epecepecepecepec epecepecepecepec last hours of living module 12 the project to educate physicians...
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EEPPEECC
EEPPEECC
Last Hours of LivingLast Hours of Living
Module 12Module 12Module 12Module 12
The Project to Educate Physicians on End-of-life CareSupported by the American Medical Association andthe Robert Wood Johnson Foundation
The Project to Educate Physicians on End-of-life CareSupported by the American Medical Association andthe Robert Wood Johnson Foundation
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Last hours of livingLast hours of living
Everyone will dieEveryone will die
< 10% suddenly< 10% suddenly
> 90% prolonged illness> 90% prolonged illness
Last opportunity for life closureLast opportunity for life closure
Little experience with deathLittle experience with death
exaggerated sense of dying processexaggerated sense of dying process
Everyone will dieEveryone will die
< 10% suddenly< 10% suddenly
> 90% prolonged illness> 90% prolonged illness
Last opportunity for life closureLast opportunity for life closure
Little experience with deathLittle experience with death
exaggerated sense of dying processexaggerated sense of dying process
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Preparing for the last hours of life . . .Preparing for the last hours of life . . . Time course unpredictableTime course unpredictable
Any setting that permits privacy, Any setting that permits privacy, intimacyintimacy
Anticipate need for medications, Anticipate need for medications, equipment, suppliesequipment, supplies
Regularly review the plan of care Regularly review the plan of care
Time course unpredictableTime course unpredictable
Any setting that permits privacy, Any setting that permits privacy, intimacyintimacy
Anticipate need for medications, Anticipate need for medications, equipment, suppliesequipment, supplies
Regularly review the plan of care Regularly review the plan of care
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. . . Preparing for the last hours of life. . . Preparing for the last hours of life CaregiversCaregivers
awareness of patient choicesawareness of patient choices
knowledgeable, skilled, confidentknowledgeable, skilled, confident
rapid responserapid response
Likely events, signs, symptoms of Likely events, signs, symptoms of the dying processthe dying process
CaregiversCaregivers
awareness of patient choicesawareness of patient choices
knowledgeable, skilled, confidentknowledgeable, skilled, confident
rapid responserapid response
Likely events, signs, symptoms of Likely events, signs, symptoms of the dying processthe dying process
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EEPPEECC
EEPPEECC Module 12, Part 1
Physiologic Changes, Symptom Management
Module 12, Part 1 Physiologic Changes, Symptom Management
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ObjectivesObjectives
Assess, manage the Assess, manage the pathophysiologic changes of dyingpathophysiologic changes of dying
Assess, manage the Assess, manage the pathophysiologic changes of dyingpathophysiologic changes of dying
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Physiologic changes during the dying processPhysiologic changes during the dying process Increasing weakness, fatigueIncreasing weakness, fatigue
Decreasing appetite / fluid intakeDecreasing appetite / fluid intake
Decreasing blood perfusionDecreasing blood perfusion
Neurologic dysfunctionNeurologic dysfunction
PainPain
Loss of ability to close eyesLoss of ability to close eyes
Increasing weakness, fatigueIncreasing weakness, fatigue
Decreasing appetite / fluid intakeDecreasing appetite / fluid intake
Decreasing blood perfusionDecreasing blood perfusion
Neurologic dysfunctionNeurologic dysfunction
PainPain
Loss of ability to close eyesLoss of ability to close eyes
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Weakness / fatigueWeakness / fatigue
Decreased ability to moveDecreased ability to move
Joint position fatigueJoint position fatigue
Increased risk of pressure ulcersIncreased risk of pressure ulcers
Increased need for careIncreased need for care
activities of daily livingactivities of daily living
turning, movement, massageturning, movement, massage
Decreased ability to moveDecreased ability to move
Joint position fatigueJoint position fatigue
Increased risk of pressure ulcersIncreased risk of pressure ulcers
Increased need for careIncreased need for care
activities of daily livingactivities of daily living
turning, movement, massageturning, movement, massage
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Decreasing appetite / food intakeDecreasing appetite / food intake Fears: “giving in,” starvationFears: “giving in,” starvation
RemindersReminders
food may be nauseatingfood may be nauseating
anorexia may be protectiveanorexia may be protective
risk of aspirationrisk of aspiration
clenched teeth express desires, controlclenched teeth express desires, control
Help family find alternative ways to Help family find alternative ways to carecare
Fears: “giving in,” starvationFears: “giving in,” starvation
RemindersReminders
food may be nauseatingfood may be nauseating
anorexia may be protectiveanorexia may be protective
risk of aspirationrisk of aspiration
clenched teeth express desires, controlclenched teeth express desires, control
Help family find alternative ways to Help family find alternative ways to carecare
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Decreasing fluid intake . . .Decreasing fluid intake . . .
