Chapter 24

1. Chapter 24 Loss, Death, and End-of-Life Care

2. Learning Objectives • Discuss the needs of the terminally ill patient’s significant others. • Discuss the ways in which nurses can intervene to meet the needs of the terminally ill patient’s significant others. • Explore the responses of the nurse who works with terminally ill patients. • Explore the needs of the nurse who works with terminally ill patients. • Identify issues related to caring for the dying patient, including advance directives, do-not-resuscitate decisions, brain death, organ donations, and pronouncement of death.

3. Learning Objectives • Describe beliefs and practices related to death and dying. • Describe responses of patients and their families to terminal illness and death. • Identify nursing diagnoses that are appropriate for terminally ill patients. • Identify nursing goals that are appropriate for terminally ill patients. • Identify nursing interventions to meet the needs of terminally ill and dying patients.

4. Concept of Loss Loss may be defined as a real or potential absence of someone or something that is valued Real losses occur when something actually happens: valued people or possessions are no longer available Potential losses: an individual’s perceptions of what might occur if a valued person or object were lost permanently Anxiety, fear, and grief are common with real and potential losses

5. Types of Losses Change in self-image Perceived change in body image, such as pregnancy, hair loss, disability, or radical surgery, can alter a person’s self-concept The uncertainties and insecurities in role changes result in perceived loss in terms of former roles Developmental changes Changes or milestones may cause insecurities, fears, and feelings of loss Age-related physical and body function changes, as well as a return to dependence, can lead to a loss of self-concept in addition to the developmental loss

6. Types of Losses Loss of possessions Possession has perceived value to the owner; its value may not be apparent to others An object may be irreplaceable because of memories associated with it, or it may be valuable from a monetary standpoint When significant object is lost or left behind, the individual loses a part of his or her identity

7. Types of Losses Loss of significant others Through death, separation, growth of children, change of residence, divorce, or lack of communication Separation from significant others may be related to actual distance, or it may be emotional Emotional: lack of fulfillment of expected roles Communication breakdowns or barriers can divide significant others as completely as changing their place of residence

8. Grief

9. Definition A normal, natural response to a loss Emotional reaction necessary to maintain quality in emotional and physical well-being Grieving process: total individual experience associated with thoughts, feelings, behaviors Usually most profound when loss is death Bereavement: individualized response to the loss of a significant person

10. Adaptive Grief A healthy response May be associated with grieving before a death actually occurs or when the reality that death is inevitable is known

11. Anticipatory Grief Usually related to a loss or death May be a healthy or an unhealthy response to the grief process Patient and family members can experience anticipatory grieving

12. Reactive Grief After an actual loss or a death occurs

13. Dysfunctional Grieving Grief that is delayed or exaggerated May relate to a real loss or a perceived loss May occur in the absence of anticipatory grief, when grief is not resolved from a prior experience, or when the expression of grief is blocked in some way Feelings and behaviors may become exaggerated and disruptive to a person’s typical lifestyle

14. The Grieving Process Culture, religious beliefs, and age affect a person’s understanding of and reaction to death or loss People who believe in “toughing it out” or “being strong” may not express themselves when they have experienced a tragic loss Expressing feelings of loss encouraged and accepted Religious beliefs influence a person’s reaction to loss and death The age or stage of development affects a person’s reactions to death and dying

15. The Grieving Process A child who loses a loved one to death may regress or be delayed in emotional development until the grief can be resolved Adults generally become experienced in accepting the inevitability of death For older adults, effect from death of a spouse is profound Loss of one’s child at any age is an especially traumatic event

16. Stages of Grieving Kübler-Ross Denial Anger Bargaining Depression Acceptance Stages may alternate; not everyone experiences all stages, and there is no predictable timetable for the stages to occur

17. Stages of Grieving Martocchio Shock and disbelief Yearning and protest Anguish, disorganization, and despair Identification in bereavement Reorganization and restitution

18. Stages of Grieving Rando Avoidance Confrontation Accommodation

19. Common Signs and Symptoms of Grief Physical symptoms Tightness in the chest, shortness of breath, suffocation, generalized weakness, intense tightening in the abdomen, and emptiness or churning in the stomach Symptoms may fluctuate throughout the grief process May occur with the initial acknowledgment of death as the outcome The patient and the family members may experience the symptoms of a stress reaction Nursing intervention may be needed to assist a person in regaining a sense of physical function

20. Common Signs and Symptoms of Grief Awareness of terminal illness Awareness of terminal illness and impending death affects the dying person and the family emotionally and physiologically

