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My second sandbox

Stages

Elisabeth Kubler Ross, a pioneer in the study of death and dying, identified what she believed to be the five stages of dying. Those that people pass through as a result of a terminal illness in an adjustment to death. They include denial, anger, acceptance, bargaining, depression, and acceptance.

The first stage, denial, is thought to be the patients initial reaction to dying. Denial is used as a defense mechanism for the patient to avoid the implications of their terminal illness. Reactions can include the patient acting as if the illness is not severe, or that may go away quickly. In some extreme cases patients have been reported as denying that they actually have a disease, even after a clear diagnosis. Thus the denial stage is a subconscious way of blocking the full realization of the implications of being diagnosed with a terminal illness.

The third stage is bargaining. The patient has decided in this stage to try another strategy other than anger, and that is trading good behavior for good health. This behavior usually involves some pact with God, and the signs may include the patient acting uncharacteristically pleasant or a overtly charitable.

Following is the fourth stage, depression. At the this stage the patient has realized that they have little to no control on over the progression of their illness. This could come on as a result of worsening symptoms or other evidence that the illness is not being cured. As a result of this realization the patient may feel nauseated or tired, they also may have trouble eating, keeping focused attention, and my constantly feel they cannot escape pain or discomfort. Ross believed that this depression was a result of the patient mourning the aspect of their own death, know as anticipatory grief. The depression often comes in two waves, first the sense of the loss of past relationships and valued activities, and second the realization of the loss of future relationships and activities. Although unpleasant this depression can actually help the patient begin to prepare for the future, and for that reason it may be wise to not intervene on the depression immediately and let it run its course for a short while.

Caregiving

Home care. Many people choose to die at home or in the home of a family member. You can assume the role of caregiver or hire home care services for support. Hospice care — services that help ensure the highest quality of life for whatever time remains — can be provided at home as well. Inpatient care. Some people may prefer round-the-clock care at a nursing home, hospital or dedicated inpatient hospice facility. Hospice and palliative care — a holistic treatment approach intended to ease symptoms, relieve pain, and address spiritual and psychological concerns — can be provided in any of these environments.

Significance to Patient

The physical dependance the patient has on the hospital staff is large, considering the patient may need help with he most simple tasks such as going to the bathroom, brushing their teeth, or even turning over in bed. The hospital staff may also be the only people who know the the patients actual physical state, thus being the patients only source for reliable, unbiased information. Also the staff may be the only people who know the patients true feelings, as they may be cheerful in front of visitors and family in an attempt to not upset them. The medical staff is even of more importance to those patients without friends or family who can visit them regularly, as the staff will be the only people that see the patient regularly. Also, the staff is important emotionally as they are exposed to the most personal and private time of persons life, their process of dying.

Risk to the Staff

Terminal care is very hard on the hospital staff. Being palliative care, it is usually the most uninteresting for the staff. Palliative care is directed at the comfort level of the patient, unlike curative care which is directed at curing the patients disease and therefore palliative care is far less stimulating work for the staff. Terminal care involves a lot of unpleasant work, including feeding, changing, and bathing the patient. The staff is negatively effected emotionally, as they may become burnt out after seeing patient after patient continue to die. This can cause the staff to act more withdrawn in their treatment, more of an efficient style to their care instead of a warm, supportive, and personnel nature to their care.

Dying

Psychological and social issues related to dying include changes in the patients self concept. They may have difficulty maintaining control of their biological functions, including mental regression and the inability to concentrate. Socially the patient may fear that their condition will upset visitors, and they may experience withdrawal from family and friends because they either have a fear of depressing others or a fear of being a burden on others.

Do Not Resuscitate Order

The DNR Order is the belief that people have the right to refuse CPR, life support, or other options that may save their life if their heart or breathing were to stop. It is a way in which people are allowed to die with dignity, and not be left as a vegetable relying on life support machines to keep that individual alive.

Euthanasia or assisted suicide involves the help by a physician in ending the life of the terminally ill patient upon their request. Although most states do not allow euthanasia in 1994 Oregon passed a law permitting physician assisted dying. This was followed by the Supreme Court Decision in 1997 that ruled physician assisted death is not a constitutional right, however it is not a federal matter and therefore should be decided in each state. A living will is a request from a patient that extraordinary life-sustaining procedures not be used if person is unable to make this decision on his/her own. In medicine, a "do not resuscitate" or "DNR" , sometimes called a "No Code", is a legal order written either in the hospital or on a legal form to respect the wishes of a patient to not undergo CPR or advanced cardiac life support (ACLS) if their heart were to stop or they were to stop breathing. The DNR request is usually made by the patient or health care power of attorney and allows the medical teams taking care of them to respect their wishes.

In 1991 Congress passed into law the Patient Self-Determination Act that mandated hospitals honor an individual's decision in their healthcare. Forty-nine states currently permit the next of kin to make medical decisions of incapacitated relatives, the exception being Missouri. Missouri has a Living Will Statute that requires two witnesses to any signed advanced directive that results in a DNR/DNI code status in the hospital.

In the U.S., CPR and advanced cardiac life support (ACLS) will not be performed if a valid written "DNR" order is present. Many US states do not recognize living wills or health care proxies in the prehospital setting and prehospital personnel in those areas may be required to initiate resuscitation measures unless a specific state sponsored form is appropriately filled out and cosigned by a physician.

State laws vary but typically emergency medical services personnel who are presented with a valid DNR form, signed by your doctor, or who identify a standard DNR bracelet on you, must comply with the DNR order.

References

Taylor, Shelley. Health Psychology. 8th. 1. New York City, New York: McGraw-Hill, 2012. 355-356. Print.

Medline Plus http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000473.htm

Palliative Care http://www.palliativedoctors.org/about/index.html

American Hospice Foundation http://www.americanhospice.org/articles-mainmenu-8/working-through-grief-mainmenu-13/80-anticipatory-grief-symptoms-whats-the-big-deal

Kübler-Ross, Elizabeth Family Limited Partnership; Kessler, David. On Grief and Grieving: Finding the meaning of grief through the five stages of loss. 2005