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(Relates to Chapter 11, “Palliative Care at End of Life,” in the textbook

)

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• Any form of care or treatment that focuses on reducing the severity of disease symptoms, rather than trying to delay or reverse the progression of the disease itself or provide a cure • Includes hospice, end-of-life care, and bereavement
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• Overall goals
 Prevent and relieve suffering  Improve quality of life for patients with

serious, life-limiting illnesses

• Initiated after a person receives a diagnosis of a life-limiting illness

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3

4 . involves interdisciplinary team  Physicians  Social workers  Pharmacists  Nurses  Chaplains  Other health care professionals Copyright © 2011. an affiliate of Elsevier Inc. 2007 by Mosby.. Inc.• Ideally.

and support for the dying and their families • Exists to provide support and care for persons in last phases of incurable diseases Copyright © 2011. 2007 by Mosby.• Concept of care that provides compassion.. Inc. an affiliate of Elsevier Inc. 5 . concern.

an affiliate of Elsevier Inc. free-standing. Inc.• Approximately 1½ million patients receive hospice services each year.. • Organized under a variety of models  Hospital-based. 6 . or communitybased • Emphasizes palliative rather than curative care Copyright © 2011. part of existing home health care agencies. 2007 by Mosby.

• Can be part-time.. oncall. an affiliate of Elsevier Inc.• Care is provided in a variety of locations. Inc. or continuous basis • Services are available 24 hours a day. Copyright © 2011. regularly scheduled. 7 . intermittent. 7 days a week. 2007 by Mosby.

8 . 2007 by Mosby.• Medically supervised interdisciplinary team of professionals and volunteers • Hospice nurse is an integral part.  Pivotal role in coordination of hospice team  Educated in pain control and symptom management Copyright © 2011. an affiliate of Elsevier Inc. Inc..

Inc. Copyright © 2011.  Patients or family may see it as giving up. 9 . 2007 by Mosby.  Lack of information about hospice care  Physician may view decline as personal failure. an affiliate of Elsevier Inc..• To begin hospice is a difficult decision.

Copyright © 2011. Inc. ▪ Must agree that curative care can be used to treat the terminal illness  Physicians must certify that patient has 6 months or less to live.. 2007 by Mosby. 10 .• Admission has two criteria:  Patient must desire services. an affiliate of Elsevier Inc.

” 4. More readily recognizes advance directives related to “right to die.Audience Response Questions A patient with advanced cancer is referred for hospice care. Copyright © 2011. an affiliate of Elsevier Inc. Focuses on helping the patient and family prepare for death.. 11 . Is delivered in the home and does not rely on the technology of hospitals. Provides for more complete pain control. 2. 3. The nurse explains to the patient and the family that the goal of hospice care differs from the goal of traditional care in that hospice care 1. Inc. 2007 by Mosby.

” 4.” 12 Copyright © 2011.” 3. “I don’t think that I can live without my husband to take care of me. “We have shared so much that it is hard to realize that I will be alone.” 2. 2007 by Mosby. “I don’t feel guilty about leaving him to go to lunch with my friends.. 1. . “I wonder if expressing my sadness makes my husband feel worse. an affiliate of Elsevier Inc. Inc.Audience Response Questions The hospice nurse identifies an abnormal grief reaction in the wife of a dying patient who says.

13 .. Inc. 2007 by Mosby. respiratory. and brain function Copyright © 2011. an affiliate of Elsevier Inc.• Occurs when all vital organs and body systems cease to function • Irreversible cessation of cardiovascular.

including the brainstem • A clinical diagnosis that can be made in patients whose hearts continue to beat and who are maintained on mechanical ventilation in the ICU • Cerebral cortex stops functioning or is irreversibly damaged. Inc.• An irreversible loss of all brain functions. 14 .. an affiliate of Elsevier Inc. 2007 by Mosby. Copyright © 2011.

legal and medical standards require that all brain function must cease for brain death to be pronounced and life support to be disconnected by the physician.. 15 . 2007 by Mosby. • Currently. Inc.• Controversies have arisen related to an exact definition of death. Copyright © 2011. an affiliate of Elsevier Inc.

