Nurb end of life comm loss and final hours Flashcards
: acknowledging vulnerability, intuition, empathy, being in the moment, and serenity and silence.
Presence requires
everyone grief is their own, never say that you know how they feel
-setting the right atmosphere: who you want in the room, take to private room, spoke slowly and calmly, say pt died then stop, gave them time does the family want to talk, attentive listening
Effective Communication:
: the patients current medical status including the likely course if no treatment, interventions that might improve prognosis, professional opinion about alternatives available to the patient, recommendation from physician
disclosure
: take reasonable precautions to ensure that such information is not inappropriately divulged
confidentiality
: legal term, practical application of respect of the patients autonomy
informed consent
: ability to understand or to make choices, ability to understand relevant information, appreciate the medical situation and its possible consequences, communicate a choice, goal in relation to the recommended treatment options
decisional capacity
: frequently concerned that when crucial decision must be made about their medical care, no longer capable of participating in those decisions, solution to the problem, essential that patients discuss these concerns with their family and their health care provider, record in patients record
Advanced care planning
from medical paternalism to patient self-determination, requires that all hospitals receiving federal funds must ask patients at the time of admission whether they have advance directives
Patient self-determination act:
- person appointed by a judge to act on behalf of a minor when the court system has determined that the minor requires protective oversight of person and estate, not all state offer
Court appointed guardian
-person or organization appointed by the court to care for an adult who cannot care for self or manage life eof decisions
court appointed conservator
- person who is authorized to make a decision on behalf of another who is incapacitated, next of kin have been considered the natural, family members for the consent
surrogate
- Patient family expectations
- Palliative care planning
- Verbal and non-verbal communication
- Listening/ silence
- Presence
- Guidelines for encouraging free conversation
BARRIERS TO COMMUNICATION
2. Myths/Realities of communication
A. Communication process
A. Family system
B. Financial/educational
C. Physical Limitations
D. Health care professional
Factors Influencing Communication
- Lack of continuity of care among caregivers
2. Lack of support (physical or emotional) among family members
Factors Influencing Communication
Family system
: Financial insecurity/ Anxiety, stress, grief/ Inability to comprehend/communicate
Factors Influencing Communication
Financial/educational
Sensory changes, Sleep deprivation, Inability to comprehend/communicate
Factors Influencing Communication
Physical Limitations:
- Behaviors and communication style be aware
- Communication barriers
- Family meetings/ breaking bad news
- Communication strategies to facilitate end-of-life decision
Factors Influencing Communication
Health care professional
: review medical issue and history, coordinate health care team, discuss goals of meeting with team, identify a meeting leader among the health care team, discuss with family members, arrange private quiet and location, minimize distractions
Recommendations for conducting a family meeting
1. Prepare for meeting
: intro all in attendance, review med situation, establish goal of meeting “everyone understands and answer all questions”
Recommendations for conducting a family meeting
Open the meeting
: ask family question “what do you know about the patient’s conditions” Follow up question: is there anything that isn’t clear that we can help to explain”
Recommendations for conducting a family meeting
Elicit family understanding
A. open ended questions= what are your hopes? What are important for the patient?
B. understand ethnic and cultural influences
C. maintains focus on the pts perspectives, can help to relieve guilt that family members may feel over making decisions
D. dealing with decisions that need to be made:
E. close the meeting
follow up on the meeting
Recommendations for conducting a family meeting
Elicit Patient and Family Values and Goals:
offer brief summary, ask for any final questions, statement of appreciation and respect for the family, make a clear follow up plan family and how to contact health care team
Recommendations for conducting a family meeting
Elicit Patient and Family Values and Goals:
E. close the meeting
document the meeting in chart, follow up any information or reassessment agreed upon during the meeting
Recommendations for conducting a family meeting
Elicit Patient and Family Values and Goals:
follow up on the meeting
common understanding of issues, “have you decided what you want and don’t want?”, open ended assessments then specific interventions, offer clear recommendations, coming to an understanding, check understanding of decision s made
Recommendations for conducting a family meeting
Elicit Patient and Family Values and Goals:
dealing with decisions that need to be made:
- : factual content, style of pt statements, emotional content
6 step protocol for breaking bad news
finding out how much the pt know
- physical context right
- finding out how much the pt know:
- find out how much the pt wants to know
- sharing medical communication:
- responding to the pts feelings
