Assessing the patient's reaction to loss. Assessing the patient's previous reactions to stress, especially to losses

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Plan:

2. Hospice.

3. Psychology of the problem of death.

5. Stages of mourning.

8. Pain, pain assessment.

9. Dying.

10.

Features of psychological communication between the patient and medical personnel

Currently, a fairly large number of patients have an incurable or terminal stage of the disease, so the issue of providing such patients with appropriate assistance becomes relevant, i.e. about palliative treatment. Radical medicine aims to cure disease and uses every means at its disposal as long as there is even the slightest hope of recovery. Palliative medicine replaces radical medicine from the moment when all means are used, there is no effect and the patient dies.

According to WHO definition palliative care - This is active, multifaceted care for patients whose illness is not curable. The primary goal of palliative care is to relieve pain and other symptoms and resolve psychological, social and spiritual problems. The goal of palliative care is to achieve the best possible quality of life for patients and their families.

Highlight the following principles palliative care:

Support life and treat death as a natural process;

Do not hasten or delay death;

As death approaches, reduce pain and other symptoms in patients, thereby reducing distress;

Integrate psychological, social, spiritual issues of caring for patients in such a way that they can come to a constructive perception of their death;

Offer patients a support system that allows them to remain as active and creative as possible until the end;

Offer a support system for families to help them cope with the challenges of a loved one's illness and during grief.

Patients with malignant tumors, irreversible cardiovascular failure, irreversible renal failure, irreversible liver failure, severe irreversible brain damage, and AIDS patients need palliative care.

The ethics of palliative care is similar to general medical ethics: it is about preserving life and alleviating suffering.

At the end of life, the relief of suffering is of much greater importance, since it becomes impossible to preserve life itself.

In a palliative approach, the patient is provided with four types of care: medical, psychological, social and spiritual.

The versatility of this approach allows us to cover all areas related to the patient’s needs and focus all attention on maintaining the quality of life at a certain level. Quality of life is the subjective satisfaction experienced or expressed by an individual. Life is truly high quality when the gap between expectations and reality is minimal.

Hospice

Palliative care is a new branch of practical medicine that solves the medical and social problems of patients who are in the last stage of an incurable illness, mainly through hospices (from the Latin hospes - guest; hospitium - friendly relations between host and guest, the place where these relationships develop ). The word "hospice" does not mean a building or establishment. The concept of hospice is aimed at improving the quality of life of seriously ill patients and their families. Hospice providers are committed to caring for people in the final stages of a terminal illness and providing care to them in a way that makes their lives as fulfilling as possible.

The first institution for caring for the dying, called a hospice, arose in 1842 in France. Madame J. Garnier founded a hospice in Lyon for people dying of cancer. In England, the Irish Sisters of Charity were the first to open hospices in London in 1905. The first modern hospice (St Christopher's Hospice) was founded in London in 1967. Its founder was Baroness S. Saunders, a trained nurse and social worker. Since the early 1960s. Hospices began to appear all over the world.

In Russia, the first hospice was created in 1990 in St. Petersburg thanks to the initiative of V. Zorza, a former journalist whose own daughter died of cancer in one of the English hospices in the mid-1970s. He was very impressed by the high quality of care at the hospice, so he set out to create similar centers himself that would be available to all regions. V. Zorza promoted the idea of hospices in Russia in his interviews on television and radio, and in newspaper publications. This found a response in government agencies throughout the country - the Order of the Ministry of Health of the RSFSR dated February 1, 1991 No. 19 “On the organization of nursing homes, hospices and nursing departments of multidisciplinary and specialized hospitals” was adopted. Currently, there are more than 20 hospices operating in Russia.

The structure of hospices in St. Petersburg, Moscow, Samara, Ulyanovsk mainly includes: visiting service; day hospital; inpatient department; administrative unit; educational and methodological, socio-psychological, volunteer and economic units. The core of hospice is the outreach service, and the primary work unit is a nurse trained in palliative care.

The basic principles of hospice activities can be formulated as follows:

1) hospice services are free; one cannot pay for death, just as one cannot pay for birth;

2) hospice is a house of life, not death;

3) control of symptoms allows you to qualitatively improve the patient’s life;

4) death, like birth, is a natural process. It cannot be slowed down or rushed. Hospice is an alternative to euthanasia;

5) hospice - a system of comprehensive medical, psychological and social care for patients;

6) hospice - a school for relatives and friends of the patient and their support;

7) hospice is a humanistic worldview.

There comes a moment in the patient's condition when he understands the inevitability of death. Accordingly, it is at this time that support and friendly participation acquire great value. Constant attention to the patient should demonstrate that doctors will not leave him, no matter what, this will support both the patient and his family. Fundamental to palliative care tasks is establishing understanding and trust with the patient and family.

In achieving this goal, the first meeting and the first conversation with the patient are important. You need to allocate as much time for it as necessary and do everything to ensure that it is not interrupted and is carried out in a secluded environment. To establish contact, touch is very important, which allows you to establish a person’s readiness to communicate and express what is difficult to convey in words, this is especially important during moments of information exchange.

The nurse must know the psychology of patients, the possible reactions of the patient and his relatives to the information received, and be prepared to provide adequate psychological support from this moment and for the entire period of palliative care.

Psychology of the problem of death

The most difficult task facing a person is solving a “life-death” problem. Children aged 5-6 years have no idea of death or it is filled with all kinds of fantasies. In adulthood, a person puts aside thoughts about his own death. But the older he gets, the more he is faced with the death of loved ones and acquaintances and begins to become calmer about the inevitability of the end.

There are various types of death perception:

"We'll all die." This state of “habituated” death arises from the acceptance of death as a natural inevitability.

"My own death." A person discovers his individuality in death, since he will have to undergo the Last Judgment.

"Your death". Death is perceived as an opportunity for reunion with a previously deceased loved one.

"Death inverted." The fear of death is so great that it is forced out of consciousness, its existence is denied.

Death can be the last and most important stage of growth, since it is a crisis of individual existence. Sooner or later, a person must come to terms with the end of life, try to comprehend his end, and take stock of the life he has lived. Before death the following specific features are observed: changes in perception of life:

1. The priorities of life are re-evaluated - all sorts of little things, insignificant details and details lose their significance.

2. A feeling of liberation arises - what you don’t want to do is not done; The categories of obligation “must”, “must”, “necessary”, etc. lose their power.

3. The momentary current sensation and experience of the life process intensifies.

4. The significance of elementary life events increases (rain, leaf fall, change of seasons, time of day, full moon in the sky).

5. Communication with loved ones becomes deeper, more complete, and richer.

The fear of being rejected decreases, the desire and ability to take risks increases, a person frees himself from conventions, allows himself to live with his thoughts, feelings, and satisfy his desires.

But even having resigned himself, a person can spend the remaining time allotted by nature in different ways: either in inaction and waiting for the inevitable tragic ending, or living life as fully as possible, realizing himself as much as possible in activity, investing his potential in every moment of his existence, self-realization. With fortitude and courage, the patient can make his own dying as less difficult as possible for those around him. Leaving behind the best memories.

However, the patient can stop at any of these five stages, then the process of care will be difficult both for him and for those around him. But in any case, one must treat the dying person with understanding and patience.

A person who learns that he is hopelessly ill, that medicine is powerless, and that he will die, experiences various psychological reactions that can be divided into five successive stages:

Pain

One of the main problems of cancer patients is pain. Palliative care provides adequate, as complete pain relief as possible for hopelessly ill patients. For hospice care, pain management is of paramount importance. The International Association for the Study of Pain gives following definition: Pain is an unpleasant sensory and emotional experience associated with existing or possible tissue damage. Pain is always subjective. Each person perceives it through experiences associated with receiving any damage in early years his life.

Pain is a difficult sensation, it is always unpleasant and therefore an emotional experience. The sensation of pain depends on the following factors: past experience; individual characteristics of a person; states of anxiety, fear and depression; suggestions; religion.

The perception of pain depends on the mood of the patient and the meaning of pain for him. The degree of pain experienced is a result of different pain thresholds. With a low pain threshold, a person feels even relatively weak pain, while other people, having a high pain threshold, perceive only strong pain sensations.

The pain threshold is reduced discomfort, insomnia, fatigue, anxiety, fear, anger, sadness, depression, boredom, psychological isolation, social abandonment.

The pain threshold is increased sleep, relief of other symptoms, empathy, understanding, creativity, relaxation, anxiety reduction, pain relievers.

Superficial pain– appears when exposed to high or low temperatures, cauterizing poisons or mechanical damage.

Deep pain– usually located in the joints and muscles, and the person describes it as a “long-lasting dull ache” or “excruciating, gnawing pain.”

Pain in internal organs is often associated with a specific organ: “heart pain,” “stomach pain.”

Neuralgia– pain that occurs when the peripheral nervous system.

Radiating pain- example: pain in the left arm or shoulder due to angina pectoris or myocardial infarction.

Phantom pains felt as a tingling sensation in the amputated limb. This pain may last for months, but then it goes away.

Psychological pain is observed in the absence of visible physical stimuli; for the person experiencing such pain, it is real and not imaginary.

Types of cancer pain and causes of their occurrence.

There are two types of pain:

1. Nociceptive pain caused by irritation of nerve endings.

There are two subtypes:

somatic- occurs when bones and joints are damaged, spasm skeletal muscles, damage to tendons and ligaments, germination of skin, subcutaneous tissue;

visceral- in case of damage to the tissues of internal organs, hyperextension of hollow organs and capsules of parenchymal organs, damage to the serous membranes, hydrothorax, ascites, constipation, intestinal obstruction, compression of blood and lymphatic vessels.

2. Neuropathic pain caused by dysfunction of nerve endings. It occurs when there is damage, overexcitation of peripheral nervous structures (nerve trunks and plexuses), or damage to the central nervous system (brain and spinal cord).

Acute pain has different durations, but lasts no more than 6 months. It stops after healing and has a predictable ending. Manifestations of acute pain syndrome include patient activity, sweating, shortness of breath, and tachycardia.

Chronic pain persists for a longer time (more than 6 months). Chronic pain syndrome accompanies almost all common forms of malignant neoplasms and differs significantly from acute pain in the variety of manifestations due to the persistence and strength of the feeling of pain. And it manifests itself with such signs as sleep disturbance, lack of appetite, lack of joy in life, withdrawal into illness, personality changes, fatigue.

Pain assessment

The patient marks on the ruler the point corresponding to his sensation of pain. To assess the intensity of pain, a ruler with images of faces expressing different emotions can be used. The use of such rulers provides more objective information about the level of pain than the phrases: “I can’t stand the pain anymore, it hurts terribly.”

A ruler with images of faces to assess the intensity of pain: 0 points - no pain; 1 point - mild pain; 2 points - moderate pain; 3 points - severe pain; 4 points - unbearable pain.

Dying

In most cases, dying is not an instantaneous process, but a series of stages, accompanied by a consistent disruption of vital functions.

1. Preagonia. Consciousness is still preserved, but the patient is inhibited and consciousness is confused. The skin is pale or cyanotic. The pulse is threadlike, tachycardia occurs; Blood pressure drops. Breathing quickens. Eye reflexes are preserved, the pupil is narrow, the reaction to light is weakened. The duration of this phase ranges from several minutes to several days.

2. Agony. There is no consciousness, but the patient can hear. Sharp pallor of the skin with pronounced acrocyanosis, marbling. The pulse is determined only in the large arteries (carotid), bradycardia. Breathing is rare, arrhythmic, convulsive, like “swallowing air” (agonal breathing). The pupils are dilated, the reaction to light is sharply reduced. Convulsions, involuntary urination, and defecation may occur. The duration of this phase ranges from several minutes to several hours.

3. Clinical death. This is a transitional state, which is not yet death, but can no longer be called life. Clinical death occurs from the moment breathing and heart stop. In this case, consciousness is absent; the skin is pale, cyanotic, cold, marbling and vascular spots appear; pulse is not detected in large arteries; there is no breathing; the pupils are extremely dilated, there is no reaction to light. The duration of this phase is 3 – 6 minutes.

If the vital functions of the body have not been restored with the help of resuscitation measures, then irreversible changes occur in the tissues and biological death occurs.

The fact of the patient's biological death is confirmed by the doctor. He makes an entry in the medical history, indicating the date and time of its occurrence. A death that occurs at home is confirmed by a local doctor; he also issues a certificate indicating the clinical diagnosis and cause of death.

TOPIC 15. LOSS, DEATH, GRIEF

Plan:

1. Features of psychological communication between the patient and medical staff.

2. Hospice.

3. Psychology of the problem of death.

4. Nursing intervention at different stages of patient grief.

5. Stages of mourning.

6. The role of the nurse in meeting the needs of the doomed patient.

7. Rules for handling the body of the deceased.

8. Pain, pain assessment.

9. Dying.

10. Psychological problems medical personnel.

1. Stages of grief.

2. The concept and principles of palliative care.

3. Ethical and deontological features of communication with a doomed person, his family and friends.

4. Post-mortem care in a medical organization.

Nurses often have to deal with patients who are worried about people close to them. A person’s natural reaction to loss is a feeling of grief, mourning. This feeling helps a person adapt to loss.

Each person reacts to loss differently. But, nevertheless, there is a group of certain reactions to loss.

Today, a conditional division into 5 emotional stages is accepted, which a person goes through when he receives news of an upcoming loss (death). The duration of each period proceeds differently for everyone, and the transition from one stage to another can either be forward or return to an already passed stage.

Stage I- psychological shock: “This can’t be!” - the reaction is negative. This helps to process what happened gradually, but if it lasts for a long time, problems may arise.

Stage II- an aggravated reaction, a reaction of anger, anger, directed both at oneself and at the one who is responsible for what happened. Anger may be directed at the family or staff, but in fact, resentment is directed at the current unfortunate situation.

stage Grief often results in a person turning to religion, in the desire to find at least some way out of this situation, a person rushes between the desired and the possible.

stage- feelings of grief associated with loss may give way to depression. The person experiences confusion and despair. He cries, loses interest in others, in himself. It is necessary to find words of consolation and encouragement to support the person at this time.

Stage V- this is the acceptance of loss, it can be considered as the most positive reaction, since it returns a person to the problems of the existing day. For some people, this stage manifests itself in the form of a hopeless situation, a kind of “dead end”, in which case they need psychological help.

All of the above situations can occur sequentially and can return. Intense grief associated with the loss of a loved one can last from 6 months. up to 12 months, and the grief that comes later - from 3 to 5 years. A nurse who encounters patients in a situation of grief must show maximum patience, tact, and endurance. She will need the ability to “see” the psychological situation, be aware of it, be able to react sensitively and help find an acceptable solution to the current situation. Thus, the nurse will be required to have knowledge of deontology, ethics, psychology, logic, rhetoric, speech culture, and pedagogy.

Palliative treatment begins when all other treatments have failed.

The goal of palliative treatment is to create opportunities for the patient and his family to have a decent quality of life under the circumstances - this is when the disease cannot be cured.

All work of nurses should be aimed at satisfying not only physiological needs, but also equally important psychological, social and spiritual ones.

In palliative treatment, the main goal is not to prolong life, but to create conditions of comfort worthy of a person.

Palliative treatment will be effective if:

create and maintain safe living conditions;

if the patient feels his independence as much as possible;

if he has no pain;

if psychological, social and spiritual problems are resolved in a way that helps the patient come to terms with his death;

If efforts to create a daily comfortable state acceptable for his health are not in vain and help him and his loved ones prepare for death.

The nurse provides care for the following patients:

it is necessary to be able to prepare the patient to accept the inevitable onset of death;

CHAPTER 29 LOSS, DEATH AND GRIEF

Emotional stages of grief. Often there is a terminal patient in the department. A person who has learned that he is hopelessly ill, that medicine is powerless and that he will die, experiences various psychological reactions, the so-called emotional stages of grief (Table.

It is very important to recognize what stage the patient is currently in in order to provide him with appropriate assistance.

For a number of patients, the denial stage is shocking and protective in nature. They have a conflict between the desires to know the truth and avoid anxiety. As soon as the patient realizes the reality of what is happening, his denial gives way to anger. The patient is irritable, demanding, and his anger is often transferred to the family or medical staff. Sometimes the patient tries to make a deal with himself or others and gain more time to live. When the meaning of the disease is fully realized, the stage of depression begins. Signs of depression are:

constant bad mood;

loss of interest in the environment;

feelings of guilt and inferiority;

hopelessness and despair;

suicide attempts or persistent thoughts of suicide.

The emotional and psychological state of the patient at the stage

adoption is undergoing fundamental changes. A person prepares himself for death and accepts it as a fact. At this stage, intense spiritual work occurs: repentance, assessment of one’s life and the measure of good and evil by which one can evaluate one’s life. The patient begins to experience a state of peace and tranquility.

