University of Calgary

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Research Centres, Institutes, Projects and Units Family Nursing Unit

2003

Loss, grieving and death

Raffin Bouchal, S.; Moules, Nancy J.

Pearson Education

Raffin Bouchal, S. & Moules, N. (2003). "Loss, grieving and death." In S. Raffin Bouchal & S. Hirst

(Eds.), Fundamentals of nursing: the nature of nursing practice in Canada . Toronto, ON: Pearson

Education, pp. 1340-1364.

http://hdl.handle.net/1880/45151

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Downloaded from PRISM: https://prism.ucalgary.ca

Loss, Grieving, and Death

L ms, griming, and death are experienced by everyone at some Eime during their life. People rnay suffer the loss

ofdued relationships through life changes, such as moving from one city to another, separation, divorce, or the death of a parent, spouse, or friend. People m y grim changing Iife roles as they watch p w n chihen l m e home or when hey retire from their lifelong work The loss of valued mateid objects through theft or n a n d disaster mn evoh f e e of grief and loss. When people's lives are affected by civil or national strife, they may grieve dx loss of &ed ideals, such as safety, Ereedom, and dmoaacy. h the &id setting, the nurse exlcountm clients who

may be experiencing grief related to d d q g health, loss of a body pare, terminal illness, or the impending death of self or a significant other. Tbe nurse may also work in community settings with clients who are grieving losses dated to personal crises (e.g., dim=, separation) or n a d disasters (eatthquakes, floods, or hurricanes). Therefore, it is important that the n m t understand the signifime of 1- and develop the aUy to assist clients in their experiences of grief.

Nurses may in- with dying en^ and their families or caregivers in a variety of setting, &om the demise of a fetus, to that of an adolescent victim of an accident to that of an dderly dient who ha& mcamb to a chronic illness. Nurses must recognize the various influences on the dyhg proms-legal, ethical, religious and spiritual, biologid, and p e r s o n a l d be prepared to provide sea- si&e, skilIed, and supportive care to all those affected.

Loss is an a d or potential situation in which something that is valued is changed, no longer available, or p e . People can experience the loss of body image, a sigdtcant other, a sense of well-being, a job, personal possessions, beliefs, or a sense of self. Illness and h o s p i ~ t i o n often produce losses.

Death is a fundamental loss, both for the d p g person and for those who sm7tive. Although dea& is inevitable, it is an experience that each person ultimately faces alone. Yet, death, like loss, can stimulate people to grow in their understanding of themseIves and others. Death can be viewed not simply as lGoflife but as the dymgpmon's hal oppnmmiy to experience Iife in ways that bring meaning and fulfilIment.

There are two general types of loss, actual and perceived. 00th tosses can be anticipatory. An An loss can be idend5ed by others and mn arise either in response to or in anticipation of a situation. Far example, a woman whose husband is dying may & a c e actual loss in anticipation of his deah Aperoeived loss is e x p e r i d by one person

Chapter 48 Loss, Grievitg, d Death

but cannot be verilied by others. PsychologicaI losses are often perceived losses in that they are not direcdydabJe. For example, a woman who leaves her employment to care for her children at home may perceive a loss of inde- pendence and Morn. An antkipatmy loss is w r i e n d before rhe loss actually occurs. Lo= can be viewed as sit- uational or developmental. The loss of one's job, the death of a Md, or the loss offunetional ability as a result of acute illness or injury, for example, are unexpected situational Iww. Loses that occur in the process of normal dwel- opment-ch as the departare of grown children horn the home, retirement from a career, and the death ofaged parents-me developmefital losses dmt can, t~ same extent, be anticipated and prepared for. How individuals deaI with 1- is d d y related to their life and past q r i - ences, personal and f a d y reso-, social support sys- tems, and their beliefs abour the loss idf.

There are many sources of loss: (1) loss of an aspect of oneself--a body part, a physiological function, or a psy- chologid attribute, (2) lass of an abject external to o n 6 (3) separation from an accustomed environment, and (4) Ioss of a loved or vdued person.

Aspect of Seif The loss of an aspect of =if changes a person's body image, even rhaugh the loss may not be obvious to others. A face scarred h r n a burn is generally obvious to people; loss of p of the stomach or loss of ability to feel motion may nor be as obvious. The degree to which &ese losses affect a person largely depends on the integrity of the person's body irnage (part of self-mnrnpt). Any change that the per- son perceives as negative in the way the person relatm m rhe environment can be considered a loss of self. It should be nored that self is a culturally influenced concept, and therefore, experiences of self-10s are particular m individ- uals and their particular dturaI and personal influences.

Such losses as divorce an have a considerable impact. A divorce may mean lass of h a n d security, a home, daily routines, arid one's role as spouse. Thedore, even when the divorce was desired, the sense of loss m be subsmtial.

During old age, changes occur in physical and mental capabilities. Agam the self-image is d e r a b l e . Old age is when people usu$y experience many 10- of employ- ment, of m a 1 activities, of independence, of health, of &ends, and of family.

External Objects Loss of external objects includes (1) loss of inanimate objects that have importance to tf ie person, such as the loss of money or the bmhg dawn of a family's house, and (2) loss of animate objects, such as pets that provide love and companioflship,

FamiIiar Environment Separation h m an environment and people who provide security can result in a sense of 1 ~ . The six-year-dd is

likely to fed 10s when first laving the usual environment to attend school. The university student who moves away from home for the h t h e a h experiences a sense dlm,

Loved Ones The loss of a a d o m ar valued penon through illnew, separation, or death can, amang other tqeriences, m a t e sufkhg. In some. Un-, a person may m d e ~ p n - d i t y c h m g e s & a r m k e ~ d s d ~ f e e l t h e y h a v e lost that paon.

The,da& of a loved one is a p e m e n t and complete loss. In prlmicbe societies, death was cansidered e 51omd,

natural wen& 4 life was seldom long: In contemporary No&Amerimn mi-, death is o h denied. Peoplemay be mcmfomMe taking about death and being mmd people who are dying. SomdmesB in an effort to escape the M t y of dm&, rhere is a d e n q to w e wmordiaarg measure8 ht pralong and pr-e life.

through a series of s m g a or phases rqukhg work or par- ri& w h d m i d t i n a W m l u t i o n ofg'ieffdings {lcowles & R c r d p , 1981; Engd, 1% Rando, 19WB Schneider, 19% Worden, 1991). Out df this explanation, stage model. &caries, some ofwhich m based w ESlbhr- Ross5 (1 969) work on dath and dyingi have p d d d one temphk for mdersmdhg tbe qer iene of Hef. A cri- tique, of stage model theories is that dbugh m y provide some nmdkmandingt xeqpiti~n, and hguage fur dm experience of grief, rhey may &o seme to o h uuipne and individual experiences ofgrief ( M o w 19%). They--lyhm on ~ loP;a l r%spomeswhih ~ 1 ~ s o c d , s p i r i t u s Z ~ a n d p h y s i c a l d o m a i n s of the errperience of grid. To ~11dwstand @d as a staged qeriertee c a x l ~ n l y ~ t e the Miefthat griefamm passively in q e a e d sequences &at disregard W d d expienx?es and rhat fail to mnate 9li& the qmiencis people a m d y underp in @wing.

Mm&o (1985) dimmed fivechmrs d@e& which exemplify common eqerienws in the eef response. These include shock and disbdid; ye+ and prow6 anguish, dhxpizarion, and despair; identifiation in bereamneat; and reorganization and tes6tlltiotl. W~tbjn & e 5 e ~ ~ m m m ~ h o w e w t , t h ~ i s n o s m g l e m r - rect way or timetable. Whether a person c a ~ l succwfdly intqpre rhelossmd how &his accmplishedare dated to &at person's individual development and personal m h p . Individuals responding ta the very same loss annot be qwtd to b h w the same pm and schedule or reach dm same ourcome.

Axlothex popul-tion df the experience d grief is that there is a nomd grief reation and an ;rbnormal or &tlq me. Geftlsar d m not f o h a prdm'ble or

and add, in addition to the experience of loss, e sense mal W m and incompe&nce (Mode, 1998.

of one's He-bialogm& psy&olo+l, and spirituaL Grief endures in a way tha evenmllymthg amutible or dmghg most often, P Herime rebdondip wirh che loss. or not, this visitox, @4 & up residence in

their lost ohm and say hello t~

weight Ims, difficulti headaches, dizziness,

a cantinning eqeriace of remembrance, corn men debration of a W weIl lived asd I c r t rd

belief that aII people mperhce grief in a This beliefmight lead family members into of each oxher &t amot: be M e d and

sense of alienation, isolation, or even mntlict among hose people who are qwtd to provide cordon and connection for each ather. There is some suggestion in the literature that gender differences play out in a M y ' s experience of grief and that men and women experience, express, and have differing expectations of rhemse1ves and each other in the experience of grief and loss (Attig, 1996; DeFrain, 199 1 ; Hugh- & Page-Lieberman, 1989; Moore, Gilliss, & Martinson, 1988; Modes, 1998; Park, 1988; Rosen, 1990; Shapiro, 1994).

Comp1ic;tting an individd 's experience of grief might be ambivalence, unmoIvd issues, or pre-exis- conflict with the lost person; a pervasive and unrelenting sense of guilt or responsibiliy, past experiences of loss; and the type, timing, and context of the lass (Hem Brown, 1989). Cemin kinds of lasses.that are not synchronous with Me smge expectations, such as the loss of a child as opposed to an elderly prmq can (but do not meessarily) generate more intense experiences of grief (Cawles & Rodprs, 1991; Rolland, 1991) and have the potential for more complimtio~ in the experience.

A number of factors affect a person's response to a loss or death. These hctm include age, d@caxlce of the loss, c u l m , spiritual beliefs, gender, socioeconomic matus, mpport systems, and the muse of the loss or death. Nurses can barn general concepB about the influence of these factors on g r i m experience, but the constella- tion of these factors and their sigaifi-ce wilt vary from individual to individual.

