Week 7:

 Chapter 8: Legal Aspects of Gerontological Nursing  Chapter 35: Family Caregiving

 Chapter 9: Ethical Aspects of Gerontological Nursing  Chapter 36: End-of-Life Care
 Chapter 25: Skin Health

- Objectives
o Summarize the effects of aging on the skin. (25-1)
o Discuss measures that help older patients cope with skin problems. (25-4)
o Relate the ethical and legal issues faced by older adults.
o Identify risks to caregivers and ways to avoid them. (35-4)
o Identify signs of elder abuse. (35-6)
o Discuss interventions to reduce family dysfunction. (35-7)
o Discuss the difficulty people may experience in facing death. (36-1)
o Describe the stages people commonly go through when facing death and related nursing
interventions. (36-2)
o Discuss physical care needs of the dying patients, as well as ways to support the family, friends, and
staff dealing with dying individuals (36-3,4, 5).

Week 7 – Chapter 25 Skin health

- Summarize the effects of aging on the skin

o Common aging changes to the integumentary system include:
 flattening of the dermal–epidermal junction
 reduced thickness and vascularity of the dermis
 decreased rate of epidermal turnover
 degeneration of elastic fibers
 increased coarseness of collagen
 reduction in melanocytes
o Increased fragility of the skin pose challenges to older adults and their caregivers causing risks of:
 Skin tears
 Bruising
 Pressure injuries
 Skin infection
o Appearance is highly visible signs of the aging process affecting
 Body image
 Self-concept
 Reactions from others
 Socialization
 Psychosocial factors
- Discuss measures that help older patients cope with skin problems
o Psychological support is important to the patient with a dermatologic problem.
o Visitors and staff may avoid touching and being with the patient in reaction to his or her skin problems.
 The nurse can reassure visitors regarding the safety of contact with the patient and provide
instruction for any special precautions that must be followed.
o Emphasize the patient is still normal, with normal needs and feelings, and will appreciate normal
interactions and contact.
o Older adults are distressed at visible signs of aging reflected in wrinkles.
 Advise all ages wrinkles can be prevented by:
 avoiding excess sun exposure
 use sunscreen.
 Other ways to prevent wrinkles
 topical products can reduce wrinkling  α- or β-hydroxy acids
  cosmetic surgery is used for gaining a more youthful looking skin may be considered
o advise individuals to seek reputable providers who are experienced in these
procedures.
o Pruritus – drying of the skin
 Bath oils, moisturizing lotions, and massage are beneficial in treating and preventing pruritus.
 Vitamin supplements and a high-quality, vitamin-rich diet may be recommended.
 Topical application of zinc oxide is effective in controlling itching in some individuals.
 Antihistamines and topical steroids may also be prescribed for relief.
o Keratosis
 actinic or solar keratoses, are small, light colored lesions, usually gray or brown, on exposed
areas of the skin
 cutaneous horn with slightly reddened/swollen base
 Freezing agents and acids can be used to destroy the keratotic lesions, but electrodesiccation or
surgical excision ensures a more thorough removal.
o Seborrheic keratosis
 dark, wart-like projections on the skin
 Older adults commonly have these lesions on various parts of their bodies.
 freezing agents or by a curettage and cauterization procedure can be used
o Skin Cancer
 Suspicious lesions should be evaluated and biopsied
 melanomas are excised with removal of some of the surrounding tissue and subcutaneous fat.
 Some physicians recommend removal of all palpably enlarged lymph nodes.
 Nurses should teach older adults to inspect themselves for melanomas, identify moles that
demonstrate changes in pigmentation or size, and seek evaluation of suspicious lesions.
 Early detection improves the prognosis.
o Vascular lesions
 Good nutrition a diet high in vitamins and protein is recommended.
 Once healing has occurred avoid situations that promote stasis dermatitis.
 Give instruction regarding a diet for weight reduction or the planning of high-quality meals.
 Elevate the legs several times a day
 Prevent interferences to circulation, such as
 standing for long periods, sitting with legs crossed, and wearing garters
 Elastic support stockings may be prescribed and, although effective, can be a challenge for some
older adults to apply.
 Assess the older adult’s ability to properly put on these stockings and provide instruction
as needed.
 Some patients may require ligation and stripping of the veins to prevent further episodes of
stasis dermatitis.
o Pressure Injury
 Prevent formation by avoiding unrelieved pressure
 Encourage activity or turn the patient who can not move independently
 Shearing forces that cause two layers of tissue to move across each other should be prevented
by:
 not elevating the head of the bed more than 30 degrees,
 not allowing patients to slide in bed,
 lifting instead of pulling patients when moving them.
 Use of pillows, floatation pads, alternating pressure mattresses, and water beds can disperse
pressure from bony prominences.
 these devices do not eliminate the need for frequent position changes.
 When sitting in a chair, patients should be urged to move and should be assisted with shifting
their weight at certain intervals.
 Lamb’s wool and heel protectors prevent irritation to bony prominences.
 The nurse should make sure that sheets are kept wrinkle free
  Check the bed frequently for foreign objects, such as syringes and utensils, which the patient
may be lying on unknowingly.
 Use sensitivity when medical devices are used for diagnostic or therapeutic purposes (e.g.,
braces, BP cuffs) they can apply pressure and injure the skin
 A high-protein, vitamin-rich diet to maintain/improve tissue health to avoid formation of
pressure injury.
 Good skin care is essential in prevention.
 Skin should be kept clean and dry; blotting the patient dry will avoid irritation from rubbing the
skin with a towel.
 Bath oils and lotions, used prophylactically, help keep the skin soft and intact.
 Massage of bony prominences and range of motion exercises promote circulation and help keep
the tissues well nourished.
 A person who is incontinent should be cleansed with soap and water and dried after each
episode to avoid skin breakdown from irritating excreta.
 States of pressure injuries
 Hyperemia - Redness of the skin appears and disappears quickly if pressure is removed.
o No break in the skin, and the underlying tissues remain soft.
 Relieve pressure by using a square of adhesive foam
 protect the skin with DuoDerm (Squibb) or Tegasorb (3M) before
applying the adhesive.
 Ischemia. Redness of the skin develops from up to 6 hours of unrelieved pressure and is
accompanied by edema and induration.
o Can take several days to return to its normal color, during which the epidermis
may blister.
 Protect skin with Vigilon, it contains water and is soothing to the area.
 If skin surface is broken cleanse daily with normal saline or the
product suggested by your agency.
 Necrosis. Unremitting pressure extending over 6 hours causing ulceration with a necrotic
base.
o Use a transparent dressing that protects from bacteria but is permeable to
oxygen and water vapor.
o Thorough irrigation is essential during dressing changes.
o Sometimes topical antibiotics are used.
o May take weeks to months for full healing to occur.
 Deep tissue damage. If pressure is not relieved, necrosis will extend through the fascia
and potentially to the bone.
o Eschar, a thick, coagulated crust, is present, and bone destruction and infection
may occur.
o Unless eschar is removed, the underlying tissue will continue to break down, so
debridement is essential.

