Coping With Loss.docx

COPING WITH LOSS, DEATH & GRIEVING

INTRODUCTION Death is inevitable, yet the loss of a close friend or family member always showers us with a range of emotions. One day we might desperately try to avoid the pain, anxiety and feelings of helplessness we feel when a loved one dies. Other days, we feel like life has returned to normal—at least until we realize that our life has changed irrevocably. Despite the gamut of emotions we feel, grieving for a loved one helps us cope and heal. The intense, heart-breaking anguish indicates that a deep connection has been severed. Without a doubt, grieving is painful. But it is also necessary. Going forward doesn’t mean forgetting about the loved one who died. Enjoying life again doesn’t imply that the person is no longer missed. It simply means that your grief has run its course.

LOSS MEANING OF LOSS A person experiences loss in the absence of an object, person’s body part or function, or emotion that was formerly present. TYPES OF LOSSES i.

Necessary loss

ii.

Actual loss

iii. Perceived loss iv. Maturational loss v.

Situational loss

vi. Anticipatory loss vii. Developmental loss viii. Loss of external objects ix. Loss of known environment x.

Loss of an aspect of life

xi. Loss of life or death

i.

Necessary loss: Necessary losses are something natural and positive • Start and leave school, change friends. E.g. growing up process.

ii.

Actual loss: It is easily identified and can be recognized by others as well as person sustaining the loss. E.g. loss of a limb, of a spouse, of an object and of a job.

iii. Perceived loss: uniquely defined by the person experiencing the loss & is less obvious to other people (rejection by a friend that creates loss of confidence or changes their status in social group).e.g. loss of confidence or prestige. iv. Maturational loss: loss resulting from normal life transition e.g.loss of youth, of financial independence). v.

Situational loss: loss occurring suddenly in reference to a specific external event e.g. sudden death of loved one).

vi. Anticipatory loss: in this a person displays loss and grief behavior for a loss that has yet to take place, e.g. sickness or death. vii. Developmental loss: This term implies the loss of something intangible or physical viii. Loss of external objects: extend of grieving depends on object’s value, sentiment attached to it, and its usefulness. E.g. misplacement, detoriation, destruction by natural causes. ix. Loss of known environment: Loneliness or a new unfamiliar environment threatens self esteem, and makes grieving difficult. For eg - moving to a new neighborhood, hospitalization, new job. x.

Loss of aspect of life: significant others- Loss of family member, friend , trusted people or animal companion.

xi. Loss of life or death: Loss of life created grief for those left behind. People facing death often fears pain, loss of control, dependency on others.

Grief Meaning of grief Grief is a natural emotional response to loss. It’s the emotional suffering you feel when something or someone you love is taken away. The more significant the loss, the more intense the

grief will be.Grief is the physical, psychological & spiritual response of loss.The time grieving depends on the significance of loss, the length of time the person was known, the anticipation of or preparation for the loss, the person’s emotional stability and coping ability. Meaning of mourning Mourning is the outward sign of grief. Meaning of bereavement - It is the acknowledgment of the objective fact that one has experienced a death Types of grief  Normal grief - It consists of normal feelings, behaviors and reactions to loss. This response to a loss can prove helping one to mature and develop as a person. It includes resentment, sorrow, anger,crying, loneliness and temporary withdrawal from activities  Anticipatory grief - The process of disengaging or letting go that occurs before an actual loss of death has occurred.  Complicated grief - When the person has difficulty in progressing through the normal process of grieving, bereavement become complicated. a) Chronic grief- begins as normal grief but continues long term, with little resolution of feelings and inability to rejoin normal life. b) Delayed grief- A grief that is put of until a later time. c) Exaggerated grief - Exaggerated grief is where the bereaved person is so overwhelmed by the death of their loved one, that they develop major psychiatric disorders such as phobias and disabling helplessness. d) Masked grief- Occurs when the person is grieving but expressing the grief through other types of behaviors.  Disenfranchised grief - Person experiences grief when a loss is experienced and cannot be openly acknowledged, socially sanctioned, or publically shared e.g loss of a partner due to AIDS.

Goals of grieving process  Healing the self  Recovering from the loss

 Undoing psycho social bonds to loved one and eventually creating new ties  Adding new roles, skills, and behaviors  Pursuing a healthy lifestyle  Integrating the loss into life

Factors that influence grief and loss  Human development  Personal relationship  Nature of loss  Coping strategies  Socioeconomic status  Culture and ethnicity  Spiritual and religious beliefs  Hope  Gender  Support system  Cause of loss or death

i.

