Unit X Concept of Loss & Grieving and Death and Dyingsouth city.ppt

Briefly describe the concept of death and dying and also bereavement

1. 1
INSTITUTE NAME : SON, NATIONAL INSTITUTE OF CHILD
HEALTH,
DISCIPLINE : B SC NURSING(G) DEGREE PROGRAM
CLASS / LEVEL : 1
ST
YEAR, 2
ND
SEMESTER
SUBJECT : FUNDAMENTAL OF NURSING-2
COURSE WAITAGE : FOUR CREDIT HOURS
CHAPTER NO. : DEATH, DYING,
BEREAVEMENT
PREPARED AND PRESENTED BY
BY
MUHAMMAD FAROOQ SAEED
PROGRAM COORDINATOR
SON, NICH, KARACHI

2. Objectives
At the end of this presentation, the participants will be able to;
Define end-of-life and its care
Recognize phases and signs and symptoms of death
Explain the Kubler-Ross’ model
Manage ethical and legal issues of dying patient
Interpret the hospice and palliative care
Implement the nursing care for dying patient
Improve the nursing intervention for grief work facilitation
Summarize the end-of-life care
2

3. Introduction to End-of-Life Care
Dying and death are painful experiences for those that are dying and their
loved ones caring for them.
End of life has not been thought of as an important clinical topic in critical
care.
More than one third of patients who died spent at least 10 days in a critical
care unit.
Content on end of life in critical care textbooks, both medical and nursing,
is minimal.
3

4. Introduction to End-of-Life Care
The first textbook on end of life in critical care was only published in 1998
and the second in 2001
Death of a patient is generally regarded as a failure
The language around end of life is stated in negative terms e.g. the phrase
withdrawal of care is used---imagine the impact of that phrase on families
4

5. Definition:
Death and Dying:
The act of dying; the end of life; the total and permanent cessation of all
vital functions of the body including the heartbeat, brain activity
(including the brain stem), and breathing.
Verb die:
To cease to live; undergo the complete and permanent cessation of all
vital functions; become dead.
5

6. Definition:
Bereavement:
A period of mourning after a loss, especially after the death of a loved
one.
Abstract:
Bereavement care is an important, yet often forgotten, area of care.
Evidence suggests that early and prompt interventions for high-risk
individuals can facilitate grief and can minimize the adverse
consequences of grief.
Nurses can play a pivotal role in providing care to bereaved
individuals. However, it is essential to have a thorough knowledge of
the normal grief response, and a framework for assessment and
management.
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7. Leading Causes of Death
7

