End of Life | Nursing-LPN

Abbreviated grief

is brief but genuinely felt. This can occur when the lost object is not significantly important to the grieving person or may have been replaced immediately by another, equally esteemed object.
For example: the replacement of an old stolen phone with a ne

Actual loss

can be identified by others and can arise either in response to or in anticipation of a situation

Algor mortis

the gradual decrease of the body's temperature after death. When the blood circulation terminates and the hypothalmus ceases to function.

Anticipatory grief

grief experienced before loss occurs. The loss can be actual or perceived.
for example: wife who grieves before her ailing husband dies. A young person may grieve in advance of an operation that will leave a scar.

Anticipatory loss

the experience of loss before the loss actually occurs
For example: a women whose husband dying may experience actual loss in anticipation of his death.

Bereavement

a subjective response of a person who has experienced the loss of a significant other through death

Cerebral Death

Occurs when cerebral cortex is irreversibly destroyed
Permanent loss of cerebral and brainstem function
Absence of responsiveness to external stimuli
Absence of cephalic reflexes
Apnea
Isoelectric EEG for at least 30 minutes in the absence of hypothermia

Closed awareness

a type of awareness in which the client is unaware of impending death

Complicated grief

Unhealthy grief that is pathologic; exists when the strategies to cope with the loss are maladaptive.
This disorder may be said to exist if the preoccupation lasts for 6 months and leads to reduced ability to function formally.

Delayed grief

occurs when feelings are purposely or subconsciously suppressed until a much later time.

Difference between Living Will and Power of Attorney

The living will allows the client to indicate specific medical treatments to be omitted in the event of terminal illness, while durable power of attorney legally appoints another to make those decisions on the behalf of the client.

Disenfranchised grief

A person is unable to acknowledge the loss to other persons. Socially unacceptable loss that cannot be spoken about, such as suicide, abortion, or giving a child up for adoption.

End-of-life care

the care provided in the final weeks before death

Exaggerated grief

A survivor who appears to be using dangerous activities as a method to lessen the pain of grieving.

Grief

Is the emotional response related to loss, emotional suffering often caused by bereavement
Symptoms: anxiety, depression, weight loss, difficulties swallowing, vomiting, fatigue, headaches, dizziness, fainting, blurred vision, skin rashes, excessive sweat

Grieving

Permits the individual to cope with the loss gradually and to accept it as part of reality.

Heart-lung death

the traditional clinical signs of death: cessation of the apical pulse, respirations, and blood pressure

Higher brain death

Occurs when the higher brain center, the cerebral cortex, is irreversibly destroyed. Also known as cerebral death

Hospice

care that focuses on support and care for the dying person and family, with the goal of facilitating a peaceful and dignified death

Inhibited grief

Many of the normal symptoms of grief are suppressed and other effects, including somatic (affecting the body) are experienced instead.

Livor mortis

discoloration of the skin caused by breakdown of the red blood cells; occurs after blood circulation has ceased; appears in the lowermost or dependent areas of the body

Loss

an actual or potential situation in which something that is valued is changed or no longer available.
example: People can experience the loss of body image, a significant other, a sense of well-being, a job, personal possessions, or beliefs. Illness and h

Mortician

a person trained in the care of the dead; also called an undertaker

Mourning

is the behavioral process through which grief is resolved or altered

Mutual pretense

a type of awareness in which the client, family, and health personnel know that the
prognosis is terminal but do not talk about it and make an effort not to raise the subject

Open awareness

a type of awareness in which a client and people around know about the impending death

Palliative care

the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual

Perceived loss

the loss experienced by a person that cannot be verified by others
Psychological losses
are often perceived as losses in that they are
not directly verifiable
.
Example: A women who leaves her employment to take care of her children at home may perceive a

Postmortem care

care of the body after death

Rigor mortis

stiffening of the body that occurs 2 to 4 hours after death. Starts in the involuntary muscles (heart, bladder, and so on), then progresses to the head, neck and trunk, and finally reaches the extremities.
Rigor mortis usually leaves the body after 96 hou

Shroud

a large piece of plastic or cotton material used to enclose a body after death

Undertaker

A person trained to care for the dead.

