Chapter 43: Loss, Grief and Dying

1. Explain the concepts of loss and grieving, including types of loss and grief reactions a. Loss: inaccessibility or change in a valued person, object, or situation. i. Actual loss: loss tangible to both the person sustaining the loss and to others. 1. Ex: loss of a limb, a child, a valued object such as money, and a job ii. Perceived loss: loss tangible only to the person sustaining it. 1. Loss of youth or growing up too quickly iii. Physical loss: loss of life, limb, an object, person, pet, or job. 1. A person who loses an arm in an automobile crash suffers from both the physical loss of the arm and the psychological loss that may be caused by an altered self-image and the inability to return to his or her occupation or other activities. iv. Psychological loss: loss that affects a person’s self-image. v. Anticipatory loss: loss behaviors displayed before the actual loss occurs. 1. Ex: diagnosis with breast cancer and getting a vasectomy and losing the breast vi. Maturational loss: is experienced as a result of natural developmental processes. 1. Ex: A first child may experience a loss of status when a sibling is born 2. Ex: The parent of a single child may experience a sense of loss when the child begins school. vii. Situational loss: experienced as a result of an unpredictable event 1. Ex: traumatic injury, disease, death, or national disaster b. Grief: emotional response to loss. i. Normal expressions of grief may be: 1. physical:(crying, headaches, difficulty sleeping, fatigue) 2. emotional:(feelings of sadness and yearning) 3. social:(feeling detached from others and isolating yourself from social contact) 4. spiritual:(questioning the reason for your loss, the purpose of pain and suffering, the purpose of life and the meaning of death). ii. Dysfunctional grief: distorted or abnormal grief response, including 1. inhibited grief:(suppression of grief reaction) a. manifest somatic (body) symptoms, such as abdominal pain or heart palpitations. 2. unresolved grief:(lengthy or denied grief reaction). iii. Abbreviated grief: short but genuine grief reaction. iv. Anticipatory grief: grief reaction before actual loss. v. Engel’s six stages are: 1. shock and disbelief a. refusal to accept the fact of loss, followed by a stunned or numb response: “No, not me.” CHAPTER 43: LOSS, GRIEF AND DYING 2. developing awareness a. physical and emotional responses such as anger, feeling empty, and crying: “Why me?” 3. Restitution a. rituals surrounding loss; with death, it includes religious, cultural, or social expressions of mourning, such as funeral services 4. resolving the loss a. void left by the loss 5. Idealization a. exaggeration of the good qualities of the person or object, followed by acceptance of the loss and a lessened need to focus on it 6. Outcome a. dealing with loss as a common life occurrence vi. Kübler-Ross five stages of reaction: 1. Denial and isolation 2. Anger 3. Bargaining 4. Depression 5. Acceptance 2. Describe the signs of impending death. a. Difficulty talking or swallowing b. Nausea, flatus, abdominal distention c. Urinary or bowel incontinence or constipation d. Loss of movement, sensation, and reflexes e. Decreasing body temperature with cold or clammy skin f. Weak, slow, or irregular pulse g. Decreasing blood pressure h. Noisy, irregular, or Cheyne–Stokes respirations i. Restlessness or agitation j. Cooling, mottling, and cyanosis of the extremities and dependent areas i. Mottling: purpling of the skin ii. Cyanosis: bluing of the skin 3. Compare and contrast the five emotional stages of dying defined by Kübler-Ross. i. Stages can be flowed through backward and forward, no timeline b. Denial: The patient denies the reality of death and may repress what is discussed. i. Ex: patient may think, “They made a mistake in the diagnosis. Maybe they mixed up my records with someone else’s.” c. Anger: The patient expresses rage and hostility and adopts a “why me?” attitude: i. Ex: “Why me? I quit smoking and I watched what I ate. Why did this happen to me?” d. Bargaining: The patient tries to barter for more time. Many patients put their personal affairs in order, make wills, and fulfill last wishes, such as trips, visiting relatives, and so forth. It is important to meet these wishes, if possible, because bargaining helps patients move into later stages of dying. i. ex: “If I can just make it to my son’s graduation, I’ll be satisfied. Just let me live until then.” e. Depression: The patient goes through a period of grief before death. The grief is often characterized by crying and not speaking much i. ex:“I waited all these years to see my daughter get married. And now I may not be here to see her walk down the aisle. I can’t bear the thought of not being there for the wedding—and of not seeing my grandchildren.” f. Acceptance: When the stage of acceptance is reached, the patient feels tranquil. The patient has accepted the reality of death and is prepared to die. i. Ex: The patient may think, “I’ve tied up all the loose ends: made the will, made arrangements for my daughter to live with her grandparents. Now I can go in peace knowing everyone will be fine.” 4. Identify ethical and legal