1. Stages of Grief and Loss
    • Denial
    • Anger: Blaming God
    • Bargaining: If I do this, then something else will happen.
    • Depression
    • Acceptance

    Not necessarily in order and phases can be experienced more than once.  
  2. Factors Affecting Grief
    • Significance of the loss
    • Amount of support for the bereaved
    • Conflict existing at the time of death
    • Circumstances of the loss
    • Previous loss
    • Developmental stage
    • Spiritual and cultural background
    • Timeliness of death
  3. Types of Grief
    • Uncomplicated: Natural response to loss 
    • Complicated: Classified by time, length, emotion. 
    • --Chronic: Persistant, unresolved grief. Unable to rejoin normal, daily functions. 
    • --Masked: Grief expressed through non-typical behaviors. Almost a change in personality. 
    • --Delayed: Grief is postponed. 
    • Disenfranchised: Difficult to acknowledge because there is no clearly defined ritual to deal with grief. 
    • Anticipatory: Terminal illness is a good example. 
  4. How is death defined?
    Historical definitions

    • Heart-lung death
    • Whole-brain death
    • Higher-brain death: irreversible cessation of higher brain function. 
    • Uniform Determination of Death Act
  5. Physiological stages of dying
    • 1 to 3 months prior to death: pt will withdraw from society, decrease sleep, decrease appetite.
    • 1 to 2 weeks prior to death: vital signs drop and skin color changes. R will increase or decrease and change in pattern. 
    • Days to hours prior to death: Energy surge. Pt will want to eat, talk, mentally very clear. Possibly r/t endorphine surge. 
    • Moments prior to death:
    • difficulty swallowing,
    • dehydration.
    • Death rattle: distinct rattle associated with failing respiratory system. NI: turn pt on side, raise head of bed.
    • Cheyne-Stokes: rapid/slow/rapid/slow pattern of breathing.
    • Cold/Clammy/Mottling esp on back. 
    • Decreased urinary output
    • Hypoxic->restleness and irritation
    • Unresponsive, long periods of apnea.  
  6. Palliative vs. hospice care
    Palliative care: Holistic comfort care for chronic or life-threatening illness, ie COPD, CHF. Focuses on relief of symptoms when disease process no longer repsonds to treatment. 

    Hospice care: Holistic care of dying clients. Typically <6mo to live. Must be suggested by MD. 
  7. What's the point of palliative/hospice care?
    • The goal in Palliative and Hospice Care is to alleviate suffering through interdisciplinary collaboration.
    • Physical
    • Psych/Social
    • Spiritual
    • Cultural
  8. Legal and Ethical considerations with legal implications
    • Advance directives: What do you want done in specific medical situations in which you cannot make a decision in the moment. Will include living will, POA.
    • DNR: Can be revoked at any time. Document and notify MD immediately. Does not mean Do Not Treat. 
    • Assisted suicide
    • Euthanasia
    • Autopsy
  9. The nursing process with terminal illness
    • Knowledge base
    • History of loss
    • Coping abilities and support systems
    • Meaning of the loss/illness
    • Depression or grief?
    • Physical assessment
    • Cultural and spiritual assessment
  10. Planning/intervensions/evaluations/implimentations
    NOC Standardized Outcomes

    NIC Standardized Interventions

    • Make pt family part of the planning/implementation process.
  11. Therapeutic communication's importance in nursing care for the terminally ill. 
    • Perfect your listening skills
    • Encourage and accept expression of feelings
    • Reassure it is not wrong to feel anger, relief, or other “unacceptable” feelings
    • Respond to nonverbal cues with touch, eye contact
    • Increase your self-awareness
    • Continue to communicate, even in case of coma
    • Silence is golden 
  12. Facilitating Grief
    • Expressing feelings
    • Recalling memories
    • Finding meaning
    • Dealing with children
  13. RN responsibilities to the terminally ill
    • Promote dignity and self-esteem in as many interventions as possible
    • On admission assessment:
    • Ask if patient has basic information concerning living wills and POA
    • Initiate Advanced Care Directives now?
    • If one is already prepared, can you provide it now?
    • Have you discussed your end of life choices with your family or designated surrogate and healthcare team members?
    • ANA feels that nurses should play a primary role in the implementation of the PSDA
    • Initiate discussions with patients about their life values and preferences for end-of-life care
    • Help families & Assist patients to exercise their right to die in the way they choose 
    • Maximize the clients quality of life as well as the qualities surrounding the death of a client
  15. Nurse's responsibility post mortum
    • Nurse responsible for coordination of all aspects of care surrounding the death of a client incuding:
    • Make the patient presentable
    • Consider lighting
    • Body is clean 
    • Bed is clean
    • Position according to protocol - remove tubes that you can remove
    • Room is quiet
    • Lighting for viewing
    • Remove all extraneous supplies/ garbage from the room
    • Rigor mortis (begins 2-4hrs after death). NI: get dentures in, place something under jaw to prevent it from staying in open position, close eyes, prop up with pillows.
    • Crying is okay so long as it's not unconsolable weeping.  
  16. Recognition of death
    • Unresponsive
    • Cessation of Respirations
    • Pulselessness
    • Importance of Knowledge of Resuscitation Status
Card Set
End of Life