- planning and summarizing:
6 step protocol for breaking bad news
align, educate, give info in small amounts, use lamen terms, check reception frequently, reinforce the info, blend concerns and anxieties
6 step protocol for breaking bad news
4. sharing medical communication:
identify coping of pt and reinforce, other sources of support for the pt
6 step protocol for breaking bad news
6. planning and summarizing:
presence during cpr
in or out introduction now outcome relationship option understanding time
Family Presence yourself as a nurse, clearly short sentences, use pt name
during CPR: in or out
Introduction:
explain pt current status, lamen terms when explaining
during CPR: in or out
now
explain the possible results, realistic don’t give false hope, say work die
during CPR: in or out
outcome
learn who makes the decisions, next of kin
during CPR: in or out
relationship
: assess comprehension, prepare the family for what see and hear, reassure they can leave if they wish
during CPR: in or out
understanding
take action, when is it time to go in, alert healthcare team that family is entering the room, if family behavior is disruptive let the family know behavior is making it hard for the healthcare team to do their best work
during CPR: in or out
time
Interdisciplinary team, Resolving conflict
Team Communication:
: loss for words at least say I am sorry for your loss, it is okay to say I don’t know
. Summary
eof
- be prepared, be brief, tell the truth, listen carefully, be reassuring, be yourself
: gear info toward dev age younger concrete and older abstract, begin with child experiences
: begin with basic info
: look for clues to talk, accept w.e emotion is presented
: ask to summarize what they heard, clarify misunderstandings
: books movies, name people who have had it
Talk to children about death: Begin on the child’s level: Let the child’s questions guide Provide opportunities for the child to express feelings Encourage feedback Use of other resources
): death is temporary and reversible, death is mixed up with trips and sleep, may wonder what the deceased is doing
Children’s understanding of death:
3-5 (preschool
think about finality and biologic process of death, death is related to mutilation, spirit gets you when you die, who cares for them if parent die, their actions and words caused the death
6-9 death understanding
understanding and finality of death, show their feelings they are weak, need to be in control of their feelings, actions and words caused the death
12 and older (teenagers):
death understanding
experience the world through sensory information: aware of tension and separation, comfort by familiar people
Children’s concepts of death:
Infancy 0-2:
death as reversible death is not personalized, magical thinking, don’t believe it could happen to them, think they caused death bc wished go away
Children’s concepts of death:
Early childhood 2-6:
: personalize death, aware death is final, death is caused by and event then later age cause by illness
Children’s concepts of death:
Mid childhood 7-12
: appreciate universality of death my feel distant, engage in risky behavior
Children’s concepts of death:
Adolescence
The Grief Process:
Loss, grief, mourning, and bereavement
physical emotional cognitive and behavioral actions to death
Grief:
: reaction of the survivor to the death of a family member or close friends
Bereavement
: grief before loss
Anticipatory grief
: regular feelings, behaviors, and reactions to loss
Normal grief
normal grief reactions that do not subside and continue over very long periods of time
Complicated grief
1. chronic grief:
chronic grief
delay grief
exaggerated grief
masked grief
Complicated grief
normal grief reactions that are suppressed or postponed,survivor consciously or unconsciously avoids the pain of the loss
delay grief:
survivor resorts to self-destructive behavior such as suicide, drugs, alcohol
exaggerated grief:
: survivor is not aware that behaviors that interfere wit normal function are a result of loss
Masked grief
. Risk factors: sudden losses: heart attack, stroke, tragic death,
Violent death: suicide, homicide/ multiple losses/ child loss
complicated grief
loss cannot be openly acknowledged or socially sanctioned, not recognized by employers, biological family,
Disenfranchised grief:
At risk: aids partners, ex-spouses, step parent child, terminated pregnancy
Disenfranchised grief:
mourn, grieve based on their development level, in spirts, act out=behavioral changes
- Based on age and developmental level
Children’s grief:
nervousness, uncontrollable rages, frequent sickness, accident proneness, antisocial behavior, rebellious,hyperactivity, nightmares, depression, memories fading in and out, excessive dependency on remaining parent
Symptoms of grief in younger children:
difficulty concentrating, forgetfulness, poor school work, insomnia, social withdraw, over dependence or regression, talk of attempted suicide, nightmares, frequent illness, depression, alcohol or drugs, sexual promiscuity, compulsive behavior
Symptoms of grief in older children:
- Notification/shock
- Experience the loss
- Reintegration
Stages and tasks of grief
A. Who it includes
B. When it occurs
C. Nursing assessment of grief
. Grief Assessment
- Type of grief
- Grief reactions
- Stages and tasks of grief
- Factors that affects the grief process
- Caregiver assessment
C. Nursing assessment of grief
-Plan of care, Attitude, Cultural practices, What to say, Children and parents
Bereavement Interventions
- Decrease in sense of loss
- Is advance directive in place?