8. Phases and Signs/Symptoms of Death
The individual dying and facing eventual death may go
through two main phases prior to actual death;
Pre-active phase
Active phase
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9. Phases and Signs/Symptoms of Death
Pre-active Phase
Person withdraws from social activities and spends more time alone
Person speaks of "tying up loose ends" such as finances, wills, trusts
Person desires to speak to family and friends and make amends or
catch up
Increased anxiety, discomfort, confusion, agitation, nervousness
Increased inactivity, lethargy or sleep
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10. Phases and Signs/Symptoms of Death
Pre-active Phase
Loss of interest in daily activities
Increased inability to heal from bruises, infections or wounds
Less interest in eating or drinking
Person talks about dying, says that they are going to die or asks
questions about death
Person requests to speak with a religious leader or shows increased
interest in praying or repentance
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11. Phases and Signs/Symptoms of Death
Active Phase
Person states that he is going to die soon
Has difficulty swallowing liquids or resists food and drink
Change in personality
Increasingly unresponsive or cannot speak
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12. Phases and Signs/Symptoms of Death
Active Phase
Does not move for longs periods of time
The extremities—hands, feet, arms and legs—feel very cold to touch.
Not all people show these signs. These signs of death are merely a
guide to what may or often happens; some may go through few signs
and die within minutes of a change being noticed
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13. Phases and Signs/Symptoms of Death
Other signs and symptoms of Dying
Coolness
Sleeping
Disorientation
Incontinence
Secretions
Breathing pattern changes
Reduced production of urine
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14. Phases and Signs/Symptoms of Death
Other signs and symptoms of Dying
Withdrawal
Vision like experiences
Refusing food or drink
Unusual communication
Giving permissions
Saying goodbye
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15. Diagnosis
The official signs of death include the following:
No pupil reaction to light
No response of the eyes to caloric (warm or cold) stimulation
No jaw reflex (the jaw will react like the knee if hit with a reflex
hammer)
No gag reflex (touching the back of the throat induces vomiting)
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16. Diagnosis
The official signs of death include the following:
No response to pain
No breathing
A body temperature below 86 °F (30 °C)
No blood circulating to the brain, as demonstrated by angiography
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17. Changes in Body After Death
Rigor Mortis:
Body becomes stiff within 4 hours after death as a result of decreased ATP
production. ATP keeps muscles soft and supple.
Algor Mortis:
Temperature decreases by a few degrees each hour. The skin loses its elasticity
and will tear easily.
Livor Mortis:
Dependant parts of body become discolored. The patient will likely be lying on
their back, their backside being the 'dependant' body part. The discoloration is
a result of blood pooling, as the hemoglobin breaks down.
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18. Response to Death and Dying
Kubler-Ross' (1969) theory of the stages of grief has gained wide
acceptance in nursing and other disciplines.
The duration of any stage may range from as little as a few hours
to as long as months. The process varies from person to person.
The five stages of dying are:
Denial
Anger
Bargaining
Depression
Acceptance
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19. Response to Death and Dying
Denial
On being told that one is dying, there is an initial reaction of shock.
The patient may appear dazed at first and may then refuse to believe
the diagnosis or deny that anything is wrong.
Anger
Patients become frustrated, irritable and angry that they are sick.
The anger may be displaced onto the hospital staff or the doctors who
are blamed for the illness.
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20. Response to Death and Dying
Bargaining
The patient may attempt to negotiate with physicians, friends or even
God, that in return for a cure, the person will fulfill one or many
promises, such as giving to charity
Depression
The patient shows clinical signs of depression- withdrawal,
psychomotor retardation, sleep disturbances, hopelessness and possibly
suicidal ideation.
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21. Response to Death and Dying
Acceptance
The patient realizes that death is inevitable and accepts the universality
of the experience.
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22. Barriers to Death or Dying
Ellershaw (2003) identified a number of barriers to
diagnosing dying;
Hope for the patient to improve
Unclear diagnosis
Pursuance of futile interventions
Disagreement about the patient’s condition
Failure to recognize key signs and symptoms
Concerns about withdrawal and withholding
Medico-legal issues
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23. Management of Dying Patient
Cassen (1991) suggests seven essential features in the
management of the dying patient:
Concern: Empathy, compassion, and involvement are essential.
Competence: Skill and knowledge can be as reassuring as warmth and
concern.
Communication: Allow patients to speak their minds and get to know
them.
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24. Management of Dying Patient
Children: If children want to visit the dying, it is generally advisable;
they bring consolation to dying patients.
Cohesion: Family solidity reassures both the patient and family.
Cheerfulness: A gentle, appropriate sense of humor can be palliative; a
somber or anxious behavior should be avoided.
Consistency: Continuing, persistent attention is highly valued by
patients who often fear that they are a burden and will be abandoned.
24

25. DNR & CPR and its Impact
CPR
Cardiopulmonary resuscitation, commonly known as CPR, is an
emergency procedure performed in an effort to manually preserve
intact brain function until further measures are taken to restore
spontaneous blood circulation and breathing in a person who is in
cardiac arrest.
25

26. DNR & CPR and its Impact
Impact of CPR:
A person who is resuscitated may not be able to fully recover or
resume previous activities.
Resuscitation may have been too late, or the brain may have been
without oxygen for so long that there will be serious, permanent nerve
damage and/or mental impairment.
26

27. DNR & CPR and its Impact
DNR
Do not resuscitate (DNR), or no code, is a legal order written either in
the hospital or on a legal form to withhold cardiopulmonary
resuscitation (CPR) or advanced cardiac life support (ACLS), in
respect of the wishes of a patient in case their heart were to stop or they
were to stop breathing.
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28. DNR & CPR and its Impact
Impact of DNR
Patient with DNR order sometimes received less care.
Some treatments were withheld without being specified in the DNR
order.
Sometimes thought to mean DO NOT CARE, but that is not intent.
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29. Comfort Care
The decision to withdraw life-sustaining treatment and switch
to comfort care at end of life should be made with as much
involvement of patient as possible.
The goal of withdrawal or withheld of life-sustaining
treatments is to remove the treatments that are not beneficial
and may be uncomfortable.
Once the goal of comfort has been chosen, each procedure
should be evaluated to see if it is necessary, or if it causes
discomfort.
29