Communicating with terminally ill people requires a skill that can be learned. To do this, you need to know yourself, the patient and his family, as well as their attitude and approach to this problem. The ability to communicate requires a person to be honest, respect the feelings of others and have the ability to be compassionate. This skill includes body language, spoken language, and the trust that is established between interlocutors. There are several types of needs of patients and their families:

Table 29.1

Nursing intervention at various stages of the patient's grief Stage Nursing intervention Denial Clarification of one's feelings in relation to death, since personal rejection and fear can be transferred to the dying person.

The patient is asked to describe on paper his feelings, concerns, and fears. This promotes psychological processing of these emotions. It is important to sit by the patient’s bed (his feeling of abandonment decreases); listen carefully and empathize with the patient (reduces the feeling of isolation, promotes relationship building); holding a hand, touching a shoulder (physical touch brings a feeling of comfort to some patients and demonstrates care for them).

Informing the patient. Encouraging questions (the right information can reduce anxiety and clarify the situation). However, if the patient has a pronounced denial reaction and does not want to know about death, you cannot talk about it. Anger Recognition of the patient’s right to experience anger, which causes a feeling of support and mutual understanding (allowing the patient to “splash out”).

Work with the patient should be structured so that he turns his anger into a positive direction (setting goals, making decisions, fighting the disease). This will help the patient increase self-esteem, keep emotions under control and feel supported by medical staff. Request

delay Providing support (the opportunity to turn to someone and be understood helps the patient cope with his feelings). The patient should not be encouraged to endure adversity, to hold on and be strong. Depression The patient is drawn into his usual way of life (reduces the time spent in thinking). They devote a sufficient amount of time to the patient and communicate with him (reduces the feeling of isolation and is able to build mutual understanding).

They try to keep the feeling of pain under control (a comfortable state increases the patient's desire to interact with others and reduces the tendency to withdraw).

The patient is encouraged to discuss issues of guilt and loss, which will help reduce feelings of guilt and possible thoughts of punishment for past actions.

Stage Nursing intervention Provide the patient with the necessary personal space (when using the toilet, bathing). This maintains self-esteem Acceptance Maintains contact even if the patient does not want to communicate (reduces feelings of isolation).

Continue to control pain (maintains a state of peace and tranquility at the final stage).

Provide spiritual support. This helps the patient to rethink his life and, if necessary, to repent

in communication; information; council; consolation; discussing treatment and prognosis; conversation about feelings and professional psychological support.

The relationship between a nurse and a doomed patient is based on trust, so it cannot be deceived. However, you should not provide amended information. Mindless frankness must also be avoided. In general, patients want to know as much as possible about their condition. However, you should stop if the patient indicates that he has received enough information.

It is very important to be able to listen to the patient. Set aside time for a leisurely, uninterrupted conversation. Let the patient know that there is time for him. The nurse's gaze should be on the same level as the patient's. It is very important to speak in a private setting. It is important to encourage the patient to continue the conversation by showing interest with a nod of the head or the phrase: “Yes, I understand.”

When people suffer, they seek informal communication. Remember that when talking with a patient, it is very important to have optimal physical space between him and the nurse. The patient will feel uncomfortable if the nurse is too close to him. If she is far away, this will be an additional barrier to communication. Much depends on the response of the patient and his family to communication. It shows how the nurse influences the patient and how he reacts to her. A breakdown in communication may occur due to the fact that what the nurse says is inappropriate to the patient, so medical language should be avoided.

The nurse should be prepared for religious and philosophical conversations, dialogues with the patient about fairness!

the meaning of life, good and evil. The whole difficulty in such a situation lies in the fact that philosophical judgments here are primarily important not in themselves, but as a means of consolation, reconciliation of a doomed person with his fate. Dying patients very keenly feel the insincerity of their interlocutor and are sensitive to the slightest manifestations of indifference. Therefore, when communicating with them, it is very important to maintain goodwill, mercy and professionalism, regardless of personal problems and circumstances.

Communication with relatives of the dying person. Death is often a severe shock for the patient’s relatives, so in such cases they should be treated with special care and attention and given psychological support. How to behave at the bedside of a dying person, how and what to talk to him about, how to pay visits to a patient - this is what a nurse should teach the relatives of the doomed person.

If a dying person is in a hospital due to the severity of his condition, then relatives can be involved in his care, teaching them the elements of care. They can, for example, feed the patient, straighten the bed, and carry out some hygiene measures.

To prevent the patient from feeling lonely and abandoned, relatives can sit next to him, hold his hand, touch his shoulder, hair, or read a book to him.

An incurable disease or the death of a loved one is a great psychological trauma for his family. They may get tired, they may develop irritation, depression, and anger towards the dying person. Rendering psychological assistance the family of a dying person is an important part in the work of a nurse who can support the family even after his death.

A family experiencing the death of a loved one also goes through stages of grief. The consequences of loss can affect the mental balance of relatives and undermine their health. It is impossible to hide from grief, it must be accepted and deeply experienced; the loss must be perceived not only by the mind, but also by the heart. Without this full experience, grief will be prolonged and can lead to chronic depression, loss of joy in life and even any desire to live. Experiencing grief makes a person able to remember the deceased without emotional pain and keep feelings alive for others.

Relatives of the deceased experience several stages of grief.

Shock, numbness, disbelief. Grieving people may feel disconnected from life because the reality of death has not yet fully sunk in and they are not yet ready to accept the loss.

Pain experienced due to the absence of a deceased person.

Despair (excitement, anger, reluctance to remember). The stage occurs when the realization comes that the deceased will not return. Decreased concentration, anger, guilt, irritability, anxiety, and excessive sadness are common during this time.

Acceptance (awareness of death). Grieving people may be mentally aware of the inevitability of a loss long before their feelings give them the opportunity to accept the truth. Depression and emotional fluctuations may continue for more than a year after the funeral.

Resolution and reconstruction. Together with the deceased person, old behavioral habits go away and new ones arise, which lead to a new phase of decision-making. At this stage, a person is able to remember the deceased without overwhelming sadness.

Knowledge of the stages of grief experienced by the relatives of the deceased is necessary in order to avoid an incorrect attitude towards the mourner and a quick-tempered judgment about his experiences at the moment. Supporting the griever can help promote a healthy grieving process. The idea that something can be done and that there is an end to the experience is a powerful antidote to the helplessness experienced by the bereaved.

Many relatives are left with a complete feeling of guilt. They think: “If only I had done this, he would not have died.” We need to help them express and discuss their feelings. Some people are known to be particularly vulnerable when grieving the loss of a loved one, so there is a risk that they will grieve too emotionally. This can manifest itself in unusually strong reactions and last for more than 2 years.

The following groups are at risk of severe grief:

older people experiencing the loss of a loved one feel more isolated and need sympathy;

children who have lost people close to them. - are very vulnerable and perceive death more consciously than adults think about it.

Children under 2 years old cannot realize that someone in the family has died, but they are very worried about it. Ages 3 to

children do not consider death to be an irreversible phenomenon and think that the deceased will return. Between 6 and 9 years old, children gradually begin to understand the irreversibility of death, and their thoughts may be associated with ghosts. Teenagers are emotionally vulnerable and experience loss particularly hard. Children react in a special way to the loss of their parents. There are several situations that can affect a child:

when the remaining parent is in deep sadness;

the child does not understand what happened because it was not clearly explained to him;

change of place of residence and school;

few family social contacts;

deterioration of social and economic situation families, especially when the father dies;

marriage of the remaining parent until the child gets used to the idea that the deceased will not return;

deterioration in child care.

The process of a child experiencing sadness may have the following problems: sleep disturbance, appetite disorder, increased general anxiety (reluctance to leave the house or go to school), moodiness, mood swings from euphoria to crying, depression, solitude.

When providing assistance to a bereaved family, a nurse performs the following functions:

explains to the remaining parent the child's physical and emotional reactions and emphasizes that they are normal;

encourages the remaining parent to help the children draw, write about topics related to their loss, and talk about it with others they trust;

Encourages the remaining parent to take care of their financial, emotional and social needs. In this case, it is easier for him to respond to the needs of his children.

Dying. In most cases, dying is not an instantaneous process, but a series of stages, accompanied by a consistent disruption of vital functions.

Preagonia. Consciousness is still preserved, but the patient is inhibited and consciousness is confused. The skin is pale or cyanotic. The pulse is threadlike, tachycardia occurs; Blood pressure drops to 80 mm Hg. Art. Breathing quickens. Eye reflexes are preserved, the pupil is narrow, the reaction to light is weakened. The duration of this phase ranges from several minutes to several days.

Agony. There is no consciousness, but the patient can hear. Severe pallor of the skin with pronounced acropianosis, marbling. The pulse is determined only in the large arteries (carotid), bradycardia. Breathing is rare, arrhythmic, convulsive, like “swallowing air” (agonal breathing). The pupils are dilated, the reaction to light is sharply reduced. Convulsions, involuntary urination, and defecation may occur. The duration of this phase ranges from several minutes to several hours.

Clinical death. This is a transitional state, which is not yet death, but can no longer be called life. Clinical death occurs from the moment breathing and heart stop. In this case, consciousness is absent; the skin is pale, cyanotic, cold, marbling and vascular spots appear; pulse is not detected in large arteries; there is no breathing; the pupils are extremely dilated, there is no reaction to light. The duration of this phase is 3 - 6 minutes.

If, with the help of resuscitation measures, the vital activity of the body has not been restored, then irreversible changes occur in the tissues and biological death occurs.

Ascertainment of death. The fact of the patient's biological death is confirmed by the doctor. He makes an entry in the medical history, indicating the date and time of its occurrence. A death that occurs at home is confirmed by a local doctor; he also issues a certificate indicating the clinical diagnosis and cause of death.

Rules for handling the body of the deceased. A nurse prepares the body of the deceased for transfer to the pathology department. Preparation is carried out in a certain order.

They remove the deceased's clothes and place him on his back on a bed without pillows with his limbs straightened.

tied up lower jaw.

Valuables are removed from the deceased in the presence of the attending or duty doctor, a report is drawn up together with the doctor and an entry is made in the medical history. Valuable items are handed over to the senior nurse for safekeeping, who returns them to the relatives of the deceased against receipt.

Catheters, probes are removed, IVs are removed, etc.

On the thigh of the deceased, his full name and medical history number are written.

Cover the body with a sheet and leave in this position for 2 hours (until obvious signs of biological death appear).

Take off gloves and wash hands.

A cover sheet is drawn up, indicating the name of the deceased, medical history number, diagnosis, date and time of death.

Relatives are notified of the patient's death.

After 2 hours, the body is delivered to the pathology department.

Bedding (mattress, pillow, blanket) is taken to a disinfection chamber. The bed, walls, floor, bedside table are treated with disinfection solutions and the compartment in which the body was located is quartzed for at least 1 hour.

What are the main stages of grief?

Formulate the content of nursing intervention at various stages of patient adaptation to mental trauma due to a serious illness.

What are the needs of the family and loved ones of the doomed patient, providing them with psychological support?

Name the main groups of people at risk of extreme grief.

What is the role of the nurse in helping a bereaved family?

Name the main clinical manifestations of the stages of the terminal condition.

What are the rules for handling the body of a deceased person?

Currently, a fairly large number of patients have an incurable or terminal stage of the disease, so the issue of providing such patients with appropriate assistance becomes urgent, i.e. about palliative treatment. Radical medicine aims to cure a disease and uses every means at its disposal as long as there is even the slightest hope of recovery. Palliative (from Latin pa1 Po - cover, protect) medicine replaces radical medicine from the moment when all means are used, there is no effect and the patient dies.

According to the WHO definition, palliative care is active, multifaceted care for patients whose illness cannot be cured. The primary goal of palliative care is to relieve pain and other symptoms and resolve psychological, social and spiritual problems. The goal of palliative care is to achieve the best possible quality of life for patients and their families.

The following principles of palliative care are distinguished:

support life and treat death as a natural process;

do not hasten or prolong death;

during the period of approaching death, reduce pain and other symptoms in patients, thereby reducing distress;

integrate psychological, social, spiritual issues of caring for patients in such a way that they can come to a constructive perception of their death;

offer patients a support system that allows them to remain as active and creative as possible until the very end;

Offer a support system for families to help them cope with the challenges caused by a loved one's illness and during grief.

Patients with malignant tumors, irreversible cardiovascular failure, irreversible renal failure, irreversible liver failure, severe irreversible brain damage, and AIDS patients need palliative care.

The ethics of palliative care is similar to general medical ethics: it is about preserving life and alleviating suffering. At the end of life, the relief of suffering is of much greater importance, since it becomes impossible to preserve life itself.

There are six ethical principles of palliative care, which can be formulated as follows:

respect patient autonomy (respect the patient as an individual);

act fairly (impartially);

the patient and the family are a single whole; caring for the family is a continuation of caring for the patient;

In a palliative approach, the patient is provided with four types of care: medical, psychological, social and spiritual.

Quality of life is the subjective satisfaction experienced or expressed by an individual. Life is truly high quality when the gap between expectations and reality is minimal.

Hospice. Palliative care is a new branch of practical medicine that solves the medical and social problems of patients who are in the last stage of an incurable illness, mainly through hospices (from the Latin hoyarea - guest; bozrIsht - friendly relations between the host and the guest, the place where these relationships develop ). The word "hospice" does not mean a building or establishment. The concept of hospice is aimed at improving the quality of life of seriously ill patients and their families. Hospice providers are committed to caring for people in the final stages of a terminal illness and providing care to them in a way that makes their lives as fulfilling as possible.

The first institution for caring for the dying, called a hospice, arose in 1842 in France. Madame J. Garnier founded a hospice in Lyon for people dying of cancer. In England, the Irish Sisters of Charity were the first to open hospices in London in 1905. The first modern hospice (St Christopher's Hospice) was founded in London in 1967. Its founder was Baroness S. Saunders, a trained nurse and social work specialist. Since the early 1960s. Hospices began to appear all over the world.

In Russia, the first hospice was created in 1990 in St. 1st 1erburg thanks to the initiative of V. Zorza, a former journalist whose sleeping daughter died of cancer in one of the English hospices in the mid-1970s. He was very impressed by the high quality of care at the hospice, so he set out to create similar centers himself that would be available to all regions. V. Zorza promoted the idea of hospices in Russia in his interviews on television and radio, and in newspaper publications. This found a response in government agencies throughout the country - the Order of the Ministry of Health of the RSFSR dated February 1, 1991 No. 19 “On the organization of nursing homes, hospices and nursing departments of multidisciplinary and specialized hospitals” was adopted. Currently, there are more than 20 hospices operating in Russia.

The basic principles of hospice activities can be formulated as follows:

Hospice services are free; one cannot pay for death, just as one cannot pay for birth;

hospice is a house of life, not death;

control of symptoms allows you to qualitatively improve the patient’s life;

death, like birth, is a natural process. It cannot be slowed down or rushed. Hospice is an alternative to euthanasia;

hospice is a system of comprehensive medical, psychological and social care for patients;

hospice is a school for the patient’s relatives and friends and their support;

Hospice is a humanistic worldview.

Patient care. When planning and implementing hospice care, the emphasis is on solving the patient's present and potential problems. The most common problems are cachexia, confusion, pain, shortness of breath, cough, nausea, vomiting, anorexia, constipation, diarrhea, itching, edema, ascites, drowsiness, insomnia, bedsores, wounds, decreased self-esteem and self-worth, guilt. in front of loved ones (children), depression, isolation and self-isolation, fear of death, drug addiction.

Hospice care involves teaching the patient's relatives how to care. The nurse clearly explains and shows them what and how to do, explains the consequences of non-compliance with care recommendations. Active involvement of family members allows you to achieve better results and cope with the feelings of guilt, helplessness and uselessness that often arise among relatives of a terminally ill person. When monitoring symptoms, the nurse pays great attention to the prevention of their occurrence, non-drug treatment methods, including psychotherapy and diet therapy.

When caring for a patient, the nurse pays special attention to the condition of the patient’s skin, eyes, and oral cavity to prevent the development of bedsores, conjunctivitis and stomatitis (Table 30.1). Symptom control is an important part of the nurse's work when providing palliative care. It includes all stages of nursing activity: collecting information, identifying the problems of the patient and his family, goals of nursing care, drawing up a plan, its implementation and evaluation. To tasks

The role of the nurse in meeting the needs of a doomed patient. Need Nursing care In nutrition A variety of menus, taking into account the wishes of the patient and the diet prescribed by the doctor.

Eating easily digestible food in small portions 5-6 times a day.

Providing artificial nutrition (feeding through a tube, parenteral, nutritional enemas, through a gastrostomy tube) to the patient if it is impossible to feed naturally.

Involving, if necessary, close relatives in feeding. In drinking. Ensuring a sufficient amount of fluid. If necessary, administer fluids as prescribed by a doctor intravenously by drip. In the isolation Provide an individual bedpan and urinal bag.

Monitoring the regularity of physiological functions. For constipation, an enema as prescribed by a doctor.

