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Cholera

Cholera is an infection of the small intestine caused by the bacterium Vibrio cholerae.

The infection is characterized by profuse watery stools, vomiting, dehydration, and collapse.

Cause

Cholera is specifically caused by the bacterium Vibrio cholerae.

This bacterium is Gram stain negative and possesses a flagellum, a long projecting part that enables it to move, and pili, hair-like structures that it uses to attach to the intestinal tissue.

Transmission

The primary mode of transmission for cholera is through the fecal contamination of food and water, often resulting from poor sanitation practices. When individuals infected with cholera have untreated diarrheal discharge, the bacteria can enter waterways or drinking water supplies, contaminating them.
Consuming food that has been washed in contaminated water can also lead to transmission. It is important to note that cholera is rarely spread directly from person to person.

Susceptibility: Several factors influence the susceptibility to cholera:

Ingestion of bacteria: In a normal, healthy adult, approximately 100 million bacteria must typically be ingested to cause cholera. This highlights the importance of a significant bacterial load for infection to occur.
Age: Children, particularly those between the ages of two and four, are more susceptible to cholera infection. This could be attributed to their underdeveloped immune systems and increased likelihood of exposure due to their behavior and hygiene practices.
Lowered immunity: Individuals with weakened immune systems, such as those with AIDS or malnourished children, are at higher risk of experiencing severe cases if they become infected with cholera. Their compromised immune function makes it more difficult for their bodies to fight off the infection effectively.

Pathophysiology of Cholera

Cholera is a gastrointestinal illness caused by the bacterium Vibrio cholerae. The bacteria produce a toxin that causes the body to lose water and electrolytes, leading to severe diarrhea.

How the Bacteria Enter the Body

Most Vibrio cholerae bacteria are killed by the acidic environment of the stomach. However, a small number of bacteria can survive and travel to the small intestine. The bacteria attach to the intestinal wall and produce a toxin that causes the body to lose water and electrolytes.

The Toxin

The toxin produced by Vibrio cholerae is called cholera enterotoxin. The toxin binds to cells in the small intestine and activates an enzyme that causes the cells to pump water and electrolytes into the intestine. This results in the production of large amounts of watery diarrhea.

More Detailed Pathophysiology:
Upon consumption, most Vibrio cholerae bacteria do not survive the acidic conditions of the human stomach. However, a small number of bacteria manage to survive. As they exit the stomach and reach the small intestine, they need to navigate through the thick mucus lining in order to reach the intestinal walls, where they can establish themselves and multiply. Vibrio cholerae bacteria possess flagella for mobility and pili to attach to the intestinal tissue.

Vibrio cholerae bacteria produce a toxin that is responsible for causing the most severe symptoms of cholera. This toxin, known as an enterotoxin, acts on human cells, prompting them to extract water and electrolytes from the body, primarily from the upper gastrointestinal tract. The extracted fluid and electrolytes are then pumped into the intestinal lumen, resulting in the excretion of diarrheal fluid.

Signs and Symptoms

The incubation period for cholera is typically 2-3 days. The first signs and symptoms of cholera are watery diarrhea and vomiting. The diarrhea can be so profuse that it can lead to dehydration and shock.

In a typical case of severe cholera, the disease progresses through three stages:

Stage I:

Profuse watery stools are expelled by the patient. Over time, fecal matter becomes nearly clear fluid with mucous flakes, giving it the characteristic \”rice-water\” appearance.
Vomiting occurs, initially expelling food and later becoming restricted to rice-water-like fluid.
Severe cramps develop in the abdomen and limbs due to salt loss.

Stage II:

Dehydration and collapse occur during this stage.
The body becomes cold, and the skin appears dry and inelastic.
Blood pressure drops, sometimes becoming unrecordable.
The pulse becomes rapid and weak.
Urine production stops, and the patient may be at risk of shock.

Stage III:

This stage marks the recovery phase, which can happen spontaneously or with treatment.
Diarrhea decreases, allowing the patient to tolerate fluids.
The general condition of the patient rapidly improves.

Diagnosis of Cholera

The diagnosis of cholera is based on the following:

History: The patient may have a history of travel to an area where cholera is common, or they may have been in contact with someone who has cholera.
Symptoms: The patient will typically have watery diarrhea and vomiting. The diarrhea may be so profuse that it can lead to dehydration and shock.
Physical examination: The doctor will examine the patient for signs of dehydration, such as dry skin, sunken eyes, and decreased urination.
Laboratory tests: The following laboratory tests may be performed to diagnose cholera:
- Stool culture: This test is used to grow the bacteria in the laboratory.
- Polymerase chain reaction (PCR): This test is used to detect the genetic material of the bacteria.
- Rapid diagnostic test (RDT): This test is a rapid way to detect the bacteria.

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Prevention of Cholera

Cholera is a serious disease that can be fatal, but it is preventable. The best way to prevent cholera is to follow proper sanitation practices.

Here are some specific steps you can take to prevent cholera:

Hand hygiene: Always wash hands with water and soap before preparing, serving, or consuming food. Additionally, it is important to wash hands with soap and water after using a latrine.
Safe drinking water: Boil all drinking water or treat it with chlorine. Store the treated water in a clean container to prevent recontamination.
Food safety: Consume food when it is still hot. If consuming raw foods such as fruits and vegetables, ensure they are properly washed, and when possible, peeled before eating.
Food storage: Cover all foods to prevent contamination by dust, house flies, and cockroaches.
Reporting and burial practices: In the unfortunate event of a cholera-related death, report it immediately to health authorities. Burial should take place promptly, and it is crucial to avoid serving food during this time.
Surveillance and reporting: Active surveillance and prompt reporting of suspected cases allow for the rapid containment of cholera epidemics.
Disinfection: Kill the germs by sprinkling germ-killing solutions, such as JIK, on stool or vomitus, as well as on any other materials used by the person suffering from cholera.
Water and sanitation improvement: Enhance water and sanitation infrastructure to reduce the transmission of infection, such as by improving access to clean water sources and implementing proper waste management systems.
Outbreak investigations: Conduct thorough investigations of diarrheal outbreaks to identify the source of contamination and implement appropriate control measures.
Cholera vaccination: Consider immunization with cholera vaccines in areas prone to outbreaks or for individuals at high risk of exposure.
Treatment of malnutrition: Address malnutrition, as individuals with weakened immune systems are more susceptible to severe cholera. Providing adequate nutrition can help improve their overall resilience.

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Management and Treatment

Patient admission: The patient can be admitted to temporary hospitals, schools, or churches. Cholera beds with a central hole are used, allowing continuous stools to pass into a calibrated bucket containing a disinfectant.
Oral Rehydration Solution (ORS): ORS is the primary treatment for cholera. It is recommended for rehydrating patients and replenishing electrolytes lost through diarrhea. In cases of severe dehydration, intravenous Ringer\’s lactate or normal saline, along with ORS, may be administered. The patient should be reassessed every one to two hours, and hydration should be continued. If there is no improvement in hydration, the intravenous drip rate may be increased. During the first 24 hours of treatment, the patient may require 200ml/kg or more of fluid. If hydration improves and the patient is able to drink, switching to ORS solution is recommended.
Nasogastric tube: In young children, a nasogastric tube can be used to administer fluids if necessary, ensuring adequate hydration.
Antibiotics: In certain cases, antibiotics may be prescribed. Doxycycline 300mg or ciprofloxacin as a single dose can be given, but they are contraindicated in pregnancy. For pregnant women, septrin can be used. In children, cotrimoxazole, doxycycline, ciprofloxacin, or erythromycin may be considered based on the specific circumstances.
Hypoglycemia management: If hypoglycemia is present, intravenous dextrose should be administered to correct low blood sugar levels.
Zinc supplementation: Zinc supplementation is effective in treating and preventing diarrhea, especially among children. It can be provided to aid in recovery.
Isolation and infection control: Patients should be isolated to prevent the spread of infection, as stools and vomit are highly infectious. Proper disposal of stools and vomit should be carried out, preferably into a pit latrine.
Equipment and instrument disinfection: Hospital equipment should be cleaned with a disinfectant such as JIK. Instruments can be cleaned with JIK or sterilized to prevent the transmission of the infection.
Fluid balance chart: A fluid balance chart should be instituted to monitor the patient\’s hydration status closely.

Complications

Shock
Electrolyte imbalance
Acute renal failure
Convulsions/Fits
Anaemia
Coma

Gastroenteritis (GE)

Gastroenteritis is a medical condition characterized by inflammation of the gastrointestinal tract that involves both the stomach (\”gastro\”-) and the small intestine (\”entero\”-), resulting in some combination of diarrhea, vomiting, and abdominal pain and cramping.

The severity of infectious gastroenteritis depends on the immune system’s ability to resist the infection.

Electrolytes (mainly sodium and potassium) may be lost as the infected individual vomits and experiences diarrhea.

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Causes of Gastroenteritis

Viruses

Rotavirus, norovirus, adenovirus, and astrovirus are known to cause viral gastroenteritis.
Rotavirus is the most common cause of gastroenteritis in children.
Norovirus is the leading cause of gastroenteritis among adults, causing greater than 90% of outbreaks.

Bacteria

In the developed world Campylobacter jejuni is the primary cause of bacterial GE.
Escherichia coli
Salmonella, Shigella, and Campylobacter species.
Salmonella is contracted by ingesting the bacteria in contaminated food or water and by handling poultry.
Campylobacter occurs by the consumption of raw or undercooked poultry meat and other foods. It is also associated with unpasteurized milk or contaminated water.
Clostridium difficile is an important cause of diarrhea that occurs more often in the elderly. It is a common cause of diarrhea in those who are hospitalized and is frequently associated with antibiotic use.
Staphylococcus aureus infectious diarrhea may also occur in those who have used antibiotics.

Parasites

A number of protozoans can cause gastroenteritis – most commonly: – Giardia lamblia

– Entamoeba histolytica
– Cryptosporidium

Non-infectious causes

– Medications like NSAIDs
– Certain foods such as lactose (in those who are intolerant).
– Crohn\’s disease.

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Transmission:

The transmission of germs occurs through the feces or vomit of individuals infected with the illness. Gastroenteritis can be spread through the following means:

Consuming untreated or unboiled water from rivers, streams, lakes, ponds, or unprotected springs.
Eating cold food that has been exposed to dust, flies, or cockroaches.
Neglecting to wash hands with soap and water after using a latrine.
Eating unwashed fruits and vegetables.
Serving food and drinks in dirty containers.
Storing drinking water in unclean containers.
Improper disposal of feces.
Presence of open rubbish in areas that attract flies and cockroaches.

Signs and Symptoms:

The primary symptom is diarrhea, often accompanied by vomiting. Infected individuals may notice the presence of blood or mucus in their stools. Crampy abdominal pain is a common occurrence, which may temporarily ease after passing stool. There may be a low-grade fever, headache, and body aches. Symptoms of dehydration may include:

Muscular cramps, sunken eyes, decreased urine output, dry mouth and tongue, weakness, and irritability. In severe cases, adults may experience symptoms such as fatigue, dizziness or lightheadedness, headache, weakness, confusion, rapid heart rate, coma, and significantly reduced urine production.

Diagnosis:

Gastroenteritis is diagnosed clinically, based on a person\’s signs and symptoms.
Stool cultures should be performed especially in those with blood in the stool.

