Understanding Death and Grief Management

Hey guys, we're here in chapter 14 and we're going to discuss death and dying to finish out this unit. So we all know that death is inevitable. It's a part of life, basically. As a nurse, it's something that you're going to have to deal with often. How people react to death is very individual and is often influenced by how the death occurred, whether it was sudden or unexpected or whether it was an expected death. The age of the person lost, cultural beliefs, spiritual beliefs have a lot to do with how people respond to death. Grief is the feeling or expression of loss one experiences in response to a death. Anticipatory grief may be experienced when someone has a terminal illness or has been steadily declining and the loved ones experience the loss in anticipation of the impending death. So they're feeling that loss before it even happens because they are anticipating the inevitable or expected to be inevitable loss of their loved one. Sometimes it can be a good thing. It gives the family time to say things they need to say or gives the person time to get their affairs in order. After a loss, survivors experience a state of mourning, which again is individual in intensity and length. but hopefully the loved ones eventually are able to resume their normal activities. In maladaptive grief, this would be where the loved ones or the people experiencing grief have this persistent long-term trouble recovering from the loss, difficulties processing their grief and resuming their life or their normal life. So it's kind of like a persistent long-term. difficulties with this group where they don't adapt and resume their normal activities as well. Mourning is a process following a death that eventually leads to resumption of a normal life and bereavement is a state of having sustained a loss. So those are just some terms to be aware of there. Some theories of loss and grief. We have Kubler-Ross's stages of grief. You'll Often you may be able to see this in the healthcare world. If you observe a patient or family member from diagnosis to death, you will be able to identify these stages. The stages may occur out of order and last for varying times. So again, it's very individualized how people respond to grief and loss. So then the denial stage, it's disbelief. They question the diagnosis. They express that they can't really be dying or a family member may deny. that someone has died suddenly. Psychologists say that this is our way of blocking this unthinkable news until we can absorb the truth. You know, this can't be happening. I have too much to do. I have too much that I want to still do. So that denial is sort of a way of processing or way of dealing with the issue at first because we just can't we just can't process it so we're going to block the news moving on to anger the individual becomes upset they may lash out at family members doctors nurses they're looking for somebody to blame nurses often get the brunt of this so you have to be prepared and not take it to heart it's just part of the process in the bargaining stage the person bargains for more time maybe they bargain with with god for more time um If I can just see my son graduate or if I can just make it to the wedding, they may bargain for more time through God or whomever they believe in spiritually. Moving on to depression, the person becomes very sad as they realize this is indeed happening to them or to their family member. So it's like it's this despair state and they realize death is going to occur regardless of their anger, regardless. regardless of their bargaining or anything else. And the next stage is acceptance. The person realizes that death will occur and they want to put their affairs in order. They want to see certain people or make certain arrangements, plans, documents, things like that. So they're sort of accepting that this is going to happen and they want to take care of things before that before it does and they want to say their goodbyes. Bulby stages of separation and mourning. Bulby noted how separation reaction of children are similar to adult grief patterns. You can read through this slide and see the similarities. The stages of separation, you've got protest, upset, crying, despair, where they're sad and subdued, and detachment, where they just resign themselves to the loss. In mourning, the numbing stage, painful stage, disorganization and despair. then coming back to reorganizing. So first they feel numb, then it's very painful, then they're very full of despair and disorganized, and then they come back to reorganizing. Here's some different types of losses you can read down through there. Loss of a spouse is huge and tolerated differently depending on which sex is the surviving spouse and the age of the surviving spouse. So remember we talked about in our older adult lecture the difficulties one might face if their spouse for many many years has passed on so tolerated differently depending on age and and things like that loss of a parent for an adult would perhaps be an expected loss but still very difficult when a child loses a parent it affects their sense of security so special care should be given to their needs loss of a child is a monumental loss Parents don't expect to outlive their children. Many parents never fully recover from the loss of a child. Fetal loss, regardless of what stage of pregnancy, is very difficult. So death of an unborn or fetal loss. Early pregnancy loss is difficult because often the mom isn't showing signs of pregnancy outwardly yet, so the pregnancy isn't visible to other people. And these moms often suffer in silence because no one wants to talk to them for fear of upsetting them. I know there's been