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Chapter 29

Loss and End-of-Life Issues

Employment to retirement

Lifelong home to a smaller home or senior apartment

Very active to being less so

Health to chronic illness

Marriage to widowhood

Extensive social networks to smaller circles of family and friends

Losses Associated With Aging

Successful aging requires learning to deal with losses and adapting to changes over time

Loss: broad term that connotes losing or being deprived of something such as one’s health, home, or a relationship

Bereavement: the state or situation of having experienced a death-related loss

Grief: one’s psychologic, physical, behavioral, social, and spiritual reactions to loss

Mourning: used to refer to ritualistic behaviors in which people engage during bereavement

Definitions

Life transitions such as retirement, ill health, and death of loved ones evoke varying responses of grief.

Many older adults experience multiple losses with little time for grieving between losses.

Individual coping styles, support systems, ability to maintain a sense of control, griever’s health status, and spiritual beliefs all influence responses to multiple losses.

Response to Multiple Losses

Bereavement includes grief and mourning.

Death of a spouse is most significant loss.

Surviving spouses must take on new responsibilities while coping with the loss.

Perceived social support after death of a spouse has been shown to be a factor affecting adjustment of many surviving spouses.

Other factors: ambivalent or dependent relationships, mental illness, low self-esteem, and multiple prior bereavements

Bereavement

Bereavement adjustments are multidimensional.

It is a highly stressful process.

The overall effect on the physical and mental health is not as devastating as expected.

Older bereaved spouses commonly experience both positive and negative feelings simultaneously.

Loneliness and problems with the tasks of daily living are two of the most common and difficult adjustments.

The process is most difficult in the first several months.

Much diversity in how older adults adjust to the death of a spouse

Bereavement Experiences of Older Persons

Early phase: shock, disbelief, and denial

Middle phase: intense emotional pain and separation often accompanied by physical symptoms and labile emotions

Last phase: reintegration and relief occur as the pain gradually subsides and a degree of physical and mental balance returns

Phases of Normal Grief Reactions

Tearfulness, crying, loss of appetite

Feelings of hollowness in the stomach, decreased energy, fatigue, lethargy, and sleep difficulties

Tension, weight loss or gain, sighing, feeling something stuck in one’s throat, tightness in one’s chest or throat

Heart palpitations, restlessness, shortness of breath, dry mouth

Physical Symptoms of Grief

Feelings of sadness, guilt, anxiety, anger, depression, apathy, helplessness, and loneliness

Diminished self-concern, a preoccupation with the deceased, and a yearning for their presence

Some become confused and unable to concentrate

Grief spasms, periods of acute grief, may come when least expected.

Psychological Responses of Grief

Depends on the type of relationship and the definition of social roles within the relationship

Bereaved person must often learn new skills and roles to manage tasks of daily living.

Socialization and interaction patterns also change.

LGBT partners grieve differently because of previous experiences with discrimination.

Social Responses of Grief

Examination of meaning of life

Religion and spirituality can provide a stabilizing influence during grief.

Anger at God, sometimes followed by a crisis of faith and meaning, may accompany bereavement.

Gender, social class, ethnicity, and culture may influence one’s spiritual response to grief.

Spiritual Aspects of Grief

Anticipatory grief: grieving that occurs before actual loss

Disenfranchised grief: grief that is not validated or recognized by others

Complicated grief: four types

Chronic grief reactions

Delayed or postponed grief reactions

Exaggerated grief reactions

Masked grief reactions

Types of Grief

Ritualistic activities such as wearing dark clothes during bereavement or lighting candles for the dead

Processes related to learning how to live with one’s loss and grief

Mourning

Accept the reality of the loss—realize the person is dead

Experience or work through the pain of grief—prevents physical manifestations of pain

Adjust to an environment in which the deceased is missing—assuming roles that the deceased was responsible for

Emotionally relocate the deceased and move on with life—removing the emotional attachment

Four Tasks of Mourning

The meaning of a loss to a bereaved person has a significant effect on his or her responses to that loss.

Caregivers should explore the perceptions of the bereaved to understand and assist them as they mourn their loss.

The bereaved are encouraged to find or create new meaning in their lives and in the deaths of the deceased.

Meaning Making

Assist and support bereaved persons through the grieving process

Recognize that pain is a normal and healthy response to loss

Allow bereaved persons to accomplish the tasks of mourning in their own ways

Nursing Care

Simple tool to assess progress in bereavement is the 10-Mile Mourning Bridge (Worden,1991)

On the bridge, the 0 represents the time before grief; 10 reflects Worden’s last stage, where patients recover the emotional energy consumed by grieving and reinvest it in their own lives.

Nursing Assessment

Help the survivor actualize the loss, identify, and express his or her feelings.

