Hospice Care for C.N.A.s Prepared by Ellen Williams, CAHPN for Capitol Community College
Jan 19, 2016
Hospice Care for
C.N.A.s
Prepared by Ellen Williams, CAHPNfor
Capitol Community College
Objectives
At the end of the course learner will be able to:
• Discuss hospice philosophy and care
• Discuss importance of communication and IDT in hospice care
• State the role of C.N.A. in pain control
• State the role of C.N.A. in dyspnea
• Discuss nearing death awareness
• State the role of the C.N.A. at time of death
• Discuss the importance of self care
2
Dying Well
• Deeply personal experience• Natural part of life• Growth opportunity
3
Dying Well
• Manage needs of patient and family– Physical
– Emotional
– Spiritual
• Goals– Symptoms well controlled
– Be at peace
4
Fears That Arise When Thinking of Own or Family Death
• Being alone
• Having discomfort
• Loosing control
• Loosing loved ones/ life without him/her
• Life had no meaning
• Unknown
5
History of Healthcare in Dying
• No treatment--death at home
• Focus on treatment of disease--death is failure
• Death in hospitals, institution
• Medical technology has limits
• Hospice movement
• Education and training
6
Hospice Care and Philosophy
7
Goals in Hospice
• Quality of life
• Symptom control
• Openness and honesty in dealing with dying process
• Support for patient and family
• Focus on patient and family goals
• Peaceful death
• Allow natural death
8
Overview of Hospice Philosophy
• Interdisciplinary team
• Pt and family as unit of care
• Across many settings
• Pt and family as unit of care
• Quality of life
• Aggressive symptom control
• Cancer
• Non cancer illness
• Let nature take its course
9
Hospice Interdisciplinary Team
• Nursing– CNA’s
• Counseling– Social work
– Spiritual
– Bereavement
– Dietary
• Volunteers• Medical director
10
Symptom Control
• Pain• Difficulty breathing• Cough• Respiratory congestion• Nausea and vomiting• Nutrition and hydration• Anxiety• Delirium
11
Hospice Medicare Benefit
• Available for anyone who has Medicare A• Covers hospice services• Covers medicine and equipment related to
terminal condition• Levels of care
– Routine– Inpatient– Continuous care– Respite
12
Cancer
• People who are not responding to treatment
• People who choose not to have treatment
• People who are not candidates for treatment
13
Non-Cancer Illnesses
14
Non-Cancer Illnesses for which Hospice may be Appropriate
• Acute Cerecute Cerebrovascular Accident (CVA) – Commonly referred to as a ‘stroke’ when patient has severe deficits.
• Autoimmune Deficiency Syndrome (AIDS) – Caused by a virus, which attacks the body’s immune system and leaves the patient susceptible to many life-threatening diseases including bacterial infections and cancers.
• Amyotrophic Lateral Sclerosis (ALS) – This is also called Lou Gehrig’s disease. Cause unknown, but the disease is characterized by an advancing degeneration of portions of the nervous system, causing weakness and progressive loss of function.
• Alzheimer’s Dementia – Caused by degeneration of the brain cells. The disease is progressive, with the rate of progression varying widely among individuals. In the final stages the patient frequently discontinues eating and drinking.
15
Non-Cancer Illnesses ... (continued)
• Cardiac Disease – This group includes many diseases of the heart that may be life threatening, such as congestive heart failure and cardiomyopathy. Fluids may accumulate in the tissues, generating swelling (edema) or in the lungs producing congestion and difficulty breathing.
• Chronic Obstructive Pulmonary Disease (COPD) – This includes several diseases on the lungs, characterized by obstruction of the tiny air passages or air sacs in the lungs. Breathing becomes difficult and patients frequently require oxygen.
• Debility Syndrome – or Failure To Thrive. Patients without one specific diagnosis that is considered terminal, but with multiple diagnoses contributing to a general system failure.
• Kidney Disease – Kidneys are not functioning correctly. Patient chooses to stop dialysis or not start.
16
Non-Cancer Illnesses ... (continued)
• Liver Disease – Diseases may include cirrhosis, hepatitis or vascular disorders of the liver. Patients with end stage liver disease may become confused then lapse into a coma due to accumulations of toxins in the blood. Cirrhosis is caused by many different things, not necessarily alcohol.
• Multiple Sclerosis - Multiple Sclerosis is a progressive disease in which nerve fibers of the brain and spinal cord lose their myelin cover.
