LOSS, GRIEVING

AND DEATH

Prepared by:
Bernadette Wyne Tosoc Lee RN, MAN
 LOSS
¡ An actual or potential situation in which something
that is valued is changed, no longer available or
gone.
¡ People experiencing loss often search for the
meaning of the event and it is generally accepted
that finding meaning is needed in order for healing
to occur.
 TYPES OF LOSS
1. Actual loss – can be recognized by others as well
as the person sustaining the loss
¡ Example: Loss of a limb, loss of a spouse

2. Perceived loss – experienced by one person but

cannot be verified by others.
¡ Example: loss of youth or financial independence
¡ Both losses can be anticipatory loss . Anticipatory
loss is experienced before the loss actually occurs.

¡ Situational loss –the loss of one’s job, the death of

a child, or the loss of functional ability because of
acute illness or injury.

¡ Developmental loss – loss that occur in the process

of normal development such as the departure of
grown children from the home, retirement from a
career and the death of aged parents.
 SOURCES OF LOSS
1. Loss of an aspect of oneself – a body part, a
physiologic function or a psychological attribute

2. Loss of an object external to oneself – includes loss of

inanimate objects that have importance to the person,
such as loss of money or the burning down of a family’s
house and loss of inanimate objects such as pets that
provide love and companionship.

3. Separation from an accustomed environment

4. Loss of a loved or valued person

 GRIEF
¡ The total response to the emotional experience
related to loss

¡ Manifested in thought, feelings and behaviors

associated with overwhelming distress or sorrow.
 BEREAVEMENT
¡ The subjective response experienced by the
surviving love ones after the death of a person with
whom they have shared a significant relationship.
 MOURNING
¡ The behavioral process through which grief is
eventually resolved or altered; it is often influenced
by culture, spiritual beliefs and custom.
 TYPES OF GRIEF RESPONSE

Normal Grief Reaction

1. Abbreviated grief
§ Brief but genuinely felt
2. Anticipatory grief
§ Experienced in advance of the event

Disenfranchised Grief
¡ Occurs when a person is unable to acknowledge
the loss to other persons
Unhealthy Grief
1. Unresolved grief
§ Extended in length and severity
§ The bereaved may have difficulty expressing
grief, may deny the loss or may grieve beyond
the extended time.
2. Inhibited grief
§ Many of the normal symptoms of grief are
suppressed, and other effects, including
somatic are experienced instead.
3. Delayed Grief
• Occurs when feelings are purposely or
subconsciously suppressed until a much later
time.
4. Exaggerated Grief
• Experienced by a survivor who appears to be
using dangerous activities as a method to
lessen the pain of grieving.
 FACTORS THAT CONTRIBUTE TO
UNRESOLVED GRIEF AFTER DEATH
¡ Ambivalence (intense feelings, both positive and negative)
toward the lost person
¡ A perceived need to be brave and in control; fear of losing
control in front of others
¡ Endurance of multiple losses, such as the loss of an entire
family, which the bereaved finds too overwhelming to
contemplate.
¡ Extremely high emotional value invested in the dead person;
failure to grieve in this instance helps the bereaved avoid the
reality of the loss
¡ Uncertainty about the loss – for example, when a loved one is
“missing in action”
¡ Lack of support systems.
 KUBLER ROSS’S STAGES OF GRIEVING

STAGES BEHAVIORAL RESPONSES

Denial Refuses to believe that loss is happening
Is unready to deal with practical problems, such as prosthesis
after loss of leg.
May assume artificial cheerfulness to prolong denial

Anger Client or family may anger at nurse or staff about matters that
normally would not bother them

Bargaining Seeks to bargain to avoid loss. May express feelings of guilt or

fear of punishment for past sins, real or imagined.

Depression Grieves over what has happened and what cannot be.
May talk freely or may withdraw.

