Stages of grief experienced by relatives of the deceased. Loss, death, grief, palliative care Loss, death, grief, palliative care
STATE AUTONOMOUS EDUCATIONAL INSTITUTION
SECONDARY VOCATIONAL EDUCATION
NOVOSIBIRSK REGION
"KUPINSKY MEDICAL TECHNIQUE"
METHODOLOGICAL DEVELOPMENT
(practical lesson)
FOR INDEPENDENT WORK
according to the professional module:
“Performing work in the profession of a junior nurse caring for patients”
Section: PM3. Provision of medical services within the limits of their powers.
MDK 07.01. Technology of medical services.
Topic: Providing assistance with loss, death, grief.
Specialty: 060101 General Medicine
(in-depth training)
Specialties 060501 “Nursing”
(basic training).
Kupino
2014
Considered at the meeting
Subject-cycle commission of professional modules
Protocol No.___ "__" ________________2014
Chairman
Skitovich N.V.
Kupino
2014
Explanatory note
to methodological development for the professional module “Performing work in the profession of a junior nurse caring for patients on the topic: Providing assistance in the event of loss, death, grief.
The methodological manual was developed for independent work of students in order to develop skills and knowledge on the topic: Providing assistance in the event of loss, death, grief.
« The methodological development is compiled in accordance with the requirements for skills according to the Federal State Educational Standard of the third generation, for use in a practical lesson within the framework of specialty 060101 “General Medicine” (advanced training) specialty 060501 “Nursing” (basic training).
In accordance with the Federal State Educational Standard, after studying this topic, the student must be able to:
Collect information about the patient's health status.
Identify the patient's problems related to his health condition.
Provide a safe hospital environment for the patient, their environment and staff.
Carry out routine and general cleaning of premises using various disinfectants.
know:
Technologies for performing medical services.
Factors affecting the safety of patients and staff.
Basics of prevention of nosocomial infections.
Methodological development consists of: Explanatory note, presentation of new material, independent work of students.
SUBJECT:
PROVIDING HELP IN LOSS, DEATH, GRIEF.
For a patient in a terminal state, a lot can always be done to alleviate his suffering, reconciling him with himself and the world.
T. Orlova, hospice doctor
The student must know:
Possible real and potential problems of a seriously ill patient;
Types of pain;
Factors influencing the sensation of pain;
Concepts and principles of palliative care;
The needs of the dying person, his family and loved ones;
The student must be able to:
Conduct nursing interventions for the real problems of a seriously ill patient;
Teach the patient/family the necessary elements of self-care/care;
Assess the intensity of pain;
Implement nursing interventions to reduce pain
ETHICAL AND DEONTOLOGICAL PROVISION
Often, relatives are near the victim, who, as a rule, are very frightened and with their behavior can interfere with the provision of first aid.
The person providing assistance should try to reassure them and tactfully ask them not to interfere with the provision of assistance. Clear, confident, quick actions of the rescuer always instill in the relatives and friends of the victim faith in a favorable outcome.
SAFETY REGULATIONS
When performing artificial ventilation using the mouth-to-mouth, mouth-to-nose, or tracheostomy methods, it is necessary to isolate the patient's mouth or nose or tracheostomy with a gauze pad (or handkerchief) to avoid infection with infectious diseases that the patient may suffer from.
Diagnostic criteria for resuscitation
Reanimatology is the science of the patterns of extinction of the basic functions of the body, their immediate restoration and long-term active maintenance with the help of special techniques, methods and means.
Reanimation - restoration of lost vital functions of the body when breathing and circulation stop. The term "resuscitation" means "revival", "return to life". The main task of resuscitation is to maintain human life.
This is a method of resuscitation aimed at reviving, returning to life. Our Russian scientist V.A. Negovsky is considered the founder of the science of resuscitation.
Academician V.A. Negovsky was the first to determine the clinical and biological stages of death. Cardiac arrest and cessation of breathing are a transitional process from life to biological, irreversible death.
The components of modern resuscitation are the restoration of cardiac activity and breathing after they have completely stopped and then continued intensive care of life-threatening disorders.
Terminal state - a reversible state, the final stage of the extinction of life, precedes biological death, includes several stages.
Causes of terminal conditions:
severe injuries of various organs and systems;
illnesses and injuries with heavy bleeding;
traumatic brain injury;
electrical injury;
extensive myocardial infarction;
asphyxial conditions (foreign bodies in the respiratory tract - vomit, food, various objects);
drowning;
poisoning of various etiologies;
embolism, thrombosis of blood vessels in the brain and lungs;
allergic conditions;
severe diseases and infections (septic endocarditis, acute hepatitis with acute liver failure, kidney disease with acute renal failure).
Cardiac arrest and cessation of breathing do not mean the onset of biological death; tissues and organs continue to live for some time. In this case, cardiopulmonary resuscitation (CPR) must be started immediately.
The terminal state according to clinical signs is divided into 3 stages, following one after another:
Each of them occurs individually, their severity and duration depend on the reactivity of the body, age and pathology, leading the body to death.
After the onset of clinical death, there is a certain period of 3-6 minutes during which it is possible to restore the vital activity of the brain, other vital organs and revive the body. If this time is missed, biological death occurs.
Preagonal period - the initial stage of a terminal condition - dysfunction of the central nervous system, a sharp deterioration in hemodynamics - duration from several minutes to several days.
Signs - confused consciousness;
disturbance of the rhythm and type of breathing (respiratory rate up to 30-40 per minute, then up to 8 per minute, pathological breathing is possible);
progressive drop in blood pressure, centralization of blood circulation, cessation of peripheral circulation;
threadlike pulse, tachycardia, bradycardia;
change in skin color: pallor, cyanosis or marbling;
a sharp decrease in skin temperature.
Between pre-agony and agony there may be terminal pause, duration from a few seconds to 3 – 4 minutes.
Signs: - lack of breathing;
slowing of the pulse, preservation only in the central arteries;
wide pupils, reaction to light gradually disappears.
Agony - stage of transition to clinical death.
Signs
Duration: from several minutes to several hours;
Consciousness: absent, but the patient can hear;
Skin: pale, may have acrocyanosis, marbling; cyanosis of the scalp;
Arterial pressure: low, systolic not higher than 60-40 mmHg;
Pulse: bradycardia or tachycardia is determined only in large arteries;
Breath: rare, convulsive, arrhythmic, deep, Kussmaul or Cheyne-Stokes;
Eye reflexes: the pupils are dilated, the reaction to light is sharply slowed down.
The last breath - and clinical death occurs.
The actions during the development of agony are exactly the same as during preagony.
Clinical death - a state between the extinction of life and biological death, duration - 3-6 minutes.
Signs:
lack of consciousness;
lack of breathing;
absence of pulse in the carotid arteries;
pupils are wide, do not react to light;
deathly pale or sallow-gray complexion;
facial features are sharply pointed;
the muscles are relaxed, there are no reflexes;
relaxation of the sphincters - involuntary urination or defecation.
Clinical death– cessation of functions of vital organs, when resuscitation measures are effective and revival of the body is possible.
Clinical signs
Duration: 3-6 minutes at a temperature of +18-28°; 30 minutes at a temperature of +5-0° and below;
Consciousness: absent
Skin: pale, cold, possible cyanosis
Arterial pressure: not defined
Pulse: not detected even on large arteries (carotid artery)
Breath: absent
Eye reflexes: the pupils are wide, there is no reaction to light.
Diagnostic criteria for clinical death:
lack of consciousness;
lack of breathing;
absence of pulsation in the great vessels (carotid and femoral arteries);
wide pupils without reaction to light.
Biological death– an irreversible state of cessation of the functions of vital organs, which occurs after clinical death, when resuscitation measures are ineffective and revival of the body is no longer possible.
Along with the signs of clinical death, reliable signs of biological death appear:
Early signs of biological death include:
– clouding and drying of the cornea of the eyes 15 - 20 minutes after the onset of biological death
– softening of the eyeballs, the “cat’s eye” symptom (when the eyeball is squeezed, the pupil is deformed and resembles a cat’s eye) appears after 30-40 minutes
Late signs of biological death are:
– CORPSE SPOTS – areas of blue-violet and crimson-red color appear 40 minutes – 2 hours after the onset of biological death. When the body is positioned on the back, they appear in the area of the shoulder blades, lower back, buttocks, and when positioned on the stomach - on the face, neck, chest, and abdomen.
– Rigor mortis – occurs 2-4 hours after the onset of biological death, appears in the facial muscles, then spreads to the muscles of the trunk and lower limbs.
– Body temperature is equal to ambient temperature.
Airway obstruction
Asphyxial conditions are associated with the entry of foreign bodies into the tracheobronchial tree of the affected person.
Obstruction (lat. obstruction - obstruction, blockage) - the presence of an obstacle in a hollow organ.
Airway blockage is possible when:
trying to swallow a large piece of poorly chewed food;
intoxication;
presence of dentures;
fastwalking, running with an object (medicine, food, toy) in the mouth;
fright, crying, falling;
laughing while eating.
There are partial and complete obstructions .
Signs partial blockage respiratory tract - oxygen deficiency: cough, noisy breathing between breaths, hoarseness; up to aphonia; the ability to speak is preserved. The victim is excited, rushing about, grabbing his throat with his hands. Manifestations of anxiety are a sign that a person is suffocating.
Signs complete obstruction - cessation of gas exchange: lack of speech, cough, breathing, severe cyanosis. The clinical picture depends on the level of localization of the foreign body and the severity of respiratory disorders.
The cause of airway obstruction in unconscious patients is tongue retraction.
Obstruction of the airways requires a full range of resuscitation measures, since cessation of breathing contributes to cardiac arrest. Aspiration should be stopped and the cause of its occurrence should be identified. Until the obstruction is eliminated, attempts at artificial respiration and external cardiac massage are futile. The rescuer must act fast: call an ambulance via mobile phone or with the help of strangers, and independently begin resuscitation measures.
If there is difficulty breathing due to a foreign body entering the tracheobronchial tree, the tactics of the surrounding people is to perform sharp mechanical pushes with the base of the palm in the interscapular area of the victim.
An effective method to relieve airway obstruction - Henmlich maneuver - pushing out a foreign body by a series of pushes in the epigastric region. Mechanical effects change the air pressure in the tracheobronchial tree, which helps convert complete obstruction to partial due to the displacement of a foreign body, and therefore save a person’s life.
Self-help
With obstruction of the respiratory tract, in some cases, a person can help himself: induce a cough, vomiting, use the Heimlich maneuver, as well as improvised means of a sharp-round shape (railings, headboards, chairs).
The following methods of artificial pulmonary ventilation (ALV) are used in practice:
Mouth-to-mouth method.
The mouth-to-nose method.
Ventilation through a tracheostomy.
When performing mouth-to-nose ventilation, it is necessary to close the mouth and at the same time move the victim’s lower jaw forward For P prevention of tongue retraction.
Do not remove removable dentures if they are present. ,
Do not tilt the victim’s head when performing mechanical ventilation through a tracheostomy.
The intervals between “breaths” should be 5 seconds (10-12 cycles per minute), it is important to ensure a sufficient volume of artificial inspiration.
The frequency of mechanical ventilation for the victim during simultaneous chest compressions (full resuscitation) is 6-8 breaths per minute.
Criterion for the effectiveness of mechanical ventilation:
expansion of the chest and upper anterior abdominal region nki, synchronous with injection.
Ventilator errors:
free patency of the respiratory tract is not ensured: the head is not thrown back enough, the lower jaw is not extended, a foreign body in the respiratory tract, the absence of a cushion under the interscapular space;
tightness is not ensured when air is blown in;
lack of control over chest excursion;
insufflation of air during chest compression;
swelling of the epigastric region during mechanical ventilation - air entering the stomach. In this case, it is necessary to turn the victim’s head and shoulders to one side and gently press on the epigastric area.