Week 7 – Chapter 8 & Chapter 9:

Chapter 8: Legal aspects of gerontological Nursing

- Acts that can result in legal liability for nurses (THESE THINGS PATIENTS CAN BE SUBJECTED TOO)
o Assault - deliberate threat or attempt to harm another person that the person believes could be carried
through
 EX: telling a patient he will be locked in a room without food for the entire day if he does not
stop being disruptive
o Battery - Unconsented touching of another person in a socially impermissible manner or carrying
through an assault. Even a touching act done to help a person can be interpreted as battery
 EX: performing a procedure without consent
o Defamation of character - oral or written communication to a third party damaging a person’s
reputation.
 Libel is the written form of defamation
 slander is the spoken form.
 With slander, actual damage must be proven, except when:
o Accusing someone of a crime
o Accusing someone of having a loathsome disease
o Making a statement that affects a person’s professional or business activity
o Calling a woman unchaste
 Defamation does not exist if the statement is true and made in good faith to persons with a
legitimate reason to receive the information.
 Example of Defamation (Accusation)
 Stating on a reference that an employee was a thief because narcotics were missing
every time he or she was on duty can be considered defamation if the employee was
never proved guilty of those charges.
 Example of non-defamation (Proven facts)
 Stating a employee was fired for physically abusing patients is not defamation if the
employee was found guilty of those charges.
o False Imprisonment
 Unlawful restraint or detention of a person
 Actual physical restraint does not need to be used for false imprisonment to occur
 EX of false imprisonment:.
o Preventing a patient from leaving a facility
o telling a patient he or she will be tied to the bed if he or she tries to leave
 EX of a non-false imprisonment
o Preventing a patient from leaving If they have a contagious disease or could
harm himself/herself/others.
o Fraud
 Willful and intentional misrepresentation that could cause harm, a loss to a person, or property
 EX: selling a patient a ring claiming memory will be improved when it is worn
o Invasion of Privacy
 Invading the right of an individuals personal privacy including unwanted publicity, releasing a
medical record to unauthorized persons, giving patient information to an improper source, or
having one’s private affairs made public.
 Only exceptions: reporting communicable diseases, gunshot wounds, and abuse
 EX: Allowing a visiting student to look at a patient’s pressure ulcers without permission
can be an invasion of privacy.
o Larceny
 Unlawful taking of another person’s possession
 EX: assuming a patient will not be using his or her owned wheelchair anymore and giving
it away to another patient without permission.
o Negligence
 Omission or commission of an act that departs from acceptable and reasonable standards, which
can take several forms:
 Malfeasance: committing an unlawful or improper act
o EX: nurse performing a surgical procedure
 Misfeasance: performing an act improperly
o EX: including the patient in a research project without obtaining consent
 Nonfeasance: failure to take proper action
o EX: not notifying the physician of a serious change in the patient’s status
 Malpractice: failure to abide by the standards of one’s profession
 o EX: not checking that a nasogastric tube is in the stomach before administering a
tube feeding
 Criminal negligence: disregard to protecting the safety of another person
o EX: allowing a confused patient, known to have a history of starting fires, to have
matches in an unsupervised situation
o Malpractice
 Standard of care - the norm for what a reasonable individual in a similar circumstance would do
 When performance deviates from the standard of care such as:
 Giving incorrect meds to a patient causing adverse reaction
 Identifying respiratory distress but not informing the physician in a timely manner
 Leaving irrigation solution at the bedside of a confused patient who drinks the solution
 Forgetting to turn immobile patient during shift, resulting in a pressure injury
 Patient falls when one staff member tries to lift the patient when lift device is standard
 In order for a negligent act (malpractice) to occur these conditions must exist:
 Duty: relationship between nurse and patient in which the nurse has assumed
responsibility for the care of the patient
 Negligence: failure to conform to the standard of care (i.e., malpractice)
 Injury: physical or mental harm to the patient or violation of the patient’s rights resulting
from the negligent act
 Other situations can cause nurses to be liable for negligence, if not malpractice , including the
following:
 Failing to take action
o EX: not reporting a change in the patient’s condition or not notifying the
administration of a physician’s incompetent acts
 Contributing to patient injury
o EX: not providing appropriate supervision of confused patients or failing to lock
the wheelchair during a transfer
 Failing to report a hazardous situation
o EX: not letting anyone know the fire alarm system is inoperable
o EX: not informing anyone that a physician is performing procedures under the
influence of alcohol
 Handling patient’s possessions irresponsibly
 Failing to follow established policies and procedures
o Confidentiality
 Many have access to person medical information and ease with information being transferred
there are increased opportunities for confidential information to fall into unintended hands
 To protect security and confidentiality the federal government developed HIPAA
 HIPAA – provides patients with access to their medical records and control over how
personal health information is used and disclosed
o Pts can ask providers to
 add or change incorrect info to their record
 they can request their information not be shared
 Congress authorized civil and criminal penalty that misuse personal health information
 Administrative Simplification compliance Act:
o Amended HIPAA and required claims submitted to Medicare electronically
o Patient Consent
 Patients are entitled to know the full implications of procedures and make an independent
decision as to whether they choose to have them performed.
 procedures become so routine to staff that they fail to realize patient permission must be
granted, or a staff member may obtain a signature from a patient who has a fluctuating level of
mental competency and who does not fully understand what he or she is signing.
 Consent must be obtained before performing any medical or surgical procedure; performing
procedures without consent can be considered battery.
  When patients sign consent this authorizes staff to perform certain routine measures:
 Bathing, examination, care-related treatments, emergency interventions
 They do not qualify as carte blanche consent for all procedures.
 Blanket consent forms patients sign, authorizing staff to do anything required for
treatment and care, are not valid safeguards and may not be upheld in a court of law.
 Consent is obtained for anything that exceeds basic care routine measures
 Consent should be gotten when there is:
 Any entry into the body by incision or natural body openings
 Use of anesthesia
 Cobalt or radiation therapy
 Electroshock therapy
 Experiment procedures
 Research participation
 Invasive or not
 Any procedure, diagnostic or treatment that carries more than a slight risk
 Consent must be INFORMED
 It’s unfair and legally unsound to obtain the patient’s signature for a procedure without
telling what that procedure entails.
 The written consent that describes the procedure, its purpose, alternatives to the
procedure, expected consequences, and risks should be signed by the patient,
witnessed, and dated
 The person performing the procedure (e.g., the physician or researcher) is the one to
explain the procedure and obtain the consent.
 Nurses/staff members should not be obtaining consent for the physician because:
o it is illegal
o they may not be able to answer the medical questions posed by the patient.
 Patients who do not fully comprehend or who have fluctuating levels of mental function
are incapable of granting legally sound consent.
 Nurses can play a role in the consent process by:
o ensuring that it is properly obtained,
o answering questions,
o reinforcing information,
o making the physician aware of any misunderstanding or change in the desire of
the patient.
o Nurses should not influence the patient’s decision in any way.
 Every conscious/mentally competent adult has the right to refuse consent for a procedure.
 To protect the agency/staff, have the patient sign a release stating that consent is denied
and the patient understands the risks associated with refusing consent.
 If the patient refuses to sign the release, this should be witnessed, and both the
professional seeking consent and the witness should sign a statement that documents
the patient’s refusal for the medical record.
o Patient Competency
 Persons who are mentally incompetent are unable to give legal consent.
 Staff will turn to the next of kin to obtain consent for procedures
 Appointing of a guardian to grant consent for the incompetent individual is the
responsibility of the court.
 When the patient is incompetent encourage:
o family members to seek legal guardianship of the patient or request assistance
of the state agency on aging in petitioning the court for appointment of a
guardian.
 If they are declared incompetent by a judge people are entitled to make their own decisions.
 Various forms of guardianship (also called conservatorship) can be granted when a person has
been judged incompetent
  The guardian is monitored by the court to ensure they are acting in the best interests of