21. Common Signs and Symptoms of Grief Strauss and Glaser: three states of awareness Closed awareness The family and the patient recognize that the patient is ill; there is a lack of awareness related to impending death Mutual pretense The patient, the loved ones, and the care providers know of the terminal prognosis; no one discusses the issue openly Open awareness Patient and others freely discuss the impending death

22. Fears Associated with Terminal Illness and Death Fear of pain Physiologically, no indication that death is always painful Psychologically, may occur based on the anxieties and separations related to the loss through dying Terminally ill patients who do experience physical pain should have medication available Prevention of pain handled with compassion When death inevitable, nursing interventions aimed at maintaining comfort rather than promoting wellness

23. Fears Associated with Terminal Illness and Death Fear of loneliness Most terminally ill/dying people don’t want to be alone Many are afraid that they will be abandoned by loved ones who cannot cope with imminent death Dying patients typically want someone they know and trust to stay with them Presence of someone provides support and comfort Simply providing companionship allows the dying person a sense of security

24. Fears Associated with Terminal Illness and Death Fear of meaninglessness During dying process, most people review their lives Patients need to look at positive aspects of their lives Relatives can help patients review their lives. The worth of the dying person needs to be expressed You can assist patients and their families by pointing out the positive qualities of the patient’s life Prayers, thoughts, and feelings may provide comfort for the patient

25. Clinical Signs of Impending Death Loss of muscle tone The muscular system weakens gradually Body movements slow; facial muscles lose tone, jaw may sag Speech difficult: decreased muscle coordination Swallowing increasingly difficult; gag reflex lost Functions of the GI and genitourinary systems slow Peristalsis diminishes, which can lead to constipation, gas accumulation, distention, and nausea Pain medications may enhance gastrointestinal slowing Loss of sphincter control: fecal and urinary incontinence

26. Clinical Signs of Impending Death Circulatory and respiratory changes The pulse slows and weakens Blood pressure drops Temperature may be elevated Respirations rapid, shallow, and irregular, or very slow Breathing may sound wet and noisy Cheyne-Stokes respirations are irregular with periods of apnea and develop as a person nears death Decreased circulation causes the skin to become fragile The extremities become mottled and cyanotic The skin feels cool to the touch, first in the feet and legs, then progressing to the hands and arms

27. Clinical Signs of Impending Death Sensory changes Include decreasing pain and touch perception, blurred vision, and decreasing sense of taste and smell Blink reflex lost eventually; patient appears to stare The sense of touch decreases first in the lower extremities in response to circulatory changes Hearing is commonly believed to be the last sense to remain intact during the death process Assume that the patient can hear and understand

28. Clinical Signs of Impending Death Sensory changes Body gradually relaxes until all function ends Generally, respirations cease first The heart stops beating within a few minutes The physician is responsible for ordering discontinuation of life support if it is in use Physician also responsible for pronouncement of death in most situations

29. Clinical Signs of Impending Death In 1968, Harvard Medical School faculty developed the Harvard Criteria: determines a permanently nonfunctioning brain Unresponsiveness to external stimulation that would normally be painful A complete absence of spontaneous movement and breathing A total lack of reflexes that are normally found on a neurologic examination, particularly the reaction of the pupils to light A flat electroencephalogram (EEG) for 24 hours, which indicates that there is no electrical activity in the brain The lack of circulation to the brain for 24 hours as identified by technology

30. Clinical Signs of Impending Death Cerebral death Cerebral cortex stops functioning or is irreversibly destroyed Cerebral cortex or the higher brain is responsible for voluntary movement and actions as well as thought Many people believe that cerebral cortex function is the individual Currently, legal and medical standards require that all brain function must cease for brain death to be pronounced and life support to be disconnected by the physician

31. Physical Changes After Death: Decomposition Rigor mortis Within 2 to 4 hours the body stiffens Caused by chemical changes within the body’s cells that prevent muscle relaxation Usually fully developed in 6-12 hours and will disappear with the decomposition process within 36 hours

32. Physical Changes After Death: Decomposition Algor mortis The body begins to cool Body temperature falls until it reaches the environmental temperature in approximately 24 hours As body cools, the skin loses elasticity and can be broken easily

33. Physical Changes After Death: Decomposition Livor mortis Breakdown of red blood cells causes a discoloration in the skin Skin may appear bruised with reddish purple discoloration Generally, the blood settles in the dependent parts of the body Usually occurs within 30 minutes to 2 hours

34. Nursing Care of Terminally Ill and Dying Patients

35. Assessment Document the specific event that brought patient to the health care facility Record medical diagnoses, medication profile, and allergies If the patient is alert, briefly review the body systems to detect important signs and symptoms Document pain or nausea for prompt intervention