Stage C - restoration of blood circulation. Tissue hypoxia cannot be eliminated without restoring cardiac activity and circulation. This stage includes closed (indirect cardiac massage (CHM).
Causes of cardiac arrest:
acute poisoning;
severe injuries;
acute blood loss;
asphyxia;
drowning;
electrical injuries;
severe systemic diseases of various etiologies;
comatose states.
Signs of cardiac arrest:
pallor or cyanosis of the skin and mucous membranes;
dilated or wide pupil and lack of reaction to light;
absence of pulse in large arteries;
blood pressure is not determined;
lack of consciousness;
lack of chest excursion.
If you find a victim with the above symptoms, you must call a doctor or an ambulance through a third party and immediately begin basic cardiopulmonary resuscitation.
The mechanism of closed cardiac massage
The heart is located between the sternum and the spine. When sharp pressure is applied to the sternum, the heart is compressed (artificial systole) and blood is released into the aorta and pulmonary artery. The cessation of compression returns the heart to its previous volume, blood from the vena cava and pulmonary veins enters the atria and ventricles (artificial diastole). The rhythm of mechanical influences ensures blood circulation in the body, and therefore life.
Indirect cardiac massage is performed simultaneously with mechanical ventilation.
Before performing a cardiac massage, sometimes mechanical defibrillation should be performed - a precordial blow - a short strong blow with a fist in the area of the middle third of the sternum.
Conducting closed massage, heart
The criterion for correct massage is the pulse wave on the carotid (femoral) artery.
The effectiveness of ZMS is:
the appearance of a pulse in large arteries;
systolic blood pressure above 65 mm Hg. Art.;
constriction of the pupils;
pink coloration of the skin and mucous membranes.
ZMS errors:
the victim lies on a soft surface;
The arms are positioned incorrectly: low - on the xiphoid process, brought to the edges of the sternum, bent at the elbow joints, when performing compressions the rescuer tears the palms off the sternum.
Complications of cardiac compressions:
fractures of ribs, sternum;
injuries to the lungs, pleura, heart.
Combination of mechanical ventilation with VMS
When resuscitating by one or two rescuers, it is necessary to perform 30 compressions after 2 air injections (the ratio of ventilation to compression is 2:30).
Every 2-3 minutes, check the pulse in the carotid artery (when two rescuers are working, this is done by the resuscitator performing mechanical ventilation). If there are no positive results of resuscitation - there is no pulsation in the central arteries in time with the “massage” shocks, the pupils remain wide and do not respond to light, there are no independent breaths - the rescuer needs to check the correctness of each element of resuscitation.
When a distinct pulsation of the carotid/femoral arteries appears, cardiac massage is stopped, and mechanical ventilation is continued until spontaneous breathing is restored.
Prolonged absence of consciousness, areflexia, dilated pupils signal the ineffectiveness of the measures taken.
Failures of primary resuscitation: irreversible changes in the brain, heart, caused by disease or injury, late or improper resuscitation.
Diagnostic stage: lack of breathing, pulsations in the carotidarteries
violation of mechanical ventilation and mechanical ventilation techniques; lack of control over the effectiveness of activities; premature cessation of resuscitation measures (resuscitation must be carried out before the arrival of a specialized emergency medical team).
Resuscitation is stopped after 30 minutes if there is no revitalization effect.
EFFECTIVE RESUSCITATION
After effective resuscitation measures have been carried out and the functions of vital organs have been restored, intensive therapy and observation of the patient in the intensive care unit are subsequently carried out.”
Further specialized resuscitation measures are carried out by an ambulance team or in the intensive care unit of a hospital.
INEFFECTIVE RESUSCITATION
If after 10 - 15 (maximum 30 minutes) from the start of mechanical ventilation and chest compressions, cardiac activity and breathing are not restored and reliable symptoms of biological death appear, it should be considered that irreversible changes have occurred in the body and brain death has occurred. In this case, it is advisable to stop CPR.
With both effective and ineffective resuscitation carried out outside a medical institution,
you should wait for the ambulance to arrive.
Basic resuscitation
Diagnostic stage - absence:
consciousness;
breathing;
pulsations on the main arteries;
pupillary reflex; pupils are wide
Preparatory stage:
lay the victim on a flat, hard surfacexness;
free his chest and stomach from constricting clothing;
ensure that the resuscitation team is called.
Actually resuscitation
Stage B
Start mechanical ventilation with 2 breaths! (duration of inhalation - 1.5-2 seconds,
second breathstarts only after the first exhalation,
inspiratory volume - 10-15 ml/kg post body weight
There is no pulse - start CMS.
Regardless of the number of saveslei ratio inhalation: compression = 2:30
(inhalation frequency - 6-8 per 1 min., compression frequency - 100 per 1 min.)
Revival/ Social death / Biological death
INDEPENDENT WORK OF STUDENTS.
GLOSSARY OF TERMS
Algogen – a substance that causes pain.
Pain - a timely psychophysiological state of a person arising as a result of exposure to super-strong or destructive stimuli.
Grief - emotional response to loss, separation.
Introvert – a person who is not inclined to communicate.
Irradiation of pain - spread of pain beyond the pathological focus.
Contracture – persistent restriction of movements in the joint.
Orthostatic collapse – acutely developing vascular insufficiency with a sharp change in the body in space.
Total pain - pain subsequently for various reasons.
Hospice - a medical institution that provides medical and social assistance that improves the quality of doomed patients.
Control questions
Real problems of a seriously ill patient.
Potential problems for the critically ill patient
Pain intensity assessment
Causes of pain.
Characteristics of acute pain.
Signs of chronic pain.
Principles of patient care in a hospice setting.
The needs of the dying person, his family and loved ones.
Emotional stages of grief.
The concept and reasons for palliative care.
Test tasks.
Complete the correct answer.
1. The first stage of the terminal condition is ___________________________________.
2. The basis of palliative medicine is the improvement of ______________________________
patient.
3. Agony is the process of ______________________ external signs of the body’s vital activity.
4. In clinical death, pathological changes in all organs and systems are completely____________________.
5._____________________ death - the development of irreversible changes in the brain.
6.The Latin word “palliative” means ______________________.
7.Euthanasia is assistance in ending the patient’s ________________.
8. ________________________ treatment is active general care for an oncological patient.
9. A hospice is a medical institution that provides medical care that improves_______________ ________________.
10. Of particular importance in the work of a hospice nurse is the provision of____________________ support to the dying.
11. The first hospice was created in England_________________(by whom?)
12. The onset of biological death is confirmed by ________________________.
13. Hospice is a system of comprehensive patient care: __________________________,__________________________ and social.
14. Palliative treatment is carried out under the condition __________________________________________
all other treatment methods.
15. Borderline state between life and death____________________
16. The main tasks of a nurse when providing palliative care are _______________
pain and alleviation of other painful symptoms.
17. Pain is the body’s reaction to damaging ________________________________
18. Biological death - post-mortem changes in all organs and systems that are ____________________, permanent.
19. Palliative care is carried out: on _______________, in a clinic, in a hospital, ______________, by an outreach service.
20. Aspects of palliative care: medical, _______________, ____________, spiritual.
Recommendations: Doctors who are aware of the upcoming or recent the death of the patient's relatives, must take into account the risk of an abnormally severe reaction and must provide emotional support. Clinicians should also pay attention to symptoms of pathologically severe grief.
A large number of Americans are losing relatives or close friends. More than 2.1 million people died in the US in 1986. That means about 8 million Americans have lost a family member. More than 920 thousand people became widows or widowers. There were 95 thousand deaths of children and young people under 25 years of age. Grief is considered abnormally severe if the depression persists for a year or more. Approximately 16% of the total number of people who have lost loved ones are registered with this symptom.
People grieving abnormally hard, increase the number of morbidity and mortality from both psychological and physical diseases. Potential complications include depression, social isolation, and alcohol or drug abuse. Some children develop emotional difficulties in later years. Individuals who are particularly bereaved may commit suicide. Suicide is particularly common among widowers, especially the elderly, and men who have lost their mothers. Risk factors are poorly defined, but persons without adequate social support, women who have not remarried or live alone, persons with pre-existing psychiatric conditions, or those who use alcohol or drugs may be considered.
Efficacy of screening tests for abnormally severe bereavement reactions.
Grief after the death of a loved one naturally, and it is often difficult for doctors to distinguish a person’s normal grief from an unnaturally severe reaction. Over time, the diagnosis becomes clear, but the patient may no longer be helped by the clinical and social measures taken. A better understanding of risk factors may make it easier for clinicians to develop strategies to identify and treat such people immediately after (or before) death. The number of risk factors is approximately determined. These include characteristics of the person experiencing grief (inadequate support, mental or mental illness, alcohol dependence, financial difficulties); relationship with the deceased and the circumstances of the death itself (for example, sudden death). Unfortunately, these characteristics cannot be generalized. Screening recommendations based on them have a low level of prediction. Thus, a large number of those identified as reacting inadequately to loss later showed themselves to be quite normal. Special clinical intervention in such cases is simply unacceptable.
The effectiveness of early detection of abnormally severe reactions to bereavement.
Detection of complications at the beginning of the mourning period is potentially important for reducing physical and mental morbidity. Theoretical advice and social support help a bereaved person cope with their grief. The effectiveness of such interventions is, however, limited. Pre-death interventions including emotional support, information and practical assistance have been examined, but no consistent results have been found. Studies of children with terminally ill parents have shown some benefit from the intervention, but a similar study examining families of children with terminal leukemia showed no benefit.
In a controlled clinical trial, widowers Those considered to be at risk for severe grief were assigned to either a group that received 3 months of emotional support or a control group that received no support. After 13 months, a survey showed that morbidity was lower in the group receiving support. A non-statistical control study found that pairing widowers together made the mourning period easier. In addition, it has been shown that intervention after the onset of abnormally severe grief symptoms may also be beneficial.
Counseling can reduce stress levels, and in severe cases, professional psychotherapy is used. Antidepressants may help some patients. Others benefit from emotional support from special groups.
Official recommendations There is no way to identify symptoms of abnormal grief.
To determine the characteristics of abnormal grief Further research is needed, but it is already clear that many suffer from physical and mental illness during the period of mourning. It is also clear that support measures in general and clinical interventions in particular reduce people's suffering. There are no accurate tests to determine the need for intervention. Therefore, it is important for doctors not to miss possible pathological grief syndrome.
Doctors foreseeing the imminent death of a patient's loved ones, should assess potential risk factors for severe grief (inadequate social support, loneliness, pre-existing mental illness, alcohol or drug addiction) and prepare patients emotionally. Although methods of assistance are individual in each case and at each stage of grief, doctors must help the patient accept the loss of a loved one, learn to cope without the deceased, and develop new relationships. Doctors should also look for symptoms such as delayed mourning, depression or suicidal ideation, and increased alcohol and drug use. Abnormally grieving patients should receive help from professional psychotherapists.
Plan:
1.
2. Hospice.
3. Psychology of the problem of death.
4.
5. Stages of mourning.
6.
7.
8. Pain, pain assessment.
9. Dying.
10.
Features of psychological communication between the patient and medical staff
Currently, a fairly large number of patients have an incurable or terminal stage of the disease, so the issue of providing such patients with appropriate assistance becomes relevant, i.e. about palliative treatment. Radical medicine aims to cure disease and uses every means at its disposal as long as there is even the slightest hope of recovery. Palliative medicine replaces radical medicine from the moment when all means are used, there is no effect and the patient dies.
According to WHO definition palliative care - This is active, multifaceted care for patients whose illness is not curable. The primary goal of palliative care is to relieve pain and other symptoms and address psychological, social and spiritual problems. The goal of palliative care is to achieve the best possible quality of life for patients and their families.
