Discuss the grieving process across the lifespan: types and stages of grief.
Explain the cultural factors that affect loss, grief, and dying reactions.
Identify ethical and legal considerations of end-of-life care: advance directives, DNR/DNI, and euthanasia.
Describe the physiologic, psychological, and spiritual care of a dying client and family.
Identify the signs of the dying process.
Recall nursing responsibilities associated with post-mortem care.
Identify resources to aid the client or family adjustment to loss: palliative and hospice services.
Apply the nursing process to meet the needs of the grieving client or family member.
Grief Concepts
Mourning: The process of expressing grief.
Grief: The emotional suffering one feels when something or someone the individual loves is taken away.
Bereavement: Period of mourning following a loss.
Types of Loss
Actual Loss: Refers to a loss that can be recognized by others (e.g., loss of a loved one).
Anticipatory Loss: Refers to the sense of loss that occurs before the actual loss happens, often experienced during prolonged illness.
Perceived Loss: A loss that is experienced by a person but not necessarily evident to others (e.g., loss of self-worth).
Types of Grief
Acute Grief: Intense and immediate reaction to loss.
Normal Grief: A healthy and adaptive response to loss.
Disenfranchised Grief: Grief that cannot be openly acknowledged or socially supported.
Complicated Grief: Prolonged and intense grief that interferes with daily functioning.
Chronic Grief: Persistent and pervasive grief that can last for years.
Delayed Grief: Grief that is postponed or not expressed at the time of the loss.
Exaggerated Grief: Grief that is overwhelming and persistent.
Masked Grief: Grief that is expressed through maladaptive behaviors instead of emotional reactions.
Kubler-Ross Five Stages of Grief (1969)
Denial & Isolation: Refusal to accept loss; isolation from support systems.
Anger: Feelings of anger and resentment towards the situation or others.
Bargaining: Attempting to negotiate a way out of loss.
Depression: Deep feelings of sadness, despair, and hopelessness following the realization of the loss.
Acceptance: Coming to terms with the loss; finding ways to move forward.
Cultural Factors in Grief and Loss
Grief responses can vary significantly across different cultures. Factors such as beliefs about death and mourning rituals play a crucial role in how grief is processed.
Child's Grief
Children may express grief through actions rather than words.
Grief expression is highly influenced by the developmental stage of the child.
Understanding is shaped by their age and previous experiences with loss.
Legalities Related to Grief and Loss
Autopsy: Examination of the body post-death to determine cause.
Certification of Death: A legally required document that certifies the death and indicates the cause of death.
Organ Donation: The process of donating organs for medical use after death.
Euthanasia:
Active Euthanasia: Taking active steps to cause death painlessly.
Passive Euthanasia: Withdrawing medical treatment with the intention of causing death painlessly.
Assisted Suicide: Involves a physician providing a means for a patient to end their own life, such as prescribing lethal doses of medication.
Advance Directives
Do-Not-Resuscitate (DNR): Medical order instructing not to perform CPR if breathing or heartbeat stops.
Do-Not-Intubate (DNI): Medical directive not to intubate if the patient cannot breathe.
Comfort Care: Care focused on alleviating symptoms rather than curative measures; aimed at improving quality of life.
End-of-Life Care Dimensions
Psychological: Managing emotional distress.
Physical: Addressing symptoms and bodily comfort.
Spiritual: Providing support for spiritual needs.
Social: Handling interactions with others and support networks.
Palliative and Hospice Care
Palliative Care: Focuses on symptom management and quality of life in patients with life-limiting illnesses.
Hospice Care: Specifically tailored for terminally ill patients focusing on comfort and quality of life until death occurs.
Signs of the Dying Process
Presenting symptoms include:
Pain
Cough
Dyspnea
Anorexia
Cachexia
Constipation
Diarrhea
Nausea and vomiting
Depression
Anxiety
Terminal restlessness
Confusion
Delirium
Fatigue
Seizures
Sleep disturbances
Phases of Dying
Actively Dying Phase: Characterized by severe symptoms like pain, dyspnea, and and depression.
Transitioning Phase: Involves withdrawal and decreased interaction; patients may experience hallucinations.
Imminent Phase: Death may occur at any moment, due to multisystem organ failure.
Signs of Imminent Death
Cardiovascular: Cool, clammy skin; mottled extremities; rapid or irregular pulse.
Musculoskeletal: Mobility loss; inability to ambulate.
Respiratory: Abnormal breathing patterns such as Tachypnea, terminal secretions, Cheyne-Stokes respirations, and noisy breathing.
Urinary: Decreased urine output; changes in urine color.
Post-Mortem Care
Stepwise approach:
Verify: Confirm death.
Remove: Any medical equipment if necessary.
Clean: Ensure body is presentable.
Position: Place in appropriate position for family viewing.
Change Linens: Replace bedding as required.
Nursing Process Application - Case Studies
Case Study 1: Mr. Yun
Subjective Data: Reports difficulties with concentration and sleep; emotional distress after losing his wife.
Objective Data: Weight loss of 15 pounds in the previous month, increased alcohol consumption to cope.
Nursing Diagnosis: Ineffective Coping related to inability to deal with situational stress manifesting through weight loss, concentration issues, insomnia, and substance use.
Expected Outcome: Mr. Yun will identify three positive coping strategies by the end of teaching.
Case Study 2: Mrs. Lyn
Patient in hospice, actively dying.
Care involves addressing the family’s emotional needs and providing comfort measures for symptoms like dyspnea.
Requires supportive communication when family members are present, facilitating their involvement at the end of life.
Case Study 3: Terry
Diagnosis of advanced colon cancer; seeking understanding of his condition.
Nurse assists Terry with understanding palliative care and advance directives.
Diagnoses may include grief and coping-related issues.
Expected outcomes: Enhancements in coping skills through nursing interventions.
Nursing Diagnoses Related to Grieving
Anticipatory Grieving: Preparing for loss before it occurs.
Complicated Grieving: Risks associated with prolonged grief.
Ineffective Coping: Failure to manage stressors effectively.
Powerlessness: Feeling of loss of control.
Fear: Anxiety about future events or loss.
Chronic Pain: Ongoing physical pain related to grief.
Anxiety: Heightened nervousness associated with loss.
Disturbed Body Image: Changes in self-perception related to loss.
Social Isolation: Withdrawal from social interactions following grief.