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Chapter 14 Study Guide: (The End of Life: Death, Dying, Grieving and Loss)Understanding death is a fundamental concept.Nurses are likely to care for patients who are dying in emergency rooms, acute care, hospice care and nursing homes or a client’s home.The Dying Process:Dying is a unique and intimate process for each individual.KEY CONCEPT:Death is one of the most profound emotional experiences humans encounter. Fear and anxiety are natural.A continuing challenge for many individuals is to resolve personal feelings about the process of dying and the finality of death.As a nurse you can become more comfortable with the concept of death by confronting your own personal feelings.End of Life Care:Specific acute situations, illnesses, or trauma affect events related to the dying process.Terminal illness: State in which an individual faces a medical condition that will end in death within a relatively limited period.Palliative care: Collaboration of client, caregiver, and family that focuses on the treatment of symptoms for clients with a serious illnesses, usually, but not always, associated with a terminal illness.Often incorporated into the treatment plan during the months, days, or hours that occur during a terminal condition.The goal is to improve the quality of life by providing for relief of symptoms such as pain, nausea, anxiety, and depression.It is appropriate for many illnesses and can be provided simultaneously with curative care.As natural death approaches, called active dying, the LT caregiver role changes. As the client enters the last phases of life, a steady decline toward death becomes notable, and the care given to the client must adjust to changing needs.The needs of the dying client vary according to the individual’s condition.The needs of each client typically vary from day to day. As death approaches, emotional support, reassurance, and pain relief become the caregiver’s priorities.KEY CONCEPT:Physical care and emotional care are two very different types of care.Physical care, usually some form of treatment, can be observed and quantified.Emotional care relates to the physiological support. It effects cannot be measured and may seem less immediately obvious than those of physical care, but is equally important to the well-being of the client.Impact of the Dying Process:Often, caregivers and families are coping with deep feelings of anticipated loss.Stress of the caregivers or family should not be overlooked.Efforts to appear hopeful and cheerful may appear non-supportive or insincere.Not all family members can cope with death and the dying process.Each family member or caregiver will progress through the grieving and loss process.End-of-life Discussions and Advanced Directives:End-of-life Discussions:These discussions should take place as a routine, practical adult responsibility.They should occur ASAP after a terminal diagnosis has been given.They need to include the goal of care and treatment options which range from an overview of the needs for basic nutritional supplementation to the use of advanced life support.Advanced Directives:Utilization of AD can be of great assistance to the dying client and their family.Wishes of the client are more likely to be followed if that individual has considered his or her own desires and ensured that these wishes are given in writing to physicians, family and significant others.Without an AD, the healthcare provider or a family member may be given the responsibility to dictate life or death decisions.These decisions can result in feelings of guilt, self-doubt about making the “right” decisions, and hostility among family members.Relief of Pain:Relief of pain is an important palliative treatment.Use of opioid analgesics, narcotic pain meds such as morphine, are known interventions of palliative care. Caregivers may be afraid to give meds that could be beneficial in a rumored fear of addicting the client or causing the client’s premature death due to med overdose.Providing adequate pain meds can result in a client who has improved alertness because their physical body is not fighting pain. When a client is able to swallow, oral pain meds can be used.KEY CONCEPT: The family should realize that crying or sadness in front of a dying loved one is acceptable. Such behavior can be therapeutic, because otherwise the dying individual may feel that nobody cares.Finances and Economic Concerns:Financial concerns, such as cost of meds or specialized equipment, may become an increasing source of worry and stress.Daily events and routine concerns contain economic considerations.Funeral or commemorative services can be costly.Some individuals prepay for finances so that these costs do not affect the finances