Module 7 End of Life Care, Death and Dying Flashcards
how does grief affect survivors?
physically, psychologically, socially, and spiritually because of very real concrete and perceived losses
describe the nurses role in facilitating the grief process?
includes assisting survivors to feel the loss, express the loss, and complete the stages of the grief process
what must nurses have a thorough understanding of in relation to death and dying?
must have a thorough understanding of a patients loss, its significance and meaning to the patient and family, and how It affects the patient’s and family’s ability to carry on
what are the ways people can experience loss?
-absence of an object, person, body part, child, relationship, or role at work
describe a perceived loss and give example
Perceived loss is any loss that is defined uniquely by the grieving patient, it may be less obvious to others
ex. loss of confidence or prestige
describe a maturational loss and give example
Maturational loss is any change in the developmental process that is normally expected during a lifetime
ex. parents feeling of loss as a child goes to school for the first time
what are maturational losses?
they are part of normal life transitions
describe a situational loss and give exmaple
Situational loss is any sudden, unpredictably external event. Often this type of loss includes multiple losses rather than a single loss
ex. Car accident may leave a driver paralyzed, and grieving over the death of a passenger in the accident
what does the type and perception of loss determine?
the type of loss and perception of loss influences the depth and duration of grief that a person experienes
what is it incorrect to assume about a loss?
that the loss of an object does not generate the same level of grieving as the loss of a loved one
what is the ultimate loss?
death
what is something that all want to do once death is imminent?
nearly all want companionship and want to strengthen relationships with significant others
what are the factors that are influenced by the way someone approaches dying?
influenced by personal fundamental beliefs and values, past experiences with death, culture, spirituality, and the quality of the human emotional support available
what is the emotional response to death?
grief
what are grieving differences based on?
individual experience, previously established coping strategies, cultural expectations, and spiritual beliefs and involve the process of mourning and the process of adapting to a loss
describe bereavement
includes grief and mourning; it is the state of having lost a significant other to death
although no one ever “gets over” a loss, what do they do?
the individual can heal and adapt to the loss
what happens during Kubler-Ross’s Stages of grief?
- During denial, an individual acts as though nothing has happened and may refuse to believe or understand that a loss has occurred
- In the anger stage, individual resists the loss and may strike out at everyone and everything
- During bargaining, the individual postpones awareness of the reality of the loss and may try to deal in a subtle or overt way as though the loss can be prevented
- Person finally realizes full impact and significance of the loss during the stage of depression, which may make them feel overwhelming and lonely and withdraw from interpersonal interaction
- During the acceptance stage, the individual accepts the loss and begins to look to the future
Stages and phases of grief may occur nonsequentially or may overlap
describe Bowlby’s phases of mourning
(a person can move back and fourth between any two of the phases while responding to the loss:
1. Numbing phase may last from a few hours to a week or more and may be interrupted by periods of extremely intense emotion. Briefest phase of mourning 2. Yearning and searching arouses emotional outbursts of tearful sobbing and acute distress in most people. It is necessary for the bereaved person to experience the pain of grief in order to finish the work of grief, through finding the meaning of loss a. Therefore, anything that continually allows the person to avoid/suppress the pain can be expected to prolong the course of mourning b. Common physical symptoms: tightening of chest, SOB, feeling of weakness, insomnia, loss of appetite c. Person may also feel an intense yearning for the object or individual who is lost d. This phase may last for months or years 3. Disorganization and despair, an individual may constantly examine how and why the loss has occurred a. Common for the person to express anger at anyone who might be responsible b. This examination gradually gives way to an acceptance that the loss is permanent 4. Reorganization, the person begins to accept unaccustomed roles, acquire new skills, and build new relationships a. People experiencing this phase must be encouraged to find meaning and hope in their loss without lessening its importance
how is attachment described?
