coping wth loss,death and grieving
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COPING WTH LOSS,DEATH AND GRIEVING
Prepared bySalman habeeb
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What is loss• Loss can be defined as the undesired change or
removal of a valued object ,person or situation.
•Types • necessary loss Necessary losses are something natural and
positive• Start and leave school, change friends
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actual loss eg . Loss of body part ,role at work
Perceived loss Any loss that is uniquely defined by The grieving client
eg. Loss of confidence or prestige
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•Maturational loss• anychange in the development process
that is normally expected during a life time•Loss of external objects•Loss of life •Loss of known environment
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GRIEF•Grief is the physical ,psychological and spiritual responses to loss.
mourning is the psychlogical process through which the individual passes on to successful adaptation to the loss of a valued object.
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TypesNormal grief eg; crying,sorrow ,anger
Anticipatory grief process of disengaging or letting go that occurs before an actual loss of death has occurredComplicated grief difficulty in progressing through normal process of grieving
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• chronic grief• masked griefDisenfranchised Person experiences grief when a loss is experienced and cannot be openly acknowledged,socially sanctioned or publicly shared
Eg .loss of partner from AIDS
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FACTORS INFLUENCING LOSS AND GRIEF
•Human development•Psychological perspectives of loss and grief
•Socioeconomic status•Personal relationships•Nature of loss•Amount of support for bereaved•Culture and ethinicity•Spiritual beliefs
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Stages of grieving
•MODEL OF SUCCESSFUL GRIEVING; ENGEL
(1964) 1.SHOCK AND DISBELIEF2.DEVELOPING AWARENESS3.RESTITUATION 4.RESOLVING TO LOSS5.IDEALIZATION6.OUTCOME
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Stages of grieving ;kubler ross (1975)
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RANDO’S STAGES OF GRIEF•1. avoidance•2.confrontation•3.accomodation
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STAGES OF BEREAVEMENT(BOWLBY,1961)
•PROTEST•DISORGANISATION•REORGANISATION
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William worden’s theory• 1. realizing that loved one is gone• in the hours and days after a significant loss,the
grieving person typically feels numb hand unable to accept the fact of the loss,this numbness is thought to be an helpful form of denail.
•2.experiencing the pain• once the grieving person has accepted the
reality of loss,the feelingand emotions that surface are intense and can change rapidly. This makes the person feel out of control
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3 Adjusting to the environment without the deceased: .This means performing activities alone ,such as going
for walk or shopping, that were once shared or taking on roles and responsibilities that the deceased previously held
4 investing emotional energy: Initially all energy is focused on the deceased:
thinking about the person, talking about her, reliving memories and so on. When the person’s energy begins to flow toward others or to different or former interest, the healing process is in progress.
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Death and dying
• Death• in 1981,the president’s commission for the
study of ethical problems in medicine , behavioral and biomedical research defined death as an individual has sustained either irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain ,including brain stem.
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STANDARDS OF DEATH DETERMINATION A person is dead when, according to ordinary
standards of medical practice, there is irreversible cessation of the person’s spontaneous respiratory and circulatory functions. (Patient is pulseless, apnoeic and unresponsive to verbal stimuli for a period of at least 2 – 5 minutes).
•If artificial means of support that a person's spontaneous respiratory and circulatory functions have ceased, the person is dead when according to ordinary standards of medical practice, there is irreversible cessation of all spontaneous brain function.
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Dying person’s bill of rightsFrom American Journal of nursing, 75(1)99
•I have the right to be to be treated as a living human being until i die.
•I have the right to maintain a sense of hopefulness, however changing its focus may be.
•I have the right to be cared for by those who can maintain a sense of hopefulness, however changing this may be.
•I have the right to express my feelings and emotions and my approaching death in my own way.
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•I have the right to participate in decisions concerning my care.
•I have the right to expect continuing medical and nursing attention.
•I have the right not to die alone.•I have the right to be free from pain.•I have the right to have my questions
answered honestly.•I have the right not to be deceived.•I have the right to have help from and for
my family in accepting my death.•I have the right to die in peace and dignity.
