1 define the concepts of loss, death, grief. Stages of grief experienced by relatives of the deceased. Ministry of Education and Science of the Russian Federation

1. 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.

2. Pain, experienced due to the absence of a deceased person.

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

4. 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.

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. 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.

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::

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

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

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.

PALLIATIVE CARE

According to WHO definition: “Palliative care is an activity aimed at improving the quality of life of patients with a terminal illness and their loved ones by preventing and alleviating suffering through early detection, careful assessment and management of pain and other physical, psychological, social and spiritual suffering.”

Accompanying the patient and his family begins from the moment of diagnosis and often does not end with the end of his earthly life, but switches to his closest relative, who has suffered a bereavement and often needs not only psychological and spiritual support, but also medical care.

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 conditions of the brain, 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:

1) respect the patient’s autonomy (respect the patient as an individual);

2) do good;

3) do no harm;

4) act fairly (impartially);

5) 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. 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 Russia, the first hospice was created in 1990. In St. Petersburg, thanks to the initiative of V. Zorza, a former journalist, whose only daughter died of cancer in one of the English hospices in the mid-1970s.

Order No. 19 of the Ministry of Health of the Russian Federation dated December 1, 1991 d “On the organization of nursing homes of multidisciplinary and specialized hospitals” is basic document to decide whether to open a palliative care unit or hospice.

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 the nurse trained in palliative care.

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

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

4) death, like birth - 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 assistance sick;

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

7) hospice is a humanistic worldview.

Patient care. When planning and implementing hospice care, the emphasis is on addressing the present and potential problems patient. 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.

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

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. Involving close relatives in feeding, if necessary.
In drinking	Security sufficient quantity liquids. If necessary, administer fluids as prescribed by a doctor intravenously.
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
In sleep and rest	Providing the most comfortable conditions for the patient’s sleep and rest (silence, dim lighting, fresh air flow, comfortable bed). Ensuring that you take sleeping pills as prescribed by your doctor
In maintaining body temperature	Providing physical and mental peace. Measuring the patient's body temperature. Patient care depending on the period of fever
In move	Providing the patient with a rational regime of physical activity (turning, sitting up in bed, carrying out simple physical therapy, etc.)
In dressing and undressing	Help with dressing and undressing
Avoiding danger	Assessing the patient's reaction to 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

Suicidal symptoms of the MMPI profile

Based on all of the above, we highlight MMPI profile features, especially alarming in relation to suicidal readiness.

High values on the correction scale (K);

Peak profile on scale 4 - antisocial psychopathy (Pd);

The leading peak of the profile on a scale of 8 is schizophrenia (Sc);

Any combination of peaks on scales 2 (depression), 4 (antisocial psychopathy), 8 (schizophrenia) and 9 (hypomanic).

The reliability and accuracy of suicide risk assessment using the MMPI increases with repeated follow-up studies. For example, if the first study reveals a peak on scale 2 (depression) and a decrease in the profile on scale 9 (hypomania), then in the absence of other peaks, such a picture, despite the presence of depressive experiences, does not indicate a high suicidal risk. Even if there are suicidal intentions, the subject’s motor potential is reduced and during the study period he simply does not have the strength to commit suicidal actions. If, in subsequent studies, an increase in values on scale 9 is noted, then this indicates an increase in the likelihood of committing suicide, even if the peak on scale 2 decreases. The increase in suicidal risk is due to the fact that the subject becomes more active, actuators are activated, as a result of which he can commit a previously planned suicide.

American psychiatrist J. Moltsberger proposed a clinical method for assessing suicidal risk, which he called “Methodology for determining the risk of suicide”. This methodology takes into account the following aspects:

Valid biographical material;

Information about the patient’s disease (disorder);

Assessing the patient's current mental state.

The Moltsberger method for determining suicide risk includes five factors:

1) assessment of the patient’s previous reactions to stress, especially to losses;

2) assessment of the patient’s vulnerability to three life-threatening affects:

Loneliness

Self-contempt

Morbid hatred;

3) assessment of the availability and nature of external support resources;

4) assessment of the occurrence and emotional significance of fantasies about death;

5) assessing the patient’s ability to test his judgments with reality.

