Geri End/OB Start: Module 6 - Coping and Death

Question 1

What may a mother with a handicapped or stillborn infant and the elder mourn the loss of (despite being alive?

Answer 1

the visualized “perfect” infant

memorialize the “perfect” self that no longer exists

Question 2

Loss ___ an individual

Answer 2

changes

Question 3

What can coming through the grieving process supported help do?

Answer 3

help the individual experience a loss to be able top put the loss into perspective and start to create a new life for themselves

Question 4

Elizabeth Kubler-Ross Model Stages of Grief

Answer 4

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

Question 5

Who were the stages of grief for?

Answer 5

Originally for a dying person but now it is used for the grievers

Question 6

Denial Stage

Answer 6

First Stage

Usually only a temp. defense for the individual.
This is generally replaced with heightened awareness of situations and individuals that will be left behind after death

Ex: “I feel fine;” “This can’t be happening not to me”

Question 7

Anger Stage

Answer 7

Second Stage

The individual recognizes denial cannot continue

Because of anger, the person is very difficult to care for due to misplaced feelings of rage and envy. Any individual that symbolizes life or energy is subject to projected resentment and jealousy.

Ex: “ Why me? Its not fair!”; “How can this happen to me?”; “Who is to blame”

Question 8

Bargaining Stage

Answer 8

Third Stage

involves the hope that the individual can somehow postpone or delay death. Usually, the negotiation for an extended life is made with a higher power in exchange for a reformed lifestyle. Psychologically, the person is saying, “I understand I will die, but if I could just have more time…”

Ex: “Just let me live to see my children graduate.”; “I’ll do anything for a few more years.”; “I will give my life savings if…”

Question 9

Depression Stage

Answer 9

Fourth Stage

the dying person begins to understand the certainty of death. Because of this, the individual may become silent, refuse visitors and spend much of the time crying and grieving. This process allows the dying person to disconnect himself from things of love and affection. It is not recommended to attempt to cheer an individual up that is in this stage. It is an important time for grieving that must be processed.

Ex: “I’m so sad, why bother with anything?”; “I’m going to die . . . What’s the point?”; “I miss my loved one, why go on?”

UPWARD TURN NEEDS TO COME ON ITS OWN NOT FORCED

Question 10

Acceptance Stage

Answer 10

Fifth and Final Stage

comes with peace and understanding of the death that is approaching

generally the person in the fifth stage will want to be left alone

feelings and physical pain may be non-existent

Stage described as the “end of the dying struggle”

ex: “Its going to be okay”; “I cant fight it, I may as well prepare for it”

Question 11

2 Problems with the Original 5 Stages of Grief?

Answer 11

1. Dr Kubler Ross made it in 1969 while working with people DYING OF CANCER - the stages were supposed to be for the grief a dying person goes through, not those grieving the death of another person
2. Stage interpretation neglected the patient’s situations and how they could affect the cycle (ex: relationship supports, effects of illnesses)

Question 12

The Seven Stage Model

Answer 12

A 7 stage model for the grieving individual dealing with a loss

The stages move in a U shape of worsening mood with an upward swing

Question 13

What are the 7 Stages of a Grieving Individual?

Answer 13

1. Shock and Denial
2. Pain and Guilt
3. Anger and Bargaining
4. “Depression”, Reflection, Loneliness
5. The Upward Turn
6. Reconstruction and Working Through
7. Acceptance and Hope

Question 14

Shock and Denial Stage

Answer 14

Stage 1 of 7

Griever will reach to learning of the loss with NUMBED DISBELIEF

May DENY reality of the loss as some level to avoid pain

Shock provides emotional protection from being overwhelmed all at once!!!!

Can last for weeks

Question 15

Pain and Guilt Stage

Answer 15

Stage 2 of 7

Shock and denial is replaced with SUFFERING UNBELIEVABLE PAIN

While pain is excruciating and almost unbearable, IT IS IMPORTANT THAT IT IS EXPERIENCED FULLY - do not hide it, avoid it, or escape with drugs or alcohol

May have feelings of guilt or remorse over things they did or did not do with a loved one

Life feels chaotic and scary at this phase

Question 16

Anger and Bargaining Stage

Answer 16

Stage 3 of 7

Frustration gives way to anger

May lash out and lay unwarranted blame for the death on someone else - could cause permanent relationship damage!

This is a time of release of bottled up emotion

May rail against fate with “why me?”

