Chapter 34: Care of the Dying Child Flashcards
Dying and Death
total cessation of life
-difficult to comprehend and might be mysterious, ambiguous, or confusing for the child and family
-process is unique, and the exact time or date of death is unpredictable
>when the child enters the dying process, the body begins to shut down physically, emotionally, and spiritually; happen slowly or rapidly
Do Not Resuscitate (DNR)
withholding life-sustaining treatment
-no attempt be made to revive a child who has clinically died
>decisions to withhold, withdraw, or limit medical treatment; the benefits must be weighed against the burden of continuing treatment for the child
-no lifesaving measures will be initiated in the event of cardiac or respiratory arrest
-removing medical equipment such as a ventilator or monitor, dialysis machine, feeding tube used for artificial nutrition, and IV fluids for hydration
-aggressive treatments such as chemotherapy or radiation can also be terminated
Perceptions of Death
- varies across the age continuum
- nurse assists the child according to the appropriate developmental level to help make the transition to death fearless, peaceful, and painless
Understanding Death
-related to the level of cognitive development
Infant’s Perception of Death
based on degree of discomfort and the reactions of the parent and others in the environment
>nurse can ensure the infant’s basic physiological needs are met, and she is able to build trust with the caregivers
-provides comfort through rocking, touch, non-nutritive sucking, and making sure familiar people and transitional or security objects (toys) are present
Toddler’s Perception of Death
-more developed perception; can sense by the way that parents react that something is wrong
-unable to distinguish fact from fantasy, which inhibits a true comprehension of death
>death may mean separation from parents or disruption in routine
-see death as reversible
-dying toddler responds to the possibility of death with fear and sadness
-nurse= encourage parents to stay with the child by giving 24-hour unlimited visitation and ensuring needs are met and comfort is maintained
Preschool Child (3 to 6 years) Perception of Death
-can comprehend death more than can be verbalized
-able to see the body changing and can understand something is wrong
-fear of death may be present as early as 3 years of age; nurses can discuss death simply and honestly in response to the child’s questions; keep answers short
-preschooler is a magical thinker and may view illness or injury as punishment for bad behavior; reinforce condition is not caused by bad behavior
>because they are concrete thinkers, death should NOT be described as “going to sleep”; a child of this age takes this response literally and fears going to sleep, so the nurse must never equate sleep with death
-provide concrete information about the state of being dead (e.g. a dead person no longer breathes or eats)
The School-aged child (6 to 12 years) Perception of Death
-realistic understanding about the seriousness of the condition, but understanding of death is not precise until he/she can understand the concept of time
-aware of non-verbal cues and often understands more of what is overheard than parents and nurses realize
>attempts to shield the school-age child from death can be perceived as distrust; nurse must include children of this age in discussions about their care, condition, treatment or non-treatment, prognosis, and death
-child may request graphic details about death (e.g. burial and decomposition)
>nurse= evaluates for fears of abandonment, destruction, or body mutilation
-important to foster the child’s sense of mastery and sense of control
Adolescent Perception of Death
-capacity to understand death at the adult level
-has difficulty accepting it as reality and often thinks death can be defied
-thinks the body is invincible, hence some of the risk-taking behaviors among this group
>adolescence is a difficult time to deal with death because establishing identity and independence is important
-adolescent has a fear of becoming dependent on parents
-nurse= can help family realize that even though the cognitive ability to understand death is present, the emotional maturity to face death is absent
-include adolescent in decision making
-adolescent might wish to write a final poem or message; say good-bye to friends
>important to allow the adolescent talk about feelings and disappointments about goals and experiences never to be attained
-may want to speak about unrealized plans (e.g. going to college, getting married, etc.)