Let's consider each of the factors in more detail.

Particular attention is paid to significant and critical life events and periods:

Start of school

Adolescence,

Disappointments in love, work or school,

Family conflicts,

Death of relatives, friends, children or pets,

Divorce and other psychosocial trauma and loss.

An attempt should be made to discover the consistency of suicidal behavior with the general style of behavior throughout life. People tend to overcome future difficulties in the same ways as in the past.

Of particular interest are past suicide attempts, their cause, purpose and severity. In addition, it is necessary to determine who or what is the patient's support during difficult times.

Next, one should find out whether the patient has a history of depression and whether he has a tendency to lose hope when faced with difficulties, in other words, whether he is prone to manifesting despair. Suicide and serious suicide attempts are much more strongly correlated with despair than with depression.

Plan:

2. Hospice.

3. Psychology of the problem of death.

5. Stages of mourning.

8. Pain, pain assessment.

9. Dying.

10.

Peculiarities psychological communication between patient and medical staff

Enough for now a large number of patients have an incurable or terminal stage of the disease, therefore it becomes topical issue on providing such patients with appropriate assistance, 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 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 address 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 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

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 nurse with higher education and a 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. 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 basic principles of hospice activities can be formulated as follows:

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) 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 become of great importance. 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. The foundation of 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 process of life intensifies.

4. The significance of elementary life events intensifies (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 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.

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 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 mild 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 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;

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 nerve structures(nerve trunks and plexuses), 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 change, 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 of medical personnel.

State Budgetary Educational institution Higher Vocational Education Moscow State Medical and Dental University named after A.I. Evdokimova

Department of Disaster Medicine and Life Safety

on the topic: "Loss. Death. Grief."

Completed by: 2nd year FSF student

Kocharyan Hakob

Teacher: Yakimchuk V.I.

Moscow 2014

Plan

Introduction

Introduction

Sadness and worries -this is a specific behavior that appears after loss significant person, someone close or dear, and also after the loss of any organ or part of the body. They disappear after the person comes to terms with the loss.

Grief is an emotional response to loss or separation that occurs in several phases.

Mourning -These are rituals and traditions that help a person cope with grief.

Emotional state of a dying person

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 he receives news of an expected death or loss. The time a person needs to go through these stages is purely individual. Often a person can move from one stage to the second, both moving forward and returning to the previous stage. The shock that arises can turn into mental attacks and hysteria. Shock leads to a reaction of denial. It's there first stage of emotions.It helps you gradually perceive what happened.

As the patient's well-being deteriorates, denial of the possibility of imminent death may be combined with apprehension of the present situation, and in some cases with a full awareness of imminent death. Sometimes a person begins by admitting the presence of an illness and the certainty of death, and then returns to the stage of denial. In some patients, the denial reaction persists until the last minute of life, accompanied by unjustified optimism; in some patients, denial leads to severe numbness.

The reaction to loss is reaction of anger, rage,which is directed both at oneself and at the one who is responsible for what may happen. Anger may be directed at family or staff.

In the 3rd stagethe patient makes attempts to conclude agreements, negotiate with God. The man promises to do something to him if he gives him the opportunity to live to a certain time. In some cases, the feeling of grief can turn into depression,but on the other hand, grief itself helps the victim get used to the loss or death. A person experiencing depression feels confused and hopeless. And at this time it is necessary to give the person the opportunity to speak out, trying to encourage him, or convince him that he should thank fate for the past joy in life.

Accepting losscan be considered as positive reaction, because it is accompanied by a great desire to do everything possible to alleviate the pain of loss. The intense grief associated with the loss of a loved one lasts from 6 to 12 months, and the grief that comes afterwards can last from 3 to 5 years. The unexpected death of young people causes a strong shock to the friends and relatives of the deceased, and the condition that arises as a result of a chronic illness, AIDS, cancer, spinal cord injuries is accompanied by various sufferings that lead to painful death. Severe chronic illnesses lead to personality changes that alter a person's views on life and death. And it is possible to alleviate suffering with the help of palliative treatment.