of caregivers or family members.Occasionally, accumulated stress becomes difficult for families to handle, resulting in increased conflicts and outbursts of emotion or domestic violence.Support from friends, neighbors, and coworkers can be helpful.Children and Their Concern:Families question how to handle death when children are involved in the family.They do grieve and need to be part of the family’s mourning.Adults should talk honestly and clearly with children about illness and death when it occurs.Children should be allowed to see the body or attend the funeral (or both) if they wish to do so.Children who are dying should be told the truth and be allowed to ask questions.SPECIAL CONSIDERATIONS CULTURE:Cultural, ethnic, and religious beliefs help to shape people’s attitudes towards death. The cultural context often determines the procedures related to death, dying, and after death care.Some cultures view death as an intensely personal experience, with families keeping most of their emotions and feelings within a private circle. Other cultures grieve openly.BOX 14-1 Traditional Religious Beliefs and Practices Related to Death:RELIGION:PRACTICES:Amish and MennoniteFamily cares for the body. Funeral often at home.BaptistPrayer. Communion. Call pastor.BuddhistPriest performs last rites and chanting rituals. Cremation is common.Christian ScienceReader is called. No last rites. Autopsy is forbidden.EpiscopalPrayer. Communion. Confession. Sacrament of the sick.Friends (Quakers)Individual communicates with God. No belief in afterlife.Greek OrthodoxPrayer. Communion. Sacrament of the sick. Mandatory baptism.HinduPriest performs ritual of thread around neck or wrist, water is put in mouth. Family cares for the body. Cremation is common.JudaismAfter death, a rabbi or designate cleanses the body.LDS/MormonBaptism required (adults). Body is dressed in temple garments. Call Bishop or Elder.LutheranPrayer. Communion. Call Pastor.MuslimImam performs specific procedures for washing and shrouding the body, with assistance of the family. Body is buried facing Mecca.PentecostalPrayer. Communion. Call Pastor.PresbyterianPrayer. Communion. Call Pastor.Roman CatholicPrayer. Sacrament of the sick. Communion. Mandatory baptism.Russian OrthodoxPrayer. Communion. Sacrament of the sick. Mandatory baptism.ScientologistConfession. Visit with pastoral counselor.Seventh-Day AdventistBaptism. Communion.UnitarianPrayer. Cremation is common.KUBLER-ROSS’S STAGES OF GRIEF AND LOSS:Dr. Elisabeth Kubler-Ross, a psychiatrist that described certain phases through which a person may pass in an attempt to cope with impending death.Formerly referred to as stages of death and dying.Well known for her initiation of the terms; death, anger, bargaining, depression, and acceptance. (DABDA)NURSING ALERT:A key nursing intervention for the dying client is to be aware that physical care is enhanced by understanding the grieving process and augmenting by providing emotional support during these phases.Greif: Common to all individuals; however, not all individuals experience grief in the same way.There is no right or wrong way to grieve.Loss: Can include grief, but does not necessarily have to include death. Loss can be related to any emotional suffering, such as the loss of health, the breakup of a relationship, or the loss of employment.Loss also includes the realization that one’s personal ambitions will not or cannot be achieved.All terminally ill people pass through some of these stages, unless death is instantaneously or the person is unable to resolve conflicts.KEY CONCEPT:The Kubler-Ross stages of grief and loss typically also occur in individuals who are close to the person who has died or is expected to die. These stages have also been identified and used for many or life’s situations.Denial:The preliminary stage, occurs when the person does not believe that the diagnosis is correct.During the stage of denial, the individual may seek advice from several doctors, hoping the one of them will offer a more acceptable prognosis.Concept Mastery Alert - Stages of grief:In caring for an elderly client who is dying, it is important to use the client’s statements as clues to the client’s stages of grief. A statement of “Why did this happen to me?” indicates that the client is in the anger stage of grief. In anger, the client asks, “Why?” Conversely, a statement of “Not, not me!” reflects the denial stage of grief.Anger:In the anger stage, the individual is angry and may have periods of acting-out or rage.Often, the individual envies the person who is young and healthy; he or she may lash out at family members or healthcare personnel.The anger that the person is expressing generally ................
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