Before The Child Dies
- nurse completes the institution’s checklist to ensure all of the necessary policies and procedures are followed
- can contact the bereavement team before the death so they are ready to offer support when the death occurs
- can also create a file that includes community resources that the family may need after the death to receive ongoing support
- a ledger may be created as a follow-up for acknowledging important times in the child’s life (e.g. on the child’s birthday or another special day)
- later, a nurse can send a :thinking of you” card to let the family know that the child is still remembered on these occasions
- nurse can also make a note of the child’s death date to make a follow-up phone call tat can allow parents to ask unanswered questions or express feelings
Signs and Symptoms of Impending Death
- loss of sensation
- loss of the body’s ability to maintain thermoregulation: skin may feel cool
- skin color pale to eventually cyanotic
- loss of bowel and bladder function
- loss of awareness, consciousness, and slurring of speech
- alteration in respiratory status
- Cheyne-Stokes respirations (a waxing and waning of respiration in the depth of breathing with regular periods of apnea)
- noisy chest or respirations with the accumulation of fluid in the lungs or in the posterior pharynx
- decreased, weak, or slow pulse rate
- drop in blood pressure
- confusion, delirium, or disorientation
- weakness, fatigue
- changes in pain perception
- restlessness and agitation
- alertness or alternation in sleep
- decreased oral intake
- seizures
Nursing Care Once Medical Treatment is Halted and The family Has Determined That Death is Inevitable
-focus is on allowing the child to die
-nurse can shift from the curative technological approach to providing care that enables the child to move toward death by accessing his/her own inner resources
>to help the child have a peaceful death, comfort measures are essential to help create a positive outcome at the time of the child’s death as well as later on for the family
-nurse= aware of family needs and communicate genuine feelings of kindness and sympathy to the family
Nursing Supportive Behaviors in End-of-Life Care
- allow the parent to hold the child while life support is being discontinued
- provide a peaceful dignified scene at the bedside
- teach the family that the child can still hear you
- encourage family to talk to the child
- use the team approach
- encourage family to ask questions
- validate the family’s caretaking decisions
- provide continuity of care
- if the family is able, have them help care for the child
Nursing Insight: Presence
nurse responds sympathetically to the family at the time of death
- be present
- presence includes a receptive, nonverbal posture that signals to the family that the nurse is willing to sit quietly and listen
- being present may reduce the family’s feelings of isolation
- the family may not need the nurse to say profound words; may simply want the nurse’s support and willingness to remain in the room
The Nurse Can Perform The Following Actions to Support the Dying Process
- promote good communication with the health-care team
- manage pain and discomfort
- create a peaceful and comfortable environment
- assist the child to die with dignity
- cease unnecessary treatments
- allow the family to express their end-of-life care wishes
Physical Touch and the Dying Process
-physical contact is a major source of comfort to both the child and family
-touch from the nurse’s hand, gently stroking the child’s head, or placement of a favorite toy next to the child shows the family that the nurse truly cares about the child
>when offering touch, family members may lean toward the nurse and respond positively
>some might respond with stiffening or drawing back; in this situation, nurse can quietly remove the hand and take a step back
-nurse also realizes it is not the time to share personal stories about losses; keep focus on family
Giving the Family Choices During the Dying Process
- give choices about what is possible during the dying process
- can ask family members if holding the child is desired
- if death is imminent, the nurse must be sure to tell the family that death could occur while holding the child
- a request to get into the bed with the child; is an acceptable behavior
The Environment During the Dying Process
-nurse assesses situation and creates a peaceful environment
-may be appropriate to give family short periods to be alone with the child, or the family may want a health-care professional in the room at all times
>if the family does not respond, ask the family again a few moments later because sometimes the family member cannot absorb everything that is occurring
Care of The Dying Child is Addressed in Three Ways
- palliative care
- hospice care
- end-of-life care
Palliative Care
care that seeks to prevent, relieve, reduce, or soothe the symptoms produced by serious medical conditions or their treatment and to maintain a patient’s quality of life
>palliative care for children is the active total care of the child’s mind, body, and spirit, and also involves giving support to the family
-provides support and care for people, including children, facing life-threatening illnesses
-care is focused on enhancing the quality of life remaining by integrating physical, psychological, social, and spiritual care as defined by the child and family
>interdisciplinary team is aware of child’s needs and uses the approach and interventions that affirm life and neither hasten nor postpone death
-can coexist with curative measures
-goal= advocate for the needs of the child and family so that they can continue to live their lives with dignity and allow the child to die in a manner that is meaningful
Complementary and Alternative Medicine (CAM)
group of diverse medical and healthcare systems, practices, and products that are generally not considered part of conventional medicine
-grouped into 3 groups such as natural products that include a variety of herbal medicines and vitamins, minerals, and natural products; mind and body medicine that includes meditation, acupuncture, and yoga; and manipulative and body practices such as spinal manipulation and multiple massage methods
>Advantages:
-easy to understand, familiar methods, many are noninvasive, many have fewer side effects than medical treatments, help improve overall quality of life, help maintain current state of health, more holistic and in balance with nature
>Disadvantages:
-some treatments are complex
-have not undergone adequate testing of effectiveness
-many herbal preparations and remedies lack Food and Drug administration approval
-many not covered by third-party reimbursement
Hospice Care
-provides palliative (comfort) care across a variety of settings, based on the philosophy that dying is part of the normal life cycle
>promotes concept “living until you die”
-uses a variety of services (medial equipment, diagnostic procedures, and therapeutic interventions) provided by a multidisciplinary group of health-care providers
>once hospice care is initiated, the nurse can help the family determine the best place for the child to spend the final days
At Home Hospice Care
-most children prefer
-receives nursing care that includes visits, treatments, medications, supplies, and equipment offered by the home care agency
-at home, the child is exposed to normal daily activities and surrounded by family members as death draws near
-he/she may be able to continue to play with other children and “feel normal” for as long as possible
>some parents may have too much grief to care for the dying child at home and other children along with household responsibilities; hospice care also provides respite care that allows family members to “take a break” or “time off” to reenergize before returning to the role of the primary caregiver
-also offers professional support after the death of the child
Children’s Hospice International
says it is important to give clear answers to children who are dying
-evasive answers may confused child; keep short and simple
-must remember that the child may be at a developmental level at which he/she may take conversations literally (3 to 6 years preschool)
>When talking to the child it is important to remember:
-do not tell the child that death is sleeping peacefully; the child may fear going to sleep
-do not tell the child abstract concepts like, “it is God’s will”, or “you are such a good boy that God wants you to be with him.” He or she may start to misbehave so as not to die
-approach the child with compassion, honesty, support, and love
