a referral to the OPO
- As donation is voluntary, the donor must give authorization before death, or a surrogate can give permission when the client has not previously consented to organ/tissue donation
- After the nurse makes the referral, an organ procurement coordinator (OPC) will contact the client or surrogate to discuss the option of donation
- The nurse’s role is to assists families who are dealing with this challenging decision
-