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On Death And Dying

As important as its impacts on health care and research have been, the cultural influence of On Death and Dying extends to the fundamental ways in which Americans have come to understand illness and dying.

On Death and Dying

Medical professionals will work with dying patients in all disciplines, and the process is difficult as care shifts from eliminating or mitigating illness to preparing for death. This is a difficult transition for patients, their loved ones, and healthcare providers to undergo. This activity provides paradigms for the process of moving toward death as well as a discussion of how they should and should not be applied, supporting the interprofessional team to address the unique needs of their patients and guide them and their loved ones through the process.

Objectives:Describe the five stages of death, as outlined by Elisabeth Kubler-Ross.Describe alternative paradigms for experiencing death and grief, in addition to those introduced by Kubler-Ross.Explain the potential underlying process generating these outwardly demonstrated stages to provide a context for supporting patients, families, caregivers, and healthcare providers experiencing death.Outline interprofessional team strategies for improving care coordination and communication in a dying patient.Access free multiple choice questions on this topic.

Medical professionals in all disciplines work with dying patients, and doing so effectively can be difficult. In the context of death and dying, patients, their loved ones, and the health care team must shift their goals. Where treating acute and chronic illness usually involves finding a tolerable path to eliminating or preventing the progression of a condition, treating terminal illness must involve preparing for death as well as efforts to mitigate symptoms.[1] Understanding the experience of dying and grief allows providers to support the unique needs of patients, their loved ones, and other healthcare team members.[2][3][4]

Dr. Elizabeth Kubler-Ross introduced the most commonly taught model for understanding the psychological reaction to imminent death in her 1969 book, On Death and Dying. The book explored the experience of dying through interviews with terminally ill patients and outlined the five stages of dying: denial, anger, bargaining, depression, and acceptance (DABDA). This work is historically significant as it marked a cultural shift in the approach to conversations regarding death and dying. Prior to her work, the subject of death was somewhat taboo, often talked around or avoided altogether. Dying patients were not always given a voice or choices in their care plan. Some were not even explicitly told about their terminal diagnosis. Her work was popular in both the medical and lay cultures and shifted the nature of conversations around death and dying by emphasizing the experience of the dying patient.[4][5] This led to new approaches to working with patients through the final phase of life. She highlighted the importance of listening to and supporting their unique experiences and needs and spurred new perspectives on ways practitioners can support terminally ill patients and their family members in adjusting to the reality of impending death.[6]

Acceptance describes recognizing the reality of a difficult diagnosis while no longer protesting or struggling against it. Patients may focus on enjoying the time they have left and reflecting on their memories. They may begin to prepare for death practically by planning their funeral or helping to provide financially or emotionally for their loved ones. It is often portrayed as the last of Kubler-Ross's stages and a sort of goal of the dying or grieving process. While caregivers and providers may find this stage less emotionally taxing, it is important to remember that it is not inherently more healthy than the other stages. As with denial, anger, bargaining, and depression, understanding the stages has less to do with promoting a fixed progression and more to do with anticipating patients' experiences to allow more empathy and support for whatever they go through.[4][5][6][7]

The DABDA model has been increasingly criticized in recent years. The model has both historical and cultural significance as one of the most well-known models for understanding grief and loss. Many alternative models have been developed based at least in part on the original DABDA model. The principal criticisms of Kubler-Ross's stages of death and dying are that the stages were developed without sufficient evidence and are often applied too strictly. Kubler-Ross and her collaborators developed their ideas qualitatively through in-depth interviews with over two hundred terminally ill patients.[7]

Worden's model of grief does not rely on stages but instead notes that the patient must complete four tasks to complete bereavement. These tasks do not occur in any specific order. The grieving person may work on a task intermittently until it is complete. This model applies to the grief of a survivor but may also be applied to a patient facing death.

An all-consuming focus on impending death will cause the patient to ignore other roles in life that are important to them. The patient will typically resume daily activities such as restarting work or hobbies or becoming engaged as a spouse or parent to complete this task.

Neimeyer views grieving as a process of meaning-making. He acknowledges that people co-construct their understanding of reality through a narrative of their own life stories, influenced by their beliefs and world views. He describes "six key realities influenced by death." In these six realities, he acknowledges that significant loss can validate or invalidate a person's framework and beliefs in life. It may require developing a new framework to heal and incorporate the loss into their worldview. Grief is simultaneously universal and unique, so the therapy for the bereaved must be tailored to each client's individual needs. The process of griefing is inherently an active rather than passive period, filled with decision-making and reconstruction both practically and existentially.

The transition in care, from attempting to heal the patient to caring for them near death, can be difficult for everyone involved. Healthcare providers sometimes feel as if "their job is done" as they can no longer heal the patient and "drop out" of the patient's care. This can lead patients, and their loved ones, to feel they are being abandoned as they near death. They often wish for guidance on the complex changes that the patient is going through emotionally and physically. Actions that are a normal part of the dying process, such as anger and refusing visitors, can leave loved ones confused and upset. Understanding the stages of grief allows providers to give support and guidance during the dying process. The explanations provided by medical caregivers hold particular importance for patients and family members as they seek to understand and subsequently make sense of terminal illness. These key moments of communication and connection can be pivotal in the process of making sense of and healing from significant loss.[12][13] Facility with the grieving process is also imperative for the healing and resiliency of medical caregivers as they navigate through grief alongside their patients.[14]

For the healthcare team, caring for patients near death can be uniquely challenging for everyone involved. Healthcare providers sometimes feel as if "their job is done" as they can no longer heal the patient and "drop out" of the patient's care. This can lead to patients and their loved ones feeling abandoned by the healthcare team as they near death.[15] They often wish for guidance emotionally and physically. This is where an end-of-life interdisciplinary team can be very helpful. Physicians can provide clarity on diagnostic and prognostic information. Pharmacists participate by dispensing appropriate comfort medication in a timely fashion by working directly with the nursing staff. Hospice care providers, including social workers and nursing staff, can provide counsel, administer comfort care, deliver emotional support, and empathize with both the patient and the family. The healthcare team should possess an understanding of the models for grief, which allows providers to give support and guidance during the dying process and provides a coordinated effort to provide the patient and family with much-needed emotional support. [Level 5]

Death is a part of natural life; however, society is notorious for being uncomfortable with death and dying as a topic on the whole. Many caregivers experience a level of burden from their duties during end-of-life care. This burden is multi-faceted and may include performing medical tasks, communicating with providers, decision-making and possibly anticipating the grief of impending loss. Similarly, many healthcare providers across the spectrum of care feel unprepared to provide end-of-life care or communicate with patients and families about the complex topics related to death and dying. They can attribute this to the fact that during formal education these topics were not discussed or only briefly talked about. It is imperative that patients and families have access to the care and support they require when entering a terminal phase of life. This phase is different for each patient, and the needs may differ for each patient and family, but it is vital for healthcare providers to provide care and support in a way that respects the patient's dignity and autonomous wishes. This activity reviews the evaluation and management of death and dying and the role of interprofessional team members in collaborating to provide well-coordinated care and enhance patient outcomes.

Objectives:Review the common causes of death in the USA.Describe the process/stages of death.Summarize what is hospice and palliative careOutline the evaluation and management of death and dying and the role of interprofessional team members in collaborating to provide well-coordinated care and enhance patient outcomes.Access free multiple choice questions on this topic. 041b061a72


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