Unresolved grief or Chronic grief

extended in length and severity. The bereaved may also have difficulty expressing the grief, may deny the loss, or may grieve beyond the expected time

Types of Loss

1. Actual
Recognized by others
2. Perceived
Experienced by one person but cannot be verified by others
3. Anticipatory
Experienced before loss occurs
Can be actual or perceived
4. Situational
i.e., Loss of job, death of child
5. Developmental
i.e., Depart

Sources of Loss

1. Aspect self
2. External objects
3. Familiar environment
4. Loved ones

Aspect self

The loss of an aspect of self changes a person's body image, even though the loss may not be obvious.
for example: A face scarred from a burn is generally obvious, loss of a part of stomach or loss of ability to feel emotion may not be obvious.

External Objects

includes (a) loss of inanimate objects that have importance to the person, such as the loss of money or the burning down of a family's house; and (b) loss of animate (live) objects such as pets that provide love and companionship.

Familiar environment

Separation from an environment and people who provide security can result in a sense of loss.
For example: 6 years old is likely to feel loss when first leaving the home environment to attend school.

Loved one

The loss of a loved one or valued person through illness, divorce, separation, or death can be very disturbing.
For example: a person may undergo personality changes that make friends and family feel they lost that person.

Kubler-Ross (Kubler.R) Stages of Grief

1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance

Denial Stage (Kubler.R)

Refuses to believe that loss is happening.
Is unready to deal with practical problems, such as prosthesis after the loss of a leg
May assume artificial cheerfulness to prolong denial.
Nursing implications:
Verbally support but do not reinforce denial
Exam

Anger Stage (Kubler.R)

Client or family may direct anger at nurse or staff about matters that normally would not brother them.
Nursing Implications:
Help client understand that anger is normal response to feelings of loss and powerlessness
Avoid withdrawal or retaliation; do no

Bargaining stage (Kubler.R)

Seeks to bargain to avoid loss
example: "let me just live_____ and then i will be ready to die"
Nursing implications:
Listen attentively, and encourage client to talk to relieve guilt and irrational feel.
If appropriate, offer spiritual support.

Depression stage (Kubler.R)

Grieves over what has happened and what cannot be
May talk freely (reviewing past losses such as money or job) or may withdraw
Nursing Implications:
Allow client to express sadness
Communicate nonverbally by sitting quietly without expecting conversation.

Acceptance stage (Kubler.R)

Comes to terms with loss
May have decreased interest in surroundings and support people.
May wish to begin making plans (e.g., will, prosthesis, altered living arrangements).
Nursing Implications:
Help family and friends understand client's deceased need

Sanders Phases of Bereavement

1. Shock
2. Awareness of loss
3. Conservation/withdrawal
4. Healing: the turning point
5. Renewal

Shock phase (Sanders)

Survivors are left with feelings of confusion, unreality, and disbelief that the loss has occurred.They often unable to process the normal thought sequences. Phase may last from a few minutes to many days.
Behavioral Responses
Disbelief
Confusion
Restless

Awareness of loss phase (Sanders)

Friends and family resume normal activities
The bereaved experience the full significance of their loss
Behavioral Responses:
Separation anxiety
Conflicts
Acting out emotional expectations
Prolonged stress
Physical symptoms
: crying and sleep disturbance

Conversational/Withdrawal phase (Sanders)

During his phase, survivors feel a need to be alone to conserve and replenish both physical and emotional energy. The social support available to the bereaved has decreased, and they may experience despair and helplessness
Physical symptoms
: weakness, fa

Healing: the turning point phase (Sanders)

During this phase, the bereaved move from distress about living without their loved one to learning to live more independently.
Behavioral responses
Assuming control
Identity restructuring
Relinquishing roles, such as spouse, child, or parent
Physical sym

Renewal phase (Sanders)

In this phase, survivors move on to a new self-awareness, and acceptance of responsibility for self, and learning to live without the loved one
Renewal Behavioral responses
Functional stability
Revitalization
Assumption of responsibility for self-care nee

