Care of terminally ill patient
Terminal illness is a disease that cannot be cured or adequately treated and that is reasonably expected to result in the death of the patient within a short period of time. This term is more commonly used for progressive diseases such as cancer or advanced heart disease than for trauma. An illness in which death is expected within a limited space of time.
Loss is an actual or potential situation in which something that is valued is changed or no longer available. People can experience the loss of body image, a significant other, a sense of wellbeing, a job, personal possessions, or beliefs. Illness and hospitalization often produce losses.
· Actual loss can be recognized by others as well as by the person sustaining the loss. E.g.-loss of limb, loss of job.
· A perceived loss is experienced by one person but cannot be verified by others e.g. Psychological losses.
· An anticipatory loss is experienced before the loss actually occurs.
· Maturational loss- normally expected life changes across the life span.
· Necessary loss- replaced by other thing
· Situational losses -Loss of one's job, the death of a child, or the loss of functional ability because of acute illness or injury are.
· Developmental loss- occur in the process of normal development-such as the departure of grown children from the home, retirement from a career, and the death of aged parents
Sources of loss
· Loss of an aspect of oneself-body part, physiologic function, psychological attribute.
· Loss of an object external to oneself
· Separation from accustomed environment
· Loss of a loved or valued person.
Total response to the emotional experience related to loss. Manifested in thoughts, feelings, and behaviours. Essential for good mental and physical health. Permits the individual to cope with the loss gradually and to accept it as part of reality.
· Grief is the emotional response to a loss, manifested in ways unique to an individual and based on personal experiences, cultural expectation and spiritual beliefs.
· Subjective response experienced by the surviving loved ones after the death of a person with whom they have shared a significant relationship.
· Behavioural process through which grief is eventually resolved or altered. Actions and expressions including symbols and ceremonies outward of grief
· Mourning is outward social expressions of grief and behaviours associated with loss.
· Help to accept loss is real
· Encourage new relationships
· Support efforts to adjust to the loss
· Allow time to grieve
· Provide continuing support
Types of Grief Responses
· Normal grief (uncomplicated) grief- emotional, cognitive, social, physical, behavioural, spiritual response to loss and death
· Abbreviated grief is brief but genuinely felt. Occur when the lost object is not significantly important to the grieving person or may have been replaced immediately by another, equally esteemed object.
· Anticipatory grief is experienced in advance of the event -young girl may grieve in advance of an operation that will leave a scar on her body
· Disenfranchised grief occurs when a person is unable to acknowledge the loss to other persons. Socially unacceptable loss that cannot be spoken about, such as suicide, abortion, or giving a child up for adoption.
· Pathologic or complicated grief-exists when the strategies to cope with the loss are maladaptive.
· Exaggerated grief- response often exhibits self destructive or maladaptive behavior, obsessions, or psychiatric disorders.
· Unresolved or chronic grief is extended in length and severity. same signs are expressed as with normal grief, but the bereaved may also have difficulty expressing the grief, may deny the loss, or may grieve beyond the expected time.
· Is an unresolved emotional sorrow experienced over a long period of time as the result of not accepting a significant loss.
· Inhibited grief,-many of the normal symptoms of grief are suppressed
· Masked grief- grief interferes with normal functioning
· Ambiguous loss- when lost person physically present but not psychologically e.g. dementia
· Delayed grief occurs when feelings are purposely or subconsciously suppressed until a much later time.
· Complicated grief after a death: The client fails to grieve; for example, a husband does not cry at, or absents himself from, his wife's funeral. The client avoids visiting the grave and refuses to participate in memorial services, even though these practices are a part of the client's culture. Even after a prolonged period, the client continues to search for the lost person. Some may consider suicide to effect reunion.
Stages of Grieving
Kubler-Ross (1969), who described five stages: denial, anger, bargaining, depression, and acceptance DA-BDA
Denial: Refuses to believe that loss is happening. Is unready to deal with practical problems, such as prosthesis after the loss of a leg. May assume artificial cheerfulness to prolong denial.
· Verbally support client but do not reinforce denial.
· Examine your own behaviour to ensure that you do not share in client's denial.
Client or family may direct anger at nurse or staff about matters that normally would not bother them. Person express resistance and feel intense anger at God.
· Help client understand that anger is a normal response to feelings of loss and powerlessness.
· Do not take anger personally.
· Deal with needs underlying any angry reaction.
· Provide structure and continuity to promote feelings of security.
· Allow clients to take control over their lives as much as possible
Seeks to bargain to avoid loss. May express guilt or fear of punishment for past sins, real or imagined. Postpones awareness of loss
· Listen attentively, and encourage client to talk to relieve guilt and irrational fear.
· If appropriate, offer spiritual support
Grieves over what has happened and what cannot be. May talk freely
· Allow client to express sadness by sitting quietly without expecting conversation.
· Convey caring by touch
Comes to terms with loss. May have decreased interest in surroundings and support people. May wish to begin making plans.
· Help family and friends understand client's decreased need to socialize.
· Encourage client to participate as much as possible in the treatment program.
- Shock and disbelief
- Developing awareness
- Resolving the loss
Factors Influencing the Loss and Grief Responses
1. Age: Children differ from adults not only in their understanding of loss and death but also in how they are affected. Can threaten the child's ability to develop. Regression :Early and middle adulthood Experience as a part of normal develpoment
2. Late adulthood: Losses experienced by older adults include loss of health, mobility, independence, and work role. Limited income and the need to change one's living accommodations can also lead to feelings of loss and grieving.
3. Significance of the Loss: The significance of a loss depends on the perceptions of the individual experiencing the loss.
A number of factors affect the significance of the loss:
- Importance of the lost person, object, or function
- Degree of change required because of the loss
- The person's beliefs and values
4. Culture: "Grief is a private matter to be endured internally. The death of a family member in a typical nuclear family leaves a great void because the same few individuals fill most of the roles. Some persons have adopted the belief that grief is a private matter to be endured internally. Therefore, feelings tend to be repressed and may remain unidentified. Some cultural groups value social support and the expression of loss.
5. Spiritual Beliefs: Most religious groups have practices related to dying, and these are often important to the client and support people. Religious beliefs provide positive attitudes toward health.
6. Gender: Men are frequently expected to "be strong" and show very little emotion during grief, whereas it is acceptable for women to show grief by crying. A man might consider his facial scar to be "macho," but a woman might consider hers ugly.
7. Socio economic factors : A pension plan or insurance, for example, can offer a widowed or disabled person a choice of ways to deal with a loss;
8. Support System: Many people are uncomfortable or inexperienced in dealing with losses, the usual support people may withdraw from the grieving individual. Support may be available when the loss is first recognized, but as the support people return to their usual activities, the need for ongoing support may be unmet.
"The grieving individual is unable or unready to accept"
9. Cause of Loss or Death: Some diseases are considered "clean," such as cardiovascular disorders, and engender compassion, whereas others may be viewed as repulsive and less unfortunate. Line of duty, are considered honourable
10. Personal relationships: Quality and meaning of lost relationship influence the grief response. When no supportive understanding and compassion from others grief becomes complicated.
11. Coping strategies: Rely first on familiar coping strategies, when fails use new one. E.g .Writing letters to lost one.
l . Kozier B, Berman A, Snyder J Shirlee, , Erb Glenora. Fundamentals of Nursing, Concept Process and Practice. 8th edition, Dorling Kidersley (India)Pvt. Ltd, Delhi,2008.
2. Potter A Patricia, Perry G Anne. Basic Nursing; essentials for nursing. 6th edition, By Mosby Publications, St Lowis, 2007.