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•I have the right to retain my individuality and not be judged by my decisions, which may be contrary to the beliefs of others.
•I have the right to discuss and enlarge my religious or spiritual experiences, regardless of what they mean to others.
•I have the right to expect that the sanctity of the human body will be respected after death.
•I have the right to be cared for by caring, sensitive, knowledgeable people who will attempt to understand my needs and will be able to gain some satisfaction in helping face my death.
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CLINICAL MANIFESTATIONS AT THE END OF LIFE
•SENSORY SYSTEM•Hearing - usually last sense to disappear•Touch - decreased sensation - decreased perception of touch
and pain•Taste - decreased with disease progress.•Smell - decreased with disease progress.• Sight -blurring of vision•-blink reflex absent•-eyelids remain half open
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•INTEGUMENTARY SYSTEM• -Cold clammy skin• -cyanoses on nose, nail beds• RESPIRATORY SYSTEM• -Increased respiratory rate• -cheyne stroke respiration (alternating
periods of apnoea, deep and rapid breathing)• -irregular breathing gradually slowing
down to terminal gasps (guppy breathing)• -noisy wet sounding (death rattle)
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• URINARY SYSTEM• -Gradual decrease in urinary output• -urinary incontinence or unable to
urinate• GASTROINTESTINAL SYSTEM• -Accumulation of gas•-distension and nausea•-loss of sphincter control•-possible cessation of GI function•-bowel movement may occur before
imminent death or at the time of death
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• MUSCULOSKELETAL SYSTEM•-Gradual loss of ability to move•-loss of gag reflex•-sagging of jaw results in loss of facial muscle
tone, dysphagia, difficulty in speaking• CADIOVASCULAR SYSTEM• -Increased heart rate: later slowing• -irregular rhythms• -decreased blood pressure• -weakening of pulse
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PSYCHOSOCIAL MANIFESTATIONS
•A variety of feelings and emotions affect the dying patients at the end of life care. They are
•Altered decision making•Fear of loneliness•fear of pain•Helplessness•Restlessness•Anxiety•Impending doom•Grief
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ASPECTS OF END OF LIFE CARE
•Palliative care•Preparation at the end of life care•Advanced directives•Understanding CPR and DNR•Hospice care
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PALLIATIVE CARE •The palliative care means taking care of the
whole person-body, mind and spirit, heart and soul.
.The goal of palliative care not to give cure to the disease condition but to reduce the pain and side effects and to improve the quality of life
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PRINCIPLES OF PALLIATIVE CARE
•palliative care respects the goals, likes, and
choices of the dying person and his or her loved ones and helping them to understand the illness and what can be expected from it, and to figure out what is most important during the time.
•Palliative care looks after the medical, emotional, social and spiritual needs of the dying person with a focus on making sure he or she is comfortable, not left alone, and able to look back on his or her life and find peace.
•Palliative care supports the need of family members, helping them with the responsibilities of care giving and even supporting them as they grieve
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•Palliative care helps to gain access to needed health care providers and appropriate care settings involving various kinds of trained providers in different settings, tailored to the needs of the patient and his or her family.
•Palliative care builds a way to provide excellent care at the end of life through education of care providers, appropriate health policies, and adequate funding from insures and the government
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THE PALLIATIVE CARE TEAM
doctor
nurses
Social worker
Spiritual advisordietitian
physiotherapst
Grief and berievement cordinator
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PALLIATIVE CARE SETTINGS
•HOSPITALS•Despite the economic and human costs
associated with death in the hospital settings, as many as 50%of all deaths occur in the acute care settings. It is clear that many patients will continue to opt for hospital care or default will find themselves in hospital settings at the end of life care.
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IN HOME CARE SETTING
•Where ever the patient may ultimately die, they are likely to spend most of their last year of life in their own home being cared for by close family members. When the patient and the family’s hopes are focussed on allowing the patient to die in his or her own home ,the nurses need to be acutely sensitive to the shifting needs of the caring family.
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. PREPARATION AT THE END OF LIFE CARE
•GRIEVING LOSSES•Learning that persons illness has become
terminal can bring about intense feelings of anger, fear grief, regret and other strong emotions.•Encourage the patientsTalking about feelings and concerns with family, friends and caregivers can help bring comfort.
