Care of Terminally Ill

Concept of Loss

The fact or process of losing something or someone.

oxford dictionary

Loss is an actual or potential situation in which something that is valued is changed , no longer available or gone.
People can experience loss of body image ,a job, sense of self etc.
Death is an functional loss , both for dying person and for those who survive .

Types of loss

Actual loss – Can be recognized by others. Eg – death.This is the type of loss that has actually happened in one's life. It can be recognized by the person who has sustained the loss, as well as by the other people.
Perceived loss – It is experienced by one person , but cannot be verified by others (psychologic loss) Eg:-a woman who leaves her job to care for child may experience a loss of independence and freedom.
Situational loss- loss of one’s job , death of a child , loss of functional ability because of injury.
Developmental loss – Loss occur in the process of normal development Eg: departure of grown children from home , retirement , death of aged parents.
Anticipatory loss- It is experienced before the loss has actually occurred. For example, it can be experienced by the family of a terminaly ill patient.

Concept of Grief

Grief is the total response to the emotional experience related to loss
Grief is manifested in thoughts , feelings and behaviors associated with sorrows.
Grieving is essential for mental and physical health.
It help the person to cope with the loss gradually and to accept it as part of reality.

Theories of Grief

Stages of Grief- Theory by Kubler-Ross

1. Denial -“This can’t be happening to me.”

Refuses to believe the loss. eg: unready to deal with practical problems such as prosthesis after the loss of leg.

Nursing implications-

Verbally support the client.
Monitor own behaviour.
Dont't Share the denial of the Client.

2. Anger - “Why is this happening? Who is to blame?”

The intense reaction to pain and loss generally the anger.

Client / family may direct anger at nurse / staff.

Nursing implications -

Help client to understand that anger is a normal response to feelings of loss / powerlessness.
Do not take anger personally.
Deals with needs underlying any anger.

3. Bargaining-“Make this not happen, and in return I will ____.”

Seeks to bargain to avoid loss
May express feelings of guilt / fear of punishment for past sins.

Nursing implications-

Listen attentively and encourage client to talk to relieve guilt and fear
If appropriate , provide spiritual support.

4. Depression - “I’m too sad to do anything.”

This is a step towards acceptance.

Grieves over what has happened and what caanot be
May talk freely or may withdraw.

Nursing implications -

Allow to express sadness
Communicate nonverbally by sitting quietly with out conservation
Convey caring by touch.

5. Acceptance - “I’m at peace with what happened.”

Comes in terms with loss
May have decreased interest in surroundings and support people.

Nursing Implications-

Encourage the family to participate as much as possible in their daily life.
Suggest socializing.

Rando's Six R's Process Model

Apart from Kübler-Ross's theory and stages of grief, Rando gave six stages of process of mourning

Recognize the Loss-One must acknowledge the death, understanding of death occurs in avoidance phase.
React to the Separation- Pain experience, overwhelming feelings, experiencing reaction to the loss occurs in confrontation phase.
Recollect and Re-experience- Remembering the dead, reviving feelings occurs in confrontation phase.
Relinquish old Attachments- Occurs in confrontation phase.
Readjust- Development of new relationships, adapting into a new world with the memories of the past may establish new identity occurs in accommodation phase.
Reinvest- Investing emotions into other people, diverting energy in new goals occurs in accommodation phase.

Types of Grief Responses

Abbreviated grief-This grief is brief but is genuinely felt. It occurs when the loss isn't significant enough and/or is instantly replaced.
Anticipatory grief-The loss is expected and the grief is experienced in advance. For example, in case of terminal illness.
Disenfranchised grief-This type of grief occurs when someone isn't able to acknowledge his/her loss to other people. Such grief response occurs when the loss is often socially unacceptable or the person isn't comfortable to speak about it. For example, suicide, abortion, etc.
Complicated grief-When a person undergoing grief process cannot cope up with the grief and loss, and all his/her strategies to cope are maladaptive, he/she is said to be experiencing complicated grief.

Unresolved grief- When the grief is extended in length and severity, it is said to be unresolved or chronic grief.
Inhibited grief-In this kind of grief response, the normal grief symptoms are not evident, however, other effects in the body are apparent.
Delayed grief-In this kind of response, the sad feelings are suppressed, intentionally or subconsciously, until a very later time.
Exaggerated grief-Certain people who have experienced loss try to lessen their emotional pain through various dangerous activities. This is a kind of response to grief and is termed as exaggerated grief.

Common grief/Manifestations of Grief

1.Physical

Loss of appetite
Weight loss or gain
Fatigue
Decreased libido
Decreased immune system response
Decreased energy
Head ache/stomach pain

2. Behavioural

Forgetfulness
Withdrawn
Insomnia or too much of sleep
Dreaming of deceased
Verbalizing the loss
Crying
Loss of productivity at work

3. Emotional

Anger
Anxiety
Sadness
Guilt
Shock
Numbness
Loneliness
Fear
Powerlessness
Helplessness

4.Cognitive:

Decreased concentration
Impaired judgement
Obsessive thought of lost object
Preoccupation
Confusion
Questioning spiritual beliefs
Searching for understanding
Searching for purpose and meaning

Death

Death can be defined as the cessation of all vital functions of the body including the heartbeat, brain activity (including the brain stem) and breathing.