Age Age affects a person's ~~~ding of and reaction to lass. Wirh experience, people u m d y increase their under- standing and acceptance of life, loss, and death.

People do not usually experience the loss of loved ones at d a r intervals. Bs a mdtl preparation for these experi- ences is difficult Coping with other loss= in life, such as the loss of a pet, the loss of a hiend, the loss of a job, and the loss ofyouth, can prepare paople to anticipte the more swere loss of death.

ChiUbd Children differ from add& not: only in heir nnderstandiug of loss and death but also in how they are

, affected by the loss of others. The child's partem progress mpidly; adult patterns of growth and development are generally stable. The loss of a parent or other significant

. persw can threaten the child's abili~y to develop, and I regression sometimes d t s . Assistingthe child with the

grief experience includes helping the child regain the normal continuity and pace of emotional development

Some adults may assume that children do not have the [ same need as an adult to grieve the loss of orhers. In situ-

Chapter 48 Loss, Grieving, and Death

RESEARCH NOTE

What Factors Account for Bereavement Outcome Among Spouses and Children of People Who Haw Died from Cancer?

The family rnemhs of It3 adults who d i d from cancer in hstralta were inkmiwed three times; six weeks, sk morrths, a d 1 3 month a h the death. In addition to apn-ended imtewiwsr tk spxm and availabt~ children ako completed instruments k t rneasvmd thoughts and feelings about the p e r m who ' h d d W: depesitq pyrldqim1 sympmm, and 'm&l futwtbns. The data ware anatpd for cop- relations, fhe -reese&rs found at the spwm's rat- ing of "rweral [.family coping" mnsktently correlated with grief intenshy, psych6Iogid distress, depression, and social adjustment. That U,,@ &th the family coping was v W , the tess was the d i m , and &psion, a d b & r adjusbnents were rewed. The authors were able to clawfy familia ,in@ five groups: supportive, mnsnfl r ~ o l v i q , wllen, M l e , aml intermediate. tt is p & e thae he latter three g r o v are at p t w risk for d@m&nal grieving and coping.

hphcatians: This research supprb the i ~ ~ p ~ c e of conkd~ring the fundioning ,of the entire family w h assessin8 the me& d dying d i ~ and their SignjfmFlf ~theru. It s w that there are character- i& of famil@ that m y Mp identify them as hing at h@er ri& for M o p i n g i n W * grieving and c O p i R g * ~ .

wffe: Warn, D. w, h h , S., & M-, D, E I1997,kky). Family m Q i ~ a n d ~ ~ t ~ m . ~ r i V e ~ n e , 17,191-201.

ations of crisis and loss, children are sometimes pushed aside or protected horn the pain. They can feel a h i d , abandoned, and lonely. Greful work with bereaved cM- d m is especially necessary because qxriencing a loss in childhood can have serious effe& l am in life.

hr& dM!YbW A d d h a d As people grow, they come w experience loss as part of normal development. By d d d e age, for exampIe, the loss of a parent b u & death seems a normal occurrence compared with the death of a younger persoa Coping with the death of aa aged parent has wen been viewed as a necessary developmend task af rhe middleaged a d d t

The middle-aged adult can experience losses other than death. For m p 1 e , losses resulting from impaired health or body function and loses of various role func- tions can he dii5eult for the middle-aged adult. How ttre middle-aged adult responds to such lossa is iduenced by previous qeriences with lm, the persm's sense of self- esteem, and he strength and adabi l iy of support

1344 SECTION 4 Nursing Therapeutics

A h M d Losses @end by older ad& include loss of health, loss af mobilityI loss of independence, and loss of work role. Limited income and rhe need to b g e one's living accommodations can also lead to feelings of lass and grieving,

Fur older adults, the loss &mu& death of a longtime mate is pfozmd. Although M d u a f s differ in heir abil- ity m d d with such a loss, xesearch suggests that health problems hr widows and widawers increase during the 6rst year faUowing the death of h e spouse (Richtef, 1984). Bemuse the majority of deaths occur among elderly peo- ple and because rhe number of elderly people is increasing in North America, nurses will need to be especdy dert t~ the potential problem of older $xiwing adults.

Significance of the Loss The qpdicaflce of a lass depends on dze p e n q h n s of h e individual ~ @ e n c i q the loss. One p e r s o n ~ ~ r i e n c e a p a t sense of hss over a divorce; another may h d it only mildly h p t i n g . Anumbmof~rs&ct&esignificranoe of the 10s:

Value placed on the lost person, object, or function

m Degree of h g e required because of the loss

The person's beliefs and vaIum

For older people w b have alrea* encountered many losses, an anticipated l a , such as their own death, m y not beviewedasahighlynegakl~, and they may& apathetic about it instead of reactive. More than fearing death, some may fear loss of control or becoming a burden.

Culture 'Culture influences an individual's reaction to loss. How grief is expressed is o h determind by the customs of h e cultnxa In the Unhd States and Canada, &an extended h d y mucmm mists, grief is handled by the nudear family. The death of a f a d y member in a typid nuclear North American family leaves a great void h u s e the same few individuals fd most of the roles. In d m where several generarims and extended W y members either reside in the same househoId or are phpically dose, the impact of a fmpily m e m M d d may be softened h u s e the roles of the deceased are quickly Wed by other relatives.

Many N o d Americans appear to have adopted tbe belief dmt grief is a private matcer to be endured internally. Therefore, f&gs tend to be repressed and may remaiu nnidentified. Feople who have been socialized to 'be strong'' and rhe best of the simtiw" mgp not express deep feeling or persod concern when they experience a serious loss.

Some cultural groups d u e social support and the expression of lorn. In some p u p s , h e -mion of grief through wailing, q h g , php id pmsrration, and o e outward demonstrations are aoceprable and encouraged.

Other groups may frownLon tbk demonstration as of wntmII fawuhg a quieter and more of grief. Jn cultural g r o q where strong mainrained, pbysiml a d emotional s u p n and mnce are provided by family members.

SpMtual Belfefs Spiritual beliefs and practices greatly influenw both" person's reaction m Ioss and subsequent behaviour. religious groups have practices related ta dyingI and are often important to h e client and support p p l additional hhrmatian, see Chapter 13. To provide sup@ at a time of death, nurses need io understand the && pmdar beliefs and practica. A pzct of one's spiritdip& repmmwd in, and idaenm, the way onemakes madti# of the experience of loss. &king questions of a @5& nature is within the domain of nursing practice (Mod%, 1999; Wright, 1997; 1949).

Gender h mentioned ~ I i e r , h e gender roles into which many people are sacidzed in the United States and Canah affect their reactions at times of loss. Men are b-tlx + m"be srrong" and sho-wvv Iide emotion d- grieving, whereas it is accepmble for w o m a to show grid ' by @%.

Gender roles also affect the signifimce of body h a & changes to &em. A man might consider his facial s w be Umacho," bur a woman might consider hers ugly. Thus, the woman, but not the man, w d d see it m a loss.

Sodoeconomic Status

able ra cope with either,

1 The socioeconomic stam of an individual often affects tk support system adable at tbe time of a 10s. A pension plan or insurance, for o r p l e , can om a widowed or disabled ' y a & i ~ o f ~ w d e a I ~ & a b . A - w h o b a hand and mn no Ionger any out work-relaad tasks mar be able twr pursoe voational re-edumtios; a wealthy perm whose spouse has died map decide to take a cnrise or visit relatives ia Europe. CavmIy, a person who is co&nted with both severe ros and economic bardship may not be.

Support System The people dosest to the grieving individual are often the first to recognize and provide needed emotional, pwcd, and fnnctional asismice. However, bwme many people are uncomfomb1.e or inexperienced in dealing with l ~ ~ , the usual support p p l e may instead withdraw from the grieving individual. Also, support may be available when the loss is first recognized, but as the support people return co their usual activities, the need for ongoing sup- port may be m e t Sometimes, the grieving individual is unable or unready to accept support when it is ofEered

Cause of Loss or Death Individual and socied views on the muse of a lass or d=& may @mdy iDflnence h e grief r e p m e Some diseases are coosidered uclean,n such as cardiovascular disorders, and engender mpasion, whereas others may be viewed as repulsive and less u&mnate. A loss or dm& rhat is beyond the mnml of those involved may be more accqmblethananedut ispreyenrabIe, suchasa dnmkdriv- ing accident, Injuris or deaths occming during mpected *ties, mrch as "in the h e of duy," are considered honourable, whereas those occunhg during illicit a&- ties may be considered the individual's just rewar&.

Nursing assament of the client and M y expetiendng a loss iucludes three major componenw (1) nursing his- tory, (2) aswment of personal coping mums, and (3) physical mwsment. During ttte routine hedh assess- m a t of every client, the nurse poses questions regarding previous and w e n t losses. The nature of the loss and the meaning of such losses to the client must be explored.

If& is a cumnt or recent loss, PET detail is needed in the mwsment Because clients do not always associate physical ailments with m o ~ d mpns, such as grief, the

11 Loss and Grieving

Chapter 48 hss. Grieving. and L)eath

nurse may need to probe to ideneify possible 10s-related Ifthe: clientreprisQ@caat itis imprmt

to examine how the dent uslEayl c o p *& IOSS and what resources are available to assist rhe client in coping. Dam regarding general heal& mnrs; other personal stres- sow cultural and spiritual traditions, rim& and Mefs related to Ioss and grieving, and the person's suppon net- work will be needed in order to determine a plan of a r e (see the Assessment fnrerview box below). In assessing t h e d i e n t ' s m q m n s e t o a ~ l o s s , & e n u t s e ~ i d e n ~ comphations of grief that m y be best m i z d by a heal&- care profesional who is expert in misting such en^^. If the nursing assessment reveals severe physical or psyche logical signs and symptoms, the client should be referred to an appropriate care provider. Such complimtims may include cIinical depression, extensive social &lation and withdrawal, severe ph+orogtcal symptoms, suiddal thoughts or urga, or unrelenting and oppressive sorrow that per- sists for prolonged pwiods of time and is not balanced by any relief or joy-filled qxriencs.