Principles of palliative care

This treatment begins when all other treatments are no longer effective.

The purpose of treatment iscreating the opportunity for a better quality of life for the patient and his family.

In palliative care, the primary goal is not to continue living, but to make life more comfortable and meaningful. This treatment will be effective:

.If it was possible to create a comfortable and safe environment for the patient.

2.If the patient feels his independence.

.If the patient does not feel pain.

.If psychological, social and spiritual problems are expressed in such a way that the patient comes to terms with his death as much as possible.

.If, despite impending death, the support system provided to the patient helps him live actively and creatively until death.

.If the efforts to help the patient in his grief and in overcoming it are not in vain.

.If we can help the patient and his loved ones prepare for death.

Rendering psychological assistance dying man

The nurse must cope with the patient's deteriorating health status. She must be able to emotionally prepare the patient for the inevitable onset of death. The nurse should always create an opportunity for the patient to turn to someone for support and encourage his ability to grieve, as this helps him cope with his feelings. The most important thing that the patient would like to hear during the inevitable is the words “No matter what happens, we will not leave you” and this communication should not only be verbal, touch and the ability to find contact with the patient are very important.

It is necessary to give him the opportunity to express his feelings. There is no need to prevent the manifestation of negative emotions. It is always necessary to take into account that even if your patient is terminally ill, he should never see fear in your eyes or the eyes of others. The patient can guess his diagnosis by your eyes, facial expressions, gestures and body language. You should not pretend to be cheerful, lie, or avoid direct and honest conversation.

When communicating with a patient, answering his question regarding the future, death, it is necessary to take into account physical state the patient and the characteristics of his personality, his emotional state of mind, his worldview and his desire to know or not know what awaits him in the future.

psychological help dying grief

Communication with a patient should be based on two principles: on the one hand, never deceive him, and on the other, avoid soulless frankness. The Latin expression says that: “The most important thing in life is death, and the most insignificant thing is its time.” On the one hand, a person must always be ready for death, but on the other hand, death is perceived by a person as something that can happen to anyone, but not to him.

Death of a loved one. How to cope with the loss of a loved one

During his life, a person constantly gains something and loses something, this is the law. IN eastern countries birth and death are treated as traditions. This is facilitated by the idea of reincarnation - the idea of the cycle of birth and death, constant reincarnation. Many studies show that dying people are not necessarily depressed; they are often the most cheerful people, with a great sense of humor. Their life and sensations are maximally compressed, concentrated, they are able to enjoy every moment of life.

In the event of news of death, people experience a feeling of pre-loss, preliminary grief. After a loss has occurred, the psyche must cope with it. The process of these changes is called bereavement or grief. The loss response is complete when the person is able to function adaptively, feel safe, and have a sense of identity without what they have lost.

Stages of experiencing the reaction of loss:

· The reaction of inevitability.Or maybe he didn't die.

· Despair.No , still died.

· Anger.For example: How could he/she leave me?

· Humility.

· Search for new meaningful relationships.Thoughts that you need to change something in your life.

· Regret.

· Creating new connections and relationships.The functions that the deceased person performed are taken over by other people.

· Saying goodbye to this person.

The reaction of loss occurs at its own speed; this process cannot be accelerated. The grief process can normally last from two months to two years. The grief of parents who have lost children can last 4-5 years.

Physical manifestations of the reaction of loss:

· Emotional shock, even if it is an expected death.

· Intestinal disorders: nausea, stomach pain, feelings of tension, compression, flatulence.

· Tension in the neck, spine, throat.

· Increased sensitivity to noise.

· A feeling of unreality of what is happening.

· Lack of air, suffocation, desire to breathe frequently, accompanied by fear of suffocation (hyperventilation).

· Muscle weakness, lack of energy, general weakness.

· Dry mouth.

· Headache, heart pain, increased blood pressure, tachycardia.

·Sleep disturbance.

· Loss of appetite (refusing food or overeating).

· Other physical manifestations.

Such symptoms may last for two to three weeks.

Emotional manifestations of the reaction of loss:

·Sadness, tears

· Motor reactions

· Irritation, anger, auto-aggression (that is, aggression towards oneself)

· Aggression in particular can be expressed in accusations of doctors, relatives, funeral directors and other people.

