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
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.
Types
· 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.
Grief
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.
Bereavement
· Subjective response
experienced by the surviving loved ones after the death of a person with whom
they have shared a significant relationship.
Mourning
· 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.
Chronic grief
· 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.
Nursing implications
· Verbally support
client but do not reinforce denial.
· Examine your own
behaviour to ensure that you do not share in client's denial.
Anger
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
Bargaining
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
Depression
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
Acceptance
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
- Restitution
- Resolving the loss
- Idealization
- Outcome
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.
References:
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.
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