Management:

Gastroenteritis is usually an acute and self-limiting disease that does not require medication.
The preferred treatment in those with mild to moderate dehydration is oral rehydration therapy (ORT).
Intravenous delivery may be required if there is a decreased level of consciousness or if dehydration is severe.
Plain water may be used if more specific and effective ORT preparations are unavailable or not palatable.
A nasogastric tube can be used in young children to administer fluids if necessary.
Institute a fluid balance chart.
Metoclopramide may be helpful in some children, and butylscopolamine is useful in treating abdominal pain.
Fermented milk products (such as yogurt) are similarly beneficial.
Zinc supplementation is effective in both treating and preventing diarrhea among children.
Antibiotics are not usually used for gastroenteritis, although they are sometimes recommended if symptoms are particularly severe or if a susceptible bacterial cause is isolated or suspected.
- If antibiotics are to be employed, a macrolide (such as azithromycin) is preferred. Metronidazole or Tinidazole is used if the cause is protozoa.
Isolation of the patient to prevent cross-infection.
Proper disinfection and disposal of stool and vomit.

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Prevention and Control:

Always wash hands with water and soap before preparing, serving, or eating food.
Always wash hands with soap and water after using a latrine.
Boil all drinking water or treat it with chlorine. Store it in a clean container.
Consume food while it is still hot.
Ensure that raw foods such as fruits and vegetables are properly washed and, whenever possible, peeled before eating.
Cover all foods to prevent contamination by dust, house flies, and cockroaches.
In the event of a person\’s death due to diarrhea, report it immediately to the health authorities.
Kill germs by using germ-killing solutions like JIK (bleach) on stool or vomit and on all other materials used by the person suffering from diarrhea.
Improve water and sanitation to reduce the transmission of infection.
Conduct investigations of diarrheal outbreaks.
Treat other infections such as typhoid, dysentery, etc.
Address and treat malnutrition.
Consider immunization with Rota vaccine, which provides protection against rotavirus, a common cause of gastroenteritis.

Gastroenteritis (GE) Read More »

Introduction to communicable diseases

Communicable diseases, also known as infectious diseases or transmissible diseases are diseases that spreads from one person or animal to another or from a surface to a person.

Communicable diseases occur at all age groups outmost serious in childhood due to intensive exposure and poorly developed immunity. These diseases are to a great extent preventable

In countries where the disease have been largely prevented, other conditions like accidents, and degenerative and malignant diseases that occur at an old age have become the commonest, the process known as epidemiological transmission

Tropical countries, Uganda, inclusive have continued to struggle with poverty related diseases that occur at an old age which include: diarrhea, parasite infestations, respiratory infections, immunizable childhood infections, eye infections and malnutrition. These countries are at the same time facing steady increase of diabetes, CVA, rheumatic conditions and cancer

Communicable’ diseases are divided into

Contact contagious diseases
STDs and HIV/AIDs
Vector borne diseases
Diseases related to contaminated water and food
Airborne diseases
Blood borne diseases
Diseases from the animals and their products
Helminthic diseases

Some Communicable diseases and there causative agents.

Causative Organism	Disease/Infection
Rabies virus	Rabies
Influenza A virus	Avian influenza (Bird flu)
Vibrio cholerae	Cholera
Plasmodium species	Malaria
Severe acute respiratory syndrome coronavirus (SARS-CoV)	Severe acute respiratory syndrome (SARS)
Trypanosoma species	Trypanosomiasis
Tsetse fly	Sleeping sickness (African trypanosomiasis)
Wuchereria bancrofti	Elephantiasis
Dracunculus medinensis	Guinea worm disease
Rotavirus	Diarrhea (caused by rotavirus)
Mumps virus	Mumps
Human immunodeficiency virus (HIV)	HIV/AIDS
Varicella-zoster virus	Chickenpox
Measles virus	Measles
Yellow fever virus	Yellow fever
Arboviruses	Arboviral diseases
African swine fever virus	African swine fever
Brucella species	Brucellosis
Salmonella enterica serovar Typhi	Typhoid fever
Schistosoma species	Schistosomiasis
Poliovirus	Poliomyelitis
Shigella species	Dysentery
Bacillus anthracis	Anthrax

Why are communicable diseases important in Africa?

Many of them are very common
Some of them are very serious and cause death and disability
Some of them cause widespread outbreaks of the disease- epidemics 4. Many of them are preventable by fairly simple means
Many are particularly serious and more common in infants and children.

Organisms and agents of disease

The living organisms that cause communicable diseases are of different sizes and sorts. The largest, like tape or filarial worms are visible to the eyes. They are made of many cells and are called metazoa.

Complicated but single celled organisms like malaria parasites and amoeba are called protozoa. They are smaller and can only be seen when magnified with a microscope. Smaller still are bacteria which are simple, single cell, best seen under a microscope after they have been stained with dyes.

Rickettsiae and chlamydiae are smaller and can only multiply within cells. Smallest of all are the viruses. These cannot be seen with an ordinary microscope.

Epidemiological Triad

Patterns of communicable diseases

Different diseases are common in different places and different times. To understand why this happens we need to consider the living organisms of disease- the agent; the people they infect the host and the surrounding in which they live- the environment.

The agents need a suitable environment in which to grow and multiply and must be able to spread and infect other hosts. If they do not succeed in doing this, they die out.

There is therefore a balance between the agent, the host and the environment which can change and be made to change in different ways.

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Hosts (people) are affected by environment, for example, they may live in a hot climate in which there many mosquitoes. But people can also change this environment by draining swamps, changing the vegetation and adding competing hosts such as animals.

Similarly, the environment can affect the agent, for example, the altitude and the temperature for malaria.

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Terminology

Infectious disease

An infectious disease is an illness due to a specific infectious agent or its toxic products that arise through a transmission of that agent or its products from an infected person, animal or reservoir to a susceptible host, either directly through an intermediate plant or animal host, vector or inanimate environment.

Infection

Infection is the entry and development of an infectious agent in the body accompanied by an immune response.

Disease

Manifestation of infection through symptoms and signs

Exposed

Someone who has met with an infectious agent in a way that is known to cause disease

Colonization

Colonization is the presence of a replicating microorganism without clinical or subclinical infection or disease. No immune response.

Carrier

Carrier is a person that harbours a specific infectious agent in the absence of clinical disease and serves as a potential source of infection.

Reservoir

The reservoir of infection is the animal or place in which a particular organism usually lives and multiplies. Most of the important communicable diseases humans are the main reservoirs.

Route of transmission

The route of transmission is the way in which an organism leaves the infected host or source and travels to a new susceptible person.

Source

The source of infection is the animal or place from which the particular organism spreads to its new host.

Incubation period

The incubation period is the time between infection and the appearance of signs and symptoms of illness.

Epidemiology

Epidemiology is the study of the distribution and patterns of health events, health characteristics and their causes or influences in a well defined population. Or

It is a branch of medicine that deals with the study of the causes, distribution and control of diseases in the population.

Endemic

It means the disease is present in the community at all times but in a relatively low frequency Something that is endemic is typically restricted or peculiar to a locality or region. For example malaria is endemic in some areas of Africa.

Epidemic

An epidemic is a sudden severe outbreak of an infectious disease that spreads rapidly within a region or group, affecting a large proportion of people.

Pandemic

A pandemic occurs when an epidemic becomes widespread and affects a whole region, a continent or the entire world.

Clinical disease

A clinical disease is a disease which has physical manifestations (clinical signs and symptoms).

Susceptible host

A susceptible is someone that is exposed to an infectious disease.

Vector

A vector is an animal, usually an insect that transmits parasitic microorganisms from person to person or from infected animals to human beings.

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Transmission cycle

The transmission cycle describes how organisms grow, multiply and spread. In some cases humans may be the only host, in which case the infection spreads directly from person to person, e.g. measles. In other cases, humans are the final hosts from whom the organism has no chance to pass further, e.g. tetanus.

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There are three parts of a transmission cycle for an agent or organism:

Source —-> Transmission —-> Susceptible Host

Source

The source of an infection can be an infected person or animal, or soil. People and animals may have clinical disease, subclinical disease or be carriers.

Transmission

The main routes of transmission are:

❖ Direct contact (skin, mucous membrane, sexual intercourse)
❖ Vector transmission
❖ Fecal contamination of soil, food and water which are ingested.
❖ Contact with animals or their products (e.g. biting)
❖ Airborne transmission (inhalation)
❖ Transplacental (mother to child) transmission
❖ Blood contact (injections, surgery, blood transfusion)

Susceptible Host

A susceptible host is one with low resistance to a particular infection. Low resistance may be due to:

Not having met the organism before and therefore not having any immunity to it. For example, at the age of 6-12 months, a child loses the passive immunity against measles which was acquired from the mother during pregnancy. When in contact with another child who has measles, the child will develop the disease because of no immunity against measles
Having another serious illness like AIDS at the same time. Such people have a higher risk of developing tuberculosis.
Malnutrition which can make the infection worse.

Principles of communicable disease control and prevention

The aim of control is to tip the balance against the agent. This may be done by:

Attacking the source
Interrupting route of transmission
Protecting the host

Attacking the Source	Interrupting Transmission	Protecting the Host
Treatment	Environmental sanitation	Immunization
Isolation	Personal hygiene	Chemoprophylaxis
Reservoir control	Vector control	Personal protection
Notification	Disinfection and sterilization	Better nutrition

Introduction to communicable diseases Read More »

Psychosocial support to terminally ill patients

Terminal illness refers to a condition that cannot be cured and is expected to result in the patient’s death within a certain timeframe. This devastating diagnosis not only affects the physical health of the individual but also has profound emotional and psychological implications. The knowledge that one’s life will soon come to an end can elicit feelings of fear, sadness, and anxiety, both for the individual facing the illness and their loved ones.

Terminal Illnesses

Cancer. Cancer is a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body.
Dementia. Dementia is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life.
Heart disease. Heart disease is a group of conditions that affect your heart. Heart diseases can be caused by a number of factors, including high blood pressure, high cholesterol, smoking, and obesity.
Lung disease. Lung disease is a general term for any condition that affects your lungs. Lung diseases can be caused by a number of factors, including smoking, air pollution, and infections.
Neurological diseases. Neurological diseases are diseases that affect the brain, spinal cord, or nerves. Neurological diseases can be caused by a number of factors, including genetics, infections, and toxins.
End-stage renal disease. End-stage renal disease is a condition in which the kidneys can no longer function properly. End-stage renal disease can be caused by a number of factors, including diabetes, high blood pressure, and infections.
HIV/AIDS. HIV/AIDS is a chronic, life-threatening condition caused by the human immunodeficiency virus (HIV). HIV attacks the body’s immune system, making it difficult to fight off infections.
Amyloidosis. Amyloidosis is a group of diseases in which amyloid proteins build up in organs and tissues. Amyloid proteins are abnormal proteins that can’t be broken down by the body.
Lou Gehrig’s disease. Lou Gehrig’s disease, also known as amyotrophic lateral sclerosis (ALS), is a progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord. ALS causes muscle weakness and wasting, which can eventually lead to paralysis and death.
Parkinson’s disease. Parkinson’s disease is a chronic, progressive neurological disorder that affects movement. Parkinson’s disease is caused by the loss of dopamine-producing cells in the brain.