the incompetent individual.
 In the case of a guardian of property, the guardian must file financial reports with the court
 Types of decision-making authority
 Guardianship  used by competent individuals to appoint someone
o Court appointed individual or organization to have authority to make decisions
for an incompetent person.
o Guardians can be granted decision-making authority for specific types of issues:
 Guardian of property (conservatorship):
 limited guardianship
 allows the guardian to take care of financial matters
 Guardian of person:
 decisions pertaining to consent or refusal for care
 treatments can be made by persons granted
 Plenary guardianship (committee ship):
 all decisions pertaining to person and property can be made by
guardians
 . POWER OF ATTORNEY
o Power of attorney becomes invalid if the individual granting it becomes
incompetent except in the case of durable power of attorney
o Legal mechanism by which competent individuals appoint parties to make
decisions for them;
 Limited power of attorney:
 decisions are limited to certain matters (e.g., financial affairs)
and power of attorney becomes invalid if the individual
becomes incompetent.
 Durable power of attorney:
 provides a mechanism for continuing or initiating power of
attorney in the event the individual becomes incompetent.
 This is recommended for people with dementias or other
disorders which competency can be declined
 To protect patients
o nurses should recommend that patients and their families seek legal counsel for
guardianship and power of attorney issues
o Clarify the type of decision-making authority that the appointed parties possess
o Staff Supervision
 nurses are responsible for supervising other staff, whom may be unlicensed
 Nurses are responsible for their own actions and the actions of the staff they are supervising.
 This falls under the doctrine of respondeat superior (“let the master answer”).
 If a patient is injured by the employee they supervise while the employee is working within the
scope of the applicable job description, nurses can be liable.
 Ensure caregivers to whom tasks were delegated to are competent and carry out the
assignments properly
 Various types of situations can create risks for nurses:
 Permitting unqualified or incompetent persons to deliver care
 Failing to follow up on delegated tasks
 Assigning tasks to staff members for which they are not qualified or competent
 Allowing staff to work under conditions with known risks
o EX: being short staffed and improperly functioning equipment)
o Medications
 Nurses are responsible for safe administration of prescribed medications
 Preparing, compounding, dispensing, and retailing medications fall within the practice of
pharmacy NOT NURSING
o Restraints
 The Omnibus Budget Reconciliation Act (OBRA)
 heightened awareness of the impact of restraints by imposing strict standards on their
use in long-term care facilities.
 Anything physically or mentally restricting a patient’s movement can be considered a restraint
 EX: protective vests, trays on wheelchairs, safety belts, geriatric chairs, side rails, and
medications.
 Improperly used restraining devices violate regulations concerning their use and results in
litigation for false imprisonment and negligence .
 At no time should restraints be used for the convenience of staff
 Chemical restraints (only used when other methods are ineffective)
 Haloperidol, benzodiazepines, lorazepam  reduces agitation
o Complications: aspiration and pneumonia
 Alternatives to restraints to help manage behavioral problems and protect the patient:
 alarmed doors, wristband alarms, bed alarm pads, beds and chairs close to the floor
level, and increased staff supervision and contact.
 Document behavior that creates risk to the patient and other
 Assessment of the risk posed by the patient not being restrained and effective
alternatives should be included
 When restraints are necessary:
 Obtain a physician’s order for the restraints
 State specific conditions which they to be used
 Type of restraint
 Duration of use
 When documenting it should include
 Time of initiation and release
 Effectiveness
 Patients response
 Staff may assess restraint use is required, but the patient/family objects and refuses to have a
restraint used.
 If counseling does not help the patient and family understand the risks involved in not
using the restraint, the agency may have the patient/family sign a release of liability that
states the risks of not using a restraint and the patient’s or family’s opposition.
 This may not free the nurse/agency from all responsibility, some limited protection may
be afforded
o signing the release, the patient and family may realize the severity of the
situation.
o Telephone orders
 In home health and long-term care settings, nurses often do not have an on-site physician.
 Requests for new or altered treatments may be communicated over the telephone, and, in
response, physicians may prescribe orders accordingly.
 Accepting telephone orders puts nurses at risk because the order can be heard or written
incorrectly or the physician can deny that the order was given.
 Minimize risks everyway possible
 have the physician fax the written order or send it online
 Do not involve third parties in the order
o do not have the order communicated by a secretary or other staff member for
the nurse or the physician).
 Communicate all relevant information to the physician, such as vital signs, general
status, and medications administered.
 Do not offer diagnostic interpretations or a medical diagnosis of the patient’s problem.
 Write down the order as it is given and immediately read it back to the physician
 Place the order on the physician’s order sheet, indicating
 o it was a telephone order,
o the physician who gave it,
o time and date,
o nurse’s signature.
 Obtain the physician’s signature within 24 hours.
 Recorded telephone orders are helpful to validate what was heard,
o they may not offer much protection in the event of a lawsuit unless the
physician is informed the conversation is being recorded or unless special
equipment with a 15-second tone sound is used.
o Do not Resuscitate Orders
 If an order specifically states a patient should not be resuscitated, failure to attempt to save that
persons life could be viewed as negligence
 DNR orders
 Ensure the DNR order is legally sound
 These are medical orders written and signed on the physicians order sheet to be valid
 DNR on the care plan or special symbol on the bedside is not legal without the medical
order
 Obtain consent for DNR unless it detrimental to the patients well being or the patient is
incompetent
o If patient can’t consent a family consent should be gotten
 Every agency should have a DNR policy
o Advanced directives and issues related to death and dying
 Advance directives  express the desires of competent adults regarding terminal care, life
sustaining measures, and issues pertaining to their dying and death.
 2 types of Advance directives
 Durable power of attorney for health care
o Document that appoints a person the patient selected to make decisions on the
patients behalf if the patient becomes incompetent
 Living will
o A patient’s preferences and gives instructions to health care providers if the
patient is unable to make or communicate decisions and has no one appointed
as proxy
o For a will to be valid, the person making it must be of sound mind, legal age, and
must not be coerced or influenced into making it.
o The will should be written some states recognize oral or nuncupative wills signed
dated and witnessed by person not name in the will
 Patient Self-Determination Act
 requires all health care institutions receiving Medicare or Medicaid funds to ask patients
on admission if they possess a living will or durable power of attorney
 The patients response must be recorded
 Advance directive protects health care professionals from civil and criminal liability
 Nurses should avoid witnessing a will
 They can help obtain legal counsel to execute or change it
 IF a patient want to dictate a will to the nurse, write it exactly as stated, sign, and date it;
have the patient sign it if possible; and forward it to the agency’s administrative offices
for handling.
 Pronouncement of death
 may be illegal for nurses in some states, the act of pronouncing a patient dead falls
within the scope of medical practice, not nursing.
 Nurses should safeguard their licenses by holding physicians responsible
 Postmortem exams
 Cause of death could be associated with:
o criminal act, malpractice, or an occupational disease,
  an autopsy may be mandatory unless it’s the medical examiners cases
consent for the autopsy must be obtained from next of kin
o Elder Abuse
 Types of elder abuse
 Physical abuse
 Emotional or psychological abuse
 Sexual abuse
 Financial or material exploitation
 Neglect
 Abandonment
 Self-neglect
 Abuse can include:
 inflicting pain or injury , stealing, mismanaging funds, misusing medications, causing
psychological distress, withholding food or care, or confining a person, or threatening to
commit any of these acts
 It may be undetected due to:
 reluctance to report the problem due to fear or shame
 the older persons lack of contact with others
o EX: being homebound and no contact with anyone but the abuser
 Signs of abuse could be the following:
 Delay in seeking necessary medical care
 Malnutrition
 Dehydration
 Unexplained bruises
 Poor hygiene and grooming
 Urine odor, urine-stained clothing/linens
 Excoriation or abrasions of genitalia
 Inappropriate administration of medications
 Repeated infections, injuries, or preventable complications from existing diseases
 Evasiveness in describing condition, symptoms, problems, and home life
 Unsafe living environment
 Social isolation
 Anxiety, suspiciousness, and depression