36. Assessment Functional assessment of activities of daily living elicits information about the patient’s abilities, food and fluid intake, patterns of sleep and rest, and response to the stress of terminal illness Determine how patient (if able to communicate) and family are coping Abbreviated; detects changes with terminal illness Frequency of assessment depends on patient’s stability but is done at least every 8 hours

37. Assessment Neurologic assessment especially important; includes level of consciousness, reflexes, and pupil responses Evaluate vital signs, skin color, and temperature; indicates changes in circulation Monitor respiratory status; describe character of respirations and characteristics of breath sounds Renal and GI functions: monitor nutritional and fluid intake, urinary output, and bowel function Monitor skin; becomes very fragile and may break down

38. Assessment General nursing diagnosis of grieving deals with normal grieving experienced following a loss Psychosocial and physiologic reactions to a loss Resolution of grief is primary goal for diagnoses of Anticipatory and Dysfunctional Grieving Evaluation of patient-centered goals focuses on specific coping skills learned and expressed by the patient or the significant others

39. Interventions Priority interventions for Anticipatory and Dysfunctional Grief: provide an environment that allows the patient to express feelings Respect the patient’s privacy and need or desire to talk Honestly answer questions and give information Grieving relatives, friends, and significant others can provide emotional support for one another Community counseling and local support may assist some people in working through their grief

40. Interventions Identify person’s stage of grief (denial, anger, bargaining, depression, acceptance) Awareness of the stage permits the nurse to react according to individual needs Respect for the person’s right to privacy, right to have emotions, and right to talk when he or she chooses is necessary for developing the nurse-patient relationship Anger is a common and normal response to grief Nurses are sometimes the target of the anger and must understand what is happening Nursing care during the last stages of life involves comfort measures and physical maintenance care

41. Interventions Meeting patient’s physiologic needs and needs for safety are priorities Physical requirements for oxygen, nutrition, pain relief, mobility, elimination, and skin care remain throughout the life cycle Physical care maintained and monitored People who are dying deserve and require the same physical care as people who are expected to recover

42. Care of the Body After Death Following death, the body must be prepared for transfer to the morgue or the funeral home Nurse responsible for body care and preparation Dignity and privacy for the deceased and the family must be maintained See Table 24-4, p . 360

43. Care of the Body After Death Legal and moral issues may affect the care required for the disposition of the body Autopsy A postmortem examination of the deceased Autopsy may be requested by the next of kin, suggested by the physician, or required by law Consent must be signed before the procedure can be performed unless procedure required by law Each state has its own laws regarding autopsy In most states, an autopsy is required if a person expires by suicide, homicide, within 24 hours of admission to a health care facility, or from unknown causes

44. Care of the Body After Death The family may want to view the body before it is transported to the mortuary or the morgue It is important to make the environment as comfortable for the family as possible Place the body in the supine position with the arms at the sides or hands across the abdomen Identification bands should remain in place A single pillow is placed under the head and shoulders to prevent discoloration of the face from pooling of the blood

45. Care of the Body After Death Gently holding the eyelids closed for a few seconds helps them to remain closed Dentures may be inserted gently to maintain the normal facial appearance The mouth should be closed Soiled areas of the body should be washed A clean gown is applied, and the hair is combed Remove tubes unless an autopsy is required

46. Care of the Body After Death Straighten top linens; pull up to the shoulders Family may view the body after preparation is complete When the family leaves, apply additional identification tags to the wrist and ankle or toe The gown is removed, and the body may be wrapped in a shroud ID tag is placed on the outside of the shroud Body is then transported to the morgue or removed by the mortician

47. Issues Related to Terminal Illness and Death

48. Organ Donation May be made by anyone who is legally competent Any body part or the entire body may be donated Decision to donate may be made before death Decision to donate may be made by immediate family members following death Follow law and facility policy for organ donation The physician should be notified immediately when organ donation is intended because some tissues must be used within hours after death

49. Cardiopulmonary Resuscitation Much written about the right to die and right to choose Many believe that the patient or the patient’s family has the right to decide whether cardiopulmonary resuscitation (CPR) will be used It is no longer the sole decision of the physician 1991: Omnibus Reconciliation Act of 1990 It is frequently known as the Patient Self-Determination Act Requires all institutions that participate with Medicare to provide written information concerning patient rights to accept or refuse treatment Must explain the patient’s right to initiate advance directives

50. Advance Directive Written statement of person’s wishes regarding medical care Developed 1974 by Euthanasia Education Council It was called a living will Most states have replaced the idea of living wills with natural death acts Within many of these acts are specific aspects related to the individual’s wishes and durable powers of attorney for health care Specific details for withholding or withdrawing treatments must be included