Chapter 43, Loss, Grief, and Dying

Case Studies, Chapter 43, Loss, Grief, and Dying 1. You are an inpatient hospice nurse caring for your patient, a 42-year-old woman with metastasized breast cancer whose prognosis is terminal. Hospice physicians indicate she has approximately 1 month to live; she is spending her time with her husband and three children, who demonstrate affection. Her family is attentive, supportive, and significantly involved in her care. They spend their time playing games (with the patient watching if she doesn’t have the energy to compete), wheeling her around the flower gardens, and talking of future plans for the family after her death. In the evening, after her family has gone home, she speaks to you about how difficult it is to speak of the future, knowing she won’t be there to participate. (Learning Objectives 1, 2, and 6) a. What factors would contribute to your patient experiencing a “good death”? “Good death”- A death that allows a person to die on their own terms, relatively free of pain, and with dignity. Other aspects of a good death include: - Being free of avoidable distress and suffering for families, and caregivers - Being in general accord to the families’ wishes and reasonably consistent with clinical, cultural, and ethical standards. - Characteristics of a good death include: Control of symptoms Preparation for death Opportunity for the person to have a sense of completion of his or her life And a good relationship with healthcare professionals b. Describe the care that would be deemed “excellent” for your dying patients. The care is guided by the values and preferences of the individual patient. Independence are central issues for many dying patients, especially in older adults. Maintaining control and not being a burden are also relevant concerns. Palliative care- should attend to both the needs of the patient and the family. Care- should focus on relieving symptoms (not just relieving pain) and use both pharmacologic and nonpharmacologic means. All healthcare professionals- should receive in-depth, insightful, and culturally sensitive instruction in the optimal care of dying patients. Adequate funding for research- is essential to improving endof-life care. c. How could you best meet the needs of your patient when she wants to discuss how difficult some conversations are with her family? Listening- the patient may want to talk to someone who is nonjudgemental in what they are concerned about. Education- Tell the patient about what will happen towards the end. Do not give any false reassurance. d. In what ways can a nurse promote personal communication with dying patients? Show your vulnerable side to the patient and use nonverbal communication as appropriate. e. Once your patient has neared the end of her journey, what are some of the physical signs and symptoms that can signal impending death? Dysphagia or dysphasia GI s/s- Nausea, flatus, abdominal distention Incontinence- with bowel and/or urine or constipation Loss of movement, sensation, reflexes Decreasing body temperature and cold or clammy skin Weak, slow, or irregular pulse Decreasing BP Noisy, irregular, or Cheyne-Stokes respirations Restlessness or agitation Cooling, mottling, and cyanosis of extremities and dependent areasz 2. Your home health care patient is a 10-year-old girl who has been unresponsive since she was toddler, after a cardiac arrest. Over the years, you have seen her undergo numerous hospitalizations from infection. She has a tracheostomy, gastric feeding tube, and suprapubic catheter. The child is a full code. Her single mother provides care day and night with little family support. Upon entering the home, you find the mother holding her daughter’s hand. Sobbing, she says to you, “I can’t do this anymore. Please help me let her go.” (Learning Objectives 3, 4, and 5) a. Outline the role of a nurse in active euthanasia. Nurses do NOT participate in active euthanasia as it is against the ANA’s Code of Ethics. The ANA Code for Ethics states that the nurse “should provide interventions to relieve pain and other symptoms in the dying patient consistent with palliative care practice standards and may not act with the sole intent to end life.” b. How might this patient and family benefit from palliative instead of curative care? Palliative care will help the family view dying as a natural and personal part of life as it involves taking care of the person as a whole (body, mind, and spirit, as well as their heart and soul). Through palliative care, the patient will be able to receive the best quality of life they can by the aggressive management of symptoms. c. Describe an appropriate reaction of a nurse to the death of a patient for which the nurse has provided care for a significant amount of time. Grief after the death of a patient is natural; nurses should allow themselves to go through the grieving process rather than shut off the grief. Work pressures can make it difficult to create the time and space to respond to a patient’s death, but nursing leadership is increasingly affirming the need to do this. Nurses should also address their personal health needs.