Session 4 Flashcards
“Good Death”
Having control over pain and other
symptoms.
Dying in the place of choice.
Having good relationship with family.
Cared by staff with high level of knowledge and expertise.
Anticipating and preparing
Is the patient
comfortable?
Review medication for appropriateness for end-of-life stage.
- Switch essential medications to non-oral route.
- Anticipatory medication (example:
standby Haloperidol for delirium
Stop unnecessary medications,
procedures, monitoring such
as blood pressure or Sp02.
Family/caregiver
coping ability
Evaluate symptoms such as
pain, breathlessness, dry
mouth, agitation, secretions.
Nursing care- Skin, oral,
bladder and bowel
Onset of Dying
- Profound weakness
- Gaunt appearance
- Drowsiness
- Disorientation
- Diminished oral intake
- Difficulty taking oral
medications - Poor concentration
- Skin colour changes
- Temperature change at
extremities
Symptoms management
- Pain
Assess and manage appropriately:
- non verbal expression such as grimacing, tensed body, moaning.
Symptoms management
- Breathlessness
Assess and manage appropriately:
- any use of accessory muscles, frowning, tensed facial muscles.
Symptoms management
- Fever
Tepid sponge
Administer paracetamol suppository or NSAIDS (as appropriate)
Symptoms management
- Dry skin and
mouth
Apply skin moisturiser
Perform oral care
Symptoms management
- Body felt cold
Cover with blanket to keep patient warm and comfortable
Symptoms management
- More sleepy/drowsy
Keep calm environment
Continue to communicate with patient (include family members and loved ones)
Terminal Secretions
Terminal secretions (rattling) are
often observed in an imminently
dying person.
It often indicates a short
prognosis. In general, it is within
hours to short days after
secretions are first diagnosed.
It may be distressing to family or
caregivers.
Terminal secretions causes
- As a person is dying, becoming
increasing unconscious and
causing the salivary secretions
or bronchial secretions accumulating in the pharynx and upper airways. - As air moves over a pooled
secretion in the oropharynx and bronchi, resulting turbulence and produces “rattling” sound.
Terminal secretions Management
pharmacological
Anti-muscarinic / anti-cholinergic drugs are used to reduce terminal secretions, it should be given subcutaneously or sublingual, examples:
- SC Buscopan
- SC Scopolamine
- SC Glycopyrrolate
- Atropine 1% eye drops
Terminal secretions Management
Non-pharmacological
Non-pharmacological
* Position patient on the side or a semi-prone position to facilitate postural drainage
- Good mouth hygiene
- Stop or reduce artificial nutrition and hydration
- Proactively explain and reassure family:
- No evidence it is distressing to patient
- Patient is not ‘drowning’
- Most secretions are usually below the pharynx and inaccessible to suctioning. It is also causing
discomfort to patient. Routine deep suctioning is discouraged.
Causes of Terminal Restlessness
- Patient is uncomfortable.
- Full bladder.
- Urinary retention.
- Impacted bowel .
- Inadequate pain or symptoms control.
- Drug toxicity.
- Emotional upset.
- Fear, anxiety, unresolved issues.
- Altered biochemistry-hypercalcemia, uremia.
- Cerebral anoxia.
- Stimulation of busy care environment- activity
and lighting.
Terminal Restlessness
what family can do
- Participate in basic hygiene such as oral care.
- Apply lotion to skin.
- Continue talking to patient such as saying goodbye.
- Prepare calm environment such as playing soothing music or prayers.
Place of Death
Most people expressed ideally like to die at home.
- Social circumstances.
Example: close family is supportive of being at home. - Psychological factors.
Example: many people do not want to feel a burden to their family.
Compassionate Discharge
Compassionate discharge is defined as a discharge home when patients are critically ill and likely to pass away within short hours or days.
- For seriously ill patients with little chance of recovery, it is a good practice to proactively discuss about patients’ preference of place of
death to facilitate early planning and
coordination.
Compassionate Discharge
Patient
- Has patient expressed a desire to die at home?
- Will symptoms be manageable at home?
- Could patient die enroute?
Compassionate Discharge
Family/Caregiver
Are there caregivers available?
Is the family able to cope physically and emotionally with
patient’s care and demise?
Is the family aware of what to expect (e.g. about the signs of dying), how to respond, and who to contact when
patient dies?
Compassionate Discharge
Resources/Equipment
What equipment is needed (e.g. hospital bed, oxygen
concentration)?
Should referral to a home hospice team or home care
services be made?