Chapter 9: Ethical Aspects of Gerontological Nursing

- Philosophies guiding ethical thinking

o Utilitarianism – greatest number of people will benefit and gain happiness
o Egoism – act is morally acceptable if it is of greatest benefit of oneself and there is no reason to
perform an act that benefits others
o Relativism - right and wrong are relative to the situation
o Absolutism – There are specific truths to guide actions
 EX: Christian’s view differ from an atheist’s view on certain moral behaviors, and a person who
supports a political view of democracy may believe in truths different from those of a
communist.

- Ethical principles
o Beneficence: to do good for patients.
 Based on belief that education and experience of nurses enables them to make sound decisions
that serve patients’ best interests.
  Nurses are challenged to take actions that are good for patients while not ignoring patients’
desires.
 Paternalism - Overriding patients’ decisions and invoking professional authority to take action
that nurses view as the patients’ best interests and interferes with the freedom and rights of
patients.
o Nonmaleficence: to prevent harm to patients.
 Subset of beneficence because the intent is ultimately to take action that is good for patients.
 To not directly causes harm, actions such as informing management that staffing is inadequate
to provide safe care
o Justice: to be fair, treat people equally, and give patients the service they need.
 Patients are entitled to services based on need, regardless of the ability to pay.
 Scarce resources have challenged this concept of unrestricted access and use of health care
services.
o Fidelity and veracity:
 Fidelity - respect our words and duty to patients;
 veracity - truthfulness.
 This principle is central to all nurse–patient interactions because the quality of this relationship
depends on trust and integrity.
 Older patients may have higher degrees of vulnerability and may be particularly dependent on
the truthfulness of their caregivers.
o Autonomy: to respect patients’ freedoms, preferences, and rights.
 Ensuring and protecting older patients’ right to provide informed consent
o Confidentiality: to respect the privacy of patients.
 Patients share highly personal information with nurses and need to feel assured that their trust
will not be violated.
 Health Insurance Portability and Accountability Act and other laws have afforded people the
legal right to privacy and consequences if this is violated.
- Cultural Considerations
o The belief that individuals have the right to make their own decisions regardless of their sex and should
be empowered to do so.
 In many Amish, German, Greek, Haitian, Irish, and Puerto Rican families, individuals discuss
important decisions with family members and may prefer to have the family involved in the
decisions.
 Jewish individuals may seek the advice of a rabbi.
 Some people may not want to discuss issues and confront decision-making; f
 Filipinos, Chinese, and Japanese view discussions of death as taboo.
o Women are equal to men.
 In Arab, Iranian, Hindu, and some Italian families, it is common for males to assume decision-
making roles, and women may yield their decision-making authority to them.
o Prayer is a beneficial supplement to medical treatment.
 Prayer may not be welcomed by patients who are agnostic or atheistic.
 People who do believe in prayer, there may be differences in the deity worshipped and method
of prayer.
o People have the right to have the confidentiality of their health information protected, even from
relatives.
 To individuals who view family involvement in decision-making as natural and preferable, there
may be a desire to have health information shared with the family.