Key Components of Psychosocial Support

A. Emotional support: Nurturing mental well-being Emotional support plays a pivotal role in promoting the mental well-being of terminally ill individuals. This component involves actively listening to their concerns, validating their emotions, and offering empathy and compassion. Providing a safe space where patients can freely express their fears, hopes, and anxieties can contribute significantly to their overall emotional well-being. By addressing emotional needs, healthcare providers help alleviate distress and foster a sense of emotional resilience during their journey.
B. Counseling and therapy: Addressing psychological distress Psychological distress commonly accompanies terminal illness, ranging from depression and anxiety to existential crises. Counseling and therapy offer a structured and supportive environment for individuals to explore these complex emotions and develop coping strategies. Trained professionals can facilitate cognitive-behavioral therapy, creating a space for patients to challenge and reframe negative thoughts, promoting adaptive coping mechanisms.
C. Social support: Fostering connections and combating isolation Social support plays a critical role in promoting the well-being of terminally ill individuals. Encouraging connections with loved ones, friends, and support groups can help combat the feelings of isolation that often accompany terminal illness. By fostering a supportive network, patients can find comfort, share experiences, and derive strength from the understanding and empathy of others navigating similar journeys.
D. Spiritual care: Enhancing existential well-being Recognizing the spiritual dimension of individuals facing terminal illness is vital in providing comprehensive psychosocial support. Spiritual care may involve assisting patients in exploring their values, beliefs, and finding meaning in their lives. By acknowledging and respecting their spiritual needs, healthcare professionals can foster a sense of existential well-being and promote inner peace amidst the challenges of the illness.
E. Supporting families and caregivers: Recognizing their crucial role Psychosocial support should extend beyond the patient and encompass the families and caregivers who play an integral role in their care. Recognizing and addressing the emotional and psychological well-being of families and caregivers are paramount. By offering support groups, counseling, and respite care, healthcare providers can alleviate the burden and stress faced by these individuals, ensuring they have the resources and support they need to provide optimal care and maintain their own well-being.

Signs and Symptoms faced by patients with terminal illnesses

Patients

Pain and availability of palliative care
Sleeping
Nutritional Support.
Medication Side effects
ADL’s(mobility, bathing, toileting)
Changes in Responsiveness.
Anger, embarrassment,

Caregiver

Exhaustion
Sleeping.
Physical requirements of caregiving.
Nutritional support

Management of Terminal illness

Manage according to symptoms, click here for more

Affective:

Antidepressant therapy is generally well-tolerated in most cases.
Expert consensus recommends starting treatment promptly for depression.
Psychostimulants, SSRIs, and tricyclic antidepressants are commonly used for end-of-life depression.
Sertraline, paroxetine, mirtazapine, and citalopram have shown effectiveness in treating fatigue and depression in patients nearing the end of life.
Methylphenidate has been found effective in addressing low energy and apathy in patients with cancer or HIV.
The effectiveness of pharmacologic treatment for anxiety in palliative care is inconclusive according to a Cochrane review.

Cognitive:

Assess the client and family’s understanding of the prognosis and address any uncertainties.
Provide information on the nature, extent, and trajectory of the illness.
Discuss the meaning and impact of the illness.
Explain symptoms and how to manage emergencies.
Address financial and legal concerns, as well as end-of-life decisions and options.
Guide the client and family through the process of death and dying.

Environmental:

Ensure continuity of care and a structured approach in the care process.
Provide necessary supplies and accommodations for both the client and caregivers.
Inform about community resources for shopping, cleaning, and transportation.
Pay attention to sensory stimuli and create a comfortable environment.
Consider environmental factors in both hospital/long-term care facilities and home settings.

UNMEB related question.(feb 2022)

33 (b) Outline 12 reasons why terminally ill patients die with uncontrolled pain

Inadequate pain assessment: Failure to accurately assess the intensity and characteristics of the patient’s pain can lead to ineffective pain management and uncontrolled pain.
Underestimation of pain severity: Healthcare professionals may underestimate the severity of pain experienced by terminally ill patients, leading to insufficient treatment and uncontrolled pain.
Fear of opioid addiction: Misconceptions and fears surrounding opioid addiction may result in healthcare providers prescribing lower doses of pain medication than necessary, resulting in inadequate pain relief.
Inadequate knowledge of pain management: Lack of knowledge or training in pain management techniques can contribute to ineffective pain control and uncontrolled pain.
Suboptimal medication administration: Incorrect administration techniques, inadequate dosing intervals, or failure to provide breakthrough pain medication as needed can result in uncontrolled pain.
Reluctance to escalate pain medication: Healthcare providers may be hesitant to increase pain medication doses or switch to stronger opioids, leading to uncontrolled pain due to fear of side effects or concerns about respiratory depression.
Lack of access to pain specialists: Limited availability of pain specialists or palliative care teams can result in inadequate pain management, especially in resource-limited settings.
Physical tolerance and opioid titration: Some patients may develop tolerance to opioid medications over time, requiring dose adjustments or switching to alternative medications. Failure to titrate opioids appropriately can lead to uncontrolled pain.
Psychological factors: Emotional distress, anxiety, or depression can exacerbate the experience of pain and make it more challenging to achieve adequate pain control.
Inadequate support for non-pharmacological interventions: Non-pharmacological approaches, such as physical therapy, relaxation techniques, or complementary therapies, can complement pain management. However, limited access or lack of support for these interventions can contribute to uncontrolled pain.
Co-existing medical conditions: The presence of comorbidities, such as renal or hepatic impairment, can affect the choice and dosing of pain medications, potentially leading to inadequate pain control.
Communication barriers: Ineffective communication between patients, caregivers, and healthcare providers can impede the understanding of pain symptoms and hinder appropriate pain management, resulting in uncontrolled pain.

Psychosocial support to terminally ill patients Read More »

Nearing death awareness

Near death awareness (NDA) is a term to describe a dying person’s experiences of the dying process. It refers to a variety of experiences such as end of life dreams or visions.

Their attempts to share the wonders of these experiences are often obstructed by our lack of understanding of the symbolic language they use. Often they are talking while the experience is actually happening.

When nurses are equipped with the tools to recognize this type of communication, they may experience the benefit of participating in this
transformative process.

Signs of Near Death Awareness (NDA)

Near Death Awareness (NDA) is a phenomenon that occurs when individuals approach the end of their lives. It is characterized by a variety of signs and experiences, including:

Communication with the Deceased : individuals claim to have spoken with someone who has already passed away. They may describe vivid conversations with deceased loved ones, feeling their presence or receiving messages from them. These encounters can bring comfort and reassurance, as patients find solace in the belief that their departed loved ones are near and supporting them during this transitional phase.
Interaction with Unseen Beings : Patients experiencing NDA might engage in conversations or interactions with people who are not visible to others present in the room. These unseen beings may be described as spiritual guides, angels, or companions that accompany the individual on their journey. While these interactions cannot be objectively observed, they hold deep personal significance for the individual, often providing a sense of guidance and companionship during their final days.
Visions of a Serene Place : Another remarkable aspect of NDA is the description of a beautiful and luminous place that patients perceive during their experiences. They may talk about seeing a serene landscape, often described as a garden, meadow, or heavenly realm. These visions evoke a sense of peace, tranquility, and transcendence, offering patients a glimpse of the potential beauty that awaits them beyond life.
Gestures and Reaching for Unseen Objects : Patients in the throes of NDA may exhibit physical gestures such as reaching out, grasping for unseen objects, or waving to invisible beings. These actions suggest a heightened awareness and interaction with a realm beyond the tangible world. While these gestures may appear puzzling to observers, they hold deep significance for the individuals experiencing them, reinforcing their connection to a reality that lies beyond our immediate perception.
Encounters with Spiritual Beings : NDA experiences often involve encounters with spiritual beings beyond deceased loved ones. Patients may describe encounters with angels, religious figures, or entities associated with their personal spiritual beliefs. These encounters can elicit profound feelings of awe, reverence, and a strengthened connection to the divine.
Confusion and Disorientation : It is common for individuals undergoing NDA to exhibit periods of confusion and disorientation. This can be attributed to the shifting boundaries between the physical and spiritual realms. Nurses and caregivers should approach these episodes with patience and understanding, providing reassurance and a calming presence to alleviate any distress experienced by the patient.
Symbolism of a Journey : In the context of NDA, patients may express a sense of embarking on a significant journey or trip. They may speak metaphorically about preparing for departure, gathering their belongings, or anticipating a transition to a different realm. These symbolic references reflect their understanding and acceptance of the impending end of life and can serve as a powerful coping mechanism for patients as they navigate this profound phase.
Foreknowledge of Death : Perhaps one of the most bewildering aspects of NDA is when individuals accurately predict the exact timing of their death. Some patients may express an intuitive awareness of when their journey will come to an end. While this may seem inexplicable, it is crucial for healthcare professionals to approach such statements with respect and sensitivity, acknowledging and exploring the patient’s feelings and beliefs surrounding their impending passing.

In Summary;
People who are experiencing nearing death awareness may:

Say that they have spoken to someone who has already died
• Converse with people who are not visible to you
• Describe another place of beauty and light
• Reach or grasp for unseen objects, wave to unseen beings, and/or make hand gestures
• Describe spiritual beings
• Appear confused and disoriented
• Talk about taking a trip or going on a journey
• Tell you exactly when they will die

These behaviors do not mean that they are hallucinating, confused, or having reactions to medications. They often have specific meaning to the patient’s life, and the person who is closest to the patient may best understand what is being said and what it means.

Roles of a Nurse during Nearing Death Awareness:

Providing Presence and Support: One of the primary roles of a nurse during Nearing Death Awareness is to be present with the person. The nurse should sit with them, offering a calm and supportive presence. This allows the patient to feel secure and encourages them to communicate if they wish to.
Facilitating Communication: Nurses can play an active role in facilitating communication during Nearing Death Awareness. They can ask open-ended questions such as, “Who do you see?” or “What are you seeing?” This encourages the patient to share their experiences and perceptions. Additionally, asking about their emotional state by inquiring, “How does that make you feel?” helps the patient express their emotions related to the visions or experiences they are having.
Active Listening and Validation: It is important for the nurse to actively listen to the patient’s experiences and validate them. Rather than dismissing or doubting what the patient is sharing, the nurse should acknowledge and accept their perceptions as real and meaningful. Validating their experiences can provide comfort and reassurance to the patient during this vulnerable time.
Avoiding Contradiction or Argumentation: Nurses should avoid contradicting, explaining away, or arguing with the patient about their experiences. Even if the experiences seem unusual or impossible to the nurse, it is crucial to respect the patient’s beliefs and perceptions. Engaging in arguments or attempting to rationalize their experiences may cause distress or feelings of invalidation for the patient.
Collaborating with the Hospice Team: Nurses should maintain open communication with the hospice team regarding the patient’s Nearing Death Awareness experiences. Sharing these communications with the interdisciplinary team, which may include physicians, social workers, counselors, and spiritual care providers, allows for a holistic approach in supporting the patient. Collaborating with the team ensures that the patient receives comprehensive and coordinated care during this delicate phase.

Supportive Methods for Near-Dying Patients:

Pain Management 💊: Ensure effective pain control to keep the patient comfortable.
Emotional Support 🤗: Offer emotional reassurance and a listening ear to address their fears and concerns.
Spiritual Care 🙏: If the patient is spiritual or religious, provide spiritual support.
Hospice Care 🏡: Consider transitioning to hospice care for specialized end-of-life support.
Companionship 👫: Ensure the patient is not alone and has companionship.
Dignity and Respect 🙌: Uphold their dignity and respect their preferences.
Communication 🗣️: Communicate openly about the patient’s condition and prognosis.
Hygiene and Comfort 🛀: Keep the patient clean, comfortable, and well-cared for.
Nutrition and Hydration 🥗: Provide adequate nutrition and hydration as needed.
Quality of Life 🌟: Focus on improving the patient’s quality of life and making their remaining time meaningful.