• Parkinson’s Disease - a slowly progressive neurological disorder characterized by resting tremor, shuffling gait, stooped posture, rolling motions of the fingers, drooling and muscle weakness, sometimes with emotional instability.
17
Dementia
• Dependent with dressing• Dependent with bathing• Unable to ambulate independently• Incontinent of bowel and bladder• Unable to speak more than six words
meaningfully
18
Dementia
At least one of the following medical complications:• Aspiration pneumonia
• Recurrent fever despite antibiotic treatment
• Upper respiratory infection
• Urinary tract infection
• Weight loss of 10 % in six months or less
19
Goals of Care
• To provide care that matches the resident’s and family’s goals and values
• To guide everyday clinical decisions and actions• To make sure we use healthcare resources
wisely
20
C.N.A. Roles
• Listening to residents and families and helping them to identify and express their goals, values, and wishes
• Communicating goals, values, and wishes to other team members
• Encouraging residents and families to discuss their goals and wishes with other hospice interdisciplinary team members (e.g, MD, spiritual care counselor, social worker, nurse)
21
Goals of Medical Therapies
• Care
• Control
• Comfort/palliation
22
Decisions at the End of Life
Should I continue with treatments aimed at curing my disease or condition?
or
Should the focus of my medical care be on keeping me comfortable?
23
Decisions at the End of Life
If my condition gets worse or I develop a If my condition gets worse or I develop a medical problem:medical problem:
Do I want to be transferred to a hospital?
or
Do I want to be cared for at the nursing home or my home or my child’s?
24
Decisions at the End of Life
• If I can no longer make decisions for If I can no longer make decisions for myself, who should make the decisions for myself, who should make the decisions for me?me?
• What decisions do I need to make to get What decisions do I need to make to get my affairs in order?my affairs in order?
25
Decisions at the End of Life
If I needed machines and other medical If I needed machines and other medical treatments to stay alive:treatments to stay alive:
Would I want to receive those therapies?
or
Do I want nature to take its course?
26
Treatment Options
Decision makers need to understand risks/benefits and probable outcomes of therapy:
• CPR/mechanical ventilation• Kidney dialysis• Diagnostic tests• Hospitalization• Antibiotics• Blood transfusions• Tube feeding/intravenous fluids• Pain management and comfort care
27
Exploring Values and Beliefs
• Who should speak for me?• What makes my life worth living?• What are personal and spiritual beliefs that
influence decisions?• Hope for recovery?
28
Advance care planning,
informed consent,
and
medical decision making are
Processes
29
Ideally, identifying goals of care
occurs
before a major change
in resident status or a medical crisis
30
Ideally, the Resident is Able to Make Decisions
• Understands the information given
• Thinks clearly about treatment options
• Can communicate decisions
31
Residents Who Might Not be Able to Make Decisions
• Those with advanced dementia
• Who have had strokes that decrease their ability to understand or to speak
• Who are in a coma
• Who have a serious mental disease
32
Don’t Assume a Resident is Unable to Make Good Decisions Because:
• They are strange or odd• They don’t speak your language• They are not well educated• They are physically handicapped• They are deaf• They disagree with their family or the health
care team
33
Advance Directives
• Are written instructions (directives) to a health care provider before (advance) the need for medical treatment
• Ensure that your wishes are followed in the event that a future accident or illness makes it impossible for you to communicate your wishes
• In an AD, you can refuse or consent to future treatment
34
Types of Advance Directives
• Living will (health care directive)• Durable power of attorney for health care
(health care proxy)• No code/do not resuscitate (DNR)• Anatomical gifts - tissue/organ/body
donation• Do not hospitalize (DNH)
35
Purposes of Advance Directives
• To help a person maintain autonomy after he or she can no longer make decisions; helps ensure that person’s wishes are honored
• Provides guidance to family and caregivers about type and goals of care
• Can decrease family and caregiver distress about decision making
• Can decrease conflict around EOL decision making
36
Who Can Make Decisions if the Resident isn’t Capable?