The sW mat relevant to situations of loss and grief are attentive Iistening, silence, open and c l o d questioning,

Rerfous bsses cumem LOSS

Have you ww lost someone or mething very What haw you been told b u t (the toss)? Is &ere important to you? anything eke you would like to know or do not

Have you or your farnjly ever moved your home? understand?

What w s it like for yau wken you first smkl r What changes do you think this (illness, surgery, prob- school? Maved away from hame? Got a job? Retired? lem) will cause in your Life? What do you think it will Are you physidy able to do all the things you like ta do? Used to do?

r Has anyone important or dose to you died? Do you thinktherewill banylossesinyour lifein the near future?

M o u s Grieuing Tell me about (the loss). What was losing like for you? Did you have trouble sleeping1 Eating? ConcermtingZ What kinds of thin@ did you do to make purseif feel better when sornding like that happened?

r Are there spiritual or cultural practices you observed when you had a lm IIke that?

r Whom did you turn to if you were very upset about (the loss)? How long did it take yw to fed more like yourself again and back to your usual activities?

be like without (the lost object)? Have you ever experienced a loss like his before? Can you think of anything good that might come out of this? What kind of help do you think yau will d P Who is going to b helping you with this lw? Are there any people or orpnkdons in p u r community that might be able to help?

CU"M wdng Are p having trouble sleeping? Eating? Conm~ting? Breathing? Pu pain orother new ~ h ~ i a j ~oblem?

Are you taking any drug or medications to help you cope with this loss?

r What are you doing to help you deal with this lossl

/

1 I lmpiications for Nursing hadice The Canadian Hospice Palliative Care Asssciation (CHPCA) is the re+-d national organization for leadership in palliative care. The mission of CHPCA is to promote palliative care awareness, education, and march, advacatingat a national level for policy development, reMlurce allocation, and support for caregivers.

Each province and territory has a provincial palliative care amcidon that is linked tn the CHPCA.

The CNA Board of Directors has awarded palliative care h e designation of specialty, making it the 12th discipline ro become a spaiaky. Over the next two years, at least 60 palliative a& nurses from across the country will be imrblved in the development of mmpetenci;es and itern writing for the mtification emination. It is h o w that he first plliitive care nursing axtifiation examination will be afkred in 2004.

Nu= need to be aware d the poliky papers on nursi@j care of h e dying that have been actepted by a& pmfmional association, in amordance with CHPCA standards.

Nurseg interested in palliative.care may want to ~ n s i d ~ rnernkrship in the= associations. '

This is a tremendous achievement for palliative care nursing in Canada, and it is expected that this initiative will lead to the enhancement of palliative care for all Canadians.

paraphrasing, cla-g and reflecting Wings, and smn- marking, Less helpful to clients are rqmnses that give advice and evaluation, those that interpret and analyze, and those that give unwarranted reassurance. T h e offering of p h t i h is often a temption rn those aying to comfort someone who i s&&g a b. Though welI intended and o h arising out of a loss for words, such platitudes as "It must have happened for a reason; you need to accept ib" "Time hds all wounds," UTiy not to think a b u t ib"'Ym'll get over it in time," or "Now you've got a littIe angel in havenn serve only to contribute to mwagm that a visible grief is unhdthy and d m grief is time limited (Modes & Amundson, 1997). These messages deny the right and need of the bereaved ro my experience, admawledge, and express gief as a part of incorpomt+ng lass inw; their k. What the nurse says or does is dways best gnided by the client and in response to the client's needs. Some- times, a simple sratement of Y am sorry for your loss: or a silent presence is what is most needed, To ensure effective commnnication, h e n m must make an a m t e assess- ment of what is appropriak for the client

Commrmiation wit41 grieving clienes needs to be rele- vant to meeting clients at the poin't of tb& needs, not rhe needs of the nurse. To determine the point of a client% need, thenursehasmbe~toIistento~eclient'spainand sufhingandnotbe draw11 w the te.mptationtottyto& the pain away or heal it, even if such a thing were possible.

In addition to effective oommmication skills, there are spe&cwaptharamwsecaasupportandmeforadient a p h c i n g 1.0s. Of&, probably the most h p r t a n t is that the nnrse *make m m far grkF (Modes, 1998). By

~wemarthtEbenursewcep~,Wtates,smdnr m h the exprbrnand q & g n ofgrief. This ean done in sever%l a&m and attitude portrayed by h e mq

r Re presen~ be comfortabIe with dam, & mueb the p m kdimws h t d d be t o d i n g .

AchowIedge pain and &ring. ~ t a k i n g a b o u t t h e . l w s a n d & e h e d ~ but accept if clients cannot crr do not wish to do so.

r Fqdore md respect &ents'37tcid, cul-religiod personal, and Wyduesinrheir exp&on.of@ Explore tbir sapport symm and pasad mom W'ho is i s a b l e to be with them? Who wonld IR most helpful right now? Who mu help rhem take care of practical mgements-and details? Assist &endfadiesin understanding that Mefh e x p d diffemndy by different ppJe and indm2c uaIs cannot be expected ro adhere to others' q e ~ ~ tions uf appropriate m p m e s to grief. If children are inmIved, ensoumge M y m e d m to be mthful and to allowthe cMd to participate% rhe p k h g activities dothers.

I Though maybe mt at tbe time of the b m d h lo: suppbrtJientsinexpIoringt4eme&ngtheyhm maded&eirloss,how&eyhmecamemd~ it or Jive with it, and how hey have come ro malce mbm for a relatiomhip with @dm tk& lh.

r F d d e teswres and supporthtbpmation, ~ & c lad grief mppoa p p s at cmmding.

Cbpter48 h a Grieving.and Death 1347

Nm*mg a d G&f 'VTo enter the world of one who is grieving, we must choose to listen to the pain behind the wordsn (Gibbons, 1993, p. 599). TO n m e clients who are suffering wi& loss and who are experiencing grief is not a painless practice. It is, however, a vital part of nursing. As people, we are nor immune to experiences of loss and grief. These experiences are inesmpable in the human condition. As such, nurses play a fdammtal and impor- rant role in helping people move through these e;gperi- a c e s With grace, snpport, dipiv, and kindness.

Gyday (1989) suggested that grief is a journey h t is often blurred and muddy. This journey is a journey of relationship-relationship with the lost person, with one- self, with raminkg people, with healthaxe profession- als, and ultimately with grief itself People struggle w m a l r e ~ o f l o s s a n d d b r ~ ~ m ~ i n a c h a n ~ relationship with the last person. They move through the volatile, changing, unpredictable experietm of grieving, somwing, debrating, and change. Tn d& movement, people come to their own methods of £inding a way to make room for grief in their lives. People feel grief when a loss is sipibnc Grief, then, in some regards, might be seen as the act and emotion of sorrowing and celebrating the space that was made for another in love. Nurses often have &e privilege of waking alongside dents for a part of this journey of relatiomhip, and they have an abliga- tion to do it with integrity and human mpasion.

Dying and Death The concept: of death is developed wer time, as rhe person giows, ~~ various lasses, and r e f l e a on m m e t e and a b a conqts. In gened, humans nuwe from a childhood belief in death as a tempmy s ~ t e , m adult- hood in which death is accepted as very real but h m y @axling, and and older adulthood in which death maybe viewed as more desirable than living with a v r qualitp of life. Table 48.1 d&bes some of the spec& beliefs com- mon. to &&rent age pups. The nurse's ImowIedge of these developmend sages helps in undamnding some of the client's m p o m ~ ~ to a &-threatening s i tuah .

Und-djng responses to death m a dying begin with dxe recognition that dying M d n a E &within a fam- ily system. The nnrse considers the impgct of the dying individnd's illuess on the whole family and famd#s respwses &at affect the patient. Caring for the dying individual's ~~IIY invoIves undmmndhg b d y in the broadest sense. FamiIy may include spouses and clddren, or those the dymg individual defines as a *si@f~cant other" who h c t i o ~ ~ ~ in supportive ways &ring emo- ti4 spiritual, axld socioeconomic companionship and, possrbly, intimate bonds (Gilliss, Him, 8 Robam, 1989).

T A B L E 48.1 Development of the Concept of Death 1

Chapter 48 G r h h g , and Death 13-49

md receive treament that they do not wish. Advance M v a have been suggmed as one way to ad* this problem The Canadian Nurses Assotiation (CNA, f 998b) and otherqmmrs p d d a Joint Stasemmt on Advane . . Drrecnves for n m ' use in practice. Advance directives are "the means used to document and ~mmunica te a p"m5 prefkrences repding libm-g -mat in the event that they become incapable of expressing thaw wishes for r h d " (CNA, 1998b, p. 1). Advance directives are cornmonly"ppessed in two ways: an insnzrc- tion directive, or living d, which h t i f i m what l i b s-g treatment a person wishes in certain situations; or a proxy directive, which explains who is to make healthcare deckions if the person becomes incompetent. A p m directive is often referred to as a power of attor- ney for personal care (CNA, 1998b). A routine part of any admission w a hospital now includes inquiry about the 'client's advance d i r e h s ; if they exist, they are induded as part of the medical directives.

It has become newsary for nurse m be aware of rhe legal sratns of d types of advance h t im in their province or territory. As antlined by the CNA (1998b), some provinces and territories only recognize proxy directive as legally bin-, while othm recognize both proxy and insmcriod directives, In addition, nnrses need to become hrdhr with hws and documents regard- ing a person's competence to consent, issues re&g ~~~diopulmonary resusdtatim (CPR), and issues at the end of life as these are closely related to advance direc- tiva Figwe 48.1).