- Changes increasing ethical dilemmas

o Expanded role of nurses
 they have a wide scope of functions that increase the accountability and responsibility
for the care of the patients
 o Medical technology
 Artificial organs, genetic screening, new drugs, computers, lasers, ultrasound, and other
innovations have increased the medical community’s ability to diagnose and treat problems and
to save lives that they couldn’t do before.
 Problem with these advances, such as determining on whom, when, and how this technology
should be used.
o New Fiscal Constraints
 health care providers and agencies are to provide quality services to help people maintain and
restore health.
 They are competing and overriding concerns, including the following:
 being cost-effective, minimizing bad debts, and developing alternate sources of
revenue.
 Patients’ needs are weighed against economic survival, causing difficult decisions.
 Due to rationed care and scarce resources, questions are raised regarding the right of older
adults to expect a high quality and quantity of health and social services while other groups
lack basic assistance
o Conflict of interest
 Nurses can face a variety of situations that present a conflict of interest.
 Examples:
o a nurse, believing a resident’s life could be extended with nasogastric feedings
and antibiotic therapy, feeling that a resident’s and family’s rejection of this care
is inappropriate;
o a patient’s physical therapy discontinued due to insurance restrictions and the
nurse knowing that the patient has the potential to make continued progress
with the therapy;
o the nurse knowing the employer is intentionally keeping staffing levels below
what is needed but not objecting or advocating for proper staffing because the
nurse does not want to jeopardize his or her position.
o Greater number of older adults
 Entitlement programs and services for older persons had less impact whena small portion of the
population was old, but with growing numbers of people spending more years in old age and the
increasing ratio of dependent individuals to productive workers, society is beginning to feel
burdened.
 Although older adults’ problems and needs are more evident, the ability and responsibility of
society to support these needs are in question.
o Assisted Suicide
 Although participating in a patient’s assisted suicide is unethical and inappropriate, nurses may
discuss options with terminally ill individuals who accept and desire assisted suicide
 nurses have the right to conscientiously object to being involved in aiding assisted suicide.
 Nurses may face the dilemma of knowing that a competent patient is arranging an assisted
suicide and believing that they must intervene.
 Nurses may know that a competent patient is arranging an assisted suicide, and while
understanding and respecting the patient’s decision, they feel they are violating professional
standards by not reporting it so that it may be halted.

Week 7 – Chapter 35: Family Caregiving

- Identify risks to caregivers and way to avoid them

o Sandwich generation – women who care for their parents and children
 People employed full-time also have caregiving responsibilities
 At first assistance is a subtle gradual process
o EX: daughter phones her mother after appointment. As time progresses
daughter many accompany mother to physicians office, discuss meds, and call
her mother daily to monitor response to drugs. Later on the daughter may have
to lift her mother, undress her for an exam, administer meds
o Types of assistance families provide to older members
 Maintaining and cleaning the home  Reminding to take meds, keep
 Managing finances appointments, and take actions
 Shopping  Monitoring and administering medications
 Transporting  Performing treatments
 Providing opportunities for socialization  Supervising
 Advising  Protecting
 Explaining  Bathing and dressing
 Troubleshooting  Feeding
 Reassuring  Toileting
 Accompanying to physician’s office and hospital  Assisting with decision-making
 Negotiating services  Maintaining a file of health documents
 Cooking and providing meals
o Long-distance care giver
 Individual who assists someone in need of care who lives more than 1 hour away
 Assistance offered:
 Arranging/ coordinating in-home care, managing finances, and providing respite.
 They begin with occasional visits, telephone calls, and troubleshooting and progresses to daily
telephone calls and regular home visits
 As with direct caregiving by family members, family members who do not live close to the
person need to discuss the person’s needs and the family member(s) best able to manage them.
 If a family member lives close to the person, that family member may not be the best
person to manage care.
o Nurses should guide families about long distance caregiving by helping them to
review tasks needed by the person and evaluate who is best able to assist
o Nurses can link families to:
 Services in the persons community
 Resources to educated them about the persons condition/care
 Caregivers giving direct or long-distance care need to consider physical, emotional, social and
economic assistance they can provide and set limits
 Nurses need to advise long-distance caregivers about what issues they should review during
telephone calls such as:
 when groceries were last purchased
 what time the person goes to sleep and awakens
 food consumption
 status of prescriptions
 contact with others
 new symptoms
 Nurses can recommend to long-distance care-givers to:
 Plan visits at times when medical appointments are scheduled
 Find local geriatric care managers to asses a persons needs
 coordinate care locally
 Challenges:
 Family members can’t determine the quality of care
o Have local friends/family visit and communicate observations
 o Pay attention to mood and unusual incidents (missing valuables, injuries) can
give clues about abuse
o Unannounced visits by family can aid in assessing quality of care
 When a person can no longer remain in their home
o Admission to an assisted living facility can be costly and difficult for the person
 Nurse should assist in how to select a nursing home
o Having a person move in with a family member requires adjustments and costs
 Discuss issues to consider and this could affect all household member
 Family caregiving at a distance does not make family members immune to guilt,
frustration, anxiety, anger, and depression about their loved one
o Encourage them to share feelings and seek support groups
o Remind them about the importance of taking care of themselves
o Protecting the health of the older adult/caregiver
 the health of all family members must be maintained and promoted.
 Maintaining older persons’ independence facilitates normality in family relationships.
 Living and being cared for family members threatens the role of older persons causing
 anger, resentment, and other feelings to develop
 Sound health practices to prevent disease and disability maintain self-care ability and
independence.
 If illness occurs, attention should be paid to avoiding complications and restoring the
affected person to a healthy state.
o Interventions such as:
 environmental modifications, financial aid, home-delivered meals,
assistance with chores, transportation for the physically disabled,
telephone reassurance, or a home companion can supplement deficits
and strengthen the older person’s independent living.
 Risks for caregivers:
 Disruption in family functions due to:
o transition, crisis, or uncertainly of outcome.
o The family is unable to meet physical, emotional, socioeconomic, or spiritual