(List is in order of priority)• Appointed guardian• DPOA - HC• Patient's spouse• Adult (18+ years) children• Patient’s parents• Adult brothers and sisters• If none of the above, guardian may be appointed
RCW 7.70.065
37
Communication in Hospice
• Staff
• Patient
• Family
38
Basic Principles of Communication
• One cannot not communicate• Communication is a two way activity• Much communication is nonverbal• Actions and words are perceived by the
receiver based on own personal experiences• Listening is one of the most important parts of
EOL communication
39
Communicating with Staff
• Hospice IDT important in exploring all aspects
• Need to update one another with patient and family issues
• Each patient has individual needs• Update nurse as you find new information or
needs• Update individual care plans
40
Co-Workers
• Update them on new concerns with patient or family or care needs
• Report how the day is going• There may be emotional upheavings• Report what has helped
41
How to Address Your Patients
• Ask what they want to be called• Find if they have a nickname they want used• Many folks find “honey” and “sweetie”
insulting
42
Cultural Influences
• One’s rules for communication (is touching OK?)
• How emotions are expressed• One’s view of illness and death• How the family makes decisions and who the
sick person wants to speak for him or her
43
Life Experiences
• People often die how they have lived• People who have not trusted much most likely
still will not trust• People who have been demanding will
probably continue to be demanding• People who have been fairly happy will
probably still be somewhat pleasant
44
Some Challenges in Communication in Hospice
• Society's denial of death -- how openly families will talk about approaching death
• Patient and family’s fears and emotions• Dementia and severe illnesses where patients
are not able to talk about their wishes
45
Caregiver Challenges
• Not sure of what to say• Not having “the answers”• Fear of showing own emotions• Fear of making a mistake which might upset
the family or patient• One’s own fear of dying• Having trouble with patient or family
reactions
46
Family Emotions
• Fear
• Guilt
• Hopelessness
• Helplessness
• Anger
• Sadness
• Relief
• Ambivalence
• Acceptance
47
Tips on How to Respond
• Remove yourself from the situation
• Ask yourself : what am I feeling? Anger? Fear?
• How are you showing these feelings?
• Are they affecting your care?
• Talk with other team members
• Make a plan to deal with the conflict with the team
• Use “I” statements: ”I feel uncomfortable when you raise your voice”
48
When Communicating With Someone Who Is Upset
• Stay calm • Do not raise your voice• Treat them with respect• Do not argue or touch the person• Answer questions or if you do not know, find
someone who can• Let the person vent but do not let them abuse you• Remember anger is normal part of grieving process
49
Concepts in EOL Communication
• Being present is most important• Use active listening• Allow the patient and family let you know
what is important to them• Encourage life review • Listen to all tell their story
50
Working With Hospice Families
• Legitimize their feelings: “I would feel that way, too”
• Normalize feelings: “Many families feel this way when going through this transition time”
• Be aware of your own personal opinions:– Do not bring your own agenda into any discussion
– Ask yourself: Who wants this?
– Our expectations may not be met-- allow patients their own agenda
51
Keep Questions to a Minimum
• Only ask necessary questions• Respect privacy of both patient and family• If you need to ask a sensitive question, explain
why it is important
52
Hope at EOL
• Self: accepting and moving beyond current suffering
• Rational: setting goals and keeping control• Relational: being connected to others• Spiritual: being connected to God or
something larger than self
53
Professional Relationships
• Are different from personal relationships• Are one way• Stick to agency rules• Are confidential but not secret• Do not continue outside of work
54
Common Mis-Assumptions
• It’s the other person’s fault/problem when communication is poor
• The other person can always change the way they are
• It works to treat everyone the same way
55
Communication Don’t’s