The following principles of palliative care are distinguished:
Support life and treat death as a natural process;
Do not hasten or delay death;
As death approaches, reduce pain and other symptoms in patients, thereby reducing distress;
Integrate psychological, social, spiritual issues of caring for patients in such a way that they can come to a constructive perception of their death;
Offer patients a support system that allows them to remain as active and creative as possible until the end;
Offer a support system for families to help them cope with the challenges of a loved one's illness and during grief.
Patients with malignant tumors, irreversible cardiovascular failure, irreversible renal failure, irreversible liver failure, severe irreversible brain damage, and AIDS patients need palliative care.
The ethics of palliative care is similar to general medical ethics: it is about preserving life and alleviating suffering.
At the end of life, the relief of suffering is of much greater importance, since it becomes impossible to preserve life itself.
In a palliative approach, the patient is provided with four types of care: medical, psychological, social and spiritual.
The versatility of this approach allows us to cover all areas related to the patient’s needs and focus all attention on maintaining the quality of life at a certain level. Quality of life is the subjective satisfaction experienced or expressed by an individual. Life is truly high quality when the gap between expectations and reality is minimal.
Hospice
Palliative care is a new branch of practical medicine that solves the medical and social problems of patients who are in the last stage of an incurable illness, mainly through hospices (from the Latin hospes - guest; hospitium - friendly relations between host and guest, the place where these relationships develop ). The word "hospice" does not mean a building or establishment. The concept of hospice is aimed at improving the quality of life of seriously ill patients and their families. Hospice providers are committed to caring for people in the final stages of a terminal illness and providing care to them in a way that makes their lives as fulfilling as possible.
The first institution for caring for the dying, called a hospice, arose in 1842 in France. Madame J. Garnier founded a hospice in Lyon for people dying of cancer. In England, the Irish Sisters of Charity were the first to open hospices in London in 1905. The first modern hospice (St Christopher's Hospice) was founded in London in 1967. Its founder was Baroness S. Saunders, a trained nurse and social worker. Since the early 1960s. Hospices began to appear all over the world.
In Russia, the first hospice was created in 1990 in St. Petersburg thanks to the initiative of V. Zorza, a former journalist whose own daughter died of cancer in one of the English hospices in the mid-1970s. He was very impressed by the high quality of care at the hospice, so he set out to create similar centers himself that would be available to all regions. V. Zorza promoted the idea of hospices in Russia in his interviews on television and radio, and in newspaper publications. This found a response in government agencies throughout the country - the Order of the Ministry of Health of the RSFSR dated February 1, 1991 No. 19 “On the organization of nursing homes, hospices and nursing departments of multidisciplinary and specialized hospitals” was adopted. Currently, there are more than 20 hospices operating in Russia.
The structure of hospices in St. Petersburg, Moscow, Samara, Ulyanovsk mainly includes: visiting service; day hospital; inpatient department; administrative unit; educational and methodological, socio-psychological, volunteer and economic units. The core of hospice is the outreach service, and the primary work unit is a nurse trained in palliative care.
The basic principles of hospice activities can be formulated as follows:
1) hospice services are free; You can’t pay for death, just like you can’t pay for birth;
2) hospice is a house of life, not death;
3) control of symptoms allows you to qualitatively improve the patient’s life;
4) death, like birth, is a natural process. It cannot be slowed down or rushed. Hospice is an alternative to euthanasia;
5) hospice - a system of comprehensive medical, psychological and social care for patients;
6) hospice - a school for relatives and friends of the patient and their support;
7) hospice is a humanistic worldview.
There comes a moment in the patient's condition when he understands the inevitability of death. Accordingly, it is at this time that support and friendly participation become of great importance. Constant attention to the patient should demonstrate that doctors will not leave him, no matter what, this will support both the patient and his family. The foundation of palliative care tasks is establishing understanding and trust with the patient and family.
In achieving this goal, the first meeting and the first conversation with the patient are important. You need to allocate as much time for it as necessary and do everything to ensure that it is not interrupted and is carried out in a secluded environment. To establish contact, touch is very important, which allows you to establish a person’s readiness to communicate and express what is difficult to convey in words, this is especially important during moments of information exchange.
The nurse must know the psychology of patients, the possible reactions of the patient and his relatives to the information received, and be prepared to provide adequate psychological support from this moment and for the entire period of palliative care.
Psychology of the problem of death
The most difficult task facing a person is solving a “life-death” problem. Children aged 5-6 years have no idea of death or it is filled with all kinds of fantasies. In adulthood, a person puts aside thoughts about his own death. But the older he gets, the more he is faced with the death of loved ones and acquaintances and begins to become calmer about the inevitability of the end.
There are various types of death perception:
"We'll all die." This state of “habituated” death arises from the acceptance of death as a natural inevitability.
"My own death." A person discovers his individuality in death, since he will have to undergo the Last Judgment.
"Your death". Death is perceived as an opportunity for reunion with a previously deceased loved one.
"Death inverted." The fear of death is so great that it is forced out of consciousness, its existence is denied.
Death can be the last and most important stage of growth, since it is a crisis of individual existence. Sooner or later, a person must come to terms with the end of life, try to comprehend his end, and take stock of the life he has lived. Before death the following specific features are observed: changes in perception of life:
1. The priorities of life are re-evaluated - all sorts of little things, insignificant details and details lose their importance.
2. A feeling of liberation arises - what you don’t want to do is not done; The categories of obligation “must”, “must”, “necessary”, etc. lose their power.
3. The momentary current sensation and experience of the process of life intensifies.
4. The significance of elementary life events intensifies (rain, leaf fall, change of seasons, time of day, full moon in the sky).
5. Communication with loved ones becomes deeper, more complete, and richer.
The fear of being rejected decreases, the desire and ability to take risks increases, a person frees himself from conventions, allows himself to live with his thoughts, feelings, and satisfy his desires.
But even having resigned himself, a person can spend the remaining time allotted by nature in different ways: either in inaction and waiting for the inevitable tragic ending, or living life as fully as possible, realizing himself as much as possible in activity, investing his potential in every moment of his existence, self-realization. With fortitude and courage, the patient can make his own dying as less difficult as possible for those around him. Leaving behind the best memories.
However, the patient can stop at any of these five stages, then the process of care will be difficult both for him and for those around him. But in any case, one must treat the dying person with understanding and patience.
A person who learns that he is hopelessly ill, that medicine is powerless, and that he will die, experiences various psychological reactions that can be divided into five successive stages:
Pain
One of the main problems of cancer patients is pain. Palliative care provides adequate, as complete pain relief as possible for hopelessly ill patients. For hospice care, pain management is of paramount importance. The International Association for the Study of Pain defines it as follows: pain is an unpleasant sensory and emotional experience associated with existing or potential tissue damage. Pain is always subjective. Every person perceives it through experiences associated with receiving some kind of damage in the early years of his life.
Pain is a difficult sensation, it is always unpleasant and therefore an emotional experience. The sensation of pain depends on the following factors: past experience; individual characteristics of a person; states of anxiety, fear and depression; suggestions; religion.
The perception of pain depends on the mood of the patient and the meaning of pain for him. The degree of pain experienced is a result of different pain thresholds. With a low pain threshold, a person feels even relatively mild pain, while other people, having a high pain threshold, perceive only strong pain sensations.
The pain threshold is reduced discomfort, insomnia, fatigue, anxiety, fear, anger, sadness, depression, boredom, psychological isolation, social abandonment.
The pain threshold is increased sleep, relief of other symptoms, empathy, understanding, creativity, relaxation, anxiety reduction, pain relievers.
Superficial pain– appears when exposed to high or low temperatures, cauterizing poisons or mechanical damage.
Deep pain– usually located in the joints and muscles, and the person describes it as a “long-lasting dull ache” or “excruciating, gnawing pain.”
Pain in internal organs is often associated with a specific organ: “heart pain,” “stomach pain.”
Neuralgia– pain that occurs when the peripheral nervous system is damaged.
Radiating pain- example: pain in the left arm or shoulder due to angina pectoris or myocardial infarction.
Phantom pains felt as a tingling sensation in the amputated limb. This pain may last for months, but then it goes away.
Psychological pain is observed in the absence of visible physical stimuli; for the person experiencing such pain, it is real and not imaginary.
Types of cancer pain and causes of their occurrence.
There are two types of pain:
1. Nociceptive pain caused by irritation of nerve endings.
There are two subtypes:
somatic- occurs with damage to bones and joints, spasm of skeletal muscles, damage to tendons and ligaments, germination of skin and subcutaneous tissue;
visceral- in case of damage to the tissues of internal organs, hyperextension of hollow organs and capsules of parenchymal organs, damage to the serous membranes, hydrothorax, ascites, constipation, intestinal obstruction, compression of blood and lymphatic vessels.
2. Neuropathic pain caused by dysfunction of nerve endings. It occurs when there is damage, overexcitation of peripheral nervous structures (nerve trunks and plexuses), or damage to the central nervous system (brain and spinal cord).
Acute pain has different durations, but lasts no more than 6 months. It stops after healing and has a predictable ending. Manifestations of acute pain syndrome include patient activity, sweating, shortness of breath, and tachycardia.
Chronic pain persists for a longer time (more than 6 months). Chronic pain syndrome accompanies almost all common forms of malignant neoplasms and differs significantly from acute pain in the variety of manifestations due to the persistence and strength of the feeling of pain. And it manifests itself with such signs as sleep disturbance, lack of appetite, lack of joy in life, withdrawal into illness, personality change, fatigue.
Pain assessment
The patient marks on the ruler the point corresponding to his sensation of pain. To assess the intensity of pain, a ruler with images of faces expressing different emotions can be used. The use of such rulers provides more objective information about the level of pain than the phrases: “I can’t stand the pain anymore, it hurts terribly.”
A ruler with images of faces to assess the intensity of pain: 0 points - no pain; 1 point - mild pain; 2 points - moderate pain; 3 points - severe pain; 4 points - unbearable pain.
Dying
In most cases, dying is not an instantaneous process, but a series of stages, accompanied by a consistent disruption of vital functions.
1. Preagonia. Consciousness is still preserved, but the patient is inhibited and consciousness is confused. The skin is pale or cyanotic. The pulse is threadlike, tachycardia occurs; Blood pressure drops. Breathing quickens. Eye reflexes are preserved, the pupil is narrow, the reaction to light is weakened. The duration of this phase ranges from several minutes to several days.
2. Agony. There is no consciousness, but the patient can hear. Sharp pallor of the skin with pronounced acrocyanosis, marbling. The pulse is determined only in the large arteries (carotid), bradycardia. Breathing is rare, arrhythmic, convulsive, like “swallowing air” (agonal breathing). The pupils are dilated, the reaction to light is sharply reduced. Convulsions, involuntary urination, and defecation may occur. The duration of this phase ranges from several minutes to several hours.
3. Clinical death. This is a transitional state, which is not yet death, but can no longer be called life. Clinical death occurs from the moment breathing and heart stop. In this case, consciousness is absent; the skin is pale, cyanotic, cold, marbling and vascular spots appear; pulse is not detected in large arteries; there is no breathing; the pupils are extremely dilated, there is no reaction to light. The duration of this phase is 3 – 6 minutes.
If the vital functions of the body have not been restored with the help of resuscitation measures, then irreversible changes occur in the tissues and biological death occurs.
The fact of the patient's biological death is confirmed by the doctor. He makes an entry in the medical history, indicating the date and time of its occurrence. A death that occurs at home is confirmed by a local doctor; he also issues a certificate indicating the clinical diagnosis and cause of death.
