CHAPTER 20 Loss & End of life Issues

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LOSS
Natural part of life and aging The more people live the more losses they experience

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Loss of Relationship
Death of the spouse or life partner is usually the most significant loss that an older person may experience.

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Grief
An acute reaction to ones perception of loss, including physical, psychologic, social and spiritual aspect Other characteristic:
Involves many changes overtime Natural reactions to all kinds of losses Based on ones perception of loss

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Feelings that may accompany grief

Anger Shame Helplessness Sadness Guilt Despair Relief Peacefulness
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Mourning
The long-range process of resolving acute grief reactions It enables the person to resume a satisfying life

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Bereavement
Defined as a state of having experienced a significant loss. May or may not be accompanied by grief

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Perceptions of loss
Perceived in variety of ways
Punishment by the supreme beings Suffering that must be overcome and endured Normal part of life experiences Opportunity for personal growth and transcendence

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Responses to Loss
Worden (1991) Four Task of Mourning
1. Accept the reality of loss 2. Work through the pain of grief 3. Adjust to an environment in which the deceased is missing 4. Emotional relocate the deceased and move on with life
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NORMAL GRIEF RESPONSE

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 Psychologic Response
Feeling of sadness Guilt and regret regarding ones relationship with the person who has died can be troublesome Shock and disbelief may immediately follow the death or loss Diminished self concern, and a yearning for his presence Confused, unable to concentrate Grief spasm- periods of acute grief Feelings of relief and emancipation after prolonged suffering or difficult relationship
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 Physical Symptoms
Commonly associated with acute grief response Tearfulness, crying Loss of appetite, feeling of hollowness in the stomach Decreased energy, fatigue, lethargy Sleep difficulty

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 Social Changes
Lack of interest in activities Lack of energy in making decision Socialization and interaction pattern also change

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 Spiritual Aspects
Death of a loved one causes bereaved people to ponder the existential issues of life and to examine the meaning not only of the lost loved ones life but also of their own. Anger to God, sometimes followed by a crisis of faith

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Complicated Grief Reaction

Complicated Mouring and Abnormal Grief
When grief progresses in an unhealthy way and does not move toward. Dysfunctional grieving- is the nursing diagnosis for complicated grieving or abnormal grief Occurs for an extended time and severe in its intensity

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 Disenfranchised Grief
Refers to the grief that is not or cannot be openly acknowledged Complicates the grieving process because it cannot expressed and because social support is not available
When relationship is not recognized by others (cohabitation, same sex partner) When a loss is not recognized(death of a pet) When griever is not recognized When the death is disenfranchising (suicide)

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Complicated grief reactions may manifest as:

Chronic grief reactions
Prolonged and never reach a satisfactory conclusion

Delayed or postponed grief reactions

The griever response at the time of the loss is either absent or not sufficient to deal with the loss Feelings of hostility or ambivalence are usually present
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 Exaggerated grief reactions

Occur when normal feelings of anxiety, depression, or hopelessness grow to unmanageable proportions.

Masked grief reactions

Occur when bereaved persons experience feelings related to the loss but do not express or recognize the source of these feelings This reaction may occur as a self-protective mechanism, since some people may not be able to bear the stress of mourning Usually manifests as either physical symptoms or some type of maladaptive behavior Page 18

Factors Affecting Grief Response

Psychologic Factors
Characteristic and meaning of the lost relationship Personal characteristic of the bereaved Circumstances surrounding the death

Social factors
Support system Sociocultural or religious background Economic status
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 Physical factors
Use of drugs and sedatives Nutritional state Adequacy of rest and sleep Nurses need to be aware of how all these factors affect dying persons and families so that they may provide the best care possible

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Nursing Care
The goal is to assist and support bereaved persons through the grieving process, recognized pain and accomplish the task of mourning in their own ways.

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 Grief Counselling
Used to facilitate successful progression through the grief process

Grief therapy
Is intended for those experiencing complicated mourning

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Approaching Death: older persons perspective

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1. Denial: This cannot be true. 2. Anger: Why me?

Five Stages of Dying (Kubler Ross)

3. Bargaining: I just want to see my grandchild's birth, then I'll be ready. 4. Depression: I just don't know how my kids are going to get along after I'm gone. Acceptance: I've lived a good life, and I have no regrets. ** mgt: Allow expression of feelings
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 Psychologic Aspects
Once people identified themselves as nearing the end of their lives they engage in a process called Life review.- they try to make sense of life as a whole(Buttler) Erickson- identified the last task of life as a psychosocial crisis of integrity vs despair

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 Spiritual Aspect
Plays an important life in older person making sense of their life. 3 spiritual needs of a dying person(Doka 1993)
To search for the meaning of life To die appropriately To find hope that extends beyond the grave

Reasons for spiritual care:

Preparing for death & afterlife Dealing with anger over dying Seeking forgiveness for pass wrongs Searching for peace

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 Social aspect
Role changes is initiated or reinforced by family Adoption of sick role by acceptance of ones fate Alternately, may adopt a fighting stance, determined to do all they can to outwit death Some, refusing to accept dying, and thus living each day as fully as possible
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General Health Care Needs

Stabilizing and supporting vital functions Determining functional deviation and adjusting treatment Relieving distressing symptoms & suffering Assisting client and family interaction Supporting a client and his family in coping in the realities of death Palliative care

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END

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