Human development Person of differing age and stages of development will display different and unique symptoms

of grief. ii. Psychological perspective of loss and grief Age, gender, status, race, spirituality, religious beliefs, intellect, achievement, self expression, and cultural opportunity are the basis for individual to define and qualify the definition of life or death. iii. Socioeconomic status

The socioeconomic status of an individual often affects the support system available at the time of loss. A pension plan or insurance, for example, can offer a widowed or disabled person a choice of ways to deal with a loss; a person who is confronted with both severe loss and economic hardship may not be able to cope with either. iv. Personal relationship When the loss involves a loved one, the quality and the meaning of the relationship are critical in understanding a person’s grief experience. It has been said that to lose your parents is to lose your past, to lose your spouse is to lose your present and to lose your child is to lose your future. When client do not receive supportive understanding and compassion from others, they become unable to handle grief and look to the future. v. Nature of loss The ability to resolve grief depends on the meaning of the loss and the situation surrounding to the loss. The visibility of the loss influences the support a person receives. vi. Culture and ethnicity Interpretation of the loss and the expression of the grief arise from cultural background and family practices. Critical components of culture are their basic core belief systems that they can and often do hold on to. vii. Spiritual beliefs Spiritual beliefs and practices greatly influence both a person's reaction to loss and subsequent behavior. Most religious groups have practices related to dying, and these are often important to the client and support people. To provide support at a time of death, nurses need to understand the client's particular beliefs and practices. viii. Hope “Even though we cannot see beyond the headlights we know that the road goes on.” That is what it means to have hope! And in the face of loss that is what it means to grieve as others do who have not yet experienced such hope.

ix. Gender The gender roles into which many people are socialized in the United States and Canada affect their reactions at times of loss. 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. Often when a wife dies, the husband, who is the chief mourner, is expected to repress his own emotions and to comfort sons and daughters in their grieving. x. Support system The people closest to the grieving individual are often the first to recognize and provide need emotional, physical and functional assistance. However, because many people are uncomfortable or inexperienced in dealing with losses, the usual support people may instead withdraw from the grieving individual. In addition, support may be available when the loss is first recognized, but as the support people return their usual activities, the need for ongoing support may be unmet. Sometimes, the grieving individual is unable or unready to accept support when it is offered. xi. Cause of loss or death Individual and societal views on the cause of loss or death may significantly influence the grief response. Some diseases are considered "clean", such as cardiovascular disorders, and engender compassion, whereas others may be viewed as repulsive and less unfortunate. A loss or death that is beyond the control of those involved may be more acceptable than one that is preventable, such as drunk driving accident. Injuries or deaths occurring during respected activities, such as "in the line of duty", are considered honorable, whereas those occurring during illicit activities may be considered the individual's just rewards. Concepts and theories of the grieving process Nurses must recognize the signs of grieving to understand and support the client through the grieving process. The therapeutic relationship and therapeutic communication skills are paramount when assisting grieving clients. Using these skills, nurses may promote the expression and release of emotional as well as physical pain during grieving. i.

Engle’s theory(1964) George Engel (1964) described five stages of grieving as follows:

·

Shock and disbelief: The initial reaction to a loss is a stunned, numb feeling accompanied by

refusal to ac-knowledge the reality of the loss in an attempt to protect the self against overwhelming stress.

·

Developing awareness: As the individual begins to ac-knowledge the loss, there may be

crying, feelings of helplessness, frustration, despair and anger that can be directed at self or others, including God or the deceased person. ·

Restitution: Participation in the rituals associated with death, such as a funeral, wake, family

gathering, or religious ceremonies that help the individual accept the reality of the loss and begin the recovery process. ·

Resolution of the loss: The individual is preoccupied with the loss, the lost person or object is

idealized, the mourner may even imitate the lost person. Eventually, the preoccupation decreases, usually in a year or perhaps more. ·

Recovery: The previous preoccupation and obsession ends, and the individual is able to go

on with life in a way that encompasses the loss.

ii. Kubler-Ross stages of Dying(1969) Elisabeth Kubler-Ross (1969) established a basis for under-standing how loss affects human life. As she attended to clients with terminal illnesses, a process of dying became apparent to her. Through her observations and work with dying clients and their families, Kubler-Ross developed a model of five stages to explain what people experience as they grieve and mourn: ·

Denial is shock and disbelief regarding the loss.