•Inform It is normal to grieve and mourn the loss of your abilities, the loved ones you will leave behind, and the days you will not have.
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GETTING AFFAIRS IN ORDER•Setting patient affairs include locating and
organizing important legal and financial documents, such as will, marriage and birth certificates, social security card, insurance policies, bank statements and investment summaries.
•Some people also find it helpful to plan some aspects of their own funeral. This can be done with set of written instructions or talking to family or close friends about your wishes.
•As we approach the end of your life there may be certain things you wish to accomplish in the time you have left. such as rereading a favourite book or spending time with those who are important to you.
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RELIGION AND SIRITUALITY
•The spirituality is a key component of comprehensive nursing for terminally ill patients and their families. Include counselling to patient and family members
•The patient’s and family’s preferences , individual needs related to spiritual
TO BE RESPECTED•Eg: Giving anointment.
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ADVANCED DIRECTIVES
•Advance directives are the legal documents that explain the kind of medical treatment would want and would not want if patient become unable to make these decisions for yourself.
• Advance directives protect client’s rights and preferences for the medical treatment and diminish the burden of family members and the other caregivers making decision for client
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Types of advance directive•LIVING WILL A type of advance directive in which
the individual documents treatment preferences. . A living will can include
•Whether client want the medical team to use cardiopulmonary resuscitation(CPR) and or artificial life support such as mechanical ventilator, if breathing or heart stops.
•Whether client want to receive a feeding tube, if you cannot be fed otherwise?
•Whether client want certain procedures such as dialysis.
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DURABLE POWER OF ATTORNEY FOR
HEALTH CARE•It is a legal document through which the signer appoints and authorizes another individual to make decisions on his or her behalf when he/she is no longer able to speak for him/herself.
•Once patient choose a health care agent he can still make your own decisions about his medical care:
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UNDERSTANDING CPR AND DNR•A DNR order is a type of advance directive
and it is the written physician’s order instructing health care providers not to attempt CPR and it is often requested by patient and family. A ‘no code ‘or DNR order allows the person to die with comfort measures only and without the interference of the technology
•Unlike other advance directives that are written and signed by the individual, a DNR order must be completed and signed by doctor or other health care provider.
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Providing comfort
•Use foam cushions to make beds and chairs more comfortable and help the patient to change positions frequently and change the bed linens as necessary.
•Elevate the patient’s head or turn the patient on his or her side to help make breathing easier.
•Use blankets to help keep the person warm & gently rub the person’s hand, feet or soak the hands and feet in warm water.
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Controlling pain
•Controlling pain is an important part of dying comfortably and peacefully.
•Administer medications around the clock in a timely manner and on a regular basis to provide constant relief rather than waiting until the pain is unbearable.
•Concentrated morphine solution can be very effective by delivered by the sublingual route.
•In case of uncontrolled pain, palliative sedation
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HOSPICE CARE•Hospice is not a place but a concept of care
that provides compassion, concern, and support for dying. Hospice and palliative care are frequently used interchangeably. Hospice exists to provide support and care for person in the last phases of the incurable diseases so that they might live as fully and as comfortable as possible.
• Criteria for hospice care•1.the patient must desire the services;•2.a physician must certify that the patient
has 6 months or less to live
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•Comparing palliative care and hospice care
•Although the term palliative care and hospice care are sometimes used interchangeably, they have slightly different meanings
•Palliative care starts much earlier in a disease process where as hospice is traditionally is limited to the projected last six months of life.
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LEGAL AND ETHICAL ISSUES AFFECTING END OF LIFE
CARE•ORGAN AND TISSUE DONATON•TERMINAL WEANING•EUTHANASIA
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NURSING MANAGEMENT: END OF LIFE CARE
•TO REDUCE THE PAIN•TO PREVENT DEHYDRATION•FOR DYSPNOEA•TO PREVENT SKIN BREAKDOWN•FOR WEAKNESS AND FATIGUE•FOR ANOREXIA ,NAUSEA AND VOMITING•PSYCHOSOCIAL CARE
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RESEARCH STUDIES
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