In case of acute urinary retention, catheterization of the bladder with a soft catheter In breathing Place the patient in a forced position to facilitate breathing (with the head end raised).

Need Nursing care Cleanliness Carrying out morning toilet in bed.

The patient is washed at least 2 times a day.

Carrying out measures to prevent bedsores. Changing underwear and bed linen as they become dirty During sleep and rest Providing maximum comfortable conditions for the patient’s sleep and rest (silence, dim lighting, influx fresh air, comfortable bed).

Ensuring that you take sleeping pills as prescribed by your doctor Maintaining your temperature Ensuring physical and mental rest. Measuring the patient's body temperature.

Caring for the patient depending on the period of fever In motion Providing the patient with a rational regime of physical activity (turning, sitting up in bed, performing simple physical therapy, etc.) In dressing and undressing Assistance in dressing and undressing In avoiding danger Assessing the patient’s reaction on losses and his ability to adapt to them.

Providing psychological support.

Helping the patient through grief and overcoming it. Providing the patient with psychological support from his relatives and friends

The nurse also includes teaching the patient and his family nutritional therapy, which is necessary to reduce a number of symptoms (nausea, vomiting, loss of appetite, constipation, etc.).

In cancer patients, the need for food and water often decreases. Due to constant nausea, the patient refuses food and water. If there is a problem of choosing between taking water or food, then preference is given to taking liquids.

Hospice doctors and nurses are palliative care specialists, a completely new medical specialty that studies the end-of-life process. They profess the following ethical credo: if it is impossible to interrupt or even slow down the progression of the disease, ensuring the patient's quality of life becomes more important than increasing its duration; if the patient cannot be healed, then his fate must be alleviated. He continues to live and needs a dignified death. A special relationship develops in hospice between a doctor and a nurse. This is a job of equals. The role of a nurse is not limited to just dispensing medications or administering injections. She sees the patient every day, makes decisions in emergency situations when the doctor may not be nearby.

Pain. One of the main problems of cancer patients is pain. Palliative care provides adequate, as complete pain relief as possible for hopelessly ill patients. For hospice care, pain management is of paramount importance.

The International Association for the Study of Pain gives the following definition: pain is an unpleasant sensory and emotional experience associated with existing or possible tissue damage. Pain is always subjective. Every person perceives it through experiences associated with receiving some kind of damage in the early years of his life. Pain is a difficult sensation, it is always unpleasant and therefore an emotional experience. The perception of pain depends on the mood of the patient and the meaning of pain for him.

The degree of pain experienced is a result of different pain thresholds. With a low pain threshold, a person feels even relatively weak pain, while other people, having a high pain threshold, perceive only strong pain sensations.

The pain threshold is reduced by discomfort, insomnia, fatigue, anxiety, fear, anger, sadness, depression, boredom, psychological isolation, social abandonment

Pain thresholds are increased by sleep, relief of other symptoms, empathy, understanding, creativity, relaxation, anxiety reduction, pain medications.

Chronic pain syndrome accompanies almost all common forms of malignant neoplasms and differs significantly from acute pain in the variety of manifestations due to the persistence and strength of the feeling of pain. Acute pain varies in duration, but lasts no more than 6 months. It stops after healing and has a predictable ending. Chronic pain persists for a longer period of time (more than 6 months). Manifestations of chronic pain syndrome can be reduced to such signs as sleep disturbance, lack of appetite, lack of joy in life, withdrawal into illness, personality changes, and fatigue. Manifestations of acute pain syndrome include patient activity, sweating, shortness of breath, and tachycardia.

Types of cancer pain and causes of their occurrence. There are two types of pain.

Nociceptive pain is caused by irritation of nerve endings. There are two subtypes:

somatic - occurs with damage to bones and joints, spasm of skeletal muscles, damage to tendons and ligaments, germination of skin, subcutaneous tissue;

visceral - in case of damage to the tissues of internal organs, overstretching of hollow organs and capsules of parenchymal organs, damage to the serous membranes, hydrothorax, ascites, constipation, intestinal obstruction, compression of blood and lymphatic vessels.

Neuropathic pain is caused by dysfunction of nerve endings. It occurs when there is damage, overexcitation of peripheral nervous structures (nerve trunks and plexuses), or damage to the central nervous system (brain and spinal cord).

Pain assessment. When assessing pain, determine:

intensity and duration (mild, moderate or severe, unbearable, prolonged pain);

character (dull, shooting, cramping, aching, tormenting, tiring);

factors contributing to its appearance and intensification (what reduces pain, what provokes it);

its presence in the anamnesis (how the patient suffered similar pain before).

Pain intensity is assessed using two methods.

Subjective method - verbal rating scale. The intensity of pain is assessed by the patient based on the sensation:

0 points - no pain;

I point - mild pain;

2 points - moderate (average) pain;

3 points - severe pain;

4 points - unbearable pain.

Visual analogue scale - line at the left end of the

The first was marked by the absence of pain (0%), on the right - unbearable pain (100%). The patient marks on a scale the intensity of the symptoms he feels before and during therapy:

0% - no pain;

0-30% - mild pain (corresponds to 1 point on the verbal rating scale);

30 - 60% - moderate (2 points on the verbal rating scale);

60 - 9 0% - severe pain (3 points on the verbal rating scale);

90-100% - unbearable pain (4 points on the verbal rating scale).

They also use special rulers with a scale on which the strength of pain is assessed in points. The patient marks the point on the ruler that corresponds to his sensation of pain. To assess the intensity of pain, a ruler with images of faces expressing different emotions can be used (Fig. 30.1). The use of such rulers provides more objective information about the level of pain than the phrases: “I can’t stand the pain anymore, it hurts terribly.”

Rice. 30.1. Ruler with images of faces to assess pain intensity:

0 points - no pain; I point - mild pain; 2 points - moderate pain;

3 points - severe pain; 4 points - unbearable pain

Drug therapy to relieve pain. The nurse plays a big role in carrying out drug therapy to eliminate pain. It is very important that she understands how a particular pain reliever works. In this case, the nurse can collaborate with the patient to make an ongoing assessment of the adequacy of pain relief. To conduct a final assessment of the effectiveness of analgesic therapy, objective criteria are required. Rulers and scales for determining pain intensity can serve as one of the criteria for assessing pain.

For cancer, the traditional three-step ladder of pharmacotherapy is used (Table 30.2).

To eliminate pain, use non-narcotic analgesics (aspirin, paracetamol, analgin, baralgin, diclofenac, ibuprofen), weak opiates (non-narcotic analgesics) (codeine, dionine, tramal), strong opiates (morphine hydrochloride, omnopon).

There is a certain danger that the patient will develop drug addiction. However, according to WHO, pain relief with narcotic analgesics is most often needed by patients in the terminal stage of the disease (preagonia, agony, clinical death), so the risk of developing addiction is not comparable in importance to the relief brought to the patient. Experts

Three-step ladder for pharmacotherapy of cancer pain (WHO, 1986) Step

pain Feeling of pain Drug used 1 Mild pain (1 point) Non-narcotic analgesic + auxiliary means 2 Moderate pain (2 points) Mild opiate + non-narcotic analgesic + auxiliary means 3 Severe pain (3 points)

Unbearable pain (4 points) Strong opiate + non-narcotic analgesic + auxiliary agents

WHO believes that morphine doses can be increased almost unlimitedly in cancer patients as tolerance develops. For an adequate effect, most patients require a single dose of morphine up to 30 mg (I% solution - 3 ml). But there are cases, H)1 And much larger doses are necessary.

The optimal route of administration of morphine is through the mouth. It can be administered subcutaneously as single injections every 4 hours or as continuous infusions using a dosage syringe, with the cannula placed centrally and inserted below the clavicle on the anterior surface of the chest. Medicines are injected into a dosage syringe with morphine: 0.9% sodium hydrochloride solution and cerucal or other antiemetic. Side effects of morphine may include nausea, drowsiness (the patient is “loaded” for the first 2–3 days), constipation, and dry mouth. Doctors' fear of respiratory depression when using morphine is not always justified. Pain serves as a natural stimulant for breathing, so as long as pain remains,

respiratory depression is out of the question.

Auxiliary drugs are used to enhance the effect of analgesics, alleviate the painful symptoms of tumor growth, and eliminate the side effects of analgesics.

Laxatives - sena preparations, castor oil, bisacodyl, guttalax, suppositories with glycerin.

Antiemetics - cerucal, droperidol, haloperidol.

Psychotropic - sedatives (Corvalol, Valocordin, tinctures of valerian and motherwort); sleeping pills (radedorm, barbital); tranquilizers (diazepam, phenazepan, elenium); antidepressants (famitriptyline, azaphene).

In addition to drug therapy administered by a nurse as prescribed by a physician, there are independent nursing interventions aimed at relieving or reducing pain:

changes in body position;

application of cold or heat;

teaching the patient various relaxation techniques;

music therapy and art;

rubbing or lightly stroking the painful area;

distracting activities (occupational therapy).

This holistic treatment of chronic pain syndrome is used in hospice, where the patient is taught how to live with pain, and not just how to “cure” it. People doomed to live with chronic pain need this type of care.

Psychological problems of medical personnel. Nursing staff providing care to dying patients are in a constant state of emotional and physical

voltage. Relieving painful symptoms, reducing suffering and pain, being with the patient until the last minutes of his life and seeing death, nurses experience the following problems:

professional and human responsibility not only to the patient, but also to his environment;

feeling of one's own mortality;

perception and experience of one's own helplessness;

stress, constant loss of those for whom I had to look after.

As a result, nurses, like all medical

personnel need psychological support to maintain emotional and physical health.

Psycho-emotional stress is reduced by:

good organization of work;

creating an atmosphere of cooperation, support and mutual understanding between all team members;

availability of psychological relief rooms for medical personnel.

If someone caring for others gets sick, the quality of care will decrease. Therefore, all caregivers should eat well, have personal time, including breaks from caregiving work, spend some time with other people, and have enough exact time for sleep.

What are the basic principles of palliative care?

Which patients require palliative care?

Name the ethical principles of palliative care.

What is a hospice and what are the basic principles of its activities?

What is pain and what determines the strength of its perception?

What are the types of pain in cancer of different locations?

Summary of theoretical lesson on topic 14: “Loss, death, grief. Nursing assistance"

Principles of patient care in a hospice setting.

Emotional stages of grief.

Principles of patient care in a hospice setting .

Hospices are medical institutions in which doctors and nurses carry out activities to eliminate physical and mental suffering from terminally ill people. Hospice patients receive psychological and medical support. The purpose of hospice is to give a sick person the opportunity to die peacefully and without suffering; bring spiritual relief to his relatives going through difficult trials.

The first modern hospice was created in England by Dr Cecilia Saunders in 1967. Today there is a nationwide network of hospices in this country. Since the beginning of the 1980s, the ideas of the hospice movement began to spread throughout the world and began to appear in Russia.

The basis of the hospice movement is the principles of palliative medicine (medicine for temporary health maintenance and pain relief). Palliative care is a branch of medical and social activities, which aims to improve the quality of life of incurable patients and their families by preventing and alleviating their suffering through early detection, careful assessment and management of pain and other symptoms - physical, psychological and spiritual.

affirms life and views death as a normal process;

does not speed up or slow down death;

provides psychological and day care aspects of nursing;

provides relief from pain and other bothersome symptoms;

offers a support system to help patients live active lives to the end;

offers a support system to help families cope during the illness of a relative, as well as after his death.

The needs of the dying person and his family And loved ones

good control over the manifestations of the disease (monitor the patient’s appearance, breathing, pulse, blood pressure and physiological functions);

feeling of safety (if possible, do not leave the patient alone);

the desire to feel needed and not be a burden to anyone;

human communication (contact) favor;

the opportunity to discuss the dying process;

ability to participate in decisions (self-esteem);

the desire, despite any mood, to be understood.

The patient's relatives and friends experience a sense of loss and need care during the course of the patient's illness, during his death and after the death of the patient. Death is a severe shock for family and friends, and therefore they should be treated with special attention. Caring for the relatives of a sick person and talking with them are an integral part of palliative care.

The loved ones of a dying person go through the same stages of grief that the doomed person himself goes through. Grief begins before death and continues for months or even years after death.

The loss itself can be expressed in different ways: as grief over lost health, about a changed family, children, etc., and as enormous pain because a person is preparing to say goodbye to the world. During this period, you need to let the person speak out. By pouring out his soul, he is more likely to come to terms with his fate and will be grateful to those who, in this stage of depression, calmly remain next to him, without repeating that there is no need to be sad and without trying to cheer him up. Many people who are depressed need the presence and support of a priest.

Loss, death, grief, palliative care

Concept and principles of palliative care. Hospice movement and spectrum of patients. The needs of the dying person and his loved ones. Palliative care departments in the structure of multidisciplinary hospitals, treatment and consultation centers for outpatient care.

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Emotional Stages of Grief

Dr. Elisabeth Kübler-Ross, based on her many years of research, has identified 5 emotional stages through which a person passes from the moment he receives fateful news.

First stage: reluctance to accept the fact of the inevitability of impending death (disagreement and solitude). Most sick people experience psychological shock when diagnosed with a terminal illness, especially if the loss is sudden. Shock leads to a reaction of denial (This can't be true!). This happens both to those who immediately learn the truth and to those who realize it gradually.

Second stage-- anger, protest, aggression, which can be directed against the sick person himself (suicide) or, what happens more often, against the world around him (family and friends, caring staff). This is a period of resentment, resentment and envy. Behind all this is the question: “Why me?” At this stage, the family and caregivers have a very difficult time with the sick person, as his anger is poured out for no apparent reason and in all directions. But you should treat the patient with understanding, give time and attention, and he will soon become calmer and less demanding.

Third stage- negotiations with fate. In the first stage, the patient is unable to admit what happened, in the second he quarrels with God and with the world, and in the third he tries to delay the inevitable. The patient’s behavior is reminiscent of the behavior of a child who at first demanded his insistence, and then, not receiving what he wanted, politely asks, promising to be obedient: “Lord, if You do not give me eternal life on earth and all my indignation has not changed Your decision, then perhaps You will condescend to my request.” The main desire of a terminally ill person is almost always to extend his life, and then - at least a few days without pain and suffering.

Fourth stage-- depression (deep sadness about the impending loss of one's own life). Numbness, stoic acceptance of what happened, anger and rage soon give way to a feeling of horror at what was lost.

The loss itself can be expressed in different ways: as grief over lost health, about a changed family, children, etc. and how great pain it is that a person is preparing to say goodbye to the world. During this period, you need to let the person speak out. By pouring out his soul, he is more likely to come to terms with his fate and will be grateful to those who, in this stage of depression, calmly remain next to him, without repeating that there is no need to be sad and without trying to cheer him up. Many people who are depressed need the presence and support of a priest.

Fifth stage- consent, final humility and acceptance of death. The dying person is tired, very weak and sleeps or dozes for a long time. This dream is different from the sleep of the period of depression; now it is not a respite between attacks of pain, not a desire to get away from what happened, and not rest. A sick person wants to be left alone, his circle of interests becomes narrower, he receives visitors without joy and becomes taciturn. At this stage, the family needs help, support and understanding more than the patient himself.

Palliative care concept

About 60-70% of cancer patients in the generalization phase of the disease suffer from pain of varying severity. The nurse's task is to alleviate the patient's condition for this period.

A diagnosis of cancer is a shock for a person, his family and loved ones. The course of the disease and the patient's associated needs and responses may vary depending on the individual. The nurse's function is to find out the specifics of the reaction, recognize the patient's potential needs, stress factors, and determine ways to alleviate the patient's psychological state. A person may have thoughts of death, a feeling of doom and panic. And at the same time, the patient may be lonely and deprived of the support of loved ones.

In any case, a person should not be left alone with a terminal illness. IN critical situation Palliative medicine is called upon to provide assistance to the patient. “Palliative” (pallio) is a term of Latin origin, meaning “to cover, to protect.” “Palliative” - weakening the manifestations of the disease, but not eliminating its cause.

The goal of palliative care is not to prolong the patient's life, but to achieve the highest possible quality of life for him and his family. Palliative treatment is carried out if all other treatment methods are ineffective.

Palliative care is needed:

· incurable (dying) cancer patients;

· patients who have had a stroke;

· patients in the terminal stage of HIV infections.

The quality of life of a terminal patient is the subjective satisfaction that he periodically continues to experience in a situation of progressive disease. This is a time of spiritual synthesis of the life path.

The quality of life of a family is an opportunity for loved ones to accept the approaching death of a relative, understand his wishes and needs, and be able to provide the necessary assistance and care for him.

IN Russian Federation At the present stage, palliative care is provided by: palliative care centers, hospices, pain therapy rooms, hospitals and nursing departments, palliative care departments in multidisciplinary hospitals, and outpatient treatment and consultation centers.

In this case, both home care and outpatient care, which can be organized on the basis of a hospice, are equally acceptable. In addition to professional medical care, such care is provided throughout the world by community volunteers.