• Use “should” or “ought”• Give advice or offer solutions• Argue and/or repeat your point• Make dramatic comments• Judge, criticize, or place blame• Threaten• Interrupt
56
Communication Don’t’s (continued)
• Make light of patient’s problems• Feed into patient’s problems• Promise extra care “this time”• Talk about other patients or families• Talk about your own problems• Dwell on the past• Ask for their help
57
Communication Do’s
• Be consistent
• Be kind
• Follow agency policies
• Set clear boundaries
58
Keys to Good People Skills
• Self-awareness• Thinking about and taking into account
someone else: “walk a mile in their shoes”• Know your purpose; be aware of what you are
trying to accomplish• Avoid making the other person wrong• Change your approach if the one you are using
is not working
59
Techniques
• Smile
• Open eyes
• Steady even rhythm
• Give patient and family choice
• Explain what you will do
60
Techniques (continued)
• Listen
• Repeat back what you understand the person to have said
• Find common ground
• Honor diversity
• Be as specific as possible
61
The Basic Principles
• Focus on the situation, issue, or behavior, not the person
• Help to maintain the self-confidence and self-esteem of others
• Maintain constructive relationships• Take initiative to make things better• Lead by example
Zenger Miller, Inc
1994
62
Points to Remember
• Remember why you are there • Be aware of your own reactions and how they
impact how you are coming across• Be respectful• Know that how you communicate makes a
difference
63
Emotional Issues
64
Emotional Issues
• Deal with anxiety about terminal illness• Unfinished business• Long term planning for self and family• Family issues: “Did I do enough?”• Financial issues
65
Dealing With Emotional Issues
• Listening is important• Realize family patterns cannot be changed• Allow patient and family to talk about feelings
• Feelings may change from day-to-day or hour-to-hour
66
Pain
67
Pain Definitions
• “an unpleasant sensory or emotional experience” -- IASP
• “anything the patient says it is” -- Margo McCaffrey
68
Pain Versus Suffering
• Pain can be on many levels• Most people think it is only physical• When emotional or spiritual pain is involved,
this often becomes suffering• Sometimes the physical pain needs to be
controlled for the patient to get to this level• All the members of the hospice IDT become
involved and are important
69
Common Types of Pain
• Arthritis• Nerve related -- diabetic neuropathy, after
shingles, phantom pain after amputation• Constipation• Cancer pain• Injury related• After surgery
70
Acute and Persistent Pain
• Acute– Sudden onset
– After injury or surgery
– Usually improves with healing
• Persistent– Slow onset or follows acute
– Cause may not be known
– Goal: keep function and quality of life
71
Myths About Pain in the Elderly
• Natural part of growing old• Older folks are less sensitive to pain• If one does not report pain, they are not
experiencing it• If one is sleeping, they are not experiencing
pain
72
Issues With Addiction
73
Tolerance
The body becomes used to certain doses of medicine and needs higher doses to
relieve pain
74
Physical Dependence
• Body has withdrawal symptoms if medicine is stopped abruptly
• This occurs with many pain medicines, as well as antidepressants and steroids
75
Addiction
• Biological and emotional illness• Loss of control over drug use• Continued use despite harm to self and others
76
Pseudo-Addiction
• Occurs with under-treatment of pain
• May appear like addiction, but behaviors stop when pain is relived
77
Common Words Used to Describe Pain
• Discomfort• Sore• Ache• Heavy• Crampy• Burning• Pressure
78
Intensity
1 2 3 4 5 6 7 8 9 10
Mild Moderate Severe
79
C.N.A. Role in Pain
• Observe for discomfort and report it and get help for patient
• Observe for changes after treatment-- Does it get better? Is patient having new confusion?
• Administer non drug treatments, exercise, ROM, as directed by nurse
• If patient uses heating pad or ice, check skin for redness or burns.
80
Things to Observe
• What seems to make patient more uncomfortable?
• What helps to make it better?• Is there a pattern (when you transfer? when you
roll him/her in bed)?
81
Screening for Pain
• Always ask if the patient is uncomfortable or hurts or aches
• Believe The Patient!