TOPIC 15. LOSS, DEATH, GRIEF
Plan:
1. Features of psychological communication between the patient and medical staff.
2. Hospice.
3. Psychology of the problem of death.
4. Nursing intervention at different stages of patient grief.
5. Stages of mourning.
6. The role of the nurse in meeting the needs of the doomed patient.
7. Rules for handling the body of the deceased.
8. Pain, pain assessment.
9. Dying.
10. Psychological problems of medical personnel.
Rudik Svetlana Vasilievna
Job title: teacher of special disciplines
Educational institution: GBPOU DZM "MK No. 7" Zelenograd branch
Locality: Moscow, Zelenograd
Name of material: methodological manual for teachers
Subject:"Loss. Death. Grief. Nursing assistance"
Publication date: 28.11.2016
Chapter: secondary vocational
1 State budgetary vocational educational institution of the Moscow Department of Health “Medical College No. 7” Zelenogradsky branch
METHODOLOGICAL DEVELOPMENT FOR TEACHERS
subject:
Discipline:
PM 04 Performing work in the profession of a junior nurse caring for a patient MDK 04.03 Technology for the provision of medical services
Speciality
:
02/34/01 nursing
2
Explanatory note
Methodological development for PM 04 “Performing work in the profession of a junior nurse caring for patients” MDK 04.03 “Technology for the provision of medical services” is intended for conducting a practical lesson on the topic: “Losses, death, grief. Nursing assistance." The purpose of creating a methodological development is dictated by the implementation of one of the most important areas of the educational program - introducing new forms and methods of teaching. This methodological development will allow the teacher to successfully prepare for and conduct a practical lesson. Methodological development materials can be used when students perform independent extracurricular work, as well as for self-preparation for a lesson on this topic. Educational and methodological development consists of: organizational and methodological block; block for monitoring the initial level of knowledge; reference and information block; independent work block; block of final knowledge control; block of response standards; applications The organizational and methodological block includes: 1. Competencies being developed 2. Objectives of the lesson. 3. Scheme of interdisciplinary connections. 4. Lesson equipment. 5. Literature for teachers and students. 6. Chronological map. 7. Motivation. The block for monitoring the initial level of knowledge consists of a task with a blind scheme and test tasks. The reference information block includes: 1. Glossary of terms. 2. Basic summary. The block of independent work for students includes: 1. Assignments for independent work. The block of final knowledge control is represented by situational tasks, as well as tasks in test form. The methodological development also contains a block of standard answers and a literary appendix that can be offered to students for independent reading.
3
CONTENT
Explanatory note………………………………………………………………………. 2
I. Organizational and methodological block
…………………………………………………………………… 4-9 1.1 Competencies being developed……………………………………………………………….. 4 1.2 Lesson objectives……………………………………………………………………………… 4 1.3 Interdisciplinary connections…………………………………………………… ………………………………… 6 1.4 Lesson equipment…………………………………………………………………………………. 7 1.5 Literature………………………………………………………………………………... 7 1.6 Chronological map………………………… …………………………………………………………... 8 1.7 Motivation……………………………………………………………………………………… …… 9
II. Block of control of the initial level of knowledge
……………………………………………. 10-11 2.1 Task 1 “Study of pulse”……………………………………………………… 10 2.2 Task 2 Tests of initial level of knowledge…………………………… ……………….. eleven
III. Reference and information block
…………………………………………………………………… 12-30 3.1 Glossary of terms………………………………………………………………………………… ……… 12 3.2 Basic summary “Losses. Death. Grief. Nursing assistance"………………….. 13-30
IV. Student independent work block
……………………………………………………………… 31 4.1 Tasks for independent work ………………………………………………………………. 31
V. Block of final knowledge control
…………………………………………………….. 32-35 5.1 Situational tasks…………………………………………………………… …………. 32 5.2 Final test control…………………………………………………………………….………. 34
VI. Block of response standards
…………………………………………………………………………………. 36-39 6.1 Standards of answers to tasks in the block of control of the initial level of knowledge…………….. 36 6.2 Standards of answers to situational tasks………………………………………………………………. 6.3 Standards of answers to final level tests…………………………………….. 37 39
VII. Applications
……………………………………………………………………….. 40-48 7.1 Appendix 1. Acceptance receipt …….………………… …………………………... 41 7.2 Appendix 2. “Death Certificate” ……………………………………………………………… ………... 42 7.3 Appendix 3. Literary. “Excerpts from the diary of Elizaveta Glinka”……….. 43-48
I.
ORGANIZATIONAL AND METHODOLOGICAL BLOCK
Name of discipline
– “PM 04 Performing work in the profession of junior nurse for patient care” MDK 04.03 “Technology for the provision of medical services”
Subject -
“Loss, death, grief. Nursing assistance"
4
Type of activity
– practical
Type of activity
– combined
Lesson duration
– 270 minutes
Location
– preclinical practice room
I.1.
ORGANIZED
COMPETENCIES
Obshi
e:
OK 1.
Understand the essence and social significance of your future profession, show sustained interest in it.
OK 2.
Organize your own activities, choose standard methods and ways of performing professional tasks, evaluate their implementation and quality.
OK 3.
Make decisions in standard and non-standard situations and take responsibility for them.
OK 6.
Work in a team and team, communicate effectively with colleagues, management, and consumers.
OK 7.
Take responsibility for the work of team members (subordinates) and for the results of completing tasks.
Professional:
PC 2.1.
Present information in a form understandable to the patient, explain to him the essence of the interventions.
PC 2.2.
Carry out therapeutic and diagnostic interventions, interacting with participants in the treatment process.
PC 2.3.
Cooperate with interacting organizations and services.
PC 2.4.
Use medications in accordance with the rules for their use.
PC 2.5.
Comply with the rules for using equipment, equipment and medical products during the diagnostic and treatment process.
PC 2.6.
Maintain approved medical records.
PC 2.8.
Provide palliative care.
PC 3.2.
Participate in the provision of medical care in emergency situations.
PC 3.3.
Interact with members of the professional team and volunteer assistants in emergency situations.
1.2 C
CLASSES
Educational
Formation of general and professional competencies that allow solving professional problems.
Developmental
Stimulation of mental activity, cognitive interest, logical thinking, development of skills to act independently.
Educational
Fostering a sense of empathy, compassion, respect, and responsibility for one’s actions.
5
As a result of the lesson, the student must
know:
Stages of experiencing loss. Peculiarities of behavior of people experiencing fear of death. Peculiarities of behavior of people who have accepted the inevitability of death. Ethical and deontological features of communication with a doomed person, his family and friends. Signs and stages of terminal condition. Concept and principles of palliative care. Principles of patient care in a hospice setting. Hospice movement.
be able to:
Provide assistance to the patient and/or family members experiencing loss. Provide post-mortem care in health care facilities and at home.
1.3 M
INTERDISCIPLINARY
CONNECTIONS
SECURED
SECURED
MDK 04.03
Technology
providing
medical
services
"Losses. Death. Grief. Nursing assistance"
6
Supporting topics:
Infectious safety; Disinfection; Assessing the patient’s functional state (determining respiratory rate, pulse, measuring blood pressure); Cardiopulmonary resuscitation; Signs of clinical and biological death.
1.4 O
EQUIPMENT
CLASSES
Technical equipment:
PROVIDING
PROVIDING
BASICS
LATIN LANGUAGE
WITH MEDICAL
TERMINOLOGY
ANATOMY AND
PHYSIOLOGY
PERSON
PSYCHOLOGY
BIOETHICS
PALLIATIVE
HELP
SAFETY
LIFE ACTIVITIES
TI AND MEDICINE
DISASTER
RESUSCITATION
SURGERY
INTRADISCIPLINARY
CONNECTIONS
7 Projector, laptop
Material equipment:
simulation mannequin "SUSIE" soap inventory form tray death notice forms blank disposable apron and clean sheets envelope disposable gloves adhesive plaster identification bracelets disposable napkins wide adhesive tape
Methodological equipment:
methodological development for the teacher; handouts for students: tasks to control the initial level, action algorithms, reference summary “Losses. Grief. Death. Nursing care", situational tasks; educational (documentary) video and thematic PowerPoint presentation.
1.5 L
ITERATURE
For teachers:
1. Mukhina S.A., Tarnovskaya I.I. Practical guide to the subject “Fundamentals of Nursing”: textbook. – 2nd ed., corrected. and additional – M.: GEOTAR-Media, 2009. 2. Fundamentals of nursing: textbook. for students avg. prof. textbook establishments / [I.Kh. Abbyasov, S.I. Dvoinikov, L.A. Karaseva and others]; edited by S.I. Dvoinikov. – 2nd ed., erased. – M.: Publishing Center “Academy”, 2009. 3. Obukhovets T.P., Sklyarova T.A., Chernova O.V. "Fundamentals of Nursing" ed. “Phoenix”, Rostov-on-Don 2006 1. Khetagurova A.K. “Palliative care: medical, social, organizational and ethical principles” ed. Moscow State Educational Institution VUNMC Ministry of Health of the Russian Federation 2003. 2. Magazine “Nurse” No. 3 2004 3. Orthodox magazine “FOMA” Access mode: fomaxospis-eto-shkola-zhizni.html
For students:
Main:
1. Mukhina S.A., Tarnovskaya I.I. Practical guide to the subject “Fundamentals of Nursing”: textbook. – 2nd ed., corrected. and additional – M.: GEOTAR-Media, 2009.
8
1.6
CHRONOCARD OF PRACTICAL LESSON
plan Contents timing
1.
Organization of the lesson
1.1. Organizational moment * readiness of the audience for the lesson (sets on the topic) * readiness of students (dress code, absentees) * filling out the magazine * announcement of the topic, goals of the lesson. 5 minutes
2.
Main part
2.1. Introduction to the topic (initial motivation). *introduction to the course of the lesson 10 min 2.2. Monitoring the initial level of knowledge (filling out a blind chart - “Pulse Study” and solving test tasks) 15 min 2.3. Presentation of new material by the teacher. 65 min 2.4. Watching an educational (documentary) video on the topic. 30 min 2.5. Writing an essay after watching the video 20 min 2.6. Independent work of students: - drawing up situational tasks according to a template (in pairs); - determination of signs of clinical and biological death on a mannequin (solving the problem); - ascertaining death, filling out documentation; - rules for handling a corpse. 65 min 2.7. Determining the final level of knowledge of students - solving test tasks - solving situational problems 35 min
3.
Final part
3.1. Reflection * summarize the information received, * analyze mistakes, * causes of difficulties and successes, * degree of achievement of goals. 10 min 3.2. Summing up the lesson * assessing the work of the team * assessing the work of each student * posting grades in the journal 10 min 3.3. Homework assignment 5 min
Total
270 min
* Due to the use of different means to achieve goals in each group of students, the time map is indicative.
9
1.7 M
OTIVATION
From the moment of birth, a person goes to meet death. Death is a natural stage of life, its completion. Man is the only living creature who knows about the inevitability of death. However, “in essence, no one believes in their own death. Or, which is the same thing, each of us, without realizing it, is convinced of our immortality,” writes S. Freud. The most painful thing is to accept the thought that, having left this world, a person will bring great grief to his family and people close to him. All dreams, desires, goals, love, joy, happiness - all this will go into oblivion. That is, it is impossible for him to think that he will leave, and everything that was his personality will leave with him. Fear of death is a natural feeling. In our clinics, a dying person receives medical care, but psychological care leaves much to be desired. And the worst thing is that dying became lonely. No one knows, and sometimes does not want to know, what horror a person experiences when standing on the edge of an abyss, knowing that there is no way back, and in the depths of his soul that last weak light of hope is extinguished. Where did this heartlessness, this indifference come from? Perhaps from not accepting death as a natural life process, if this is so, then it will be much easier to correct the mistake. What if this is callousness instilled in us by our age? Warriors, destruction, son for father, brother for brother, isn’t this the answer to the question posed? Isn’t this the reason for the low empathy among medical personnel, and among us all? It is possible to correct this error, although it will require much more time and effort. And you need to start small - start with yourself. It is quite possible that rethinking your life will lead to self-discovery. It is necessary for a person to speak out and speak out not for himself, but also for a person subject to the same passions, the same vices and weaknesses. He needs to be listened to and understood. It's not that difficult, is it?