Assist the survivor in living without the deceased

Facilitate the survivor’s emotional withdrawal from the deceased.

Provide the survivor with time to grieve.

Interpret “normal” behavior for the survivor.

Allow for individual survivor differences.

Provide continuing support for the survivor.

Examine the survivor’s defenses and coping styles.

Identify pathologic conditions and make appropriate referrals.

Principles of Grief Counseling

Used to facilitate successful progression through the grief process

Grief counseling is used to facilitate successful progression through the grief process—nurses may provide

Grief therapy is intended for those who are experiencing complicated mourning—skilled therapist necessary

Grief

Help the survivor actualize the loss.

Help the survivor identify and express feelings.

Assist the survivor in living without the deceased.

Facilitate the survivor’s emotional withdrawal from the deceased.

Give the survivor time to grieve.

Interpret “normal” behavior for the survivor.

Allow for individual survivor differences.

Worden’s Grief Counseling Principles (1 of 2)

Provide continuing support for the survivor.

Examine the survivor’s defenses and coping styles.

Identify pathologic conditions, make appropriate referrals.

Worden’s Grief Counseling Principles (2 of 2)

An older adult has moved through all the phases of grief when which of the following has occurred?

The patient cries every day for the deceased spouse.

The patient talks about the spouse as if the deceased is still in the hospital.

The patient takes on the daily chores of cooking and cleaning the house.

The patient talks about the spouse in the past tense.

Quick Quiz!

ANS: D

Answer to Quick Quiz

Major concerns are fears of a long debilitating illness, fears of being a burden, pain and suffering, quality of life, and fear of dying suddenly and not being found.

A person who has had positive experiences of coping and is relatively well adjusted usually approaches the stress of being close to death with adaptation and acceptance

Life review: process where one tries to make sense of life as a whole

Approaching Death: Psychologic Aspects

Religious beliefs and spiritual experiences play an important part when older persons make sense of their lives.

Dying or a threat of loss can trigger a crisis of faith, in which people question their previous beliefs in an effort to make sense of the present experience.

Assessing patients’ desires for religious and spiritual assistance is particularly important when they are dying.

Approaching Death: Spiritual Aspects

Adoption of the sick role may be accompanied by an acceptance of one’s fate.

Dying individuals may adopt a fighting stance, determined to do all they can to forestall death

The stance people take toward dying is affected by sociocultural, psychologic, and life history factors.

Death and dying have been regarded as taboo topics in American society.

Social isolation often results as friends and sometimes family seemingly abandon the dying person.

Approaching Death: Social Aspects

Terminal illness: a life expectancy of 6 months or less, which is the length of time determined by Medicare for receipt of hospice benefits

There is no clear definition of dying for older persons not diagnosed with a terminal illness; must be explored individually.

Death for older persons usually results from complications from one or more chronic illnesses rather than from a sudden, unexpected incident or illness.

Approaching Death: Physical Aspects

Stabilize vital functions

Adjust treatment plan

Relieve distressing symptoms and suffering

Assist patient and family interaction

Support patient and family in coping with death

Health Care Needs of the Dying

Predispose older persons to greater potential for problems in the following areas:

Hygiene and skin care

Nutrition

Elimination

Mobility and transfers

Rest and sleep

Pain management

Respiration

Cognitive and behavioral functioning

Age-Related Changes

Examine your own feelings about death and values regarding older people.

Requires knowledge of the complexities of gerontologic and end-of-life nursing combined with the knowledge, skill, and compassion necessary to deliver holistic care to both dying patients and their families

Nursing Care of the Dying

Careful and ongoing assessments must be made of physical, psychosocial, and spiritual needs.

Special attention to potential problem areas: skin integrity, respiratory status, nutrition, elimination, sensory abilities, cognitive functioning, comfort, and rest.

Psychosocial needs of dying person, family, and caregivers must be carefully assessed.

Spiritual needs of dying person

Nursing Care: Assessment

Older adults require more frequent assessment, application, and evaluation of the effectiveness of nursing strategies.

Particularly difficult problems include pain, dyspnea, constipation, urinary incontinence, restlessness, hallucinations and delusions, and nutritional problems.

Good communication

Educate and support families

Nursing Care: Strategies

Too often, life-support technology, tests, treatments, and drug therapy are used causing needless suffering.

Hospice refers to a philosophy of caring that can be implemented wherever the patient may be dying—at home, the hospital, or a nursing facility.

Palliative care refers to “an approach that improves the quality of life of patients through the prevention and relief of suffering-treating of pain and other problems, physical, psychosocial, and spiritual.”

Nurses caring for very ill older adults need to understand the legal status of advance directives, living wills, and DNR orders.

Environment and Care Services