• Remember pain is whatever the person says it is, occurring whenever and wherever the person says it does
• People have different coping patterns and may not always look like you think a person with pain should look like
82
Screening for Pain (continued)
• Patients may display any of the following either at rest or while being moved:
– Sleeping a lot of the time or having difficulty sleeping
– Coping with pain by using behaviors such as watching TV, humor, conversation, listening to music and guided imagery
83
Pain in Cognitive Impairment
84
Pain in Cognitive Impairment
• Many folks can still report discomfort• Need extra time• Look for changes in behavior• Look for facial expressions
85
Pain in Cognitive Impairment
• Observe– Facial expressions
• Grimacing
• Frowning
• Wrinkling of the brow (forehead)
– Verbal expressions• Moaning• Groaning• Crying out
86
Pain in Cognitive Impairment
• Movements– Restlessness– Fidgeting– Pacing– Rocking back and forth– Wringing hands– Clenching fists– Rubbing or protecting the place that hurts
87
Pain in Cognitive Impairment
• Changes in– Eating or sleeping – Usual behaviors (for example a very vocal patient
becomes quiet or a very quiet patient becomes very vocal)– Activity level or resisting activity or movement– Tone of vocalization
• Withdrawal from family, friends• Noisy, labored breathing• Looking scared, worried or troubled
88
Cognitively Impairment Pain
• If you notice any of the above behaviors– Check for hunger, thirst, incontinence, positioning
issues, hot or cold issues, over-stimulation
– If none of the above helps, notify nurse of behaviors as possible pain behaviors
89
Dyspnea
90
Dyspnea Definition
• Respiratory distress• A feeling of air hunger• Breathlessness• Can’t catch breath
91
Causes of Dyspnea
• Pneumonia
• COPD
• Tumors
• Anemia
• Ascites
• Panic
92
Symptoms of Dyspnea
• Rapid respiratory rate• Using accessory muscles• Sweating• Being anxious• Gasping
• Flaring nostrils
93
C.N.A. Role in Dyspnea
• Listen– Report feelings of breathlessness – Report inability to catch breath
• Observe– Rapid respiratory rate
– Periods of apnea (no breathing) of up to 40 seconds
– Respiratory congestion
94
C.N.A. Role in Dyspnea
• Report to nurse• Raise head of bed• Raise arms on pillows• Some patients prefer to lean forward over table• Cool cloths• Fan if patient desires
95
Nausea and Vomiting
96
Nausea and Vomiting
• People can be nauseous without vomiting and still feel miserable
• If patient vomits, save it for nurse or approximate amount and color
97
Possible Causes of Nausea and Vomiting
• Constipation• Obstruction• Medication side effects• Coughing• Tumors• Overeating• Emotional response• Pain
98
C.N.A. Role in Nausea and Vomiting
• Report to nurse• Remove food• Offer liquids, if authorized by nurse• Start with ice chips or sips of water• Avoid acid juices (such as cranberry, grape,
apple)
99
C.N.A. Role in Nausea and Vomiting
• Cool cloths to head• Wash patients face and hands• Change clothes• Clean floor or linen if needed• Quiet calm environment
100
Anxiety
101
Anxiety/Agitation
• Anxiety– Feeling worried, apprehensive or uneasy, especially
about the future
• Agitation– Very restless with increased mental and physical
activity
102
Possible Causes of Anxiety/Agitation
• Medication side effects• Chemical changes in the body• Family concerns• Financial concerns• Fears of the unknown
103
C.N.A. Role in Anxiety/Agitation
• Listen– Reports of anxiety or worry– Feeling heart is pounding hard
• Observe– Increased agitation– Increased respiratory rate– Patient wanting you to stay all the time
• Report any of the above to the nurse
104
How to Help in Anxiety
• Listen compassionately• Stay with the person• Hold their hand or touch their shoulder (gentle
touch)• Decreased stimulation (turn off TV, lights)• Try to move away from noisy folks• Reassure patient he/she is safe
105
Anorexia
106
Anorexia/Cachexia
• Anorexia -- loss of appetite• Cachexia -- muscle wasting and weight loss• Observe changes in eating patterns or
swallowing• Measure weights
107
Possible causes of Anorexia/Cachexia
• Medications• Difficulty swallowing• Loosing muscle ability• Depression• Constipation• Obstruction• Mouth sores• Dentures not fitting
108
C.N.A. Role in Anorexia
• Think about your own beliefs about tube feelings (but don’t share them)
• Assure family they are not starving patient• Provide small frequent snacks or sips, at patient
desire• Use thickeners, if ordered
109
Ways to Help in Anorexia
• Support patient/family decisions• Remind family that decreased appetite occurs
often at end of life• Provide good mouth care every two hours
110
Nearing Death Awareness
111
Nearing Death Awareness
• A special knowledge about the process of dying that some patients experience
• The attempt of dying people to describe what they are experiencing
• It may be an attempt to request something the person needs for a peaceful death
112
Signs of Nearing Death Awareness
• Appearance of confusion
• Seeing and/or speaking to those already dead or spiritual beings
• Talking about seeing other places of light, peace, or beauty
• Uses symbolic language – talks of journeys, luggage, standing in line
• Going home
• May begin to ask for people with whom they need closure
