PSYCHOSOCIAL AND MENTAL HEALTH IN END OF LIFE, LOSS, ANTICIPATORY GRIEF, MOURNING , BEREAVEMENT, GRIEF THEORY, END OF LIFE  CAREGIVING IN THE FINAL STAGES OF LIFE, PALLIATIVE CARE HOSPICE CARE

1. SEMINAR ON PSYCHOSOCIAL AND
MENTAL HEALTH IN END OF LIFE
Presented by
Selvaraj.p
Ph.D Scholar
Oct-2019 Batch Guide
Dr.Sasi.Vaithilingan
Professor Cum Vice-Principal
VMCON Pondicherry.

2. OBJECTIVES
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3. INTRODUCTION
• People are complex, biopsychosocial beings. When they
experience the onset of a psychiatric disorder or medical
illness, undergo diagnosis for altered health states,
experience a loss, or progress into the end stage of life, their
responses may range from mature to psychotic.
• Coping styles depend on medical, psychological, cultural, and
social factors as well as the individual’s personality and
experiences.
• Caring for clients who experience a loss or who are terminally
ill is an integral part of nursing1/13/2021 VMRF(DU) NSG 19 OCT 07

4. LOSS
• Everyone has experienced some type of major loss at one
time or another.
• Quality of life can be affected by variables such as stress,
change in physical or mental health, unmet needs, or
victimization.
• Personal losses may include loss of valued social roles and
daily routine, loss of one’s former self, loss of relationships,
and a sense of loss of the future. Conversely, losses can also
affect one’s mental or physical health
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5. DEFINITION
• Loss The experience of separation from something of
personal importance
• The psychological context of loss is different for
younger people compared to older adults and the
elderly
• In younger individuals, losses tend to be sudden and
unexpected. For older adults and the elderly, losses are
not generally unexpected and are perceived as inherent
to living a long life1/13/2021 VMRF(DU) NSG 19 OCT 07

6. DEFINITION GRIEF
• Grief is a normal, appropriate emotional response to an
external and consciously recognized loss. It is the
process of experiencing psychological, behavioral,
social, and physical reactions to the loss.
• Grief is an emotional pain that needs to be
acknowledged and experienced.
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7.  Anticipatory grief allows the individual and others to
get used to the reality of the loss or death and to
complete unfinished business (eg, saying “good-bye,” “I
love you”).1/13/2021 VMRF(DU) NSG 19 OCT 07

8. MOURNING
• It is a term used to describe an individual’s outward
expression of grief regarding the loss of a love
object or person.
• The individual experiences emotional detachment
from the object or person, eventually allowing the
individual to find other interests and enjoyments
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9. BEREAVEMENT
• Some individuals experience a process of grief known
as bereavement(eg, feelings of sadness, insomnia, poor
appetite, deprivation, and desolation).
• The accumulation of loss over time can lead to
bereavement overload if the individual is unable to
work through the grief or pain.
• The best way to help an individual who is grieving is to
listen, be empathic, acknowledge the loss, and
experience the event at his or her own pace.1/13/2021 VMRF(DU) NSG 19 OCT 07

10. GRIEF THEORY
• Grief theory proposes that grief occurs as a process
Dr. Kubler ross model of death and grieving
 Swiss psychiatrists
 Analyzing patterned exhibited in the attitudes
of terminally ill patients
 The five stage are response to loss that many
people have but there is no typical response to
loss1/13/2021 VMRF(DU) NSG 19 OCT 07

11. 1/13/2021 VMRF(DU) NSG 19 OCT 07

12. 1. DENIAL
• The person displays a disbelief in the prognosis of
inevitable death.
• This stage serves as a temporary escape from reality.
• Typical responses include: “No, it can’t be true,” “It isn’t
possible,” and “No, not me.”
• Denial usually subsides when the client realizes that
someone will help him or her to express feelings while
facing reality.
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13. 2.ANGER
• Feelings associated with this stage include
sadness, guilt, shame, helplessness, and
hopelessness. Self-blame or blaming of others may
lead to feelings of anger toward the self and others.
• “Why me?” “Why now?” and “It’s not fair!” are a
few of the comments commonly expressed during
this stage. The client may appear difficult,
demanding, and ungrateful during this stage
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14. 3.BARGAINING
• At this stage in the grief response, the individual
attempts to strike a bargain with God for a second
chance or for more time.
• The person acknowledges the loss, or impending
loss, but holds out hope for additional alternatives,
as evidenced by statements such as, “If only I could.
. .” or “If only I had. . . .”
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15. 4.DEPRESSION
• In this stage, the individual mourns for that which has
been or will be lost. This is a very painful stage, during
which the individual
• Reactive depression-feelings associated with having lost
someone or something of value
• Preparatory depression- Feelings associated with an
impending loss
• Regression, withdrawal, and social isolation may be
observed behaviors with this stage1/13/2021 VMRF(DU) NSG 19 OCT 07