Incidence

More than 2.5 million people die in the United States each year.
25% of all deaths take place at home, with about 50% occurring in hospitals. Remaining 25% occur in nursing homes.

Indications of death

Total lack of response to external stimuli
No muscular movement, especially breathing
No reflexes
Flat encephalogram (brain waves)

Physical manifestations of approaching death/Impending Death

System	Manifestations
Sensory	Decreased sensation, decreased perception, blurring of vision, sinking and glazing of eyes, blink reflex absent, eyelids remain half opened.
Integumentary	Mottling on hands,feet,arms and legs, cold,clammy skin,cyanosis on nose,nail beds,knees,wax like skin when very near to death.
Respiratory	Increased respiratory rate, Cheyne-stokes respiration inability to cough or clear secretions resulting in granting,gurgling, irregular breathing.
Urinary	Decreased urinary output, urinary incontinence, unable to urinate.
Gastrointestinal	Accumulation of gas, distension and nausea, loss of sphincter control.
Musculoskeletal	Inability to move, sagging of jaw, difficulty speaking, difficulty in swallowing, difficulty maintaining body posture and allignment, loss of gag reflex, jerking

Cardiovascular

Increased heart rate , slower and weakening pulse, irregular rhythm. Decreased in blood pressure, delayed absorption of drugs

Psychosocial Manifestations of Approaching Death

Altered decision making
Anxiety about unfinished business
Withdrawal
Decreased socialization
Fear of loneliness
Fear of meaninglessness of one’s life
Fear of pain
Helplessness
Life review
Peacefulness
Restlessness
Saying goodbyes
Unusual communication
Vision like experiences

Types of Death

Natural death- is typically end result of disease or due to physiological ageing.
Suicide death- is an act of causing one own death intentionally. There can be risk factors like substance abuse, personality disorder, depression etc.
Accidental death- is caused by the road traffic accident, fall or slip or anything which did not have malice intention. Accidental death are mainly due to negligence or human errors.
Homicide death- When a person kills another person like gunshot death or stabbing etc.

Clinical Death	Biological Death
Clinical death is cessation of heart function or pumping of blood.	Biological Death-death sets in where brain is damaged and cells in heart, brain and other vital organs die due to lack of oxygen.

Biological Death	Brain Death
Biological death occurs after the cessation of heart pumping	Brain death is the loss of the cerebral & brainstem function as manifested by external stimuli absence of cephalic reflexes and heart is pumping due to the ventilatory support.

Care of Dying Patient

Domains of Care for the Dying Patient

Key domains to comprehensive care for the dying patient, given by The National Consensus Project for Quality Palliative Care are

Structure and process of care	Plan of care is made. It is based on detailed assessment of patient and family.
Physical aspects of care	Pain and other symptoms are managed. Attention to disease specific pain and side effects.
Psychological and psychiatric aspect of care	Assessment of psychological status. If necessary, psychiatric problems are assessed and are taken care of.
Social aspects of care	Client's social needs are assessed and are fulfilled.
Spiritual, religious, and existential aspects of care	Spiritual, existential dimensions are assessed, and are respected and responded well.
Cultural aspect of care	Assessment and attempt to meet cultural needs of clients.
Care of immediately dying patient	Recognizing the signs and symptoms.of impending death. Appropriate care is provided.
Ethical and legal aspects of care	All the care, preferences and choices are fulfilled within the ethical framework. Standards of medical care are taken care of.

Nursing Management of The Dying Patient.- The role of the nurse during the active dying phase is to support the patient and family. Nurses need to ensure that the client is treated with honor and respect.

Help the client to consistent with their values , beliefs and culture.

A. Physiological Needs-

According to Maslow's Hierarchy of needs,physiological needs must be met before others, because they are essential for existence.

1. Respiration- Oxygen is frequently ordered for the patient experiencing labored breathing. Suctioning may be needed to remove secretions that the client is unable to swallow and to keep the airway clear.

2. Fluids and nutrition-

"The refusal of food and fluids is almost universal in dying patients. It is believed that the client is not feeling thirst and hunger.
Although the issue of permitting dehydration in terminally ill clients is often met with great resistance.
Artificial nutrition often increases the patient agitation leads to increased use of limb restraints and increases the risk of aspiration pneumonia.
Gain an IV access for fluid replacement and parenteral nutrition as prescribed.

3. Mouth-

Oral discomfort is the only documented side effect of dehydration in the terminally ill client.
Both the administration of oxygen and mouth breathing increase the need for meticulous oral care.