II. BLOCK
CONTROL OF THE INITIAL LEVEL OF KNOWLEDGE
10
1. Introduce students to tasks 1 and 2 to control the initial level. 2. Distribute tasks with instructions, announce the time for their completion. 3. After solving each task, the teacher offers to check the correctness of its completion.
Task 1. “Pulse study”
Instructions:
Task 2. Baseline control tests
11 Instructions: choose one index of the correct answer
1.
The respiratory rate of an adult at rest is (normal):
A)
10-14
B)
12-16
IN)
16-20
G)
24-26
2.
The preagonal state is characterized by:
A)
drop in blood pressure, tachycardia, increased breathing
B)
a sharp drop in blood pressure, decreased heart rate, deep respiratory distress
IN)
paralysis of the respiratory and vasomotor centers Instructions: complete the phrase:
3.
Lack of breathing is called - ________________________________________
Decrease in heart rate - _______________________________________
Increased heart rate - _______________________________________
The bed of a seriously ill patient should be remade
A)
2 times a day
B)
3 times a day
IN)
4 times a day
G)
as it gets dirty Instructions: choose one index of the correct answer
7.
Signs of clinical death are all except:
A)
rigor mortis
B)
respiratory arrest
IN)
heart failure
G)
dilated pupils
8.
Signs of biological death are all except:
A)
heart failure
B)
rigor mortis
IN)
cadaveric spots
G)
corneal clouding
9.
Duration of clinical death by time:
A)
5-6 min
B)
8-10 min
IN)
7-9 min
10.
What is the most gentle and gentle way to transport a seriously ill patient?
comfortable?
A)
on hands
B)
on a gurney
IN)
on a stretcher
G)
on foot accompanied by a nurse
III. REFERENCE INFORMATION BLOCK
12
Instructions for the teacher:
1. Explain new material using a teaching outline or topic presentation. 2. Demonstrate practical skills using models, explaining your actions.
3.1 C
LOVAR
TERMS
Grief
an emotional response to loss or separation that goes through several stages.
DEPRESSION
sad, depressed mood.
PALLIATIVE
TREATMENT
treatment that is started when all other treatments have failed and the disease cannot be cured.
TERMINAL
STATE
the borderline state between life and death, the stages of the dying of the body (pre-agony, agony, clinical death).
HOSPICE
a specialized medical institution for doomed patients, where comprehensive medical, psychological and social assistance is provided.
EMPATHY
the ability to experience another’s feelings, to empathize. The ability to “feel” into another person, to grasp his inner state, to see the world through his eyes from his point of view.
THANATOLOGY
A branch of medicine that studies issues related to the mechanisms of the dying process and the clinical, biochemical and morphological changes that arise in the body.
THANOTOGENESIS
Causes and mechanisms of death in each specific case.
TERMINAL
Finite
3.2 O
PORN
ABSTRACT
13
Stages of experiencing loss and grief
Often there is a terminal patient in the department. When death suddenly appears close and inevitable, it is difficult to face it. A person who has learned that he is hopelessly ill, that medicine is powerless, and that he will die, experiences various psychological reactions, the so-called emotional stages of grief (defined by the American psychiatrist E. Kübler-Ross in the classic work “On Death and Dying”).
1. Denial, shock, numbness
The person may feel as if they are out of touch with reality. Mental shock can turn into mental seizures and hysteria. Shock leads to a reaction of denial (“This can’t be!”, “No, not me,” “It’s not true”). The stage is protective in nature.
2. Reaction of anger, anger
Shock and numbness gradually give vent to intense emotions. A person no longer doubts that this is true, but perceives such reality as the greatest injustice and feels resentment towards people and God. Anger can be directed both at oneself and at the medical staff or family (“Why me?”, “Who is to blame?”). This unfair anger should be treated with understanding.
3. Attempt to negotiate with a “Higher Spiritual Being.”
A patient in a state of terminal illness is in some ways similar to a child. When the anger reaction does not give the desired result, he wants to make a deal with God, with the doctors. A person promises to do something to “Him” if “He” heals him or his loved one (“Not yet”, “A little more”).
4. Stage of depression
It is accompanied by a feeling of confusion and despair. A person often cries and loses interest in his own appearance. Sometimes this leads to isolation from the outside world. A person is mentally capable of accepting the finality of a loss much earlier than his emotions allow him to accept this truth (“Yes, this will happen to me, I will die,” “There is no way out, it’s all over”).
Signs of depression:
constant bad mood; loss of interest in the environment; feelings of guilt and inferiority; hopelessness and despair; suicide attempts or persistent thoughts of suicide.
5. Acceptance
Farewell to life, humility (“Let it be”, “You can’t go anywhere, that means fate”). At this stage, intensive spiritual work takes place - repentance, assessment of one’s life and the measure of good and evil by which one can evaluate one’s life. The patient begins to experience a state of peace and tranquility. The time it takes a person to go through all these stages is purely individual. Often these reactions appear in different sequences and some of them can occur simultaneously. Sometimes humility gives way to a reaction of denial. It is very important to recognize what stage the patient is currently in in order to provide him with appropriate assistance.
14
WITH
ESTRINSKY
INTERVENTIONS
VARIOUS
STAGES
ADAPTATIONS
PATIENT
MENTAL
INJURY
Stages of Grief Nursing Intervention
1. "Denial"
1.
Find out your feelings towards death, because... personal hostility and fear can be transferred to the dying person.
2.
Ask the patient to describe on paper his feelings, concerns, and fears. This promotes psychological processing of these emotions. It is important to sit by the patient’s bed (his feeling of abandonment decreases); listen carefully and empathize with the patient’s feelings (reduces feelings of isolation, promotes relationship building); support your hand, touch your shoulder (physical touch brings a feeling of comfort to some patients and demonstrates care for them).
3.
Inform the patient. Encourage questions that he is willing to ask (the right information can reduce anxiety and clarify the situation). However, if the patient has a pronounced denial reaction and does not want to know about death, then you cannot talk about it, it would be a mistake.
2. "Anger"
1.
Recognize the patient’s right to feel anger, which creates a feeling of support and mutual understanding (allow the patient to “splash out”).
2.
Work with the patient so that he turns his anger into a positive direction (setting goals, making decisions, fighting the disease). This will help the patient increase self-esteem, keep emotions under control and feel supported by medical staff.
3. "
Request for
deferment
1.
Provide support (the opportunity to turn to someone and be understood helps the patient cope with his feelings). Do not encourage the patient to endure adversity, to hold on and be strong.
4. "Depression"
1.
Involve the patient in his usual way of life (reduces time spent in thinking).
2.
Spend sufficient time with the patient and communicate with him (reduces feelings of isolation and promotes mutual understanding).
3.
Try to keep the feeling of pain under control (a comfortable state increases the patient's desire to interact with others and reduces the tendency to withdraw).
4.
Encourage the patient to discuss issues of guilt and loss, which will help reduce feelings of guilt and possible thoughts of punishing past actions. 5. Provide the patient with the necessary personal space (when using the toilet, bathing). This maintains self-esteem.
5. "Acceptance"
1.
Maintain contact even if the patient does not want to communicate (reduce feelings of isolation).
2.
Continue to control pain (maintains a state of peace and tranquility in the final stage).
3.
Provide spiritual support (invite a priest...). This will help you rethink your life, repent, and dispel an unreasonable approach to issues of religion and faith.
15
E
TICO
DEONTOLOGICAL
PECULIARITIES
COMMUNICATIONS
DOOMED
A PERSON
FAMILY
CLOSE
Communicating with terminally ill people requires a skill that, although not without difficulty, can be learned. To do this, you need to know yourself, the patient and his family, as well as their attitude and approach to this problem. The ability to communicate requires a person to be honest, respect the feelings of others and have the ability to be compassionate. This skill includes body language, spoken language, and the trust that is established between you and the interlocutor. Communication needs of patients and their families: need for communication between people; in information; in the council; in consolation; in discussing treatment and prognosis; in a conversation about feelings and professional psychological support.
Remember!
The relationship between a nurse and a doomed patient is based on trust. Therefore, do not deceive the patient. In general, patients want to know as much as possible about their condition. However, be prepared to stop if the patient indicates to you that they have received enough information. 1. Set aside time for leisurely, uninterrupted conversation. 2. Sit down and let the patient know that you have time for him. 3. Try to keep your gaze level with the patient's. 4. It is very important to speak in a private environment. 5. It is important to encourage the patient to continue the conversation by showing interest with a nod of the head or a phase: 6. “Yes, I understand.” When people are suffering, they tend to socialize informally, as opposed to when they are calm and in control. Remember that when talking with a patient, it is very important to have optimal physical space between you. The patient will feel uncomfortable if you are too close to him. If it’s far away, this will be an additional barrier to communication. Most people who are dying feel the need to have their closest relatives around them, and everything possible must be done to achieve this. The most important thing that the patient would like to hear during the impending uncertainty is: “No matter what happens, we will not leave you.” “You are dying, but you are still important to us” “Truth is one of the most powerful therapeutic agents available to us, but we still need to know the exact meaning of its clinical pharmacology and find out the optimal time and dosage for its use. It seems we need to delve into the intimate connection between hope and its denial." Simpson
16 The purpose of such communication is: 1. to eliminate uncertainty 2. to give new meaning to relationships with others 3. to help the patient and family choose the right direction For the most part, information should be conveyed not by verbal means, but by touch, glance, and eye expression.
Touch
– an important means of conveying confidence and comfort to the patient (for example, holding his hand, shoulder). There is no need to prevent the manifestation of negative emotions (feelings of anger, grief). M/s must have tact, restraint, and attention. Be prepared for religious and philosophical conversations, dialogues with the patient about justice, the meaning of life, good and evil. The whole difficulty in such a situation lies in the fact that philosophical judgments here, first of all, are important not in themselves, but as a means of consolation, reconciliation of a doomed person with his fate. Dying patients very keenly feel the insincerity of their interlocutor and are sensitive to the slightest manifestations of indifference. Therefore, when communicating with them, it is very important to maintain goodwill, mercy and professionalism, regardless of personal problems and circumstances. Death is often a severe shock for relatives, and therefore in such cases they should be treated with special care and attention and given psychological support. How to behave at the bedside of a dying person, how and what to talk to him about, how to visit a patient - this is what a nurse should teach the relatives of the doomed person. Thus, communication with the patient should be built simultaneously on two principles: on the one hand, never deceive him, on the other, avoid soulless frankness. Fear of death is sometimes associated with fear of the dying process, which in cases of chronic illness is usually accompanied by the appearance or increase of helplessness. It is necessary to convince the patient and his relatives that they will not abandon their loved one and will take care of him until the last minutes. If the patient refuses nursing care related to assistance in ambulation, turning over in bed, to the extent possible, his requests should be fulfilled. At the same time, you should continue basic nursing care, hygiene procedures, ensure cleanliness and prevent bedsores, and use relaxing procedures such as deep breathing, rubbing, massage of the back and limbs, etc. If the dying person is in a hospital due to the severity of his condition, then You can involve relatives in caring for him by teaching them the elements of care. They can, for example, feed the patient, straighten the bed, and carry out some hygiene measures.
Hope
“Hope is the expectation of a little more than nothing in achieving a goal.” "Hope dies last". Why deprive a person of that small ray breaking through the darkness of the night, why deprive him of his last opportunity to be human and realize that he is still needed here, that he is loved.