·

Anger may be expressed toward God, relatives, friends, or health care providers.

·

Bargaining occurs when the person asks God or fate for more time to delay the inevitable

loss. ·

Depression results when awareness of the loss becomes acute.

·

Acceptance occurs when the person shows evidence of coming to terms with death.

iii. Rando’s theory Phase 1: Avoidance The avoidance phase is when you may be unable or unwilling to fully understand what has happened. Though you might understand the fact that your loved one has died, a part of you can still not accept this as reality. The avoidance phase has one task:

Recognise the loss. According to Rando, fully recognising the loss means understanding what happened and really accepting it, knowing in your heart, that your loved one has gone. Phase 2: Confrontation The confrontation phrase involves dealing with your grief and finding ways to process what you are experiencing. There are three tasks in this phase: React to the separation. This means understanding and embracing all the complex, powerful emotions you are feeling. It also means acknowledging something known as ‘secondary losses’. For example, the death of a spouse may also mean the loss of financial security, the loss of your idea of the future, the loss of romantic intimacy. These are all secondary losses for which you may also be grieving. Recollect and re-experience. Recollecting means remembering your time with your loved one, through the good and bad. These memories will become an important way of maintaining a relationship with your loved one, as they will continue being an important influence in your life. Relinquish old attachments. This may sounds harsh at first, but ‘relinquishing old attachments’ does not necessarily mean moving on or forgetting your loved one. It’s a long and very gradual process where you slowly begin to process the impact of your loved one’s absence. Phase 3: Accommodation The accommodation phase is all about finding meaning in life again. This doesn’t mean you won’t still have feelings of sadness or longing, but you will be able to have moments of happiness again. There are two tasks in this phase: Readjust to the new world without forgetting the old world. Readjusting can mean becoming more comfortable with new roles and responsibilities, but also accepting who you are now and how the death of your loved one may have changed you. You will be feeling more able to cope with day-to-day life while still remembering and cherishing your loved one. Reinvest emotional energy. This is another way of describing the act of enjoying life again, finding new friends or projects, and rediscovering a sense of purpose. This should not be interpreted as ‘replacing’ your loved one, as Rando very much emphasises the continuation of your love for them. Rather, it is about allowing yourself to care about new things and even enjoy yourself. iv. Sanders Phases of Bereavement Shock – confused, unreal, disbelief

Awareness of loss – conflict, stress, seperation anxiety Conservation/Withdrawal – despair, hopeless, isolation Healing – identity, control Renewal – acceptance, revitalization Clinical symptoms of grief i.

Emotional symptoms of grief A person who is dealing with grief will most likely display some of the emotional symptoms

associated with grieving. 

Increased irritability

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Numbness

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Bitterness

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Detachment

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Preoccupation with loss

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Inability to show or experience joy While these emotional symptoms are normal in the days and weeks after a traumatic event,

they can be indicators of a more serious disorder if they do not fade over time. ii. Physical symptoms It may come as a surprise that grief is not entirely emotional. There are very real effects that grief can have on the body. 

Digestive problems

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Fatigue

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Headaches

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Chest pain

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Sore muscles

Though these symptoms are normal during the grieving process, if it persists it need to be treated at the earliest Caring for the Bereaved 

Have contact physically and emotionally with the person

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Assess when the person is in the grieving process

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Demonstrate genuine compassion and caring

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Mention the loss or the deceased person’s name

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Allow the person to take a break from grieving and focus on self care

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Encourage the person to talk about the relationship he or she had with the deceased person

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Understand that people need to talk about the events and feelings around the death and will repeat themselves

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Tell the person to expect mood swings, pain, and various life changes

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Focus on clarifying and using coping skills

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Identify secondary losses and unfinished business

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Acknowledge that there will be eventual recovery

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Discuss the anniversary phenomena

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Encourage medical or psychiatric care as need

Nursing implications  Nursing care involves providing comfort ,maintaining safety ,addressing physical and emotional needs ,and teaching coping strategies to terminally ill patients and their families .  More than ever ,the nurse must explain what is happening to the patient and the family and be a confident who listens to them talk about dying.  Hospice care , attention to family and individual psychosocial issues ,and symptom and pain management are all part of the nurse's responsibilities.  The nurse must also be concerned with ethical considerations and quality-of-life issues that affect dying people.  Of utmost importance to the patient is assistance with the transition from living to dying, maintaining and sustaining relationships, finishing well with the family, and accomplishing what needs to be said and done.