instinctive behaviour that leads to the development of affectionate bonds between children and their primary caregiver
describe Worden’s four tasks of mourning
- This usually takes minimum of one year**
Task 1: to accept that the person or object is gone and will not return
Task 2: to work through the pain and grief. It is impossible to experience a loss and work through grief without emotional pain. Individuals who deny or shut off their pain prolong their grief
Task 3: to adjust to the environment in which the deceased is missing. A person does not realize the full impact of a loss for at least 3 months. At this point, many friends/associates make less frequent contact, and the person is left to ponder the full impact of loneliness
Task 4: to emotionally relocate the deceased and move on with life. Goal: not to forget the deceased or give up the relationship with the deceased but to have the deceased take a new, less prominent place in the person’s emotional life. This is often the most difficult task to complete because people fear they’re being disloyal. A person completes this stage once the person realizes it is possible to love other people without loving the deceased less
list the 4 types of grief and why is knowing the different types important for a nurse?
knowledge of types of grief enables a nurse to implement appropriate bereavement therapies
- Normal Grief
- Anticipatory Grief
- Complicated Grief
- Disenfranchised Grief
describe normal grief
Normal to uncomplicated grief consists of the normal feelings, behaviours, and reactions to a loss, including resentment, sorrow, anger, crying, loneliness, and temporary withdrawal from activities
describe anticipatory grief
- The process of disengaging or “letting go”, that occurs before an actual loss or death has occurred is called anticipatory grief
Ex. Once a person or family member receives a terminal diagnosis, they begin the process of saying goodbye and completing life affairs
what is the risk of anticipatory grief?
Family members may withdrawal emotionally from the patient too soon, leaving the patient with no emotional support as death approaches
describe complicated grief and what are the 4 sub types of complicated grief?
- When a person has difficulty progressing through the normal (generally accepted) phases or stages of grieving, bereavement becomes complicated and prolonged
In these cases, bereavement appears to “go wrong” and loss has not been adequately dealt with.- Chronic grief: an active acute mourning characterized by normal grief reactions that do not subside and continue over very long periods and that becomes complicated mourning
a. May also be known as unresolved grief, or complicated grief
b. Coping strategies tend to be maladaptive - Delayed grief: characterized by normal grief reactions that are suppressed or postponed and by the survivor’s conscious or unconscious avoidance of the pain of the loss
a. Active grieving is held back, only to re-surface later, usually in response to a trivial loss or upset - Exaggerated grief: grief that overwhelms people to the point that they cannot function
- Masked grief: lack of awareness by survivors that feel behaviours that interfere with normal functioning are a result of their loss
- Chronic grief: an active acute mourning characterized by normal grief reactions that do not subside and continue over very long periods and that becomes complicated mourning
describe disenfranchised grief
- People experience grief when a loss is experienced and cannot always be openly acknowledged, socially sanctioned, or publicly shared due to stigmatization
Ex. Loss of a partner from an accidental fentanyl overdose, loss of child in utero or at birth, loss of family member through suicide
who does grief theory apply to?
individuals who mourn over lost independence, body integrity, and a change in body image
what can have a significant influence on people’s views of death and how a dying person should be cared for?
culture
in general, people feel greater burden from a loss when what are lacking?
when financial, education, or occupational resources are lacking
what do they say about loss and personal relationships?
it has been said that to lose parents is to lose the past, to lose a spouse is to lose the present, and to lose a child is to lose the future
what part of loss influences the support a person receives?
the visibility of loss influences it. ex. The loss of ones home from a fire prompts support from the community, whereas a private loss of an important possession may prompt less support from others or losses from miscarriage, abortion etc
patients who have a stronger interconnectedness with a higher power have an easier time with what?
typically are very resilient and able to face death with relatively minimal discomfort. Alternatively, patients faced with a life-threatening or terminal illness may begin to question their faith and wonder why this would be allowed to happen to them
describe hope
the anticipation of a continued good or of an improvement in, or lessening of, something unpleasant
what have nurses reported to make the greatest difference in patients lives?
by telling the patients to keep hope alive; by increasing a patient’s awareness of what is possible
in order to preserve patient autonomy, what do many people use?
advance directives which may include living wills or the designation of a health care proxy
what is a disadvantage of advanced directives?