• Generally refers to the final phase of a patient’s illness. an affiliate of Elsevier Inc. 16 . 2007 by Mosby. when death is imminent • The time from diagnosis of a terminal illness to death varies considerably. Copyright © 2011. depending on the patient’s diagnosis and extent of disease. Inc..

they may be uncertain whether the end is close at hand. Inc. • In other cases. it is obvious to health care providers that the patient is in this phase.• In some cases.. an affiliate of Elsevier Inc. 2007 by Mosby. Copyright © 2011. 17 .

• Term used for issues related to death and dying. 2007 by Mosby.. 18 . an affiliate of Elsevier Inc. as well as for services provided to address these issues • Focuses on physical and psychosocial needs of the patient and the patient’s family Copyright © 2011. Inc.

19 .. an affiliate of Elsevier Inc. 2007 by Mosby. Inc.• Goals  Provide comfort and supportive care during dying process  Improve quality of remaining life  Help ensure a dignified death  Provide emotional support to the family Copyright © 2011.

• Metabolism is decreased. • Respiration generally ceases first. Inc.  Heart stops beating within a few minutes. 20 . 2007 by Mosby. an affiliate of Elsevier Inc.. • Body gradually slows down until all function ends. Copyright © 2011.

• Decreased sensation • Decreased perception of pain and touch Copyright © 2011.• Hearing is usually last sense to disappear.. 2007 by Mosby. Inc. an affiliate of Elsevier Inc. 21 .

Inc. • Decreased sense of taste and smell Copyright © 2011. 22 .. 2007 by Mosby. an affiliate of Elsevier Inc.• Blurring of vision • Blink reflex absent • Patient appears to stare.

Inc. nail beds. feet.. arms. and legs • Cold or clammy skin • Cyanosis on nose. or knees • “Waxlike” skin when very near death Copyright © 2011.• Mottling on hands. 23 . an affiliate of Elsevier Inc. 2007 by Mosby.

or noisy congested breathing (“death rattle”) Copyright © 2011. 2007 by Mosby.• Irregular breathing • Cheyne-Stokes respiration • Inability to cough or clear secretions  Grunting. 24 . an affiliate of Elsevier Inc.. Inc. gurgling.

Inc. 2007 by Mosby. an affiliate of Elsevier Inc.• Gradual decrease in urinary output • Incontinent of urine • Unable to urinate Copyright © 2011. 25 ..

26 . 2007 by Mosby. Copyright © 2011. an affiliate of Elsevier Inc.• Slowing of digestive tract and possible cessation of function • Accumulation of gas • Distention and nausea • Loss of sphincter control • Bowel movement may occur before imminent death or at the time of death. Inc..

an affiliate of Elsevier Inc.. 27 . 2007 by Mosby. Copyright © 2011.• Gradual loss of ability to move • Loss of facial muscle tone  Sagging of jaw  Difficulty speaking  Swallowing can become more difficult. Inc.

Inc.• Difficulty maintaining body posture and alignment • Loss of gag reflex • Jerking seen in patients on large amounts of opioids Copyright © 2011. an affiliate of Elsevier Inc. 28 . 2007 by Mosby..

. 29 . Inc. an affiliate of Elsevier Inc.• Decreased heart rate  Later slowing and weakening of pulse • Irregular rhythm • Decreased blood pressure • Delayed absorption of drugs Copyright © 2011. 2007 by Mosby.

an affiliate of Elsevier Inc.• Altered decision making • Anxiety about unfinished business • Decreased socialization • Fear of loneliness • Fear of meaninglessness • Fear of pain Copyright © 2011. 30 . Inc. 2007 by Mosby..

Inc.. 2007 by Mosby. an affiliate of Elsevier Inc. 31 .• Helplessness • Life review • Peacefulness • Restlessness • Saying goodbyes Copyright © 2011.

an affiliate of Elsevier Inc. Inc. 2007 by Mosby.• Unusual communication • Vision-like experiences • Withdrawal Copyright © 2011. 32 ..

33 . 2007 by Mosby. Copyright © 2011. an affiliate of Elsevier Inc. Inc..• Bereavement is the period of time following the death of a loved one during which grief is experienced and mourning occurs.