A hospice is a medical institution that provides medical and social assistance that improves the quality of life of doomed people.

· affirms life and views death as a normal process;

· does not accelerate or slow down death;

· provides psychological and spiritual aspects of patient care;

Provides relief from pain and other bothersome symptoms;

Offers a support system to help sufferers live an active life

life to the end;

Offers a support system to help families cope

difficulties during a relative’s illness, as well as after his death.

The needs of the dying person, his family and loved ones

The seriously ill and dying require constant monitoring day and night, since at any time the condition of the sick person may deteriorate or death may occur.

Any patient expects, firstly, medical competence, and secondly, our human attitude towards him.

To provide care and palliative care, the needs of the dying patient should be taken into account:

· good control over the manifestations of the disease (monitor the patient’s appearance, breathing, pulse, blood pressure and physiological functions);

· feeling of safety (if possible, do not leave the patient alone);

in the desire to feel needed and not be a burden to anyone;

· human communication (contact) favor;

· the opportunity to discuss the dying process;

· the ability to take part in decisions (self-esteem);

· the desire, despite any mood, to be understood.

Relatives suffer, worry, do not know what or how to say to a hopelessly ill person. Silence causes additional tension. Some relatives need advice on how to behave during visits. For a doomed person, the very presence of relatives, loved ones, and the feeling that he is not alone is often important. The loved ones of a dying person go through the same stages of grief that the doomed person himself goes through. Grief begins before death and continues for months or even years after death. palliative care hospice outpatient

Relatives need psychological support. You should talk to them tactfully, and not impose your own expectations on them or the patient in connection with the grief they are experiencing. Surrounded by attention, care, and support, the relatives and friends of the doomed person will be able to cope with the loss more easily.

1. L.I. Kuleshova, E.V. Pustovetova "Fundamentals of Nursing", Rostov-on-Don: Phoenix,. T.P. Obukhovets, O.V. Chernova "Fundamentals of Nursing", Rostov-on-Don: Phoenix,. S.A. Mukhina, I.I. Tarnovskaya "Theoretical foundations of nursing" part I, Moscow 1996

4. V.R. Weber, G.I. Chuvakov, V.A. Lapotnikov "Fundamentals of Nursing" "Medicine" Phoenix. I.V. chYaromich "Nursing", Moscow, ONICS,. K.E. Davlitsarova, S.N.Mironova Manipulation technology, Moscow, Forum-INFRA, Moscow, 2005

7.Nikitin Yu.P., Mashkov B.P. Everything about caring for patients in the hospital and at home. M., Moscow, 1998

8. Basikina G.S., Konopleva E.L. Educational and methodological manual on the basics of nursing for students. - M.: VUNMTs, 2000.

1. Mikhailov I.V. Popular dictionary of medical terms. - Rostov-on-Don, Phoenix, 2004

2. Magazines: “Nursing”, “Nurse”

3.Shpirn A.I. Educational and methodological manual on “Fundamentals of Nursing”, M., VUNMC, 2000

Need	Nursing assistance
In nutrition	A variety of menus taking into account the wishes of the patient and the diet prescribed by the doctor.
Eating easily digestible food in small portions 5-6 times a day.	Providing artificial nutrition (feeding through a tube, parenteral, nutritional enemas, through a gastrostomy tube) to the patient if it is impossible to feed naturally.
Involvement of close relatives in feeding if necessary	In drinking
Ensuring sufficient fluid intake.	If necessary, administer fluid as prescribed by a doctor via intravenous drip
In selection	Providing an individual bedpan and urine bag.
Monitoring the regularity of physiological functions.	For constipation, an enema as prescribed by a doctor.
For acute urinary retention, catheterization of the bladder with a soft catheter	In my breath
Giving the patient a forced position that makes breathing easier (with the head end raised).	Providing oxygen therapy
Clean	Carrying out morning toilet in bed.
The patient is washed at least 2 times a day.	Carrying out measures to prevent bedsores.

Change underwear and bed linen when soiled

Pain

One of the main problems of cancer patients is pain. Palliative care provides adequate, as complete pain relief as possible for hopelessly ill patients. For hospice care, pain management is of paramount importance. The International Association for the Study of Pain defines it as follows: pain is an unpleasant sensory and emotional experience associated with existing or potential tissue damage. Pain is always subjective. Every person perceives it through experiences associated with receiving some kind of damage in the early years of his life.

The pain threshold is reduced discomfort, insomnia, fatigue, anxiety, fear, anger, sadness, depression, boredom, psychological isolation, social abandonment.

The pain threshold is increased sleep, relief of other symptoms, empathy, understanding, creativity, relaxation, anxiety reduction, pain relievers.

Superficial pain– appears when exposed to high or low temperatures, cauterizing poisons or mechanical damage.

Deep pain– usually located in the joints and muscles, and the person describes it as a “long-lasting dull ache” or “excruciating, gnawing pain.”

Pain in internal organs is often associated with a specific organ: “heart pain,” “stomach pain.”

Neuralgia– pain that occurs when the peripheral nervous system is damaged.

Radiating pain- example: pain in the left arm or shoulder due to angina pectoris or myocardial infarction.

Phantom pains felt as a tingling sensation in the amputated limb. This pain may last for months, but then it goes away.

Psychological pain is observed in the absence of visible physical stimuli; for the person experiencing such pain, it is real and not imaginary.

Types of cancer pain and causes of their occurrence.

There are two types of pain:

1. Nociceptive pain caused by irritation of nerve endings.

There are two subtypes:

somatic- occurs with damage to bones and joints, spasm of skeletal muscles, damage to tendons and ligaments, germination of skin and subcutaneous tissue;

Rudik Svetlana Vasilievna
Job title: teacher of special disciplines
Educational institution: GBPOU DZM "MK No. 7" Zelenograd branch
Locality: Moscow, Zelenograd
Name of material: methodological manual for teachers
Subject:"Loss. Death. Grief. Nursing assistance"
Publication date: 28.11.2016
Chapter: secondary vocational

1 State budgetary vocational educational institution of the Moscow Department of Health “Medical College No. 7” Zelenogradsky branch
METHODOLOGICAL DEVELOPMENT FOR TEACHERS

subject:

Discipline:
PM 04 Performing work in the profession of junior nurse caring for patients MDK 04.03 Technology for the provision of medical services
Speciality

:
02/34/01 nursing

2
Explanatory note
Methodological development for PM 04 “Performing work in the profession of a junior nurse caring for patients” MDK 04.03 “Technology for the provision of medical services” is intended for conducting a practical lesson on the topic: “Losses, death, grief. Nursing assistance." The purpose of creating a methodological development is dictated by the implementation of one of the most important areas- introduce new forms and methods of teaching.
3
This methodological development will allow the teacher to successfully prepare for a practical lesson and conduct it.
Methodological development materials can be used when students perform independent extracurricular work, as well as for self-preparation for a lesson on this topic. Educational and methodological development consists of:  organizational and methodological block;  block for monitoring the initial level of knowledge;  reference and information block;  independent work block;  block of final knowledge control;  block of response standards;  applications The organizational and methodological block includes: 1. Competencies being developed 2. Objectives of the lesson. 3. Scheme of interdisciplinary connections. 4. Lesson equipment. 5. Literature for teachers and students. 6. Chronological map. 7. Motivation. The block for monitoring the initial level of knowledge consists of a task with a blind scheme and test tasks. The reference information block includes: 1. Glossary of terms. 2. Basic summary.
The block of independent work for students includes: 1. Assignments for independent work. The block of final knowledge control is represented by situational tasks, as well as tasks in test form. The methodological development also contains a block of standard answers and a literary appendix that can be offered to students for independent reading.
CONTENT
Explanatory note………………………………………………………………………. 2
I. Organizational and methodological block
…………………………………………………………………… 4-9 1.1 Competencies being developed……………………………………………………………….. 4 1.2 Lesson objectives……………………………………………………………………………… 4 1.3 Interdisciplinary connections…………………………………………………… ………………………………… 6 1.4 Lesson equipment…………………………………………………………………………………. 7 1.5 Literature………………………………………………………………………………... 7 1.6 Chronological map………………………… …………………………………………………………... 8 1.7 Motivation……………………………………………………………………………………… …… 9
II. Block of control of the initial level of knowledge
……………………………………………. 10-11 2.1 Task 1 “Study of pulse”……………………………………………………… 10 2.2 Task 2 Tests of initial level of knowledge…………………………… ……………….. eleven
III. Reference and information block
…………………………………………………………………… 12-30 3.1 Glossary of terms………………………………………………………………………………… ……… 12 3.2 Basic summary “Losses. Death. Grief. Nursing assistance”………………….. 13-30
…………………………………………………….. 32-35 5.1 Situational tasks…………………………………………………………… …………. 32 5.2 Final test control…………………………………………………………………….………. 34
VI. Block of response standards
…………………………………………………………………………………. 36-39 6.1 Standards of answers to tasks in the block of control of the initial level of knowledge…………….. 36 6.2 Standards of answers to situational tasks………………………………………………………………. 6.3 Standards of answers to final level tests…………………………………….. 37 39
VII. Applications
……………………………………………………………………….. 40-48 7.1 Appendix 1. Acceptance receipt …….………………… …………………………... 41 7.2 Appendix 2. “Death Certificate” ……………………………………………………………… ………... 42 7.3 Appendix 3. Literary. “Excerpts from the diary of Elizaveta Glinka”……….. 43-48
I.

ORGANIZATIONAL AND METHODOLOGICAL BLOCK

Name of discipline
– “PM 04 Performing work in the profession of junior nurse for patient care” MDK 04.03 “Technology for the provision of medical services”
Subject -
“Loss, death, grief. Nursing assistance"
4
Type of activity
– practical
Type of activity
– combined
Lesson duration
– 270 minutes
Location
– preclinical practice room
I.1.

ORDERED

COMPETENCIES

Obshi
e:
OK 1.
Understand the essence and social significance of your future profession, show sustained interest in it.
OK 2.
Organize your own activities, choose typical methods and ways of performing professional tasks, assessing their implementation and quality.
OK 3.
Make decisions in standard and non-standard situations and take responsibility for them.
OK 6.
Work in a team and team, communicate effectively with colleagues, management, and consumers.
OK 7.
Take responsibility for the work of team members (subordinates) and for the results of completing tasks.
Professional:

PC 2.1.
Present information in a form understandable to the patient, explain to him the essence of the interventions.
PC 2.2.
Carry out therapeutic and diagnostic interventions, interacting with participants in the treatment process.
PC 2.3.
Cooperate with interacting organizations and services.
PC 2.4.
Use medications in accordance with the rules for their use.
PC 2.5.
Comply with the rules for using equipment, equipment and medical products during the diagnostic and treatment process.
PC 2.6.
Maintain approved medical records.
PC 2.8.
Provide palliative care.
PC 3.2.
Participate in the provision of medical care in emergency situations.
PC 3.3.
Interact with members of the professional team and volunteer assistants in emergency situations.
1.2 C

CLASSES

Educational
Formation of common and professional competencies that allow you to solve professional problems.
Developmental
Stimulating mental activity, cognitive interest, logical thinking, development of skills to act independently.
Educational
Fostering a sense of empathy, compassion, respect, and responsibility for one’s actions.
5
As a result of the lesson, the student must

know:
 Stages of experiencing loss.  Peculiarities of behavior of people experiencing fear of death.  Peculiarities of behavior of people who have accepted the inevitability of death.  Ethical and deontological features of communication with a doomed person, his family and friends.  Signs and stages of terminal condition.  Concept and principles of palliative care.  Principles of patient care in a hospice setting. Hospice movement.
be able to:
 Provide assistance to the patient and/or family members experiencing loss.  Provide post-mortem care in health care facilities and at home.
1.3 M

INTERDISCIPLINARY

CONNECTIONS

PROVIDED

MDK 04.03

Technology

providing

medical

services
"Losses. Death. Grief. Nursing assistance"
6
Supporting topics:
 Infectious safety;  Disinfection;  Assessing the patient’s functional state (determining respiratory rate, pulse, measuring blood pressure);  Cardiopulmonary resuscitation;  Signs of clinical and biological death.
1.4 O

EQUIPMENT

CLASSES

Technical equipment:

PROVIDING

BASICS

LATIN LANGUAGE

WITH MEDICAL

TERMINOLOGY

ANATOMY AND

PHYSIOLOGY

PERSON

PSYCHOLOGY

BIOETHICS

PALLIATIVE

HELP

SAFETY

LIFE ACTIVITIES

TI AND MEDICINE

DISASTER

RESUSCITATION

SURGERY

INTRADISCIPLINARY

CONNECTIONS

7 Projector, laptop
Material equipment:
simulation mannequin "SUSIE" soap inventory form tray death notice forms blank disposable apron and clean sheets envelope disposable gloves adhesive plaster identification bracelets disposable napkins wide adhesive tape
Methodological equipment:
methodological development for the teacher; handouts for students: tasks to control the initial level, action algorithms, reference summary “Losses. Grief. Death. Nursing care", situational tasks; educational (documentary) video and thematic PowerPoint presentation.
1.5 L

ITERATURE

For teachers:
1. Mukhina S.A., Tarnovskaya I.I. Practical guide to the subject “Fundamentals of Nursing”: textbook. – 2nd ed., corrected. and additional – M.: GEOTAR-Media, 2009. 2. Fundamentals of nursing: textbook. for students avg. prof. textbook establishments / [I.Kh. Abbyasov, S.I. Dvoinikov, L.A. Karaseva and others]; edited by S.I. Dvoinikov. – 2nd ed., erased. – M.: Publishing Center “Academy”, 2009. 3. Obukhovets T.P., Sklyarova T.A., Chernova O.V. "Fundamentals of Nursing" ed. "Phoenix", Rostov-on-Don 2006 1. Khetagurova A.K. “Palliative care: medical, social, organizational and ethical principles” ed. Moscow State Educational Institution VUNMC Ministry of Health of the Russian Federation 2003. 2. Magazine “Nurse” No. 3 2004 3. Orthodox magazine “FOMA” Access mode: fomaxospis-eto-shkola-zhizni.html
For students:

Main:
1. Mukhina S.A., Tarnovskaya I.I. Practical guide to the subject “Fundamentals of Nursing”: textbook. – 2nd ed., corrected. and additional – M.: GEOTAR-Media, 2009.
8
1.6

CHRONOCARD OF PRACTICAL LESSON
plan Contents timing
1.

Organization of the lesson
1.1. Organizational moment * readiness of the audience for the lesson (sets on the topic) * readiness of students (dress code, absentees) * filling out the magazine * announcement of the topic, goals of the lesson. 5 minutes
2.

Main part
2.1. Introduction to the topic (initial motivation).
3.

*introduction to the course of the lesson 10 min 2.2. Monitoring the initial level of knowledge (filling out a blind chart - “Pulse Study” and solving test tasks) 15 min 2.3. Presentation of new material by the teacher. 65 min 2.4. Watching an educational (documentary) video on the topic. 30 min 2.5. Writing an essay after watching the video material 20 min 2.6. Independent work of students: - drawing up situational tasks according to a template (in pairs); - determination of signs of clinical and biological death on a mannequin (solving the problem); - ascertaining death, filling out documentation; - rules for handling a corpse. 65 min 2.7. Determining the final level of knowledge of students - solving test tasks - solving situational problems 35 min
Final part
3.1. Reflection * summarize the information received, * analyze mistakes, * causes of difficulties and successes, * degree of achievement of goals. 10 min 3.2. Summing up the lesson * assessing the work of the team * assessing the work of each student * posting grades in the journal 10 min 3.3. Homework assignment 5 min

Total
270 min * Due to use various means
9
To achieve goals in each group of students, the chronomap is indicative.

1.7 M

From the moment of birth, a person goes to meet death.
Death is a natural stage of life, its completion.
Man is the only living creature who knows about the inevitability of death.
10

However, “in essence, no one believes in their own death. Or, which is the same thing, each of us, without realizing it, is convinced of our immortality,” writes S. Freud.
The most painful thing is to accept the thought that, having left this world, a person will bring great grief to his family and people close to him. All dreams, desires, goals, love, joy, happiness - all this will go into oblivion. That is, it is impossible for him to think that he will leave, and everything that was his personality will leave with him. Fear of death is a natural feeling.

In our clinics, a dying person receives medical care, but psychological care leaves much to be desired. And the worst thing is that dying became lonely. No one knows, and sometimes does not want to know, what horror a person experiences when standing on the edge of an abyss, knowing that there is no way back, and in the depths of his soul that last weak light of hope is extinguished.
Where did this heartlessness, this indifference come from? Perhaps from not accepting death as a natural life process, if this is so, then it will be much easier to correct the mistake. What if this is callousness instilled in us by our age?

Warriors, destruction, son for father, brother for brother, isn’t this the answer to the question posed? Isn’t this the reason for the low empathy among medical personnel, and among us all? This error can also be corrected, although it will require much more time and effort. And you need to start small - start with yourself.
1.

