grief, loss, end of life care Flashcards
1
Q
types of loss
A
Actual loss: can no longer feel, hear, see, or know a person or object, can be recognized by others
Perceived loss: is felt by person but is less obvious to others
Physical loss versus psychological loss
Maturational loss: experienced as a result of natural developmental process
Situational loss: experienced as a result of an unpredictable event
Anticipatory loss: loss has not yet taken place
2
Q
mourning and Bereavement
A
- Mourning is the period of time following the death of a loved one and may involve cultural rituals.
- The time spent in bereavement depends on a number of factors, including how attached one was to the person who died and how much time was spent anticipating the loss.
- Although often used interchangeably, bereavement refers to the state of loss and grief refers to the reaction to loss.
3
Q
grief
A
- Grief is the normal process of reacting to loss
- Dynamic process
- Includes both psychologic and physiologic responses
- Grief occurs in response to real loss as well as what might have been.
- Psychologic responses include anger, guilt, anxiety, sadness, depression, and despair.
- Physiologic reactions include sleeping problems, changes in appetite, physical problems, and illness.
- Complex and intense emotional experience that affects all aspects of life
- Priority interventions-provide for patient to express feelings
4
Q
Anticipatory Grief
A
- Is what happens when you know there will be a loss, but it has not yet occurred.
- Caregivers of patients with chronic illness often begin to grieve long before the actual death; grief grows worse with each downturn in patient status.
- People say they feel like they are living with a “pit” in their stomach that won’t go away.
- Attempting to cope with fear of death may cause personality changes from day to day, or even moment to moment.
- Perhaps the most difficult…. Tolerating living in a state of emergency for an extended period of time. The mind can only take so much “angst.”
- May struggle to spend the remaining time together in the most meaningful way, keeping the lines of communication open, overcoming the feeling of “giving up,” and self acknowledgement that these feelings are normal and allowed when processing grief.
5
Q
Disenfranchised grief
A
- When the relationship to the deceased person is not sanctioned, cannot be shared openly, or seems less significant
- Cut off from social support and sympathy
- Ambiguous Loss: type of disenfranchised grief that occurs when a person who is physically present but not psychologically available (dementia, brain injury) or the person is gone (POW, kidnapping, disaster and body not found)
6
Q
complicated grief
A
- Prolonged or significantly difficult time moving forward after a loss
- Suffering a chronic and disruptive yearning for the deceased
- Feeling excessively bitter, emotionally numb, emptiness, or anxious
- Chronic Grief – Normal grief that extends for a longer period of time (years to decades)
- Exaggerated Grief – Exhibits self-destructive or maladaptive behavior, obsessions, or psychiatric disorders (risk of suicide)
- Delayed Grief – the person’s grief response is unusually delayed or postponed because the loss is so overwhelming
- Masked Grief – the loss survivor is not aware that their behaviors that interfere with normal grief are a result of a loss (headache, heartburn, rash, tachycardia)
7
Q
Model of Grief Kubler-Ross – 5 Stages of Grief
A
Not everyone experiences all the stages and not necessarily in progressive order.
- Denial - may last minutes to months and be characterized by withdrawal.
- Anger - may be focused in any number of directions:
-The person who inflicted the hurt
-At the world for letting it happen
-At oneself even though nothing could have been done to stop an event from happening (car accident). - Bargaining - for more time or something other than the death
- Depression - may be expressed in numbness, anger, or sadness.
- Acceptance - admitting the reality of the loss results in a calmer phase known as acceptance.
8
Q
factors influencing loss and grief
A
- Human Development – Age of person grieving
- Personal Relationship with the person who has died (spouse, parent, child, etc.)
- Nature of the Loss – avoidable, due to disease, sudden, unexpected
- Coping Strategies – adaptive, maladaptive
- Socioeconomic resources
- Cultural beliefs
- Religious influences and spiritual beliefs
9
Q
grief support
A
- Bereavement and grief counseling are core components of patient- and family-centered palliative care.
- The grieving process takes time, energy, and work.
- The process of resolution in normal grief may take months to years.
- Grief counseling facilitates discussion of feelings and cultivates an environment for open expression of all feelings (anger, fear, guilt).
- Respect for privacy and desire to talk or not to talk is important.
- Honesty in answering questions and giving information is essential.
- Should be integrated into the plan of care before as well as after the death
10
Q
palliative care
A
- Care or treatment focusing on reducing the severity of symptoms
- Begins during curative or restorative health care
- Extends into end-of-life care
- Bereavement care follows death
- Chronic illness is debilitating, costly, and, along with terminal illness, can be a significant burden for caregivers. Therefore, palliative care can help:
- Improves quality of life
- Decreases costs of health care
- Alleviates the burden of care
11
Q
palliative care
A
- Palliative care is indicated when a diagnosis of a life-limiting illness is made and involves; example: cancer, heart failure, COPD, dementia, or ESRD can benefit from implementation of palliative care.
