Bereavement (13 Nov) Flashcards
What is a “Good Death”?
- Having control over pain and other
symptoms. - Dying in the place of choice.
- Having good relationship with family.
- Cared by staff with high level of knowledge
and expertise.
Anticipating and preparing for death
- Is the patient comfortable?
* Review medication for appropriateness for
end-of-life stage.
* Switch essential medications to non-oral
route.
* Anticipatory medication (example:
standby Haloperidol for delirium)
* Stop unnecessary medications,
procedures, monitoring such
as blood pressure or Sp02.
* Evaluate symptoms such as pain, breathlessness, dry mouth, agitation, secretions.
* Nursing care - Skin, oral, bladder, bowel - Family/caregiver coping ability
Onset of dying symptoms
- Profound weakness
- Gaunt appearance
- Disorientation
- Diminished oral intake
- Poor concentration
- Skin colour changes
- Drowsiness
- Difficulty taking oral medications
- Temperature change at extremities
Symptom management for pain
Assess and manage appropriately:
- non verbal expression such as grimacing, tensed body, moaning.
Symptom management of breathlessness
Assess and manage appropriately:
- any use of accessory muscles, frowning, tensed facial muscles.
Symptom management of fever
Tepid sponge
Administer paracetamol suppository or NSAIDS (as appropriate)
Symptom management of Dry skin and mouth
Apply skin moisturiser
Perform oral care
Symptom management of “missy my body feels cold”
Cover with blanket to keep patient warm and comfortable.
Symptom management of sleepiness/drowsiness
Keep calm environment
Continue to communicate with patient (include family members and loved ones)
What are terminal secretions?
- Terminal secretions (rattling) are
often observed in an imminently
dying person. - It often indicates a short
prognosis. In general, it is within
hours to short days after
secretions are first diagnosed. - It may be distressing to family or
caregivers.
Causes of terminal secretions
- As a person is dying, becoming
increasing unconscious and
causing the salivary secretions
or bronchial secretions
accumulating in the pharynx
and upper airways. - As air moves over a pooled
secretion in the oropharynx
and bronchi, resulting
turbulence and produces
“rattling” sound.
Pharmacological management of terminal secretions
- Anti-muscarinic / anti-cholinergic drugs
are used to reduce terminal secretions, it
should be given subcutaneously or
sublingual, examples: - SC Buscopan
- SC Scopolamine
- SC Glycopyrrolate
- Atropine 1% eye drops
Non-pharmacological management of terminal secretions
- Position patient on the side or a semi-prone
position to facilitate postural drainage - Good mouth hygiene
- Stop or reduce artificial nutrition and hydration
- Proactively explain and reassure family:
- No evidence it is distressing to patient
- Patient is not ‘drowning’
Why is suctioning not performed in palliative patients with terminal secretions?
- Most secretions are usually below the pharynx
and inaccessible to suctioning. It is also causing
discomfort to patient. Routine deep suctioning is
discouraged.
What are causes of terminal restlessness?
- Patient is uncomfortable.
- Full bladder.
- Urinary retention.
- Impacted bowel .
- Inadequate pain or symptoms control.
- Drug toxicity.
- Emotional upset.
- Fear, anxiety, unresolved issues.
- Altered biochemistry-hypercalcemia, uremia.
- Cerebral anoxia.
- Stimulation of busy care environment- activity
and lighting.
How to communicate with family/caregiver regarding end of life and bereavement?
- No longer able to have oral intake (Discuss about hunger and thirst, if not already done.)
- Prepare them of impending death so that
they can say farewell. - Encourage them to continue
communicating with patient through: Touch, Assuring statements such as ‘I am here with you’, ‘we love you’.
What can family do when patient is actively dying?
- Participate in basic hygiene such as oral care.
- Apply lotion to skin.
- Continue talking to patient such as saying
goodbye. - Prepare calm environment such as playing
soothing music or prayers.
What are some factors affecting where patients wish to die?
- Social circumstances. (Example: close family is supportive of being at home.)
- Psychological factors. (Example: many people do not want to feel a burden to their family.)
What is a Compassionate Discharge?
- Compassionate discharge is defined as a discharge home when patients are critically ill and likely to pass away within short hours or days.
What should be discussed with seriously ill patients with little chance of recovery before compassionate discharge?
- For seriously ill patients with little chance of recovery, it is a good practice to proactively discuss about patients’ preference of place of death to facilitate early planning and coordination.
What should be addressed with the patient before compassionate discharge?
- Has patient expressed a desire to die at home?
- Will symptoms be manageable at home?
- Could patient die enroute?
What should be addressed with the family/caregiver before compassionate discharge?
- Are there caregivers available?
- Is the family able to cope physically and emotionally with
patient’s care and demise? - Is the family aware of what to expect (e.g. about the signs
of dying), how to respond, and who to contact when
patient dies?
What should be addressed regarding resources/equipment before compassionate discharge?
- What equipment is needed (e.g. hospital bed, oxygen
concentration)? - Should referral to a home hospice team or home care services be made?