It is quite possible that rethinking your life will lead to self-discovery. For a person, it is necessary to speak out and speak out not for himself, but also for a person subject to the same passions, the same vices and weaknesses. He needs to be listened to and understood. It's not that difficult, is it?

II. BLOCK
10-14
CONTROL OF THE INITIAL LEVEL OF KNOWLEDGE
12-16
1. Introduce students to tasks 1 and 2 to control the initial level. 2. Distribute tasks with instructions, announce the time for their completion. 3. After solving each task, the teacher offers to check the correctness of its completion.
16-20
Task 1. “Pulse study”
24-26
2.

Instructions:

II. BLOCK
Task 2. Baseline control tests
CONTROL OF THE INITIAL LEVEL OF KNOWLEDGE
a sharp drop in blood pressure, decreased heart rate, deep respiratory distress
1. Introduce students to tasks 1 and 2 to control the initial level. 2. Distribute tasks with instructions, announce the time for their completion. 3. After solving each task, the teacher offers to check the correctness of its completion.
paralysis of the respiratory and vasomotor centers Instructions: complete the phrase:
3.

Lack of breathing is called - ________________________________________

Decrease in heart rate - _______________________________________

Increased heart rate - _______________________________________

The bed of a seriously ill patient should be remade

II. BLOCK
2 times a day
CONTROL OF THE INITIAL LEVEL OF KNOWLEDGE
3 times a day
1. Introduce students to tasks 1 and 2 to control the initial level. 2. Distribute tasks with instructions, announce the time for their completion. 3. After solving each task, the teacher offers to check the correctness of its completion.
4 times a day
Task 1. “Pulse study”
as it gets dirty Instructions: choose one index of the correct answer
7.

Signs of clinical death are all except:

II. BLOCK
rigor mortis
CONTROL OF THE INITIAL LEVEL OF KNOWLEDGE
respiratory arrest
1. Introduce students to tasks 1 and 2 to control the initial level. 2. Distribute tasks with instructions, announce the time for their completion. 3. After solving each task, the teacher offers to check the correctness of its completion.
heart failure
Task 1. “Pulse study”
dilated pupils
8.

Signs of biological death are all except:

II. BLOCK
heart failure
CONTROL OF THE INITIAL LEVEL OF KNOWLEDGE
rigor mortis
1. Introduce students to tasks 1 and 2 to control the initial level. 2. Distribute tasks with instructions, announce the time for their completion. 3. After solving each task, the teacher offers to check the correctness of its completion.
cadaveric spots
Task 1. “Pulse study”
corneal clouding
9.

Duration of clinical death by time:

II. BLOCK
5-6 min
CONTROL OF THE INITIAL LEVEL OF KNOWLEDGE
8-10 min
1. Introduce students to tasks 1 and 2 to control the initial level. 2. Distribute tasks with instructions, announce the time for their completion. 3. After solving each task, the teacher offers to check the correctness of its completion.
7-9 min
10.

What is the most gentle and gentle way to transport a seriously ill patient?

comfortable?

II. BLOCK
on hands
CONTROL OF THE INITIAL LEVEL OF KNOWLEDGE
on a gurney
1. Introduce students to tasks 1 and 2 to control the initial level. 2. Distribute tasks with instructions, announce the time for their completion. 3. After solving each task, the teacher offers to check the correctness of its completion.
on a stretcher
Task 1. “Pulse study”
on foot accompanied by a nurse
III. REFERENCE INFORMATION BLOCK

12
Instructions for the teacher:
1. Explain new material using a teaching outline or topic presentation. 2. Demonstrate practical skills using models, explaining your actions.
3.1 C

LOVAR

TERMS

Grief
an emotional response to loss or separation that goes through several stages.
DEPRESSION
sad, depressed mood.
PALLIATIVE

TREATMENT
treatment that is started when all other treatments have failed and the disease cannot be cured.
TERMINAL

STATE
the borderline state between life and death, the stages of the dying of the body (pre-agony, agony, clinical death).
HOSPICE
a specialized medical institution for doomed patients, where comprehensive medical, psychological and social assistance is provided.
EMPATHY
the ability to experience another’s feelings, to empathize. The ability to “feel” into another person, to grasp his inner state, to see the world through his eyes from his point of view.
THANATOLOGY
A branch of medicine that studies issues related to the mechanisms of the dying process and the clinical, biochemical and morphological changes that arise in the body.
THANOTOGENESIS
Causes and mechanisms of death in each specific case.
TERMINAL
Finite
3.2 O

PORN

ABSTRACT

13
Stages of experiencing loss and grief
Often there is a terminal patient in the department. When death suddenly appears close and inevitable, it is difficult to face it. A person who has learned that he is hopelessly ill, that medicine is powerless, and that he will die, experiences various psychological reactions, the so-called emotional stages of grief (defined by the American psychiatrist E. Kübler-Ross in the classic work “On Death and Dying”).
1. Denial, shock, numbness
The person may feel as if they are out of touch with reality. Mental shock can turn into mental seizures and hysteria. Shock leads to a reaction of denial (“This can’t be!”, “No, not me,” “It’s not true”). The stage is protective in nature.
2. Reaction of anger, anger
Shock and numbness gradually give vent to intense emotions. A person no longer doubts that this is true, but perceives such reality as the greatest injustice and feels resentment towards people and God. Anger can be directed both at oneself and at the medical staff or family (“Why me?”, “Who is to blame?”). This unfair anger should be treated with understanding.
3. Attempt to negotiate with a “Higher Spiritual Being.”
A patient in a state of terminal illness is in some ways similar to a child. When the anger reaction does not give the desired result, he wants to make a deal with God, with the doctors. A person promises to do something to “Him” if “He” heals him or his loved one (“Not yet”, “A little more”).
4. Stage of depression
It is accompanied by a feeling of confusion and despair. A person often cries and loses interest in his own appearance. Sometimes this leads to isolation from the outside world. A person is mentally capable of accepting the finality of a loss much earlier than his emotions allow him to accept this truth (“Yes, this will happen to me, I will die,” “There is no way out, it’s all over”).
Signs of depression:
 constant bad mood;  loss of interest in the environment;  feelings of guilt and inferiority;  hopelessness and despair;  suicide attempts or persistent thoughts of suicide.
5. Acceptance
Farewell to life, humility (“Let it be”, “You can’t go anywhere, that means fate”). At this stage, intensive spiritual work takes place - repentance, assessment of one’s life and the measure of good and evil by which one can evaluate one’s life. The patient begins to experience a state of peace and tranquility.
14
The time it takes a person to go through all these stages is purely individual. Often these reactions appear in different sequences and some of them can occur simultaneously. Sometimes humility gives way to a reaction of denial.

It is very important to recognize what stage the patient is currently in in order to provide him with appropriate assistance.

WITH

ESTRINSKY

INTERVENTIONS

VARIOUS

STAGES

ADAPTATIONS

PATIENT
MENTAL
INJURY

1.
Stages of Grief Nursing Intervention
2.
1. "Denial"
3.
Find out your feelings towards death, because... personal hostility and fear can be transferred to the dying person.
Ask the patient to describe on paper his feelings, concerns, and fears. This promotes psychological processing of these emotions. It is important to sit by the patient’s bed (his feeling of abandonment decreases); listen carefully and empathize with the patient’s feelings (reduces feelings of isolation, promotes relationship building); support your hand, touch your shoulder (physical touch brings a feeling of comfort to some patients and demonstrates care for them).

1.
Inform the patient. Encourage questions that he is willing to ask (the right information can reduce anxiety and clarify the situation). However, if the patient has a pronounced denial reaction and does not want to know about death, then you cannot talk about it, it would be a mistake.
2.
2. "Anger"
Recognize the patient’s right to feel anger, which creates a feeling of support and mutual understanding (allow the patient to “vent”).

Work with the patient so that he turns his anger into a positive direction (setting goals, making decisions, fighting the disease). This will help the patient increase their self-esteem, keep their emotions under control and feel supported by the medical staff.

3. "

1.
Request for
deferment

1.
Provide support (the ability to turn to someone and be understood helps the patient cope with his feelings). Do not encourage the patient to endure adversity, to hold on and be strong.
2.
Spend sufficient time with the patient and communicate with him (reduces feelings of isolation and promotes mutual understanding).
3.
Try to keep the feeling of pain under control (a comfortable state increases the patient's desire to interact with others and reduces the tendency to withdraw).
4.
Encourage the patient to discuss issues of guilt and loss, which will help reduce feelings of guilt and possible thoughts of punishing past actions. 5. Provide the patient with the necessary personal space (when using the toilet, bathing). This maintains self-esteem.
5. "Acceptance"

1.
Maintain contact even if the patient does not want to communicate (reduce feelings of isolation).
2.
Continue to control pain (maintains a state of peace and tranquility in the final stage).
3.
Provide spiritual support (invite a priest...). This will help you rethink your life, repent, and dispel an unreasonable approach to issues of religion and faith.
15
E

TICO

DEONTOLOGICAL

PECULIARITIES

COMMUNICATIONS

DOOMED

A PERSON

FAMILY

CLOSE
Communicating with terminally ill people requires a skill that, although not without difficulty, can be learned. To do this, you need to know yourself, the patient and his family, as well as their attitude and approach to this problem. The ability to communicate requires a person to be honest, respect the feelings of others and have the ability to be compassionate. This skill includes body language, spoken language, and the trust that is established between you and the interlocutor. Communication needs of patients and their families:  need for communication between people;  in information;  in the council;  in consolation;  in discussing treatment and prognosis;  in a conversation about feelings and professional psychological support.
Remember!
The relationship between a nurse and a doomed patient is based on trust. Therefore, do not deceive the patient. In general, patients want to know as much as possible about their condition. However, be prepared to stop if the patient indicates to you that they have received enough information. 1. Set aside time for leisurely, uninterrupted conversation. 2. Sit down and let the patient know that you have time for him. 3. Try to keep your gaze level with the patient's. 4. It is very important to speak in a private setting. 5. It is important to encourage the patient to continue the conversation by showing interest with a nod of the head or a phase: 6. “Yes, I understand.” When people are suffering, they tend to socialize informally, as opposed to when they are calm and in control.
Remember that when talking with a patient, it is very important to have optimal physical space between you. The patient will feel uncomfortable if you are too close to him. If it’s far away, this will be an additional barrier to communication.
Most people who are dying feel the need to have their closest relatives around them, and everything possible must be done to achieve this. The most important thing that the patient would like to hear during the impending uncertainty is:  “No matter what happens, we will not leave you.”  “You are dying, but you are still important to us” “Truth is one of the most powerful therapeutic agents available to us, but we still need to know the exact meaning of its clinical pharmacology and find out
– an important means of conveying confidence and comfort to the patient (for example, holding his hand, shoulder). There is no need to prevent the manifestation of negative emotions (feelings of anger, grief). M/s must have tact, restraint, and attention.
Be prepared for religious and philosophical conversations, dialogues with the patient about justice, the meaning of life, good and evil. The whole difficulty in such a situation lies in the fact that philosophical judgments here, first of all, are important not in themselves, but as a means of consolation, reconciliation of a doomed person with his fate.
“Hope is the expectation of a little more than nothing in achieving a goal.” "Hope dies last". Why deprive a person of that small ray breaking through the darkness of the night, why deprive him of his last opportunity to be human and realize that he is still needed here, that he is loved.
17 To take away hope means to kill, to kill mercilessly, mercilessly.
A dying person must hope, and honey must give him this hope. worker, with his warmth, care, affection, respect.
We must never forget that we are all mortal, that sooner or later we will also have to leave this mortal world.
Let us remember and love life with all its joys and sorrows and there is no need to darken the last moments of life. Factors Contributing to Hope Decreasing hope Increased hope Undervalued as a person Valued as a person Abandonment and isolation Significance in relationships Lack of direction Realistic goals Uncontrollable pain pain relief discomfort When there is very little hope left, it is quite possible to hope for more than one death.
After loved ones learn the truth from the doctor, the sister can answer questions related to care and ensuring a decent lifestyle.
Often relatives have a feeling of guilt towards the dying person, in some cases they experience feelings of anger, rage, and even aggression towards health workers. You should help your loved ones relieve feelings of guilt and tension.
Some relatives need to be taught how to behave as if they were at home, how to pay a visit to a sick person. When visiting him, it is not necessary to talk; it is better to show care by adjusting the pillow, carrying out hygiene procedures, and feeding him. Even just sitting and reading a book, a newspaper, or watching TV together can be very important for the patient, because... he feels that he is not alone. When talking with loved ones, asking them questions about the life of the dying person, make it clear that you are ready to provide them with psychological support. Explain to family members that even if the dying person is unconscious, they can hear and feel touch. This means that a quiet conversation with him, a touch on his hand will help him survive the loss.
18 It will be easier for family members if they see that their loved one is being cared for in good faith and that a comfortable environment is maintained in the ward. Despite weakness and helplessness, we must not forget about the patient’s right to choose; every manipulation must be carried out with his permission.
.
Grieving people may feel disconnected from life because... the reality of death has not yet fully sunk into consciousness and they are not yet ready to accept the loss. 2. Pain experienced due to the absence of the deceased person. (the absence of the deceased is felt everywhere, the home and family are filled with painful memories, the mourner is overcome by intense melancholy). 3. Despair (excitement, anger, reluctance to remember). It occurs when the realization comes that the deceased will not return. At this time, the following are often noted: * decreased concentration, * anger, * guilt, * irritability, * anxiety, * excessive melancholy. 4. Acceptance (awareness of death). Depression and emotional fluctuations may continue for more than a year after the funeral. 5. Resolution and reconstruction. Together with the deceased person, old behavioral habits go away and new ones arise, which lead to a new phase of decision-making. A person is able to remember the deceased without overwhelming sadness.
Knowledge of the stages of grief experienced by the relatives of the deceased is necessary in order to avoid an incorrect attitude towards the mourner and hot-tempered judgment about his experiences at the moment.

Groups at risk of extreme grief:
Aged people,
Those experiencing the loss of a loved one feel more isolated and need sympathy. 
Children,
those who have lost people close to them are very vulnerable and perceive death more consciously than adults think about it: 1. up to 2 years of age, children cannot realize that someone in the family has died. But they are very concerned about it. 2. from 3 to 5 years old, children do not consider death to be an irreversible phenomenon and think that the deceased will return. 3. between 6 and 9 years old, children gradually begin to realize the irreversibility of death, and their thoughts may be associated with ghosts. 4. Teenagers are emotionally vulnerable and experience loss especially hard.
1.
19 Children react in a special way to the loss of their parents. There are several situations that can affect a child:  the remaining parent is in deep sadness;  the child does not understand what happened because it was not clearly explained to him;  change of place of residence and school;  small number of family social contacts;  deterioration of the social and economic situation of the family, especially when the father dies;  marriage of the remaining parent until the child gets used to the idea that the deceased will not return;  deterioration in child care. The process of a child experiencing sadness may have the following problems:
2.
appetite disorder,
3.
increased general anxiety (reluctance to leave home or go to school),
4.
moodiness,
5.
mood swings from euphoria to crying, depression,
6.
privacy. A child through the eyes of a parent Very often, parents do not know what to expect from their child and often deny that the child is influenced by what happened. They are often unable to comprehend or respond to obvious signals of childhood grief. This is directly related to the parent’s perception of loss, which can be pathological:  denial (continue to live as if nothing happened);  hasty choice of a new partner;  prolonged denial and anger at responsibilities not fulfilled by the spouse;  chronic depression and self-blame.
The role of the nurse in helping a bereaved family:
1. Explain to the remaining parent the physical and emotional reactions the child is exhibiting and emphasize that these are normal in a bereavement situation for children. 2. Recommend books and brochures on these topics. This will help you consider the situation intelligently. Reading these books with your children can be a conversation starter. 3. Encourage the remaining parent to help the children draw, write about a topic related to their loss, and talk about it with others they trust. 4. Encourage the remaining parent to take care of their financial, emotional and social needs. In this case, it is easier for them to respond to the needs of their children.
How to help your child
A child who understands what happened, who spent time with the sick parent before death and said goodbye to him after death, is better able to relate to the new situation with himself. The child must be given the opportunity to express his feelings. A grandparent or friend who urges a child not to cry so as not to upset the living parent should not do so. Children sometimes need to be given permission to express their grief. They need to see their parents' grief and share it with them. The child's basic needs must be satisfied. Regular eating and sleeping patterns in the first weeks after loss; relief from financial problems. The school must be made aware of the child's critical condition.
20 The child needs to be given simple, specific information and the opportunity to ask the same questions, and the adult needs to know for sure that the child understands the answers to his questions. The child needs to constantly discuss what happened, sometimes for months, and he should have this opportunity.
The child needs confidence that he will continue to receive attention and that promises will be kept. The child should not be in a state of denial. If the child does not ask questions and acts as if nothing happened, the adult should help the child express hidden feelings and unasked questions. Even very young children need to be talked to and helped to understand that the deceased father/mother will not return. It is very easy to idealize a deceased parent. If the surviving parent and child can grieve together for the one who died, recalling both the good and the bad, the child will feel more comfortable about having mixed feelings about the deceased parent. He also needs assurance that he did not cause or contribute to the illness or death of the parent.