a lot of talk. I see things about, you know, talking about this and making it acceptable to talk about and process and things like that. Late pregnancy loss is horrible as well in its own right. No one knows what to do or say and nothing is really helpful. It's a very devastating thing for patients experiencing that. Loss of a sibling is difficult on the surviving sibling. They have to deal with their own grief, plus the grief that their parents are experiencing. Facing one's own death, your patients tend to know if you have a patient tell you that they feel like they're going to die, you should listen. If someone's trying to tell you something that they need or that they need you to tell someone something for them, listen. Let them talk about their fears. Let them talk about their needs. It helps them to put things in place and gives them a sense of control. So developing a concept of death. Children often don't understand the permanence of death, not until school age, especially with TV and video games where people die and then come back to life. Concepts of death vary according to one's developmental stage. Adolescents feel like they are bulletproof so they don't expect someone of their age to die. Young adults are busy building a life and a career so death at that stage is unexpected. Middle adults see their body aging and start to think about their mortality. Older adults realize that death will occur at some point and normally start to prepare. One part of preparation for death is called a life review. Older adults will tell the most wonderful story, so as a nurse, please take time to listen to them. Some signs of approaching death. Family members will often ask you many questions. When do you think it's going to happen? When do you think my family member is going to pass? We honestly can't tell them. We're not in charge of that. However, there are some signs and symptoms that you will see that signal death is approaching. So withdrawal, the patient gets less talkative, may sleep a lot, they seem very introspective. Decrease in senses, again, it's like they disengage, like they're already seeing the other side, so to speak, and are pulling away from this world. They can still hear, so conversation should remain supportive and calm. Activity changes, they may either be sleeping a lot or may become more restless. Often they may attempt to climb out of bed, pick at the air, talk to people that we can't see. This can be very upsetting for the family, but reassure them that it's totally normal. After this active phase, they normally will sleep a lot. Breathing changes. There's something that happens called Shane Stokes respirations, which are irregular with apneic pauses. As far as their vital signs, their blood pressure drops somewhere around 70 over 40. Their pulse slows. They have a loss of bowel and bladder control. They may go on to level of consciousness changes, not able to be aroused. and they also will get some body cooling progressive cooling from extremities to core extremities become pale and cold you'll see modeling or pooling of blood in dependent areas and you can look on the box listed there on your slide for some signs and symptoms to read through those the self-care determination act All individuals must be offered the opportunity to create advanced directives so they can get ready for the time that they are not able to make those decisions. They can make them ahead of time. You will see this prompt on admissions, and if you're admitting a person totally unrelated to anything about death, there's going to be a prompt to ask if they have advanced directives and offer them the opportunity to get those in order. usually during admission, admission assessment, and again on discharge. So the patient needs to be given an opportunity to create an advanced directive. Often it's the nurse that initiates these conversations with the patient or the family. You can also take a look at the dying person's bill of rights in Potter and Perry. So healthcare facilities must offer this opportunity. If they fail to inform a patient of this right, that can result in a failure to reimburse. So if it isn't documented, you guys will probably hear if it isn't documented, it isn't done. So if it isn't documented that the patient was given this opportunity, the facility could be denied reimbursement. So us as nurses may be the ones having this difficult conversation with our patients sooner in their disease process. Some more end-of-life issues. Advanced directives are a legal document stating the person's wishes for medical treatment in the event they cannot make these decisions. A living will is a form of advanced directive stating the wishes of a person regarding life-sustaining treatment in case of serious illness. So in case they become incapacitated or they're very ill and not able to speak for themselves, what are their wishes in that case? What treatments do they want? How far do they want those treatments to go? There are some handouts in Moodle, a couple of good handouts from the Southern West Virginia, Hospice of Southern West Virginia, some resources that they have on their website. So it kind of further explains some of these advanced directives and things like that. So you can take a look at those. Some more end of life issues. A durable power of attorney is. someone to carry out the patient's wishes for medical care in the event they cannot speak for themselves. So you name a person to carry out your wishes and make sure that person is aware of what your wishes are. A DNR or do not resuscitate order is an order stating the patient does not want measures taken to resuscitate them in event of cardiac or respiratory arrest. So they don't do not want