Inc.• Grief is the normal process of reacting to loss or adapting to change. an affiliate of Elsevier Inc. 34 . • Dynamic process • Includes both psychologic and physiologic responses following a loss Copyright © 2011. 2007 by Mosby..

Inc. an affiliate of Elsevier Inc. 2007 by Mosby..• Manifested in a variety of ways  Feelings  Behaviors  Thoughts  Physical manifestations Copyright © 2011. 35 .

. 2007 by Mosby.• Intensity of grief is driven by  Individual’s personality  Nature of the relationship with the dying person  Concurrent life crises  Coping resources  Availability of support systems  Cultural beliefs Copyright © 2011. an affiliate of Elsevier Inc. 36 . Inc.

37 .Kübler-Ross (1969) Martocchio (1985) Denial Shock and disbelief Anger/bargaining Depression Yearning and protest Anguish. an affiliate of Elsevier Inc. Inc. 2007 by Mosby. disorganization. and despair Reorganization and restoration Rando (1993) Avoidance Confrontation Acceptance Accommodation Copyright © 2011..

• Adaptive grief  Healthy response  Grief that assists the person in accepting the reality of death Copyright © 2011. 2007 by Mosby. an affiliate of Elsevier Inc. Inc. 38 ..

39 . 2007 by Mosby..• Prolonged grief disorder  Prolonged and intense mourning  Denial of the loss for longer than 6 months Copyright © 2011. Inc. an affiliate of Elsevier Inc.

40 .. Inc.• Goals for the grief process  Resolving emotions  Reflecting on the dying person  Expressing feelings of loss and sadness  Valuing what has been shared Copyright © 2011. an affiliate of Elsevier Inc. 2007 by Mosby.

2007 by Mosby.• Patient also experiences grief. Inc. an affiliate of Elsevier Inc. 41 .. • Goals for grief resolution include  Patient expression of feelings related to grief  Acknowledgment of the impending loss  Demonstration of behaviors that reflect progress in grief resolution Copyright © 2011.

and an afterlife. • At the end of life. Copyright © 2011. many patients question their beliefs about a higher power..• Spiritual needs do not necessarily equate to religion. an affiliate of Elsevier Inc. 2007 by Mosby. Inc. religion. their own journey through life. 42 .

• Deep-seated spiritual beliefs may surface for some patients when they deal with their terminal diagnosis and related issues. • Spiritual distress may occur.

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• Cultural beliefs affect a person’s understanding of and reaction to death or loss. • In some cultural/ethnic groups, death and dying are private matters shared only with significant others.
 Often feelings are repressed or

internalized.
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• Other cultural groups, such as African Americans and Hispanic/Latinos, may express their feelings and emotions easily. • In such cultures, family members, both immediate and extended, provide support for one another.
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Inc.. Copyright © 2011. 2007 by Mosby. pain expression) and use of health care services also exist. an affiliate of Elsevier Inc. • Cultural variations in symptom expression (e.g.• Families with non–English-speaking members are at risk for receiving less information about their family member’s critical illness and prognosis.. 46 .

2007 by Mosby. an affiliate of Elsevier Inc.• Nursing assessment of beliefs and preferences should be made on an individual basis. Inc.. • Avoids stereotyping individuals with different cultural belief systems Copyright © 2011. 47 .

• Outcomes related to care based on patient’s wishes  Organ and tissue donations  Advance directives ▪ Medical power of attorney or living wills  Resuscitation Copyright © 2011. 2007 by Mosby. 48 .. Inc. an affiliate of Elsevier Inc.

• Advance directives  Written statements of medical care wishes • Directive to physicians  Patient’s desire to accept or deny treatment Copyright © 2011. an affiliate of Elsevier Inc. 49 . 2007 by Mosby. Inc..

• Do not resuscitate (DNR)  Order instructing health care providers not to attempt CPR  Variety of CPR decisions Copyright © 2011. 2007 by Mosby. an affiliate of Elsevier Inc. Inc.. 50 .

• Withholding or withdrawing treatment must be included in an advance directive. an affiliate of Elsevier Inc. Copyright © 2011. 2007 by Mosby. Inc.. • What is to be done and what is not to be done must be included in clear terms. 51 .