17 To take away hope means to kill, to kill mercilessly, mercilessly. A dying person must hope, and honey must give him this hope. worker, with his warmth, care, affection, respect. We must never forget that we are all mortal, that sooner or later we will also have to leave this mortal world. Let us remember and love life with all its joys and sorrows and there is no need to darken the last moments of life. Factors Contributing to Hope Decreasing hope Increased hope Undervalued as a person Valued as a person Abandonment and isolation Significance in relationships Lack of direction Realistic goals Uncontrollable pain pain relief discomfort When there is very little hope left, it is quite possible to hope for more than one death.
Right to report diagnosis
It is not customary in all hospitals to tell the truth about the diagnosis and prognosis to doomed patients. The principle applies: “White lies.” Supposedly, this lie helps maintain hope. However, false optimism is the destroyer of hope. Both doctors and nurses act on this principle. This is most likely due to an inability to communicate bad news. In our country, the doctor has the right to inform the patient and his relatives of the diagnosis. The nurse must be able to discuss issues with the patient (if he wishes) and his family within the framework of the information received from the doctor. If you approach this problem professionally and responsibly, then the choice of time and place for such a conversation becomes of fundamental importance. Because this conversation touches on the deep layers of human existence. Sometimes a doctor has to prepare as carefully as for a complex operation. Care should be taken to avoid any interference; In no case should the conversation be “passing” - the doctor (nurse) is obliged to spend as much time on it as the patient needs.
Nursing assistance to loved ones experiencing loss
After loved ones learn the truth from the doctor, the sister can answer questions related to care and ensuring a decent lifestyle. Often relatives have a feeling of guilt towards the dying person, in some cases they experience feelings of anger, rage, and even aggression towards health workers. You should help your loved ones relieve feelings of guilt and tension. Some relatives need to be taught how to behave as if they were at home, how to pay a visit to a sick person. When visiting him, it is not necessary to talk; it is better to show care by adjusting the pillow, carrying out hygiene procedures, and feeding him. Even just sitting and reading a book, a newspaper, or watching TV together can be very important for the patient, because... he feels that he is not alone. When talking with loved ones, asking them questions about the life of the dying person, make it clear that you are ready to provide them with psychological support. Explain to family members that even if the dying person is unconscious, they can hear and feel touch. This means that a quiet conversation with him, a touch on his hand will help him survive the loss.
18 It will be easier for family members if they see that their loved one is being cared for in good faith and that a comfortable environment is maintained in the ward. Despite weakness and helplessness, we must not forget about the patient’s right to choose; every manipulation must be carried out with his permission.
Stages of grief experienced by relatives of the deceased.
Providing psychological assistance to the family of a dying person is an important part of the work of a m/s, which can support the family even after his death. A family experiencing the death of a loved one also goes through stages of grief. 1. Shock, numbness, disbelief
.
Grieving people may feel disconnected from life because... the reality of death has not yet fully sunk into consciousness and they are not yet ready to accept the loss. 2. Pain experienced due to the absence of the deceased person. (the absence of the deceased is felt everywhere, the home and family are filled with painful memories, the mourner is overcome by intense melancholy). 3. Despair (excitement, anger, reluctance to remember). It occurs when the realization comes that the deceased will not return. At this time, the following are often noted: * decreased concentration, * anger, * guilt, * irritability, * anxiety, * excessive melancholy. 4. Acceptance (awareness of death). Depression and emotional fluctuations may continue for more than a year after the funeral. 5. Resolution and reconstruction. Together with the deceased person, old behavioral habits go away and new ones arise, which lead to a new phase of decision-making. A person is able to remember the deceased without overwhelming sadness. Knowledge of the stages of grief experienced by the relatives of the deceased is necessary in order to avoid an incorrect attitude towards the mourner and hot-tempered judgment about his experiences at the moment.
Groups at risk of extreme grief:
Aged people,
Those experiencing the loss of a loved one feel more isolated and need sympathy.
Children,
those who have lost people close to them are very vulnerable and perceive death more consciously than adults think about it: 1. up to 2 years of age, children cannot realize that someone in the family has died. But they are very concerned about it. 2. from 3 to 5 years old, children do not consider death to be an irreversible phenomenon and think that the deceased will return. 3. between 6 and 9 years old, children gradually begin to realize the irreversibility of death, and their thoughts may be associated with ghosts. 4. Teenagers are emotionally vulnerable and experience loss especially hard.
19 Children react in a special way to the loss of their parents. There are several situations that can affect a child: the remaining parent is in deep sadness; the child does not understand what happened because it was not clearly explained to him; change of place of residence and school; small number of family social contacts; deterioration of the social and economic situation of the family, especially when the father dies; marriage of the remaining parent until the child gets used to the idea that the deceased will not return; deterioration in child care. The process of a child experiencing sadness may have the following problems:
1.
sleep disturbance,
2.
appetite disorder,
3.
increased general anxiety (reluctance to leave home or go to school),
4.
moodiness,
5.
mood swings from euphoria to crying, depression,
6.
privacy. A child through the eyes of a parent Very often, parents do not know what to expect from their child and often deny that the child is influenced by what happened. They are often unable to comprehend or respond to obvious signals of childhood grief. This is directly related to the parent’s perception of loss, which can be pathological: denial (continue to live as if nothing happened); hasty choice of a new partner; prolonged denial and anger at responsibilities not fulfilled by the spouse; chronic depression and self-blame.
The role of the nurse in helping a bereaved family:
1. Explain to the remaining parent the physical and emotional reactions the child is exhibiting and emphasize that these are normal in a bereavement situation for children. 2. Recommend books and brochures on these topics. This will help you consider the situation intelligently. Reading these books with your children can be a conversation starter. 3. Encourage the remaining parent to help the children draw, write about a topic related to their loss, and talk about it with others they trust. 4. Encourage the remaining parent to take care of their financial, emotional and social needs. In this case, it is easier for them to respond to the needs of their children.
How to help your child
A child who understands what happened, who spent time with the sick parent before death and said goodbye to him after death, is better able to relate to the new situation with himself. The child must be given the opportunity to express his feelings. A grandparent or friend who urges a child not to cry so as not to upset the living parent should not do so. Children sometimes need to be given permission to express their grief. They need to see their parents' grief and share it with them. The child's basic needs must be satisfied. Regular eating and sleeping patterns in the first weeks after loss; relief from financial problems. The school must be made aware of the child's critical condition.
20 The child needs to be given simple, specific information and the opportunity to ask the same questions, and the adult needs to know for sure that the child understands the answers to his questions. The child needs to constantly discuss what happened, sometimes for months, and he should have this opportunity. The child needs confidence that he will continue to receive attention and that promises will be kept. The child should not be in a state of denial. If the child does not ask questions and acts as if nothing happened, the adult should help the child express hidden feelings and unasked questions. Even very young children need to be talked to and helped to understand that the deceased father/mother will not return. It is very easy to idealize a deceased parent. If the surviving parent and child can grieve together for the one who died, recalling both the good and the bad, the child will feel more comfortable about having mixed feelings about the deceased parent. He also needs assurance that he did not cause or contribute to the illness or death of the parent.
The dying process and its periods
Dying
- in most cases, this is not an instant process, but a series of stages, accompanied by a sequential violation of vital functions.
Death -
irreversible cessation of the body's vital functions. Issues related to the study of the mechanisms of the dying process, as well as the clinical, biochemical and morphological changes in the body that arise during this process, constitute the subject of thanatology (from the Greek thanatos - death, logos - teaching), which is a branch of theoretical and practical medicine. Causes and mechanisms of death outcomes in each specific case are referred to as thanatogenesis. The main causes of death may include, for example, severe injuries incompatible with life of certain organs, massive blood loss, hemorrhages involving the most important centers of the brain, cancer intoxication, etc. The immediate causes of death in various diseases are most often heart or respiratory failure. States bordering between life and death are called
terminal
(from Latin terminalis - final). This condition also includes the process of dying, which gradually affects all organs and systems of the body and includes several stages.
1. Pre-agonal state
(phase duration – from several minutes to several days) the patient’s consciousness is preserved, but confused; Blood pressure drops to 80 mm Hg; increased heart rate and breathing are replaced by their slowdown; skin is pale or cyanotic; thready pulse, tachycardia; breathing becomes faster; ocular reflexes are preserved, the pupil is narrow, the reaction to light is weakened. The preagonal period ends with the appearance of a terminal pause (short-term cessation of breathing), which continues
21 from 5 -10 seconds to 3 - 4 minutes and is replaced by an agonal period (agony).
2. Agony
(from the Greek agonia - struggle) It is characterized by a short-term activation of mechanisms aimed at maintaining vital processes. Initially, the following are noted: a slight increase in blood pressure; increase in heart rate; sometimes short-term (up to several minutes) restoration of consciousness. The apparent improvement in the condition is then quickly replaced again by: a sharp drop in blood pressure (up to 10 -20 mm Hg); slowing down the heart rate (up to 20 - 40 per minute); deep breathing disorder and deep breathing movements such as “swallowing air”; loss of consciousness; pain sensitivity disappears; corneal, tendon, and skin reflexes are lost; general tonic convulsions are observed; involuntary urination and defecation occur (sphincter paralysis) body temperature decreases. The agonal period lasts from several. min. (for example, during acute cardiac arrest), up to several hours or more (with slow dying), after which clinical death occurs. Caring for an agonizing patient The patient must be isolated: o Removed from the general ward. o Separate with a screen. o Transfer to intensive care unit. department o Establish an individual nursing station. M/s should not be absent from the patient: Monitors breathing, pulse, blood pressure, consciousness, and carries out doctor’s orders. In case of sudden disruption of vital functions, it is necessary to call a doctor. When clinical death occurs, the m/s begins resuscitation measures (except for those who died as a result of disorders incompatible with life: malignant neoplasms, blood diseases, cerebral vascular lesions, cardiopulmonary failure, hepatic coma, uremia, etc.)
3. Clinical death
It is a reversible stage of dying, during which external manifestations of the body’s vital functions (breathing, heartbeats) disappear, however, irreversible changes in organs and tissues do not yet occur. The duration of this period is usually 5-6 minutes. Within the specified time frame, with the help of resuscitation measures, complete restoration of the body’s vital functions is possible. After this, irreversible changes occur in the tissues (primarily in the cells of the cerebral cortex), defining a state of biological death, in which complete restoration of the functions of various organs can no longer be achieved.
22 The duration of the period of clinical death is influenced by the type of dying, its duration, age, and body temperature at dying. Thus, with the help of deep artificial hypothermia (lowering a person’s body temperature to 8 - 13 ° C), the state of clinical death can be extended to 1 - 1.5 hours.
4.
Offensive
biological death
it is established both by the cessation of breathing and cardiac activity, and on the basis of the appearance of so-called reliable signs of biological death: decrease in body temperature below 20 ° C; formation of cadaveric spots after 2-4 hours (occur due to the accumulation of blood in the underlying areas of the body); development of rigor mortis (thickening of muscle tissue).
Ascertainment of death and rules for handling a corpse
Ascertainment of biological death is carried out by doctors of hospital departments (if the patient died in the hospital), clinics and emergency medical services (in cases where the patient died at home), as well as forensic experts (when examining a corpse at the place of its discovery) based on a combination of a number of signs : 1. dilation of the pupils and lack of their reaction to light; 2. absence of corneal reflex; 3. clouding of the cornea; 4. cessation of breathing; 5. lack of pulse and heartbeat; 6. muscle relaxation; 7. disappearance of reflexes; 8. typical facial expression; 9. the appearance of cadaveric spots, rigor mortis; 10. decrease in body temperature. If the patient died in a hospital, then: the fact of his death and the exact time of its occurrence is recorded by the doctor in the medical history. the corpse is undressed, laid on its back with the knees bent, eyelids are lowered, the jaw is tied up, covered with a sheet and left with a sheet and left in the department for 2 hours (until cadaveric spots appear).