May try bargaining in vain with powers that be for a way out of despair (“I will never do ___ again if you bring them back”)

Question 17

“Depression”, Reflection, Loneliness Stage

Answer 17

Stage 4 of 7

When friends may thing its time to get on with life, a long period of sad reflection will set in

This is a normal stage so they should not be “talked out of it”

Encouragement from others is not helpful to them during this stage!!

During this time they finally realize the true magnitude of their loss and it depresses them

May isolate on purpose, reflect on things, and focus on past memories

May feel emptiness or despair

Question 18

The Upward Turn Stage

Answer 18

Stage 5 of 7

As the griever adjust to life post-loss, life becomes a little calmer and more organized

Physical symptoms lessen, and “depression” begins to lift slightly

Question 19

Reconstruction and Working Through Stage

Answer 19

Stage 6 of 7

As they become more functional, their mind starts working again, and they find themselves seeking realistic solutions to problems posted by life without their loved one.

They will start to work on practical and financial problems and reconstructing themselves and their life

Question 20

Acceptance and Hope Stage

Answer 20

Stage 7 of 7

Learn to accept and deal with the reality of the situation

Acceptance does not necessarily mean instant happiness!

Given the pain and turmoil experienced, they can never return to the carefree untroubled self that existed before this tragedy, but a way forward is found

Question 21

What is the timetable for grief?

Answer 21

There is none

Question 22

Is there a right or wrong way to grieve?

Answer 22

No

Question 23

Grief is as ___ as the person experiencing a loss, their relationship with their lost one, and the circumstances of the death or loss are

Answer 23

individual!

Question 24

Grief is a ___ and ___ process that may cause you to wonder what?

Answer 24

Grief is an unpleasant and lengthy process that may cause you to wonder as to how long it all will last and when you can expect some relief from the pain

Question 25

How may grief differ between people?

Answer 25

Some may find within a few months it subsides and they can find closure while others may face years of relentless waves of grief, getting stuck in chronic mourning, and needing professional help Grief never follows the neat progression of stages as it is complicated and personal, a person may have regression or backtracking

Question 26

If a person regresses or backtracks to an earlier grief stage what does this mean?

Answer 26

it just means the individual was not finished with it yet and are fully working it through in their own way

Question 27

Factors that influence loss and grief

Answer 27

Age of the individual dying and of the individuals surviving. Significance of the loss Culture Spiritual beliefs Gender Socioeconomic status Support system Cause of loss or death

Question 28

Cultural and religious differences can result in differences in how individuals or families...

Answer 28

View the significance of the event or loss. Attribute the cause of the illness. Feel about the appropriateness of medical interventions. Communicate their responses to the event or loss.

Question 29

Coping and Grieving Nursing Diagnoses Examples

Answer 29

Grieving Complicated grieving Interrupted family process Risk-prone health behavior Risk for loneliness Role strain Risk for ineffective parenting

Question 30

What are the unit of care as defined by the patient in hospice?

Answer 30

the patient and family are the unit of care

Question 31

Hospice uses what to address patient and family needs?

Answer 31

an interdisciplinary team

Question 32

What is the emphasis in Hospice?

Answer 32

Comfort Dignity QOL Autonomy

Question 33

Medical treatment of distressing symptoms occurs in hospice related to the terminal diagnosis but...

Answer 33

does not provide interventions to CURE disease or PROLONG life

Question 34

What is the life expectancy in hospice?

Answer 34

6 mo or less if the terminal illness runs its normal course

Question 35

Hospice eligibility is covered under...

Answer 35

the Medicare hospice benefit

Question 36

In order to be placed in hospice, one must …

Answer 36

meet "Local Coverage Determination" (LCD) and have documented rapid clinical decline or significant co morbidities *Scales like FAST and PPS can be used to document functional status*

Question 37

FAST Scale

Answer 37

Used for dementia functional status does not stage alzheimers

Question 38

PPS

Answer 38

Palliative Performance Scale More related to mobility

Question 39

Barriers and Issues in Hospice Care

Answer 39

Difficulty determining 6 month or less life expectancy Referrals when death is imminent Healthcare professionals, patient, or family reluctant to discuss DNR or “give up hope.” A Need to change focus to hope for comfort instead of hope for a cure.

Question 40

What things can be expected during the Dying Process

Answer 40

Neurologic dysfunction Decreasing level of consciousness Terminal delirium Loss of ability to swallow

Question 41

What should the RN do at the time of death?