Oral rehydrating fluidsOral rehydrating fluids
Fears: dehydration, thirstFears: dehydration, thirst
Remind families, caregiversRemind families, caregivers
dehydration does not cause distressdehydration does not cause distress
dehydration may be protectivedehydration may be protective
Oral rehydrating fluidsOral rehydrating fluids
Fears: dehydration, thirstFears: dehydration, thirst
Remind families, caregiversRemind families, caregivers
dehydration does not cause distressdehydration does not cause distress
dehydration may be protectivedehydration may be protective
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. . . Decreasing fluid intake. . . Decreasing fluid intake
Parenteral fluids may be harmfulParenteral fluids may be harmful
fluid overload, breathlessness, cough, fluid overload, breathlessness, cough, secretionssecretions
Mucosa / conjunctiva careMucosa / conjunctiva care
Parenteral fluids may be harmfulParenteral fluids may be harmful
fluid overload, breathlessness, cough, fluid overload, breathlessness, cough, secretionssecretions
Mucosa / conjunctiva careMucosa / conjunctiva care
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Decreasing blood perfusionDecreasing blood perfusion Tachycardia, hypotensionTachycardia, hypotension
Peripheral cooling, cyanosisPeripheral cooling, cyanosis
Mottling of skinMottling of skin
Diminished urine outputDiminished urine output
Parenteral fluids will not reverseParenteral fluids will not reverse
Tachycardia, hypotensionTachycardia, hypotension
Peripheral cooling, cyanosisPeripheral cooling, cyanosis
Mottling of skinMottling of skin
Diminished urine outputDiminished urine output
Parenteral fluids will not reverseParenteral fluids will not reverse
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Neurologic dysfunctionNeurologic dysfunction
Decreasing level of consciousnessDecreasing level of consciousness
Communication with the Communication with the unconscious patientunconscious patient
Terminal deliriumTerminal delirium
Changes in respirationChanges in respiration
Loss of ability to swallow, sphincter Loss of ability to swallow, sphincter controlcontrol
Decreasing level of consciousnessDecreasing level of consciousness
Communication with the Communication with the unconscious patientunconscious patient
Terminal deliriumTerminal delirium
Changes in respirationChanges in respiration
Loss of ability to swallow, sphincter Loss of ability to swallow, sphincter controlcontrol
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2 roads to death2 roads to death
RestlessRestless
ConfusedConfused TremulousTremulous
HallucinationsHallucinations
Mumbling DeliriumMumbling Delirium
Myoclonic JerksMyoclonic JerksSleepySleepy
LethargicLethargic
ObtundedObtunded
SemicomatoseSemicomatose
ComatoseComatose
SeizuresSeizures
THE USUAL ROAD
THE USUAL ROAD
THE DIFFICULT ROAD
THE DIFFICULT ROAD
NormalNormal
DeadDead
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Decreasing level of consciousnessDecreasing level of consciousness ““The usual road to death”The usual road to death”
ProgressionProgression
Eyelash reflexEyelash reflex
““The usual road to death”The usual road to death”
ProgressionProgression
Eyelash reflexEyelash reflex
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Communication with the unconscious patient . . .Communication with the unconscious patient . . .
