Philosophers and Theorists Death & Culture Alternative Therapies Dying and society over time Terminology

Coping
Describes the behavior one uses to respond to stress Healthy- adaptive coping. Unhealthy- Maladaptive o Alcohol abuse due to cancer diagnosis

Used to avoid stress or conflict Unable to face fear denial o o o Act in his or her own behalf Finding the right doctor once diagnosed Taking time from important goals if dying

Taking advice without thinking it through Two ways to achieve adaptive coping o o o o Work on the relationship between the stressor and the individual Increase skills in perception and intra/interpersonal communication Confront the problem Change some of the psychophysiological results of stress for the individual Relaxation, humor, imagery, biofeedback

Pain
Is what the patient says it is Subjective, involving total person A senation, emotion, cognitive, motivation, and an energy Pervieve pain based on

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Education, Ethnicity, Culture, Physical condition, Experience, Tolerance , Severity, Location , Secondary meaning

Accident, abuse, changing life status, a warning, deterioration in physical condition, illness

Assessment Recognition that the pt perceives pain to be present Documentation of pain treatment Documentation of progress Some pts dont report pain until severe because of o o o Culture learned response Fear of becoming addicted Dont understand when pain control should be started

Rating scales Allows nurse to evaluate pain management strategies Flow chart 1-10 Facial expressions

Palliative Care
- caregiver understands that the medical prognosis of the patient of limited - care focuses on quality of life rather than length - affirms life and regards dying as normal process - neither hastens nor postpones death - provides relief from pain and other distressing symptoms - integrates the psychological and spiritual aspects of care - offers a support system to help patients live as actively as possible until death and help familes cope during the patients illness and their own bereavement.

Grief theory
Universal Human experience Internal sadness resulting from loss and cannot be measured in time

Loss- absence of someone meaningful Bereavement a response to the loss of something or someone Mourning- a feeling or expression of sorrow or sadness following loss Depression- 1- sadness gone awry 2- a clinical diagnosis of an illness that sometimes follows significant loss. It can be treated successfully in most people 3- a stage of grief in some theories that is normal if not prolonged. Links concepts into a whole fabric of ideas that help decide action Origins in: o o o o Frued- psychoanalytic theory Caplan- psychology Kushner- pastoral care Kubler-Ross, Lindemann- medicine

KR 5 stages to cope with loss 1- Denial and Isolation o o o o o Avoid Dr. Appointments May shop around for physicians Patients will have VERY large tumors before going to physician No, not me, it cant be true Usually a temporary defense

2- Anger o o o No, its not true is replaced with yes it is me but it was a mistake Anger, rage, envy, resentment Difficult for staff and family because anger is often displaced and projected towards them Anger often projected towards God

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3- Bargaining

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If God did not respond to my angry pleas, maybe if I ask nicely he will If I am good then maybe my illness will go away Make promises in order to live longer

4- Depression o o o They can no longer deny illness Anger and rage becomes replaced with a sense of great loss Preparatory grief for final separation from this world

5- Acceptance o o o o o Takes time to reach stage Neither depressed or angry about fate Ability to express feelings he experienced in other stages Family may need more help in this stage Pain is gone, the struggle is over and there comes a time for the final rest before the long journey. It is not a time of happiness Elisabeth Kubler-Ross

Characteristics of grief Cowles and Rogers (1991) defined grief as a pervasive highly individualized dynamic process Pervasive- can affect every aspect of life Physical symptoms: palpitations, chest pain, hyperventilation Cognitive symptoms: forgetfulness, loss of concentration Grief is dynamic to indicate a changing moving nature Found little evidence of stages Viewed grief as process moving back and forth between feelings and sensations Grief is very individualized Dependent upon:

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Nature of the relationship Support system Previous losses Religious/spiritual background Cultural beliefs

Family theory
Provides guidance for nursing practice Everyone is a product of a family and emotional system Each individual is part of a greater wholeto provide competent end-of-life care you need to be aware of family dynamics

Types of familes Nuclear family Single parent Kin network Cohabitating couple Commune

