Approaching Communication, while maintaining a Therapeutic Relationship in End of Life Care. Give a couple of reasons why it would be beneficial for the nursing students.

This is the powerpoint for the project, it is already submited, the research paper must be based on this PowerPoint. I need to explain how this can be beneficial to nursing students. If needed you can send me an email so I can send you the PowerPoint project. You will find the rubric at the end of the page.
Approaching Communication, while maintaining a Therapeutic Relationship in End of Life Care. Give a couple of reasons why it would be beneficial for the nursing students.
Approaching Communication, while maintaining a Therapeutic Relationship in End of Life Care
By:
❑ Background


❑ Reasons Behind Avoiding Death & Dying
❑ Fear of Dying
❑ Kubler Ross Grief Cycle
❑ Religion & End of Life Care
❑ How Different Cultures View the End
❑ Family Views of Death as a “Taboo Topic”
❑ Having “The Talk”
❑ What NOT to Say
❑ Communicating with Dying Patients
❑ Communicating through Touch/Types of Touch
❑ Do Not Resuscitate Order
❑ How to Deal with the Loss of a Patient as a Nurse
❑ Questions
❑ References

 LEARN: Listen, Explain, Acknowledge, Recommend, Negotiate
 RESPECT: Rapport, Empathy, Support, Partnership, Explanations, Cultural Competence, Trust
 ETHNIC: Explanation, Treatment, Healers, Negotiate, Intervention, Collaboration

Background
❑ Communication has meaning behind it, whether it be information, a message, emotions, or even beliefs. All of
this is being transferred from one individual to another.
❑ Every individual experiences some type of loss throughout their lifetime, it is important that each individual that is going through the process of dying, to have a strong support system around them in order to make it peaceful for the dying patient.
❑ Each individual family have different belief systems; their views and emotions when it comes to the concept of
death are each distinct.
❑ Showing empathy towards the patient and their family helps keep the relationship therapeutic.
❑ There are many challenges with communication at the end of life; societies have a belief that the topic of death and dying should be avoided.
Therapeutic Communication Skills

Reasons Behind Avoiding Death & Dying
❑ Fear
❑ Religious Beliefs
❑ Cultural Norms
❑ Family views of death as a “taboo topic”
Within the presentation, each reason will be discussed in further detail.

Fear of Dying
❑ Common fears of those who are dying are fear of the unknown, pain, suffering, loneliness, loss of the body, and loss of personal control.
❑ Discussing death and dying in safe and voluntary environments, rather than during the course of a terminal illness, may help with alleviating fear of death and allow the communication at the end of life to be normal in nature.
❑ As nurses the ultimate duty is to communicate effectively, explain to the patient that measures will be taken if requested to prevent pain while dying. Patients have a fear of suffering during the process of dying, although if a patient would like pain medication to be administered this can ease the process and make it pain free.
❑ There is an organization run by volunteers called the, Death Café that brings together professionals to discuss the broader cultural impacts of death. This movement gives individuals a safe space to meet and have a normal discussion about death without any judgements. This can make it easier for individuals in the healthcare field to gain the courage to discuss death or dying with their patients. It is difficult to speak in regards to the topic of dying because not many people want to discuss death out of fear of death itself. Raising awareness, education, and promotion of change in people’s ability to communicate openly about issues regarding death can make it easier for patients to overcome the fear of death and be able to discuss death freely.
❑ Dying is inevitable, it will happen. Although, it doesn’t have to have a sense of fear strung along with it. Communicating with the patient in

Knowledge of grieving theories assists you in how to help a grieving person
Stages of Dying: Kubler-Ross
❏Denial: The patient cannot accept the fact of the loss
❏Anger: Express resistance and anger at people and God, or
the situation
❏Bargaining: Postpones awareness of the loss by trying to prevent it from happening. Ex: Promises
❏Depression: When the patient realizes the full impact of the
loss
❏Acceptance: Incorporate the loss into life and find a way to move forward

Religion & End of Life Care

Religion and End of Life Decisions
❑ Death is defined by each religion uniquely, therefore, it is one of the main reasons that it is what drives
decision-making in End-of-Life Care.
❑ End-of-Life Care Decisions include:
❑ Advance Directives (i.e. DNR/DNI vs Full Resuscitation)
❑ Physician-Assisted Euthanasia (PAE)
❑ Artificial Nutrition and Hydration (i.e. Enteral and Parenteral nutrition)
❑ Pain Management (i.e. Morphine Drips)
❑ Autopsy or Post-Mortem Examination
❑ Understanding our patients’ beliefs gives us as nurses a more comprehensive glimpse into our patients’