16. 5.ACCEPTANCE
• At this time, the individual has worked through the
behaviors associated with the other stages and
accepts or is resigned to the loss.
• Anxiety decreases, and methods for coping with the
loss have been established.
• The client is less preoccupied with what has been
lost and increasingly interested in other aspects of
the environment1/13/2021 VMRF(DU) NSG 19 OCT 07

17. END OF LIFE
• End-of-life care refers to the nursing care given during
the final weeks of life when death is imminent
• Death is denied or compartmentalized with the use of
medical technology that prolongs the dying process
and isolates the dying person from loved ones.
• On the other hand, death is embraced as a frantic
escape from apparently meaningless suffering through
means such as physician-assisted suicide
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18. ADVANCE CARE PLANNING
• Advance care planning is a thoughtful, facilitated
discussion that encompasses a lifetime of values,
beliefs, and goals for the client and family.
• Advance care planning often involves completion of
an AD.
• living will or the health care directive
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19. Con’t
• The living will is a document filled out by the client
with specific instructions
• Living wills give some guidance, but a document
called Five Wishes enables all caretakers to know
and understand the desires of a dying client. Each
wish gives a specific desire regarding end of-life care
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20. FIVE WISHES
• Wish 1: State the name of the person you want to make
health care decisions about medical tests, treatments, or
surgery, or admission to a hospital,
• Wish 2: Describe the kind of medical treatment you want or
don’t want. Choices are listed for clinical situations
• Wish 3: State how comfortable you want to be. Several
choices are given regarding activities of daily living, pain
management, and relaxation techniques or interventions.
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21. Con’t
• Wish 4: Describe how you want people to treat you.
This wish addresses the spiritual needs of the client
during the dying process, such as having someone
present at bedside, and expressing the desire whether
to die at home or in the hospital.
• Wish 5: Explain what you would like your loved ones to
know. This wish addresses how the client wants to be
remembered and gives him or her opportunity to relay
funeral and memorial wishes1/13/2021 VMRF(DU) NSG 19 OCT 07

22. COMMON RESPONSES
1. Behavioral: Avoidance, controlling, distancing
2. Emotional: Anger, anxiety, depression, emotional outbursts,
frustration, guilt, sarcasm, emotional withdrawal from family
or friends
3. Physical: Fatigue, fluctuation in vital signs, impaired sleep,
impaired mental processes such as confusion or delirium,
persistent physical symptoms such as pain, weight gain, or
weight loss
4. Spiritual: Verbalization of a sense of hopelessness,
emptiness, or meaninglessness1/13/2021 VMRF(DU) NSG 19 OCT 07

23. EMOTIONAL AND SPIRITUAL END-OF-LIFE
SIGNS
• Giving away belongings and making funeral plans.
• Withdrawal.
• Vision-like experiences.
• Restlessness.
• Communication and permission.
• Saying goodbye..
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24. CAREGIVING IN THE FINAL STAGES OF LIFE
SYMPTOMS PROVIDING COMFORT
Drowsiness Plan visits and activities for times
when the patient is most alert.
Becoming
unresponsive
Many patients are still able to hear
after they are no longer able to speak,
so talk as if your loved one can hear.
Confusion about time,
place, identity of loved
ones
Speak calmly to help re-orient your
loved one. Gently remind them of the
time, date, and people who are with1/13/2021 VMRF(DU) NSG 19 OCT 07