 In the hospital, in long-term care facilities, and in home settings, the nurse explores choices and end-of-life decisions with the patient and family. Referrals to home care and hospice services, as well as specific referrals appropriate for the management of the situation, are initiated. The nurse is also an advocate for the dying person and works to uphold that person's rights. The use of living wills and advance directives allows the patient to exercise the right to have a"good death or to die with dignity.  The nurse assesses spiritual strength by inquiring about the person's sense of spiritual well-being, hope, and peace.  The nurse assesses current and past participation in religious or spiritual practices and notes the patient's response to questions about spiritual needs.  Another simple assessment technique is to inquire about the patient's and family's desire for spiritual support.  For nurses to provide spiritual care, they must be open to be present and supportive when patients experience doubt, fear, suffering, despair, or other difficult psychological states of being.  Interventions that foster spiritual growth or reconciliation include being fully present; listening actively; conveying a sense of caring, respect, and acceptance; using therapeutic communication techniques to encourage expression; suggesting the use of prayer, meditation, or imagery; and facilitating contact with spiritual leaders or performance of spiritual rituals.  Nurses can alleviate distress and suffering and enhance wellness by meeting their patients' spiritual needs. 

Offer ‘memory making’ options, if that is a practice in your hospital. Things like hair locks, thumb prints, or hand prints can be a meaningful way for some families to say goodbye (especially if there are children present).

 Give them space if they need it. Many families will want time with each other and with the person who just died. Take your cues from the family and give them space if they need it.

DEATH

Definition “A permanent cessation of all vital functions : the end of life” - Merriam Webster "An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem is dead. A determination of death must be made in accordance with accepted medical standards." - The National Conference of Commissioners on Uniform State Laws

Death in 1981,the president’s commission for the study of ethical problems in medicine , behavioral and biomedical research defined death as an individual has sustained either irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain ,including brain stem

Manifestations of impending death SENSORY SYSTEM • Hearing - usually last sense to disappear • Touch -decreased sensation - decreased perception of touch and pain • Taste - decreased with disease progress. • Smell - decreased with disease progress. • Sight -blurring of vision • -blinkreflex absent • -eyelids remain half open INTEGUMENTARY SYSTEM • -Cold clammy skin • -cyanoses on nose, nailbeds RESPIRATORY SYSTEM • -Increased respiratory rate • -cheyne stroke respiration (alternating periods of apnoea, deep and rapid breathing) • -irregular breathing gradually slowing down to terminal gasps (guppy breathing) • -noisy wet sounding (death rattle) URINARY SYSTEM • -Gradual decrease in urinary output • -urinary incontinence or unable to urinate GASTROINTESTINAL SYSTEM • -Accumulation of gas • -distension and nausea • -loss of sphincter control • -possible cessation of GI function • -bowel movement may occur before imminent death or at the time of death MUSCULOSKELETAL SYSTEM • -Gradual loss of ability to move • -loss of gag reflex • -sagging of jaw results in loss of facial muscle tone,dysphagia, difficulty in speaking CADIOVASCULAR SYSTEM • -Increased heart rate: later slowing

• -irregular rhythms • -decreased blood pressure • -weakening of pulse

Psycho social manifestations • A variety of feelings and emotions affect the dying patients at the end of life care. They are • Altered decision making • Fear of loneliness • fear of pain • Helplessness • Restlessness • Anxiety • Impending doom • Grief Traditional clinical signs of death  Unreceptivity and unresponsiveness  No movement or breathing  No reflexes  Flat encephalogram  Absence of apical pulse  Cessation of respirations  Pupils dilated and not reactive to light.  No response to painful stimuli. Others, .Absence of corneal reflexes. • Cloudiness of the cornea. • Rigor mortis (begins approximately three hours after death). • Decreased temperature. World medical assembly guidelines for death Determination of death can be made on the basis of the irreversible cessation of all functions of the entire brain, including the brain stem, or the irreversible cessation of circulatory and respiratory functions. This determination will be based on clinical judgment according to accepted criteria, supplemented, if necessary, by standard diagnostic procedures, and it will be made by a physician. Helping clients die with dignity Dying Person’s Bill of Rights (Potter 2010) Adapted from Barbus, A. J. (1975) The client has a right to:

have a sense of purpose.

be cared for by those who can maintain a sense of

hopefulness.

participate in decisions about my care.

expect continuing medical and nursing

attention even though “cure” goals must be changes to “comfort” goals. die in peace and dignity.

retain my individuality and not be judged for my decisions that may be

contrary to beliefs of others.

be cared for by caring, sensitive, knowledgeable people who will try

to understand my needs and will be able to gain some satisfaction in helping me face my death. Dying Person’s Bill of Rights (Potter 2010) Adapted from Barbus, A. J. (1975) Strategies to facilitate discussions about death Assisting families of Dying client Care of the body after death .