Advice for Family and Caretakers:

Emotional Support 🤗: Offer love, comfort, and a reassuring presence to the patient.
Respect Wishes 🤝: Respect the patient’s end-of-life decisions and preferences.
Effective Communication 🗣️: Keep open and honest communication within the family.
Self-Care 🧘: Care for your own well-being to provide the best support to the patient.
Religious and Spiritual Support 🙏: If the patient is religious, help them connect with their faith.
Create Memories 📷: Spend quality time together and create meaningful memories.
Coordinate with Healthcare Providers 🏥: Collaborate with healthcare professionals for optimal care.
Address Pain and Symptoms 💊: Ensure the patient is comfortable and free from distressing symptoms.
Make Legal and Financial Arrangements 💼: Address legal and financial matters as needed.
End-of-Life Planning ✍️: Discuss and plan for the patient’s end-of-life care and preferences.

Nearing death awareness Read More »

Will Making

Will: This document expresses the desires of a person regarding the distribution of their property among specific individuals or parties after their demise.

Will: A will is a document created by an individual during their lifetime, wherein they state how their property and affairs should be handled after their death.

Will: A will is a written document produced by a person while they are alive, clearly instructing how their property should be managed or divided following their passing.

In Uganda, the law governing inheritance is outlined in the SUCCESSION ACT, Chapter 139 of the Laws of Uganda, as amended by Decree No. 22 of 1972.

This legislation covers the process of creating wills and the subsequent procedures following the death of a will-maker. It also addresses the distribution of property when a person passes away without leaving a will.

However, customary laws and practices often prevail over the legal provisions, leading to property distribution that may not adequately consider the welfare of widows, widowers, and children. Consequently, it is crucial for individuals to create a will during their lifetime to ensure that their property and assets are distributed according to their wishes.

Terms used in the Will

Administrator/Administratrix: A person authorized by a court of law to manage the property owned by the deceased.
Child: An individual under the age of 18, including both legitimate and illegitimate children.
Customary heir: A person designated by the deceased or the family clan members to succeed the deceased based on the customs of the deceased’s tribe.
Deceased: A person who has passed away.
Dependent relatives: These include a spouse, children under the age of 18, or children above 18 who were substantially dependent on the deceased. It also encompasses parents, siblings, grandparents, or grandchildren who relied significantly on the deceased for their basic needs.
Estate: Refers to all the immovable and movable assets of the deceased, such as houses, agricultural produce, land, livestock, food supplies, personal belongings, motor vehicles, shareholdings, bank deposits, and outstanding debts owed to the deceased.
Executor: A male individual appointed in the will of a deceased person to carry out the instructions stated in the will.
Executrix: A female individual appointed in the will of a deceased person to carry out the instructions stated in the will.
Husband: A man who is legally married according to the laws of Uganda or any other foreign jurisdiction where the marriage was celebrated.
Wife: A woman who is legally married according to the laws of Uganda or any other foreign jurisdiction where the marriage was celebrated. This term does not include individuals who had children with the deceased without being legally married.
Personal representatives: Individuals appointed by the court to manage the estate of a deceased person, upon whom probate or letters of administration have been conferred.
Probate: The legal authorization granted by a court of law to manage the estate of the will-maker.
Letters of Administration: The legal authorization granted by a court of law to a person who passes away without leaving a will.
Residential Holding: The primary residence of the deceased person.
Testator: A person who creates a will.

Types of marriages

The law of Uganda recognizes three (3) different types of marriages

Marriage Registration: Marriage celebrated either in a Registered Church, or the Office of the Chief Administrative Officer, or the Registrar General’s
Customary Marriage: A marriage celebrated according to the customs of a given tribal community in These marriages are known as a customary marriage and must be registered.
Sharia Marriage: A marriage celebrated in accordance with the Moslem religion, a Marriage celebrated in accordance with the Hindu

INHERITANCE

Inheritance is the process through which the property and responsibilities left by a deceased person are distributed among specific individuals according to the wishes of the deceased or according to the regulations outlined in the law.

There are two main ways in which inheritance occurs:

Inheritance with a Will: When a person leaves behind a legally recognized document called a will, it specifies how their property should be distributed after their death. The will serves as a guide for the distribution of assets and ensures that the wishes of the deceased are respected.
Inheritance without a Will: In cases where a person passes away without leaving a will, the distribution of their property follows the guidelines established by the applicable laws. These laws determine the order of priority for distributing the assets among the surviving family members.

HOW CAN ONE MAKE A WILL?

Eligibility: Any individual, whether male or female, married or single, can create a will. However, the person making the will must meet the following requirements:
- Be 21 years of age or older
- Be of sound mind (able to understand the implications of making a will)
- Be aware that they are creating a will
Writing the Will: A will should be in writing. The person making the will can choose to handwrite it themselves. If the individual cannot write, they may ask a trusted person to write it on their behalf, while they provide instructions.
Legal Assistance: Alternatively, a lawyer can be hired to draft the will. In such cases, the lawyer will charge a fee for their services.
Ensuring Understanding: It is important to ensure that the person making the will understands its contents and implications. Patiently explain the terms and provisions, addressing any questions or concerns.
Clarity: The will should be clear and unambiguous, leaving no room for misinterpretation.
Seek Support: During the process of making a will, provide emotional support and actively listen to the individual, as it can be a sensitive and personal matter.

WHO CAN MAKE A WILL?

Eligibility: Any individual, regardless of gender or marital status, can make a will if they meet the following criteria:
- Have reached the age of 21 years or older
- Possess sound mental capacity (able to understand the consequences of making a will)
- Act voluntarily and without coercion
- Be aware of their actions while making the will (not too sick or under the influence of alcohol or drugs)

Note: For soldiers at war or marines at sea, the minimum age for making a will is 18 years.
A person who is usually deemed mentally incompetent can create a will during periods of lucidity.
It is important to note that a person who creates a will is referred to as a “testator.” A will is not legally recognized if it is made by a person who:

Is below 21 years of age
Lacks mental capacity at the time of making the will
Was too ill to realize they had not left a will In such cases, the property will be distributed as if no will existed.

IN WHAT FORM CAN A WILL BE MADE?

A will must be in writing. It can be handwritten by the testator themselves. If the testator cannot write, they may dictate the contents to a trusted person who will transcribe it for them.

Alternatively, a lawyer can be engaged to draft the will for a fee.

IMPORTANCE OF MAKING A WILL

Clearly Expressing Wishes: A will articulates the testator’s desires, ensuring that their intentions are followed during the distribution of their property.
Asset Protection: A will establishes guidelines for managing and distributing the testator’s property, providing protection and clarity.
Guardianship Provision: A will may designate guardians for minor children, ensuring their care and well-being.
Avoiding Disputes: By clearly stating the beneficiaries and their entitlements, a will helps prevent disputes and conflicts among relatives.
Establishing Paternity: A will can help avoid disputes over the paternity of children.
Debt Collection: The executor of the will can collect any debts owed to the deceased.
Beneficiary Flexibility: A will allows the testator to allocate their property to individuals beyond immediate relatives.
Debt Settlement: The testator can indicate any outstanding debts owed to them, ensuring their repayment.
Estate Administration Guidance: A will provides instructions for the proper administration of the deceased’s assets and properties.
Responsibilities Allocation: A will can assign various relatives the responsibility of raising children or fulfilling specific duties.
Social and Financial Security: A will helps ensure the well-being and financial stability of dependents, such as orphans and widows.
Debt Acknowledgment: The testator can state if they owe any debts and specify the repayment method.

ESSENTIAL CONTENTS OF A WILL

Full Identification: The will should include the full names, place of birth, tribe, place of origin, names of parents, clan/religion, and address of the testator (person making the will).
Date of Will: The date when the will is made should be clearly stated, including the day, month, and year.
Cancellation of Previous Will: If the testator is revoking a previous will, it should be explicitly stated in the current will.
Executor(s) or Executrix: The names of the executor(s) or executrix (person(s) responsible for carrying out the testator’s wishes as stated in the will) should be mentioned.
Appointment of Heir/Heiress: The full names of the customary heir/heiress (woman entitled to inherit or has a right of inheritance) should be specified.
Guardianship: If there are minor children, the names of the guardians appointed to care for them should be included.
Marital Status and Spouse Information: The marital status of the testator should be indicated, along with the name(s) of the spouse(s) and the place and date of marriage. If separated or divorced, the date of divorce/separation should be stated.
Children: The names and number of all children, whether born within or outside marriage, should be listed.
Dependent Relatives: If the testator wishes to provide for any dependent relatives in the will, their names should be mentioned.
Property Description: A comprehensive list and description of the testator’s property should be provided. This should include assets belonging solely to the testator and not those of others.
Beneficiaries and Distribution: The names and addresses of the individuals, including spouse’s children and relatives, who will inherit the property should be stated. The will should also specify how the property is to be distributed after the testator’s death.
Additional Wishes: Any additional wishes of the testator, such as burial preferences or specific instructions related to the will, should be included.
Creditors and Debt Repayment: Any creditors to whom the testator owes money should be mentioned, along with instructions on how to repay them.
Debtors and Amounts Due: If there are individuals who owe the testator money, their names and the amounts owed should be included.
Signature or Thumbprint: The will should be signed or thumbprinted by the testator to indicate their approval and authentication.
Witness Information: The names, addresses, and signatures of at least two witnesses should be present on the will. Witnesses should not read the will but must attest that the testator voluntarily made the will while of sound mind.

Additional Information to Consider:

It can be useful to include the following details in the will:

Employment Information: Name and address of the employer, start date, job position, salary, and other benefits.
Self-Employment: If self-employed, state the nature of the work and relevant details.
Business Interests: List the names and addresses of businesses in which the testator holds shares or has an economic interest, along with the extent of such interest.
Insurance Policies: Provide information about any insurance policies that benefit the testator or their family members.
Bank Accounts: Specify the names and addresses of banks where the testator holds accounts, including the account numbers.
Burial Wishes: State burial preferences, including the desired burial location and specific instructions for the funeral.
Copies of the Will: Indicate the names and addresses of individuals or places where other copies of the will are kept.

Note: Witnesses to the will must be of sound mind, 21 years of age or older, and should not be beneficiaries named in the will. The will can be written in any preferred language as long as it is understood well by the testator and expressed in simple language.

CAN I CHANGE MY WILL?

Yes, you have the right to change your will at any time based on your preferences and circumstances. There are various situations that may warrant a change in your will, such as acquiring or losing property, having children whom you wish to include as beneficiaries, or getting married to another spouse.

If you decide to make changes to your will, follow these steps:

Create a New Will: You can either draft a completely new document or make the necessary changes to the existing will. If you choose to make changes, clearly state that it is a new will and include the date of the previous will that is being canceled.
Date and Specify Changes: Ensure that the new document is dated and explicitly states that it is amending the first, second, or subsequent wills, mentioning the respective dates. List the specific changes you want to make to the will.
Signatures and Witnesses: Sign your name on every page of the new will or the pages containing the changes, and sign again on the final page. Number the pages accordingly. Two witnesses should witness your signature or thumbprint.
Testator’s Authority: Remember that only the testator (person making the will) has the authority to change their own will. Neither the family nor the clan can alter the will on your behalf.