How Different Cultures View The End
Death is marked in so many ways around the world that an understanding of different rituals can be helpful, particularly in a cross cultural environment.
❑ In Korea, where cremation is becoming commonplace nowadays, there is a trend to have the ashes of a loved one refined and turned into colorful beads.
❑ White is the color of mourning in China, not black. This is why giving white flowers to a Chinese person is inappropriate.
❑ Japan is the opposite. Death is seen as liberation and acceptance is more important than expressing oneself. Bodies are cremated but the ashes then separated from the bones, these remains sometimes being divided up between the temple, the family and even the employer of the departed.
❑ Ghana is another example of this belief in an afterlife. Funerals are enormous affairs, often costing more than weddings, and advertised on huge
billboards so that nobody in the community misses out.
❑ Muslims bury their dead, rather than cremate them, in the belief that there will be a physical resurrection on the Day of Judgment. The dead are buried facing Mecca and graves raised above the ground, or marked by stones, so nobody walks on them.
❑ In the Hindu faith, it is preferable to die at home, surrounded by family. The soul is believed to go on, according to one’s karma.

Family Views of Death as a “Taboo Topic”
❑ Families are usually hesitant in discussing the topic of death, mainly because it is something that is not pleasant. Although, the discussion needs to be have with anticipation in order to make the whole process easier on everyone who is involved.
❑ When the discussion of death is brought up towards the little time a person has left, it can create an immense feeling of anxiety and sorrow.
❑ Families should begin talking about death as soon as a child understands that death is just another part of one’s lives, usually after 13 years of age the discussion should be brought up. When a topic such as this is brought up in one’s early life it makes it simpler to understand and get through the loss of a loved one.
❑ Families should discuss beforehand what interventions their loved one would want performed or not performed with ample time for all their wishes or requests
to be put in order.
❑ Families do not usually discuss dying, due to relatives living many miles away from one another. Which makes it easier to avoid the situation, this may make it easier on the families. Although, it may make it difficult for the individual who is actually going through the dying process due to the fact that they do not have a strong support system by their side.
❑ When a loved one is dying, it is crucial for people that they care for to be there. The reason behind this is, to allow the dying individual to sense that they are not
alone and that they don’t have to do this on their own. This will allow for the individual who is dying to gain the strength they need to accept that they’re dying and move on and to the other side without being uncomfortable throughout the process.

Having “The Talk”
❑ Have conversations about where you want death to happen, or if family presence is wanted
❑ Direct conversations need to be had regarding what patient and family wants
❑ Repeat back that what you’re hearing is what they’re saying; “Oh, so what you’re saying is [blank]?” Clarification
(Rephrasing)
❑ Active listening: respond to what they are saying, maintaining eye contact and summarizing what they said shows that you are genuinely interested in their concerns.
❑ The use of open questions such as “What… or How…” encourage someone to give more than a single word answer. While giving the patient/family member to answer and also allow for further responses by stating ‘Is there something else?’, this allows for further communication.

What NOT to Say:
 “You are dying…” The patient is not terminal, the condition is terminal
 “You have about a month or two left to live.” Never give life expectancy (prognosis) unless studies have expected otherwise.
 DO NOT EXPRESS YOUR OPINION; PRESENT FACTS
 Do not compare your experienced with theirs, you are not the person on the bed.
 Never assume a patient’s needs, ask.

Communicating With Dying Patients
❑ The therapeutic relationship starts with a trusting relationship, be honest and straightforward with your patient while maintaining respect
❑ Willingness to talk about dying
❑ Giving bad news sensitively
❑ Active Listening when communicating with patients
❑ Encourage questions
❑ Being compassionate

Communicating through Touching
❑ Touch is usually determined by people’s culture, there are some cultures where exhibiting touch is permissible while in others it is prohibited.
❑ Male health providers are usually forbidden from touching or examining certain female areas, with cultures such as Hispanics & Arabs. It also may be inappropriate for female health care providers to care for males.
❑ Asian Americans and touch, their culture sees the use of touch of the head as being impolite. The reason behind this is because the spirit lies within the head.
❑ It is extremely important that you obtain permission before touching someone in any way; whether it be task-oriented touch, therapeutic touch, caring touch, or protective touch.
❑ Although, touch can also be a way to communicate with your patients,

