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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.
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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
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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.
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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
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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.
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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.
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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
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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
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The nursing process with terminal illness
Assessment
- Knowledge base
- History of loss
- Coping abilities and support systems
- Meaning of the loss/illness
- Depression or grief?
- Physical assessment
- Cultural and spiritual assessment
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Planning/intervensions/evaluations/implimentations
outcomes
NOC Standardized Outcomes
NIC Standardized Interventions
- Make pt family part of the planning/implementation process.
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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
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Facilitating Grief
- Expressing feelings
- Recalling memories
- Finding meaning
- Dealing with children
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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
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POST MORTEM CARE
ASSISTING CLIENTS, FAMILIES AND YOURSELF TO RESPOND TO GRIEF &
COPE WITH LOSS
- INDIVIDUALIZATION OF CARE
- COMFORT
- DIGNITY
- COOPERATION
- Maximize the clients quality of life as well as the qualities surrounding the death of a client
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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.
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Recognition of death
- Unresponsive
- Cessation of Respirations
- Pulselessness
- Importance of Knowledge of Resuscitation Status
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