30. Debatable Methods of Comfort Care
Euthanasia:
The term normally implies an intentional termination of life by another
at the explicit request of the person who wishes to die. Euthanasia is
generally defined as the act of killing an incurably ill person out of
concern and compassion for that person's suffering. It is sometimes
called mercy killing
30

31. Debatable Methods of Comfort Care
Passive Euthanasia:
Hastening the death of a person by altering some form of support and
letting nature take its course is known as passive euthanasia.
Examples include such things as turning off respirators, halting
medications etc.
31

32. Debatable Methods of Comfort Care
Active euthanasia:
Active euthanasia involves causing the death of a person through a
direct action, in response to a request from that person.
A well-known example of active euthanasia was the death of a
terminally ill patient on September 17, 1998. Dr. Jack Kevorkian
videotaped himself administering a lethal medication to Thomas Youk,
a 52-year-old Michigan man with amyotrophic lateral sclerosis. He was
found guilty of second-degree murder in 1999 and sent to prison.
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33. Debatable Methods of Comfort Care
Physician-assisted suicide:
Somewhat of a hybrid between passive and active euthanasia is
physician-assisted suicide (PAS), also known as voluntary passive
euthanasia. In this situation, a physician supplies information and/or
the means of committing suicide (e.g., a prescription for lethal dose of
sleeping pills, or a supply of carbon monoxide gas) to a person, so that
that individual can successfully terminate his or her own life.
33

34. Pain Management
Four general principles are used in prescribing and dosing
analgesic medications:
The choice of analgesic drug should be based on the type of pain
Patients with chronic or frequently recurring pain should receive
medications around the clock according to the recommended dosing
schedules.
Episodic or breakthrough pain should be anticipated and treated with
needed pain relief in addition to the regularly scheduled analgesics.
Medication dosages should be titrated promptly to achieve effective
pain control.
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35. Ethical/Legal Issues
Legal and ethical principles guide many of our decisions in
caring or the dying patient and his family.
The patient is respected as autonomous and able to make
his/her own decisions.
When the patient is unable, same respect should be accorded
to surrogates
35

36. Ethical/Legal Issues
Two of the basic principles underlying the provision of health
care are;
Beneficence: intending to benefit the other through one’s actions
Nonmaleficence: means to do no harm
Sometimes, these are seen in conflict, such as when CPR is
attempted under beneficence but does cause harm
36

37. Advance Directives
Definition:
Advance directives are written, legal instructions regarding your
preferences for medical care if you are unable to make decisions for
yourself. Advance directives guide choices for doctors and caregivers
if you're terminally ill, seriously injured, in a coma, in the late stages of
dementia or near the end of life.
37

38. Advance Directives
Power of Attorney:
A medical or health care power of attorney is a type of advance
directive in which you name a person to make decisions for you when
you are unable to do so.
38

39. Advance Directives
Living Will:
A living will is a written, legal document that spells out medical
treatments you would and would not want to be used to keep you alive, as
well as other decisions such as;
Resuscitation
Mechanical ventilation
Tube feeding
Dialysis
Organ and tissue donations
Donating your body
39

40. Advance Directives
DNR and DNI orders:
You don't need to have an advance directive or living will to have do
not resuscitate (DNR) and do not intubate (DNI) orders. You can make
your preferences known to your physician, who can write the orders
and put them in your medical record.
40

41. Prognostic tools (outcome scoring system)
There are two common tools for estimating critical care unit
mortality;
Acute Physiology And Chronic Health Evaluation:
The APACHE score was developed in 1981 to classify groups of
patients according to severity of illness and was divided into two
sections: a physiology score to assess the degree of acute illness; and a
preadmission evaluation to determine the chronic health status of the
patient
41

42. Prognostic tools (outcome scoring system)
Multiple Organ Dysfunction Score:
The development of the MODS was based on a literature review of 30
publications that had characterized organ dysfunction. For each organ,
the first parameter is used to calculate the score and a score of 0
(normal) to 4 (most dysfunction) is awarded, giving a total maximum
score of 24.
42