Types of Touch
❑ Task-Oriented: Nurses and physicians are given an unwritten license to enter the pt’s personal space to provide care. (Ex: starting an IV, inserting a foley, etc.)
❑ Therapeutic: effective in controlling pain in some patients, the use of touch helps a pt relax and focus on relaxation response.
❑ Caring: a form of nonverbal communication, influences a patient’s comfort and security, enhances self-esteem, increases confidence of caregivers, and improves mental well-being. (Ex: holding a pt’s hand, gently position a pt, giving a massage, etc.)
❑ Protective: a form of touch that protects a nurse and/or pt.
Whether it be preventing a fall or protecting the nurse’s emotional wellbeing. (Ex: holding and bracing a pt to avoid a fall, withdrawing from an emotional situation.)


Do Not Resuscitate Order (DNR)
 A DNR order allows for you to choose whether or not you want to be resuscitated through Cardiopulmonary Resuscitation (CPR) in an emergency.
 Some patients request this order, to prevent having to live with brain/heart damage after being resuscitated.
 While others do not want to be a burden to their loved ones any
longer, making it another reason to chose to sign a DNR order.
 Nursing home staff are legally bound to perform CPR on their patients unless they have a signed DNR (A DNR form is usually yellow in color and should be in every patient's chart/file).

How to Deal with the Loss of a Patient as a Nurse
Key Points throughout Educational Video
❑ It is okay to cry with family members, it shows that you cared about their family member. Although, don’t let your grief over power the grief of the family.
❑ Listen to family members and their memories of the pt, this
assists in coping with the process.
❑ Allow for the family members to be as involved as possible.
❑ Educate them on what is going on with their family. This gives the family a sense of control of what is currently happening with their loved one.
❑ Allow them to talk and touch their family member.

The nurse has cared for a patient for several days. The patient is terminal and is very near death. The nurse notices the heart rate on the monitor decreasing and then the absence of a pattern. The family is standing at the patient’s bed, and when the nurse checks the patient and finds no pulse or blood pressure, the family begins sobbing and hugging each other. Some hold the patient’s hand. The nurse is overwhelmed by the presence of grief and leaves the room to cry in the nurses’ lounge. What is the nurse demonstrating?

Question?

a. Task-oriented touch
b. Caring touch
c. Protective touch
d. None of the above

A patient diagnosed with terminal cancer says to the nurse "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic?
Question?

The nonverbal communication that expresses emotion is:

Question?

a. Body Positioning
b. Facial Expressions
c. Eye Contact
d. Cultural Artifacts

References
● Baldwin, P. K. (2017, April 26). Death Cafés: Death Doulas and Family Communication. Retrieved from https://www(dot)ncbi(dot)nlm(dot)nih(dot)gov/pmc/articles/PMC5485456/
● Chakraborty, R., El-Jawahri, A. R., Litzow, M. R., Syrjala, K. L., Parnes, A. D., & Hashmi, S. K. (2017). A systematic review of religious beliefs about major end-of-life issues in the five major world religions. Palliative & supportive care, 15(5), 609–622. https://doi(dot)org/10.1017/S1478951516001061
● Keeley, M.P. Final conversations: Survivors’ memorable messages concerning religious faith and spirituality. Health Commun. 2004, 16, 87–104.
● Keeley, M. P. (2017, July 14). Family Communication at the End of Life. Retrieved from https://www(dot)ncbi(dot)nlm(dot)nih(dot)gov/pmc/articles/PMC5618053/#B18-behavsci-07-00045
● Mansur, E. (2018, May 16). Taboo topics: Death and dying. Retrieved from http://www(dot)dailynebraskan(dot)com/culture/taboo-topics-death-and- dying/article_dad98b16-dc0f-11e4-ac68-9f18c637a7b6.html
● Marjorie D. Wenrich, MPH; J. Randall Curtis,MD, MPH; Sarah E. Shannon, RN, PhD; et al
● Morrow, A. (2019, June 24). When to Choose and How to Implement a "Do Not Resuscitate" Order. Retrieved from https://www(dot)verywellhealth(dot)com/hands-off-do-not-resuscitate-1132382
● Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. (2019, p. 558). Essentials for nursing practice. St. Louis, MO: Elsevier.
● Prince-Paul, M., & DiFranco, E. (2017, April 12). Upstreaming and Normalizing Advance Care Planning Conversations-A Public Health Approach. Retrieved from https://www(dot)ncbi(dot)nlm(dot)nih(dot)gov/pmc/articles/PMC5485448/
● Smeltzer, C. S. (2009, p.104-105). Brunner & Suddarths textbook of medical-surgical nursing, 12 th ed (12th ed., Vol. 1). Lippincott.
● Woogara, N. (2019, August 3). Communicating at the end of life. Retrieved from https://www(dot)nursingtimes(dot)net/students/communicating-at-the- end-of-life-31-08-2011/
● Writers, R. N. S. (2020, March 2). Therapeutic Communication: NCLEX-RN. Retrieved from https://www(dot)registerednursing(dot)org/nclex/therapeutic-
Undergraduate Nursing Rubric
Name: ____________________ Panther ID Number: ____________________
Qualities and Criteria Low (Below Standard) Middle (Approaching or At Standard) High (Meets and Exceeds Standard)
Point Value 0 to 1 2 to 3 4 to 5