Factors enabling people to die at home
- Family/ caregivers
- Adequate nursing care
- Night service
- Good symptoms control
- Homecare services and access to home hospice care
- Clear plan of wishes and preferences; including
resuscitation status - Effective care co-ordination
- Sufficient information for family and carers
- Effective out of office hour medical and nursing services
Care after death
- Confirmation of death
- Care of the deceased
- Bereavement support to family members.
Factors influencing behaviour in responding to death
- Exposure to death
- Life expectancy
- Perceived control
over the force of
nature - Belief system
what is Grief?
A “normal” response to an “abnormal” situation.
* process of reacting to the loss, with emotional, physiological, and
cognitive symptoms resulting in a unique behavioral response.
what are the 2 types of grief?
“Normal” grief reactions/ uncomplicated grief
“Abnormal” grief reactions/ complicated grief
what are the Kubler Ross 5 Stages of Grief?
Denial – “Oh no, this can’t be happening to me!”
Anger– “Why me?”
Bargaining– “If I do this, then that won’t happen…..”
Depression
Acceptance
What is the impact of normal grief on the person experiencing it?
Usually causes mild functional impairment. Lasts about 6 months.
how long does normal grief last?
lasts about 6 months.
expression of normal grief varies from person to person because….?
it depends on cultural norms and expectations.
What is complicated grief?
- Failure to return to normalcy.
- Prolonged, overly intense, delayed or absence.
What are the Risk factors for complicated grief?
- Sudden or unexpected death.
- Intimate relationship with the deceased.
- History of mood or anxiety disorders.
- Poor health.
- Multiple stressors.
- Poor social support.
what are the Consequences of complicated grief?
- Depression
- Anxiety
- Alcohol abuse
- Increased use of prescribed drugs
- Suicidal tendencies
- Health deterioration
what is Mourning and what is it influenced by?
the process someone adapt to a loss, which influenced by culture, spiritual and society norm
there are 4 tasks of mourning. what is task one?
Accepting the reality that the person has died and is not coming back.
there are 4 tasks of mourning. what is task two?
- Feeling and expressing the
grief. - The pain should not be denied or avoided.
there are 4 tasks of mourning. what is task three?
Adjusting to life without the deceased:
a) At functional level- taking on roles of the deceased.
b) At internal level - adjusting own sense of self.
c) At spiritual level - how does the death impact upon the bereaved
sense of beliefs, values and meaning.
there are 4 tasks of mourning. what is task four?
The bereaved establishes an enduring connection with the dead person that enables him or her to feel connected and also to get on with life. It is about finding an appropriate place for the dead person in
their emotional life, a sense of connection.
bereavement is described as….
Period of grief and mourning after the loss of someone.
Factors influencing the impact and outcome of bereavement. (Factor 1: Who the person was)
Different impact with different relationship-spouse, child, friends, grandparents etc.
Factors influencing the impact and outcome of bereavement. (Factor 2: Nature of the attachment relationship)
- Strength of the attachment -intensity of grief matches intensity of love.
- Security of the attachment -can the survivor survive without the others,
level of dependency. - Ambivalence –those grieving the loss of someone they are ambivalent
about often experience more problems in bereavement. - Conflict-history of conflict over years of the relationship or immediately
prior to death may give rise to complication in bereavement.
Factors influencing the impact and outcome of bereavement. (Factor 3: Nature of the death)
Untimely death more difficult to grief.
Bereavement following suicide is a unique and challenging experience.
Violence of traumatic deaths are difficult to deal with.
Multiple losses can cause “bereavement overload.”
Factors influencing the impact and outcome of bereavement. (Factor 4: Previous experiences)
How have people dealt with previous losses.
Factors influencing the impact and outcome of bereavement. (Factor 5: Personality)
Coping style - healthy or unhealthy.
Attachment style - secure or insecure. Secure-able to move on.
Insecure - complicated grieving.
Cognitive style - optimism or pessimism.
Sense of self esteem and self efficacy - stronger better outcome.
Factors influencing the impact and outcome of bereavement. (Factor 6: Social Variables)
Level of support from family, friends and society and processes of
communication. Better support and open communication results in better
outcome.
Factors influencing the impact and outcome of bereavement. (Factor 7: Concurrent Variables)
Experiencing high levels of disruption prior to or following death affects
outcome of grief negatively.
Types of bereavement support
- Written information- keeping journals, blog, story book, self-help book
- Counselling/ psychotherapy
- Family/Peer support
- Self-help group
- Voluntary services
- Spiritual
Assessment of needs
- Good communication to facilitate expression of emotion.
- Familiar with events surrounding death.
- An understanding of social background.
- Awareness of risk factors.
Nurse’s role in grief
- Being there.
- Non-judgmental.
- Active listening.
- Demonstrates understanding.
- Encourage them to talk about the deceased.
- Be comfortable with silent.
- Offer appropriate reassurance.
- Be familiar with own feelings about grief.
- Attend to your own needs.
- Do not take anger personally.
- Accept that you cannot make them feel better.
- Respect that some people are not willing to
talk.