CPR, they don't want intubated, they basically don't want life-saving. They don't want resuscitative measures in the event of cardiac arrest or respiratory arrest. So that's a DNR. The code status of your patient is very important when you're taking care of them. Make sure that you're aware of if they are a full code or if they are a DNR. So that's going to be something important going forward to be aware of the patient's code status. Moving on to some ethical decisions regarding end of life. Euthanasia is basically the deliberate ending of a life or sometimes referred to as assisted death or assisted suicide. This is a very, can be a controversial topic. Some states it is legal in. You've probably heard news stories about this. This is basically deliberately or assisted assisted death basically is what this is often if the person is suffering and things like that so right to die all patients have the right to refuse treatment even if that refusal will result in death religious religious rights come to mind here also so just keep in mind that your patient does have the right to make that choice Palliative care. What palliative care is, is care that focuses on management of symptoms and holistic comfort care of dying patients. So holistic, we've talked about being the whole person, so taking care of their emotional, spiritual needs as well as physical needs. And this is basically comfort care of patients that are terminally ill. Hospice care. These terms, hospice care and palliative care, are sometimes used interchangeably. But what hospice care is, is comfort care, not curative care. So this is care for comfort, not for curing the disease. This is for terminally ill patients. This can occur in a patient's home or in a hospice facility. So there are hospice nurses and hospice services that can go to the home and they can assist with a lot of things, comfort, bathing. things like that medications education supplies so that could be either in the home or in a facility we have hospice of southern west virginia here locally is the service so those are just some ethical decisions end-of-life terms and concepts to be aware of to discuss hospice a little bit Our requirements for hospice are less than six months life expectancy, request for hospice care, physician supports, palliative plan of care. It's normally comfort measures only and focuses on symptom control. So again, not curative, this is comfort care and not actively seeking curative treatment. So that is some hospice requirements. Some symptoms of the terminally ill. You've got pain, skin discomfort, renal irritation, fatigue, anxiety, nausea, constipation, diarrhea, urinary incontinence, altered nutrition, dehydration, ineffective breathing. And you can look there on the page listed to read further about these symptoms. So these would be symptoms that comfort care measures would address. Again, the treatment given is not curative for whatever the main disease process is going on, but it can help manage the symptoms of pain and things like that that they're going through and make them more comfortable. Take some time to read Care of the Grieving Family on the pages listed there in your fundamentals book. There's also some things about care after death and documenting end of life care. Just some things to consider. If a patient has some sort of accidental, an accident or fall or something like that, they may want to do an autopsy on them. So the medical examiner typically must be notified and may decide to perform an autopsy to see if this accident or fall hastened or contributed to the death. And that's even after they're admitted if they fell and this happened. If the patient is a medical examiner case, you must not remove any lines, tubes, etc. They go with the patient. Allow the family time to sit with the patient and say goodbye. This is especially difficult in the hospital setting when room turnover is a big deal. Sometimes you as the nurse have to advocate for the family to give them the time that they need to say goodbye. Always offer to call support persons, clergy, pastors. Other family, things like that, when a death occurs. Of course, now in the age of COVID, there are rules about visitation and things like that, but typically patients are allowed visitors at end of life. Of course, it would be facility specific how many or if they could rotate or or however. So be mindful of that in these days. but typically end of life they are allowed a visitor. Sometimes the family will want to help bathe or dress their loved one. This may help them sort of perform these duties and let go. So know about that eligibility criteria for hospice. They have to be certified to have a terminal diagnosis and prognosis of six months or less. I mentioned the calling of a clergy person. Just be aware that hospitals do have clergy people that you can call or you can call their personal clergy person or if they don't have one but they want one there should be a resource available for you to call and they'll come in and see the patient. And hospice, we mentioned having home care but also the hospice house. There's a Bowers Hospice House in Beckley over toward the Cranberry Prosperity Way. They do a lot of things to help the patients and help the families. And they have counseling support groups, grief support groups, things like that. So there's a lot of resources around that we can refer our patients to and help them out the best that we can. So you can refer to the handouts as well that are posted in Moodle. They talk about hospice, palliative care, and living will, DNR. They discuss, they're pretty good handouts to discuss some of those concepts that we've gone over. So that concludes our lecture on Chapter 14. Thank you.