4. Oral care-

Caregiver can use saliva substitutes and moisturizers to alleviate discomfort.
Regular brushing of teeth should be encouraged and the tongue must also be given the same attention as is the rest of the mouth.
"Ice chips and sips of favorable beverages should be offered frequently and petroleum jelly applied to the lips,
Oral care must be given every 2-3 hrs to maintain the client's comfort.

5. Eyes-

Due to the dryness, the eyes may become irritated and artificial tears can alleviate this discomfort.
Therefore, wiping off the tears from inner to outer canthus to remove the discharges.

6. Nose-

The nares may become dry and crusted. Oxygen given by the cannula can further irritate the nares.
So, a thin layer of water soluble jelly applied to the nares will be helpful to alleviate discomfort.

7. Mobility-

"As the client's condition deteriorates, mobility decreases. The client becomes less able to move about in bed or to get out of the bed and requires more assistance.
Therefore physical dependence increases the risk of complication related to immobility. For example, atrophy and pressure ulcer. Provide meticulous skin care to ease the pressure on skin

8. Skin care-

Prevention of pressure ulcers is the priority.
In addition to the care of the pressure points keeping the skin, clean and moisturized promotes healthy tissue.
The skin should be inspected every time when positioning is done.
Gentle massages with soothing lotion are comforting.
Bed bath is adequate if the client cannot get into the tub or sit in the shower chair.

9. Elimination-

Constipation may occur due to the side effects of the analgesics and the lack of physical activities.
"Fluids and foods with high fiber contained can be effective preventive measures for the client with adequate oral intake.
The client may have incontinence of bladder and bowel. so nurse need to check.

B. Comfort

Pain relief as prescribed.
Keep the patient clean and dry.
Provide a safe and non-threatening environment.
Provide a respectful, careful attitude to provide psychological comfort by establishing good rapport.

C. Physical Environment

A soothing physical environment can significantly increase the clients comfort, like non slippery floor, side rails in the room, support to walk independently to washroom, availability of call bell etc.

Adequate lighting enhances vision without causing discomfort associated with harsh, glaring light.
Provide night light if patient requires.
Provide quite and calm environment.(even the phone can be removed if patient find it disturbing.
Analgesics are prescribed for the pain and it may cause sedation, therefore precautions shall be taken that proper safe environment is provided to the patient like bed rails raised.

D. Psychosocial Needs

Death presents a threat to not only one's physical existence but also to psychological integrity.
Even though in the presence of the nurse, the family members should be encouraged and invited to participate in the client's care, if they desire to do so and the client is willing.
Maintaining a well groomed appearance is important. Cutting the nails, shaving the beard will help to promote patients dignity.
Combing and brushing the hair not only improves appearance but is also a comforting and relaxing activity for many patients.

E. Spiritual Needs

The nurses play a major role in promoting the dying clients spiritual comfort. Dying persons are among the most vulnerable members of the human family, Providing spiritual support Expressions of feeling , prayer , meditation , reading , discussion with clergy or spiritual advisor.

Play music
Use touch
Pray with the client.
Contact clergy if requested by the client.
Commubicate empathy.
Religious literature aloud,at the patient request.

Physiological Changes after Death

After death, the body undergoes complex reactions and processes, which result in physiological changes in the body. These changes can depend on wide range of factors, such as temperature, season, cause of death, injuries to the body, etc.

A. Immediate changes

Stoppage of function of nervous system.

The subject has no sense.
There is loss of both sensory and motor function.
Loss of all reflexes.
No tonicity of muscles.
Pupils are widely dilated.
Confirmation by EEG

Stoppage of respiration.

Stoppage of respiration With somatic death there is total stoppage of respiration.

No respiratory movement will be visible.
No respiratory movement can be appreciated by palpation.
No breathing sounds can be heard by auscultation.

Stoppage of circulation.

Stoppage of circulation can be examined by examining radial, femoral and carotid pulsation.
Auscultation of heart for presence or absence of heart beat.
Confirmation E.C.G test.

B. Early changes

The early changes are associated with cell death.

Rigor mortis (latin: Rigor "stiffness" and mortis "of death") It is defined as the stiffening of body. It occurs after 2-4 hours of death. It begins in the involuntary muscles of heart, lungs, etc., and reach the other parts of the body. It is important that the dead body looks normal, therefore, nurses must close the eyes and mouth of deceased before rigor mortis comes into action.It leaves the body after approximately 96 hours of death.

Algor mortis- (from Latin algor 'coldness', and mortis 'of death'), After death, the body temperature gradually decreases due to cessation of blood circulation. The temperature reaches the room temperature as it falls at the rate of about 1°C every hour.

Livor mortis - (Latin: līvor – "bluish color, bruise", mortis – "of death") After the blood circulation has terminated the RBCs break to release hemoglobin, which then dissolves the surrounding tissues. The lack of hemoglobin results in discoloration in lowermost areas of the body. This is referred to as livor mortis. Skin changes also occur. The elasticity of skin is lost, which results in breakage.

C. Late changes

Autolysis of the body takes place.
Bacterial action can also cause decomposition of body. These bacteria can be external or internal.