If a Wife or Child is Excluded from the Will:

Dependents’ Rights: It is generally expected that the testator provides for their dependents, including the wife and children. If you are a wife or child and the will does not provide for you, you can apply to the court. The court will ensure that you are adequately provided for during the distribution of assets or may redistribute the property to guarantee your share.
Matrimonial Home: The matrimonial home cannot be disposed of in a will. It automatically passes to the surviving spouse(s), and minor children below the age of 21 are entitled to live there.

Where Should a Will be Kept?

A will can be entrusted to any of the following individuals or entities, provided you trust them:

Bank Manager
Reverend, Church Priest, or Imam
Local Council Executives
Headmaster or Headmistress
A trusted friend
A spouse
The Administrator General
Your Lawyer
Legal NGOs such as FIDA (U), Legal Aid Project of the Uganda Law Society (LAP), and Legal Aid Clinic (of the Law Development Centre)
A relative
Registrar General’s Office

Invalidation of a Will:

A will may be declared invalid (not legally recognized) by the court if the following conditions are proven:

The testator was of unsound mind or senile when making the will.
The will was made under duress or threats.
The testator was underage at the time of making the will.
The testator married after making the will, rendering it invalid.
The will is ambiguous or unclear in its provisions.
The estate or subject matter of the will no longer exists before the testator’s death.
The will was not signed by the testator or witnessed.
Some or all of the property mentioned in the will was sold, given away, or destroyed before the testator’s death or execution of the will.
The will inadequately provides for the spouse(s), minor children below the age of 21, or dependent relatives who significantly rely on the deceased for their basic needs.

Note: If the court declares a will invalid, the property of the testator will be distributed according to the laws pertaining to individuals who did not create a will.

SHARING OF PROPERTY IN THE ABSENCE OF A WILL

When a person passes away without leaving a will, the law provides specific ways to distribute the property.

The following are the key points regarding property distribution:

Consolidation of Property: All the property owned by the deceased is combined into a single estate. This estate is considered as a whole, representing 100% of the assets.
Distribution Among Dependents: The estate is divided among the eligible beneficiaries based on the presence of a surviving spouse or wives, husband or husbands, and other dependent relatives.

If the deceased left behind a spouse, children, a customary heir, and other dependents, the distribution of the estate is as follows:

All children, whether legitimate or illegitimate, share equally in 75% of the property.
The widow(s) or widower receives 15% of the property along with the family home.
Dependent relatives share 9% of the property, including relatives or adopted children.
The customary heir is entitled to 1% of the estate.

Note: A widow is not considered as property and cannot be shared or taken by another male relative of the deceased husband. However, a widow can choose to remarry freely, even within her former husband’s clan. It is illegal to evict a widow from her former husband’s home.

If the deceased has no children but is survived by a spouse or dependant relatives, the distribution of the estate is as follows:

The wife/wives or husband receives 50% of the property.
Other dependant relatives share 49% of the property.
The customary heir is entitled to 1% of the estate.

If the deceased leaves behind only a wife or dependant relatives, and the customary heir, with no children, the property is distributed as follows:

The wife/wives or husband and dependant relatives (as the case may be) receive 99% of the property.
The customary heir is entitled to 1% of the estate.

Duties and Responsibilities:

Guardians: The responsibilities of guardians appointed in a will include:

Caring for and guiding the children.
Safeguarding the children’s property and ensuring it is used only for their benefit, protecting it from misuse by other relatives.
When the children come of age, handing over the remaining property and providing an account of how it was utilized. Misuse of a child’s property by a guardian is legally punishable.

Executors/Executrix Named in the Will: The duties of executors/executrix named in a will are as follows:

Reporting the death to the office of the Administrator General or the Chief Administrative Officer within two months.
Applying to a court of law for the necessary powers to carry out the wishes of the deceased, as stated in the will.
Collecting the deceased’s property and any outstanding debts owed to or by the deceased at the time of death.
Submitting an account of the estate to the granting court within six months, detailing the distribution of the property.
Supporting the widow/widower, children, and dependant relatives, including paying for children’s school fees, using the funds from the deceased’s estate if available.
Distributing the property according to the deceased’s wishes as stated in the will after fulfilling all the above requirements.

Note: If the will does not name any executors/executrix, close individuals such as the widow/widower, heir, or adult children may individually or jointly apply to the court for letters of administration to handle the affairs of the deceased. This application is made after obtaining a letter of no objection from the Administrator General.

Role of the Local Council: The local council plays a role in inheritance matters, which includes:

Protecting widows and children from relatives who may attempt to claim their property.
Confirming and reporting the death of a person to the office of the Administrator General and the court.

Letters of Administration: Letters of Administration are the authority granted by the court to a person for administering the estate of a person who died without leaving a will.

Eligibility for Applying for Letters of Administration: The following individuals may apply for letters of administration:

The surviving wife/wives or husband of the deceased.
Adult children of the deceased.
Close relatives of the deceased.

Requirements for Obtaining Letters of Administration:

Reporting the death of the deceased with all the necessary documents.
Applying to the Administrator General for a “Certificate of No Objection.”
The certificate of no objection serves as clearance and enables the person to apply to the court for letters of administration.

Note: The acceptance of children by the deceased during their lifetime is a prerequisite for their eligibility to apply for letters of administration.

The situations outlined above represent the most common scenarios in everyday life. However, the following points should also be noted when applying any of these distribution schemes:

Residential Holding: The residential home is not included in the property subject to distribution as outlined above. The residential holding should be held by the person to whom letters of administration have been granted, in trust for the legal heir. The widow and children below a certain age are entitled to reside in the home until specific conditions are met.

In the case of a widow, these conditions include her death, remarriage, or ceasing to occupy the house for six consecutive months, or voluntarily surrendering it.
For female children, these conditions include death, reaching the age of 21, marrying before reaching 21, or ceasing to reside in the house for six consecutive months.
For male children, these conditions include death, turning 18, ceasing to reside in the house for six consecutive months, or more.

Multiple Legal Wives: In cases where there are multiple legal wives, they share the property given to them equally.
Separated Wife’s Entitlement: If a wife has been separated from her husband as a member of the household and the husband dies without a will, she will not automatically be entitled to share in the deceased’s property. She can apply to the court within six months from the husband’s death to request a share of the property. She must demonstrate that there was a reasonable cause for the separation.
Distribution in the Absence of Legal Wife: If a husband’s legal wife passes away without a will, he is entitled to 15% of the property or a larger share if there are no children or dependent relatives to share the estate.
Equal Share for Children: All children, regardless of their birth status (within or outside wedlock), share equally in the children’s share of the deceased’s estate.

It is important to note that it is illegal for anyone to evict the widow or children from the residential home, or to handle the estate without proper court authority.

Will Making Read More »

ETHICS AT THE END OF LIFE

Hastened death: It refers to the act of accelerating the dying process as a response to suffering in the context of a life-threatening condition where the patient sees no other way out.
Assisted Death: This form of euthanasia involves aiding an individual who expresses a desire to die prematurely, either through counseling or by providing a lethal substance.
Assisted suicide: It involves self-killing with the assistance of another person, often a physician or healthcare provider.
Physician-assisted suicide (PAS): This term specifically refers to assisted suicide carried out by a physician or healthcare provider.

Causes/Reasons for Hastened Death

Feeling like a burden to others.
Loss of control over the circumstances of death.
Lack of social support.
Perceived loss of dignity.
Poor quality of life.
Lack of meaning in life.

Approach of a Nurse to a Request for Hastened Death from a Patient

When faced with a request for hastened death, as a nurse, it is important to:

Ensure a clear understanding of what the patient is asking for.
Acknowledge and validate the patient’s suffering.
Actively listen to the patient, paying attention to both verbal and non-verbal communication. Assess the patient for physical, psychosocial, and spiritual distress.
Collaborate with the patient to develop a comprehensive care plan.
Inquire about the patient’s physical symptoms, including pain, dyspnea, nausea, fatigue, constipation, insomnia, itching, and other symptoms specific to their condition. Uncontrolled symptoms can contribute to a request for hastened death if the patient feels it is the only escape from suffering.
Explore the patient’s past experiences with death, which can provide insights into their fears and concerns about their own future.
Identify signs of depression, as it can be challenging to differentiate between physical symptoms of advanced illness and depressive symptoms.
Identify a team member who can establish a strong rapport with the patient and gain a deep understanding of their personal history, cultural background, and relationships. This team member can facilitate communication with other healthcare professionals and provide counseling support based on their expertise.
Understand the nature of the patient’s suffering, considering all dimensions of their experience. Suffering arises when there is a perceived threat to the person’s integrity or continued existence.
Consider the patient’s personal history, including previous experiences with illness and death, significant losses, and unfulfilled hopes and dreams, to ensure that no sources of suffering are overlooked.
Actively investigate and effectively treat symptoms.
Refer the patient to palliative care specialists, anesthetists, interventional radiologists, psychiatrists, and psychosocial and spiritual care providers to ensure comprehensive medical, psychological, and spiritual treatment of the patient’s pain and other symptoms.

Ethics and Legal Considerations in Hastened and Assisted Death

The Controversy: There is an ongoing debate surrounding hastened and assisted death. Advocates argue that terminally ill patients should have the right to die with dignity, while opponents believe that ending one’s own life goes against the principles of the Hippocratic Oath and the sanctity of life.
Ethical Implications of Physician-Assisted Death:
a. Patient Autonomy: Patients possess the ultimate authority over their lives. However, the question of whether physicians should assist them in carrying out suicide raises ethical concerns.
b. Persistent Ethical Arguments: Despite legal and political changes, the ethical arguments against the legalization of physician-assisted suicide remain compelling.
The Right to Choose:
a. Dying with Dignity: Advocates assert that terminally ill patients should have the right to die with dignity. Allowing assisted suicide would provide them with a final exercise of autonomy in their dying process.
b. Humanizing the Choice: By granting the right to choose when to die, individuals would be recognized as active participants in their own lives rather than being seen as mere spectators waiting for death.

ETHICS AT THE END OF LIFE Read More »

ADVANCE DIRECTIVES IN PALLIATIVE CARE

An advance directive, also known as an Advance Directive, is a legal document that upholds the principle of autonomy by expressing a patient’s desires regarding medical treatments when they are unable to make decisions themselves.

Advance directives serve as essential tools for documenting end-of-life patients’ wishes when they are no longer able to make decisions about their medical care. In palliative care, the two most common types of advance directives are:

Living will
Durable power of attorney for healthcare, also known as the healthcare power of attorney or healthcare proxy.

Living Will

A living will is a legally binding document that allows individuals to maintain control over their healthcare decisions in the event that they become incapable of making choices on their own.

It specifically applies to situations where the person has a terminal illness with no possibility of cure or is in a permanent unconscious state, often referred to as a “persistent vegetative state.”

The purpose of a living will is to outline the types of medical treatments the person would or would not want in these circumstances, including decisions regarding life-prolonging measures such as dialysis, tube feedings, or artificial life support like breathing machines.

This document must be written and signed by the patient, and it usually requires witnesses who are not spouses, potential heirs, the patient’s doctors, or employees of the patient’s healthcare facility.

Things to be included in the Living will

Key Elements of a Living Will

Use of medical equipment, such as dialysis machines or ventilators.
Instructions regarding “do not resuscitate” orders, indicating preferences regarding CPR if breathing or heartbeat stops.
Choices regarding the administration of fluids (typically through intravenous means) and/or nutrition (tube feeding) if the person becomes unable to eat or drink.
Decision on whether to receive food and fluids even when unable to make other decisions.
Preferences for pain management, symptom control, and palliative care, even if decision-making capacity is compromised.
Desire to donate organs or other body tissues after death.
Understanding that choosing not to pursue aggressive medical treatment is distinct from refusing all forms of medical care. Other forms of treatment, such as pain medication and antibiotics, can still be administered to ensure comfort, shifting the treatment goal from cure to comfort. It is crucial to clearly express specific preferences and wishes in the living will.