Manifestations of Grief

1. Signs and symptoms of stress reaction
2. Normal manifestations:
Verbalization of the loss
Crying
Sleep disturbance
Loss of appetite
Difficulty concentrating
3. Complicated grieving
Extended time of denial
Depression
Severe physiologic symptoms
Suicidal

Assessment Interview:
If there has been
previous grieving

Tell me about (the loss). What was losing _____ like for you?
Did you have trouble sleeping? Eating? Concentration?
What kinds of things did you do to make yourself feel better when something like that happened?
Did you observe any spiritual or cultural p

Factors Influencing Grief and Loss

Age
Significance of the loss
Culture
Spiritual beliefs
Gender
Socioeconomic status
Support systems
Cause of loss or death

Assessment Interview:
Previous loss

Have you ever lost someone or something very important to you?
Have you or your family ever moved to a new home or location?
What was it like for you when you first started school?
moved away from home? Got a job? Retired?
Are you physically able to do al

Definitions and Signs of Death

Cessation of:
1. Apical pulse
2. Respirations
3. Blood pressure
Referred to as heart-lung death

World Medical Assembly Guidelines for Death

Total lack of response to external stimuli
No muscular movement, especially during breathing
No reflexes
Flat encephalogram (EEG is flat)
In instances of artificial support, absence of brain waves for at least 24 hours

Impending Clinical Death

Loss of muscle tone
Slowing of the circulation
Changes in respirations
Sensory impairment

Impending Clinical Death:
Loss of muscle tone

Relaxation of the facial muscles (e.g., the jaw may sag)
Difficulty speaking
Difficulty swallowing and gradual loss of the gag reflex
Decreased activity of the gastrointestinal tract, with subsequent nausea, accumulation of flatus, abdominal distention, a

Impending Clinical Death:
Slowing of the circulation

Diminished sensation
Mottling and cyanosis of the extremities
Cold skin, first in the feet and later in the hands, ears and nose (client, however, may feel warm if there is a fever)
Slower and weaker pulse
Decreased blood pressure

Impending Clinical Death:
Changes in respirations

Rapid, shallow, irregular, or abnormally slow respirations
Noisy breathing, referred to as the death rattle, due to collecting of mucus in the throat
Mouth breathing, dry oral mucous membranes

Impending Clinical Death:
Sensory impairment

Blurred vision
Impaired senses of taste and smell

Nurse's Role

Explore and respect ethnic, cultural, religious, and personal values
Teach what to expect in the grief process
Encourage the client to express and share grief with support people
Teach family members to encourage the client's expression of grief
Encourage

Establish communication relationship

Communication strategies that let the client know you are available to talk about death include the following:
A. Describe what you see
, for example "You seem sad. Would you like to talk about what's happening to you?
B. Clarify your concern
, for exampl

Nursing Process:
Assessing Three types of awareness

1. Closed awareness
Client not aware of impending death
2. Mutual pretense
Client, family, and health personnel know the prognosis is terminal but do not talk about it
3. Open awareness
Client and others know about the impending death and feel comfortable

Nursing Process: Diagnosing

1. Client
Fear
Hopelessness
Powerlessness
2. Caregiver
Risk for Caregiver Role Strain
Interrupted Family Processes

Nursing Process:
Planning

1. Maintaining physiological and psychological comfort.
2. Achieving a dignified and peaceful death.
3. When planning care with these clients, "The Dying Person's Bill of Rights" can be a useful guide.

Nursing Process:
Implementing

Assist the client in a peaceful death.
1. To minimize loneliness, fear and depression
2. To maintain the client's sense of security, self confidence, dignity, and self-worth
3. To help the client accept losses
4. To provide the physical comfort

Nursing Process:
Evaluation

To evaluate the achievement of client goals, activities may include:
1. Listening to the client's reports of feeling in control of the environment surrounding death, such as control over pain relief, visitation of family and support people, or treatment p

Assessment Interview:
The family of the Dying Client

Ask the spouse, partner, or significant other:
Have you ever been close to someone who was dying before?
What have you been told about what may happen when death occurs?
Do you have questions about what may happen at the time of death?
How do you think yo