Distressing to familyDistressing to family
Awareness > ability to respondAwareness > ability to respond
Assume patient hears everythingAssume patient hears everything
Distressing to familyDistressing to family
Awareness > ability to respondAwareness > ability to respond
Assume patient hears everythingAssume patient hears everything
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. . . Communication with the unconscious patient. . . Communication with the unconscious patient
Create familiar environmentCreate familiar environment
Include in conversationsInclude in conversations
assure of presence, safetyassure of presence, safety
Give permission to dieGive permission to die
Touch Touch
Create familiar environmentCreate familiar environment
Include in conversationsInclude in conversations
assure of presence, safetyassure of presence, safety
Give permission to dieGive permission to die
Touch Touch
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Terminal deliriumTerminal delirium ““The difficult road to death”The difficult road to death” Medical managementMedical management
benzodiazepinesbenzodiazepineslorazepam, midazolam lorazepam, midazolam
neurolepticsneurolepticshaloperidol, chlorpromazinehaloperidol, chlorpromazine
SeizuresSeizures Family needs support, educationFamily needs support, education
““The difficult road to death”The difficult road to death” Medical managementMedical management
benzodiazepinesbenzodiazepineslorazepam, midazolam lorazepam, midazolam
neurolepticsneurolepticshaloperidol, chlorpromazinehaloperidol, chlorpromazine
SeizuresSeizures Family needs support, educationFamily needs support, education
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Changes in respiration . . .Changes in respiration . . . Altered breathing patternsAltered breathing patterns
diminishing tidal volumediminishing tidal volume
apneaapnea
Cheyne-Stokes respirationsCheyne-Stokes respirations
accessory muscle useaccessory muscle use
last reflex breathslast reflex breaths
Altered breathing patternsAltered breathing patterns
diminishing tidal volumediminishing tidal volume
apneaapnea
Cheyne-Stokes respirationsCheyne-Stokes respirations
accessory muscle useaccessory muscle use
last reflex breathslast reflex breaths
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. . . Changes in respiration . . . Changes in respiration FearsFears
suffocationsuffocation
ManagementManagement
family supportfamily support
oxygen may prolong dying processoxygen may prolong dying process
breathlessnessbreathlessness
FearsFears
suffocationsuffocation
ManagementManagement
family supportfamily support
oxygen may prolong dying processoxygen may prolong dying process
breathlessnessbreathlessness
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Loss of ability to swallowLoss of ability to swallow
Loss of gag reflexLoss of gag reflex
Buildup of saliva, secretionsBuildup of saliva, secretions
scopolamine to dry secretionsscopolamine to dry secretions
postural drainagepostural drainage
positioningpositioning
suctioningsuctioning
Loss of gag reflexLoss of gag reflex
Buildup of saliva, secretionsBuildup of saliva, secretions
scopolamine to dry secretionsscopolamine to dry secretions
postural drainagepostural drainage
positioningpositioning
suctioningsuctioning
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Loss of sphincter controlLoss of sphincter control
Incontinence of urine, stoolIncontinence of urine, stool
Family needs knowledge, supportFamily needs knowledge, support
Cleaning, skin careCleaning, skin care
Urinary cathetersUrinary catheters
Absorbent pads, surfacesAbsorbent pads, surfaces
Incontinence of urine, stoolIncontinence of urine, stool
Family needs knowledge, supportFamily needs knowledge, support
Cleaning, skin careCleaning, skin care
Urinary cathetersUrinary catheters
Absorbent pads, surfacesAbsorbent pads, surfaces
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Pain . . .Pain . . . Fear of increased painFear of increased pain
Assessment of the unconscious Assessment of the unconscious patientpatient
persistent vs fleeting expressionpersistent vs fleeting expression
grimace or physiologic signsgrimace or physiologic signs
incident vs rest painincident vs rest pain
distinction from terminal deliriumdistinction from terminal delirium
Fear of increased painFear of increased pain
Assessment of the unconscious Assessment of the unconscious patientpatient
persistent vs fleeting expressionpersistent vs fleeting expression
grimace or physiologic signsgrimace or physiologic signs
incident vs rest painincident vs rest pain
distinction from terminal deliriumdistinction from terminal delirium
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. . . Pain. . . Pain Management when no urine outputManagement when no urine output
stop routine dosing, infusions of stop routine dosing, infusions of morphinemorphine
breakthrough dosing as needed (prn)breakthrough dosing as needed (prn)
least invasive route of administrationleast invasive route of administration
Management when no urine outputManagement when no urine output
stop routine dosing, infusions of stop routine dosing, infusions of morphinemorphine
breakthrough dosing as needed (prn)breakthrough dosing as needed (prn)