Note: The client has the right to revoke or amend a living will at any time according to their wishes.

Durable Power of Attorney for Health Care / Health Care Power of Attorney

A durable power of attorney for health care, also known as a health care power of attorney, is a legal document that enables the client to appoint a trusted person as their proxy or agent to make health care decisions on their behalf in the event that they become unable to do so.

Principles

The appointed proxy or agent has the authority to communicate with doctors and caregivers and make decisions based on the client’s previously expressed directions.
The chosen proxy determines the treatments or procedures that the client would want or not want. If the client’s wishes are unknown in a particular situation, the agent will make decisions based on what they believe the client would choose.
It is essential to select a person as the proxy whom the client trusts to carry out their wishes, especially in times of stress, uncertainty, and sadness.
The client should have open discussions with their chosen proxy, ensuring they are comfortable with the role and discussing their wishes in detail.
It is advisable to designate an alternate person in case the primary proxy becomes unable or unwilling to fulfill their role. The law generally prohibits health care providers, such as doctors, nurses, or other caregivers, from serving as agents unless they are close relatives.

Client’s Health Care Agent

The following considerations apply to the person chosen as the client’s health care agent:

Must be 18 years of age or older.
Cannot be the client’s treating health care provider.
Cannot be an employee of the client’s health care provider, unless they are related to the client.
Cannot be the client’s residential care provider, unless they are related to the client.
Has the authority to make health care decisions on behalf of the client only when the attending doctor certifies the client as incapable of making their own decisions.
Must make health care decisions on behalf of the client if the client has not documented their health care directives, even in end-of-life situations.
Cannot make decisions for the client if the client objects, regardless of their capacity.
Cannot override a medical power of attorney if one is in effect.

Terms Used in Advance Directives

Do Not Resuscitate Order(DNR)

Resuscitation refers to the medical intervention of restarting the heart and breathing, such as through CPR or the use of life-sustaining devices.

Do Not Resuscitate (DNR) orders are instructions that indicate medical staff should not attempt to revive a patient if their heart or breathing stops.

In the hospital: A DNR order means that no life-saving measures will be taken if the patient’s heart or breathing ceases. It allows for a natural death and may be referred to as an “Allow Natural Death” order. While in the hospital, patients can request a DNR order from their doctor, although some hospitals require a new order with each admission. It’s important to note that a hospital DNR order is only applicable within the hospital setting.
Outside the hospital: Some states have an advance directive known as a Do Not Attempt Resuscitation (DNAR) or special Do Not Resuscitate (DNR) order for use outside the hospital. This order is specifically designed for Emergency Medical Service (EMS) teams and allows patients to refuse full resuscitation efforts in advance, even if EMS is called. It requires the signature of both the patient and the doctor.

Physician Orders for Life-Sustaining Treatment (POLST)

Physician Orders for Life-Sustaining Treatment (POLST) is not an advance directive but a set of specific medical orders that a seriously ill person can complete and have signed by their doctor. The POLST is carried with the patient and is applicable in various healthcare settings. Emergency personnel, such as paramedics and emergency room doctors, are obligated to follow these orders. Without a POLST form, emergency care staff typically provide all possible treatments to keep the patient alive.

Pregnancy

If a woman is of childbearing age, it is important for her to clearly state her decisions regarding healthcare during pregnancy in case of unforeseen circumstances. Whether healthcare providers will honor these decisions depends on factors such as the risks to both the mother and the fetus, the stage of pregnancy, and the policies of the doctors and healthcare facilities involved. Generally, if a woman is in the second or third trimester of pregnancy, doctors will provide necessary medical care to preserve the lives of both the mother and the fetus.

Organ and Tissue Donation

Instructions for organ and tissue donation can be included in the advance directive. Many states also offer organ donor cards for this purpose.

Note: While older adults are the primary demographic with advance directives, it is never too soon to plan for emergencies. For individuals concerned about mental illness, a mental health care directive or psychiatric care directive can outline healthcare choices in the event of serious mental incapacity.

Advantages of Advance Directives

Advance directives provide a simple and clear way for clients to express their wishes in case they become incapacitated and unable to communicate.
These directives allow clients to appoint a trusted person, such as a family member or close friend, to make decisions on their behalf when they are unable to do so or in specific circumstances they have designated.
Creating an advance directive helps alleviate the stress for both family members and healthcare professionals before a serious injury or illness occurs.
By using an advance directive, the course of medical treatment can be guided effectively throughout the patient’s hospice care.
Through an advance directive, patients can communicate their preferences and choices to healthcare providers while they are still able to do so.
Having an advance directive helps ensure that the patient can avoid unnecessary pain by clearly stating their wishes regarding medical procedures.
It also helps the patient avoid unwanted hospitalization by providing instructions on preferred locations for end-of-life care, such as hospice or home.

How a Nurse Can Help a Patient Prepare for Writing an Advance Directive

Assessing and identifying of the patient’s need of an advanced directive.
Informing the patient about the purpose and importance of advance directives.
Providing necessary information to the patient regarding the process of writing an advance directive, including the following:

Emphasizing that a lawyer is not required to prepare advance directives.
Encouraging the patient to inform their physician and loved ones about their specific requests.
Assisting the patient in appointing a healthcare agent who understands their values and is important to them.
Discussing the patient’s preferences for end-of-life care, such as staying in hospice or at home.
Clarifying that advance directives can be official with the signatures of two witnesses who are not named in the document, without the need for an attorney or notary. The completed document should be given to the physician for inclusion in the medical record.
Advising the patient to have someone review the documents to ensure they are filled out correctly.
Stressing the importance of carefully reading and following all instructions to include all necessary information and ensure proper witnessing.
Recommending the patient make multiple photocopies of the completed documents.
Advising the patient to keep the original documents in a safe yet easily accessible place and inform others about their location. The location of the originals can be noted on the photocopies.
Cautioning against keeping advance directives in a SAFE DEPOSIT BOX as others may need access to them.
Encouraging the patient to provide photocopies to their healthcare proxy (agent), doctors, and anyone else involved in their healthcare.

ADVANCE DIRECTIVES IN PALLIATIVE CARE Read More »

DEATH AND DYING

Death is the cessation of life for an individual or organism.

It marks the end of all biological functions that sustain life.

Fears and Concerns surrounding Death

When facing death, patients may have various fears and concerns:

Fear of experiencing pain and suffering during the dying process.
Fear of not being able to cope with the impending death.
Fear for the well-being and survival of loved ones after their own passing.
Fear of the unknown and what lies beyond death.
Fear of leaving unfinished tasks or responsibilities behind.
Fear of being alone in the house once their loved ones are gone.
Family concerns may include unresolved matters or tasks, decisions regarding resuscitation, transportation of the body after death, and burial arrangements.

Principles for Managing Death and Dying

Acknowledge that death is a natural part of life, and individuals should be allowed to pass away peacefully and with dignity.
Provide adequate pain and symptom management throughout the dying process.
Understand that palliative care neither hastens nor postpones death but recognizes dying as a normal process.
Deliver palliative care in a culturally sensitive manner, respecting individual beliefs and practices.
Recognize that patients receiving palliative care often have life-threatening illnesses, such as HIV/AIDS and cancer, allowing for a preparatory period for death.

Signs of Approaching Death

There are certain common signs that indicate the end of life, and it’s important for caregivers to recognize these signs and prepare the family accordingly.

Decreasing Social Interaction: Dying patients may become less socially interactive and exhibit behaviors such as confusion, mumbling, staring into space, plucking at bedclothes, odd hand movements, hallucinations, and agitation. These behaviors can be attributed to failing blood circulation, electrolyte imbalances, or multi-organ dysfunction. Clinical Management:

Explain to the family what is happening and encourage them to allow the patient to rest.
Encourage the family to be present and observant.
Maintain a familiar and comforting environment.
Provide good nursing care and explain the care procedures to the family.
Encourage the family to continue talking to the patient and engage in therapeutic touch, such as holding hands.

Pain: Pre-existing pains may worsen, and new sources of pain may arise. Clinical Management:

Monitor pain relief carefully and continue administering analgesics regularly, even if the patient is comatose.
Review drug dosages as side effects may become more prominent.
Adjust morphine dosing if there is reduced or no urine output.
Stop most drugs as side effects accumulate.

Decreasing Fluid and Food Intake: The patient may have reduced appetite and difficulty eating and drinking. Clinical Management:

Educate the family that food may be nauseating and eating/drinking becomes challenging.
Explain that forcing fluids may cause more problems than withholding, such as the risk of aspiration.
Address concerns about dehydration and emphasize that it is a protective response.
Keep the patient’s mouth clean and moist.
Respect the patient’s wishes regarding food and fluid intake.

Changes in Elimination: Urine and stool output may decrease or stop, and incontinence is possible. Clinical Management:

Reassure the family that changes in elimination may not cause discomfort for the patient.
Assist and educate the family in proper skin and pressure area care.
Use appropriate aids (urinals, bedpans, or catheters) as necessary.

Respiratory Changes: Breathing patterns may change, such as Cheyne-Stokes respiration. The presence of death rattle, a noisy and rattling breathing sound, can be distressing for relatives but usually not for the patient. Clinical Management:

Explain the nature of death rattle and reassure the family and staff.
Optimize positioning to aid postural drainage if applicable.
Suction is seldom necessary and may be traumatic unless the patient is deeply unconscious.
Anti-muscarinic medications can be used to address salivary pooling in death rattle.
Reassure family members about Cheyne-Stokes breathing, as periods of apnea can occur before death.

Circulatory Changes: The extremities may feel cold and appear bluish or grayish. Clinical Management:

Keep the patient covered and warm.
Provide gentle explanation to the family to help them understand the cause of these changes.

Journeying Towards the End of Life(Road to Dying)

It is not possible to accurately predict the exact time of death; however, certain signs indicate that death is approaching.

The dying person may remain aware of their surroundings until the moment of death, though with some limitations such as confusion, mumbling, staring into space, odd hand movements, or seeming to see things. It is important to be mindful of this and engage in conversation, including the patient even if they appear asleep or unconscious.

Encourage ongoing communication with the patient, even when they are too weak to respond.
Reduce unnecessary medications while ensuring effective pain and symptom control.
As the patient nears death, organ function declines. Hepatic and renal functions are reduced, causing medications to linger in the body. This may lead to side effects as the active ingredients accumulate in the bloodstream.
- Action: Temporarily stop morphine for a day (with instructions for breakthrough pain), then resume at a lower dose or longer intervals between doses.

Signs of Death

Breathing ceases entirely.
Heartbeat and pulse stop.
Patient is unresponsive to shaking or shouting.
Eyes may be fixed in one direction, with eyelids open or closed.
Eyeballs become soft.
Skin tone changes.
Generalized stiffness of the body (rigor mortis) occurs several hours after death.