· Feelings of guilt and self-blame.

· Experience of loneliness, especially if communication was frequent.

· Feelings like the world has collapsed. To the point of refusing to leave the house.

· Feeling helpless.

·Yearning.

· Fatigue and tiredness, apathy or numbness.

· Shock. Numbness in the shock phase.

· If feelings for the lost person were contradictory (ambivalent), then there may be a feeling of liberation.

Intellectual disabilities:

· Thoughts are scattered.

· He doesn’t believe what happened, it’s just a dream.

· Confusion of thoughts and forgetfulness.

· Intrusive thoughts in my head. For example, about the circumstances of death, about what could be changed or somehow returned.

· Feeling the presence of the deceased.

· The person thinks that he sees the deceased, hallucinations.

·Dreams about the deceased.

Changes in behavior:

· Unaccountable actions. For example, he automatically bought what the deceased liked to eat.

· Social avoidance soon after loss. This normal reaction even for people leading an active lifestyle. But if this does not go away for several months, then we can talk about depression.

· Protecting the belongings of the deceased. When a person withdraws internally, he avoids these things.

· Avoiding anything that reminds you of the deceased.

· Search and call to the deceased.

· Tireless activity, a person does something and cannot stop.

· Frequent visits to memorable places, taking care of the grave.

· The loss of a loved one, death resembles the process of separation, that is, separation from parents. But unlike separation, loss usually occurs suddenly, when a person is not ready for it, he does not have enough resources to cope with it easily.

During the grieving process, a person must solve 4 problems:

1. Acknowledgment of loss. The realization that the person is gone and will never be there again. The reaction of loss denial can reach severe psychotic forms. An example of negation: mummification - the room and things are preserved in the same form as they were with the deceased. Or the person may deny the significance of what happened. For example: We weren't that close. He wasn't a very good father. I don't miss him. Another form of denial: this is the denial of the irreversibility of what happened. For example, people turn to fortune tellers and spiritualists to reunite with a deceased relative or spouse after a divorce. People who are prone to denial constitute a risk group for the development of pathological reactions such as depression.

Feel and live the pain of loss. If a person escapes from this pain, then his behavior may be inappropriate. Also, an unreacted, unexperienced loss can be expressed in various psychosomatic and somatic reactions, such as back pain (sciatica), osteochondrosis. If a person denies this pain, painful thoughts, he may strive to immerse himself in work, travel, and fall into euphoria. For example, after the death of her mother, a daughter was sent on a trip to regain her strength and mood. The girl did not have the opportunity to grieve among loved ones or ask anything. As a result, after some time she developed severe depression.

Life changes in a new way, is rearranged, especially in those aspects where the absence of the deceased is felt. What will a person do with his time now? What will make up for a person what he has lost? New relationships begin to be built, useful skills are acquired. If this task is not solved, then the person remains helpless. This can be beneficial for a family that does not want to disturb the usual balance (homeostasis). Thus, the Milan group of family therapists describes a case where, after the death of his grandfather, the behavior of a teenage boy became autistic, that is, he closed in on himself. As an elderly man, he began to sit at home and use archaisms, that is, outdated words, in his speech. Why did the family system need this? Diagnostics showed that the grandfather brought stability to his daughter’s marriage, thereby ensuring the safety of the family.

Removing emotional energy from old relationships and transferring it into new relationships from past relationships. Examples of resistance to solving the second problem: Children resist their mother’s new marriage. A woman's romantic belief that she loves only once in her life.

If there is a feeling of guilt, fixation on past relationships, addiction, then this may interfere with the solution of task 4.

Swiss hypnotherapist Patrick Noyer talked at his training about how people constantly exchange parts of their souls with each other. A person dies or leaves and wants to take with him a piece of the one who remains. Suffering arises from the fact that we have lost part of our soul or it has been stolen from us or we have had it stolen. Therefore, one of the tasks is to return to people those parts of the soul that we took from them, and to return to ourselves what they took from us. In this way, we find ourselves again, we give a sense of freedom to ourselves and those people whom we let go. Then we have the opportunity to interact with new people. We become open to new encounters and experiences. Every day we enter into relationships as if for the first time, pure and renewed, because every day we return to ourselves and give to others what we took from them.