Hey guys, we're here in chapter 14 and we're going to discuss death and dying to finish out this unit. So we all know that death is inevitable. It's a part of life, basically.

As a nurse, it's something that you're going to have to deal with often. How people react to death is very individual and is often influenced by how the death occurred, whether it was sudden or unexpected or whether it was an expected death. The age of the person lost, cultural beliefs, spiritual beliefs have a lot to do with how people respond to death. Grief is the feeling or expression of loss one experiences in response to a death. Anticipatory grief may be experienced when someone has a terminal illness or has been steadily declining and the loved ones experience the loss in anticipation of the impending death.

So they're feeling that loss before it even happens because they are anticipating the inevitable or expected to be inevitable loss of their loved one. Sometimes it can be a good thing. It gives the family time to say things they need to say or gives the person time to get their affairs in order.

After a loss, survivors experience a state of mourning, which again is individual in intensity and length. but hopefully the loved ones eventually are able to resume their normal activities. In maladaptive grief, this would be where the loved ones or the people experiencing grief have this persistent long-term trouble recovering from the loss, difficulties processing their grief and resuming their life or their normal life.

So it's kind of like a persistent long-term. difficulties with this group where they don't adapt and resume their normal activities as well. Mourning is a process following a death that eventually leads to resumption of a normal life and bereavement is a state of having sustained a loss. So those are just some terms to be aware of there. Some theories of loss and grief.

We have Kubler-Ross's stages of grief. You'll Often you may be able to see this in the healthcare world. If you observe a patient or family member from diagnosis to death, you will be able to identify these stages. The stages may occur out of order and last for varying times. So again, it's very individualized how people respond to grief and loss.

So then the denial stage, it's disbelief. They question the diagnosis. They express that they can't really be dying or a family member may deny. that someone has died suddenly.

Psychologists say that this is our way of blocking this unthinkable news until we can absorb the truth. You know, this can't be happening. I have too much to do.

I have too much that I want to still do. So that denial is sort of a way of processing or way of dealing with the issue at first because we just can't we just can't process it so we're going to block the news moving on to anger the individual becomes upset they may lash out at family members doctors nurses they're looking for somebody to blame nurses often get the brunt of this so you have to be prepared and not take it to heart it's just part of the process in the bargaining stage the person bargains for more time maybe they bargain with with god for more time um If I can just see my son graduate or if I can just make it to the wedding, they may bargain for more time through God or whomever they believe in spiritually. Moving on to depression, the person becomes very sad as they realize this is indeed happening to them or to their family member.

So it's like it's this despair state and they realize death is going to occur regardless of their anger, regardless. regardless of their bargaining or anything else. And the next stage is acceptance.

The person realizes that death will occur and they want to put their affairs in order. They want to see certain people or make certain arrangements, plans, documents, things like that. So they're sort of accepting that this is going to happen and they want to take care of things before that before it does and they want to say their goodbyes.

Bulby stages of separation and mourning. Bulby noted how separation reaction of children are similar to adult grief patterns. You can read through this slide and see the similarities.

The stages of separation, you've got protest, upset, crying, despair, where they're sad and subdued, and detachment, where they just resign themselves to the loss. In mourning, the numbing stage, painful stage, disorganization and despair. then coming back to reorganizing.

So first they feel numb, then it's very painful, then they're very full of despair and disorganized, and then they come back to reorganizing. Here's some different types of losses you can read down through there. Loss of a spouse is huge and tolerated differently depending on which sex is the surviving spouse and the age of the surviving spouse.

So remember we talked about in our older adult lecture the difficulties one might face if their spouse for many many years has passed on so tolerated differently depending on age and and things like that loss of a parent for an adult would perhaps be an expected loss but still very difficult when a child loses a parent it affects their sense of security so special care should be given to their needs loss of a child is a monumental loss Parents don't expect to outlive their children. Many parents never fully recover from the loss of a child. Fetal loss, regardless of what stage of pregnancy, is very difficult. So death of an unborn or fetal loss.

Early pregnancy loss is difficult because often the mom isn't showing signs of pregnancy outwardly yet, so the pregnancy isn't visible to other people. And these moms often suffer in silence because no one wants to talk to them for fear of upsetting them. I know there's been a lot of talk.

I see things about, you know, talking about this and making it acceptable to talk about and process and things like that. Late pregnancy loss is horrible as well in its own right. No one knows what to do or say and nothing is really helpful.