Make the environment clean to make the body appear natural and comfortable. All equipment and supplies should be removed from the bed side.

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All tubes in the body be clamped and remain in place(according to hospital policy). All soiled linen must be removed.

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The nurse should check the client's religion and make every attempt to comply. Normally, the body is placed in supine position .Palms down or across the abdomen. The wrist band is left until it is too tight. One pillow is placed under the head and shoulder the eye lids are closed dentures are usually inserted .

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The mouth is then closed (a rolled towel under the chin will hold it closed)

Soiled areas of

the body are washed,absorbent pads are placed under the buttocks and a clean gown is placed on the client,hair is brushed and all jewelry is removed. Identification tags are applied,one to the ankle and on the wrist. .

The body is wrapped in a shroud(a winding sheet).

Another identification band is then

applied to the outside of the wrapped sheet, Then the body is taken to the mortuary

Aspects of end-of-life care Palliative care The palliative care means taking care of the whole person-body, mind and spirit, heart and soul. .The goal of palliative care not to give cure to the disease condition but to reduce the pain and side effects and to improve the quality of life Principles of palliative care Palliative care respects the goals, likes, and choices of the dying person and his or her loved ones and helping them to understand the illness and what can be expected from it, and to figure out what is most important during the time. • Palliative care looks after the medical, emotional, social and spiritual needs of the dying person with a focus on making sure he or she is comfortable, not left alone, and able to look back on history her life and find peace.

• Palliative care supports the need of family members, helping them with the responsibilities of care giving and even supporting them as they grieve Palliative care helps to gain access to needed health care providers and appropriate care settings involving various kinds of trained providers in different settings, tailored to the needs of the patient and his or her family. • Palliative care builds a way to provide excellent care at the end of life through education of care providers, appropriate health policies, and adequate funding from insures and the government

Palliative care team Despite the economic and human costs associated with death in the hospital settings, as many as 50%of all deaths occur in the acute care settings. It is clear that many patients will continue to opt for hospital care or default will find themselves in hospital settings at the end of life care. Where ever the patient may ultimately die,they are likely to spend most of their last year of life in their own home being cared for by close family members. When the patient and the family’s hopes are focused on allowing the patient to die in his or her own home ,the nurses need to be acutely sensitive to the shifting needs of the caring family. Preparation of end of life and care during final days Learning that persons illness has become terminal can bring about intense feelings of anger, fear grief, regret and other strong emotions. • Encourage the patients Talking about feelings and concerns with family, friends and caregivers can help bring comfort. • Inform It is normal to grieve and mourn the loss of your abilities, the loved ones you will leave behind, and the days you will not have. Hospice care Hospice care is end-of-life care. A team of health care professionals and volunteers provides it. They give medical, psychological, and spiritual support. The goal of the care is to help people who are dying have peace, comfort, and dignity.And hospice care is only for patients who are no longer receiving curative treatments for their illnesses, and want to focus ONLY on quality of life. Hospice patients have a prognosis of six months or less, if the illness were to follow the usual course. Hospice is a type of palliative care. Advance directives Advance directives are the legal documents that explain the kind of medical treatment would want and would not want if patient become unable to make these decisions for yourself. • Advance directives protect client’s rights and preferences for the medical treatment and diminish the burden of family members and the other caregivers making decision for client