. 2007 by Mosby. Copyright © 2011. 52 . Inc. an affiliate of Elsevier Inc.• Euthanasia is the deliberate act of hastening death. • The ANA statement on active euthanasia states that the nurse should not participate in active euthanasia.

an affiliate of Elsevier Inc. 53 .. 2007 by Mosby.• Holistic  Psychosocial and physical needs • Focuses on  Psychosocial manifestations  Grieving process  Physical changes associated with dying Copyright © 2011. Inc.

. Inc. an affiliate of Elsevier Inc. 54 .• Varies with  Patient condition  Proximity of approaching death • Limited to essential data • Document specific change that brought patient into health care agency Copyright © 2011. 2007 by Mosby.

55 .• If patient is alert  Brief review of body systems to detect signs and symptoms  Assess for discomfort. nausea. Copyright © 2011. Inc. pain. • Assess coping abilities of patient and family. or dyspnea. an affiliate of Elsevier Inc.. 2007 by Mosby.

• Functional assessment of activities of daily living  Patient’s abilities  Food and fluid intake  Patterns of sleep and rest  Response to the stress of terminal illness Copyright © 2011. Inc. an affiliate of Elsevier Inc.. 2007 by Mosby. 56 .

Copyright © 2011.• Frequency of assessment depends on stability. Inc. an affiliate of Elsevier Inc. assessment and documentation need to be done more frequently. 2007 by Mosby. 57 .  As changes occur.. but it is done at least every 8 hours.

an affiliate of Elsevier Inc. neurologic assessment is important.  Level of consciousness  Presence of reflexes  Pupil responses Copyright © 2011.. Inc. 58 .• As death approaches. 2007 by Mosby.

skin color. and temperature  Respiratory status ▪ Character and pattern of respirations Copyright © 2011. 59 ..• Evaluate and monitor  Circulation changes ▪ Vital signs. 2007 by Mosby. Inc. an affiliate of Elsevier Inc.

and bowel function  Skin condition ▪ Fragile: Note breakdown Copyright © 2011. Inc. urinary output.. an affiliate of Elsevier Inc. 2007 by Mosby.• Evaluate and monitor (cont’d)  Gastrointestinal/renal functioning ▪ Nutritional/fluid intake. 60 .

2007 by Mosby.  Use health history data available in chart. Inc. • Assess patient frequently (but not unnecessarily).. Copyright © 2011.• Be sensitive. 61 . an affiliate of Elsevier Inc.

2007 by Mosby. an affiliate of Elsevier Inc. 62 .. Inc.• Acute confusion • Chronic confusion • Compromised family coping • Death anxiety • Disturbed thought processes Copyright © 2011.

. 63 . Inc. 2007 by Mosby.• Fear • Grieving • Hopelessness • Impaired religiosity • Impaired social interaction Copyright © 2011. an affiliate of Elsevier Inc.

.• Impaired verbal communication • Ineffective coping • Ineffective denial • Interrupted family processes • Insomnia Copyright © 2011. Inc. 2007 by Mosby. an affiliate of Elsevier Inc. 64 .

Inc. 2007 by Mosby. an affiliate of Elsevier Inc.. 65 .• Readiness for enhanced spiritual well-being • Risk for loneliness • Social isolation • Spiritual distress Copyright © 2011.

Inc.• Acute pain • Bowel incontinence • Chronic pain • Constipation • Decreased cardiac output • Diarrhea Copyright © 2011. 2007 by Mosby.. 66 . an affiliate of Elsevier Inc.

an affiliate of Elsevier Inc..• Fatigue • Imbalanced nutrition: less than body requirements • Impaired bed mobility • Impaired comfort • Impaired gas exchange • Impaired oral mucous membrane Copyright © 2011. 2007 by Mosby. Inc. 67 .

. an affiliate of Elsevier Inc.• Impaired physical mobility • Impaired skin integrity • Impaired swallowing • Impaired tissue integrity • Impaired urinary elimination • Ineffective airway clearance Copyright © 2011. 2007 by Mosby. Inc. 68 .

Inc. 69 . an affiliate of Elsevier Inc.. 2007 by Mosby.• Ineffective breathing pattern • Ineffective thermoregulation • Ineffective tissue perfusion • Nausea • Risk for aspiration • Risk for infection Copyright © 2011.