Answer 41

Create peaceful environment Notify physician Shift from care of patient to care of family Prepare the body – family may or may not want to be present Notify funeral home Prepare family and caregivers for potential symptoms associated with the dying process

Question 42

What kind of death can give family closure and allow for growth?

Answer 42

A peaceful and well managed death

Question 43

2 Roads of Death

Answer 43

1. The usual road 2. The difficult road * These are the roads the dying person can travel toward death

Question 44

What occurs in the usual road of death?

Answer 44

Normal --> Sleepy --> Lethargic --> Obtunded --> Semicomatose --> Death

Question 45

What occurs in the difficult road of death?

Answer 45

Normal --> Restless --> Confused --> Tremulous --> Hallucinations --> Mumbling Delirium --> Myoclonic Jerks --> Seizures --> Semicomatose --> Comatose --> Death

Question 46

Who can pronounce death?

Answer 46

The physician

Question 47

What can a nurse do in regard to the pronunciation of death process?

Answer 47

A nurse is authorized to pronounce absence of vitals (like listening for heartbeat for a full minute but cannot find it) but then they must call the physician and let them know so they can pronounce the person dead

Question 48

What things are needed for a pronouncement of death?

Answer 48

1. Absence of Heartbeat 2. Absence of Respirations 3. Absence of Blood Pressure 4. Pupils Fixed

Question 49

What things may an elderly person lose that influences how they mourn?

Answer 49

Their past experience career home spouse children siblings functionality with chronic and acute illness

Question 50

Who are among the interdisciplinary elderly grief response team members?

Answer 50

nurses physicians social workers pastoral care funeral director family

Question 51

How to help a family death with elderly loss?

Answer 51

REFLECT ON MEMORIES: Photographs Collecting life memorabilia Creating a memorial service such as a religious ceremony, a burial or the planting of a memorial tree. Comfort, bathing, music, reading to the elder Support the patient’s advanced directives Family support – Reminisce

Question 52

The Last Bath

Answer 52

A final dignity bath that is very solemn and a gentle body cleanse: Offer the family to stay with the body and participate Gentle body cleanse Teeth, eye glasses, stay with the body Not all facilities use body bags Be respectful of the body Do not rub areas You will notice mottling/bluing of the skin as the body cools Be sure to identify the body with a tag

Question 53

What to do with a deceased person's personal items?

Answer 53

Be sure to carefully inventory Pass on to Power of Attorney or next of kin Check with the family to see if any personal belongings should be sent to the funeral home Offer spiritual services/social support services to the family

Question 54

General Nursing Interventions for Loss and Grief

Answer 54

Explore and respect ethnic, cultural, religious and personal values in their expression of grief. Teach the individual or family what to expect in the grief process Encourage the individual or family to express and share grief with support people. Sharing feelings reinforces relationships and facilitates the grief process. Teach family members to encourage the individual’s expression of grief, not to encourage the individual to “move on” or fit their expectations of grief. Encourage the individual to resume normal activities on a schedule that promotes physical and psychological health. Caution against returning too early. Prolonged return may signal a more complicated grieving process. Use silence and personal presence along with techniques of therapeutic communication. Use appropriate touch. Be genuine and caring Answer questions and refer as needed. Acknowledge the grief of the individual’s family and significant others. Offer choices that promote individual autonomy. Provide appropriate information regarding how to access resources in the community and beyond: clergy, counseling services, hospice, internet sources.

Question 55

What can you say to the grieving or dying?