Types of advance directive • LIVING WILL A type of advance directive in which the individual documents treatment preferences. . A living will can include • Whether client want the medical team to use cardiopulmonary resuscitation(CPR) and or artificial life support such as mechanical ventilator, if breathing or heart stops. • Whether client want to receive a feeding tube, if you cannot be fed otherwise? • Whether client want certain procedures such as dialysis. DURABLE POWER OF ATTORNEY FOR HEALTH CARE • It is a legal document through which the signer appoints and authorizes another individual to make decisions on his or her behalf when he/she is no longer able to speak for him/herself. • Once patient choose a health care agent he can still make your own decisions about his medical care: UNDERSTANDING CPR AND DNR • A DNR order is a type of advance directive and it is the written physician’s order instructing health care providers not to attempt CPR and it is often requested by patient and family. A‘no code ‘or DNR order allows the person to die with comfort measures only and without the interference of the technology • Unlike other advance directives that are written and signed by the individual, a DNR order must be completed and signed by doctor or other health care provider. Nursing implications Use foam cushions to make beds and chairs more comfortable and help the patient to change positions frequently and change the bed linens as necessary. • Elevate the patient’s head or turn the patient on his or her side to help make breathing easier. • Use blankets to help keep the person warm & gently rub the person’s hand, feet or soak the hands and feet in warm water. Controlling pain is an important part of dying comfortably and peacefully. • Administer medications around the clock in a timely manner and on a regular basis to provide constant relief rather than waiting until the pain is unbearable. • Concentrated morphine solution can be very effective by delivered by the sub-lingual route. • In case of uncontrolled pain, palliative sedation Legal & ethical issues affecting end of life care Organ/tissue donation .

Organ donation is the process of surgically removing an organ or tissue from one person (the organ donor) and placing it into another person (the recipient).

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Organ donation: the Indian scenario • Diabetes and hypertension are the leading causes of end-stage kidney failure in India and it is estimated that over 210,000 patients are suffering from end stage kidney failure.

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• The increasing number of liver diseases caused by B & C viruses and alcoholism has led to an increase rate of liver failure.

Registered professional nurse are often the primary care givers for patients approaching the final stage of life. • It is the nurse who facilitates the coping of patients and their families. In general, the work of transplant nurse is anchored on counseling and facilitating the process for organ or tissue donation by educating and guiding to the donor families without doubt, a difficult, heart wrenching process The nurses stay with the patients and help the family to understand the organ donation process, which includes keeping the brain dead patient’s body functioning until the organ been collected. The nurses must have in depth knowledge regarding the following aspects: • What is organ donation and why it is needed? • How does organ donation help patient with organ failure ? • Counseling of the family members of brain dead patient for organ donation ? • What body parts can be donated? • Who can be potential donors? Document required for the donor and for the recipients. • What are the ethical aspects? • • Network of organ donation, transportation and transplantation functioning. • Why to become organ donor and how and how to get registered • How does the family of decreased donor cope up with their loss? • Creating the awareness in the community about organ donation. Terminal weaning and euthanasia End of life care is an important topic that unfortunately has been overlooked in the past. In the process of striving to achieve better understanding and treatment of medical conditions, modern medicine often fails to recognize the inevitability of disease progression despite aggressive medical management. The result is that physicians sometimes fail to provide adequate supportive care for their patients near the end of life. Terminally ill patients are those whose expectancy is relatively short and whose treatment has shifted from a curative regimen to supportive or palliative care. The World Health Organization defines palliative care as “the active total care of patients whose disease is not responsive to curative regimen”. The goal is to achieve the highest quality of care for the patient and family. It affirms the sanctity of life and regards death as a normal process; neither hastens nor postpones death; provides relief from physical and psychological sufferings; and offers a support system to help the patients live as actively as possible and the family cope with bereavement. Hospice care is the final chapter of palliative medicine. It provides support and care for persons in the last phases of terminal illness, usually in the setting of home or hospice residential facilities.

One of the most controversial subjects in end of life care concerns physician-assisted suicide and euthanasia. Euthanasia is the deliberate termination of life in a person with terminal illness. Physician-assisted suicide occurs when that person requires the assistance of a medical professional in obtaining lethal doses of drugs and instructions for euthanasia. Proponents of euthanasia and physician-assisted suicide argue that it is the patient's right to self-determination and the obligation of health care professionals to relieve suffering. However, there are many problems with this argument. Patients who request euthanasia are frequently suffering from pain and other symptoms. Effective relief of these symptoms often results in patient's repudiation of the wish to die. In addition, a patient's request for euthanasia may be a choice they believe others want them to make, or request for euthanasia may be a way of expressing other feelings. In a survey of 988 terminally ill patients, 60.2% supported euthanasia or physician-assisted suicide, but only 10.6% reported seriously considering euthanasia or physician-assisted suicide for themselves. Over a few months, half the patients who seriously considered euthanasia or physician-assisted suicide changed their minds. Patients with depressive symptoms were more likely to change their minds. Is it ever appropriate and morally justified for a health care professional to respond to patient's request for euthanasia? A survey of 3299 oncologists in the US found that attitudes and practices regarding euthanasia and physician-assisted suicide were related to the availability of optimal end of life care and the adequacy of their training in these issues. Health care professionals should strive to expand palliative care services, develop better postgraduate medical training, and improve the quality of care at the end of life, so there will not be a need for euthanasia and physician-assisted suicide. Nursing management of end of life care When providing end of life care, ensure you: 