-A living will or instructional directive limits treatment
what are the 3 values that CNA identifies as being pertinent to nurses assisting individuals in end of life decision making?
- Promoting health and well-being: nurses must ensure that an individual’s wishes as stated in an advance directive are respected and that continuing care and support are provided
- Promoting and resecting informed decision making: nurses must respect and promote the autonomy of individuals, express their needs and values, help patients obtain appropriate care
- Preserving integrity: nurses must advocate on the patient’s behalf
- Nurses must assess the patient’s and family’s wishes for end-of-life care, including the preferred place of death, the use and extent of life-sustaining measures, cultural specific expectations, and expectations regarding pain control and symptoms management
- Some patients may request medical assistance in dying (MAID)
- People who make decisions about when they want their life to end
as a nurse caring for grieving patients, what must you do for yourself?
you must assess your own emotional well-being
-it is normal to have personal feelings/emotions about certain illnesses and death
what do many terminally ill patients experience?
plateaus. (periods of relatively stable health interspersed with periods of exacerbation of symptoms)
list and describe all dimensions of hope
○ Affective dimension: show empathetic understanding of patient’s strengths
○ Cognitive dimension: offer info about the illness and treatments, and correct any misunderstanding of misinformation
○ Behavioural dimension: assist the patient in using personal resources and making use of external supports to balance the need for independence with health interdependence and dependence
○ Affiliative dimension: encourage patients to foster supportive relationships with others
○ Temporal dimension: focus on short-term goals as life expectancy diminishes
-Contextual dimension: encourage development of achievable goals
list guidelines that help people who are mourning death, facing death, and grieving over an actual loss
○ Help the patient accept that loss is real.
○ Support efforts to live without the deceased person or in the presence of disability
○ Encourage establishment of new relationships
○ Allow time to grieve
○ Interpret normal behaviour
○ Provide continuing support
-Be alert for signs of ineffective coping
what is the aim of palliate care?
to relieve suffering and improve the quality of living and dying
who is palliative care for?
for any age, any diagnosis, and at any time, not just during the last few months of life
describe a palliative approach
- A PC approach ensures that a patient experiences a “meaningful death”, free of avoidable pain and suffering, in accordance with patient’s and family’s wishes
comfort for a dying patient requires management of what?
management of symptoms of disease and therapies
what is symptom distress?
the experience of discomfort or anguish related to progression of a disease
what is one symptom common among terminally ill patients? and describe it a bit
dyspnea (air hunger)
- the sense of suffocation can cause anxiety or panic in the patient and significant stress in the caregiver
- As the patients anxiety increases when he or she is unable to breathe adequately, the dyspnea worsens
what are some of the reasons why people are afraid of death and dying?
- the process of dying, with its associated pain and loss of dignity
- not knowing what will happen after death
- dying before fulfilling dreams and goals
what is hospice care?
- alternative care delivery model for terminally ill patients
- designed to assist the patient in being comfortable and maintaining a satisfactory lifestyle until death
what is the role of a nurse in hospice care?
is to meet the primary needs of the dying patient and to be amendable to individual desires of each patient
what happens in relation to the family once the patient dies?
the family becomes the primary patient when the actual death occurs and the shift of concern moves from the deceased to the living family
when caring for a patient who just died, how can it be easier for the nurse to grief?
by being present at the time of time. this allows them to “let go”
what is the role of an enduring power of attorney?
allows an adult to appoint another person (called their attorney) to make decisions regarding their financial and legal affairs.
define advance care plan
is a written summary of a capable adult’s wishes or instructions to guide a substitute decision maker if that person is asked by a physician or other health care provider to make a health care treatment decision on behalf of the adult.