Facilitating Grief Work

1. Explore the respect the client's and family's ethnic, cultural, religious, and personal values in their expressions of grief.
2. Teach the client or family what to expect in the grief process
3. Encourage the client to express and share grief with supp

Hospice

Focuses on support and care of the dying person and family, with the goal of facilitating a peaceful and dignified death. Hospice care is based on holistic concepts, emphasizes care to improve quality of life rather than cure, supports the client and fami

Strategies in Helping Clients die with Dignity

Identify personal feelings about death
Focus on client's needs
Talk to the client or family about how the client usually copes with stress
Establish communication relationship
Determine what client knows about illness
Respond with honesty and directness
M

Strategies in Helping Clients die with Dignity (cont'd)

Encourage to participate in the physical care as they are able: (a) Assist with bathing, (b) Speak or read to the client and (c) Hold hands
Support those who feel unable to care for or be with the dying
Show an appropriate waiting area if they wish to rem

Palliative care

is an approach that improves the quality of life of clients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treat

Palliative care (cont'd)

Provides relief from pain and other distressing symptoms
Affirms life and regards dying as a normal process
Intends neither to hasten nor postpone death
Integrates the psychological and spiritual client care
Offers a support system to help clients live as

Palliative care (cont'd)

Will enhance quality of life, and may also positively influence the course of illness;
Is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and incl

Hospice and Palliative care

Both include
end-of-life care
that is, the care provided in the final weeks before death.

1 to 3 months before death

the patient withdraws from the world: sleep increases and appetite decreases.

One to 2 weeks before death

patients typically exhibit decreased blood pressure, increased heart rate, increased perspiration, and temperature fluctuations

Days to hours before death

the patient may experience a surge in energy. Very near the time of death, the dying patient is typically not responsive to touch or sound.

After Client Die

Encourage the family to view the body
May wish to clip a lock of hair as a remembrance
Children should be included in the events surrounding the death if they wish family or friends wish to view the body:
Make the environment as clean and as pleasant as p

Care of the Body After Death

Follow policy of the hospital or agency
Check the client's religion rituals and make every attempt to comply
Place the body in a supine position
Place arms either at sides, palm down, or across the abdomen
Place one pillow under the head and shoulders
Clo

Care of the Body After Death (cont'd)

Wash soiled areas of the body
Place absorbent pads under the buttocks
Place a clean gown on the client
Brush and comb the hair
Remove all jewelry except a wedding band which is taped to the finger
Adjust the top bed linen to cover the client to the should

After the Family Leaves

Leave wrist identification tag on
Apply additional identification tags
Wrap the body in a shroud
Apply identification to the outside of the shroud
Take the body to the morgue
Or arrange to have a mortician pick it up from the client's room
Handle deceased

Complicated grief after a death

1. The clients fails to grieve; for example a husband does not cry at, or absents himself from, his wife's funeral
2. The clients avoids visiting the grave and refuses to participate in memorial services, even though these practices are part of client's c

Complicated grief after a death (cont'd)

5. Even after prolonged period of time, the client is unable to discuss the deceased with composure; for example, the client's voice cracks and quivers, and eyes become teary.
6. After normal period of grief, the client experiences physical symptoms simil

Assessment interview:
If there is a current loss

What have you been told about (the loss)? is there anything else you would like to know or don't understand?
What changes do you think this (illness, surgery, problem) will cause in your life? What do you think it will be like without (the loss object)?
H

Assessment interview:
Current Grieving

Are you having trouble sleeping? Eating? Concentration? Breathing?
Do you have any pain or other new physical problem?
What are you doing to help you deal with this loss?
Are you taking any drugs or medications to help you cope with this loss?

Unresolved grief

1. Ambivalence (intense feelings, both positive and negative towards the lost person).
2. A perceived need to be brave and in control; fear of losing control in front of others
3. Endurance of multiple losses, such as the loss of the entire family, which

Development of the Concept of Death:
Infancy to 5 years

Does not understand concept of death
Infant's sense of separation forms basis for later understanding of loss and death
Believes death is reversible, a temporary departure, or sleep
Emphasizes immobility and inactivity as attributes of death

Development of the Concept of Death:
5-9 years

Understands the death is final
Believes own death can be avoided
Associates death with aggression or violence
Believes wishes or unrelated actions can be responsible for death.