.• Risk for injury • Self-care deficit • Total urinary incontinence Copyright © 2011. 2007 by Mosby. an affiliate of Elsevier Inc. 70 . Inc.

71 . 2007 by Mosby. counseling. advocacy. and support Copyright © 2011. Inc.• Coordination of care focus  Patient’s needs  Family and significant other’s needs  Education.. an affiliate of Elsevier Inc.

an affiliate of Elsevier Inc.. 72 . Inc. 2007 by Mosby.• Nursing goals  Center on patient’s abilities to express and share feelings with others  Involve comfort measures and physical maintenance care Copyright © 2011.

73 Copyright © 2011. 2007 by Mosby. an affiliate of Elsevier Inc.. .• Education  Ongoing information about the disease  Dying process  Any care provided  How to cope • Denial and grieving may be barriers to patient’s learning. Inc.

74 . 2007 by Mosby. Inc.• Uneasy feeling caused by a source not easily identified • Frequently related to fear • Management  Pharmacologic or nonpharmacologic interventions Copyright © 2011. an affiliate of Elsevier Inc..

psychosocial factors from disease process or impending death.. altered physiologic states.• Causes  Uncontrolled pain. drugs used in increasing doses • Management  Encouragement. 75 . 2007 by Mosby. Inc. and education Copyright © 2011. an affiliate of Elsevier Inc. support.

an affiliate of Elsevier Inc. 2007 by Mosby.• The surviving family members may be angry with the dying loved one who is leaving them.. Copyright © 2011. Inc. • Nurses are sometimes the target of the anger and must understand what is happening and not react on a personal level. 76 .

• Common emotions at the end of life • You need to encourage realistic hope within the limits of the situation. Inc.. Copyright © 2011. an affiliate of Elsevier Inc. 77 . • Decision making about care can foster a sense of power and control for the patient. 2007 by Mosby.

78 .. an affiliate of Elsevier Inc. 2007 by Mosby. Inc.• Four specific fears  Pain  Shortness of breath  Loneliness and abandonment  Meaninglessness • Management  Coping strategies Copyright © 2011.

2007 by Mosby. 79 . Inc..• Tendency to associate death with pain • Physiologically: No indication that death is always painful • Psychologically: Pain may occur based on anxieties or separations related to dying Copyright © 2011. an affiliate of Elsevier Inc.

• Most patients want their pain relieved without the side effects of grogginess or sleepiness.• Terminally ill patients experiencing pain should have pain-relieving drugs available. 80 . 2007 by Mosby.  Do not want to be deprived of ability to interact with others Copyright © 2011. an affiliate of Elsevier Inc.. Inc.

and oxygen. bronchodilators. Copyright © 2011. • Current therapies involve the use of opioids. depending on the cause of the dyspnea. 81 . Inc.. an affiliate of Elsevier Inc. 2007 by Mosby.• The sensation of air hunger results in anxiety for the patient and family members.

an affiliate of Elsevier Inc. 82 .• Do not want to be alone • Worry loved ones cannot cope and will abandon them • Want someone they know and trust to stay  Loved one or caregiver provides comfort and support.. 2007 by Mosby. Copyright © 2011. Inc.

Inc. and listening • Simply providing companionship allows a sense of security. Copyright © 2011. touching. an affiliate of Elsevier Inc. 2007 by Mosby. 83 ..• High-quality nursing responses  Holding hands.

• Leads most to review their lives  Intentions during life and examining actions  Expressing regret  Helps recognize life’s value • Worth needs to be expressed Copyright © 2011. Inc. 84 . an affiliate of Elsevier Inc.. 2007 by Mosby.

Copyright © 2011. • Respect and accept practices or rituals associated with patient’s life review without being judgmental.• Nurse can assist patients and their families in identifying positive qualities of patient’s life. an affiliate of Elsevier Inc.. 2007 by Mosby. Inc. 85 .

Inc. • Allow patients and families time to express their feelings and thoughts. Copyright © 2011.. an affiliate of Elsevier Inc. • Use empathy and active listening.• Therapeutic communication is important nursing intervention. 2007 by Mosby. 86 .

