Geri End/OB Start: Module 6 - Coping and Death Flashcards
What may a mother with a handicapped or stillborn infant and the elder mourn the loss of (despite being alive?
the visualized “perfect” infant
memorialize the “perfect” self that no longer exists
Loss ___ an individual
changes
What can coming through the grieving process supported help do?
help the individual experience a loss to be able top put the loss into perspective and start to create a new life for themselves
Elizabeth Kubler-Ross Model Stages of Grief
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
Who were the stages of grief for?
Originally for a dying person but now it is used for the grievers
Denial Stage
First Stage
Usually only a temp. defense for the individual.
This is generally replaced with heightened awareness of situations and individuals that will be left behind after death
Ex: “I feel fine;” “This can’t be happening not to me”
Anger Stage
Second Stage
The individual recognizes denial cannot continue
Because of anger, the person is very difficult to care for due to misplaced feelings of rage and envy. Any individual that symbolizes life or energy is subject to projected resentment and jealousy.
Ex: “ Why me? Its not fair!”; “How can this happen to me?”; “Who is to blame”
Bargaining Stage
Third Stage
involves the hope that the individual can somehow postpone or delay death. Usually, the negotiation for an extended life is made with a higher power in exchange for a reformed lifestyle. Psychologically, the person is saying, “I understand I will die, but if I could just have more time…”
Ex: “Just let me live to see my children graduate.”; “I’ll do anything for a few more years.”; “I will give my life savings if…”
Depression Stage
Fourth Stage
the dying person begins to understand the certainty of death. Because of this, the individual may become silent, refuse visitors and spend much of the time crying and grieving. This process allows the dying person to disconnect himself from things of love and affection. It is not recommended to attempt to cheer an individual up that is in this stage. It is an important time for grieving that must be processed.
Ex: “I’m so sad, why bother with anything?”; “I’m going to die . . . What’s the point?”; “I miss my loved one, why go on?”
UPWARD TURN NEEDS TO COME ON ITS OWN NOT FORCED
Acceptance Stage
Fifth and Final Stage
comes with peace and understanding of the death that is approaching
generally the person in the fifth stage will want to be left alone
feelings and physical pain may be non-existent
Stage described as the “end of the dying struggle”
ex: “Its going to be okay”; “I cant fight it, I may as well prepare for it”
2 Problems with the Original 5 Stages of Grief?
- Dr Kubler Ross made it in 1969 while working with people DYING OF CANCER - the stages were supposed to be for the grief a dying person goes through, not those grieving the death of another person
- Stage interpretation neglected the patient’s situations and how they could affect the cycle (ex: relationship supports, effects of illnesses)
The Seven Stage Model
A 7 stage model for the grieving individual dealing with a loss
The stages move in a U shape of worsening mood with an upward swing
What are the 7 Stages of a Grieving Individual?
- Shock and Denial
- Pain and Guilt
- Anger and Bargaining
- “Depression”, Reflection, Loneliness
- The Upward Turn
- Reconstruction and Working Through
- Acceptance and Hope
Shock and Denial Stage
Stage 1 of 7
Griever will reach to learning of the loss with NUMBED DISBELIEF
May DENY reality of the loss as some level to avoid pain
Shock provides emotional protection from being overwhelmed all at once!!!!
Can last for weeks
Pain and Guilt Stage
Stage 2 of 7
Shock and denial is replaced with SUFFERING UNBELIEVABLE PAIN
While pain is excruciating and almost unbearable, IT IS IMPORTANT THAT IT IS EXPERIENCED FULLY - do not hide it, avoid it, or escape with drugs or alcohol
May have feelings of guilt or remorse over things they did or did not do with a loved one
Life feels chaotic and scary at this phase
Anger and Bargaining Stage
Stage 3 of 7
Frustration gives way to anger
May lash out and lay unwarranted blame for the death on someone else - could cause permanent relationship damage!
This is a time of release of bottled up emotion
May rail against fate with “why me?”