Healthare profkionaIs, iaJllchng rmrses, are respon- sible for ensuring thar advance dirmives are addresed, nor only as an admission duty, but rather as a part of the ongoing oommunication among alI members providing and care. A s ipibnt part of this proms is to ctixxrss and obtain a m m t of the individual's personal valua This inquirg bighIi&m die person's value sysrem and Wfs about health, well-being, choice, and digniq, ldendktion of the person's dries will enable the nurse m, approach rhe hospid experimce in a more holistic manner.

Euthanasia I '

The act of euthanasia can m e different things co differ- ent people. The word dm& comes from Greek words meaning "gmd death." The term is ofew used synonym m o d y with the ternm 'mercy Inlling," a concept that has drawn much con- over &e yeax. There are two forms of euthanasia: b e aud pahe . These terms are meat to convey the diff'erence between committing an act d m causw death a d omi* to d e a life-sustaining acy ahwing death to ensue,

The issue is an ethid one &at wnaitbs unsettled. It revolves around two fundamenml beliefs: the right of individuaIs to decide tbek own time and means of dpg, and the equally smng argument h a t all measures must

be tried before death is accepred as inmiable. Often, it becomes a matter of 'to weat or not to =eat;"

A legal distinction, however, is made between acting and omhing to act An action deliberately musing the dea& of m & a r person is homicide, whereas omitting treatment when it is futile or refused is not. The with- holding or withdrawing of aeamenm and the pmvkion of compassionate palliative are, even when life is short- ened, is considered ta be good and ethical medical prac- tice(lmq-,&Williams, 1 4 9 3 ) . A ~ o n I x t w e e n the physician and family members ta d&t when marment should be stopped or withdrawn is ethical and amman practice. Patiens and h d y members may requet that a dying individual not be subjected to resus- citative m e a m in the went of death, in which case tbe physician should write udo-not-&tate @NR) order" in the patient's chart.

1ndividuaIs who argue against euthanasia base their reasoning on the principle of s a n d y of life and on the traditional mles and laws pmhibI&tg the dmg of& mmpt m sindons of self-delne or war. Many are also con- cernd for thepotential abuse of d e t y i f e u t h d a w m to become Iegd They see the potential of this law "slip- ping (slippay slope argument) to extend to such o&ers as the chronimllpill, the elderly, and tfie dernenred.

Those individuals who support ~~ Mieve that there are dmtiuns in life where lik is not worth living. They believe that competent individuals &add be given the right to end their I& when it is burdened with physi- cal, emotional, and psychological pain b t is no longer possible to eliminate. These individuals Meve tttat sanc- tity of life is not an absolute principle and mn be ovenid- den out of respect for individual autonomy and for tfie dignity of human J k

Assisted suicide, on the other hand, means helping someone to commit suicide. It differs from euthanasia in &at the person choosing to die mkes the action that directIy muses death, rather than having a second person commit the act The -Psad CU& of&& (CCC) pro- hibits intmhnal killingt regardless of h e person5 con- sent or desires, and this also applies to assisted suicide. Section 14 of the CCC mtes that "no person can consent w have death idlicted on him.n And, according to section 241 of tbe CCC, it is an offence to "aid a pemn to m- rnit suicide, wheher suicide ensues or not."

Do-Not-Resuscitate Orders Technologid h c e s have raised a number of troubling

dilemmas. These dilemmas are compli~ted by the fo%gissues: hdth-mre team Con£b, lmrdvea h- $ h e s , and the shortage o f n m and otfier resoums

Physicians may order *no code" or "do mt readme* @NR) fnr &ts who are in s mge of termid, ~ ~ 1 e illnm or expected d d ADNRorder is gendyw&ten when the client or surrogate has earpressed the wish for no

1350 SECTION 4 Nursing Thempeutics

Personal Directive

1, , of , Alberta, do hereby- 1 4

Appoint , as my Agent; pursuant to the Personal Directives Act of Alberta. If ((she predeceases me or is unavailable or unwilling to act, then I appoint , to be my Aternate Agent. Any Agent appointed by me s h d have MI authoritg to interpret all personal and medical decisions, and

with loved ones, family and friends, I would like the following directions to be followed: 1. Measures of d c i a l life-support, in the above stated situation, that I refuse are:

a, Cardiopulmonary resuscitation and admittance into an intensive care anit. b. Mechanid respiration when I cannot breathe by myself. c. Prolonged gastric tube or intravenous feeding when I an indefinitely unable to eat

through my mouth. d. Antibiotic medication to treat or prevent infection e. Other:

2 .1 request to live my last days at home rather than a hospiral, if my M y agrees. 3. If any of my tissues or organs are healthy and useful. for other people I give permission for

all such donation, or as specified d d g my &: 4. I do wish to have medication mercifully administered to me in order to stop s u f f e ~ g even

though this may shorten remaiaing life,

Dated at in the Province of Alberta, this day of 9 20

W I T W S f S SIGNATURE MAKFXS SIGNATURE

F@um 48.1 Sample advanced directive appointing an agent and stating instrudions

Source: The Alberta Health Ethia Network

Chapter 48 Loss, Grieving, and k a t h

resuscitation in the event of a respiratory or cardiac mest Many physicians are reluctant to write such an order if there is any con£lict between the client and fam- ily members or among M y members. A "supportive care only" order is written ta indicate that the goal of tratmenc is a wmformble, dignified death and that for- her life-sustaining measures are not indiated.

The Canadian Amxiation. of Regis& Nurses (CNA, 1W5) developed a joint policy statement to provide guid- ance for developing policies on the appropriate use of CPR T h e following guiding princip1e.s are integral to the development of the CPR policy

1. Good health care quires open communication, dis- cussion, and sensitivity to c u l d and religious dif- ferences among caregivers, potential recipients of mre, their M y members, and si@-t others.

2. A person must be given &ent idomation about the benefits, risks, and likely outcomes of all meanent options toenablehim or her a, malreinf0nne.d decisions.

3. A competent persan has the right to refuse, or with- draw consent to, any chically indicated PearnrnG including life-saving or life-sustaining treatment. Compaence a n be difficnlt w assas bemuse it is not dways a constant state. A person may be competent to make decisions regardmg some aspem of life but not others; as well, competence can be intermitknc; a per- son may be lucid and oriented at c e m h times of he day and not at ohm. The legal delinition and asses- ment of competence are g0yerne.d by the provinces or territories. Facilities should be aware of the laws (e.g., capacity to consent and age of consent) regarding the assmment and documenmtion of incompetence.

4. When a person is incompetent, treabnent decisions must be based on his ox herwish, if hese are hown. The person's decision may be found in an advance directive or may have been communicated to the physician, orher members of h e health-are team, or orher relevant people. In some jurisdictions, legis- lation specifically address- the issue of decision mak- ing about medid mnnent for incompetent people; tbe legislative requirements should be followed.

5. When an incompetent person's wishes ate not known, treaanent decisions must be based on the person's best interests, taldng the fobwing into account:

i The person's known values and preferences

ii. Mormation received horn those who are slgnifi- cant in the person's life and who could hdp in determining his or her best interests

iii. Aspcts of the person's d m e and religion that would influence a treatment decision

iv. The person's diagnosis and prognaeis

In some jmsdictions, legislation s p d e s who &auld be recognized as des ip@d d d ~ n makers (proxies) for incompetent people; this legislation should be M- lowed TRe term " p e is used broadly m identifg: (1) people who make a treatment decision based on the decision a person wodd have made fbr himself or herself (substitute decision maker), (2) people who help in determining what deciiion w d d be in the person's best interests, and (3) people who, under tenitoriaVprovindal legislation, are deemed an appropriate choice for mmaldng treatment decisions.

6. There is so obligation to o h a person futile or non- bendcial treatment Futile and nonben&cial mat- m a t s are cmmversial concepts when applied to CPk Policy m h should determine how h e concepts should be interpreted in the policy on raw- citation, in light of the facility's mission, the values of the corn* it serves, and ethical and legal devel- opments. For tbe p q a e s of this document and in &e context of r h m t i o n , *futifen and "nonbene6- d" are understood as foUows. In some situations, a physician can determine that a treament is "med- ically" fatile or nonbenefieial became it o h no rea- sonable hope of recovery or improvement or bemuse he person is permanently unable to experience any benefit. In other cases, the utility and benefit of a matmat can only be determined with reference to the person's subjedve judgment abut his or her o v d well-being. As a general I&, a person should be invoived in determining futility in his or her case. In e x c e p t i d c k m s m , such ~ o n s may not be in the person's best interese. If the person is incompetent, rhe prindp1e.s for decision making for incompetent people should be applied.

Health- professlwals s h d d f i e q u d y &sit their policies regarding interventions such as CPR, especially in the con- of a changing socied environment that tee~gnjzes the autonomy of the individnd and encowrap increased public d i s d o n and participation in these issues. Decisions about CPR as an appropriate treatment option should be clearly idenfled on a patient's record to make mxe tbat all tbe inv~lvecl heal&- professionals are aware of rhae decisions (CNh 1995).

Various cultural and religious maditions and practices associated with deatb, dying, and the griming p m m herp people cope with h e experiences. Nurses are often present through the dying p r o m and at the moment of death. Knowledge of the client's religious and dtura l heritage helps nurses provide individualized care to clients and their families, even though they may not par- ticipate in the rituals associated with death.

Dying in solitude is generally unacceptable in mast cultures. h many cultures, people prefer a p a d death at home rather dmn in the hospital. Members of some e t h i c p u p s may request that heal&-e p r o h i d not reveal the prognosis to dying clients. They believe the person's kt days should b~ fie of worry and pin. People in other dtures prefer that a family member (preferably a male in some cultures) be mld the diagnosis sotharthed;entmnbepa&yinformedbyafmdy member in graddsmges or n a b told at all. Nurses also need ta derermine whom to call, and when, nts tlw i q d - ing death draws near,

Beliefs and attitudes abut death, its cause, and the sod also vary among cultures. U& deaths, or death," are sometimes dkthpnshed from "gmd d ~ ~ " Also, the death of a person who has behaved well in He may be considered less dma- based on the belief dmt the p n will be rehamated iaco a pod life.