least invasive route of administrationleast invasive route of administration
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Loss of ability to close eyesLoss of ability to close eyes Loss of retro-orbital fat padLoss of retro-orbital fat pad
Insufficient eyelid lengthInsufficient eyelid length
Conjunctival exposureConjunctival exposure
increased risk of dryness, painincreased risk of dryness, pain
maintain moisturemaintain moisture
Loss of retro-orbital fat padLoss of retro-orbital fat pad
Insufficient eyelid lengthInsufficient eyelid length
Conjunctival exposureConjunctival exposure
increased risk of dryness, painincreased risk of dryness, pain
maintain moisturemaintain moisture
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MedicationsMedications
Limit to essential medicationsLimit to essential medications
Choose less invasive route of Choose less invasive route of administrationadministration
buccal mucosal or oral first, then buccal mucosal or oral first, then consider rectalconsider rectal
subcutaneous, intravenous rarelysubcutaneous, intravenous rarely
intramuscular almost neverintramuscular almost never
Limit to essential medicationsLimit to essential medications
Choose less invasive route of Choose less invasive route of administrationadministration
buccal mucosal or oral first, then buccal mucosal or oral first, then consider rectalconsider rectal
subcutaneous, intravenous rarelysubcutaneous, intravenous rarely
intramuscular almost neverintramuscular almost never
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EEPPEECC
EEPPEECC Physiologic Physiologic
Changes, Symptom Changes, Symptom Management Management
SummarySummary
Physiologic Physiologic Changes, Symptom Changes, Symptom Management Management
SummarySummary
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EEPPEECC
EEPPEECC Module 12, Part 2
Expected DeathModule 12, Part 2 Expected Death
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ObjectivesObjectives
Prepare, support the patient, family, Prepare, support the patient, family, caregivers caregivers
Prepare, support the patient, family, Prepare, support the patient, family, caregivers caregivers
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As expected death approaches . . .As expected death approaches . . . DiscussDiscuss
status of patient, realistic care goalsstatus of patient, realistic care goals
role of physician, interdisciplinary teamrole of physician, interdisciplinary team
What patient experiences What patient experiences what what onlookers seeonlookers see
DiscussDiscuss
status of patient, realistic care goalsstatus of patient, realistic care goals
role of physician, interdisciplinary teamrole of physician, interdisciplinary team
What patient experiences What patient experiences what what onlookers seeonlookers see
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. . . As expected death approaches. . . As expected death approaches Reinforce signs, events of dying Reinforce signs, events of dying
processprocess
Personal, cultural, religious, rituals, Personal, cultural, religious, rituals, funeral planningfuneral planning
Family support throughout the Family support throughout the processprocess
Reinforce signs, events of dying Reinforce signs, events of dying processprocess
Personal, cultural, religious, rituals, Personal, cultural, religious, rituals, funeral planningfuneral planning
Family support throughout the Family support throughout the processprocess
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Signs that death has occurred . . .Signs that death has occurred . . . Absence of heartbeat, respirationsAbsence of heartbeat, respirations
Pupils fixedPupils fixed
Color turns to a waxen pallor as Color turns to a waxen pallor as blood settlesblood settles
Body temperature dropsBody temperature drops
Absence of heartbeat, respirationsAbsence of heartbeat, respirations
Pupils fixedPupils fixed
Color turns to a waxen pallor as Color turns to a waxen pallor as blood settlesblood settles
Body temperature dropsBody temperature drops
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. . . Signs that death has occurred. . . Signs that death has occurred Muscles, sphincters relaxMuscles, sphincters relax
release of stool, urinerelease of stool, urine
eyes can remain openeyes can remain open
jaw falls openjaw falls open
body fluids may trickle internallybody fluids may trickle internally
Muscles, sphincters relaxMuscles, sphincters relax
release of stool, urinerelease of stool, urine
eyes can remain openeyes can remain open
jaw falls openjaw falls open
body fluids may trickle internallybody fluids may trickle internally
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What to do when death occursWhat to do when death occurs Don’t call 911Don’t call 911
Whom to callWhom to call
No specific “rules”No specific “rules”
Rarely any need for coronerRarely any need for coroner
Organ donationOrgan donation
Traditions, rites, ritualsTraditions, rites, rituals
Don’t call 911Don’t call 911
Whom to callWhom to call
No specific “rules”No specific “rules”
Rarely any need for coronerRarely any need for coroner
Organ donationOrgan donation
Traditions, rites, ritualsTraditions, rites, rituals