The dying process and its periods
Dying
- in most cases, this is not an instant process, but a series of stages, accompanied by a sequential violation of vital functions.
Death -
irreversible cessation of the body's vital functions.
Issues related to the study of the mechanisms of the dying process, as well as the clinical, biochemical and morphological changes that arise in the body, constitute the subject of thanatology (from the Greek thanatos - death, logos - teaching), which is a branch of theoretical and practical medicine. Causes and mechanisms of death outcomes in each specific case are referred to as thanatogenesis. The main causes of death may include, for example, severe injuries incompatible with life of certain organs, massive blood loss, hemorrhages involving the most important centers of the brain, cancer intoxication, etc. The immediate causes of death in various diseases are most often heart or respiratory failure. States bordering between life and death are called
terminal
(phase duration – from several minutes to several days)  the patient’s consciousness is preserved, but confused;  Blood pressure drops to 80 mm Hg;  increased heart rate and breathing are replaced by their slowdown;  skin is pale or cyanotic;  thready pulse, tachycardia;  breathing becomes faster;  ocular reflexes are preserved, the pupil is narrow, the reaction to light is weakened. The preagonal period ends with the appearance of a terminal pause (short-term cessation of breathing), which continues
21 from 5 -10 seconds to 3 - 4 minutes and is replaced by an agonal period (agony).
2. Agony
(from the Greek agonia - struggle) It is characterized by a short-term activation of mechanisms aimed at maintaining vital processes. Initially, the following are noted:  a slight increase in blood pressure;  increase in heart rate;  sometimes short-term (up to several minutes) restoration of consciousness. The apparent improvement in the condition is then quickly replaced again by:  a sharp drop in blood pressure (up to 10 -20 mm Hg);  slowing down the heart rate (up to 20 - 40 per minute);  deep breathing disorder and deep breathing movements such as “swallowing air”;  loss of consciousness;  pain sensitivity disappears;  corneal, tendon, and skin reflexes are lost;  general tonic convulsions are observed;  involuntary urination and defecation occur (sphincter paralysis)  body temperature decreases. The agonal period lasts from several. min. (for example, during acute cardiac arrest), up to several hours or more (with slow dying), after which clinical death occurs. Caring for an agonizing patient The patient must be isolated: o Removed from the general ward. o Separate with a screen. o Transfer to intensive care unit. department o Establish an individual nursing station.
M/s should not be absent from the patient: Monitors breathing, pulse, blood pressure, consciousness, and carries out doctor’s orders. In case of sudden disruption of vital functions, it is necessary to call a doctor. When clinical death occurs, the m/s begins resuscitation measures (except for those who died as a result of disorders incompatible with life: malignant neoplasms, blood diseases, cerebral vascular lesions, cardiopulmonary failure, hepatic coma, uremia, etc.)
It is a reversible stage of dying, during which external manifestations of the body’s vital functions (breathing, heartbeats) disappear, however, irreversible changes in organs and tissues do not yet occur. The duration of this period is usually 5-6 minutes.
Within the specified time frame, with the help of resuscitation measures, complete restoration of the body’s vital functions is possible. After this, irreversible changes occur in the tissues (primarily in the cells of the cerebral cortex), defining a state of biological death, in which complete restoration of the functions of various organs can no longer be achieved.
4.
22 The duration of the period of clinical death is influenced by the type of dying, its duration, age, and body temperature at dying. Thus, with the help of deep artificial hypothermia (lowering a person’s body temperature to 8 - 13 ° C), the state of clinical death can be extended to 1 - 1.5 hours.
Offensive
biological death
it is established both by the cessation of breathing and cardiac activity, and on the basis of the appearance of so-called reliable signs of biological death:  decrease in body temperature below 20 ° C;  formation of cadaveric spots after 2-4 hours (occur due to the accumulation of blood in the underlying areas of the body);  development of rigor mortis (thickening of muscle tissue).
Ascertainment of death and rules for handling a corpse
Ascertainment of biological death is carried out by doctors of hospital departments (if the patient died in the hospital), clinics and emergency medical services (in cases where the patient died at home), as well as forensic experts (when examining a corpse at the place of its discovery) based on a combination of a number of signs : 1. dilation of the pupils and lack of their reaction to light; 2. absence of corneal reflex; 3. clouding of the cornea; 4. cessation of breathing; 5. lack of pulse and heartbeat; 6. muscle relaxation; 7. disappearance of reflexes; 8. typical facial expression; 9. appearance of cadaveric spots, rigor mortis; 10. decrease in body temperature. If the patient died in a hospital, then:  the fact of his death and the exact time of its occurrence is recorded by the doctor in the medical history.  the corpse is undressed,  laid on its back with the knees bent,  eyelids are lowered,  the jaw is tied up,  covered with a sheet and left with a sheet and left in the department for 2 hours (until cadaveric spots appear).
Currently, due to the widespread use of organ transplant operations, the previous deadlines for possible autopsies of dead bodies in hospitals have been revised: now autopsies can be carried out at any time after doctors in medical institutions have established the fact of the occurrence of biological death.
Before the body is transferred from the department to the morgue, the m/s performs a series of procedures that are the final manifestation of respect and care towards the patient. The specifics of the procedures vary from hospital to hospital and often depend on the cultural and religious background of the deceased and his family.
The chaplain can provide support to the family, other patients and staff. In some medical institutions, after death has been declared, morgue staff are invited to the department to prepare for the farewell to the patient.
23 An employee performing this procedure for the first time or who is a relative of the deceased requires support.
Equipment
25 To avoid contact with body fluids and to prevent infection, wear gloves and an apron. Check local infection control regulations in advance. Lay your body on your back, remove the pillows. Place your limbs in a neutral position (arms along your body). Remove any mechanical attachments, such as tires. Rigor mortis appears 2-4 hours after death. Cover your body completely with a sheet if you must be away. Gently close your eyes using gentle pressure for 30 seconds. on drooping eyelids.
26 Wounds with discharge should be covered with a clean, waterproof diaper and securely secured with wide adhesive tape to prevent leakage. Find out from relatives whether it is necessary to remove wedding ring. Fill out the form and ensure the safety of your valuables. Jewelry must be removed in accordance with hospital policy in the presence of a second nurse. A list of decorations must be included on the death notification form. Complete patient identification forms and identification bracelets. Attach the bracelets to your wrist and ankle. The death notice must be completed in accordance with the hospital's policies, which may require that the document be attached to the patient's clothing or sheet.
27 Cover the body with a sheet. Contact paramedics to transport the body to the morgue. Relatives can once again say goodbye to the deceased in the funeral hall after permission from the morgue staff. Remove and dispose of gloves and apron in accordance with local regulations and wash your hands. It is important to provide emotional support to patients even after the deceased is removed from the department. Staff may need the same support. All manipulations must be documented. A record is made of religious ceremonies. Data are also recorded on the method of wrapping the body (sheets, bag) and applied bandages (on wounds, on holes)
Palliative care
In 1981, the World Medical Association adopted the Lisbon Declaration, an international set of patient rights, including the human right to die with dignity.
28 But earlier, in most civilized countries, special institutions were opened that were involved in helping dying people and their relatives. Doctors realized that people on the verge of death do not need medical help, but an independent medical discipline that requires special training and attitude towards patients. The disease may reach a stage where curative therapy is powerless and only palliative care is possible. Previously, they died at home, but caring for such a patient is extremely difficult, and it is not always possible. This is difficult for everyone - both for the dying themselves and for their relatives. Both suffer from unbearable pain: some from physical pain, others, seeing their own powerlessness, from moral pain.
Palliative care
(WHO definition) is active multifaceted care for patients whose illness is not curable. The primary goal of palliative care is to relieve pain and other symptoms and resolve psychological, social and spiritual problems. It is also necessary for support after loss. The goal of palliative care is to create a better quality of life for the patient and his family. Principles of palliative care: 1. Affirms life and perceives dying as a normal process. 2. Does not accelerate or delay death. 3. Sees the patient and family as a unit of care. 4. Frees the patient from pain and other severe symptoms. 5. Provides a support system to help patients live as actively and creatively as their life potential. 6. Offers a support system to help families cope during the patient's illness and bereavement. The spectrum of patients in need of palliative care:  patients with malignant tumors  patients with irreversible cardiovascular failure  patients with irreversible renal failure  patients with irreversible liver failure  patients with severe irreversible brain damage  AIDS patients Interaction of people providing palliative care Palliative care is best delivered by a group of people working as a team. The team is collectively focused on the overall well-being of the patient and family. It includes: doctors, junior medical staff, psychologists, church ministers Basic principles of medical ethics:  respect life  accept the inevitability of death  use resources rationally  do good  minimize harm
29 When a person is terminally ill, their interest in eating and drinking is often reduced to a minimum. The patient's loss of interest and positive attitude should also be perceived as the beginning of a process of “non-resistance.” Apart from those who die suddenly and unexpectedly, there comes a time when death is natural. Thus, a time comes when, due to the natural order of things, the patient must be allowed to die. This means that the doctor in such circumstances takes responsibility by allowing the patient to die. In other words, in certain circumstances the patient has a “right to die.”
If physical and mental torture is considered unbearable and difficult to control, the most radical remedy is to put the patient into a state of sleep, but not to take his life.
Hospices are more than just specialized hospitals for the dying. They are in many ways the negation of “just a hospital.” The difference between a hospice and a “just hospital” is not only in the technical equipment, but also in a different philosophy of healing, according to which the patient is created with the “living space” necessary for his condition. The initial idea of the hospice philosophy is very simple: a dying person needs special help, he can and should be helped to cross this border.
30 Order of the RSFSR No. 19 “On the organization of nursing homes, hospices and specialized hospitals.” Currently, more than 20 hospices have started operating in Russia. The structure of Russian hospices mainly includes:  mobile service  day hospital  inpatient treatment  administrative unit  educational and methodological unit  socio-psychological  volunteer  economic The heart of the hospice is the mobile service, and the main working unit is a nurse trained in the provision of palliative care help.
Basic principles of hospice activities:
1. Hospice services are free. You can't pay for death, just like you can't pay for birth. 2. Hospice is a house of life, not death. 3. Controlling symptoms allows you to qualitatively improve the patient’s life. 4. Death, like birth, is a natural process. It cannot be slowed down or rushed. Hospice is an alternative to euthanasia. 5. Hospice is a system of comprehensive medical, psychological and social care for patients. 6. Hospice – school and support for the patient’s relatives and loved ones. 7. Hospice is a worldview of humanism.
IV. INDEPENDENT WORK BLOCK

Instructions for the teacher:
1. Instruct students about the regulations, rules for performing independent work, and evaluation criteria. 2. Distribute students into pairs to draw up a situational task (using a template) and practice practical skills in identifying signs of clinical or biological death (when forming pairs, you should
31 take into account the level of basic knowledge). 3. While preparing situational tasks and practicing practical skills, the teacher monitors the correctness of the manipulations, makes adjustments, and gives recommendations. 4. The teacher, using physiological indicators from situational problems (compiled by each pair), enters the data into the SUSIE simulation mannequin program and offers them for solution to other groups of students.
4.1 Z

ADANIA

INDEPENDENT

WORKS

Instructions for students

Exercise 1.
Using the supporting lesson notes and knowledge on previously studied topics PM 04 (“Assessment of the functional state of the patient”, “Cardiopulmonary resuscitation”, etc.), create a situational problem and a standard for solving it according to the proposed scheme. Situation …………………………………………………………………………………………………………… …………………… ……………………………………………………………………………………… ……………………………………………………………… ……………………………………………………………… ……………………………………………………………………………… ………………………………………………………… Symptom Indicators of functional state note Stage of dying State of consciousness Pathological type of breathing RR Artery for determining the pulse BP Presence of convulsions Presence of cyanosis Condition of the skin Condition of the pupils Presence of stomas, drainages
Task 2
. Fill out the necessary documentation for your situational task (acceptance receipt, death certificate)
Task 3.
Each pair (with the help of the teacher) puts data on their situation into the manikin program and invites other groups of students to solve it.
V. BLOCK
FINAL KNOWLEDGE CONTROL
Instructions for the teacher:
1. The teacher distributes assignments with situational problems. 2. Students take turns reading their situations out loud and commenting on their solution. 3. The teacher evaluates the student’s answer, focusing on the standard for solving the problem. 4. Students are given cards with a written task (tests, assignment
32 for compliance) 5. After solving each task, the teacher asks students to check the correctness of its completion.
5.1 C

ITUATIONAL

TASKS

Problem 1
In the therapeutic department 10 min. ago, the doctor recorded biological death in patient A. During the period of agony, a large amount of liquid, bloody stool was released. The probe, which is located in the stomach, reveals a discharge the color of coffee grounds mixed with fresh blood.
What are your next tactics?
Problem 2
Patient V. categorically refuses to lie down on the offered bed, since, according to the neighbors in the ward, another patient died on it yesterday. What should be the nurse's next strategy?
Problem 3
At your post in the department 15 minutes. ago, the doctor recorded biological death in patient M. What are your further tactics?
Problem 4
The neighbors in the ward of a dying patient approached the nurse with a request to help him. The nurse told them that nothing would help the patient and she was not going to waste time on him.
The guard nurse went into the ward to remove the IV from patient S., who was being treated in the cardiology department. Entering the room, she noticed that the patient’s eyes were closed, he was not breathing, his skin was pale with a marble tint, and he had a specific facial expression. The pulse on the carotid artery is not detected. The drip continues to drip. By all indications, the patient died. The other 2 patients in the ward are resting - sleeping during quiet time.

Determine the nurse's further tactics and actions?
Problem 6
You are a guard nurse on a therapeutic department. One of your patients was transferred to the intensive care unit during the day due to a sharp deterioration in his condition. You already know that the patient could not be saved and he died. Relatives call the post and inquire about the patient’s condition.
What can you tell your family based on the facts you know?
Problem 7
A visually impaired (practically blind) neighbor came to your house with a request to see what was wrong with his son, who had gone to rest during the day, had been sleeping for 4 hours, and when trying to wake him up, did not answer his father. Upon examination objectively:
33 - skin is cold, pale, cyanotic to the touch; - the pulse in the carotid artery cannot be felt; - eyes are closed, pupils do not react to light; - the mouth is slightly open, breathing is not audible;
Assess the situation and decide on further actions.
Problem 8
Provide psychological support to a patient in the “denial” stage.
Problem 9
34
You are a neurology nurse. When transferring duty, you were informed that there was a dying patient at your post, who kept calling for a woman named Tatyana. There is another patient in the room with the dying man. How can you help and brighten up the last hours or minutes of a dying person? What kind of help might your roommate need?

Problem 10

You are a school nurse. The class teacher of an 8-year-old boy who recently lost his mother has approached you to take part in a conversation with the remaining parent - his father. The boy has lost a lot of weight, has become less sociable, often secludes himself, cries, has become capricious, and does not want to study. Give advice to the boy's father.

5.2 I

TRADE

TEST

TOPIC

II. BLOCK
"Losses. Death. Grief. Nursing assistance"
CONTROL OF THE INITIAL LEVEL OF KNOWLEDGE
select one index of the correct answer
1. Introduce students to tasks 1 and 2 to control the initial level. 2. Distribute tasks with instructions, announce the time for their completion. 3. After solving each task, the teacher offers to check the correctness of its completion.
A reliable sign of biological death is
Task 1. “Pulse study”
absence of carotid pulse
2.

constriction of the pupils

pale skin

II. BLOCK
appearance of cadaveric spots
CONTROL OF THE INITIAL LEVEL OF KNOWLEDGE
After how many hours is the body of the deceased transferred to the pathology department?
1. Introduce students to tasks 1 and 2 to control the initial level. 2. Distribute tasks with instructions, announce the time for their completion. 3. After solving each task, the teacher offers to check the correctness of its completion.
in 2
Task 1. “Pulse study”
in 6
3.

After the doctor has confirmed the patient's death, the nurse should fill out

II. BLOCK
doctor's prescription sheet
CONTROL OF THE INITIAL LEVEL OF KNOWLEDGE
cover page of medical history
1. Introduce students to tasks 1 and 2 to control the initial level. 2. Distribute tasks with instructions, announce the time for their completion. 3. After solving each task, the teacher offers to check the correctness of its completion.
accompanying sheet
Task 1. “Pulse study”
temperature sheet
4.

The irreversible stage of the death of an organism is

II. BLOCK
clinical death
CONTROL OF THE INITIAL LEVEL OF KNOWLEDGE
agony
1. Introduce students to tasks 1 and 2 to control the initial level. 2. Distribute tasks with instructions, announce the time for their completion. 3. After solving each task, the teacher offers to check the correctness of its completion.
biological death
Task 1. “Pulse study”
preagony
5.