Written Communication: Content, Sources, and Evidence
(worth up to 15 points) *Nursing Process content is appropriate and relevant to development of simple ideas in some parts of the work.
*Demonstrates minimal attention to context, audience, purpose, and to the assigned task(s).
*Demonstrates an attempt to use sources to support ideas in the writing. *Nursing Process content is appropriate and relevant to explore ideas within the context of nursing process to shape the work and/or throughout most of the work.
*Demonstrates adequate consideration/awareness of context, audience, purpose, and focus on the assigned task(s).
*Demonstrates consistent use of credible and relevant sources to support ideas that are situated within the discipline and genre of the writing.
*Nursing Process content is appropriate/relevant and compelling to illustrate mastery of the nursing care planning process. Writer’s understanding is thoroughly conveyed and shapes the whole work.
*Demonstrates thorough understanding of context, audience, and purpose that is responsive to the assigned task(s) and focuses all elements of the work.
*Demonstrates skillful use of high-quality, credible, relevant sources to develop ideas that are appropriate to nursing and genre of the writing.
Written Communication: Critical Thinking: Context, Assumptions, Position, and Conclusions
(worth up to 20 points) *Evidence of triage (process of determining priority depending on severity/condition) not found.
*Shows an emerging awareness of present assumptions (sometimes labels assertions as assumptions).
Begins to identify some contexts when presenting a position.
*Specific position (perspective, thesis/hypothesis) is stated, but is simplistic and obvious.
*Conclusion is inconsistently tied to some of the information discussed; related outcomes (consequences and implications) are oversimplified.
*Some triage/prioritization evidence found.
*Identifies own and others' assumptions and several relevant contexts when presenting a position.
*Specific position (perspective, thesis/hypothesis) acknowledges different sides of an issue.
*Conclusion is logically tied to a range of information, including opposing viewpoints; related outcomes (consequences and implications) are identified clearly.
*Complete evidence of triage/priority determination based on severity/condition found.
*Thoroughly (systematically and methodically) analyzes own and others' assumptions and carefully evaluates the relevance of contexts when presenting a position.
*Specific position (perspective, thesis/hypothesis) is imaginative, taking into account the complexities of an issue.
Limits of position (perspective, thesis/hypothesis) are acknowledged.
Others' points of view are synthesized within position (perspective, thesis/hypothesis).
*Conclusions and related outcomes (consequences and implications) are logical and reflect student’s informed evaluation and ability to place evidence and perspectives discussed in priority order.
Written Communication: Organization, Genre, and Disciplinary Conventions
(worth up to 10 points) *No logical flow of ideas.
*Attempts for basic organization and presentation of nursing process. *Flow of ideas is evident but with disconnect between ideas.
*Basie/consistent use of organization, content, presentation, and stylistic choices. *Ideas flow and transition logically.
*Demonstrates detailed attention to and successful execution of a wide range of conventions specific to the nursing process including organization, content, presentation, formatting, and stylistic choices.
Written Communication: Syntax and Mechanics
(worth up to 10 points) *Poor or no use of APA format.
*Uses language that sometimes impedes meaning because of errors in usage. *Inconsistent use of APA format.
*Uses language that generally conveys meaning to readers with clarity, though writing may include few or some errors.
*Correct APA format utilized.
*Uses graceful language that skillfully communicates meaning to readers with clarify and fluency, and is virtually error-free.
Written Communication
(total worth up to 55 points) =
__________