Developmental Family Family has a life cycle (Duvall 1977) o Marriage Childbearing Pre-schoolSchool ageTeenagersLaunching The way a family member reacts to grief is determined to a large extent by: o o o How each accomplishes a task How they socialize with each other Extended family

Assess which stage of development the family is in, knowing grief is different for different stages

Example: If a mother is ill at a young age the socialization of the family may be affected

Family systems Theory Views families as systems that are self-regulating Identify own boundaries by identifying those who are included in the family Individuals are components of the system Specific pathways of communication are required to maintain family health A loss requires new channels of communication

Concepts Feedback or communication o o o Established communication within family and support system Means of expressing feelings Outlets for emotions

*A closed family may be distrustful, controlling its members by force, focused on predictability *An open family will welcome new ideas and actively problem solve Adaptation o o o Family strives for stability Strives to maintain preferred patterns of behavior Develops feelings of security

Holistic Nursing
Holds the patient to be more than his or her episode of illness or long term disease A patient is comprised of a physical & psychological system, skills, professional and personal experiences The healing effort of the nurse and the dying patient involves caring for body, mind, & spirit, as well as the patients family network and respecting culture

Traditional The disease is viewed as a biological event Caregiver is the authoritarian Patient plays a passive role in his illness RN/patient relationship is distanced, remote with heavy use of boundaries MDs relationship is hierarchal; dominate Goal: Cure Treatment by the use of technology Environment: Sterile and efficient Care organization is done at the convenience of staff

Holistic The illness is viewed as a human event, impacts all levels of the being RN functions as teacher, egalitarian Patient plays an active, informed role RN/patient relationship is open, empathetic, freely communicating MD functions as an equal collaborator or facilitator Goal: healing in a broader sense of body, mind & spirit Treatment with some technology but also with empathy, cultural & environmental supports Environment: warm & cozy Care is done at the convenience of the patient and family

Addresses the Follwing Areas Adaptation: How well the patient & family copes with the stress that results from the illness Coping: Are the coping mechanisms adaptive or primitive? Needs: How well are the patients & familys needs being met?

Suffering: Are symptoms being relieved? May be physical, mental, social, moral or spiritual Healing: May be reconciliation with a family member, acceptance of ones own death, or resolving anger with God Meaning: Reflects the human need to sense design, and find significance in life. Caring: To share in the patients suffering by listening, or by being fully present Empathy: The ability to know in a caring way how others feel. Love: releasing the energy from a mysterious center inside of us, a part of the universe, or an element of God that is in every human being

We meet our patients needs by addressing Participating in health teaching Being the patients advocate Functioning in a team relationship effectively, by being the leader of the team.

Communication skills
I imagine that was difficult news for you to hear You seem sad, can you tell me what you are feeling? Does the news frighten you? What worries you most about that? What does this news mean to you? I wish the news were different for you. We will try to help you as much as we can. What are you expecting to happen? What experiences have you had with others who have had a similar illness?

What do you hope or dream will happen? What frightens you most about your prognosis? This must be tough for you to go through.

Be empathetic, use touch, a light tone of voice, just being there can be more helpful than you can imagine.

Other Communication Tips for Hospice/Palliative Care Patients

When initiating a Hospice conversation you can say: Because of the severity of your illness, you and your family are eligible for the assistance of Hospice at Home. To elicit conversations on coping: What is your biggest concern today? How are you coping? How are things going? Are you having trouble thinking? What have you heard about all of this? When asked to prognosticate by a patients family you can say: I would not be at all surprised if he died in 48 hours

Avoid Saying the Following after a Death:

This must have been Gods will. At least shes not suffering anymore. It was probably for the best. I know how you feel You must get a hold of yourself he would not want to see you act like this. At least you have other loved ones. It was a good way to go. God doesnt give us more than we can bear.

 You will get over it, time heals all wounds.

Better Things to say after a Death:

Im sorry. I am here if you want to talk How are you doing? I dont know what to say. I want to help. I wish I had known him. I am sorry to hear of your loss. I have great memories of him. I dont know what to say to be of comfort to you.