issues in end-of-life care, including advance directives, physician orders, assisted suicide, and euthanasia. a. Advance Directive: written directive that allows people to state in advance what their choices for health care would be if certain circumstances should develop i. For anyone 18 and older ii. Provides instructions for future treatment iii. Appoints a Health Care Representative iv. Does not guide Emergency Medical Personnel v. Guides inpatient treatment decisions when made available 1. a living will a. provide specific instructions about the kinds of health care that should be provided or foregone in particular situation 2. durable power of attorney a. appoints an agent the person trusts to make decisions in the event of subsequent incapacity vi. 5 wishes: 1. The person I want to make care decisions for me when I can’t 2. The kind of medical treatment I want or don’t want 3. How comfortable I want to be 4. How I want people to treat me 5. What I want my loved ones to know b. POLST form: A Physician Order for Life-Sustaining Treatment form is a medical order indicating a patient’s wishes regarding treatments commonly used in a medical crisis i. POLST form must be completed and signed by a healthcare professional ii. cannot be filled out by a patient iii. These forms are always completed in close consultation with the patient to ensure that the patient’s values and goals of care are accurately represented. 1. Physician Order for Life-Sustaining Treatment (POLST) Form: a. For persons with serious illness—at any age b. Provides medical orders for current treatment c. Guides actions by Emergency Medical Personnel when made available d. Guides inpatient treatment decisions when made available c. Euthanasia: mercy killing; the deliberate termination of the life of a person i. Active euthanasia: is taking specific steps to cause a patient’s death 1. doing something to end a patient’s life a. (e.g., administers a lethal dose of medication) ii. Passive euthanasia: is defined as withdrawing medical treatment with the intention of causing the patient’s death. 1. not doing something to preserve a patient’s life. In assisted suicide a. (e.g., a prescription for a lethal dose of barbiturates) d. Assisted suicide: making a lethal combination of drugs available to a patient wishing to die or administering a lethal injection or carbon monoxide 1. The ANA Code for Ethics states that the nurse: a. “should provide interventions to relieve pain and other symptoms in the dying patient consistent with palliative care practice standards and may not act with the sole intent to end life” e. Orders: i. Do Not Resuscitate (DNR) order, or No Code: 1. patient or surrogate has expressed a wish that there be no attempts to resuscitate the patient. Means that no attempts are to be made to resuscitate a patient whose breathing or heart stops ii. Slow Code (or “Show Code”): 1. should be called in the case of cardiopulmonary or respiratory arrest, calling a code and resuscitating the patient are to be delayed until these measures will be ineffectual. iii. Allow Natural Death (AND) order: 1. Easier for families to authorize doing something positive rather than preventing something a. (i.e., a resuscitative effort) that is usually perceived to be helpful. iv. Do Not Intubate (DNI) order v. Comfort Measures Only order: 1. which indicates that the goal of treatment is a comfortable, dignified death and that further life-sustaining measures are no longer indicated. vi. Do Not Hospitalize order: 1. Often used for patients in long-term care and other residential settings who have elected not to be hospitalized for further aggressive treatment. vii. Terminal Weaning: 1. withdrawal of life-sustaining therapy with the understanding that death may result, generally after a decision is made that the therapy in question is medically futile or disproportionately burdensome a. A nurse’s role in terminal weaning: i. participate in the decision-making process by offering helpful information about the benefits and burdens of continued ventilation ii. provide a description of what to expect if terminal weaning is initiated. iii. supporting the patient’s family and managing sedation and analgesia are critical nursing responsibilities. viii. Palliative Sedation: 1. the lowering of patient consciousness with medication for the express purpose of limiting the patient’s awareness of suffering that is intractable and intolerable 5. Explain six factors that affect loss, grief, and dying a. Developmental Considerations i. Children: do not understand death on the same level as adults do 1. their sense of loss is just as great 2. likely to talk about and ask questions about death in an attempt to understand it 3. needs to go through the same grief reactions as adults to accept such a loss and maintain emotional well-being. 4. death of a parent or another significant person can retard a child’s development or may cause the child to regress developmentally. ii. Middle-aged adult: 1. Death of a parent helps to prepare the adult for the loss of a spouse or significant other and to accept his or her own eventual death. iii. Older adults: 1. may lose a spouse or friends and relatives their own age