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1. John in the intensive care unit on a ventilator, preparing the family for end

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1. John in the intensive care unit on a ventilator, preparing the family for end of life.
Using the nursing process: Assess, Diagnose (analyze), Plan, Implementation, Evaluation (outcome); create a plan to assist the family member and their grief.
Vignette
Guiding the Family in Saying Goodbye
The plan was for John to move from the intensive care unit (ICU) to home with hospice care, have his ventilator removed at that time, and die peacefully surrounded by his family. A hospice bereavement counselor was consulted to help prepare John’s four teenage grandchildren for his death. When the counselor arrived at the hospital late on the afternoon of his impending transfer home, she discovered that John was too fragile to be moved and would be extubated in the ICU instead. His wife, two adult children, and the four grandchildren were gathered in a waiting room, restless and worried. The counselor worked closely with the ICU nurse to help the family with the task of finalizing the relationship. They were invited to gather around John to touch him, tell him what he meant to them, share stories, and connect with him as each one preferred. While he was not able to respond, the nurse suggested that he might be able to hear them anyway. Gradually the family relaxed and expressed many things, crying, laughing, and holding hands. Then the staff asked if anyone wanted time alone with John. His wife immediately stepped forward. After her, each one requested private time. Finally, they were asked to leave the room so that he could be medicated and extubated in private. Each step was carefully explained by the nurse and counselor. Finally, the whole family circled his bed, weeping or silent, as he gradually stopped breathing. The two staff members kept vigil with them in a corner of the room. His death was peaceful and quiet. So was the family, as each person gave him a final kiss before leaving the room.
The message: The dying person, if cognitively intact, often has preferences about where he or she will die, with what level of consciousness, with which people around, and with what level of comfort. Each family member will usually have a sense of how it will be at the time of the death. Some know they want to be present. Others prefer to remember the patient alive. When the hopes of the survivors are not met, people usually need to reconcile themselves with their disappointment during the period of bereavement. You can help by understanding the function of hope during the time of anticipatory mourning. You can listen carefully when hopes are being abandoned or reformulated as conditions change. Be sensitive to the fact that each member of the family, including the dying person, will have differing hopes. Assess hopes by asking open-ended questions, such as “How would you like her to feel about that?” or “Ideally, how would you like this to work out?”

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