113
How to Help in Nearing Death Awareness
• Report observations to the Interdisciplinary Team
• Listen carefully to the person and affirm their communication
• Ask gentle questions if the person is expressing a need
• Involve the family in this experience and support them – assure them that this is not confusion but is a significant change in condition
• Explore with family possible meaning
114
Impending Death
115
Symptoms of Impending Death
• Sleep more• Withdraw from people or have little to say• Eat or drink less• Have trouble swallowing• Become more confused• Lose control of bowel and bladder • May have burst of energy
116
Symptoms of Impending Death
• Have moist breathing or sound congested
• Have changes in the pattern of breathing such as apnea then several quick, deep breaths
• Have blurred vision
• Have less pain
• Have cool feeling hands and arms or feet and legs
• Turn blue around nose, mouth, fingers, toes
117
C.N.A. Role in Impending Death
• Allow the patient to sleep as much as they wish• Moisten the patient’s mouth with a toothette• Continue to talk clearly to the patient;
remember that the patient may be able to hear even when not able to respond
• Keep a light on in the room, as the patient cannot see well and may be scared by darkness and shadows
118
Ways to Help in Impending Death
• Play the patient’s favorite music softly• Encourage visitors to talk directly to the patient
and tell the patient who they are• Keep things calm around the patient• Model touching and being near the patient for
loved ones
119
C.N.A. Role At Death
• Notify the nurse• Support the family, if present• Ask if there is any thing special that needs to
happen in their religion• Allow family time alone, if patient is
incontinent or drooling offer to clean this, or help family to do so
• Follow your agency protocol for post mortem care
120
Discussion
• What stresses do you experience in doing post-mortem care?
• Discuss cultural or religious concerns around care, both personal and concerns you have observed.
121
Spiritual Issues
122
Spirituality
• Different from religion• Wide possibilities, but very specific and
personal for individuals• What gives meaning to one's life• Where one turns to feel strength• What brings joy to one’s life
123
Life Review
• Finding meaning – Encourage patient to remember life both good and
bad
– Helps to emphasize the uniqueness of each life
• Helps to build a connection• Brings joy and humor and sadness• Can lessen physical and emotional pain
124
Life Review With Dementia
• Family and friends can add input• Singing• Pictures• Memories if you’ve worked with someone for a
while
125
Significance of Death in Patient’s Belief System
• Each religion has ways of dealing with death• Folks not connected to a religion have own
thoughts about death• Certain rituals may be important in folks lives• Do NOT try to change patient to your religion
126
How to Identify Spiritual Distress
• Definition: an uncomfortable experience of spiritual or existential struggle within which there is potential for growth
• Helpful to know – Fears
– Hopes and expectations
– Unfinished business
127
Fears of Dying Person
• Lack of meaning or incomplete life• Loss of control• Loss of personal identity• Loss of relationships• What happens after death• The unknown
128
More Fears
• Loneliness• Being a burden• The dying process
– Will it be painful?
– How long will it take?
– Will I be abandoned?
– Will I lose my dignity?
129
Hopes and Expectations
• To get well and be productive again• To die with dignity, surrounded by caring
people• To be able to keep some control• To mange pain• To express needs and feelings openly
130
Unfinished Business
• Seeing a loved one who is far away• Taking one last trip to ….• Completing an unfinished project• Providing for loved ones• Forgiving • Being forgiven
131
C.N.A. Role in Spiritual Distress
• Listen supportively• Stay with someone—being present• Life review• Encourage use of spiritual strengths• Referral to spiritual caregiver• Report to nurse
132
Role of Spiritual Counselor in Hospice
• Consistent presence• To help with seeing meaning in one’s life• Encourage reconciliation with estranged ones• Support in death• Help with services
133
Role of Spiritual Counselor in Hospice
• Consistent presence• To help with seeing meaning in one’s life• Encourage reconciliation with estranged ones• Support in death• Help with services
134
Self Care
Stress: Definition
State of bodily or mental tension resulting from factors that tend to alter
an existent equilibrium
Merriam-Webster online dictionary
136
Factors Which Affect Stress
• Emotional issues• Role overload• Role conflict• Issues of power and control• Team conflicts
137
Physical Signs of Stress
• Increased BP, HR, reaction time• Indigestion• Weight gain or loss
138
Psychological Signs of Stress
• Excitement or fear• Sadness, depression, apprehension• Poor sleep, fatigue• Negative attitude• Increased smoking, alcohol or drug use
139
Long Term Stress
• Multiple grief and losses
• Compassion fatigue
• Burnout
140
Stress Management
• Assertive communication• Conflict management• Lifestyle management• Forming personal philosophy• Self-renewal
141
Self-care is not . . .