needs of its members,
o deal with stress ineffectively
o communicate ineffectively or inappropriately,
o refuse to seek or accept help from others.
o They may be fearful, guarded, or suspicious when visited or interviewed.
 Contributing factors
o Illness or injury of family member
o change in dependency level of member,
o change in role or function of family member
o addition or loss of family member
o relocation
o reduced income
o added expenses
o social or sexual deviance by family member
o break in religious or cultural practices by family members
 Avoiding Risks
 Collect a comprehensive family history that includes
o profile of family (include significant others who fill family functions as family
members); age, health, and residence of members; roles and responsibilities of
each member; typical patterns of communication, problem-solving, and crisis
management; recent changes in composition of the family and members’ roles,
 responsibilities, and health statuses; new burdens; and the family’s assessment
of problem.
 Identify factors related to family dysfunction and plan interventions such as:
o family therapy, financial aid, family conference, visiting nurse, or clergy visit.
 Facilitate open, honest communication among family members; assist in planning family
conferences, promoting discussion by all members, developing realistic goals and plans,
and allocating responsibility; provide privacy for family.
 When a member is receiving health services, explain care activities and expected
outcomes, prepare for changes, and involve the family in care to the maximum extent
possible.
 Provide caregiver education and support; help caregivers identify community resources;
and emphasize the importance of respite for caregivers.
 Make the family aware of support and self-help groups that can assist them, such as
Alzheimer’s Disease and Related Disorders Association, American Cancer Society,
Alcoholics Anonymous, and American Diabetes Association.
 Evaluate physical, emotional, and social health of the caregivers periodically to ensure
they are competent to provide required services and are not jeopardizing themselves in
the process.
 Provisions must be made for what gerontological nurses refer to as caregivers’ TLC:
o T—training in care techniques, safe medication use, recognition of
abnormalities, and available resources
o L—leaving the care situation periodically to obtain respite and relaxation and
maintain their normal living needs
o C—caring for themselves via adequate sleep, rest, exercise, nutrition,
socialization, solitude, support, financial aid, stress reduction, and health
management
o Gerontological nurses should review the TLC needs of caregivers during every
contact to ensure their continued effectiveness.
 When nurses contact family caregivers the nurse should ask questions about how they are doing
 The nurse can preface questions about their status with statements such as the
following:
o “Caregiving is quite challenging, and it’s not unusual for caregivers to feel
physically and emotionally exhausted.”
o “It is very special of you to care for your mother as you do, but I’d suspect that
it’s not easy on you.”
 These statements imply an understanding of the difficulties with the role and can invite
honest expressions of frustrations and needs.
 Nursing Strategies to assist family caregivers
 Guide the family to view the situation realistically such as:
o A leave of absence rather than resignation from a job to assist a parent or
spouse through convalescence.
 Perhaps the needs are such that a caregiver (e.g., family member) will
not be able to care for them adequately.
o An objective outsider can guide the family in viewing the real situation and
understanding the extent of care needs.
 Provide information that can assist in anticipating needs.
o Guide Caregivers in exploring various scenarios that can arise and develop plans
before a crisis occurs.
o Encourage expression of feelings.
o “shoulds” and “oughts” regarding the treatment of older person, families need
to know that the guilt, anger, resentment, and depression they feel are neither
uncommon nor bad.
 Assess/monitor the impact of the caregiving on the total family unit.
 o Caregivers may feel they alone are assuming responsibility for care, they need to
examine the effects on the total family unit.
 How will their kids tuition be paid if they quit their jobs to care for a
parent?
 Will someone have to forfeit a bedroom if the relative moves in?
 What is the relationship of the spouse with the in-laws?
 Who will help lift grandma into the tub?
 Will the family be able to take vacations and entertain at home?
 Can someone relieve them if they want to go out for a special occasion?
 Introduce and promote a review of care options.
o Family members believe that care must be institutionalization or total care
provided solely by the caregiver.
 Other possibilities exist including home health aides, live-in companions,
geriatric day care, or shared family care in which the elder lives at
specific times with various relatives, or relatives spend designated days
at the elder’s home.
o Caregivers should be aided in identifying their limitations and the need for
institutional care when necessary.
- Identify signs of elder abuse
o Adult at great risk for abuse:
 Disabled woman
 Older than 75
 Lives with a relative
 Physically, socially, or financial dependent on other
o Abuse can occur in all sorts of families regardless of social, financial or ethnic background
o The actual commission of a harmful act and the threat of committing it are considered abuse
o Signs of abuse
 infliction of pain or injury
 withholding of food, money, medications, or care
 confinement, physical or chemical (drug) restraint
 theft or intentional mismanagement of assets
 sexual abuse
 verbal or emotional abuse
 neglect
 abandonment
o An older adult may not report or admit mistreatment because:
 The older adult is dependent on the family member abusing them
 They feel powerless and helpless to confront them
o EX: Caregiver is economically dependent on the elder who is dependent on the
caregiver and the caregiver uses threat of abandonment to manipulate and
financially abuse the elder. The older person fears losing the source of help on
which he or she depends and therefore allows the situation to continue without
bringing outside attention to it.
o Subtle clues of abuse include:
 Malnutrition, failure to thrive, injuries, oversedation, unexplained financial problems, and
depression
o Elder mistreatment assessment instrument
 Used to assess for abuse
 Once abuse is detected  assess the degree of immediate danger and take appropriate
actions.
o Assure abuse patient their plight will not be worsened by making the abuse
public
 o they may prefer being verbally threatened or having their money taken to the
alternative of living in an institution or foster home.
o Abusers
 Some are consciously malicious and abusive for their own gain
 Some are distressed in stressful situations coping ineffectively
o Abuse can be associated with:
 Family pattern of violence
 Emotional cognitive dysfunction of the abused or the abuser
 History of dependency of the abuse on the victim
 Retaliation for a history of earlier abuse
- Interventions to reduce family dysfunction.
o The nurse should give the family empathy not judgement
o Help families find effective ways to manage the situation such as:
 Counseling
 Respite care
o Ongoing interventions are necessary to prevent future abuse after the immediate episode was resolved