define advance care planning
is a process by which a capable adult talks over their beliefs, values and wishes for health care with their close family/friend(s) and a health care provider in advance of a time when they may be incapable of deciding for themselves.
define advance directive
is a capable adult’s written instructions that speak directly to their health care provider about the health care treatment the adult consents to, or refuses. It is effective when the capable adult becomes incapable and only applies to the health care conditions and treatments noted in the advance directive.
define allow a natural death
is when the patient receives medically appropriate care for symptoms, such as pain or shortness of breath, as death approaches.
define enduring power of attorney
is a document in which an adult authorizes another person (called their attorney) to make decisions in relation to the adult’s financial affairs, business and property. The person (attorney) is authorized to act when the adult becomes incapable, or to continue to act when the adult remains incapable. Attorneys may not make health care treatment decisions.
describe hinduism
○ death isnormalfeature of existence.
○ social event(in addition to it being individual/family event)
○ “good death” = focus heart and mind on god, Pain management, surrounded by family/friends
○ Rituals: creation of sacred space
-Placing an Icon visible to dying person, comforted by seeing/being seen by favourite god-form
-Reciting names of deities or Hindu scriptures
-Perception of death informed by purity, cleanliness, modesty (same-sex caregiver)
describe buddhism
○ Believe in reincarnation (but interpreted differently by different Buddhist traditions)
○ Embrace death as natural and opportunity for spiritual practice and liberation
○ “good death” - clear and virtuous mind at time of death, influence transition to rebirth
§ Atmosphere: calm, peaceful, no loud noises/distractions
○ Rituals: recite prayer (alleviate fears), set up small altar with image of Buddha
-When moving body afterwards: touch crown of head first to allow consciousness to leave
describe islam
○ Physical pain directly related to relationship with god, opportunity for atonement (may refuse pain meds)
○ After life more important than this life, illness is a test and opportunity to deepen ones knowledge of god
○ Rituals: religious acts are the highest concern to achieve a good death
§ Most important: offer prayer 5 times/day at designated times (even if bedridden)
§ Ritual washing of patients body in prep for prayer, same-sex.. Modesty important
§ Privacy, peaceful setting no interruptions
After death: deceased body to be bathed and buried ASAP
describe judaism
○ Ancient tradition and evolving current ideas. EOL influenced by the Torah, Talmud and rabbinic courts
○ Euthanasia prohibited, impedes natural progress of death
○ Importance of family presence and intimacy. Collectively reflecting on the persons life work
○ Emphasis on dying process itself, rather than the afterlife
-Rituals: opening words of Shema at the time of passing
describe christianity
Believe in a compassionate god, importance of maintaining hope and acceptance in adversity
○ Some believe in everlasting life = calmness toward death
○ “good death” - physically comfortable and at peace with god, family and friends
Rituals: lighting candles, taking communion, reading scripture, devotions or prayers
describe chinese traditions
○ Daoist rituals: more important earlier in life, Buddhist: common at death Confucianism: importance of duty and respect toward ones parents
○ Common threads of belief: interrelatedness of all things, importance of family, value just, peaceful, harmonious life
Social relationships take precedence over individual rights (illness cause trouble for family, children expected to take care of parents)
describe aboriginal traditions
○ Cultural value placed on non-interference with natural process of dying
-Home encompasses more than location, place of ceremonial traditions, kinship, connections and sacred space in which both life and death are experienced
what is an actual loss?
person or object that can no longer be felt, heard, or known
describe how infants to 5 years old understand the concept of death
-does not understand, believes death is reversible, separation of parents
describe how ages 5-9 years old understand the concept of death
understands death is final, may believe they are responsible, body parts
describe how 9-12years old understand the concept of death
-understands death is EOL, beings to understand own mortality
describe how 12-18 years old understand the concept of death
- fears a lingering death
- death can be defied
- not adult understanding yet