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After expected death occurs . . .After expected death occurs . . . Care shifts from patient to family / Care shifts from patient to family /
caregiverscaregivers
Different loss for everyoneDifferent loss for everyone
Invite those not present to bedsideInvite those not present to bedside
Care shifts from patient to family / Care shifts from patient to family / caregiverscaregivers
Different loss for everyoneDifferent loss for everyone
Invite those not present to bedsideInvite those not present to bedside
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. . . After expected death occurs. . . After expected death occurs Take time to witness what has Take time to witness what has
happenedhappened
Create a peaceful, accessible Create a peaceful, accessible environmentenvironment
When rigor mortis sets inWhen rigor mortis sets in
Assess acute grief reactionsAssess acute grief reactions
Take time to witness what has Take time to witness what has happenedhappened
Create a peaceful, accessible Create a peaceful, accessible environmentenvironment
When rigor mortis sets inWhen rigor mortis sets in
Assess acute grief reactionsAssess acute grief reactions
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Moving the bodyMoving the body
Prepare the bodyPrepare the body
Choice of funeral service providersChoice of funeral service providers
Wrapping, moving the bodyWrapping, moving the body
family presencefamily presence
intolerance of closed body bagsintolerance of closed body bags
Prepare the bodyPrepare the body
Choice of funeral service providersChoice of funeral service providers
Wrapping, moving the bodyWrapping, moving the body
family presencefamily presence
intolerance of closed body bagsintolerance of closed body bags
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Other tasksOther tasks
Notify other physicians, caregivers of Notify other physicians, caregivers of the deaththe death
stop servicesstop services
arrange to remove equipment / suppliesarrange to remove equipment / supplies
Secure valuables with executorSecure valuables with executor
Dispose of medications, biologic Dispose of medications, biologic wasteswastes
Notify other physicians, caregivers of Notify other physicians, caregivers of the deaththe death
stop servicesstop services
arrange to remove equipment / suppliesarrange to remove equipment / supplies
Secure valuables with executorSecure valuables with executor
Dispose of medications, biologic Dispose of medications, biologic wasteswastes
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Bereavement careBereavement care
Bereavement careBereavement care
Attendance at funeralAttendance at funeral
Follow up to assess grief reactions, Follow up to assess grief reactions, provide supportprovide support
Assistance with practical mattersAssistance with practical matters
redeem insuranceredeem insurance
will, financial obligations, estate closurewill, financial obligations, estate closure
Bereavement careBereavement care
Attendance at funeralAttendance at funeral
Follow up to assess grief reactions, Follow up to assess grief reactions, provide supportprovide support
Assistance with practical mattersAssistance with practical matters
redeem insuranceredeem insurance
will, financial obligations, estate closurewill, financial obligations, estate closure
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Dying in institutionsDying in institutions
Home-like environmentHome-like environment
permit privacy, intimacypermit privacy, intimacy
personal things, photospersonal things, photos
Continuity of care plansContinuity of care plans
Avoid abrupt changes of settings Avoid abrupt changes of settings
Consider a specialized unitConsider a specialized unit
Home-like environmentHome-like environment
permit privacy, intimacypermit privacy, intimacy
personal things, photospersonal things, photos
Continuity of care plansContinuity of care plans
Avoid abrupt changes of settings Avoid abrupt changes of settings
Consider a specialized unitConsider a specialized unit
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EEPPEECC
EEPPEECC Expected Death Expected Death
SummarySummaryExpected Death Expected Death
SummarySummary
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EEPPEECC
EEPPEECC Module 12, Part 3
Loss, Grief, Bereavement
Module 12, Part 3 Loss, Grief, Bereavement
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ObjectivesObjectives
Identify, manage initial grief Identify, manage initial grief reactionsreactions
Identify, manage initial grief Identify, manage initial grief reactionsreactions
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Loss, grief with life-threatening illness . . .Loss, grief with life-threatening illness . . . Highly vulnerableHighly vulnerable
Frequent lossesFrequent losses
function / control / independencefunction / control / independence
image of self / sense of dignityimage of self / sense of dignity
relationshipsrelationships
sense of futuresense of future
Highly vulnerableHighly vulnerable
Frequent lossesFrequent losses
function / control / independencefunction / control / independence
image of self / sense of dignityimage of self / sense of dignity