25. Loss of appetite,
decreased need for
food and fluids
Let the patient choose if and when to eat or
drink. Ice chips, water, or juice may be
refreshing if the patient can swallow.
Loss of bladder or
bowel control
Keep your loved one as clean, dry, and comfortable
as possible. Place disposable pads on the bed
beneath them and remove when they become soiled.
Skin becoming cool
to the touch
Warm the patient with blankets but avoid electric
blankets or heating pads, which can cause burns.
Labored, irregular,
shallow, or noisy
breathing
Breathing may be easier if the patient’s body is
turned to the side and pillows are placed beneath
their head and behind their back.
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26. MANAGING MENTAL AND EMOTIONAL
NEEDS
• Encouraging conversations about feelings
• Understand reactions of family, friends, and even the
medical team.
• Act of physical contact—holding hands, a touch, or a
gentle massage
• Set a comforting mood
• Music at a low volume and soft lighting are soothing
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27. END OF LIFE PLANNING
• Prepare early.
• Seek financial and legal advice .
• Focus on values.
• Address family conflicts.
• Communicate with family members.
• If children are involved, make efforts to include
them.
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28. PATIENT AND CARE GIVER NEEDS IN LATE
STAGE CARE
• Practical care and assistance.
• Comfort and dignity
• Respite Care.
• Grief support
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29. PSYCHOSOCIAL AND MENTAL HEALTH
CARE
• Anxiety -Non-pharmacological intervention for anxiety
reduction, such as soothing music, progressive music
relaxation and visualization exercises
• Depression -selective serotonin reuptake inhibitors and
new classes of antidepressants
• Care giver stress, anger, and sleep deprivation.-encourage
them to take care of their own needs as part of caring for
the person who is ill.1/13/2021 VMRF(DU) NSG 19 OCT 07

30. PALLIATIVE CARE
• It is the active total care of clients whose disease is not
responsive to curative treatment.
• It focuses on physical, emotional, and existential
suffering, and support for best possible quality of life
for patients and their family caregivers.
• It is delivered at the same time as all other appropriate
medical care and should be offered simultaneously
with curative, life-prolonging, or disease-modifying
treatments .1/13/2021 VMRF(DU) NSG 19 OCT 07

31. HOSPICE CARE
• Refers to a program that supports the client and family
through the dying process and the surviving family members
through the process of bereavement.
• It is based on a bio-psychosocial model rather than a disease
model of care.
• The essential philosophy of hospice care is the focus on
comfort, dignity, and personal growth at life’s end.
• This emphasizing quality of life and healing or strengthening
interpersonal relationships rather than prolonging the dying
process at any and all costs.1/13/2021 VMRF(DU) NSG 19 OCT 07

32. NEEDS OF DYING PERSONS AND SURVIVORS
Dying Person’s Needs Survivor’s Needs
Vent anger and frustration Provide a quality of life for the dying
person while preparing for a life without
that loved one
Share the knowledge that the end is near Be available to offer comfort and care even
though the survivor feels like running away
to escape the pain of death
Ensure the well-being of loved ones who
will be left behind, because the person
resents the fact that life will go on without
him or her
Hope that the loved one will somehow live
in spite of obvious deterioration and
inability to function. At this time, the
survivor may pray for the peace of death
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33. Vent feelings or irritation at
omissions or neglect, although the
person feels guilty over the pain
this causes
Vent feelings or irritation and
guilt over the dying person’s
demands and increased
dependency needs
Remain as independent as possible,
fearing he or she will become
unlovable
Live and appreciate each day as one
plans for a future without the loved
one
Be normal and natural at a time
when nothing appears to be normal
or natural. The dying client
generally experiences the fears of
pain, loss of control, and dying
Reassure the dying person that the
survivor will “continue in his or her
footsteps” by holding the family
together, raising the children, or
managing the business, while1/13/2021 VMRF(DU) NSG 19 OCT 07

34. HOW DO I RESPONSE TO GRIEF
• Understanding that grieving has no time limits, there is no right way
to grieve
• Track to these around you who/one you, Journal, Take time alone if
needed.
• Take a day at a time, Try not to hide from your emotions
• If your sad be sad, If your happy be happy
• Ask for help
• Family, teachers, friends and counselling are all here to assist
you1/13/2021 VMRF(DU) NSG 19 OCT 07

