Find something that interests you from each of the four chapters (use PowerPoints or textbook). Post a brief share from each chapter that will add to your classmates' understanding, insight, or future nursing practice. Your post should look approximately like this:
Chapter 30: Here is an experience I've had with [insert topic here]. Followed by a few supporting sentences that illustrate your experience.
Chapter 31: I was curious about [insert topic here]. I found this short video on YouTube that talks about [very brief summary]. Insert hyperlink here.
Chapter 32: This is something in my community that I would (or have) recommended as a resource. They do X, Y, Z. Insert hyperlink here.
Chapter 33: I researched this [insert job description]. Here's what I found about the required education, job opportunities, and potential wages.
*The examples above are NOT prescriptive and can be used in any order if you choose these prompts. These are just some formats that I think might be interesting. Please choose whatever catches your interest and write up a little something about it for the sake of discussion. You will write one post with a few sentences of information about each of the four chapters, respond to one post with substance ("that's cool!" is not substance), and read at least 10 posts, which I can track through D2L so you do not have to manufacture proof of how many you've read.
You must start a thread before you can read and reply to other threads
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Objectives
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Describe
Describe the evolution of life-saving measures and their impact on end-of-life issues.
Discuss
Discuss the role of palliative care and hospice in supporting patients and families facing chronic diseases and terminal illnesses.
Identify
Identify stages of the dying process as described by Kübler-Ross.
Objectives
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Discuss the following topics regarding death: artificial nutrition and hydration, euthanasia, and legally assisted suicide.
Describe the components of advance care planning for death.
Death and Dying
Advances in technology have blurred the line between life and death
Artificial nutrition and hydration
Artificial breathing and blood filtering
Transplants
An aging population
Unprecedented strains on healthcare system
This Photo by Unknown author is licensed under CC BY-ND.
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Models for End-of-Life Care
Hospice
Standard for care for patients facing death
Begins after treatment has stopped
Begins when it is clear survival is not possible
Focus: patient care and symptom reduction
Palliative Care
Promotes comfort
Can begin at time of diagnosis
Focus: care for people living with serious illness
This Photo by Unknown author is licensed under CC BY-NC-ND.
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Unlike hospice care palliative care can begin at the time of diagnosis and continue throughout the treatment of the illness. For palliative care people may or may not be terminally ill to benefit.
Key Components of Both Models
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Honoring patient and family experiences
01
Respecting autonomy and informed choice
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Allowing directing of care by patient (and family)
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Honoring the dignity of the patient and family
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Case Study
Mr. Dietrich has found out he has terminal brain cancer. At first he and his wife just can’t believe it’s true. They leave the doctor’s office silent and stunned, holding hands. They drive home in silence, but stop to get their mail as usual, pick up some fast food, as they always do on a Wednesday.
At home that night, he pops popcorn while she sets up the movie they’ve chosen. She looks at him and smiles. “Look at your appetite,” she says. “It’s wonderful! You don’t have brain cancer.”
“I think you’re right,” he smiles and squeezes her hand.
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Kübler-Ross’s 5 Stages
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Denial and isolation
Anger
Bargaining
Depression
Acceptance
Facilitating Death
Artificial Nutrition and Hydration
Not a comfort measure
Euthanasia
Legally Assisted Death: Relevant Arguments
Individual liberty
Autonomy
Quality of care
Nonmaleficence
Beneficence
This Photo by Unknown author is licensed under CC BY-ND.
Supplementation of food and water is not a comfort measure and is therefore not a component of basic care for the actively dying. It does not generally benefit people who are actively dying. In fact, providing artificial hydration by such means as intravenous fluids can increase edema, pulmonary congestion, ascites, nausea, and vomiting. Generally, the unwillingness or inability to eat and drink is caused by the impending death of the patient.
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Advance Care Planning
Advance directives
Statement of how you want medical decisions to be made if you cannot make them yourself
Durable power of attorney for health care
Living will
Provider orders for life-sustaining treatment (POLST)
Based on the patient’s preferred code status in the case of cardiopulmonary arrest
This Photo by Unknown author is licensed under CC BY.
Since the 1960s, people have increasingly sought to participate in decision making about healthcare. In 1990 Congress passed the Patient Self-Determination Act (PSDA) (1990) requiring that healthcare facilities provide clearly written information for every patient including legal rights to make healthcare decisions, especially the right to accept or refuse treatment. The PSDA also establishes the right of a person to provide directions, or advance directives, for clinicians to follow in the event of a serious illness.