May try bargaining in vain with powers that be for a way out of despair (“I will never do ___ again if you bring them back”)
“Depression”, Reflection, Loneliness Stage
Stage 4 of 7
When friends may thing its time to get on with life, a long period of sad reflection will set in
This is a normal stage so they should not be “talked out of it”
Encouragement from others is not helpful to them during this stage!!
During this time they finally realize the true magnitude of their loss and it depresses them
May isolate on purpose, reflect on things, and focus on past memories
May feel emptiness or despair
The Upward Turn Stage
Stage 5 of 7
As the griever adjust to life post-loss, life becomes a little calmer and more organized
Physical symptoms lessen, and “depression” begins to lift slightly
Reconstruction and Working Through Stage
Stage 6 of 7
As they become more functional, their mind starts working again, and they find themselves seeking realistic solutions to problems posted by life without their loved one.
They will start to work on practical and financial problems and reconstructing themselves and their life
Acceptance and Hope Stage
Stage 7 of 7
Learn to accept and deal with the reality of the situation
Acceptance does not necessarily mean instant happiness!
Given the pain and turmoil experienced, they can never return to the carefree untroubled self that existed before this tragedy, but a way forward is found
What is the timetable for grief?
There is none
Is there a right or wrong way to grieve?
No
Grief is as ___ as the person experiencing a loss, their relationship with their lost one, and the circumstances of the death or loss are
individual!
Grief is a ___ and ___ process that may cause you to wonder what?
Grief is an unpleasant and lengthy process that may cause you to wonder as to how long it all will last and when you can expect some relief from the pain
How may grief differ between people?
Some may find within a few months it subsides and they can find closure while others may face years of relentless waves of grief, getting stuck in chronic mourning, and needing professional help
Grief never follows the neat progression of stages as it is complicated and personal, a person may have regression or backtracking
If a person regresses or backtracks to an earlier grief stage what does this mean?
it just means the individual was not finished with it yet and are fully working it through in their own way
Factors that influence loss and grief
Age of the individual dying and of the individuals surviving.
Significance of the loss
Culture
Spiritual beliefs
Gender
Socioeconomic status
Support system
Cause of loss or death
Cultural and religious differences can result in differences in how individuals or families…
View the significance of the event or loss.
Attribute the cause of the illness.
Feel about the appropriateness of medical interventions.
Communicate their responses to the event or loss.
Coping and Grieving Nursing Diagnoses Examples
Grieving
Complicated grieving
Interrupted family process
Risk-prone health behavior
Risk for loneliness
Role strain
Risk for ineffective parenting
What are the unit of care as defined by the patient in hospice?
the patient and family are the unit of care
Hospice uses what to address patient and family needs?
an interdisciplinary team
What is the emphasis in Hospice?
Comfort
Dignity
QOL
Autonomy
Medical treatment of distressing symptoms occurs in hospice related to the terminal diagnosis but…
does not provide interventions to CURE disease or PROLONG life
What is the life expectancy in hospice?
6 mo or less if the terminal illness runs its normal course
Hospice eligibility is covered under…
the Medicare hospice benefit
In order to be placed in hospice, one must …
meet “Local Coverage Determination” (LCD) and have documented rapid clinical decline or significant co morbidities
Scales like FAST and PPS can be used to document functional status
FAST Scale
Used for dementia functional status
does not stage alzheimers
PPS
Palliative Performance Scale
More related to mobility
Barriers and Issues in Hospice Care
Difficulty determining 6 month or less life expectancy
Referrals when death is imminent
Healthcare professionals, patient, or family reluctant to discuss DNR or “give up hope.”
A Need to change focus to hope for comfort instead of hope for a cure.
What things can be expected during the Dying Process
Neurologic dysfunction
Decreasing level of consciousness
Terminal delirium
Loss of ability to swallow
What should the RN do at the time of death?
Create peaceful environment
Notify physician
Shift from care of patient to care of family
Prepare the body – family may or may not want to be present
Notify funeral home
Prepare family and caregivers for potential symptoms associated with the dying process
What kind of death can give family closure and allow for growth?