Belief about preparation of the body, aumpsy, organ donation, cremation, and prolonging life are ctoseZy allied to the permu's rd+ d-, for example, may be prohibited, opposed, w discourapd by Eastern Orthodox religions, Mnslims, Jehovah's Wltnesses, and Orthodox Jm. Some religions prohibit the r e m d of bodypartsanddictarethatdIbodyparrsbe$ivexlappr+ priate burid OPgaa -091 is prohibited by Jehovah's W~messes d M u s h I whereas Buddhists in North America mnsider it an act of mercy and encourage it. C d is discouraged, oppased, or prohibited by the Mormon, Easmn Modox, Islamic, and Jewish faiths. Hindus, in con- prefer cremation and cast the ashes in a holy river* Pmhm of q e is peraIIy encour- aged; however, some religions, such as Christian Sd- ace, are nnlikely to use medid means to prolong life, and the Jewish hith generally opposes prolonging life after irreversible brain h g e In hopeless illness, Bud- dhists may permit euthanasia.

Nurses also need w be knowledgeable about the client's death-r&d iim& sueh as hst rites and admiismtion of Holy Communion, chanting at the bedside, and &r r i d s , su& as specid p d u r e s for washing, dressing, positioning, and shroudmg the dead. For example, c e d n d m may ePish m pra&e their native asm$ in whieh findy members of the same sex wash and prepare the bady for burial and cremati.011. Muslims also rumom- ari fp turn the body toward Mecca. Nurses need to ask b d y m e m b a h t their preference and wrify who wilf carry out hese activities. B u d cloths and ather d- tuPal or religious items are often impowt symhals for the funemt For example, Edithfal Mormons are often dresssd in their "temple clothes." Some Natme Am- may be dressed in elaborate apparel and jewdery and wrapped in new biders with money. T h e nurse must ensure that any ritual items present in the health-are a g e n ~ h ~ t 0 t h e ~ o r t o t h e f u a e r ; t l home.

an e W simh that they mnst w h e intention is m protect the dying ties d t fox the b i l y and the nm-se. patients do not have the opportunity w openEg and to freely errpress their feelings,

smw that the indormation given may not be Feeling Eke their trust bas been undermined, Eb not to voice what they are sensing, and rhus, mmmmu tion becomes men more dBcult

W1th m u d pretense, the dying individual,

raise the subject. Sometim~, the dying individual

Chapter 48 h. Grieving, and Death 1353

Loss of Muscle Tone r laxa ah^ of the facial rnusdes (eg., the jaw mays@ M Difficulty spaking B Drfficulty swallowing and gradual toss ofthe gag reflex m k a w d activity of the gastrointestinal tract, with

subsequent nausea, accumulation of flatus, abdom- inal distentian, md retention of feces, qecid!y if narcotics or tranquilizers are king administered

m Possible urinary and mctal incontinence due to deaead sphincter mntrd / m Diminished body movement

SIowtng of the CIrculatFon m Diminished sewlion

Motding arid cyanosjs of the extremities R Cold skin, first in the feet and later in the hands,

ears, and nose ( ~ e client, however, may feel warm because of elevated W y temperature) Decelerated and weaker pulse b x e d b l d pressure

Changes i n Respirations a Rapid, shallow, irregular, or abnormally slow respi-

rations; Chqne-Stokes respiratians; noisy breathing, referred to ag the d m h rattk, due to coltection of mucus in the throat; mouth breathing, which leads to dry oral mucous rrtembranes

I Sensory Impairment r Blurred vision

/ rn Impair4 senre of taste and m11

I even if they are not directly informed. Qrhm believe &at maay clients remain unaware af their condition until the

I ~ftis~cuI~hmer,mtodistingcIlshwhatclientsknow horn what &yare wdkg to accept.

I Nursing mre and support for the dying client and fm- ily indude making an accrurape assessment of,& phpsi~e logid s i p of approachkg death. ln addition to sips related to the client's s p d o disease, c d other phys- ical signs are indicative of impending death. TIE four dlain cham-stic changes are loss of muscle tone, sfow- ltlg ofthe dmhtion, changes in msphtim,md impairment. See the box abwe for indica tiow of impend- ing: cliaical death.

Various c~fl~ciausness I& rxcnr jmx before death. Some dimes are dm, &XW others BZ% drowsy, sm- porous, or comatose. Hearing is thought. to be the last sense that is lost.

f \ ASSESSMENT GUIDELINES

I

Ask the spouse, partner, or significant others: Have you m r k e n dose to someone who was dy'mg? What have you been told h u t what may happen when death occurs?

m Do you have questions a b u t what may happen at the time of death? Do you have questiom about how we are caring for during these last days2

r Howdo you think you wouldlike tosay goodbye? How are you taking care of y~urself during these times? Who can you turn to far help atthis time?

r Is there anyone you would like us to contact now or when death occurs!

1

As d d apprag&esD the nurse assists the M y and other siwcant people to prepare t h d e s . Depend- hg, in part, - hadedge of the person's state of m- ness, the nurse ash questions that help identifg ways the a m can provide support during the period before and afcerdearh.hpartlcular,&enursene&toh~w~t~ h d y expects to happen when the p m n dies so accurate inhnnation can be given at the appropriate dep& See &e buxabm for sample interview questions. When the Eam- ify members h o w what w expect, they are better able to support the dying person and others who are grieving. .In addition, thqT may be able to make c d decisions about m t s surrounding the death, such as whether they will want to view the body a h death

P b n k g a P e m j W w Major d& of dyhg in&- v idds are (I) maintaining physiological and pqdioIngi- d con&* and (2) a c h i d g a dipifid and peaceful dead^, which indudes maintaining personal control and accept- ing d d k i n g heal& stam. When planning a r e with these clients, the qring Person's Bill dRi&ts can be a useful guide (see the next boxj,

Emmples ofspecific desired outcomes, dthough esbb- liahed in the planning phase, are provided h Table 48.4 entitled "Goals in Fostering a Feaaful Death" later in this chapter.

FmmpTes of nursing interpentions for the dying hdi- ddual include the following:

Hdping individuals die with dignity Meeting physioIogid needs

r Providing spiritual support

8 Providing pmmortem care

The Dvinct Person's Bii l of Riqhts I f

4 I have the right to be treated as a living human being until 1 die. I have the right to maintain a sense of hopefulness, however changing its focus may be. I have the right to be 4. for by those who can maintain a sense of hopefulness, however changing this might be. I have the right to express my feelings and emotions about my approaching death in my own way. I have the right to participate in decisions concerning my we. I have the right to expect continuing medical and nursing attention even thou$ "cure" goals must be changed to "comfort" goals. I have the right not to die alone. 1 have the right ta be free from pain. 1 have the right to have my questions answered hen* 1 haw the right not to be deceived. I have the ri$t to have help from and for my family in accepting my death. I have the right to die in peace and dignity. I have the right to retain my individuality and not be judged for my decisions which may be mtrary to beliefs d others. I Rave the right to discus and enlarge my retigious andlor spiritual experiences, whatever these may mean to athers. t haw the right to expect that the sanctity of the 4uman body will be respected after death.

I , have the right to be cared for by caring, sensitive, knowledgeable people who will attempt to under- stand my needs and will be able to gain some atisfaction in helping me faae my death.

mm: Barbus, A. I. (1975, ianuary). The dying perm's UII d~lghts, 3 1975, Amerimn journal of Nwsin# Curnpany. Reprinted R& permision ftMn the Mean I w m d olNu- 75,W.

A major hctor in detsxeminbng whether a won will die in a health-are fa* or at home is the amihbiicy of willing ad able aregives If the dyhg p a n wish@ to b at home, and b d y or others provide cad to main* sympt01pl control, tbe nurse should fadirate a referral w hospice d c e s . H q k e d a n d nurses wdl then conduct a full assessment of the home and care providers' ddls.

The major nwsing "ponsibiliv for &en& who axe dying is to assist the individual to a p a d death. More spec& responsibditi~ are the followhg

n To provide relief fmm lomhess, fear, and deptdiii

m To main& the client% sense of sanity, &a_ dence, dignitp, and self-worth To mainmin hope To help the client accept losses

To provide physical %mfort 1 P~ople Fdcing death need help facing the fact that

will have to depend on others. Some d p g &am re only mhhdcamand can be cared forwhome, Peed continnous amtian &the mvkes ofa bospi its staff. People need hJp, well in Advance of ning for the period of dependen-. Thay ne what wiU happen and how and where they WC,

Dignity may be defmed as &e Scant and integrated person. within. cen4 '1~1 dependence trol over oneself and inremaims with the are h a t e d with loss of digniy Nmes n that the dent is mted with dignity, that is* and r€!Sp%t. Dging ~Iients often feel tbey have lost crver their lives sad aver lifu: itself. By inducing mailable to, the client and s igdant others, restore and support EeeTings of control- Some cboi individuals mn make are the loation of are (e-g tal, home, or hospice), dmes ofappointmenc~ wi carre~pmfasionds, activity dednte, use of h tesourm, and of visits fromrelatiP.m and

w a a m k a b l e t o ~ ~ e e v m t s ~ d e a ? h s o can die pacefully Numacan helpindivichdsm h d ing and completeness and to detmnine. their m p h &ol@al, and social priorities. Dping peuple es.ofct@ strive for s e l f - a m p mare rhan for seIf-pre~don,~ md they need to find maningin contihuing to live whitk! s&dng, Part of the nmet challenge, rhen, is to help nuinah, day rn day, the client's will and hope. I

Often ,nurseshd i fE~ty~g&thwi tbc l i en& w h ~ a r e d y m g ~ ~ ~ i t i s m t u d f o r p e q d e m ~ ~ h b k d i s d g death, steps cap be taken w make m&: ~ ~ l s e a s i e r f o r h o t h t h e m r r s ~ a n d t h e ~ e n f . ~ (1994) lists he. fallowing mtegies:

m Idetitlfy personal feelings about death and how rhey may influence interactions with dents. Adamledge persod km a b u t dearh, axld dbms them with a friend or colleague.

