Hospice Care for C.N.A.s Prepared by Ellen Williams, CAHPN for Capitol Community College

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


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


• 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


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


• Many folks can still report discomfort• Need extra time• Look for changes in behavior• Look for facial expressions

85


• Observe– Facial expressions

• Grimacing

• Frowning

• Wrinkling of the brow (forehead)

– Verbal expressions• Moaning• Groaning• Crying out

86


• Movements– Restlessness– Fidgeting– Pacing– Rocking back and forth– Wringing hands– Clenching fists– Rubbing or protecting the place that hurts

87


• 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

159

Symptoms of Grief

160

• Disorganization• Depression• Anxiety• Sadness• Frustration• Anger

• Insomnia• Appetite changes• Tightness in throat• Restlessness• Irritability• Hostility

Symptoms of Grief

161

• Disorganization• Depression• Anxiety• Sadness• Frustration• Anger

• Insomnia• Appetite changes• Tightness in throat• Restlessness• Irritability• Hostility

Myths About Grief

162

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

163

• 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

164

• 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

165

• Maintaining control• Overwork• Realism with hope• Apathy (burnout)• Guilt• Letting go

Bereavement Overload

166

• 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

167

• 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

168

• 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

Documents

Hospice Care for C.N.A.s Prepared by Ellen Williams, CAHPN for Capitol Community College