A peaceful and well managed death
2 Roads of Death
- The usual road
- The difficult road
* These are the roads the dying person can travel toward death
What occurs in the usual road of death?
Normal –> Sleepy –> Lethargic –> Obtunded –> Semicomatose –> Death
What occurs in the difficult road of death?
Normal –> Restless –> Confused –> Tremulous –> Hallucinations –> Mumbling Delirium –> Myoclonic Jerks –> Seizures –> Semicomatose –> Comatose –> Death
Who can pronounce death?
The physician
What can a nurse do in regard to the pronunciation of death process?
A nurse is authorized to pronounce absence of vitals (like listening for heartbeat for a full minute but cannot find it) but then they must call the physician and let them know so they can pronounce the person dead
What things are needed for a pronouncement of death?
- Absence of Heartbeat
- Absence of Respirations
- Absence of Blood Pressure
- Pupils Fixed
What things may an elderly person lose that influences how they mourn?
Their past experience
career
home
spouse
children
siblings
functionality with chronic and acute illness
Who are among the interdisciplinary elderly grief response team members?
nurses
physicians
social workers
pastoral care
funeral director
family
How to help a family death with elderly loss?
REFLECT ON MEMORIES:
Photographs
Collecting life memorabilia
Creating a memorial service such as a religious ceremony, a burial or the planting of a memorial tree.
Comfort, bathing, music, reading to the elder
Support the patient’s advanced directives
Family support – Reminisce
The Last Bath
A final dignity bath that is very solemn and a gentle body cleanse:
Offer the family to stay with the body and participate
Gentle body cleanse
Teeth, eye glasses, stay with the body
Not all facilities use body bags
Be respectful of the body
Do not rub areas
You will notice mottling/bluing of the skin as the body cools
Be sure to identify the body with a tag
What to do with a deceased person’s personal items?
Be sure to carefully inventory
Pass on to Power of Attorney or next of kin
Check with the family to see if any personal belongings should be sent to the funeral home
Offer spiritual services/social support services to the family
General Nursing Interventions for Loss and Grief
Explore and respect ethnic, cultural, religious and personal values in their expression of grief.
Teach the individual or family what to expect in the grief process
Encourage the individual or family to express and share grief with support people. Sharing feelings reinforces relationships and facilitates the grief process.
Teach family members to encourage the individual’s expression of grief, not to encourage the individual to “move on” or fit their expectations of grief.
Encourage the individual to resume normal activities on a schedule that promotes physical and psychological health. Caution against returning too early. Prolonged return may signal a more complicated grieving process.
Use silence and personal presence along with techniques of therapeutic communication.
Use appropriate touch.
Be genuine and caring
Answer questions and refer as needed.
Acknowledge the grief of the individual’s family and significant others.
Offer choices that promote individual autonomy.
Provide appropriate information regarding how to access resources in the community and beyond: clergy, counseling services, hospice, internet sources.
What can you say to the grieving or dying?
“I’m sad for you.” “How are you doing with all of this?” “This must be hard for you.” “What can I do for you?” “I’m sorry.” “I’m here, and I want to listen.”
What should you not say to the grieving or dying?
“You’re young, you can have others.”
“You have an angel in heaven.”
“This happened for the best.”
“Better for this to happen now, before you knew the baby.”
“There was something wrong with the baby anyway.”
Calling the baby “fetus” or “it”. Refer to the baby by name once it is known.