Focus on the &ti needs. The client's fears and W e & map be di£fkent bum the nurse's. It is imp~r- tant that the nurse avoid imposing pwmd fears belid on the client or family.

Chapter 48 La=. Grieving. and Death 1355

r Understand the client and how the client copes. Talk ta the cIient or the W y about how the client usu- ally copes with stms. Clients will use their usual cop- ing strategies for dealing with impending death. For example, if they are usually quier and reflective, they will become quieter and more withdrawn when facing terminal illness.

[ r Establish a communiation relationship that shows I concern for and commitment to the client. Commu- I nication smregies that let the client h o w you are

available to d k about death include & following: a. Describe what you sea, for example, "Ym seem

sad. Would you lib to talk about what's happening to you?"

b. Chi* your concern, for example, "I'd like to know b e a r how yon feel and how I may help youH

c. Admowledge the client's struggle, for example, "It must be di6cult to feel so mmfomble. I a r e about you and would like to help you be more MmfOrmble?

d. Provide a caring touch. Holding the client's hand or offering a comforting massage can encourage the client to verbalize feelings.

Determine what the client knows about the illness and prognosis.

r Respond with honesty and direcmw to rhe client's questions about death.

w Make time to be available to the dent to provide support, Iism, and respond.

Hospice or palliatip.e care has emerged as a specialized field only wichin the past 30 years millings, 1998). The term hospice has sometimes been used interchangeably with the term paZLiativc care, but more recently, the terms have come to have different meanings (Vachon, 2001). In the

United Kingdom, a hospice is a building where dying pmom are cared for, bur many of these individuals are discharged home and followed up by home care pro- grams. In the United Smtes, the term refers to a s p d c programmatic model for delivering palliative care. h Canada, hmpices are o h community-based, volunteer- driven program providing care in the home or in a free- smnding hospice (Vachon, 2001).

Regardless of lacation or type af program, bee care is based on the principles of providing care to improve h e dying individual's q d t y of life, rather than ah for m e . The care is patient and family centred, focusing on needs and concerns that are most important to them. A hallmark of palliativehospice care since C i d y Saunders founded the modern hospice movement has been the combination of scient5c rigour with personal concern. By opening the St. Christopher's Hospice, Saunders developed an education program for palliative care whicb embraced three broad areas: (1) the science and tech- niques of pain management and symptom conml, (2) hmledge of psychosocial, d, and spiritual aspects of dying and grieving; (3) self-knowledge on ehe part of caregivers, especially related ro persod befiefs about death and loss (Barnard, Boston, Towers, & Lambriaidou, 2000). Hospidpalliative mre is always provided by a rndtidisciphry team of primarily physicians, nurses, social workers, and chap&.

The physmlogid needs of people who are dying are related to a slowing of body processes and to homeosmtic imM- anca. Interventions include providing personal hygiene measures; controlling pain; relieving respkto ry diff~cul- ties; assisting with movement, numition, hydration, and elimination; and pmviding measures related to sensory changes. See also Table 482.

mure 48.2 The patient/family are the "unit of care" in mure 48.3 Hospice care is based on the principles of hospice palliative care providing care to improve the dying individual's quality of life

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Chapter 48 Lofls, Grieving, d Death 1357

individualid pain assessment is the k t snep to ensuing heline data k d continued treammt resulting in an improved quality of life for the dying individual.

Once the individual's pain has been assessed, a choice of analgesic medication w mnml the pain is selected (opioid or nonopioid analgesics). The World Health Organiation (1990) recommends rhe use of an analgesic ladder to assist with andgesic selection. With chronic pain, analgesics are g e n d y mast effective if adminis- tered regularly {or around the clock) mther rhm on an as- needed basis. Frequently, when patients receive a regular

dose of medication, pain may "break through" and require additional dose to keep it d e r cmml. Oproid or can- d l e d narcotic substances are used for managing mder- ate to severe pain. For primarily historid reasons, mor- phine is the strong opidd of choice. Nonopioid medications are commonly used to ease pain and lower fwer. They are generally used for managingmild to mod- erate pain. Medications for pain management are not limited to analgesics. Medications an include torticos- teroids, antideprmam, anticanvalsants, and a n x i o ~ c s , determined by the type of pain a s x s d . Other than med-

SECTION 4 Nursing Therapeutics

icatians for the contxol of pain, there are therapeutic . comfort measures performed by the nurse, such as help- ing the patient relax, providing music, g i h g warm soothing baths or a massage, providmg distra&an, and using peripherd nerve stimulators. (See Chapter 45.) T h e presence of the nurse to mensure support, conversa- tion, and genuine concern is most important and assists in the process of reducing pain and promoting comfort.

Shomess of breath (dyspea) is an uncomfortable aware- ness of breathing. Like +, d w e a is a subjective sensa- tion involving bath the perception of breathlessness and the individual's reaction to it The prevalence of dyspnea varies according to the disease. Approximately 50 percent of the general outpatient: cancer population experiences some breathlessness, with this number rising to 45 to 70 percent in the terminal phase of the disease (Dudgeon, fistjanson, Sloan, & Leman, 1999; Fainsinger, MacEachm, Hamon, Miller, & Bruera, 1991).

Dyspnea, like pain, is rnultdhemional in nature, with not only physical spproms but also affective components which are shaped by an individual's past experience with dyxpnea. DyPpnea, liLe pain, m y not always be evident to the o k r a The nurse should rnquiTe s p & d y abut shomss of breath. Occasiody, dying individuals may have phpid signs of bchypnea and appear to be in dis- tress; h o w m y &ey may not feel m e i c or distressed. The opposite may also occur where individuals who are not tachypneic or in apparent respiratory dist~ess may describe feeling very short of breath. The extent of breath- lmnes6 experienced by a patient m y or may not be related KO the oxygen saturation l e d . Therefore, d x patient's own assmment of I d of dyspnea may fie n more reliable indi- cator than the oxygen saturation level. Dppnea k, &thus, a symptom that needs to be reported by the dying individual.

The nurse provides many comfort measures to help relieve, decrease the perception of, and comfort the expe- rience of dyspnca, including (I) the administration of medications, such as opioids, bronchodilators, and diuretics, (2) creating a therapeutic mvironment where the individual engages in distraction theraw, relaxation exercises, is dowed to rat , or be wi& family, (3) assisting the individual to a position that makes breathing easier (usually a high sitting position is kt), and offering a fan to reduce the perception of breacbI.essnw, (4) o&ring fluids and using a humidifier ro loosen mucus so cough- ing is easier, and (53 administering oxygen therapy by mask or nasal cannula. If hypoxic, maintain oxygen satn- ration above 90 percent The nurse h to be cautious in offering oxygen to a patient with chronic obsmcdve pul- monary disease (COPD); in these individuals, oxygen sat- uration should be kept around 90 percent or as ordered by the physician ( ike i ra & Bnrera, 1999). It is important that

the nurse o& these interventions early in of dyspnea m reduce anxiety and improve

The importance of teaching the dying family cannot be overlooked. S acute experience of dyspnea inclu smctured relaxation techniques, (2) of an impending exacerbation, (3) techniques to co- energy and prioritize activities, and the effectivena of taking medications, spacer with inhaLed drugs and taldng an additional dosem the medications prior to activity, as ordered.

valued dimension of d~ journey of dying hr indiviw and their W e s . Spiritual distress or 'soul pain" is a W mon experience in b e who are dying and, sometimes, s& experience rhat is not addressed or understood. The riences are complex, varied, and individual, and if I@ u n a d d r d , they may sti& the opportunity for heighten dw loss of a sense of meaning and purpm, aqd I

con mi^ ro poorly controlled symptom @fh, 2002). Often, h e experience of sufFering prompts peogde,

whether or not they see hemselves to be religious, to ask deeply spiritual quesrions and turn to God or a a $ d guide for solace. Even in the case of those who are avowee religious, dhmg can lead ro questioning of ftlndmnmd M e & (Anderson, 1989). To appreciak individual " p o n s to di%ngI it is imperative thacthe nurse a m p t w under- d the dgioudspiritual views of the &era

T h e c o ~ i a n a t e nurse, in a relationshrp with dying individuals who are suffering, cmtes space and time iri which the nurse considers the dying indipidids expmr a

sion of spirituality, The nurse embraces the experience of the dymg individual's loneliness, anxiety, the need to incorporate a transcendent dimension into om's life (hi& or religion), the need far mhtedness, andlor the need to search for meaning in suffering @a&, 2002). For m q nurses, this begins with a self-exp10ration of spiridtp that may or map not reveal an inner strength related td a

I I

belief in and a sense of inrercomectedness with a grater being. Such an expIomtion brings the nurse hce to face with e-xistentiaI questions, such as the inevitab* and Wty of death. Persod expIorarion o h leads m a spiritual search for &th and/or other religious ~ C B S

Or questions ( R a f h , 2002). Spirituditp delves into the n a m of humanity and the

deep mysteries of life. Spirituality, as rebated to nurses ia a relationship with dying individuals, encompasses duw, meaning, and purpose; turning inward to the hamaa traits of honesty, Iwe, caring1 wisdom, and wmpassicm; helping others to search for a higher authority, @dmg spirit, or transcendence that is mystical; and helping cre- ate healing of body, mind, arld spirit &at may or may not

inv01ve =@zed religion. Nurses, in helping others 6nd their expression of spirituality, allow for an open inter- pretation of what h e individd considers to be divine or a transcendent Other.

Nwes have a responsibility to not impose their own religions or spiritual beliefs on a dient hut to respond to the client in relation to the client's own background and nieds. Openness and hones y are most impartant in hdp- ing the dent articulate needs and in developing a sense of caring and trust.