35. ASPECTS OF CARE FOR
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36. PHASE-1 SYTOMPS
Emotion or
attitude
Nurse intervention
SHOCK- HELP REFOCUS ON PRESENT
FEAR PROVIDE PRESENCE
DISBELIEF SUSPEND JUDGMENT
CURIOSITY BE WATCHFULLY AWARE
HOPE OFFER WEBSITE INFORMATION
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37. PHASE-2 WAITING
Emotion or
attitude
Nurse intervention
ANXIETY- TREAT ANXIETY AS NEEDED
WORRY- FOCUS ON WHAT PATIENT CAN
CONTROL
HOPE- HELP DEAL WITH UNCERTAINTY
FEAR PROVIDE DISTRACTION
RELIEF EDUCATE CELEBRATE
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38. PHASE-3 RESOLUTION OF THREAT
Emotion or attitude Nurse intervention
DETERMINATION TO
FIGHT
GIVE INFORMATION ABOUT
THE DISEASE AND TREATMENT
FEAR PROVIDE PRESENCE
DENIAL ASK ABOUT ADVANCE
PLANNING
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39. HOPEFULNESS HELP BALANCE HOPE WITH
PRAGMATISM
HOPELESSNESS DISCUSS OPTIONS AND
CHOICES
ANGER EXPLORE EXPRESSIONS OF
ANGER WITH PATIENT AND
FAMILY
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40. EMOTION OR ATTITUDE NURSE
INTERVENTION
DEPRESSION ASSESS FOR DEPRESSION
NOT BEING IN CONTROL HELP PATIENT MAINTAIN SOME
CONTROL OVER SITUATION.
GUILT OFFER SPIRITUAL ADVISOR
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41. EMOTION OR
ATTITUDE
NURSE INTERVENTION
FEELING MORE IN CONTROL ANSWER QUESTIONS HONESTLY
COURAGE GIVE POSITIVE FEEDBACK FOR COPING
SKILLS
HOPE FOR CURE TEACH ABOUT LAB VALUES AND THEIR
SIGNIFICANCE
FAITH ASK ABOUT SPIRITUAL BELIEF
DISCOURAGEMENT REMAIN CAUTIOUSLY OPTIMISTIC, OFFER
TO HELP PATIENT DECORATE ROOM
DEPRESSION TREAT DEPRESSION, KEEP WINDOW
BLINDS OPEN1/13/2021 VMRF(DU) NSG 19 OCT 07

42. PHASE-5 DYING PROCESS
EMOTION OR
ATTITUDE
NURSE INTERVENTION
DENIAL INTRODUCE ‘WHAT IF’ IDEAS
ANTICIPATORY GRIEF BEGIN LIFE REVIEW
ANGER ADDRESS ANGER, INQUIRE ABOUT
FAMILY AND SOCIAL SUPPORT,
REFRAME HOPE
ACCEPTANCE GENTLY TEACH ABOUT DNR
ORDER AND NO ICU OPTION,
DISCUSS HOSPICE AND DYING AT
HOME OPTION/CHOICS
1/13/2021 VMRF(DU) NSG 19 OCT 07

43. Appreciation of comfort offer palliative measures
and relieve bothersome
symptoms
Hope for a good death explain to patient and
family what to expect in
the final days and
moments
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44. 1/13/2021 VMRF(DU) NSG 19 OCT 07

45. Go with loved one dying
GO WITH LOVED ONE DYING
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47. 1/13/2021 VMRF(DU) NSG 19 OCT 07

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49. SUMMARY
• The presence of a psychiatric disorder or medical illness can affect
quality of life and contribute to a loss. Loss has been described as
a condition whereby an individual experiences deprivation of, or
complete lack of, something that was previously present, such as a
job, pet, home, personal item, or loved one
• Acknowledging that our view of end-of-life care might differ from
views held by our clients and their families or significant others is
important. Lack of knowledge regarding the ethnicity, culture, and
race of a client could have a profound effect on establishing trust
with a client when planning end-of-life care
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50. REFERENCE
1. Louise Rebraca Shives, Basic Concepts of Psychiatric Mental
Health Nursing, Lippincott Williams & Williams’s
publication, Flordia.8th edition
2. Mary C. Townsend, Essentials of Psychiatric Mental Health
Nursing, FA Davis company publication, Philadelphia, 4th
edition.
3. Gail W Stuart, Principles and Practice of Psychiatric
Nursing, Elsevier publication, Newdelhi, 8th edition
4. https://www.helpguide.org/articles/end-of-life/late-stage-
and-end-of-life-care.htm
5. https://www.nia.nih.gov/health/providing-comfort-end-life1/13/2021 VMRF(DU) NSG 19 OCT 07