Providing psychological assistance to a person who has suffered a loss

It is not necessary to grieve, cry with him, letting someone else’s suffering pass through him. You will be much more effective in your help if you act rationally and thoughtfully. One way to cope with a loss is to talk about it repeatedly. In this case, strong emotions will be reacted.

You need to listen carefully to the person, answer his questions if necessary. Allowing a person to express his emotions and experiences. It could be tears, anger, irritation, sadness. You don’t give assessments or interpretations, you just listen carefully and are nearby. Tactile contact is possible, that is, you can hug a person, take a hand, or sit a child on your lap.

A person in acute grief cannot be told that you know similar cases, since his grief seems to him unique, inimitable, no one else suffers like him. Later, when the person calms down, you can say that you heard about such and such situations or were a participant in them, but of course this cannot be compared with his grief.

You can say banal phrases about how this is a heavy blow, about your sympathy and regret, and so on.

Only when a person is ready for this and starts a conversation himself, can one begin to talk about new relationships, prospects, and how life will change now.

For the first time after a loss, you may be advised to consult a psychotherapist and take sedatives. It is realistic to do psychotherapy no earlier than two months after the loss.

When talking to a bereaved person, you can ask them, “What do you miss?” He will tell you about the qualities that he valued in communication and which he lacks. Then you can ask him about those qualities that he does not miss. Thus, the image of the lost person gradually becomes balanced, his positive and negative qualities should be in balance.

It is important that a person has the opportunity to talk about death with loved ones, get support, and talk with those who knew the deceased. You can write a letter to this person, telling him how you feel and asking questions. You can compose an answer on his behalf. It is good to conduct such correspondence, expressing your feelings, conducting a dialogue until you feel that the relationship is complete.

A bereaved person often experiences feelings of guilt. Usually this feeling is irrational and has no basis in reality. But even if there is real guilt, you can ask a person whether he could have foreseen this under those circumstances? Most often, people lack the knowledge and competence to foresee everything; this is not realistic.

Almost any problem can be reformulated positively. So, one patient said: “Mom died to let me live.” Only now has she become independent. Practice finding positive aspects in different problems and placing the problem in a positive frame. For example, a cancer patient died. He no longer suffers, he has finally found peace.

You cannot radically change your life immediately after a loss. You need to give yourself time to recover. Emotional recovery is gradual. There is no need for hasty marriages, since the new partner may end up acting as a buffer; he cannot replace the lost person. Such a marriage may collapse, and this will become an additional trauma.

People experiencing loss often become irritable. You need to understand that their anger has nothing to do with you directly, but is most likely associated with a feeling of loss and injustice of what happened. It always takes time for a person to come to terms with a loss.

During the first anniversary of death, feelings may come to life; this is normal and then passes. But if a person is stuck on one of the tasks and has not fully coped with the loss, then the experiences begin to be chronic, recurring and can lead to depression.

Signs of depression:

· Apathy, loss of interest in everything, everything seems in gloomy tones.

· A person lives in the past, constantly returning in his thoughts to memories of communication with the person he lost.

· Disturbed sleep: restless sleep, early awakenings or insomnia.

· Loss of appetite: overeating or lack of appetite.

· Feeling of anxiety, restlessness.

· Feelings of melancholy, hopelessness, discomfort in the chest area, possible thoughts of death.

· If at least three of these criteria are present and the condition lasts more than six months, then a diagnosis of depression is made. Depression needs to be treated with the help of psychotherapists and psychologists.

· When a person is ready, he says goodbye to the one he lost.

Pathological reaction of grief:

Chronic grief reaction -a long-term (prolonged) grief reaction that does not come to an end, lasting several years. The inability to return to normal life, the feeling that everything has stopped.

Delayed grief reaction (suppressed) -at the moment of loss there are feelings, but they are weaker than the significance of what was lost. And in the future there will be a strong reaction to a minor loss.