Specific interventions may include Glimting expres- sions of feeling, prayer, meditation, reading, and discus- sion with appropriate clergy or a spiritual adviser. It is important for nurses to establish an effective inper&- plinary relationship with spiritual support specialists. For a W e r discussion of spiritual issues, see Chapter 13. Death-dad beliefs and practices of selected groups are discussed earlier in this chapter.

At no rime is the family more impcrxmt than during the times of death and dying, Nurses have an obligation to not only include h e family in the mre of the client but aIso w honour their wisdom, their befiefs, their wishes, and their needs. Jn this act of honouring, iic is important to meet farnilia at the point of their needs, rather than have set and unbending expecmtions of how family members will react to and inmlve thmsdues during the profound and difficult experience of watching a loved one die.

The most important thing a nurse can do to care foI farixily members is to achowledge them and include them. If the nurse shifts her t)linking h m considering the d p g individd as rhe client m accepting the entire family as the dent, then a r e becomas focused on the very sipifimnt went that is happening not just to the person but to the entire family system. Acknowledging family members incIudes consulting the family in terms of care of dent and honouring their wisdom and knowl- edge of the dying individual. h involves a collaborative evolution of ways in wbicb rhe family needs to be involved and ways in whith hey prefer the nurse to a m e care. For &ample, some &rrdy members want to be involved in physical care, whereas other family mem- bers are more comfortable with the nurse assuming these caring practices. It is importan& in asking the Edmily members' preferences, to nor imply that the nurse has an expectation rhat they assume these acts, but rather that the nurse respects the members' IeveI of comfort. One way to approach this delicate emblishment of roles and involvement would be to say to the family: "Sometimes family members like ta be involved in the physical are of their ill members, other times they prefer the nurse M asswne these things. What would be most comfomb1e for you in this area?" At times, family members want

Chapter 48 Loss, GriwiaI?, and D a t h

other kinds of invoIvemenr, rather than physical care, but are m e of how to offer this. The nurse mn help guide family members in bowing that it may be soothing to dymg individuals to speak ro them, read to them, hold their hands, or simply be presmt.

A part of what a nurse offers a family is a caring and compassionate presence. Compassion is defmed as "suf- fering with." Though the nurse b not suffering as the family is, the nurse has in some ways entered the world of the family's suffering. entering the world of the one who is sdering, we do have to open space to where we Iisten to the pain, where we see, tweh, and &el ohe pain" (Moules, 1999). Nurses &te a context where family mem- bers feel as dmugh hey can be open about tbeir pain, d- &ring, and grief. Nurses can offer information about the process of what is occurring and thereby walk dongside the family in undersmding this exprience.

When the individual dies, family members should be invited to spend time with the body as this important rit- uaI can serve as a significant event in malring room for grief and grieving. Some people ask for mementos, such as locks of hair or other bodily reminders. Children should not be b u r a g e d from being involved in this impomt r i d of viewing the body, and at times, nurses may offer mmuPagement or wen permission to W e s rhat it is appropriate to incIude children F e members may have specific desires to participate in some atre of the body, as in the case of a mother who asked to babe her child one last time and dress him in special clothes. The nurse, in Ehis instance, helped prepare clan towels and a basin far the mother, showing sensitivity in com- menting that rhe water needed to be warmer, and then remming with warm water, The mother later reported that this simple act of kindness was of great comfort to her. In a health-care system that is often pushed for beds, the nurse may, at kes, need to act as an advocate for W e s to ensure that &ey have all the b e they need to spend with the body to begin saying goodbye tu the phys- iml presence ofthis person in their lives.

hs&mrtQm care Rigor r n h is the stiEming of the body that occurs abut two to four hours after deatk It results from a lack of a d e n h e niphasphate (Am, which is not sgnthsized because of a lack of glycogen in the body. ATP is n e w - sary for muscle fibre relaxation. Its lack causes the mus- cles to contract, wllich, in torn, immobjhs the joinis. R i p mortis s m in the invoIuntary muscles fieq bladder, and so on), then progresses to the head, neck, and and 6naliy reaches the extremities.

Because the deceased persank b d y often wan^ to view the body and because it is i m p o m t that the deceased appear natural and comfombIe, nurses need to position the body, pIace dentures in the rnouh, and close rhe eyes

SECTION 4 Nursing Therapeutics

and mouth bg%r rigor mortis se& in. Kgor morris mu- ally leaves the body about 95 how after death.

AIgm r n d is the gradual detreax of the My's tem- pera- after death. When blood circulation emb bates andtheh~aIamusceasestofunction, bodytempture falls about 1°C per how until it xeaches room temperature. Simultaneously, the din loses its Wdtp and an as* be broken when removing and adhesive tape+

After blood-circulation has ceased, the red blood cells break down, releasing hemog10bin, which discolours h e m m d i n g tka.This cliscolmtion, r e M to* Imor m o d , appears in the lowermost or dependent areas of the body.

Tissues aker death become soft and w a u l $ lique- fied by bactwial fermentation. The hotter the t e m p - ture, rhe more rapid the change. Thedore, hdies are often smred in cool places to delay this process. Embalm- ing prevents the process through injection of chemicals into the body to desaoy the bacteria.

Nursing personnel may be rsponsible for care of a l d y after death. P o s t n o m em should be d e d out accord- ing to the policy of the hospital or a m . Because care of the body may be iduenmd by religious law, the nurse should check the client's religion and make every attempt to comply. If the deceased's family or friends wish to view rhe body, i t is im-t to make the environment as clean and pleasant as possible and to make the body a p p a natural and mmhmble. AU equipment, soiled linen, and sup- plies should he removed from che bedside. Some agencies require that all tubes in the body remain in place; in o h

agencies, tubes may be cut to within 2.5 an of the skin and: taped in place; in others, all tubes may be removed. Legd issues surmuading &e death (e-g., coroner's a) m y necessimce that all tubes remain in place.

Normally, the body is placed in a supine position with the arms either at &e sides, palms down, or across the abdomen. One pilIow is placed under the head and shod- ders to prevent blood b m disco~ouring the face by set- tling in it. The eyelids are closed and held in place for a few seconds so they remain clased. Denrures are usualI7 inserted ro help give the hce a n a m l appearance. Th-e month is d-m c l o d .

Sailed areas of the body are washed; however, a corn$- bach is not necessary became the body wilI be washed by the mortician (also referred to as an undertaker), a per- son trained in care ofthe dead Absorbent pads are phced under the buttocks to take up any feces and urine released bemuse of rdaxation of the sphincter muscles. A Jean gown is placed on the client, and rhe hair is brushed and combed. The top bed linem are adjusted neatly to cover the client to the shoulders. Soft lighting and chairs are provided for the family,

In the hospital, after the h d y has been viewed by the family, additional idensation tags are applied. The body is wrapped in a shroud, a large piece of plastic or comn macerial used to endose a body after death. Identification is then applied to the out$de of the shroud. The body is taken to the morgue if arrsngemen~ have not been made to have a mortician pick it up h m the cIient's room.

Mrs. Govinda was a 75-year-old female who was admit- 1 . From the data provided, demibe the phase of kl to the hospital a h repeat& episodes d pneumonia. kraavement being experienced by each of the Despite aggressive antibiotic therapy, Mrs. Covinda's con- three sons. dltion rapidly deteriorated and she died unexpectedly 2 . what factors may have how ofthe one week after being admitted to the hospital. Mrs. brothers reacted to the death of their mother? Covinda's oldest son, who lived nearby and frequently

ja What phrical might cared for his mother, made arrangements for the funeral and v i s i i with relatives. He misses his mother and cries indicated that Mrs. Govinda was dying even though

occasionally, but he managed to return to wark the fol- her death was unexpected?

lowing week. The youngest son had difficulty attending 4. What is the primary factor consider when trying the funeral, has been unable to sleep or eat, cannot can- to make the deckim to administer or withhold pain centrare at work, and cannot believe that his mother is medication when a client is dying? dead. The middle son did not weep at the funeral and 5. Explore your own feelings about death, and con- had little to say to his brothers or @her refatives. He sider how those feeling may affect the care you returned home to another province and has remained provide to the dying client. distant He is back at work but feels very fatigued and apathetic. Sze Appendix A for an- to these questions.

n J

Chapter 48 Loss, Griewhg, and Death 1361

Evah&mg &e l h c a s of& To evaluate the achieve- ment of client @, the nurse collects data in accordance with ibe desired outcomes established in the phmmg phase. Eduatiwn activities map indude the foUowing:

L i g to the client's repom of feeling in conmol of the environment surrounding death, such a con- mol aver pain relief, visitation of hmily and support people, or treatment plans Observing &e dien&&tionship wih sig&caut others

r Listening t~ the client's thoughts and feeling related to hopelessness or p e r l a m e s s

lkmp1es of desired o u ~ ~ are shawn in Table 48.4.