After the death of the patient, the mattress must be subjected to

II. BLOCK
chamber disinfection
CONTROL OF THE INITIAL LEVEL OF KNOWLEDGE
air ventilation
1. Introduce students to tasks 1 and 2 to control the initial level. 2. Distribute tasks with instructions, announce the time for their completion. 3. After solving each task, the teacher offers to check the correctness of its completion.
beating in the air
Task 1. “Pulse study”
boiling in an alkaline solution
6.

Where should the corpse be located before being sent to the pathology department?

II. BLOCK
in the ward where the patient died
CONTROL OF THE INITIAL LEVEL OF KNOWLEDGE
in the department, in a specially designated place
1. Introduce students to tasks 1 and 2 to control the initial level. 2. Distribute tasks with instructions, announce the time for their completion. 3. After solving each task, the teacher offers to check the correctness of its completion.
after the fact of death has been established, the corpse must be immediately sent to the morgue
7.

Palliative treatment is treatment with the aim of:

II. BLOCK
cure the patient
CONTROL OF THE INITIAL LEVEL OF KNOWLEDGE
lengthen life
1. Introduce students to tasks 1 and 2 to control the initial level. 2. Distribute tasks with instructions, announce the time for their completion. 3. After solving each task, the teacher offers to check the correctness of its completion.
improve quality of life
8.

Which medical personnel have the right to inform relatives about death?

patient?

II. BLOCK
doctor
CONTROL OF THE INITIAL LEVEL OF KNOWLEDGE
head nurse
1. Introduce students to tasks 1 and 2 to control the initial level. 2. Distribute tasks with instructions, announce the time for their completion. 3. After solving each task, the teacher offers to check the correctness of its completion.
nurse
9.

Unfavorable prognosis for the course of the disease received from a doctor, views

patient for life

II. BLOCK
doesn't change
CONTROL OF THE INITIAL LEVEL OF KNOWLEDGE
changes
1. Introduce students to tasks 1 and 2 to control the initial level. 2. Distribute tasks with instructions, announce the time for their completion. 3. After solving each task, the teacher offers to check the correctness of its completion.
remain unchanged
10.

Hospice is:

II. BLOCK
death house
CONTROL OF THE INITIAL LEVEL OF KNOWLEDGE
care home
1. Introduce students to tasks 1 and 2 to control the initial level. 2. Distribute tasks with instructions, announce the time for their completion. 3. After solving each task, the teacher offers to check the correctness of its completion.
life extension house
35
11.

Terminal state includes:

II. BLOCK
Stage 1
CONTROL OF THE INITIAL LEVEL OF KNOWLEDGE
2 stages
1. Introduce students to tasks 1 and 2 to control the initial level. 2. Distribute tasks with instructions, announce the time for their completion. 3. After solving each task, the teacher offers to check the correctness of its completion.
3 stages
Task 1. “Pulse study”
4 stages
12.

A terminal pause is a short-term:

II. BLOCK
respiratory arrest
CONTROL OF THE INITIAL LEVEL OF KNOWLEDGE
loss of consciousness
1. Introduce students to tasks 1 and 2 to control the initial level. 2. Distribute tasks with instructions, announce the time for their completion. 3. After solving each task, the teacher offers to check the correctness of its completion.
cardiac arrest
13.

There are 5 stages of emotional grief. Name them:

1.
______________________
2.
______________________
3.
______________________
4.
______________________
5.
______________________
14.

Before being sent to the pathology department, the corpse must be in

department within ______ hours until reliable signs of death appear.

Name them:

1.
______________________
2.
______________________
3.
______________________
4.
______________________
15.

Name the phases of the terminal state in the order they appear

1.

2.
_____________________________
3.
_____________________________
16. Instructions:
Fill out the table by entering the required characteristics from the list provided.
“Signs of clinical and biological death”

Signs of clinical death

Signs of biological death

4.
Lack of consciousness, appearance of cadaveric spots, lack of pulse, clouding of the cornea, rigor mortis, lack of breathing, decrease in body temperature to ambient temperature, lack of pupillary reaction to light.
36
VI. BLOCK OF STANDARD ANSWERS

TICKET

ANSWER

TASK

ORIGINAL

LEVEL

KNOWLEDGE

"Pulse Study"

In our clinics, a dying person receives medical care, but psychological care leaves much to be desired. And the worst thing is that dying became lonely. No one knows, and sometimes does not want to know, what horror a person experiences when standing on the edge of an abyss, knowing that there is no way back, and in the depths of his soul that last weak light of hope is extinguished.
write the names of the arteries where the pulse is examined
E

TICKET

ANSWER

TASK

CONTROL

ORIGINAL

LEVEL

1.
IN
2.
A
3.
apnea
4.
bradycardia
5.
tachycardia
6.
G
7.
A
8.
A
9.
A
10.
B
Evaluation criteria

"5"
0-1 errors
"4"
2 errors
"3"
3-4 errors
"2"
more than 5 errors
Temporal artery

Dorsal artery. feet

Popliteal artery

Radial artery

Carotid artery

Posterior tibia ar.

Femoral artery

Plechev

artery

37
6.2 E

COUPONS

ANSWERS

SITUATIONAL

TASKS

Problem 1
The nurse must work according to the rules for working with biological material and treat it as potentially infected with AIDS. To avoid contact with body fluids and to prevent infection, wear gloves and an apron.
What are your next tactics?
Liquid bloody stools are disinfected by covering them with disinfectants in the following ratio: 1 g. dry preparation per 5 g. discharge - 1:5. The probe must be removed. Wounds with discharge should be covered with a clean, waterproof diaper and securely secured with wide adhesive tape to prevent leakage.
Patient V. categorically refuses to lie down on the offered bed, since, according to the neighbors in the ward, another patient died on it yesterday. What should be the nurse's next strategy?
The nurse can offer Patient B a place in another room or on another bed. Conduct a conversation with all patients in this ward, explaining that after each patient, mattresses are disinfected in the disinfection chamber, and the bed itself is wiped down with disinfectants. Therefore, the mattress on which the deceased lay is now being processed and the bedding has been replaced with other (clean) ones.
At your post in the department 15 minutes. ago, the doctor recorded biological death in patient M. What are your further tactics?
It is important to answer questions calmly to avoid misunderstanding and fear.
The neighbors in the ward of a dying patient approached the nurse with a request to help him. The nurse told them that nothing would help the patient and she was not going to waste time on him.
1. Shut off the IV and don’t touch anything else. 2. Without disturbing the sleep of the roommates, quietly call a doctor (to confirm death). 3. Separate the deceased with a screen. 4. When waking up your roommates, if possible, ask them to leave. 5. After the doctor has confirmed the fact of death, take measures to care for the corpse, transport the corpse to the office premises for 2 hours.
38 6. Fill out the required documentation. 7. Provide the doctor with a telephone number from the medical history to inform relatives about death.

Determine the nurse's further tactics and actions?
The right to inform relatives about death must be granted to the doctor. The nurse may tell the family that the patient's condition was of concern to the doctors and he was transferred to the intensive care unit. They should obtain further information from their attending physician or by calling the intensive care physician.
You are a guard nurse on a therapeutic department. One of your patients was transferred to the intensive care unit during the day due to a sharp deterioration in his condition. You already know that the patient could not be saved and he died. Relatives call the post and inquire about the patient’s condition.
According to objective data, biological death has already occurred (in a dream). You need to call and get an ambulance to confirm the fact of death. The father needs to be seated, given a sedative and remain there until the ambulance arrives. Before the ambulance arrives, find out the phone numbers of your closest relatives.
A visually impaired (practically blind) neighbor came to your house with a request to see what was wrong with his son, who had gone to rest during the day, had been sleeping for 4 hours, and when trying to wake him up, did not answer his father. Upon examination objectively:

1.
Find out your (m/s) feelings towards death, because... personal hostility and fear can be transferred to the dying person.
2.
Ask the patient to describe on paper his feelings, concerns, and fears. This promotes psychological processing of these emotions. It is important to sit by the patient’s bed (his feeling of abandonment decreases); listen carefully and empathize with the patient’s feelings (reduces feelings of isolation, promotes relationship building); support your hand, touch your shoulder (physical touch brings a feeling of comfort to some patients and demonstrates care for them).
3.
Inform the patient. Encourage questions that he is willing to ask (the right information can reduce anxiety and clarify the situation).
Assess the situation and decide on further actions.
However, if the patient has a pronounced denial reaction and does not want to know about death, then you cannot talk about it, it would be a mistake.
Provide psychological support to a patient in the “denial” stage.
1. Explain to the remaining parent the physical and emotional reactions the child is exhibiting and emphasize that these are normal in a bereavement situation for children. 2. Recommend books and brochures on these topics. This will help you consider the situation intelligently. Reading these books with your child can be a conversation starter. 3. Encourage the remaining parent to help the boy draw, write about a topic related to their loss, and talk about it with people they trust. 4. Encourage the remaining parent to take care of their financial, emotional and social needs. In this case, it is easier for them to respond to the needs of their children.
39
6.3 E

TICKET

ANSWER

TOTAL

LESSON No. 43.

Resuscitation - revitalization of the body - is aimed at restoring vital functions, primarily breathing and blood circulation, providing tissues with a sufficient amount of oxygen.

Resuscitation tasks:

Fighting hypoxia (Hypoxia - oxygen starvation of tissues)

Stimulation of fading body functions

Breathing problems can be caused by a number of factors:

- blockage of the airways by a foreign body (airway obstruction)

- toxic irritating substances

- damage to the chest or lungs

- drowning

- electrical injury

- some medications (narcotics - morphine)

- anaphylactic and other types of shock

Resuscitation begins and is carried out in the case when there is no breathing and cardiac activity has stopped or both functions are so depressed that in practice both breathing and blood circulation do not meet the body’s needs, primarily for oxygen (hypoxia), i.e. upon the onset of a terminal condition.

Air access. Achieved if left hand place under the neck in complication of supination, right on the forehead. You should straighten your head with a fairly strong movement. At the same time, the neck is extended, the tongue rises and moves away from the back wall of the pharynx, thus eliminating the obstacle to the air. Using fingers or suction, remove all foreign objects from the mouth and throat.

Restoring breathing.

When performing artificial respiration using the mouth-to-mouth method, you need to tilt the patient's head back as much as possible, placing your hand under his neck. Then the patient’s nostrils are compressed with the thumb and index finger of the other hand. They open their mouth wide and, taking a deep breath, firmly press their mouth to the patient’s mouth and inhale air into it.

Remember! Ventilation is effective if you can see the rise and fall of the chest; feel the resistance of the lungs as they expand; hear the sounds of air when exhaling.

Restoring blood circulation. It is carried out by closed (indirect) heart massage. Contraindications to closed cardiac massage: penetrating chest wounds; massive air embolism; pneumothorax, cardiac tamponade.

T e x h n i c a m a s s a g a . The most comfortable position for the patient is lying on his back, on a rigid base (floor, table, ground, etc.). The medical worker should be on the left side, kneeling or standing if the patient is on a trestle bed or table.

The patient's belt and shirt collar are unbuttoned, and the tie is removed.

The palm of the right hand is placed on the lower third of the sternum, perpendicular to its axis. The base of the hand should be 1.5-2.5 cm above the xiphoid process. The palm of the left hand is placed on the back surface of the right at an angle of 90. The base of the left hand should be perpendicular to the base of the right hand. Bring both hands and fingers to the position of maximum extension.

The push with both hands should be sharp (using body weight), ensuring a displacement of the sternum by 3-4 cm, and with a width of the chest - by 5-6 cm.

After the push, the chest should straighten, while keeping your hands on, but not preventing its straightening.

Cardiac massage should be combined with artificial ventilation. The hand push is performed while the patient exhales.

Remember! External cardiac massage is effective if with each pressure a pulse appears in the carotid artery; With each pressure, new types of electrocardiographic artifacts appear. The patient's pupils react to light by constriction.

Indirect cardiac massage is performed at a speed of 60 shocks per minute, at the end of every 5th impulse - 1 breath (5:1). This is when cardiac massage is performed by two rescuers.

If one person performs a cardiac massage, then at the end of the 15th push there are 2 breaths (15:2).

If there are no signs of the effectiveness of resuscitation measures after 30 minutes from the start of their use, one can assume the presence of severe brain damage and doubt the advisability of further resuscitation.

Biological death. This is an irreversible cessation of the body's vital functions, occurring after clinical death.

The fact of the patient's death is confirmed only by the doctor. He records the day, hour and minutes of its onset in the medical history.

Signs of biological death:

1) absence of heartbeat, pulse, breathing, pupil reaction to light;

2) clouding and drying of the cornea of the eyes;

3) when the eye is compressed, the pupil is deformed and resembles a narrowed cat’s eye (the “cat’s eye” symptom);

4) coldness of the body and the appearance of cadaveric spots;

5) rigor mortis.

This undeniable sign of death occurs 2-4 hours after death.

LOSSES. DEATH. Grief.

WORKPLACE EQUIPMENT

Universal dummy

Gloves

Dez. Means

Death certificate

Disease history

Gauze and gauze napkins

Pen or crayon

Sheets

Recumbent wheelchair

emotional stages of grief

Before we talk about helping patients with losses, we should, apparently, decide what we mean when we talk about losses. What is behind this concept of “loss”? This could be the loss of a job, the loss of a limb as a result of amputation, the loss of the ability to move independently as a result of illness, the loss of independence, vision, the loss of a large sum of money, the loss of sexual functions, or the loss of a child of one of the parents as a result of divorce, and impending death, and ultimately the loss of life itself. Moreover, when we talk about the loss of life, we mean both the one who left us, having lost his life, and those who experience loss due to the passing of a loved one. Life is a series of losses.

Nurses often have to deal with patients who are experiencing loss. A person’s natural reaction to loss is a feeling of grief, mourning. If the patient and family do not grieve the loss, they may experience a variety of emotional, mental and social problems. The feeling of grief and grief helps a person adapt to loss.

A healthy person is rarely occupied with the thought of death, and this is probably natural for people busy with everyday worries. Medical personnel, who more often than others face losses, including death, often not only take a “professional” approach to these events, but also try to protect themselves from its impact, becoming tougher and more withdrawn. Of course, such “professional” qualities cannot help to fully understand the severity of the loss and organize adequate care for patients. Only a deep understanding of all the processes occurring in the human body in connection with loss, the desire to understand the patient himself, the whole gamut of psychological, spiritual, social and, of course, physical suffering that he experiences until the last second of life, will help nursing staff care and take really professional care.

Each person reacts to loss differently. But, nevertheless, there is a group of certain reactions to loss.

In 1969, one of the founders of the Death Awareness movement, Dr. Elizabeth Kubler-Ross (USA), identified 5 emotional stages that a person goes through when receiving news of a loss (death). The time that each person needs to go through the 5 stages is purely individual. Moreover, often a person can move from one stage to another, both forward and return to an already passed stage. Psychological shock, especially if the loss is sudden, can develop into mental attacks and hysteria. Shock leads to denial reactions (“This can’t be!”)- This is the first stage of emotions. On the other hand, the reaction of denial helps to perceive what happened gradually. But if it becomes intrusive and lasts a long time, the patient may experience certain problems. The denial reaction may interfere with plans for the future, with others, or with prescribed treatment.

As the patient's well-being deteriorates, denial of the possibility of imminent death may be combined with a presentiment of the true situation, and in some cases even with a full awareness of the inevitability of death. Sometimes a person begins by acknowledging the existence of an illness and the possibility of death, and then slips back into a stage of denial, which sustains him until he is ready to accept reality. Sometimes denial leads to a desire to isolate from others. All attempts at consolation are rejected. At the same time, in some patients the denial reaction persists until the last minute of life, accompanied in some cases by unjustified optimism. For some patients, denial leads to severe numbness. This is a rather severe emotional reaction that requires emergency measures.

The following reaction to loss is aggravated reaction of anger, anger, directed both at oneself and at the one who is responsible for what happened. Anger may be directed at family or staff. It makes it difficult to accept care or restrictions associated with the disease. Anyone who has suffered a loss or is angry on the eve of it is indignant. He asks himself: “Why did this happen to me?” He suffers from this thought. He is ready to do anything to regain what was lost or prevent loss. Anger often gives rise to other deeper emotions, such as fear and disappointment. Sometimes, when you communicate, it may seem that the indignation is directed at you, but in fact it is directed at the current situation. Typically, something is holding the patient back and he cannot (or does not want) to take out his anger on family or friends, and so he takes it out on you or other health care workers, even about minor actions.

Trying to "make a deal"“negotiating” with a higher spiritual being is the next, third stage of bereavement. A person promises “Him” to do something if “He” gives him the opportunity to live to a certain date or heals him or his loved one.

In some cases, the feeling of grief associated with the loss may change to depression. But, on the other hand, grief helps the victim get used to it and come to an understanding of its full significance in his life.