Exaggerated grief reaction.Instead of an anxious awareness of death, a phobia (intense fear) or panic attack. Behind this lies contradictory (ambivalent) feelings towards the lost person, a feeling of guilt. Here you need to look at what stage in the reaction to loss the person stopped, and go through these stages with him.

Disguised Grief Reactiona person experiences painful experiences, but does not associate them with death or other loss. For example, radiculitis, osteochondrosis, various psychosomatic diseases such as panic attacks, stomach ulcers, diabetes mellitus, heart and thyroid diseases and others. Either the person becomes irritable, aggressive, often begins to get into unpleasant situations, and other types of deviant behavior are repeated.

Signs that may indicate a pathological grief reaction:

1) A person cannot talk about the deceased without showing signs of acute grief, although the loss occurred a long time ago.

) Special events trigger intense feelings and sadness.

) A person often raises the topic of losses or the topic of his lack of rights and lack of power over the circumstances of life.

) Preservation of the deceased’s belongings within reasonable limits. For example, a room or iconostasis made from photographs is saved.

) The appearance of symptoms similar to those the patient had at death.

) A person makes radical changes in life that do not correspond to given circumstances. For example, sudden departure, emigration, abandonment of loved ones, friends, and so on.

) Chronic depression with feelings of guilt and loss of self-esteem.

) Imitation of the deceased, especially if the person has no desire to do this.

) The presence of self-destructive impulses, such as smoking, alcohol, drugs, overeating or refusing to eat, constantly getting into unpleasant situations, minor self-harm that occurs frequently, for example, cutting.

) Inexplicable sadness that occurs at the same time of year.

) Fear of dying from the same disease as this person. For example, cancerophobia, that is, the fear of getting cancer in those whose relatives died of cancer. Fear of death can also be a consequence of early, long-term separation from parents.

) Various fears (phobias), restrictive behavior. For example, a person avoids flying on an airplane, swimming (if someone has drowned), and so on.

) The grieving process lasts more than two years.

If there are two or three criteria from this list, then this may indicate the presence of a pathological grief reaction. This also requires psychotherapy with a doctor - a psychotherapist and a psychologist.

Experiencing grief in the family

Each family member may have different ways of coping with loss. It is important to understand these differences. For example, a wife has lost a child and is waiting for support and consolation from her husband, but at this moment the husband says that he wants to live separately. He experiences severe anxiety, a desire to run away, to withdraw into himself. This is how he experiences grief. His wife says he betrayed her. When, as a result of psychotherapy, she understands that he, like her, grieves for this loss, her attitude towards this case changes, she forgives him.

The family has its own resources to cope with the loss. You can talk about how family members used to cope with losses.

After loss, the family system strives to restore balance. At the same time, the configuration in the family changes. The functions that were previously performed by the deceased are redistributed among other family members.

List of used literature

1.“On Death and Dying”, Elisabeth Kübler-Ross, Sofia Publishing House, 2001.

2.S. Belousov. Psychology of fear of death. - M. 1999

.Tikhonenko V.A. The life meaning of choosing death. - M., 2002

.Humphrey D. Psychology of death. Magazine "Man", - M., 1992

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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 an extension of 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 depression period; 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

Oncopathology is one of the leading problems of modern medicine.

About 60-70% of cancer patients in the generalization phase of the disease suffer from pain in the varying degrees expressiveness. 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 a 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 as much High Quality 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.

Hospice-- a medical institution that provides medical and social assistance that improves the quality of life of doomed people.

The principle of operation of hospices.

· affirms life and views death as a normal process;

· does not speed up or slow down death;

· provides psychological and emotional aspects of nursing;

· 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 relationship to 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 appearance patient, 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.

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.

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.

Literature

1. L.I. Kuleshova, E.V. Pustovetova "Fundamentals of Nursing", Rostov-on-Don: Phoenix, 2011 2. T.P. Obukhovets, O.V. Chernova "Fundamentals of Nursing", Rostov-on-Don: Phoenix, 2011 3. 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, 2007 5. I.V. chYaromich "Nursing", Moscow, ONICS, 2007 6. 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 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

4.Regulatory documents:

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