TABLE 48.4 GoalsInFosteringa Peaeaful Death - 7

CMIII~B UI wes~neu uumurna

Maintain personal Identifies areas of personal control over control present situation Partici pat6 in self-care activities

in accordance with health status

Makes choices related to care and beatment Expresses sense of control aver the present situation

Maintain comfort Maintains physiological comfort Maintains psychological comfort Skin and oral tissues hydrated Absence of constipation or urinary retention Absence of restlessness

Accept declining Shares values and personal health status meaning of life

Verbalizes acceptance of situation

Accepts limitations and seeks help, as needed

CHAPTER. HIGHLIGHTS

r Nurm help clienm deal with all kinds of losses, inclnd- a Caring for the dying and the bereaved is one of the ing loss of body image, loss of a loved one, loss of a nurse's most complex and challenging mponslbilities. sense ofwell-being, and loss of a job. Nurses' attitudes about da& and dying directly

n IA)BS, especially loss of a loved ane or a valued body &ct their ability to provide m e . p w be vim& as e i h a dtuati6d or a d d - . ~~~m must &der the my req-g apmend Ioss and dther an a d or a perceived loss a r e in simatians involving loss, q e c d y death, (both of which a n be beticipawry).

m Nurses must be howldpble a h t their mpomibili- Grieving is a normal, subjective emotional respome ties in regard rn lqpl issues s u m d i n g death: advance to loss; it is wential for mental and physical health. d h d v a , euthanasia, and do-not-resuscitate orders. Grieving allows the b e d person to cope wi& loss gradually and to accept it as part of reality. Dying clients require open &cation, physid

help, and emotional and spiritual support to enswe a m Knowledge of different s t a p or phases of grieving pea&& and dignified deach. They need to mainmh a

and factors that influence the lass reaction can help the ,- of-1 in -E a nurse undersand the responsm and needs of clients.

r How an individual deals with loss is closely related to & individual's smge of dwelopment, personal resources, and s d support sps-

I

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Parageon, K, Bt Hailey, B. (1999). Barrim to efk&e cancer pain mmagement. A review of the literamre. J& o f P h m d S p p & m k g m m t , 18,358-360.

Pukes, C. M (1988). Research: Baewement. C h g x : m a f D d m d D y i g , 18,365-377-

Perry, B. (1998). M m e m ht tt: I- pfcxmpby d g cme. Ottawa: Cmadian Nurses Association.

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R a % h S. (2 002). Ammpazyhg tbe dyhg: Nbw mate a tlormrl ~ L U C ~ ~ ~ . Unpublished d w m d &mation, Uni- versity of Alberm, Edmonton, Afberta, Canada.

Randa, T. A. (1%). G-iCJ; t$h& 8 R d M . Champaign, IL.: Rmwch.

Reese, C. D. (1996$, Please cry wi& me: Six ways to grieve. N m i q 96,26, 56.

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Sabarino, C. 0. (1993, Januaiy/Febnmy). Surely the wizard will help us, Toto? Implementing ~ I C Rtient %If-Determi- nation Act. h h i q g s Cefftff Repwt, 23,12-16.

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SECTION 4 Nursing Thempeutics

Vachon, M. (2001). The n-5 role: The world of pahuve care. In B. FerreU & N. Gyle (Eds.), T&ok Ofpdhtk mcPsiPag (pp. 647462). New Yak Oxford University Press.

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Wood, L. C., & DelPap, L. A. (19%). Nutset' attitudes, ethi- ml reasons, and howledge of the law concerning advance directives. Ipmpge::JOsaffsJ of Nwskg S c h b i p , 28,371.

Worden, J.W. (1991). Griflcomsehg d g v i ~ t b ~ a p u : A b book+ rke pnentizl b& w h e t : New Yo& Springer.

World Health Organizstion. (1990). Cmcwpai relief r m d p k i W e m, Report of a WHO expert committee. Geneva,: Switzerland: WHO Technical Series #804.

m c e s bt fmdik mdm thw~m (pp. 6 1-75). New Yo* Guilford Press.

-1 Wrighb L. M. (1997). S&@ and spkitualiv The sod of &-

i d work with € d i e s . 3 d ofF@ N&g 39( I), 3-14. Wright, L. M. (1999). Spirituality, &g, and belie&: The

sod of haling wirh families. In E Walsh (Ed.), S p ~ d

Wright, L. m, Wa~on, W. L, & Bell, J. M (1996). Bek'&: lh bem ofbtding im@iliu a d ihm. New York Basic B&

Caregiver Network Inc. http://wwmcaregiver,on,c~:80/~ndex Caregiver Network Inc. (0, the first of its kind in Csnsda, is a resource created to help -givers of the elderly and ill, The god of the network is to make caregivers' lives easier by prodding information on the Internet and in a d e t t e r (see CNI Services); education through the 13-pan T V M e o series "Caregiving with June Callwood"; rhe Canadian Aging and Caregiving Resource Guide; and personal assisace and support through seminar series, Care h g e m e n t Codring Servioe, the Caregiver Club, and Care Across the Border.

The Canadian Hospice Palliative Care Asmiation http://www.cpca.net/abo~tls/m~s~on-mmenLhm The Canadian Hospce Palliative Care hdat im (CHPCA) is tbe national assuchtion providing leadership in haspid palliative a r e in Canada. CHPCA will &ive to achieve its d o n &rough collaboration and represenration, increased awareness, knowledge and slrilh related to hospice paIlEative a r e of h e public, health- providers and volunteerq development. of natiod smdards of pracdce for hos@ce &tive care in Canada; support of research on hospice palliative are; advocacy for i m p m d hospice pahative a r e policy, resource doation, and supports for caregivers towards the pnrsait of excellence in are Fox persons approaching death so that the burdens of &king, loneliness and grief are lesswed.

The University of Ottawa Ins6ture of Palliative Care I

http://www.paUcamo~english.Mm The University of Omwa Insumre of Palliative Care 1 o p x d in 1993. The pioneers of palliative care dweIopme& in Ottawa anticipated a growing burden of so-g ''

caused by such diseases as cancer and A I D S in the National Capial Region, and they had the foresight to' ,1 '

d l for the creation of Canada5 first universitp institurn for research and A r i o n in palliative care. Since its opening, dw institute bas &red increased access to informadon and services in pdiative a r e to patiendclients and hcalch-care prokssionals.

The Hospice h a t i o n of Ontario Life-Line h~://www.hospice1ifeIine.eom The Hospice Association af Onaria Life-Line provideg information abut a wide range of haspic%p&dve a~ services and such resources as hospicdplIiath mrc progmms, hospicdpalliative care units, community-bsd services, pain and symptom management, bereavement support semhs, md pdiative cme edumion.

1 1

b t e r 48 Loss, Cfdeving, and Death 1365

L Ca n adi a n Case S t u How Does Jackie View Her Role as a Registered ff urse?

e t l x whiie worlurrg on a busy surg$cakflmr during the Jackie felt that some d the staff believed that the 3:15 pm @ I? :l.5 pm shift, iackie, an FP1, expmd'the morale, on the unit was.hw+ and what they felt was vi& hat the taEi0 of registered h u m to patients was +mic and rdedive of health care downsiiing inadquati?..% Jackie's unit there were48 beds divided across the country, Some staff even talked of strike i m three Mom, with-1 6 pidienbpr mch. Four reljs- adon. Their hesitancy in adingrested, in pat, u p n &red nu- and thr& licensed paSeal nu= were their befief that their acrions may place patients at fisk wqrhng that evening. Wfhin the first three hours of the b u s e resources wou Id be wrce ( M u k, Fibson, shift, two new admissiw mid on the fimr its well as & 19991. They did realize that the adrniniskd~n three patients who returned hrnzhe room. might well have a srike contingency plan in place, Jackie hit that nursEng o r e was cornpromid. !%e felt lackie recognized that 'drninistmtion was making that the p m of &re cornplm a d acutely$ *& &rtr to errlpbwer the nurses on the unit Possible in a hospital setting quit& M i n g e r and empowering activities Sndded participating in o r p i t a Sabiwn (2000) haw s u w ' f h d massive ddwnsiiing tionat committees, wcy task forces, and devel~pmnt in the Canadian health-& SFrn'has mated a sense pmgarns; and f e i n g relationships outside om's of dbrnpwament attd :d among nu-. immediate work area (Laschinger & S a b i n , 2000).

Mr. R was-one cdjackie's patients, She had firsh mred far Mc R when &-was admitted diredy post surgery~o QU EST10 NS h e ,unit two d a ~ d i e L He had explorat~r~ suwv W I? remove a la& abdominai mass. The surgery had proven to be of no Gnefit because of t h i bition of the mass arfd its interre1a~hip with KMnl of the abdomiml

2* .- amlqpe o w $ . His pWmb was poor. He was extremely uncomfarfable despite$eing.rnedirzatad. To complicate ta the awe of.&. Rr hb recovery, it was felt that he had experienced a small 3. -&& .1 w ~ W hear& a&ck on the operating room table. He was contin- 4. ' W d h m b d f m ~ M n g ually-amptin to d-rsconnect h i m d from his inma- f' 5; Wbt , ~ - M & & I I . , ~ E~8&~Wtsiii'h"h' X18 &U venom line an oxygen.

Qri the day shift, staff had m i n e d Mr. R's hands. a nu=' Wke$

iadcie felt that he was probably feeling helpless and frighwned. He kept k n g to be put out of his misery, but morally the sbff could do nWng. He said to Jackie, "just let me go, it is my time."The resident had s p n h to the family and had written the order "Do not k u x i - mteH on the chart. jackie would have liked to spend rn* time with him m that she could untie his hands but she was tm b u y His wife e x p d m n w n that maybe surgw had not been the right decision for her husbandand wondered if it was yo& the effort. She said to Jackie, 'Rrhaps he would have lived longer if he did n& b e thewrger# He certainly would noi: be in ihe misery that he is now." Jade felt fmtmed and had wondered the same thing; and w a riot sure what tomsay Mr. R's wife.

VIDEO RESOURCES: Series Tde: The National Segment Tte: Patient No More Telewt Date: May 3,1999 Running Time: 1 1:53 Series Tide: The Health Show Segment Title: Informed Consent Show Number: 85 Telecast Date: February 15, 1996 Running Time: 7:41 Series Tde: The Hedth Show Segment Tde: Palli&*w Care (Dying at Home] h o w Number: 130 Telecast Date: Ma& 19,1997 Running lime: 8:49

FMhuk, C., C i b n , FX, P B&, W. (1999)- Strike canti ncy p!anning. 7he W i a n NumI 95(1), 33-97; H9rdlnpham L OODl). Eihbb the N u a s a x n h m d ronuu: ~ a o n s I* tht Winnipeg inquest A h t a mI 3713,22-23,26; Wjnger, H. K S., & Sab$ton, J, A. (20W. Staff nurse e m p o w & and wrtqdace MWours. T k Chadian Nuw, a(2),18-22.