Who is among the interdisciplinary neonatal grief response team members?
nurses
physicians
social workers
pastoral care
funeral director
geneticist
Types of Fetal Loss
Antepartum
Intrapartum
Neonatal
Examples of Antepartum Loss
Miscarriage
Ectopic Pregnancy
Molar Pregnancy
Medical Interruption
Intrauterine Death
Examples of Intrapartum Loss
Fetal Distress
Stillbirth
Antepartum
before childbirth
Intrapartum
during childbirth / Death in labor and delivery
Miscarriage
Spontaneous abortion
Loss of a fetus before 20 weeks of pregnancy
Ectopic Pregnancy
when the fertilized egg grows outside the uterus and can lead to mother and child death possibly
Molar Pregnancy
Noncancerous tumor development in the uterus as a result of a nonviable pregnancy
Medical interruption Loss
Required medical intervention leading to abortion in order to save mothers life - the pregnancy is life threatening
Intrauterine Death
Term generally describing stillbirth while still in the mother after the 20th week
Fetal Distress
uncommon complication of labor where the fetus shows signs before and during childbirth indicating it not being well
ex: Not getting enough oxygen
Stillbirth
birth of a baby who has died any time from 20 weeks in the pregnancy and on through the due date of birth
A stillborn child or in utero loss may have skin loosening and leaking of fluids and damage, so you must wrap it in such a way to prevent loss of things
Neonatal Loss
refers to loss of a child within the first 28 days after delivery
often related to prematurity, anomalies, or infection
Most important neonatal loss intervention?
CREATING MEMORIES
Examples of creating memories intervention for neonatal loss?
Seeing, holding and touching the infant
Photographs of the infant
Journaling the experience
Collecting memorabilia such as locks of hair, ID bracelets, crib cards, stuffed animals, hand and foot prints, clothing, ornaments.
Creating a memorial service such as a religious ceremony, a burial or the planting of a memorial tree.
How should neonatal loss be prepared for viewing?
Depending on the circumstances of the infant’s birth, there may be physical aspects of the infant’s appearance that the parents and those viewing the infant should be prepared for such as:
Bruising
Maceration of the skin
Loss of firmness to tissues
Leaking of body fluids
Despite the abnormal appearance of some structures of a dead/dying infant…
most parents benefit from seeing their infant, it helps them accept reality
Anomalies may be imagined as more grotesque to us than they truly are but the parents can usually find and internalize features about their infant they perceive as positive and play down the issues
5 Common Fears Regarding the Grieving Process (Neonatal)
- Loss of control
- Appearing weak to others
- That they crying will never stop
- Unable to bear the loss
- The infant will be forgotten or the loss minimalized
A leaf with a teardrop sign on the door may indicate…
a room without and infant and a loss that occurred
Important factors that influence the grief following perinatal loss
- The suddenness and unexpected nature of the loss
2. The way the infant death is socially defined in their culture
Resolve Through Sharing Program
Program adopted by most hospitals to train staff to assist parent through perinatal loss
an interdisciplinary response
provides both immediate and long term support and counseling to the parents
entire hospital staff is oriented to the marker used to identify families experiencing a loss (leaf with a teardrop on it)
Should nurses never show emotion?
It is needed to control emotions to handle a situation and provide a safe and appropriate care but periodically not showing our emotions or humanness is viewed as cold and unfeeling
So sometimes genuine emotion can be a sincere way to provide emotional support
What things about dying and grief have changed since the COVID-19 pandemic began?
The numbers of patients that nurses are caring for that are dying.
The manner in which they are dying.
The increased number of patients nurses are having to take on.
The high acuity level of the patients being cared for.
The added complexity of most of your patients being on strict isolation.
The vulnerable are dying but so are others.
Most of us will know people that die from this.
Patients are dying alone without their support system.
Friends and family members are bring traumatized by not being able to be with and comfort their loved ones.
Nurses are already overworked but are having to free up time to be with patients as they die or conduct codes.
Nurses are having to create connections with families at the time of death.
It is an interesting duality has emerged where nurses are suddenly treated as both indispensable and disposable. !!!!!!!
There’s never been a period in the history of nursing where scope of the role has been more understood and valued by the general culture. !!!!!!!!!!
Despite the increased awareness of the importance of nursing with COVID-19, what is the duality that occurs?
Nurses are treated both indispensable and disposable
There has been a lack of respect for rights to work in environments with the right protective equipment that has never occurred before - adding stress and complexity
Some nurses have been fired for speaking out publicly about issues