It's a very devastating thing for patients experiencing that. Loss of a sibling is difficult on the surviving sibling. They have to deal with their own grief, plus the grief that their parents are experiencing. Facing one's own death, your patients tend to know if you have a patient tell you that they feel like they're going to die, you should listen.

If someone's trying to tell you something that they need or that they need you to tell someone something for them, listen. Let them talk about their fears. Let them talk about their needs.

It helps them to put things in place and gives them a sense of control. So developing a concept of death. Children often don't understand the permanence of death, not until school age, especially with TV and video games where people die and then come back to life.

Concepts of death vary according to one's developmental stage. Adolescents feel like they are bulletproof so they don't expect someone of their age to die. Young adults are busy building a life and a career so death at that stage is unexpected.

Middle adults see their body aging and start to think about their mortality. Older adults realize that death will occur at some point and normally start to prepare. One part of preparation for death is called a life review.

Older adults will tell the most wonderful story, so as a nurse, please take time to listen to them. Some signs of approaching death. Family members will often ask you many questions. When do you think it's going to happen?

When do you think my family member is going to pass? We honestly can't tell them. We're not in charge of that.

However, there are some signs and symptoms that you will see that signal death is approaching. So withdrawal, the patient gets less talkative, may sleep a lot, they seem very introspective. Decrease in senses, again, it's like they disengage, like they're already seeing the other side, so to speak, and are pulling away from this world. They can still hear, so conversation should remain supportive and calm. Activity changes, they may either be sleeping a lot or may become more restless.

Often they may attempt to climb out of bed, pick at the air, talk to people that we can't see. This can be very upsetting for the family, but reassure them that it's totally normal. After this active phase, they normally will sleep a lot.

Breathing changes. There's something that happens called Shane Stokes respirations, which are irregular with apneic pauses. As far as their vital signs, their blood pressure drops somewhere around 70 over 40. Their pulse slows.

They have a loss of bowel and bladder control. They may go on to level of consciousness changes, not able to be aroused. and they also will get some body cooling progressive cooling from extremities to core extremities become pale and cold you'll see modeling or pooling of blood in dependent areas and you can look on the box listed there on your slide for some signs and symptoms to read through those the self-care determination act All individuals must be offered the opportunity to create advanced directives so they can get ready for the time that they are not able to make those decisions.

They can make them ahead of time. You will see this prompt on admissions, and if you're admitting a person totally unrelated to anything about death, there's going to be a prompt to ask if they have advanced directives and offer them the opportunity to get those in order. usually during admission, admission assessment, and again on discharge. So the patient needs to be given an opportunity to create an advanced directive.

Often it's the nurse that initiates these conversations with the patient or the family. You can also take a look at the dying person's bill of rights in Potter and Perry. So healthcare facilities must offer this opportunity. If they fail to inform a patient of this right, that can result in a failure to reimburse.

So if it isn't documented, you guys will probably hear if it isn't documented, it isn't done. So if it isn't documented that the patient was given this opportunity, the facility could be denied reimbursement. So us as nurses may be the ones having this difficult conversation with our patients sooner in their disease process. Some more end-of-life issues. Advanced directives are a legal document stating the person's wishes for medical treatment in the event they cannot make these decisions.

A living will is a form of advanced directive stating the wishes of a person regarding life-sustaining treatment in case of serious illness. So in case they become incapacitated or they're very ill and not able to speak for themselves, what are their wishes in that case? What treatments do they want?

How far do they want those treatments to go? There are some handouts in Moodle, a couple of good handouts from the Southern West Virginia, Hospice of Southern West Virginia, some resources that they have on their website. So it kind of further explains some of these advanced directives and things like that.

So you can take a look at those. Some more end of life issues. A durable power of attorney is. someone to carry out the patient's wishes for medical care in the event they cannot speak for themselves. So you name a person to carry out your wishes and make sure that person is aware of what your wishes are.

A DNR or do not resuscitate order is an order stating the patient does not want measures taken to resuscitate them in event of cardiac or respiratory arrest. So they don't do not want CPR, they don't want intubated, they basically don't want life-saving. They don't want resuscitative measures in the event of cardiac arrest or respiratory arrest.