- Emotional support
- Encourage verbalization
- Assist with role changes, education and/or resources
- Encourage life review
- Educate the patient/family about dying process
- Encourage patient/family to complete unfinished business
- Provide presence, active listening, touch and reassurance
Anticipatory grief
- Presence, active listening, touch, silence
- Identify support systems
- Use bereavement specialists, bereavement resources
- Normalize grief process and individual differences
- Individualize the grief process
- Actualize the loss and facilitating living without the deceased
- Identify and express feelings
- Disenfranchised grief- acknowledgement
- Public funerals, memorial services, rites, rituals and traditions: private rituals
- Spiritual Care
- Recognizing developmental stage of children
- Identify need for additional assistance and making referrals
Grief interventions
A. Witness to futile treatments B. Moral Distress C. Personal death awareness D. Cumulative loss E. stages of adaptation for the nurse F. Factors influencing the nurse’s adaptation process
The nurse: death anxiety, cumulative loss, grief
- Professional education
- Personal death history
- Life changes
- Support system
The nurse: death anxiety, cumulative loss, grief
- Balance
2. Assessing support systems: formal, informal, instructor
Systems of support for healthcare provider
medical futility- prolonged suffering, denial of palliative care services, nurse experience moral distress
Compassion fatigue nurses witness:
- can take a toll, burn out from setting, death on frequent basis
Cumulative loss
nurses
: finding meaning in your work, balance, assessing support systems, spiritual support, education in eof care, self-care strategies
Systems of support
nurses
- nursing does not end with the death of patent
A. Bereavement care continues after death
B. Assessment with ongoing intervention
C. Recognize own grief
D. Bereavement care is interdisciplinary
Conclusion loss grieving and berevament
provide support to staff and patients/families, interpersonal competence, being present, bearing witness, interdisciplinary care
B. Dying is an individualized, personal experience
C. The nurse as advocate- no typical death
Final Hours
A. The nurse, dying and death:
= with present and listening, education, and support in any practice setting
A. Open, honest communication as death approaches
B. The dying older adult
Patient and family preparation through advocacy, communication
signs, symptoms, and nursing interventions/
- sleepy lethargic obtunded semicomatose comatose dead
- rest confused tremulous hallucinations, myoclonic jerks seizures
- pain control, palliative sedation for difficult road
Two roads to death:
easy
hard
A. Determining prognosis B. Psychological and spiritual symptoms C. Artificial nutrition and hydration at the end of life D. Frequency of common symptoms E. Physical signs and symptoms vary
two roads of death
- Fear of the dying process, abandonment, unknown
- Nearing death awareness
- Withdrawal from family, friend and/or caregivers
- Increased focus on spiritual issues
two roads of death
psychological and spiritual symptoms
- Confusion, disorientation, delirium:
- Unconsciousness:
- Weakness/fatigue:
- Surge of energy
- Drowsiness/sleeping: edu family
- Restlessness/agitation:
- Fever
- Bowel changes
- Decreased oral intake:
- Incontinence
- Pain:
Physical signs and symptoms vary
implement safety measures, speak clearly, home care respite care for caregiver, assess cause and treat
Confusion, disorientation, delirium:
intervention and symptom
: continue to speak to patient while doing care, educate family, peaceful settings, family say what they need to say, spiritual needs
Unconsciousness intervention and symptom
increase assistance with adls, equipment, rom, respite care for family, social work for anticipatory grief, increase support, answer questions honestly
Weakness/fatigue: intervention and symptom
common in final hours, multiple causes
Restlessness/agitation: intervention and symptom
increased because progression, assess frequently, adjust meds, listen to concerns
pain intervention and symptoms
A. Assessment and management of pain is critical
B. Opioids
C. Accumulation of metabolites
D. Myoclonus-up dose of opioids
Pain during the final hours of life
-Sedation, Treatment, Comfort measures/emotional support
Intractable pain and other symptoms at the end of life
A. Universal symptoms of imminent death
B. Management of symptoms related to imminent death
C. The death vigil
- Imminent Death
- Decreased urine output
- Cold and mottled extremities
- Vital sign changes
- Respiratory congestion including respiratory bubbling
- Death rattle
- Delirium and confusion
- Restlessness
imminent death universal symptom
- Family desires/preferences: pain control, comfort care, do they want to be present
- Common fears
- Nursing interventions- never jump in to assess for death wait till family is ready
- Honor culture
The death vigil
A. Communicating the death B. Signs and symptoms of death 1. Absence of heart beat/ respiration 2. Pupils fixed 3. Color and Body temperature drops 4. Muscles, sphincters relax
- Death
A. Preparing the family
B. Nursing responsibilities for care after death
C. Death of a parent: Care for the child
Care immediately following death
- Removal of tubes, medical supplies and equipment
- Bathe, dress and position the body
- Plans for burial/embalming
- Removal of the body
- Assistance with phone call and notification of other healthcare providers
- Destroy medications (when death occurs at home)
- Assist with funeral arrangements, as needed and requested
- Initiate bereavement support
- Organ/tissue transplantation
Nursing responsibilities for care after death
A. Allow to verbalize feelings; refer at risk staff
B. Organize memorial services and rituals
C. Serve as role model
Supportive staff eof
Process it takes to deal with. The void, adapting to changes
Mourning