87 . • Listening to the silence sends a message of acceptance and comfort.. Copyright © 2011. 2007 by Mosby. Inc. an affiliate of Elsevier Inc.• Silence is OK.

. 88 . 2007 by Mosby.• Unusual communication by patient may take place at end of life. disoriented. an affiliate of Elsevier Inc. Inc. or garbled Copyright © 2011.  Confused.

• Patients may speak  To or about family members or others who have died before them  To give instructions to those who survive them  To speak of projects yet to be completed Copyright © 2011.. 89 . Inc. 2007 by Mosby. an affiliate of Elsevier Inc.

90 .• Active. careful listening allows identification of specific patterns in patient’s communication. Inc. 2007 by Mosby. an affiliate of Elsevier Inc.  Increased risk for inappropriate labeling of behaviors Copyright © 2011..

• Deserve same care as people who are expected to recover Copyright © 2011. Inc. 91 . an affiliate of Elsevier Inc.• Symptom management • Priority is to meet physiologic and safety needs. 2007 by Mosby..

92 . an affiliate of Elsevier Inc. 2007 by Mosby..• Needs  Oxygen  Nutrition  Pain relief  Mobility  Elimination  Skin care Copyright © 2011. Inc.

2007 by Mosby.• After patient is pronounced dead.. 93 . the nurse prepares or delegates preparation of the body for immediate viewing by the family. Inc. an affiliate of Elsevier Inc. Copyright © 2011.

• Considerations when preparing body
 Cultural customs  In accordance with state law

 Agency policies and procedures

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• Considerations when preparing body
 Close the patient’s eyes.  Replace dentures.  Wash the body as needed. ▪ Place pads under perineum.  Remove tubes and dressings.  Straighten body. ▪ Leave pillow to support head.
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• Family should be allowed privacy and as much as time as they need with the deceased person.

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97 .. an affiliate of Elsevier Inc.• Unexpected or unanticipated death  Preparation of the body for viewing or release to a funeral home depends on state law and agency policies and procedures. Copyright © 2011. 2007 by Mosby. Inc.

• Role of caregiver includes  Working and communicating with the patient  Supporting concerns  Helping resolve any unfinished business Copyright © 2011. Inc. an affiliate of Elsevier Inc.. 2007 by Mosby. 98 .

. 2007 by Mosby. 99 . an affiliate of Elsevier Inc.• Role of caregiver includes (cont’d)  Working with family members and friends  Dealing with own needs and feelings Copyright © 2011. Inc.

100 . 2007 by Mosby.• Recognizing signs and behaviors among family members who may be at risk for dysfunctional grief reactions is an important nursing intervention. Inc. an affiliate of Elsevier Inc.. Copyright © 2011.

Inc. an affiliate of Elsevier Inc. 101 .. 2007 by Mosby.• Risk for dysfunctional grief  Dependency  Negative feelings about the dying person  Inability to express feelings  Concurrent life crises  History of depression Copyright © 2011.

• Risk for dysfunctional grief (cont’d)  Difficult reactions to previous losses  Perceived lack of social or family support  Low self-esteem  Multiple previous bereavements  Alcoholism  Substance abuse Copyright © 2011. an affiliate of Elsevier Inc. Inc.. 102 . 2007 by Mosby.

• Encouragement to continue their usual activities • Discuss their activities and maintain some control over their lives • Discuss what can and cannot change • Encouragement to take care of themselves Copyright © 2011.. Inc. 103 . 2007 by Mosby. an affiliate of Elsevier Inc.

Copyright © 2011. Inc.. • Caring for dying patients is intense and emotionally charged.• Many nurses who care for dying patients are passionate about providing quality EOL care. 2007 by Mosby. an affiliate of Elsevier Inc. 104 .

and frustration need to be expressed. guilt. 105 .• Common for nurse to feel helpless and powerless when dealing with death.. 2007 by Mosby.  Should be aware of how these feelings affect them Copyright © 2011. Inc. an affiliate of Elsevier Inc.  Feelings of sorrow.

• Okay to cry with the patient or family during the grieving process Copyright © 2011.• Recognize and acknowledge what can and cannot be controlled. Inc. • Recognize personal feelings to allow openness. 106 . an affiliate of Elsevier Inc. 2007 by Mosby..

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