relationshipsrelationships
sense of futuresense of future
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. . . Loss, grief with life-threatening illness. . . Loss, grief with life-threatening illness Confront end of lifeConfront end of life
high emotionshigh emotions
multiple coping responsesmultiple coping responses
Confront end of lifeConfront end of life
high emotionshigh emotions
multiple coping responsesmultiple coping responses
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Loss, grief, coping Loss, grief, coping
Grief = emotional response to lossGrief = emotional response to loss
Coping strategiesCoping strategies
conscious, unconsciousconscious, unconscious
avoidanceavoidance
destructivedestructive
suicidal ideationsuicidal ideation
Grief = emotional response to lossGrief = emotional response to loss
Coping strategiesCoping strategies
conscious, unconsciousconscious, unconscious
avoidanceavoidance
destructivedestructive
suicidal ideationsuicidal ideation
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Normal griefNormal grief PhysicalPhysical
hollowness in stomach, tightness in hollowness in stomach, tightness in chest, heart palpitationschest, heart palpitations
EmotionalEmotionalnumbness, relief, sadness, fear, anger, numbness, relief, sadness, fear, anger,
guiltguilt
CognitiveCognitivedisbelief, confusion, inability to disbelief, confusion, inability to
concentrateconcentrate
PhysicalPhysicalhollowness in stomach, tightness in hollowness in stomach, tightness in
chest, heart palpitationschest, heart palpitations
EmotionalEmotionalnumbness, relief, sadness, fear, anger, numbness, relief, sadness, fear, anger,
guiltguilt
CognitiveCognitivedisbelief, confusion, inability to disbelief, confusion, inability to
concentrateconcentrate
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Complicated grief . . .Complicated grief . . .
Chronic griefChronic grief
normal grief reactions over very long normal grief reactions over very long periods of timeperiods of time
Delayed griefDelayed grief
normal grief reactions are suppressed normal grief reactions are suppressed or postponedor postponed
Chronic griefChronic grief
normal grief reactions over very long normal grief reactions over very long periods of timeperiods of time
Delayed griefDelayed grief
normal grief reactions are suppressed normal grief reactions are suppressed or postponedor postponed
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. . . Complicated grief. . . Complicated grief
Exaggerated griefExaggerated grief
self-destructive behaviors eg, suicideself-destructive behaviors eg, suicide
Masked griefMasked grief
unaware that behaviors are a result of unaware that behaviors are a result of the lossthe loss
Exaggerated griefExaggerated grief
self-destructive behaviors eg, suicideself-destructive behaviors eg, suicide
Masked griefMasked grief
unaware that behaviors are a result of unaware that behaviors are a result of the lossthe loss
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Tasks of the grievingTasks of the grieving
1.1. Accept the reality of the loss Accept the reality of the loss
2.2. Experience the pain caused by the Experience the pain caused by the lossloss
3.3. Adjust to the new environment after Adjust to the new environment after the lossthe loss
4.4. Rebuild a new life Rebuild a new life
1.1. Accept the reality of the loss Accept the reality of the loss
2.2. Experience the pain caused by the Experience the pain caused by the lossloss
3.3. Adjust to the new environment after Adjust to the new environment after the lossthe loss
4.4. Rebuild a new life Rebuild a new life
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Assessment of griefAssessment of grief
Repeated assessmentsRepeated assessments
anticipated, actual lossesanticipated, actual losses
emotional responsesemotional responses
coping strategiescoping strategies
role of religionrole of religion
Interdisciplinary team assessment, Interdisciplinary team assessment, monitoringmonitoring
Repeated assessmentsRepeated assessments
anticipated, actual lossesanticipated, actual losses
emotional responsesemotional responses
coping strategiescoping strategies
role of religionrole of religion
Interdisciplinary team assessment, Interdisciplinary team assessment, monitoringmonitoring
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Grief managementGrief management
If reactions, coping strategies If reactions, coping strategies appropriateappropriate
monitormonitor
supportsupport
counselingcounseling
ritualsrituals
If inappropriate, potentially harmfulIf inappropriate, potentially harmful
rapid, skilled assessment, interventionrapid, skilled assessment, intervention
If reactions, coping strategies If reactions, coping strategies appropriateappropriate
monitormonitor
supportsupport
counselingcounseling
ritualsrituals
If inappropriate, potentially harmfulIf inappropriate, potentially harmful
rapid, skilled assessment, interventionrapid, skilled assessment, intervention
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EEPPEECC
EEPPEECC Loss, Grief, Loss, Grief,
BereavementBereavement
SummarySummary
Loss, Grief, Loss, Grief, BereavementBereavement
SummarySummary