• An emergency response plan
• About acting selfishly
• About doing more
142
Self-care is not . . .
• An emergency response plan
• About acting selfishly
• About doing more
143
Self-care is taking the time
to be a human being,
as well as human doing
from PERT Education Program
144
Grief and Bereavement
145
Grief and Bereavement
• Patient
• Family
• Professional
146
Patient Grief
• Dealing with loss issues– Loss of employment– Loss of social network– Loss of function– Loss of independence
• Anticipatory grief– Loss of family– Loss of self or transition
147
Normal Grief
• Human reaction to loss• May include
– Experiencing the pain of loss
– Accepting reality of loss
– Adjusting to life without loved one
– Bring up previous losses
148
Early Stages of Grief
• Experiencing the pain– Stomach “tied in knots”– Shock and disbelief– Numbness– Agitation– Nausea– Panic– Hearing or seeing the deceased loved one
149
Emerging Awareness of Grief
Adjusting to new life• Fear• Guilt• Anger• Crying spells• Trouble concentrating• Withdrawal from friends and family• Mood swings• Change in sleep and appetite
150
Complicated Grief
• Absence of expected grief– Stoicism
– Total denial
• Prolonged grief (many years)• Excessive fear, anger or guilt
151
Complicated Grief
• Risk factors– Poor support systems
– Multiple losses and stresses
– Ambivalent relationship between deceased and bereaved
152
Role of C.N.A.
• Support family by telling them grieving is normal
• Using non-verbal communication– Smile
– Touch
– Hug
– Quiet listening
153
Things Not to Say
• “I know how you feel”• “This was God’s plan”• “God needed (deceased) in heaven”• “You’ll get over it”• “You shouldn’t feel that way”
154
Some Things to Say
• “I’m so sorry”• “Tell me about (your loved one)”• “What is this like for you?”• “What I remember most about him/her is…”
155
Other Ways to Help
• Provide space for grieving• Allow family time alone with the body• Send a card or note to bereaved• Attend the services
156
Family Grief
• Loss issues– Present
– Past
• Role changes• Financial issues
157
Professional Grief
• Shock and denial can happen• Each staff member will react differently• Each has personal and cultural beliefs about
death
158
Facts About Loss and Grief
• Every loss has an accompanying grief• Grief is a process• Loss, like stress, can accumulate• We all grieve differently
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Symptoms of Grief
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• Disorganization• Depression• Anxiety• Sadness• Frustration• Anger
• Insomnia• Appetite changes• Tightness in throat• Restlessness• Irritability• Hostility
Symptoms of Grief
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• Disorganization• Depression• Anxiety• Sadness• Frustration• Anger
• Insomnia• Appetite changes• Tightness in throat• Restlessness• Irritability• Hostility
Myths About Grief
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Myth– Only family members
grieve
– Grief is an emotional reaction
– Grieving means letting go of the deceased
– Grievers are best left alone
Reality– All who are attached
grieve– Grief is manifested in
many ways– We never fully detach
from those who have died
– Grievers need opportunities to share
Facts About High Loss Work
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• Workers who experience frequent losses at their work site will experience grief responses
• Professional grief is different from personal grief
• Familiarity with death does not make it easier to accept loss
Difference Between Professional and Personal Grief
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• Professional caregivers are distant mourners• Professional losses accumulate• Effects of grief are hidden and often delayed• Professional grief is a significant cause of
burnout
Coping Methods
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• Maintaining control• Overwork• Realism with hope• Apathy (burnout)• Guilt• Letting go
Bereavement Overload
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• Warning signs:– Increased irritability, anxiety, being forgetful;
having trouble meeting work demands that weren’t previously a problem
– Cynicism, resentment, procrastinating, loss of interest in social plans
– Fatigue, sadness, depression, digestive problems, hopelessness.
Things That Help
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• Talking– Talk about your feelings and your losses and good
memories
– Find a buddy who shares your values and understands why you feel the way you do
• Rituals– Attend memorial services
– Develop personal rituals of remembrance to honor the memories of the lives that you touched, and that touched you
Things That Help
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• Spirituality– Find and focus on your core beliefs– May be your religion, or other more individual
beliefs
• Physical activity– Even though you may be doing physically
exhausting work, it doesn’t leave you feeling energized
– Look for activities that leave you with a tired-happy feeling, especially things outdoors in nature