Rules for handling a corpse
Currently, due to the widespread use of organ transplant operations, the previous deadlines for possible autopsies of dead bodies in hospitals have been revised: now autopsies can be carried out at any time after doctors in medical institutions have established the fact of the occurrence of biological death. Before the body is transferred from the department to the morgue, the m/s performs a series of procedures that are the final manifestation of respect and care towards the patient. The specifics of the procedures vary from hospital to hospital and often depend on the cultural and religious background of the deceased and his family. The chaplain can provide support to the family, other patients and staff. In some medical institutions, after death has been declared, morgue staff are invited to the department to prepare for the farewell to the patient.
23 An employee performing this procedure for the first time or who is a relative of the deceased requires support.
Equipment
transfer of valuables and documents form soap death notice forms tray disposable apron and clean sheets plug disposable gloves envelope identification bracelets adhesive tape wide adhesive tape disposable wipes Prepare equipment in advance. If possible, everything should be disposable. Please read the hospital's rules regarding this procedure in advance. Privacy must be ensured at all times. It is important that loved ones can express their feelings in a quiet, calm environment.
24 As a rule, death is confirmed by the attending physician of the department, who issues a medical certificate of death. The death must be declared in the nursing journal and in the medical history. If the relatives were not near the patient, the doctor informs them (it is better to do this not by phone, but by inviting them to the hospital for a conversation). These people need sensitivity and compassion. It is necessary to treat with understanding different reactions to the news of death, to invite relatives to the ward to say goodbye to the deceased. Other patients often know that death was expected or has occurred. It is important to offer them support and comfort and answer questions calmly to avoid misunderstanding and fear.
25 To avoid contact with body fluids and to prevent infection, wear gloves and an apron. Check local infection control regulations in advance. Lay your body on your back, remove the pillows. Place your limbs in a neutral position (arms along your body). Remove any mechanical attachments, such as tires. Rigor mortis appears 2-4 hours after death. Cover your body completely with a sheet if you must be away. Gently close your eyes using gentle pressure for 30 seconds. on drooping eyelids.
26 Wounds with discharge should be covered with a clean, waterproof diaper and securely secured with wide adhesive tape to prevent leakage. Find out from relatives whether it is necessary to remove the wedding ring. Fill out the form and ensure the safety of your valuables. Jewelry must be removed in accordance with hospital policy in the presence of a second nurse. A list of decorations must be included on the death notification form. Complete patient identification forms and identification bracelets. Attach the bracelets to your wrist and ankle. The death notice must be completed in accordance with the hospital's policies, which may require that the document be attached to the patient's clothing or sheet.
27 Cover the body with a sheet. Contact paramedics to transport the body to the morgue. Relatives can once again say goodbye to the deceased in the funeral hall after permission from the morgue staff. Remove and dispose of gloves and apron in accordance with local regulations and wash your hands. It is important to provide emotional support to patients even after the deceased is removed from the department. Staff may need the same support. All manipulations must be documented. A record is made of religious ceremonies. Data are also recorded on the method of wrapping the body (sheets, bag) and applied bandages (on wounds, on holes)
Palliative care
In 1981, the World Medical Association adopted the Lisbon Declaration, an international set of patient rights, including the human right to die with dignity.
28 But earlier, in most civilized countries, special institutions were opened that were involved in helping dying people and their relatives. Doctors realized that people on the verge of death do not need medical help, but an independent medical discipline that requires special training and attitude towards patients. The disease may reach a stage where curative therapy is powerless and only palliative care is possible. Previously, they died at home, but caring for such a patient is extremely difficult, and it is not always possible. This is difficult for everyone - both for the dying themselves and for their relatives. Both suffer from unbearable pain: some from physical pain, others, seeing their own powerlessness, from moral pain.
Palliative care
(WHO definition) is active multifaceted care for patients whose illness is not curable. The primary goal of palliative care is to relieve pain and other symptoms and resolve psychological, social and spiritual problems. It is also necessary for support after loss. The goal of palliative care is to create a better quality of life for the patient and his family. Principles of palliative care: 1. Affirms life and perceives dying as a normal process. 2. Does not accelerate or delay death. 3. Sees the patient and family as a unit of care. 4. Frees the patient from pain and other severe symptoms. 5. Provides a support system to help patients live as actively and creatively as their life potential. 6. Offers a support system to help families cope during the patient's illness and bereavement. The spectrum of patients in need of palliative care: patients with malignant tumors patients with irreversible cardiovascular failure patients with irreversible renal failure patients with irreversible liver failure patients with severe irreversible brain damage AIDS patients Interaction of people providing palliative care Palliative care is best delivered by a group of people working as a team. The team is collectively focused on the overall well-being of the patient and family. It includes: doctors, junior medical staff, psychologists, church ministers Basic principles of medical ethics: respect life accept the inevitability of death use resources rationally do good minimize harm
29 When a person is terminally ill, their interest in eating and drinking is often reduced to a minimum. The patient's loss of interest and positive attitude should also be perceived as the beginning of a process of “non-resistance.” Apart from those who die suddenly and unexpectedly, there comes a time when death is natural. Thus, a time comes when, due to the natural order of things, the patient must be allowed to die. This means that the doctor in such circumstances takes responsibility by allowing the patient to die. In other words, in certain circumstances the patient has a “right to die.” If physical and mental torture is considered unbearable and difficult to control, the most radical remedy is to put the patient into a state of sleep, but not to take his life. The possibility of recovery cannot be ignored. Except in cases where death is imminent, the possibility of improvement in the patient's condition cannot be ruled out.
Principles of patient care in a hospice setting. Hospice movement
Hospices are more than just specialized hospitals for the dying. They are in many ways the negation of “just a hospital.” The difference between a hospice and a “just hospital” is not only in the technical equipment, but also in a different philosophy of healing, according to which the patient is created with the “living space” necessary for his condition. The initial idea of the hospice philosophy is very simple: a dying person needs special help, he can and should be helped to cross this border. In hospice, personality (the patient's wishes, his emotional reactions) is brought to the fore. People don’t get sick in these hospitals, much less get better; they die here, but with dignity. Hospice provides such living conditions for the patient, such a way of life, when it is the present, and not the future, that is relevant. It is customary to fulfill the patient's last wish. Literally translated from English, hospice means “house of peace.” Here the employees try to provide an acceptable comfortable quality of life. The first institution for the care of the dying to use the word "hospice" arose in France in 1842. Madame Jeanne Garnier founded a hospice in Lyon for people dying of cancer. In England, the Irish Sisters of Charity were the first to use the word "hospice" when they opened hospices in London in 1905. The first modern hospice, St Christopher's, was founded in London in 1967. Its founder is Baroness Cecilia Saunders, a trained nurse and social work specialist. This movement has spread throughout the world since the early 60s. The first hospice in Russia was created in St. Petersburg in 1990. This happened thanks to the initiative of Victor Zorza, a former journalist whose only daughter died of cancer in an English hospice in the mid-70s. He was greatly impressed by the high quality of hospice care for his dying daughter, so he set out to create similar centers himself that would be available to all regions. Victor Zorza promoted the idea of hospices in Russia in his interviews on television and radio, and in newspaper publications. This resonated with government agencies across the country. And in 1991, “The ability to live well and die well is one and the same science” Epicurus was created
30 Order of the RSFSR No. 19 “On the organization of nursing homes, hospices and specialized hospitals.” Currently, more than 20 hospices have started operating in Russia. The structure of Russian hospices mainly includes: mobile service day hospital inpatient treatment administrative unit educational and methodological unit socio-psychological volunteer economic The heart of the hospice is the mobile service, and the main working unit is a nurse trained in the provision of palliative care help.
Basic principles of hospice activities:
1. Hospice services are free. You can't pay for death, just like you can't pay for birth. 2. Hospice is a house of life, not death. 3. Controlling symptoms allows you to qualitatively improve the patient’s life. 4. Death, like birth, is a natural process. It cannot be slowed down or rushed. Hospice is an alternative to euthanasia. 5. Hospice is a system of comprehensive medical, psychological and social care for patients. 6. Hospice – school and support for the patient’s relatives and loved ones. 7. Hospice is a worldview of humanism.
IV. INDEPENDENT WORK BLOCK
Instructions for the teacher:
1. Instruct students about the regulations, rules for performing independent work, and evaluation criteria. 2. Distribute students into pairs to draw up a situational task (using a template) and practice practical skills in identifying signs of clinical or biological death (when forming pairs, you should
31 take into account the level of basic knowledge). 3. While preparing situational tasks and practicing practical skills, the teacher monitors the correctness of the manipulations, makes adjustments, and gives recommendations. 4. The teacher, using physiological indicators from situational problems (compiled by each pair), enters the data into the SUSIE simulation mannequin program and offers them for solution to other groups of students.
4.1 Z
ADANIA
INDEPENDENT
WORKS
Instructions for students
Exercise 1.
Using the supporting lesson notes and knowledge on previously studied topics PM 04 (“Assessment of the functional state of the patient”, “Cardiopulmonary resuscitation”, etc.), create a situational problem and a standard for solving it according to the proposed scheme. Situation …………………………………………………………………………………………………………… …………………… ……………………………………………………………………………………… ……………………………………………………………… ……………………………………………………………… ……………………………………………………………………………… ………………………………………………………… Symptom Indicators of functional state note Stage of dying State of consciousness Pathological type of breathing RR Artery for determining the pulse BP Presence of convulsions Presence of cyanosis Condition of the skin Condition of the pupils Presence of stomas, drainages
Task 2
. Fill out the necessary documentation for your situational task (acceptance receipt, death certificate)
Task 3.
Each pair (with the help of the teacher) puts data on their situation into the manikin program and invites other groups of students to solve it.
V. BLOCK
FINAL KNOWLEDGE CONTROL
Instructions for the teacher:
1. The teacher distributes assignments with situational problems. 2. Students take turns reading their situations out loud and commenting on their solution. 3. The teacher evaluates the student’s answer, focusing on the standard for solving the problem. 4. Students are given cards with a written task (tests, assignment
32 for compliance) 5. After solving each task, the teacher asks students to check the correctness of its completion.
5.1 C
ITUATIONAL
TASKS
Problem 1
In the therapeutic department 10 min. ago, the doctor recorded biological death in patient A. During the period of agony, a large amount of liquid, bloody stool was released. The probe, which is located in the stomach, reveals a discharge the color of coffee grounds mixed with fresh blood. What are your next tactics?
Problem 2
Patient V. categorically refuses to lie down on the offered bed, since, according to the neighbors in the ward, another patient died on it yesterday. What should be the nurse's next strategy?
Problem 3
At your post in the department 15 minutes. ago, the doctor recorded biological death in patient M. What are your further tactics?
Problem 4
The neighbors in the ward of a dying patient approached the nurse with a request to help him. The nurse told them that nothing would help the patient and she was not going to waste time on him. Evaluate the nurse's actions.
Problem 5
The guard nurse went into the ward to remove the IV from patient S., who was being treated in the cardiology department. Entering the room, she noticed that the patient’s eyes were closed, he was not breathing, his skin was pale with a marble tint, and he had a specific facial expression. The pulse on the carotid artery is not detected. The drip continues to drip. By all indications, the patient died. The other 2 patients in the ward are resting - sleeping during quiet time. Determine the nurse's further tactics and actions?
Problem 6
You are a guard nurse on a therapeutic department. One of your patients was transferred to the intensive care unit during the day due to a sharp deterioration in his condition. You already know that the patient could not be saved and he died. Relatives call the post and inquire about the patient’s condition. What can you tell your family based on the facts you know?