- Communication is important for optimal care.
- Patients may receive palliative care services in the home, long-term and acute care and mental health facilities, rehabilitation centers, and prisons.
- Many institutions have established interprofessional palliative and hospice care teams. The interprofessional palliative care team includes physicians, nurses, social workers, pharmacists, chaplains, and others.
12
Q
hospice care
A
- Hospice care is provided when curative care is forgone. Palliative care is different in that it allows a person to simultaneously receive curative and palliative treatments whereas hospice care is initiated only after the decision is made by the patient or a proxy not to pursue a cure.
- Requires physician certification that life expectancy is 6 months or less
- Hospice care is underutilized
- Patients should be referred as soon as possible to facilitate care at the end of life
- Patients do not need to be actively dying
13
Q
hospice care
A
- Approximately 1.5 million patients receive hospice services each year
- More than ¾ of hospice patients are over age 65.
- The majority are white.
- Most common diagnoses are cancer and heart disease.
- The median length of stay in a hospice program is currently 21 days.
- Almost half of patients who die in the United States are under the care of a hospice program.
14
Q
hospice care
A
- Concept of care that provides compassion, concern, and support for persons in the last phases of a terminal disease
- Hospice programs focus on:
- symptom management
- advance care planning
- spiritual care
- family support
- palliative rather than curative care
- quality rather than quantity of life.
- Available 24 hours/day, 7 days/week
- Provided by medically supervised professional teams and volunteers
- Hospice nurses are pivotal
- Pain control, symptom management, spiritual assessment, assessment and management of family needs
- Hospice nurses play a pivotal role in coordination of the hospice team and need excellent teaching skills, compassion, flexibility, cultural competence, and adaptability.
15
Q
hospice care
A
- Some cultural/ethnic groups may underutilize hospice because of lack of information about hospice services, desire to continue with curative therapies, and concerns about lack of minority hospice workers.
- Physicians may be reluctant to refer patients because sometimes they view a patient’s decline as their personal failure.
- Some patients or families see it as giving up.
- Potential barriers to care in vulnerable populations
- Veterans
- Homeless
- Impoverished
- Disabled
- Institutionalized
16
Q
hospice care
A
Admission has two criteria:
1. Patient must desire services –
* To quality, the patient must desire the services and agree in writing that only hospice care (not curative care) can be used to treat their illness. They can withdraw from the program at any time (if their condition unexpectedly improves, etc.)
- Patient must be eligible for services
* Hospice services are covered by Medicare, Medicaid, and many private insurance agencies.
- Patients can receive care for other health problems that are not related to the terminal illness, but those services may not be covered by the hospice, Medicare, Medicaid, or by the patient’s insurance company.
- Eligibility requires that 2 physicians certify that the patient’s prognosis is terminal, with less than 6 months to live. Recertification only requires 1 physician.
- Care may be provided for extended periods of treatment if the patient still meets enrollment criteria but lives past the expected 6 month survival expectation.
- If a patient’s condition stabilizes, he or she could be discharged.
17
Q
Death
A
- Uniform Definition of Death Act: An individual who has sustained either (1) irreversible cessation of all functions of circulatory and respiratory functions or (2) irreversible cessation of all functions of the entire brain, including the brainstem, is dead.
- Medical criteria used to certify a death: cessation of breathing, no response to deep painful stimuli, and lack of reflexes (such as the gag or corneal reflex) and spontaneous movement, flat encephalogram.
18
Q
End of life
A
- Refers to the period of time during which an individual copes with declining health from a terminal illness or from the frailties associated with advanced age even if death is not clearly imminent.
- Period of time from diagnosis of a terminal illness to actual death varies considerably, depending on the patient’s diagnosis and extent of disease.
19
Q
physical manifestations at EOL
A
- Metabolism is decreased
- Weight Loss
- Body gradually slows down until all function ends
- They may spend less time awake. This lack of wakefulness is because their body’s metabolism is becoming weaker. Without metabolic energy, a person will sleep a lot more.
- cardiovascular system
- Increased heart rate
- Later slowing and weakening of pulse
- Irregular rhythm
- Decreased BP
- Delayed absorption of IM or SQ drugs
20
Q
Physical Manifestations at EOLRespiratory System
A
- Respiratory changes are common at the end of life.
- Respirations may be rapid or slow, shallow, and irregular.
- Breath sounds may become wet and noisy, both audibly and on auscultation. Noisy, wet-sounding respirations, termed the death rattle or terminal secretions, are caused by mouth breathing and accumulation of mucus in the airways.
- Inability to cough or clear secretions
- Cheyne-Stokes respiration is a pattern of breathing characterized by alternating periods of apnea and deep, rapid breathing.