So that's a DNR. The code status of your patient is very important when you're taking care of them. Make sure that you're aware of if they are a full code or if they are a DNR.

So that's going to be something important going forward to be aware of the patient's code status. Moving on to some ethical decisions regarding end of life. Euthanasia is basically the deliberate ending of a life or sometimes referred to as assisted death or assisted suicide.

This is a very, can be a controversial topic. Some states it is legal in. You've probably heard news stories about this. This is basically deliberately or assisted assisted death basically is what this is often if the person is suffering and things like that so right to die all patients have the right to refuse treatment even if that refusal will result in death religious religious rights come to mind here also so just keep in mind that your patient does have the right to make that choice Palliative care. What palliative care is, is care that focuses on management of symptoms and holistic comfort care of dying patients.

So holistic, we've talked about being the whole person, so taking care of their emotional, spiritual needs as well as physical needs. And this is basically comfort care of patients that are terminally ill. Hospice care.

These terms, hospice care and palliative care, are sometimes used interchangeably. But what hospice care is, is comfort care, not curative care. So this is care for comfort, not for curing the disease.

This is for terminally ill patients. This can occur in a patient's home or in a hospice facility. So there are hospice nurses and hospice services that can go to the home and they can assist with a lot of things, comfort, bathing.

things like that medications education supplies so that could be either in the home or in a facility we have hospice of southern west virginia here locally is the service so those are just some ethical decisions end-of-life terms and concepts to be aware of to discuss hospice a little bit Our requirements for hospice are less than six months life expectancy, request for hospice care, physician supports, palliative plan of care. It's normally comfort measures only and focuses on symptom control. So again, not curative, this is comfort care and not actively seeking curative treatment. So that is some hospice requirements.

Some symptoms of the terminally ill. You've got pain, skin discomfort, renal irritation, fatigue, anxiety, nausea, constipation, diarrhea, urinary incontinence, altered nutrition, dehydration, ineffective breathing. And you can look there on the page listed to read further about these symptoms. So these would be symptoms that comfort care measures would address. Again, the treatment given is not curative for whatever the main disease process is going on, but it can help manage the symptoms of pain and things like that that they're going through and make them more comfortable.

Take some time to read Care of the Grieving Family on the pages listed there in your fundamentals book. There's also some things about care after death and documenting end of life care. Just some things to consider.

If a patient has some sort of accidental, an accident or fall or something like that, they may want to do an autopsy on them. So the medical examiner typically must be notified and may decide to perform an autopsy to see if this accident or fall hastened or contributed to the death. And that's even after they're admitted if they fell and this happened.

If the patient is a medical examiner case, you must not remove any lines, tubes, etc. They go with the patient. Allow the family time to sit with the patient and say goodbye. This is especially difficult in the hospital setting when room turnover is a big deal. Sometimes you as the nurse have to advocate for the family to give them the time that they need to say goodbye.

Always offer to call support persons, clergy, pastors. Other family, things like that, when a death occurs. Of course, now in the age of COVID, there are rules about visitation and things like that, but typically patients are allowed visitors at end of life. Of course, it would be facility specific how many or if they could rotate or or however.

So be mindful of that in these days. but typically end of life they are allowed a visitor. Sometimes the family will want to help bathe or dress their loved one. This may help them sort of perform these duties and let go.

So know about that eligibility criteria for hospice. They have to be certified to have a terminal diagnosis and prognosis of six months or less. I mentioned the calling of a clergy person.

Just be aware that hospitals do have clergy people that you can call or you can call their personal clergy person or if they don't have one but they want one there should be a resource available for you to call and they'll come in and see the patient. And hospice, we mentioned having home care but also the hospice house. There's a Bowers Hospice House in Beckley over toward the Cranberry Prosperity Way.

They do a lot of things to help the patients and help the families. And they have counseling support groups, grief support groups, things like that. So there's a lot of resources around that we can refer our patients to and help them out the best that we can.

So you can refer to the handouts as well that are posted in Moodle. They talk about hospice, palliative care, and living will, DNR. They discuss, they're pretty good handouts to discuss some of those concepts that we've gone over.

So that concludes our lecture on Chapter 14. Thank you.

Transcript for:Understanding Death and Grief Management

Transcript for:
Understanding Death and Grief Management