Week 7 – Chapter 36: End-of-life Care

- Discuss the difficulty people may experience in facing death

o Many have limited experiences with death or dying because of the decrease in mortality over the years
 In the past there were higher mortality rates
o Limited exposure to the dying process is caused by:
 Changes in the site and circumstances of death
 Previously viewed as natural process, managed by familiar faces in familiar surroundings
o Family felt comfort and closeness by being with and doing for the person dying
 More deaths occurring in an institutional (nursing homes) or hospital setting
 Parents/grandparents live in different households in different parts of the counts
o Family and friends are not with the individual or witness the dying process
o Direct experiences with death and dying are lessened, death is more impersonal and difficult to
internalize.
 Many have difficulty accepting their own mortality
o Clues to the lack of internalization of one’s mortality is:
 They avoid discussions about death
 They don’t make a will or other plans for their own death
o Nurses who understand their own mortality are comfortable helping individuals through the dying
process
o Nurses who deny their own mortality or feel angry about it tend to
 Avoid dying people
 Discourage their efforts to deal realistically with their death
 Instill false hope in the patient and families
o Patients’ reactions to dying are influenced by previous experiences with:
 Death, age, health status, philosophy of life, religious, spiritual, and cultural beliefs
- Describe the stages people commonly go through when facing death and related nursing interventions. (36-2)
o Denial – 1st stage
 Individuals deny the reality of the situation
 EX: “It isn’t true”, “There must be some mistake”, “No not me”
 Patients will sometimes shop for another physician to suggest a different diagnosis
 Patients invest in healers and fads that promise a more favorable outcome
 Useful purposes for denial in the dying person:
 Shock absorber after learning the difficult news
 Opportunity for people to test the certainty of the information
  Allows people time to internalize the info and mobilize defenses
 Denial is usually strongest early on, but is used at various times throughout the illness
 Fluctuation in between wanting to discuss impending death and denying its reality
 An individual’s life philosophy, unique coping mechanisms, and knowledge of the condition
determine when denial will be replaced by less radical defense mechanisms.
 Nursing Interventions
 Be sensitive to the persons need for defense while being ready to discuss death when
the patient needs to
 Accept the dying patients’ defenses rather than conflicting messages
o Accept the dying person’s reactions for provide an open door for honest
dialogue
o Anger – 2nd Stage
 Difficult for individuals around the dying person, they are frequently victims of displaced anger
 The dying person expresses nothing is right such as:
 Nurses don’t answer the call light soon enough
 Food tastes awful
 Doctors don’t know what they are doing
 Visitors stay too long or not long enough
 Patients with unfulfilled desires and unfinished business may cause outrage
 Their complaints and demands are used to remind those around them they are still living beings
 The family around the dying person
 may feel guilt, embarrassment, grief, or anger
 they don’t understand why their intentions are misunderstood or actions unappreciated
 They question if they are doing things correctly
 Patients may give the nurse criticism such as:
 Not being good enough
 Being to cheerful and receiving scorn
 The call light goes on the minute the nurse leaves the room
 Nursing Interventions
 Help the family gain insight into the individual’s behavior to relieve their discomfort
o This creates a more beneficial environment for the dying person
o If the family can realize the person is reacting to impending death it may
facilitate a more supportive relationship
 Guard against responding to the dying person’s anger as a personal affront
 When the nurse receives criticism the nurse should assess the behavior
o Don’t respond to anger, accept and imply that it is fine to vent these feelings
 Anticipate needs, remember favorite things, maintain pleasant attitudes
 May be useful for nurses to discuss their feelings about pts anger with an objective
colleague so the patient-nurse relationship continues to be therapeutic
o Bargaining – 3rd stage
 Dying patient may attempt to negotiate a postponement of the inevitable such as:
 agree to be a better Christian if God lets them live through one more Christmas
 they may promise to take better care of themselves if the physician initiates aggressive
therapy to prolong life
 they may promise anything in return for an extension of life.
 Most bargains are made with God and kept a secret
 Sometimes such agreements are shared with members of clergy
 Nursing interventions
 Be aware dying patient may feel
o disappointed at not having their bargain honored
o guilty of having gained time and want an additional extension even if they
agreed the request would be their last
 Explore these feelings with the dying person
 o Depression – 4th stage
 When pt is hospitalized with increasing frequency and experiences declining function and more
symptoms
 The pt may have already had losses and experienced depressions
 Lifetime savings, pleasurable past times, normal lifestyle, bodily functions, and body parts may
be lost
 The depression of a dying person may not benefit from encouragement and reassurances
 Depression of the dying is usually silent
 Nursing interventions
 It’s unrealistic to believe the dying person should not be deeply saddened by the most
significant loss of all their life
 Urging dying persons to cheer up, look at the sunny side of things implies that they
should not contemplate their impending death.
o Nurse must understand cheerful words may be far less meaningful to dying
individuals
 holding their hand or silently sitting with them, touching, comforting and being near are
significant to the dying
 Being with the dying person who openly or silently contemplates the future is important
 Prayer and a desire for visits from clergy are seen
 Be sensitive to the dying pts religious needs and facilitate clergy-patient relationship
every way possible
 Help family understand efforts to cheer the dying person can hinder them
 Reassure family for the helplessness they feel
 Emphasize this type of depression is necessary for pt to be able to approach death in a
stage of acceptance and peace
th
o Acceptance – 5 Stage
 Struggling ends and relief ensues
 Final rest is being taken to gain strength for a long journey
 Acceptance should not be mistaken for a happy state
 It implies they have come to terms with death and found a sense of peace
 Nursing Interventions
 Patients benefit more from nonverbal than verbal
 The pts silence and withdrawal should not result in isolation from human contact
 Touching, comforting, and being near the person is beneficial
 An effort to simplify the environment may be required as the dying persons circle of
interests shrinks
 Support the family in learning to understand and support their loved one
o Hope
 commonly permeates all stages of the dying process
 Provides senses of having a special mission to comfort individuals in the last days
 A realistic confrontation of impending death does not negate the presence of hope
 Used as:
 a temporary but necessary form of denial
 a rationalization for enduring unpleasant therapies
 source of motivation