Development of the Concept of Death:
9 to 12 years

Understands death as the inevitable end of life
Begins to understand own mortality, expressed as interest in afterlife or as fear of death

Development of the Concept of Death:
12-18 years

Fears of lingering death
May fantasize that death can be defied, acting out defiance through reckless behaviors (e.g., dangerous driving, substance abuse).
Seldom thinks about death, but views it in religious and philosophic terms.
May seem to reach "adul

Development of the Concept of Death:
18-45 years

Has attitude towards death influenced by religious and cultural beliefs.

Development of the Concept of Death:
45-65 years

Accepts own mortality
Encounters death of parents and some peers
Experiences peaks of death anxiety
Death anxiety diminishes with emotional well-being

Development of the Concept of Death:
65+ years

Fears prolonged illness
Encounters death of family members and peers
Sees death as having multiple meanings (e.g., freedom from pain, reunion with already deceased family members).

1. Which of the following may be considered normal or "healthy" types of grief? Select all that apply.
1. Abbreviated grief
2. Anticipatory grief
3. Disenfranchised grief
4. Complicated grief
5. Unresolved grief
6. Inhibited grief

1. Abbreviated grief (normal grief briefly experienced)
2. Anticipatory grief (experienced before loss/death but appropriate).
3. Disenfranchised grief (the emotions are felt privately, just not expressed in public).

2. A client's family tells the nurse that their culture does not permit a dead person to be left alone before burial. Hospital policy states that after 6:00 PM when mortuaries are closed, bodies are to be stored in the hospital morgue refrigerator until t

2. Inquire of the nursing supervisor how an exception to the policy could be made.
Rationale: When possible, modifications of policy that demonstrate respect for individual differences should be explored.

3. The shift changed while the nursing staff was waiting for the adult children of a deceased client to arrive. The oncoming nurse has never met the family. Which of the following greetings is most appropriate?
1. "I'm very sorry for your loss."
2. "I'll

1. "I'm very sorry for your loss.

4. At which age does a child begin to accept that he or she will someday die?
1. Less than 5 years old
2. 5-9 years old
3. 9-12 years old
4. 12-18 years old

3. 9-12 years old

5. An 82-year-old man has been told by his primary care provider that it is no longer safe for him to drive a car. Which statement by the client would indicate beginning positive adaptation to this loss?
1. "I told the doctor I would stop driving, but I a

4."Well, at least I have friends and family who can take me places."
Rationale: Adaptive responses indicate the client can put the loss into perspective and begin to develop strategies for coping and loss.

6. When asked to sign the permission form for surgical removal of a large but noncancerous lesion on her face, the client begins to cry. Which of the following is the most appropriate response?
1. "Tell me what it means to you to have this surgery."
2. "Y

1. "Tell me what it means to you to have this surgery."
Rationale: The nurse need to assess and explore the meaning of client's crying.

7. A nursing care plan includes the desired outcome of "quality of life" for a client with a chronic degenerative illness who is likely to live for many more years. Which of the following is one example that would indicate the outcome has been met?
1. The

4.The client verbalizes satisfaction with current relationships with other persons.
Rationale: Quality of life is determined by the client and
expressed
in terms of his or her satisfaction with a variety of aspects of life.

8. The nurse is caring for a family in a shelter 2 days after the loss of their home due to a fire. The fire caused minor burns to several members of the family but no life-threatening conditions. Which of the following is the most important assessment da

4. Family members' grief responses and coping behaviors
To plan with and assist the family, the nurse needs more data regarding the family's reactions to their loss.