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Case Study
Mr. and Mrs. Dietrich meet with the hospice nurse after three weeks of adjustment.
“We’d like help with advance care planning,” Mr. Dietrich says. His wife nods and holds his hand, trying not to cry. “We don’t want him to suffer. That’s my main concern. If he can’t survive this, I just don’t want him in pain or throwing up a lot, things like that.” She starts to cry, and he gives her shoulder a squeeze.
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Quick Quiz
Which Kübler-Ross stage of response is Mr. Dietrich currently experiencing?
Denial
Bargaining
Depression
Acceptance
ANS: D
Acceptance is characterized by a calmer, if somewhat withdrawn, response.
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Quick Quiz
Mr. Dietrich says, “I want to get it in writing from my doctor that I won’t get any mechanical ventilation or cardiopulmonary resuscitation—none of that nonsense.” Which advance care plan is he expressing the most interest in?
Durable power of attorney
Advance directive
Living will
POLST
ANS: D
Provider/physician orders for life-sustaining treatment (POLST) are orders the physician or advanced practice registered nurse writes based on the patient’s preferred code status in the case of cardiopulmonary arrest in which heartbeat and respirations have stopped.
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Objectives
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Distinguish nursing care at the end of life including communication, presence, and symptom management.
Discuss the process of death and associated care for the patient and the family.
Nursing Care at End of Life
Communication
Establish a therapeutic relationship before asking patients or families to make difficult decisions at the end of life
Art of Presence
Symptom Management
Anticipatory Grief
Palliative Care for Patients with Dementia
This Photo by Unknown author is licensed under CC BY-SA-NC.
Palliative Care for Patients with Dementia: Difficult behaviors in dementia patients, such as irritability or refusal to cooperate with care, are often forms of communication indicating discomfort in body, mind, or spirit. Anticipating a patient’s needs can help prevent or reduce behaviors arising from an inability to communicate needs.
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Practice the Art of Presence
Ask open-ended questions:
Would you tell me what this is like for you?
How do you see your condition right now?
Where do you see things going?
Are you worried about anything?
What are you hoping for?
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Anticipatory Grief
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Future loss is mourned in advance
Adjusting life to accommodate the time that is left
Foreseeing how the future will be altered by the loss
Anger is a common component
Palliative Care for Patients with Dementia
Challenging behaviors may indicate discomfort in mind, body, or spirit.
Proactively manage pain, depression, etc.
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Anticipate
Anticipate needs
Encourage
Encourage meaningful connections with loved ones
Identify
Identify patient goals for care
Educate
Educate family to minimize aggression during care
Eliminate
Eliminate medications that may detract from safety or quality of life
Manage
Proactively manage pain and depression
Developmental Tasks of Dying
Completion of worldly affairs
Completion of community relationships
Making meaning of one’s life
Experiencing love of self and others
Completion of close relationships; good-byes
Acceptance of finality of life
Sense of a new personhood beyond loss
Sense of meaning of life in general
Surrendering to the transcendent; letting go
This Photo by Unknown author is licensed under CC BY-SA-NC.
Please refer to Table 30.1
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The Dying Process
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Growing weakness (asthenia)
Loss of appetite
Increasing drowsiness
Change in mentation (shortening attention span difficulty processing information)
The Dying Process (Cont.)
Circulatory changes (increased heart rate, decreased blood pressure)
Mottling of skin (grayish-blue splotches on knees, ankles, feet)
Decrease in urine production
Breathing changes (Cheynes-Stokes respirations)
Possible agitation and delirium
One of the more disturbing changes that sometimes accompany the dying process is the presence of a death rattle, which is caused by pooling of saliva in the upper airway.
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At Time of Death…
The family should call their hospice provider.
A registered nurse is sent to the home to guide the family members
Identity of patient confirmed
Pronouncing time of death
Post-mortem care
Calling medical examiner in some cases
Contacting the funeral home
Sometimes family members are confused by the fact that the official time of death is the pronouncement time rather than the time that the patient stopped breathing. It might be important to clarify for family members that this is the time that is used for the death certificate.
Families will remember the actions of the nurse, so take care to communicate deep respect for both the dead and for the bereaved. The nurse should also offer to contact a social worker or chaplain, if desired. Family members should be invited to participate in this care, if they desire. Care may vary according to culture but may include bathing, combing hair, or dressing in a special outfit.