treat people compassionately

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listen to people

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communicate clearly and sensitively

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identify and meet the communication needs of each individual

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acknowledge pain and distress and take action

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recognise when someone may be entering the last few days and hours of life

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involve people in decisions about their care and respect their wishes

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keep the person who is reaching the end of their life and those important to them up to date with any changes in condition

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document a summary of conversations and decisions

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seek further advice if needed

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look after yourself and your colleagues and seek support if you need it

Nursing care “Palliative Care is about putting life into a patient’s days not days into their lives” – Nairobi Hospice Although challenging and emotionally demanding, when you are supported to have the right skills, knowledge and attitude, end of life care can be very rewarding. End of life care is provided in a range of settings which include care in the community, a hospital, care home, hospice etc. Regardless of care setting, the quality of care should be of the highest standard. When it is recognised by nurses and doctors that a person may be dying, this needs to be communicated in a sensitive and compassionate way to the dying person (as appropriate) and those close to them. How we communicate with the person who is dying will depend on each individual case. This is an extremely sensitive area and should be patient led, with gentle, honest answers using language the person understands. At no time should the conversation continue, if there is any indication that the patient doesn’t want to continue. Staff should always be mindful that some patients will not want this conversation and therefore it should not take place. However, it is crucial that conversations should take place with families to prepare them for impending death. Care of the person When you provide good nursing care for those at the end of their life, you will be providing holistic care including providing physical, emotional, psychological and spiritual support. The individual may be a patient, but remember they are also another human being that may be feeling lost, confused and have questions about their nutritional and hydration needs. Equally, the person may not come to you with questions, preferring to keep them to him or herself, or discuss with another person of their choosing. It’s important to let the person remain in control of who they wish to share these issues with. Don’t forget that those close to the individual may also be looking for support and information. It is important to be sensitive to people’s needs in relation to nutrition and hydration. If someone has a question, try your best to answer it if you are able, or make sure you seek advice from a more senior member of staff if you aren’t sure. Understanding the dying process

Caring for a person during the last few weeks and days of life can be stressful and demanding. Many different feelings and emotions may surface from all those involved. Recognition of dying is actually quite complex. This is acknowledged in the literature and in reports regarding end of life care, such as More care, less pathway (Neuberger 2013) and Dying without dignity (Parliamentary and Health Service Ombudsman, 2015). It is useful for staff to use prognostic indicator tools in the last year of life. For example, the Gold Standards Framework (GSF) and the Palliative Performance Scale 2 (PPS). When it is recognised by nurses and doctors that a person may be dying, you then need to communicate this in a sensitive and compassionate way to the person and those close to them. It is also important to communicate why it is only necessary to provide minimal hydration. A key part of the nurse’s role is being able to come alongside the person who is dying and those close to them and to support them throughout what is a natural process. The time before death is generally peaceful for patients, and there is a gentle winding down that may take several days. Many people are concerned that death will be a painful experience for the person, but the body just starts to ‘let go’ of life. At times a person can become restless, but this can be treated. There are physical signs of the natural process of the person’s body gradually slowing down. Sometimes these signs appear a few hours before death, and sometimes it can be a few days. We look further into the signs of dying in another section of this module. Learning from complaints Staff often feel defensive when a complaint is received, however this is not helpful behaviour and an apology should not be viewed as an admission that they have got it wrong. Saying sorry is one of the most helpful things you can do, when a complaint is received. There is a helpful document called ‘Saying Sorry’ around how to say sorry. Conclusion Grieving is painful, and it’s important that those who have suffered a loss be allowed to express their grief. It’s also important that they be supported throughout the process. Each person grieves differently. The length and intensity of the emotions people go through varies from person to person.

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https://www.crossroadshospice.com/hospice-caregiver-support/end-of-life-signs/