- Discuss physical care needs of the dying person

o Pain
 Degree of pain and management may be a considerable source of distress for dying individuals
 Cancer patients are more likely to experience severe pain than a person dying of other causes
 Pain can be managed effectively
 Common indicators of pain:
 pain or discomfort, nausea, irritability, restlessness, and anxiety
  Some patients may not overtly express pain, clues are:
 sleep disturbances, reduced activity, diaphoresis, pallor, poor appetite, grimacing, and
withdrawal, possibly confusion
 Nursing interventions
 Supply patient with realistic information regarding pain
 Understand pain is expressed differently based on:
o Medical diagnosis
o Emotional state
o Cognitive functions
 Understand the absence of expressions of pain does not mean it does not exist
 Regularly assess pain because it can increase/decrease over time
 Encourage patients to report pain in a timely fashion and discuss concerns about pain
o Using a scale of 0-10
 Goal of pain management for the dying:
o Prevent pain from occurring rather than responding after it occurs
 Helps avoid discomfort and amount of analgesics used
o After pattern pain is assessed a schedule for administering analgesics is used
 Mild Pain  aspirin or acetaminophen
 Moderate pain  codeine or oxycodone
 Severe pain  morphine or hydromorphone
 Contraindicated due to psychosis  meperidine and pentazocine
o Instruct patients to report:
 ineffectiveness of analgesics
 schedule of administration
 Overdosage
 Adverse reactions
o Non pharm pain measures;
 Back rubs, therapeutic touch, guided imagery, relaxation exercises, and
counseling
 acupressure, acupuncture, and hypnosis  review with physician
 Palliative care
 Care that prevents and relieves pain in persons with incurable conditions
 Provided for persons dying and is important in care of dying individuals
o Respiratory Distress
 Common in dying patients
 Patients have physical distress and psychological distress such as:
 Fear, anxiety, helplessness from the thought of suffocating
 Causes of respiratory distress range from pleural effusion to deteriorating blood gas levels
 Treatment:
 To reduce bronchial secretions  atropine or furosemide
 Control respiratory symptoms by blunting the medullary response  narcotics
 Nursing Interventions
 Elevate the head of the bed
 Pacing activities
 teaching the patient relaxation exercises
 administering oxygen
o Constipation
 Causes of constipation in dying patients:
 Reduced food/fluid intake
 Inactivity
 Medications
 Nursing Interventions
 Promote regular bowel elimination in terminally ill patients
  Increase activity
 Intake fluids and fibers
 Laxatives are given on a regular schedule
 Bowel elimination patterns are assessed and record
 What appears to be diarrhea may be seepage of liquid wastes around fecal impaction
o Poor Nutritional Intake
 Dying patient’s experience:
 anorexia, nausea, vomiting, fatigue, and weakness
 Nursing interventions
 Provide small, portioned meals with alluring appearances, aromas, and patients favorites
 An alcoholic drink before meals can boost appetite of some
 Nausea and vomiting can be controlled by:
o Antiemetics
o Antihistamines
o Ginger  natural antiemetics without side effects
 Nursing can also assist with
o Oral hygiene,
o clean and pleasant environment for dining,
o pleasant company during mealtime
o Assist with feeding as necessary
- Spiritual Care needs
o Nurses must respect religion and it’s own practices to promote the fulfillment of patients spiritual needs
o Nurses must be sensitive to differences and respect religious briefs of patients and families
o When assessing explore religious affiliation and religious practices
 Religion and spirituality are not synonymous; patients can be highly spiritual without religion
o To determine the spirituality and spiritual needs of patients nurse can ask:
 What gives you the strength to face life’s challenges?
 Do you feel a connection with a higher being or spirit?
 What gives your life meaning?
o Invite clergy and congregation members in which the patient belongs and is close to
o Nurses can offer to pray with patients or read to them from religious texts if they feel comfortable
 Ensure that prayers offered are consistent with the patients belief system
- Signs of Imminent death
o When death is near bodily functions slow and certain signs/symptoms occur such as:
 decline in blood pressure
 rapid weak pulse
 dyspnea and periods of apnea
 slower or no pupil response to light
 profuse perspiration
 cold extremities
 bladder and bowel incontinence
 pallor and mottling of skin
 loss of hearing and vision
o Identifying death allows nursing staff to assure family is notified and given the opportunity to share the
last minutes of the patient’s life
 If family is not available staff should remain with the patient
 Depending on the wishes of the patient and family, clergy may be called to visit at this time
o Do not let the patient alone even if the patient is unresponsive
 He or she should be spoke to and touched
- Advance directives
o Advance Directive - A patient expresses terminal care and life-sustaining measures through a legal
document
  Eases burden of family members during this difficult time
o All healthcare facilities receiving Medicare/Medicaid funding must provide info to patient about the
patient self-determination act
 Patient self-determination act – gives patient right to have choice in medical/surgical care and
have those preferences honored at a later time if they can’t communicate
o Review advance directives when patients are admitted to hospital/nursing home and discuss the
importance of the patient expressing desires in a legal sound manner
o Introduce and guide the discussion to dying to assure wishes are known
o If Advanced directives exist review with patient to make sure it reflects the patients preferences
o Place a copy of advanced directives in medical record to inform interdisciplinary team
o Some states implement MOLST and POLST
 individuals with serious illnesses or who are near the end of life develop these documents to
describe specific medical treatments that they wish to have during a medical emergency
 MOLST  Medical order for life-sustaining treatments
 POLST  physician orders for life-sustaining treatments
 These are not legal documents that describe desired future care (unlike advanced directives)
 They do not contain info as to surrogates who can make medical decisions on their behalf
 If individuals have MOLST or POLST they should have advance directive
- Supporting Family and Friends through the stages of the dying process
o Family and friends pass through the stages of denial, anger, bargaining, and depression before accepting
a special person in their lives is going to die
 Denial
 family and friends may discourage patients from talking or thinking about death
o visit patients less
o state patients will be better as soon as they
 return home, start eating, have their intravenous tube removed, and so
forth.
o They may shop around for a doctor or hospital to find a special cure for the
terminal illness.
 Anger
 Family/friends may include criticizing staff for the care they are giving,
 reproaching a family member for not paying attention to the patient’s problem earlier,
 questioning why someone who has led such a good life should have this happen
 Bargaining
 Family/friends may try to bargain to avoid or delay their loved ones death
 They may tell staff if they can take the patient home they could improve their condition
 Through prayers or open expression they may agree to take better care of the patient if
given another chance.
 They may consent to some particular action (e.g., going to church regularly, volunteering
for good causes, or giving up drinking) if only the patient could live to a particular time.
 Depression
 family and friends may become more dependent on the staff.
 They may begin crying and limit contact with the patient.
 Acceptance
 They may spend a great deal of time with the dying person and telling staff of the good
experiences they have had with the patient and how they are going to miss them.
 They may request staff to do special things for the patient (e.g., arrange for favorite
foods, eliminate certain procedures, and provide additional comfort measures).
 They may frequently remind staff to be sure to contact them “when the time comes.”
 They begin making specific arrangements for their own lives without the patient (e.g.,
change of housing, plans for property, and strengthening other relationships for
support).
o Nursing Support
  Nursing support for friends and family vary based on the stage the family/friend is in
 The nursing actions described for the dying individual during each stage may be applicable for
family and friends
 the stages experienced by friends/family involved with the dying person may not
coincide with the patient’s own timetable for these stages.
o EX:
 patients may already have worked through the stages, accept the reality
of death, and be ready to discuss the impact of their death and make
plans for their survivors. Family members and friends may be at
different stages and not be able to deal with the patient’s acceptance.
 Nurses need to be aware of theses discrepancies and provide individual therapeutic
interventions
 As family and friends pass through stages, the nurse can offer opportunities for the dying person
to discuss their death with a receptive party
o Helping Friends/Family AFTER death
 nurses need to be available to provide any needed support to family and friends
 Some people want several minutes of privacy with the deceased to view and touch them, some
want the nurse to accompany them, while others don’t want to enter the room
 Respect personal desires of friends/family and don’t make judgements of the family’s reaction
based on your own attitudes and beliefs
 Encourage friends/family to express their grief openly
 Crying/shouting may help with coping and working through feelings rather than
suppressing their feelings to keep calm
 Funeral arrangements may require guidance
 Survivors may experience grief, guilt, or other reactions placing them in a vulnerable
position
 A nurse, clergy, or neighbor can advocate for the family to prevent them from being
taken advantage of
 People should be encourages to learn about the funeral industry and plan in advance
o Books and memorial societies can assist in planning
 After the funeral
 The full impact of the death may first be realized
 When the most intense grief occurs fewer resources may be available to provide support
 Gerontological nurses can arrange for someone to check on family members several
weeks after death to make sure they are not experiencing any crisis
 Support through the grieving process
o Widow-to-widow and similar groups
o Provide a phone number of a person the family to contact if assistance is needed
- Supporting Nursing Staff
o It may be difficult to accept a patients death and come to terms with the whole issue of death
o Some nurses have difficulty in realizing their own mortality
 Experiences of death and exposure through formal education may be limited
 Nurses may feel
 Death is a failure because they emphasize curing
 Powerless that they can’t overcome impending death
 Nursing caregivers can experience the stages of dying
o Staff members are commonly observed to avoid
 contact with dying patients
 Tell a patient to cheer up and not think about death
 Continue to practice heroic measures although the patient is nearing death
 Grieve at the death of a patient
o Nursing staff may be limited in supporting patients and their families if they are at different stages
o The staff working with the dying needs a great deal of support
  Colleagues should help coworkers explore their own reaction to dying patient’s and recognize
when those reactions interfere with therapeutic nurse-patient relationships
 Attitude of colleagues and the environment should be that they can retreat from the situations
that is not therapeutic for them or the patient
 Encourage the nurse to cry or show emotions in other forms
 Thanatologists, hospice staff and other people can provide support to nurses