Answer 55

``` “I’m sad for you.” “How are you doing with all of this?” “This must be hard for you.” “What can I do for you?” “I’m sorry.” “I’m here, and I want to listen.” ```

Question 56

What should you not say to the grieving or dying?

Answer 56

“You’re young, you can have others.” “You have an angel in heaven.” “This happened for the best.” “Better for this to happen now, before you knew the baby.” “There was something wrong with the baby anyway.” Calling the baby “fetus” or “it”. Refer to the baby by name once it is known.

Question 57

Who is among the interdisciplinary neonatal grief response team members?

Answer 57

nurses physicians social workers pastoral care funeral director geneticist

Question 58

Types of Fetal Loss

Answer 58

Antepartum Intrapartum Neonatal

Question 59

Examples of Antepartum Loss

Answer 59

Miscarriage Ectopic Pregnancy Molar Pregnancy Medical Interruption Intrauterine Death

Question 60

Examples of Intrapartum Loss

Answer 60

Fetal Distress Stillbirth

Question 61

Antepartum

Answer 61

before childbirth

Question 62

Intrapartum

Answer 62

during childbirth / Death in labor and delivery

Question 63

Miscarriage

Answer 63

Spontaneous abortion Loss of a fetus before 20 weeks of pregnancy

Question 64

Ectopic Pregnancy

Answer 64

when the fertilized egg grows outside the uterus and can lead to mother and child death possibly

Question 65

Molar Pregnancy

Answer 65

Noncancerous tumor development in the uterus as a result of a nonviable pregnancy

Question 66

Medical interruption Loss

Answer 66

Required medical intervention leading to abortion in order to save mothers life - the pregnancy is life threatening

Question 67

Intrauterine Death

Answer 67

Term generally describing stillbirth while still in the mother after the 20th week

Question 68

Fetal Distress

Answer 68

uncommon complication of labor where the fetus shows signs before and during childbirth indicating it not being well ex: Not getting enough oxygen

Question 69

Stillbirth

Answer 69

birth of a baby who has died any time from 20 weeks in the pregnancy and on through the due date of birth A stillborn child or in utero loss may have skin loosening and leaking of fluids and damage, so you must wrap it in such a way to prevent loss of things

Question 70

Neonatal Loss

Answer 70

refers to loss of a child within the first 28 days after delivery often related to prematurity, anomalies, or infection

Question 71

Most important neonatal loss intervention?

Answer 71

CREATING MEMORIES

Question 72

Examples of creating memories intervention for neonatal loss?

Answer 72

Seeing, holding and touching the infant Photographs of the infant Journaling the experience Collecting memorabilia such as locks of hair, ID bracelets, crib cards, stuffed animals, hand and foot prints, clothing, ornaments. Creating a memorial service such as a religious ceremony, a burial or the planting of a memorial tree.

Question 73

How should neonatal loss be prepared for viewing?

Answer 73

Depending on the circumstances of the infant’s birth, there may be physical aspects of the infant’s appearance that the parents and those viewing the infant should be prepared for such as: Bruising Maceration of the skin Loss of firmness to tissues Leaking of body fluids

Question 74

Despite the abnormal appearance of some structures of a dead/dying infant...

Answer 74

most parents benefit from seeing their infant, it helps them accept reality Anomalies may be imagined as more grotesque to us than they truly are but the parents can usually find and internalize features about their infant they perceive as positive and play down the issues

Question 75

5 Common Fears Regarding the Grieving Process (Neonatal)

Answer 75

1. Loss of control 2. Appearing weak to others 3. That they crying will never stop 4. Unable to bear the loss 5. The infant will be forgotten or the loss minimalized

Question 76

A leaf with a teardrop sign on the door may indicate...

Answer 76

a room without and infant and a loss that occurred

Question 77

Important factors that influence the grief following perinatal loss

Answer 77

1. The suddenness and unexpected nature of the loss | 2. The way the infant death is socially defined in their culture

Question 78

Resolve Through Sharing Program

Answer 78

Program adopted by most hospitals to train staff to assist parent through perinatal loss an interdisciplinary response provides both immediate and long term support and counseling to the parents entire hospital staff is oriented to the marker used to identify families experiencing a loss (leaf with a teardrop on it)

Question 79

Should nurses never show emotion?

Answer 79

It is needed to control emotions to handle a situation and provide a safe and appropriate care but periodically not showing our emotions or humanness is viewed as cold and unfeeling So sometimes genuine emotion can be a sincere way to provide emotional support

Question 80

What things about dying and grief have changed since the COVID-19 pandemic began?

Answer 80

The numbers of patients that nurses are caring for that are dying. The manner in which they are dying. The increased number of patients nurses are having to take on. The high acuity level of the patients being cared for. The added complexity of most of your patients being on strict isolation. The vulnerable are dying but so are others. Most of us will know people that die from this. Patients are dying alone without their support system. Friends and family members are bring traumatized by not being able to be with and comfort their loved ones. Nurses are already overworked but are having to free up time to be with patients as they die or conduct codes. Nurses are having to create connections with families at the time of death. It is an interesting duality has emerged where nurses are suddenly treated as both indispensable and disposable. !!!!!!! There’s never been a period in the history of nursing where scope of the role has been more understood and valued by the general culture. !!!!!!!!!!

Question 81

Despite the increased awareness of the importance of nursing with COVID-19, what is the duality that occurs?

Answer 81

Nurses are treated both indispensable and disposable There has been a lack of respect for rights to work in environments with the right protective equipment that has never occurred before - adding stress and complexity Some nurses have been fired for speaking out publicly about issues