43. Prognostic tools (outcome scoring system)
Nine Equivalents of Nursing Manpower Use Score:
NEM comprised of nursing activities separated into nine categories:
basic monitoring, intravenous medication, mechanical ventilator
support, supplementary ventilator care, single vasoactive medication,
multiple vasoactive medication, dialysis techniques, specific
interventions in the ICU, specific interventions outside the ICU. Each
of these is awarded weighted points, giving a maximum score of 56.
43

44. Prognostic tools (outcome scoring system)
Other Tools:
Simplified Acute Physiology Score (SAPS)
Mortality Probability Model (MPM)
Logistic Organ Dysfunction Score (LODS)
Sequential Organ Failure Assessment (SOFA)
The Therapeutic Intervention Scoring System (TISS)
44

45. Hospice and Palliative Care
Hospice is a specialized program that addresses the needs of
the catastrophically ill and their loved ones. Components of
hospice care programme include the following:
Client and family as the unit of care
Coordinated home care with access to available inpatient and nursing
home beds
Control of symptoms(physical, sociological, psychological and
spiritual)
Physician directed services
45

46. Hospice and Palliative Care
Provision of an interdisciplinary care team of physicians, nurses,
spiritual advisers, social workers and counselors.
Medical and nursing services available at all times
Bereavement follow up after a client's death
Use of trained volunteers for frequent visitation and respite support
46

47. Hospice and Palliative Care
Palliative care is the active total care of patients whose disease
is not responsive to curative treatment (World Health
Organization). Palliative care is based on five major principles
(Foley and Carver, 2001)
It respects the goals, likes and choices of the dying person.
It looks after the medical emotional, social and spiritual needs of the
dying person.
It supports the needs of the family members.
It helps gain access to needed health care providers and appropriate
care settings.
It builds ways to provide excellent care at the end of life.
47

48. Nursing Care of Dying Patient
ÿDeal with mental suffering and fear of death
ÿTry to respond appropriately to patient’s needs by listening carefully to the
complaints
ÿBe fully prepared to accept their own counter transferences, as doubts,
guilt and damage to their self-importance are encountered.
ÿManagement of the dying patient often elicits anxiety in nursing staff.
Education and role playing can improve perspective taking and empathetic
skills, respect each other’s point of view as well as appreciate the situation
of patient and their families.
48

49. Nursing Care of Dying Patient
ÿDevelop a sense of control and efficacy.
ÿEncourage peer groups for families coping with bereavement.
ÿDeveloping increased resourcefulness in dealing with death related
situations.
ÿRecognize that a moderate level of death anxiety is acceptable.
ÿImproving our understanding of pain and suffering will also improve
communication and effective interactions.
49

50. Nursing Interventions for Family
Support
Assure family’s that best possible care is being given to patient
Appraise family’s emotional reaction to patient’s condition
Determine the psychological burden of prognosis for the family
Foster realistic hope
Listen to family concerns feelings and questions
50

51. Nursing Interventions for Family
Support
Accept the family’s values in a nonjudgmental manner
Identify nature of spiritual support for family
Promote trusting relationship with family
Encourage family decision making in planning long term patient care
Assist family members through the death and grief processes as
appropriate
51

52. Communication in End-of-life Care
Patient Communication
Patient’s capacity for decision making is limited by illness severity
Patient is the first person to be approached as decision making is
required
If patient is not able, written documents like living wills are obtained
when possible
Without these documents wishes of the patient should be ascertained
from surrogates (closest to the patient)
52

53. Communication in End-of-life Care
Family communication
How questions are asked to the surrogates is extremely important
Consequences of the questions for the family are vastly different
Increasing the frequency of communication will make subsequent
discussions easier for both patient and family and health professional.
53

54. Cultural and Religious Influences
ÿCultural and religious influences on attitudes and beliefs about death and
dying differ dramatically.
ÿThese differences may affect how the health care team is viewed, how
decisions are made, how death is met, and how grieving will occur
ÿReligion is a prime source of strength to many people when they are
dealing with death.
ÿDifferent religious theories explain the inevitability and even necessity of
death from different perspectives.
54