Factors enabling people to die at home
Family/ caregivers
Adequate nursing care
Night service
Good symptoms control
Homecare services and access to home hospice care
Clear plan of wishes and preferences; including resuscitation status
Effective care co-ordination
Sufficient information for family and carers
Effective out of office hour medical and nursing services
Care after death
Confirmation of death
* Care of the deceased
* Bereavement support to family members
Factors influencing
behaviour in responding to
death
- Exposure to death
- Life expectancy
- Perceived control
over the force of
nature - Belief system
Grief
A “normal” response to an “abnormal” situation.
* process of reacting to the loss, with emotional, physiological, and
cognitive symptoms resulting in a unique behavioral response.
Types of grief:
- “Normal” grief reactions/ uncomplicated grief
- “Abnormal” grief reactions/ complicated grief
Kubler Ross 5 Stages of Grief:
Denial – “Oh no, this can’t be happening to me!”
- Anger – “Why me?”
- Bargaining – “If I do this, then that won’t happen…..”
- Depression
- Acceptance
Normal Grief
Expression varies from person to person as it depends on
cultural norms and expectations.
Usually causes mild functional impairment and lasts about
6 months
Complicated Grief
Failure to return to normalcy.
Prolonged, overly intense, delayed or absence.
Risk factors for complicated grief
Sudden or unexpected death.
Intimate relationship with the deceased.
History of mood or anxiety disorders.
Poor health.
Multiple stressors.
Poor social support
Consequences of complicated grief
Depression
Anxiety
Alcohol abuse
Increased use of prescribed drugs
Suicidal tendencies
Health deterioration
Mourning
the process someone adapt to a loss, which influenced by
culture, spiritual and society norm.
Tasks of mourning
Task one
Accept the reality of loss
Accepting the reality that the person has died and is not coming back
Tasks of mourning
Task two
Feeling and expressing the
grief.
The pain should not be denied or avoided
Tasks of mourning
Task three
Adjust to a world without this
deceased
Adjusting to life without the deceased:
a) At functional level- taking on roles of the deceased.
b) At internal level - adjusting own sense of self.
c) At spiritual level - how does the death impact upon the bereaved
sense of beliefs, values and meaning.
Tasks of mourning
Task four
Find an enduring connection
with the deceased in the midst
of embarking on a new life.
The bereaved establishes an enduring connection with the dead
person that enables him or her to feel connected and also to get on
with life. It is about finding an appropriate place for the dead person in their emotional life, a sense of connection.
Bereavement
Period of grief and mourning after the loss of someone
Factors influencing the impact and outcome of bereavement.
- Who the person was
- Nature of the attachment
relationship - Nature of the death.
- Previous experiences
- Personality
- Social variables.
- Concurrent stresses
Explanation 1. Who the person was
Different impact with different relationship-spouse, child, friends,
grandparents etc
Explanation 2. Nature of the attachment relationship
Strength of the attachment -intensity of grief matches intensity of love.
Security of the attachment -can the survivor survive without the others,
level of dependency.
Ambivalence –those grieving the loss of someone they are ambivalent
about often experience more problems in bereavement.
Conflict-history of conflict over years of the relationship or immediately
prior to death may give rise to complication in bereavement.
Explanation 3. Nature of the death.
Untimely death more difficult to grief.
Bereavement following suicide is a unique and challenging experience.
Violence of traumatic deaths are difficult to deal with.
Multiple losses can cause “bereavement overload.”
Explanation 4. Previous experiences
How have people dealt with previous losses
Explanation 5. Personality
Gender-men and women grief differently and respond to different intervention.
Coping style-healthy or unhealthy.
Attachment style -secure or insecure. Secure-able to move on.
Insecure-
complicated grieving.
Cognitive style-optimism or pessimism.
Sense of self esteem and self efficacy- stronger better outcome
Explanation 6. Social variables.
Level of support from family, friends and society and processes of
communication. Better support and open communication results in better
outcome.
Explanation 7. Concurrent stresses
Experiencing high levels of disruption prior to or following death affects
outcome of grief negatively.
Bereavement management
Types of bereavement support:
- Written information- keeping journals, blog, story book, self-help book
- Counselling/ psychotherapy
- Family/Peer support
- Self-help group
- Voluntary services
- Spiritual
Assessment of needs
Good communication to facilitate expression of emotion.
Familiar with events surrounding death.
An understanding of social background.
Awareness of risk factors.
Nurse’s role during bereavement
Being there.
Non-judgmental.
Active listening.
Demonstrates understanding.
Encourage them to talk about the deceased.
Be comfortable with silent.
Offer appropriate reassurance.
Be familiar with own feelings about grief.
Attend to your own needs.
Do not take anger personally.
Accept that you cannot make them feel better.
Respect that some people are not willing to
talk.