Problem 7
A visually impaired (practically blind) neighbor came to your house with a request to see what was wrong with his son, who had gone to rest during the day, had been sleeping for 4 hours, and when trying to wake him up, did not answer his father. Upon examination objectively:
33 - skin is cold, pale, cyanotic to the touch; - the pulse in the carotid artery cannot be felt; - eyes are closed, pupils do not react to light; - the mouth is slightly open, breathing is not audible; Assess the situation and decide on further actions.
Problem 8
Provide psychological support to a patient in the “denial” stage.
Problem 9
You are a neurology nurse. When transferring duty, you were informed that there was a dying patient at your post, who kept calling for a woman named Tatyana. There is another patient in the room with the dying man. How can you help and brighten up the last hours or minutes of a dying person? What kind of help might your roommate need?
Problem 10
You are a school nurse. The class teacher of an 8-year-old boy who recently lost his mother has approached you to take part in a conversation with the remaining parent - his father. The boy has lost a lot of weight, has become less sociable, often secludes himself, cries, has become capricious, and does not want to study. Give advice to the boy's father.
34
5.2 I
TRADE
TEST
CONTROL
TOPIC
"Losses. Death. Grief. Nursing assistance"
Instructions:
select one index of the correct answer
1.
A reliable sign of biological death is
A)
absence of carotid pulse
B)
constriction of the pupils
IN)
pale skin
G)
appearance of cadaveric spots
2.
After how many hours is the body of the deceased transferred to the pathology department?
department after declaring biological death?
A)
immediately after death is pronounced
B)
in 1
IN)
in 2
G)
in 6
3.
After the doctor has confirmed the patient's death, the nurse should fill out
A)
doctor's prescription sheet
B)
cover page of medical history
IN)
accompanying sheet
G)
temperature sheet
4.
The irreversible stage of the death of an organism is
A)
clinical death
B)
agony
IN)
biological death
G)
preagony
5.
After the death of the patient, the mattress must be subjected to
A)
chamber disinfection
B)
air ventilation
IN)
beating in the air
G)
boiling in an alkaline solution
6.
Where should the corpse be located before being sent to the pathology department?
A)
in the ward where the patient died
B)
in the department, in a specially designated place
IN)
after the fact of death is established, the corpse must be immediately sent to the morgue
7.
Palliative treatment is treatment with the aim of:
A)
cure the patient
B)
lengthen life
IN)
improve quality of life
8.
Which medical personnel have the right to inform relatives about death?
patient?
A)
doctor
B)
head nurse
IN)
nurse
9.
Unfavorable prognosis for the course of the disease received from a doctor, views
patient for life
A)
doesn't change
B)
changes
IN)
remain unchanged
10.
Hospice is:
A)
death house
B)
care home
IN)
life extension house
35
11.
Terminal state includes:
A)
Stage 1
B)
2 stages
IN)
3 stages
G)
4 stages
12.
A terminal pause is a short-term:
A)
respiratory arrest
B)
loss of consciousness
IN)
cardiac arrest
13.
There are 5 stages of emotional grief. Name them:
1.
______________________
2.
______________________
3.
______________________
4.
______________________
5.
______________________
14.
Before being sent to the pathology department, the corpse must be in
department within ______ hours until reliable signs of death appear.
Name them:
1.
______________________
2.
______________________
3.
______________________
4.
______________________
15.
Name the phases of the terminal state in the order they appear
1.
2.
_____________________________
3.
_____________________________
16. Instructions:
Fill out the table by entering the required characteristics from the list provided.
“Signs of clinical and biological death”
Signs of clinical death
Signs of biological death
4.
Lack of consciousness, appearance of cadaveric spots, lack of pulse, clouding of the cornea, rigor mortis, lack of breathing, decrease in body temperature to ambient temperature, lack of pupillary reaction to light.
36
VI. BLOCK OF STANDARD ANSWERS
TICKET
ANSWER
TASK
ORIGINAL
LEVEL
KNOWLEDGE
"Pulse Study"
Instructions:
write the names of the arteries where the pulse is examined
E
TICKET
ANSWER
TASK
IS
CONTROL
ORIGINAL
LEVEL
1.
IN
2.
A
3.
apnea
4.
bradycardia
5.
tachycardia
6.
G
7.
A
8.
A
9.
A
10.
B
Evaluation criteria
"5"
0-1 errors
"4"
2 errors
"3"
3-4 errors
"2"
more than 5 errors
Temporal artery
Dorsal artery. feet
Popliteal artery
Radial artery
Carotid artery
Posterior tibia ar.
Femoral artery
Plechev
artery
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6.2 E
COUPONS
ANSWERS
SITUATIONAL
TASKS
Problem 1
The nurse must work according to the rules for working with biological material and treat it as potentially infected with AIDS. To avoid contact with body fluids and to prevent infection, wear gloves and an apron. Liquid, bloody stools are disinfected by covering them with disinfectants in the following ratio: 1 g. dry preparation per 5 g. discharge - 1:5. The probe must be removed. Wounds with discharge should be covered with a clean, waterproof diaper and securely secured with wide adhesive tape to prevent leakage.
Problem 2
The nurse can offer Patient B a place in another room or on another bed. Conduct a conversation with all patients in this ward, explaining that after each patient, mattresses are disinfected in the disinfection chamber, and the bed itself is wiped down with disinfectants. Therefore, the mattress on which the deceased was lying is now being processed and the bedding has been replaced with other (clean) ones. It is important to answer questions calmly to avoid misunderstanding and fear. You can involve the attending physician or psychologist in the conversation with patients.
Problem 3
1. Place your body on your back, remove the pillows. 2. Place the limbs in a neutral position (arms along the body). Remove any mechanical attachments such as tires. Rigor mortis appears 2-4 hours after death. 3. Gently close your eyes, applying light pressure, for 30 seconds. on drooping eyelids. 4. Jewelry must be removed in accordance with hospital policy in the presence of a second nurse. A list of decorations must be included on the death notification form. Fill out the form and ensure the safety of your valuables. 5. Complete patient identification forms and identification bracelets. Attach the bracelets to your wrist and ankle. 6. The death notice must be completed in accordance with the hospital policy, which may require that this document be attached to the patient's clothing or sheet. 7. Cover the body with a sheet. Contact paramedics to transport the body to the morgue. All manipulations must be documented. Data are also recorded on the method of wrapping the body (sheets, bag) and applied bandages (on wounds, on holes)
Problem 4
The nurse violated ethical standards and turned out to be indifferent to the dying man and the problems of the patients in the ward, who were also experiencing a state of psychological shock. Such a nurse has forever lost the respect and trust of her patients.
Problem 5
1. Shut off the IV and don’t touch anything else. 2. Without disturbing the sleep of the roommates, quietly call a doctor (to confirm death). 3. Separate the deceased with a screen. 4. When waking up your roommates, if possible, ask them to leave. 5. After the doctor has confirmed the fact of death, take measures to care for the corpse, transport the corpse to the office premises for 2 hours.
38 6. Fill out the required documentation. 7. Provide the doctor with a telephone number from the medical history to inform relatives about death.
Problem 6
The right to inform relatives about death must be granted to the doctor. The nurse may tell the family that the patient's condition was of concern to the doctors and he was transferred to the intensive care unit. They should obtain further information from their attending physician or by calling the intensive care physician.
Problem 7
According to objective data, biological death has already occurred (in a dream). You need to call and get an ambulance to confirm the fact of death. The father needs to be seated, given a sedative and remain there until the ambulance arrives. Before the ambulance arrives, find out the phone numbers of your closest relatives.
Problem 8
1.
Find out your (m/s) feelings towards death, because... personal hostility and fear can be transferred to the dying person.
2.
Ask the patient to describe on paper his feelings, concerns, and fears. This promotes psychological processing of these emotions. It is important to sit by the patient’s bed (his feeling of abandonment decreases); listen carefully and empathize with the patient’s feelings (reduces feelings of isolation, promotes relationship building); support your hand, touch your shoulder (physical touch brings a feeling of comfort to some patients and demonstrates care for them).
3.
Inform the patient. Encourage questions that he is willing to ask (the right information can reduce anxiety and clarify the situation). However, if the patient has a pronounced denial reaction and does not want to know about death, then you cannot talk about it, it would be a mistake.
Problem 9
It is necessary to isolate the dying person (if possible, transfer the neighbor to another ward). Using the medical history (or from a neighbor), find out the contact numbers of relatives to establish Tatyana’s identity. Invite relatives to visit the patient in the correct form. Or give the doctor the right to inform relatives about the patient’s approaching death and the need to say goodbye to him. Your roommate may need help from your attending physician or psychologist. It is important to answer questions calmly to avoid misunderstanding and fear.
Problem 10
1. Explain to the remaining parent the physical and emotional reactions the child is exhibiting and emphasize that these are normal in a bereavement situation for children. 2. Recommend books and brochures on these topics. This will help you consider the situation intelligently. Reading these books with your child can be a conversation starter. 3. Encourage the remaining parent to help the boy draw, write about a topic related to their loss, and talk about it with people they trust. 4. Encourage the remaining parent to take care of their financial, emotional and social needs. In this case, it is easier for them to respond to the needs of their children.
39
6.3 E
TICKET
ANSWER
TOTAL
Suicidal symptoms of the MMPI profile
Based on all of the above, we highlight MMPI profile features, especially alarming in relation to suicidal readiness.
High values on the correction scale (K);
Peak profile on scale 4 - antisocial psychopathy (Pd);
The leading peak of the profile on a scale of 8 is schizophrenia (Sc);
Any combination of peaks on scales 2 (depression), 4 (antisocial psychopathy), 8 (schizophrenia) and 9 (hypomanic).
The reliability and accuracy of suicide risk assessment using the MMPI increases with repeated follow-up studies. For example, if the first study reveals a peak on scale 2 (depression) and a decrease in the profile on scale 9 (hypomania), then in the absence of other peaks, such a picture, despite the presence of depressive experiences, does not indicate a high suicidal risk. Even if there are suicidal intentions, the subject’s motor potential is reduced and during the study period he simply does not have the strength to commit suicidal actions. If, in subsequent studies, an increase in values on scale 9 is noted, then this indicates an increase in the likelihood of committing suicide, even if the peak on scale 2 decreases. The increase in suicidal risk is due to the fact that the subject becomes more active, actuators are activated, as a result of which he can commit a previously planned suicide.
American psychiatrist J. Moltsberger proposed a clinical method for assessing suicidal risk, which he called “Methodology for determining the risk of suicide”. This methodology takes into account the following aspects:
Valid biographical material;
Information about the patient’s disease (disorder);
Assessing the patient's current mental state.
The Moltsberger method for determining suicide risk includes five factors:
1) assessment of the patient’s previous reactions to stress, especially to losses;
2) assessment of the patient’s vulnerability to three life-threatening affects:
Loneliness
Self-contempt
Morbid hatred;
3) assessment of the availability and nature of external support resources;
4) assessment of the occurrence and emotional significance of fantasies about death;
5) assessing the patient’s ability to test his judgments with reality.
Let's consider each of the factors in more detail.
Particular attention is paid to significant and critical life events and periods:
Start of school
Adolescence,
Disappointments in love, work or school,
Family conflicts,
Death of relatives, friends, children or pets,
Divorce and other psychosocial trauma and loss.
An attempt should be made to discover the consistency of suicidal behavior with the general style of behavior throughout life. People tend to overcome future difficulties in the same ways as in the past.
Of particular interest are past suicide attempts, their cause, purpose and severity. In addition, it is necessary to determine who or what is the patient's support during difficult times.
Next, one should find out whether the patient has a history of depression and whether he has a tendency to lose hope when faced with difficulties, in other words, whether he is prone to manifesting despair. Suicide and serious suicide attempts are much more strongly correlated with despair than with depression.