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Objectives
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Explain the distinction between grief, bereavement, and mourning.
Differentiate grieving, persistent complex bereavement disorder, and disenfranchised grief.
Describe nursing care for individuals who are grieving and are experiencing complicated grieving.
Grieving
Grief is reaction to a loss
Bereavement is the period of grieving after a death.
Mourning refers to things people do to cope with grief.
This Photo by Unknown author is licensed under CC BY-NC-ND.
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Grieving Theories
Freud’s concept of “grief work”
Kübler-Ross’s emotional phases of dying have been identified with the stages of grieving
Bowlby’s phases from shock to reorganization and recovery
Worden’s four tasks of accepting, grieving, adjusting, moving on
Stroebe’s dual process model of coping and bereavement
While viewing the grieving process as linear—from denial to eventual acceptance—is attractive, grieving is just not that neat. In reality, these stages overlap and may be non-sequential. Stroebe (1998) suggests a dual process model of coping and bereavement. It incorporates the stage/phase models of loss-oriented processes with the restoration of a new lifestyle. Table 30.2 summarizes the dual process model.
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Grief and Technology
Outlet for expressing thoughts and feelings
Source of positive supportive feedback
Potential for loved ones to continue a bond with the deceased
Sharing memories
Expressing sorrow
Gaining social support
Helps make sense of death
Helps maintain the legacy of the deceased
In one study, Facebook profiles of deceased individuals were reviewed for the posts made by loved ones. Results indicate a potential for loved ones to continue a bond with the deceased by sharing memories, expressing sorrow, and gaining social support (Getty et al., 2011).
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Grief versus Major Depressive Disorder
An individual who is grieving is clinically different from a person who has major depressive disorder. The previous edition of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Psychiatry, Fourth Edition Text Revision (DSM-IV-TR) discouraged clinicians from diagnosing an individual with major depressive disorder within 2 months of the loss of a loved one. This clinical guideline was referred to as the bereavement exclusion. The fifth edition of the manual, the DSM-5, however, removed this exclusion. Table 30.3 clarifies the difference between symptoms in grief and major depressive disorder.
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Grief
Feelings: emptiness and loss
Intensity: intense sadness and anger that occurs in waves and gradually subsides
Self-esteem: intact; reorganization tasks may impact sense of self (e.g., “Who am I without him?”)
Thoughts of death: may focus on someday reuniting with the deceased
Major depressive disorder
Feelings: depressed mood and anhedonia
Intensity: depressed mood is constant
Self-esteem: worthlessness and self-loathing
Thoughts of death: focused on ending the pain of depression; may develop a plan for death
Types of Grieving and Associated Nursing Care
Grieving
Acute grieving; the painful experience after a loss
Nursing Care
Listen; provide eye contact and suitable touch; hold a posture of attentiveness
Support positive expectations for the future and re-engaging in activities and interests
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Types of Grieving and Associated Nursing Care
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Persistent Complex Bereavement Disorder
Prolonged grieving and reactive distress that can lead to impairment of relationships, occupational performance; impacts day-to-day functioning
Nursing Care
Begins with nursing diagnosis of risk for dysfunctional grieving
Respond as for grieving, but protect from self-harm as well
Assist as needed with everyday functioning
Types of Grieving and Associated Nursing Care
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Disenfranchised grief
Grief experience not congruent with a socially recognized relationship
Nursing Care
Combine support and guidance with individual psychotherapy
Consider an anonymous virtual support group
Types of Grieving and Associated Nursing Care
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Grief Caused by Public Tragedy
Loss felt broadly across a community or the general public, threatening our sense of security and altering our world view; pain is exacerbated by 24-hour media coverage
Nursing Care
As with other losses, acknowledge and validate the personal impact of the loss; institute caring measures used for grieving in general
Self-Care
This is not happening to you.
Countertransference: talk to a trusted colleague
Protect your private life.
Admit to your limitations.
Practice humility.
Do your own mourning.
Create a healthy, balanced private life.
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Quick Quiz
After Mr. Dietrich dies, his hospice nurse finds that she feels devastated by the loss. Which type of loss does this most accurately describe?
Anticipatory grief
Dysfunctional grief
Disenfranchised grief
Persistent complex grief
ANS: C
Disenfranchised grief is a grief experience not congruent with a socially recognized and sanctioned relationship, such as loss of a lover, a pet, a caregiver, or an abortion; loss of a patient for a healthcare worker.
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