A person experiencing depression experiences confusion and despair. In some cases, in such a state of depression, he begins to really feel the proximity of loss, sadness in connection with past problems, resentment over unrealized plans. He really feels the proximity of death. During this period, a person often cries, becomes alienated, and loses interest in the house and in his own appearance. He is only concerned about his own comfort and loved ones. At this time, you need to give the person the opportunity to speak out without trying to encourage him or convince him that he needs to be grateful to fate for the past joys in life. Some men have a particularly difficult time with this period, as they believe that a man has no right to be sad and cry.

And finally, the last stage - acceptance of loss may be considered the most positive reaction because it is accompanied by a greater desire to do everything possible to alleviate the pain of loss. But in some cases, for a survivor of a loss, accepting the hopelessness of the situation leads to only one thing - the desire to rest and sleep. This means saying goodbye to life, realizing the end.

The listed reactions often appear in different sequences and some of them can occur simultaneously. Sometimes humility, the concept of loss, is again replaced by a reaction of denial. The patient makes unrealistic plans for the near or even distant future.

Speaking about the experience of grief associated with the death of a loved one, some researchers of this problem note that the stages of grief do not always follow each other in the sequence that was described. Intense grief associated with the loss of a loved one can last from 6 to 12 months, and the grief that follows can last from 3 to 5 years.

If sudden death, especially of young people, causes severe shock to the relatives and friends of the deceased, then the condition that arises as a result of a long, chronic illness (AIDS, inoperable cancer, spinal cord injuries) is accompanied by a wide variety of suffering, leading to painful death. Severe chronic illnesses lead to personality changes that change a person's views on life and death. Palliative treatment is designed to alleviate such suffering.

The nurse must be able to cope with the deterioration of the patient's health and death, i.e. she, like other members of the palliative care team (doctors, social workers, close relatives and friends, ministers of religion, etc.), must be able to emotionally prepare the patient to accept the inevitable onset of death. The nurse should always create the opportunity for the patient to turn to someone for support, encourage his ability to grieve, as this helps him cope with his feelings. It is very important for a nurse to be able to divert the patient’s attention from the disease and prepare for the dying process to be as easy and unburdensome as possible both for the patient himself and for the relatives and friends around him.

The most important thing that a patient would like to hear during the impending inevitable end is: “No matter what happens, we will not leave you.” Moreover, it should be remembered that communication with him should not be only verbal. Touch (holding the hand, shoulder) and the ability to find contact with the patient for good communication are very important. In order to provide the patient with support, he should be given the opportunity to express his feelings, even if it is a feeling of anger or grief. There is no need to prevent the manifestation of negative emotions. Tact, restraint, attention, sensitivity, empathy, mercy will help the sister win the attention of both the patient and his loved ones.

When communicating with a patient, you should think about your manner of behavior, the place of conversation, even your posture. If the patient is lying down, you should place a chair at the bedside and sit so that the eyes of the nurse and the patient are at the same level. This allows him to hope that the nurse is not in a hurry and has enough time to listen to the patient and talk with him. You should always keep in mind that even if your patient is terminally ill, he himself sometimes does not feel fear and despair until he sees fear and despair about himself in the eyes of others. The patient can guess his diagnosis by your eyes, facial expressions, gestures, i.e. by body language. You should not pretend, cheer up, lie, or avoid direct and honest conversation. The patient will always feel false optimism and will stop talking to his sister about his fears and withdraw into himself. The lack of honesty of medical personnel, including nurses, in the case when the patient wants to know what awaits him, humiliates the patient, forcing him, in turn, to also play a role, to pretend.

Unfortunately, in the vast majority of our medical institutions it is not customary to tell the truth about the diagnosis and prognosis to doomed patients. The principle applies: “White lies.” Supposedly, this lie helps maintain hope. However, false optimism is the destroyer of hope. Moreover, both doctors and nurses act on this principle. This is most likely due to an inability to communicate bad news. At the same time, it is completely ignored that focusing only on the positive in life lets a person down, relaxes and deceives him, and makes him unstable in grief. He cannot cope with the misfortune that has befallen him.

What can you say to a dying person? Who has the right to tell the dying person the truth? And finally, how do you break bad news? These ethical issues are addressed in health care settings such as hospice. In our country, the doctor has the right to inform the patient and his relatives of the diagnosis. The sister, spending more time with the patient and his relatives than the doctor, should be able to discuss with the patient (if he wishes) and his relatives questions that arise in connection with the information received from the doctor. It should be borne in mind that bad news communicated by a doctor will significantly change the patient's view of his own future.

When communicating with the patient, answering his questions about the future, the nurse should take into account the patient’s physical condition, his personality traits, his emotional mood, his worldview, and, finally, his desire to know or not know what awaits him in the future and as it will be. Communication with the patient should be built simultaneously on two principles: on the one hand, never deceive; on the other hand, to avoid soulless frankness. It must be remembered that the combination of truthful information with constant support and encouragement almost always leads to hope. But at the same time, if the patient does not want to perceive his illness as incurable, if he does not want to talk about death, then it would be a mistake to talk to him about it. There are also patients who realize that death is approaching and ask the nurse: “How will it be?” or “When will this be?” the patient has the right to receive this information, since every person has the right to dispose of his last days in my own way.

If you are visiting someone, let it be absolutely clear to him that all the time you have, even 5 minutes, belongs to him undividedly, that in these 5 minutes your thoughts will not be occupied with anything else, that there is no person in the world, more more significant to you than him.

And, besides, know how to be silent. Let the chatter recede and give way to deep, collected silence, full of genuine human concern. Silence is not easy to learn. Sit down, take the patient’s hands and say calmly: “I’m glad to be with you...” and shut up, be with him. He does not need insignificant words and superficial emotions. May your visit be a joy to him. And you will find that at some point people become able to talk seriously and deeply about the little that is worth saying. Something even more amazing will be revealed to you: that you yourself are capable of speaking exactly like that (Surozhsky A., 1995).

This is how Metropolitan Anthony of Sourozh describes it in his book “Life. Disease. Death." the feelings he had to go through after telling his mother that her cancer surgery was unsuccessful: “I remember I came to her and told her that the doctor had called and said that the operation was unsuccessful. We were silent for a while, and then my mother said: “That means I’m going to die.” And I answered: “Yes.” And then we remained together in complete silence, communicating without words. I don't think we thought anything through. We stood in the face of something that came into life and turned everything in it upside down... And it was something final that we had to meet, not yet knowing how it would affect us. We stayed together and were silent for as long as our feelings required. And then life moved on."

It should be remembered that the fear of death is sometimes associated with the fear of the dying process itself, which in cases of a chronic incurable disease is usually accompanied by the appearance or increase of helplessness due to the possible loss of physical abilities or normal functions of the body, a feeling of dependence on others and the associated feeling humiliation. In order to convince the patient and his relatives that their loved one will not be abandoned, but that they will take care of him until the last minutes, it may take a lot of time.

It is important to instill in the patient that no one is going to either hasten death or artificially prolong his life. Some believe that they need to fight for life to the end and do not ask any questions about their approaching death. The patient can monitor the most subtle changes and interpret them as signs of improvement or worsening of his condition. In any case, knowing that he is doomed, one should fight for the quality of life, and not for its duration. In this case, one should agree with the patient’s decisions, such as refusing food and visitors, or, conversely, the desire to see them, the desire to sit or lie in bed. If the patient refuses nursing care related to assistance in ambulation and turning over in bed, to the extent possible, his requests should be complied with. It will be a relief for him if he realizes that it is better to stop this senseless struggle for life and surrender to natural death. At the same time, basic nursing care should be continued, aimed at performing hygienic procedures to ensure cleanliness and prevent pressure ulcers. Use relaxing procedures such as deep breathing, rubbing and massage of the back, limbs, etc.

PRINCIPLES OF PATIENT CARE IN A HOSPICE SETTING

"The ability to live well and well

dying is the same science"

Epicurus

In 1981, the World Medical Association adopted the Declaration of Lisbon, an international set of patient rights, including the human right to die with dignity. But even earlier, in most civilized countries, special medical institutions appeared, and then a social movement to help dying people. In our country, the word “hospice” is still little known.

Hospices are more than just specialized hospitals for the dying. They are in many ways the negation of “just a hospital.” The difference between a hospice and “just a hospital” is not only in the technical equipment, but also in a different philosophy of healing, according to which the hospice patient is provided with the “living space” necessary for his condition. The initial idea of the hospice philosophy is very simple: a dying person needs special help, he can and should be helped to cross this border.

In hospice, personality (the patient's wishes, his emotional reactions) is brought to the fore.

Hospice is such living conditions for the patient, such his way of life, when it is the present, and not the future, that is relevant. It is customary for them to fulfill the last wishes of their patients.

Hospice specialists emphasize that the entire period of the terminal condition in their patients passes against the background of thoughts about death, and this is what gives a special tragic coloring to the severe physical and mental suffering of the dying. This is the psychological reality that a doctor deals with when deciding the dilemma of whether or not to tell the truth to a patient. For many, lies and omissions from doctors and medical staff in such situations become an additional source of suffering, aggravating the state of hopelessness and abandonment.

In hospices, they do not force the truth on anyone about the inevitability of early death, but at the same time they openly discuss this topic with those who are ready, who want it. The choice is given to the patient. The experience of hospice first of all denies the “holy lie” as an inert custom that ignores an individual, personal approach.

The practice of hospice in general has made serious adjustments to values. guidelines for professional medical ethics. The immorality, hopelessness, and inhumanity of depriving all doomed patients of information about what awaits them was first ethically meaningful in hospices, and then the patient’s right to information has become a universal value of modern professional ethics doctors.

Relieving pain is a matter of paramount importance. Chronic pain changes a person’s worldview and worldview. It can “poison” the patient’s relationship with all the people around him. Pain can displace moral needs and moral motivation for behavior.

But it was the experience of hospice that best demonstrated that pain, as a rule, can be brought under control in the most severe patients.

The formation of medical and social principles of hospice activity (1958-1965) is, first of all, the creation of a methodology for an integrated approach to the treatment and prevention of pain, that is, the use for this purpose, in addition to various painkillers, also psychotropic drugs, anticancer chemotherapy and etc.

Putting pain under control is the first, but not the only function of hospices, in which medical personnel strive to take into account other specific needs of a dying person, tireless monitoring of patients, competent assessment of various symptoms (shortness of breath, lack of appetite, bedsores) - all these are mandatory attributes of professionalism doctors, nurses, medical psychologists in hospices. The ability to provide physical comfort to a doomed patient, when many of his functions suffer, depends to a large extent on the technical equipment of hospices with modern functional beds, anti-decubitus mattresses, baths that change the angle of inclination using a control system, and so on.

Concern for the patient’s physical comfort in a hospice is organically combined with concern for his psychological comfort. The patient should feel from the first meeting with the medical staff that here, in the hospice, he will be safe, that he is in a place where they consider their first responsibility to be caring for him and his loved ones.

Hospice doctors and nurses are palliative care specialists, representing a completely new medical specialty that studies the end-of-life process. The goal of palliative care is the realization of the human right to a dignified death. Palliative care specialists profess the following aesthetic credo: if it is impossible to interrupt, or even slow down the progression of the disease, the patient’s quality of life becomes more important than its duration.

WHO defines palliative care as active, holistic care for patients whose illnesses cannot be cured. Control of pain and other symptoms, as well as help for psychological, social and spiritual problems, are of primary importance. This is an achievement best care, as well as life for the patient and his family.

If it is impossible to heal the patient, then we must try to alleviate the fate of the unhealed. He continues to live and needs a dignified death.

A special relationship develops in hospice between a doctor and a nurse. This is a job of equals. The role of a nurse is not limited to dispensing medications or administering injections. She sees the patient every day, makes decisions extreme situations when the doctor may not be around.

In Russia, a set of patient rights was first formulated only in 1993, but the right to a dignified death is not even mentioned there. And, nevertheless, the first hospice in our country appeared in 1990 in St. Petersburg.

There are similar institutions in Moscow and many other cities of Russia.

The basic principles of the hospice movement are as follows:

There is no price to pay for death

Hospice is a house of life, not death,

Death, like birth, is a natural process, it cannot be rushed or slowed down,

Hospice is a system of comprehensive medical, psychological and social care for the patient,

Hospice is not walls, but people, compassionate, loving and caring.

The patient’s wishes must be treated carefully, remembering the custom that has developed among people to fulfill the “last wish” of a dying person, whatever it may be. Its implementation is mandatory in medical institutions such as hospice, which are special medical and social services that provide qualified care to the hopelessly ill and dying. Moreover, desires are fulfilled that most likely could not be fulfilled if the patient were in a regular hospital, for example, to keep his favorite cat or dog near him, i.e. Only in a hospice is the patient’s personality (his wishes, emotional reactions) placed in the foreground. It was this attitude that allowed the doomed Jane Zorza, dying of cancer at the age of 25, to say: “This hospice is the best place in the world".

There are still very few hospices in Russia, while the hospice movement in the world has been around for more than a quarter of a century. And, as the creator of the first modern hospice (in 1967 in England) S. Saunders emphasizes: “...nursing care remains the cornerstone in the care of a hospice for the dying.” A new philosophy, a new worldview, and the provision of medical and technical assistance to dying people, who, as a rule, suffer from severe pain and increasing deterioration in the function of vital organs, allow hospice staff to ensure an acceptable quality of life, and therefore death with dignity.

A Latin saying says that the most certain thing in life is death, and the most uncertain thing is its hour. Therefore, on the one hand, a person must always be prepared for death, but on the other hand, death is perceived by him as something that can happen to anyone, but not to him. In hospice, patients live in the present day and are focused on the events of a specific day. Hospice is not a House of Death, it is a House of Life. A home where pain is relieved.

Death is usually a frightening, scary event. Many reasons prevent us from facing death calmly. But at the same time in developed countries A large amount of factual material has been accumulated about death and dying. Organizations have been created that unite the efforts of medical workers, priests, philosophers, and writers to provide assistance to hopeless patients.

Tests

The fact of P.’s death is stated:

c) paramedic

The fact of death is recorded in:

b) appointment books

c) duty handover log

Time of death ascertainment: M/s actions:

a) immediately A) take the corpse to the pathological department

b) after 2 hours separation

B) ties up the lower jaw, lowers the eyelids

C) undresses, lays him on his back, covers him

sheets

D) makes a note on the hip

Immediately after declaring death in a hospital, the m/s must:

a) make an inscription on the thigh of the corpse

b) undress, lay on your back, cover with a sheet

c) take him to the pathology department

After death is confirmed, the corpse is left in the department for:

a) 0.5 hours

at 5:00

Before being sent to the pathology department, the m/s writes on the thigh of the corpse:

a) Full name, no.

b) No. and/b, department

c) date of death, full name

Valuables taken from the deceased are given to relatives against receipt:

The following are subject to autopsy:

a) only with an unclear diagnosis

b) only young people

A mattress, pillow, blanket, linen after the death of a person is sent to:

a) in the wash

b) in des. camera

c) for washing - linen, for disinfection. camera - everything else

How to treat the bed and bedside table of the deceased:

a) furacillin solution

b) 96 degree alcohol

c) 3% chloramine solution

How many certificates are filled out for the deceased:

What is the first stage of grief called:

a) denial reaction

b) depression

c) acceptance of loss

In what year was the first modern hospice opened?

14. At what speed is indirect cardiac massage performed:

a) 40 pushes per minute

b) 60 shocks per minute

c) 50 shocks per minute

How many hours does it take for rigor mortis to set in?

a) 2-4 hours

b) 1-2 hours

c) 3-5 hours

Duration of clinical death:

3. aBV, bAG 11. b

LESSON No. 43.

LESSON TOPIC: Loss, death and grief.

KNOW:

1. Emotional stages of grief.

2. The concept and principles of palliative care.

3. The role of nursing staff in palliative care.

4. Principles of patient care in a hospice setting.

5. The role of the nurse in meeting the needs of the doomed patient.

6. Sisterly assistance to the family of the doomed.

7. The concept of “pain”, types of pain. Factors influencing the sensation of pain. Addressing the nursing process for pain.

8. Stages of terminal condition and their clinical manifestations.

Be able to:

1. Assess the reaction of family and loved ones to losses and their ability to adapt to them.

2. Provide nursing assistance to a family experiencing loss.

3. Assess the intensity of pain.

4. Provide nursing interventions to reduce pain.

5. Carry out the nursing process when providing palliative care using the example of a clinical situation.

6. Prepare the body of the deceased for transfer to the pathology department.

Work out:

1. Technique for ascertaining death and handling a corpse.

Name of lesson element	Time in minutes.
1.Checking those present at the practical lesson, their readiness for the lesson and an explanation of the procedure for conducting the lesson. 2. Record in diaries on the educational practice of the topic of the lesson, write down - know, be able to, work out. 3. Questioning students using tests 4. Explanation

new topic