9. The client has been close to death for some time and the family asks how the nurse will know when the client has
actually died
. Which of the following would be the most accurate response from the nurse?
1. When the blood pressure can no longer be meas

3. When there is no apical pulse.
Rationale: If there is no heartbeat, the client has died.

10. In working with a dying client, the nurse demonstrates assisting the client to die with dignity when performing which action?
1. Allows the client to make as many decisions about care as is possible.
2. Shares with the client the nurse's own views abo

1. Allows the client to make as many decisions about care as is possible.
Rationale: Assisting the client to die with dignity involves allowing the client to participate in and choose the direction of the remainder of his or her life.

11. After a nurse questions a client about relationship abuse, the client responds that she is ready to leave the abusive relationship, although past attempts were not successful due to fear, lack of support, lack of confidence, and financial consideratio

2. Loss of dreams
Rationale: Perceived loss is experienced by one person but cannot be directly verified by others. Loss of partner, residence, and lifestyle can be seen and acknowledged by others, even if they are not favorable. Dreams are something of w

12. A 22-year-old client with recent paraplegia lashes out and curses at the nurse about the breakfast meal. The nurse's best response is:
1. "I know you are angry, but I cannot let you make me become the object of your anger. I will send up the dietician

4. "I hear a lot of anger in your voice that is quite normal and healthy to hear. Is it a new breakfast you want or something else?"
Rationale: Acknowledging the client's anger and helping the client understand the source of the anger is helpful. Do not t

13. The ability of an individual to cope with death is dependent upon a number of factors. Which person likely will have the most difficulty coping with a death?
1. A parent whose 17-year-old child died in an auto accident the night before graduation
2. A

1. A parent whose 17-year-old child died in an auto accident the night before graduation
Rationale: Many factors affect the grieving experience. These include age, significance of the loss, culture, spiritual beliefs, gender, socioeconomic status, social

14. While the nurse is discussing a client's likely death with family members, one of the offspring inquires, "We plan on taking turns being here for now, but we all want to be here at the time of death. Is there any way we can tell when that time is clos

3. "You can expect more muscle relaxation and less movement. Breathing will become irregular and shallow, and change speed. Call me if you hear mucus in the throat. The pulse and blood pressure will decrease."
Rationale: Muscles relax with decreased activ

15. Following the death of a child, one of the parents begins to falsely accuse other members of the family of blaming the child's death on the parent. This leads to family members avoiding the mentioned parent for fear of the false accusation. The parent

1. Impaired family processes related to impaired adjustment
The first part of the diagnostic statement reflects the concern at hand, while the second part is the etiology or cause. There are a number of concerns present in this scenario. Following the chi

16. A family with five children experiences a stillbirth. While intervening with the family, one member expresses a view that causes special concern for the nurse. This person is:
1. A 3-year-old who wonders if the baby will come home after it gets better

3. A 13-year-old who assumes blame as punishment for shoplifting
A child of 3 does not understand the concept of death, or its permanence. A child of 5 may associate death with unrelated actions. A 15-year-old is expected to follow similar stages of grief

17. A client questions the nurse about the difference between a living will and power of attorney. The nurse's best response is:
1. A lawyer carries a living will, while a designated family member or friend carries out advanced directives.
2. In a living

4. The living will allows the client to indicate specific medical treatments to be omitted in the event of terminal illness, while durable power of attorney legally appoints another to make those decisions on the behalf of the client.
Rationale: A living

18. Elizabeth Kubler-Ross's Stages of Grieving are:

Denial, Anger, Bargaining, Depression, and Acceptance

19. Proper handling of the body following death is an important intervention for the client, family, and nurse. An intervention that reflects an important principle of postmortem care is:
1. Preparing the body to look as clean and natural as possible
2. P

1. Preparing the body to look as clean and natural as possible
Rationale: The body is to be handled with dignity at all times. This does not include using humor at this time. After the body is cleaned and the linen freshened, the sheet is pulled to cover

20. While talking to adult children of a dying client, the nurse finds them tearful, with ambivalent feelings toward the client. The client often expresses beliefs of a wasted life. The children say that the client was a parent who often showed love but f

4. Making a videotape of each child telling a story of a time when the client showed love, while the client tells of a special love for each child. Plan a time to watch it together.
Rationale: Relaxation tapes help with stress reduction, but do not help r