55. Nursing Interventions for Grief Work
Facilitation
Identify the loss
Assist the patient to identify the nature o the attachment to the lost object
or person
Assist the patient to identify the initial response to the loss
Encourage expression o feelings about the loss
Listen to expression of grief
Make empathetic statements about grief
55

56. Nursing Interventions for Grief Work
Facilitation
Encourage identification concerning the loss
Instruct phases of the grieving process as appropriate
Support progression through grieving stages
Assist patient to identify personal coping strategies
Encourage patient to implement cultural, religious, and social customs
associated with the loss
Assist identifying modifications needed in life style
56

57. Seven Recommendations to Improve
Care
The Institute of Medicine (IOM) released a report,
Approaching Death: improving care at the end of life; giving
seven recommendations to improve care as follows;
Patient with fatal illness and their family should receive reliable,
skillful, and supportive care.
Health professionals should improve care for the dying.
57

58. Seven Recommendations to Improve
Care
Policymakers and consumers should work with health professionals to
improve quality an financing of care.
Health profession education should include end-of-life content.
Palliative care should be developed, possibly as medical specialty.
Research on end-of-life should be funded.
The public should communicate more about the experience of dying
and options available.
58

59. Summarization
The key guidelines for end-of-life care in the intensive care unit, based on
research and expert panel review, are as follows;
Needs of the Patient, Family, and Clinical Team
1)Needs of Patient
Receiving adequate pain and symptom management
Avoiding inappropriate prolongation of dying
Achieving a sense of control
Relieving burden
Strengthening relationships with loved ones
59

60. Summarization
2)Needs of Family
To be with dying person
To be informed of the dying person’s changing condition
To understand what is being done to the patient and why
To be assured that their decisions were right
3)Needs of Clinical Team
Multidisciplinary teamwork
Administrative support that values intensive palliative care
Opportunity for bereavement and debriefing 60

61. Summarization
ÿComfort and Freedom from Pain
4)Clinical Assessment and Interventions
ÿAssessment of pain and suffering
ÿUse of medications to relieve pain and suffering
ÿAlleviation of symptoms such as dyspnea, nausea and vomiting, thirst,
skin irritation, anxiety, and delirium
5)Terminal Weaning vs. Extubation
ÿTerminal wean
ÿExtubation 61

62. Summarization
ÿSensitivity after the death
6)Procedures
ÿCultural and religious requests
ÿOrgan donation
ÿAutopsy
62

63. References
Robbins J, Moscrop J. caring for the dying & family. 3rd ed. London:
Chapman&Hall;1995
Craven R F, Hirnle C J. Fundamentals of Nursing. 5th ed. Philadelphia: Lippincott
Williams & Wilkins Publishers;2006
Feinberg A. W. The care of dying patients. Annals of internal medicine. 2007 Jan
17; 126 (2): 164-65.
Meyers T. a turn towards dying: presence, signature, and the social course of
chronic illness in urban America. Med Anthropol(PMID 17654261). 2007 July-
Sept;26(3):205-27.
Behuniak,
 Susan M. 2003. Physician-Assisted Suicide  The Anatomy of a
Constitutiona
 Law Issue. Lanham, Md.: Rowman & Littlefield.
Dyck,
 Arthur J. 2001. When Killing Is Wrong: Physician-Assisted Suicide and the
Court. Cleveland, Ohio:
 Pilgrim Press.
63

64. References
http://www.who.int/mediacentre/factsheets/fs310/en/
Shuchter SR and Zisook S.
 Treatment of spousal bereavement: a multidimensional
approach. Psychiatric Annals
Corr CA, Nabe CM, Corr
 DM: Death and Dying, Life and Living.
Death and Dying: Mount Sinai School of Medicine, New York.
 Encyclopedia of Life
Sciences
A Dying Person's Guide to Dying,
 Roger C. Bone, M.D. The American College of
Physicians
http://kokuamau.org/resources/cardiopulmonary-resuscitation-cpr
http://www.caringinfo.org/i4a/pages/index.cfm?pageid=3286
http://www.stoppain.org/palliative_care/content/ethical/treatment.asp
https://www.hospicenet.org/html/preparing_for.html
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65. Because being a Nurse is more than a job
THANK
Y  U
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