Preparing to Care for the Dying

Preparing Yourself:

Reflect on your own thoughts about death and preferences for dying, which can help you empathize with patients and families. However, avoid projecting your own preferences onto the patient.
Get to know the patient and their family as much as possible before death. If referred late, spend time with them to build trust.
Ensure the patient and their family are aware of your commitment to providing care.
Prepare the patient and their family well in advance for the impending death.
Acquire knowledge about medical management for all possible events.
Be sensitive to spiritual aspects and address them accordingly.
Encourage the family to communicate with the patient, provide reassurance, and engage in appropriate religious practices.
Inquire about any special requests the patient may have for their family after death.
Respect and be knowledgeable about religious and cultural rituals related to death and dying.
Facilitate bereavement support for the family.
Recognize your own emotional attachment to the patient and seek support from a trusted team member.
Remember that autonomy is crucial for adults with cognitive capacity to make decisions.

Preparing the Patient and Family:

Gently ensure the patient and family understand that death is near and explain some signs of dying, such as increased drowsiness, changes in breathing pattern, death rattle, Cheyne-Stokes respiration, changing skin color, and possible terminal restlessness.
Encourage the presence of loved ones, physical touch, prayers, and support from friends and family to bring comfort to the patient.
Reassure the patient and family that dying is typically not uncomfortable and that certain signs (e.g., grunting) do not necessarily indicate pain.
Be prepared to discuss and support cultural needs, as long as they do not cause suffering to the patient.
Address issues related to wills, inheritance, and unfinished business, providing guidance to help protect the bereaved.

Key Considerations in Caring for Dying Patients:

Explain the situation to the family and encourage them to allow the patient to rest.
Maintain a familiar environment for the patient.
Promote therapeutic touch within the family.
Encourage family members to be observant.
If the patient is experiencing pain, continue pain management without discontinuing analgesics, while monitoring relief carefully. Adjust drug dosages if needed.
Respect the patient’s wishes.
Keep the patient’s mouth clean and moist.
Provide support and address the concerns of the patient’s family.

Management of a Dying Patient in Palliative Care

Providing holistic care continues until the end of life and beyond. When necessary, seek assistance from other team members or organizations. There are different paths towards dying, and while most patients follow the “usual” road, some may face a more challenging journey. It is crucial to offer support to these patients and their families.

Navigating the Challenging Path:

Address restlessness, confusion, hallucinations, and delirium by administering haloperidol at a dose of 1.5-2.5mg. First, rule out remediable causes such as a full bladder or rectum.
Treat seizures with diazepam, 5-10mg via intravenous (IV) administration, or if IV is not possible, intramuscular (IM) injection. Alternatively, administer midazolam, 2.5-5mg subcutaneously (SC), which provides relief for up to three hours.
Maintain a calm and supportive environment for both the patient and their family members, offering appropriate physical touch and emotional comfort.

As the disease progresses towards the end of life, there may be an escalation in pain and other symptoms, necessitating adjustments and increased drug therapies. Although good palliative care should ideally control pain before the terminal stage, this may not always be the case.

The pain and symptom assessment and management strategies discussed in previous chapters remain applicable during the terminal phase of illness. However, alternative methods of analgesic administration may be required due to decreased oral intake and consciousness. These methods include:

Rectal administration
- Morphine suppositories may be available.
- Long-acting morphine, such as MST given every 12 hours, can be used rectally.
Sublingual or buccal administration
- Morphine solution can be absorbed from the buccal mucosa, although higher doses may be needed due to variable absorption.
- This method is suitable for moribund patients.
Subcutaneous administration
- The subcutaneous route is useful when the patient cannot ingest medication.
- Intermittent dosing with subcutaneous injections (using a butterfly needle) can be administered, such as 4-hourly morphine.
- Cultural and environmental factors need to be considered before using this route, as acceptability may vary across different regions.

Care After Death:

Allow the family to carry out rituals immediately after death according to their customs or religion.
The body may need preservation and transportation, which can be done in a mortuary or traditionally in the village, allowing for a funeral to take place up to 10 days later.
In Africa, burials often occur within 48 hours, particularly for Muslims who must be buried before sunset on the day they died.
Different customs and rituals are followed in various parts of Africa. For example, many cultures believe the spirit remains present for several days after death.
Friends and relatives may accompany the body for the first 24 hours, providing prayers, hymns, and comfort for both the body and the family.
Some cultures may place food and precious belongings in the coffin.
Burial may take place in the ancestral home or the garden.
Cremation is rare in some African countries, and the depth of bereavement may vary across cultures.

Special Considerations in HIV and AIDS:

Patients who are dying should receive a similar approach to care, regardless of their specific disease.
Simplify the medication regimen to focus only on medicines needed for symptom control, which may involve stopping antiretrovirals (ARVs) or anti-TB treatment.
Home-based care services and HIV support services play a crucial role in providing care.
Ensure that all caregivers are aware of universal precautions, especially when handling bodily fluids.
It can be challenging to determine the end of life for patients with opportunistic infections (OI) who experience severe illness, recover after treatment, and then become ill again.

DEATH AND DYING Read More »

BEREAVEMENT, MOURNING AND GRIEF

Bereavement is the state of having lost something or someone.

The experience of someone who is grieved or bereaved is entirely individual. The way a person grieves depends on a number of factors such as one’s personality and coping style, life experience, faith, and the nature of the loss grieving process takes time.

Grief: is a process of emotional, cognitive, functional behavioral responses to loss or death

Grief is the emotional and psychological experience activated by loss of something dear.

Grief is a natural response to loss. It is the emotional suffering you feel when something or someone you love is taken away. It is felt by an individual, family or community brought about by loss; most intensely with the death of a loved one (HAU, 2011).

Mourning is the period of time it takes to grieve

Periods of mourning vary according to:

The manner of death (long illness, sudden death or traumatic death such as car accident, murder, medical mistake)
The age of the person who dies (a child’s death often feels out of place; an older person has often had longer relationships)
The age of the bereaved (child development affects reaction; life stage is relevant)
Gender (women are often allowed more emotional expression than men)
Previous experiences of loss and their impact
Support systems
Personal coping styles
Family and cultural

Stages of Grief/Grieving

Peoples’ experiences of grief may go through stages as described below. These stages may not be orderly always as some may be missed out sometimes. These include

Stage One: Denial – refusal to believe that death would be likely outcome of this illness. No, not me ‘The tests must be wrong. God would not allow this to happen to me. There has been some mistake.’
We deny that the trauma or loss has occurred. We begin to use;
- Magical thinking: believing that by magic, this memory will go
- Regression: Believing that if we act child-like, others will reassure us that nothing is
- Withdraw: Believing that we can avoid facing the losses and the truth
- Rejection: Believing we can reject the truth and avoid facing the loss
Stage Two: Anger – questioning ‘Why me?’ It’s not fair!’ Who or what can I blame for this illness?’
- We become angry with God, it ourselves, or with others over our pain.
- We pick out a scapegoat on which to vent our anger e.g. the doctor, nurse, hospital,
- We begin to use;
- Self-blaming believing we should blame ourselves for the blame of our trauma.
- Switching blame believing we should blame others
- Aggressive anger believing we have a right to vent out the blame rage aggressively.
- Anger is a normal stage; it must be expressed to be If it is suppressed and help in, it will become locked away or replaced leading to depression that further drains away our emotional energy.
Bargaining – attempt to delay the disaster, ‘Yes, but. . .’‘If I give money to the church or pray and fast every day then I will recover.’
- We bargain or strike a deal with God or others to make the pain go away.
- We promise to do anything to make this pain go.
- We agree to take extreme measures in order to ask this pain disappears.
- We lack confidence in our attempts to deal with the pain looking elsewhere for answers.
- We begin to;
- Shop around believing we look for a cure for our pain.
- Take risks believing we can put ourselves in a jeopardy way to get an answer for our pain.
- Take more care for others believing we can ignore out our needs.

4. Depression – reaction to existing and impending ‘It’s me! ’‘What is the point of struggling on; it is all meaningless.

We become over whelmed by the anger, pain and hurt of our. We are thrown into the depth of our emotional response.
We can begin to have uncontrollable spells of crying, sobbing and weeping.
We can begin to into spells of deep silence, Morose, thinking and deep melancholy.
We begin to experience;
Guilt believing, we are responsible for our loss.
Loss of hope believing we have no hopes or being able to return back to order in life and calm.
Loss of faith believing that because of this loss, we can no longer trust.

5. Acceptance – peaceful resignation it’s part of life. I have to get my life in order. We begin to reach a level of awareness and understanding of the nature of our loss

We can now;
Describe the terms and conditions in our loss
Cope with our loss
Handle the information surrounding this loss in a more appropriate way.
We begin to use;
Adaptive behavior, believing we can begin to adjust our lives to the necessary changes
Appropriate emotion, believing we begin to express our emotional responses freely and are better able to verbalize the pain, hurt, and suffering we have experienced
Patience and self-understanding, believing we set a realistic time frame in which to learn to cope with our changed lives.

Types of grief

Normal/uncomplicated grief: It is the ability of a person to progress satisfactorily through the stages of grieving to achieve resolution.
Anticipatory grief: is the type of grief before an expected loss.
Maladaptive grief: it is the inability to progress satisfactorily through the stages of grieving to achieve resolution i.e. the following types of maladaptive include:
1. Delayed: is the type of grief not experienced immediately after a loss possibly postponed.
2. Inhibited grief: the type of grief experienced by people who have great difficulty in expressing their emotions i.e. children
3. Chronic grief/prolonged grief: It’s a situation where the grieved person continues to feel the effects of loss which extends for a long time and behaves in an abnormal way which may manifest as:
  - Frequent visits to the grave
  - Low self esteem
  - Crying whenever he/she learns of other deaths
  - Speaking and over focusing on the dead person
  - Loss of libido
  - Vague aches
Disenfranchised grief: the type of grief that occurs when a loved person or item losses some of its adorable characteristics through still present i.e. one experiences loss when a loved there is decline in physical abilities in a dementia person through still present/alive
Cumulative grief: the type of grief that occurs when multiple loses are experienced often in a short period of time i.e. it can be stressful because one does not properly grieve one loss before the other
Masked grief: it is the type of grief converted into physical symptoms or other negative behaviours that are out of character i.e. someone experiencing masked grief is unable to recognize that these symptoms or behaviors are connected to loss.
Distorted grief: it presents with extreme feeling of guilt or anger, noticeable changes in behavior, hostility towards a particular person plus other self-destructive behaviors.
Exaggerated grief: it is the intensification of the normal stages of grief as the time moves on.

Factors that can make grief more challenging, harder and prolonged.

Relationship with the deceased: The nature of the relationship you had with the person who passed away can affect the intensity and duration of grief. Having a close and positive relationship can make it harder to let go compared to a difficult or distant relationship.
Circumstances of death: The circumstances surrounding the death can impact the grieving process. Factors such as whether the death was due to natural causes, accident, suicide, or homicide, as well as whether it occurred close to or far from home, can influence the grieving experience.
Personal history: Past experiences of loss and separation, such as the early loss of a parent, can affect how an individual processes and copes with grief.
Individual personality and beliefs: Each person has unique personality traits and belief systems that can influence how they experience and handle grief. These factors can vary greatly from person to person.
Social factors: The social context surrounding the loss can play a role in the grieving process. If the loss is socially stigmatized or not openly acknowledged, such as in the case of AIDS or suicide, it can add additional challenges to the grieving individual. Lack of social support can also make the grieving process more difficult.
Unacknowledged grief: Certain groups, such as gay men, lesbians, and children, may experience grief that is not fully acknowledged or recognized by society. This lack of validation can make the grieving process more complicated for individuals in these groups.

Common reactions in bereavement

Physical Reactions	Emotional Reactions	Social Reactions	Spiritual Reactions
Aches and pains	Disbelief	Needing to say goodbye	Questioning why this has happened
Nausea and/or vomiting	Numbness	Interaction with people at public gathering, funeral	Challenging the belief system (strengthening, decrease or change in beliefs)
Headaches	Sadness	Selecting and undertaking rituals	Bargaining with a higher power
Confusion, weakness and numbness	Crying, even sobbing	Self-absorption and anti-social behaviour	Talking to the deceased
Change in sexual needs (loss/increase of libido)	Unexpected thoughts and feelings, often painful	Needing to talk of the deceased	Dreams that may have significance about the deceased
Vulnerability to infections, cold, illness (low immunity)	Guilt	A sense of isolation from the world (‘in a bubble’)	Review of the meaning of life
Changes in eating and sleeping patterns	Panic and fear	Attempting to carry on as usual (social face)
Shortness of breath	Appearing distracted	Needing to be alone or need to be with others
Dry mouth	Feelings of helplessness
Sweating	Anger (at self and others)
Frequent urination	Blame
	Regret

Grief Counseling

Grief counseling and bereavement support play a crucial role in helping individuals and families navigate the challenging journey of loss. By implementing effective principles and strategies, counselors can provide compassionate care and assist in the healing process.

Principles of Effective Grief Counseling

Convey Support and Compassion: Show empathy and understanding towards the grieving individual, offering a safe space for them to express their emotions.
Acknowledge the Loss: Validate the significance of the loss and create an environment where the person feels heard and understood.
Accept the Inability to Control: Help individuals recognize that grief is a natural process and that they cannot control or hasten its course.
Validate Feelings, Thoughts, and Behaviors: Acknowledge and normalize the range of emotions, thoughts, and behaviors experienced during grief, providing validation and reassurance.
Channel Energy to Adapt and Reestablish Equilibrium: Assist individuals in redirecting their energy towards adapting to life without the deceased, finding new routines, and establishing a new equilibrium.
Encourage Access to Supportive Networks: Emphasize the importance of seeking support from helpful individuals, such as friends, relatives, or support organizations, to foster a sense of community and connectedness.

Bereavement Counseling for Individuals Facing AIDS/Cancer

Help Acceptance of Death: Work towards helping the patient and their family accept the finality of death, while addressing fears and finding ways to ease them.
Reflect on Achievements and Past Time: Encourage patients to reminisce about their accomplishments and meaningful moments, while identifying sources of support, such as friends and relatives.
Provide Information on Symptom Management: Offer guidance on managing distressing symptoms associated with the illness, helping alleviate discomfort and improve quality of life.
Explore Religious and Cultural Beliefs: Respect and explore the patient’s religious and cultural beliefs, assisting in connecting them with appropriate sources of spiritual support.
Discuss the Future for Family: Facilitate discussions about the patient’s concerns regarding their family’s well-being after their death, encouraging open dialogue and planning for the future.

Bereavement Counseling After Death

Encourage Presence and Farewells: Support family members in spending as much time as needed with the deceased, allowing them to say their goodbyes in their preferred manner.
Sensitivity in Language: Use the deceased person’s name instead of impersonal terms like ‘the body,’ and provide detailed information if the family was not present at the time of death.
Repeat the Story of Illness and Death: Encourage family members to share and repeat the story of the illness and death, allowing them to process their experiences and emotions.
Involve Children and Explain the Situation: Include children in discussions, explaining what is happening in an age-appropriate manner to help them understand and cope with their grief.

Continuous Counseling After Death

Use Reminders for Memories: Encourage the bereaved to use photographs or other reminders to remember the deceased and cherish memories.
Involve Extended Support Network: Engage extended family members, friends, or volunteers to continue visiting and providing emotional support to the bereaved.
Encourage Open Communication: Foster an environment where family members can openly express their feelings, including guilt, relief, pain, or anger, promoting mutual understanding and support.
Active Listening: Prioritize active listening over excessive talking, allowing the bereaved person to share their emotions and experiences without interruption.
Discourage Major Life Decisions: Caution against making significant life decisions during the immediate grieving period, as emotions may cloud judgment and practical considerations may be overlooked.
Support Rituals and Grieving Processes: Acknowledge and support the use of rituals that can aid in the grieving process, respecting the bereaved person’s cultural and religious customs.
Self-Awareness of the Counselor: Maintain self-awareness of personal losses and emotions, ensuring that the counselor remains empathetic and focused on the needs of the bereaved.
Remember Special Dates: Make an effort to remember important dates such as birthdays and death anniversaries, reaching out to offer support and remembrance.
Encourage Emotional Well-being: Promote self-care, relaxation, and socialization, reminding the bereaved of the importance of taking care of themselves during the grieving process.

Complications of Grief

Chronic Depression: Prolonged and persistent feelings of sadness, hopelessness, and lack of interest in previously enjoyed activities.
Substance Abuse: Turning to drugs or alcohol as a way to cope with the pain of grief, leading to dependence and addiction.
Suicidal Behavior: Expressing thoughts or engaging in actions that indicate a desire to end one’s life. Immediate intervention and professional help are essential.
Prolonged Grief: Experiencing intense and persistent grief symptoms beyond what is typically expected, with difficulty adjusting to life without the deceased.
Chronic Physical Symptoms without Medical Reasons: Developing persistent physical symptoms such as headaches, stomachaches, or fatigue without an identifiable medical cause.
Severe Disease: The onset or worsening of chronic or severe health conditions as a result of the stress and emotional toll of grief.
Risk-Taking Behavior: Engaging in reckless or dangerous activities, potentially as a means to escape from or numb the pain of grief.
Persistent Sleep Disorders: Experiencing ongoing sleep disturbances, such as insomnia or nightmares, that significantly impact daily functioning.
Persistent Denial: Refusing to accept or acknowledge the reality of the loss, often avoiding discussions or reminders of the deceased.
Identification with the Deceased: Developing symptoms or behaviors similar to those exhibited by the deceased, as a way of connecting or holding onto their memory.

The role of the nurse in grief and bereavement

Provide Active Listening: Nurses listen attentively and non-judgmentally to individuals experiencing grief, creating a safe space for them to express their emotions and concerns.
Support Future Exploration: Nurses encourage patients to gently explore what the future may look like without the deceased, helping them envision possibilities and find hope amidst their grief.
Assess and Foster Social Support: Nurses assess the patient’s social support systems and help them develop and strengthen connections with family, friends, or support groups, recognizing the importance of a strong support network during the grieving process.
Facilitate Time with the Deceased: Nurses respect the desires of the bereaved to spend time with the body of the deceased at the time of death, creating opportunities for final goodbyes and closure.
Respect and Validate Feelings: Nurses honor the emotions of grieving individuals without judgment, recognizing that each person’s experience of grief is unique and valid.
Identify and Normalize Grief Manifestations: Nurses assist in identifying the various manifestations of grief, such as emotional, physical, and cognitive symptoms, helping patients understand that these reactions are normal and part of the grieving process.
Aid in Identifying Meaning of Loss: Nurses help survivors explore and identify the practical implications and meaning of their loss, supporting them in navigating the challenges and adjustments that come with bereavement.

Grief and Bereavement in Children:

Introduction:

School-going children require special attention following the death of their parents compared to preschoolers.
The experience of grief varies and is influenced by factors such as age, past experiences, and personality.
Children may express grief through crying and seeking solitude.
Bereaved children may experience deep sadness and a sense of something missing.
Even if their reactions are not visible, the pain of loss remains consistent.
Many children are not encouraged to grieve initially, but as they grow older, they may feel a sense of loss that can be expressed in different ways, even into adulthood.

Concept of Grief and Loss in Children:

Children’s ability to cope with death depends on their age and cognitive development.
They encounter death through various means like seeing dead animals, watching it on TV, or hearing about it in their homes, schools, and communities.
Children living with HIV may contemplate their own mortality and may have experienced multiple losses.
After a death, children need information, reassurance, and a safe space to express their feelings and participate in counseling.

Common Reactions of Bereavement in Children:

Children’s reactions to grief vary based on their age, personal development, and environment.
Understanding of death changes as children grow older:
- Children aged 0-2 years: Experience the loss of physical contact, security, and comfort when a primary caregiver dies. Show upset through changes in sleeping or eating patterns, crying, irritability, and withdrawal.
- Children aged 3-6 years: Unable to comprehend death as permanent and may expect the deceased person to return. Confuse fact and fantasy, sometimes attributing death to magic. Grieve in intermittent bursts, appearing to forget about the death at times but becoming upset again later.
- Children aged 6-9 years: Grasp that death is permanent and universal but may still imagine it as avoidable. Develop an interest in practical aspects such as what happens to the deceased person’s body. May feel a sense of responsibility for the death based on their behavior or thoughts.
- Children aged 9-12 years: Possess a similar understanding of death as adults. Recognize that death is universal, unavoidable, and permanent. Understand that death can be sudden and fear their own mortality. Begin contemplating the meaning of life and what happens after death.
- Adolescents: Have an adult-level understanding of death. May engage in risk-taking behaviors as a way to explore life and test boundaries.

Practical Ways to Support a Grieving Child:

Storytelling: Utilize storytelling as a helpful tool for children to process loss, grief, and transition.
Support and Counseling: Provide extensive support and counseling to guide a child through the bereavement period and help them transition back to normal life without complications of grief.
Communication and Expression: Encourage open communication within the family, allowing children to express their emotions through dressing, writing, storytelling, and games.
Preparation and Truthfulness: Prepare children by explaining the truth about the loss. An unprepared child may feel overwhelmed by sudden loss and experience shock and confusion.
Coping Skills Development: Help children develop coping mechanisms to navigate their grief. Offer age-appropriate guidance and support during counseling sessions.
Age-Appropriate Communication: Speak and listen to children using language and concepts suitable for their age and level of understanding.
Consistency and Stability: Maintain consistency in the child’s daily routine and environment, recognizing that grieving children may face multiple losses, such as changes in schooling or separation from their home.
Individualized Approach: Allow each child to grieve at their own pace, respecting their unique needs and providing individualized care.
Active Listening and Empathy: Assure the child that you are listening and genuinely care about their feelings at any given moment.
Normalizing Death: Teach children that death is a natural part of life by relating it to examples from nature, such as flowers, leaves, and animals, which can help them accept the reality of death.
Patience and Understanding: Recognize that children react differently to grief, requiring patience and understanding from caregivers and professionals.
Involvement and Choices: Offer grieving children choices, such as visiting the hospital, viewing the body, or attending the funeral, empowering them to participate based on their comfort level.
Continuity and School Support: Encourage a sense of continuity in the child’s schooling, as it can help them feel that life is returning to normal.

Things to Say to Children:

Explain that death is universal and inevitable, using examples from nature like flowers and leaves.
Acknowledge that death can be unpredictable.
Assure children that it’s okay to wish the person had not died.
Validate their feelings of anger and sadness.
Encourage reliance on religion and beliefs to accept and understand the concept of death.
Do not shy away from using the words “dead” or “death.”
Reassure children that they had nothing to do with the death.
Be honest about not having all the answers.
Highlight aspects of their life that will remain unchanged, such as the same room, school, toys, and friends.
Emphasize that life continues after pain and that there will be happy times again.

Things Not to Say to Children:

Avoid saying that the deceased is “sleeping” or has been “lost,” as it can confuse and frighten children.
Refrain from suggesting that the deceased “wanted” to go to heaven, as it implies a choice that may cause the child to feel abandoned.
Avoid trying to stop the grieving process by using phrases like “big boys don’t cry.” Allow children to express their grief naturally.

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