Acceptance Comes to terms with loss

May have decreased interest in surroundings and support
people.
May wish to begin making plans
 FACTORS INFLUENCING THE LOSS AND
GRIEF RESPONSES
1. Age
§ Age affects a person’s understanding of and reaction to
loss.
§ With familiarity, people usually increase their
understanding and acceptance of life, loss and death.
2. Significance of the Loss
§ Depends on the perceptions of the individual experiencing
the loss
§ Factors that affect the significance of the loss
§ Importance of the lost person, object or function.
§ Degree if change required because of the loss
§ The person’s belief and values.
3. Culture
§ How grief is expressed is often determined by the
customs of the culture
§ Some person have adopted the belief that grief is a
private matter to be endured internally.
§ Some cultural groups value social support and the
expression of loss.
4. Spiritual Beliefs
§ Most religious groups have practices related to dying, and
these are often important to the client and support
people.
5. Gender
§ Men are frequently expected to “be strong” and show very
little emotion during grief, whereas it is acceptable for
women to show grief by crying.
6. Socioeconomic Status
§ The socioeconomic status of an individual often affects
the support system available at the time of a loss.
§ A person who is confronted with both severe loss and
economic hardship may not be able to cope.
7. Support System
§ The people closest to the grieving individual are often the
first to recognize and provide needed emotional, physical
and functional assistance.
8. Cause of Loss or Death
§ Individual and societal views on the cause of a loss or
death may significantly influence the grief response.
§ A loss or death that is beyond the control of those
involved may be more acceptable than one that is
preventable.
§ Injuries or death occurring “in the line of duty” are
considered honorable.
 DEATH AND DYING
¡ Humans move from a childhood belief in death as
a temporary state, to adulthood in which death is
accepted as very real but also very frightening, to
older adulthood in which death may be viewed as
more desirable than living with a poor quality of
life.
 DEVELOPMENT OF THE CONCEPT OF
DEATH
AGE BELEIFS/ATTITUDES
Infancy to 5 years Does not understand concept of death
Infant’s sense of separation forms basis for later understanding of loss and
death
Believes death is reversible, a temporary departure or sleep.
Emphasizes immobility and inactivity as attributes of death.
5 to 9 years Understands that death is final.
Believes own death can be avoided.
Associates death with aggression or violence.
Believes wishes or unrelated actions can be responsible for death
9 to 12 years Understands death as the inevitable end of life.
Begins to understand own mortality, expressed as interest in afterlife or as
fear of death.
12 to 18 years Fears a lingering death
May fantasize that death can be defied, acting out defiance through
reckless behaviors.
Seldom thinks about death, but views it in religious and philosophic terms.
May seem to reach “adult” perception of death but be emotionally unable to
accept it.
May still hold concepts from previous developmental stages.
 AGE BELEIFS/ATTITUDES

18 to 45 years Has attitude toward death influenced by religious and cultural beliefs.

45 to 65 years Accepts own mortality.

Encounters death of parents and some peers.
Experiences peak of death anxiety
Death anxiety diminishes with emotional well-being.

65+ years Fears prolonged illness

Encounters death of family members and peers.
Sees death as having multiple meanings
 PROMOTING COMFORT IN THE
TERMINALLY ILL CLIENT
SYMPTOMS NURSING IMPLICATIONS
Discomfort Provide thorough skin care including daily baths, lubrication of skin and dry, clean
bed linens to reduce irritants.
Provide oral care at least every 2 to 4 hours.
Use soft toothbrushes or foam swabs for frequent mouth care. Apply a light film of
petroleum jelly to lips and tongue.
Eye care removes crusts from eyelid margins.
Artificial tears reduce corneal drying.
Fatigue Help the client identify values or desired tasks; then help client to conserve energy
for only those tasks.
Promote frequent rest periods in a quiet environment
Time and pace nursing activities.
Nausea Administer antiemetics; provide oral care at least every 2 to 4 hours; offer clear
liquid diet and ice chips; avoid liquids that increase stomach acidity such as coffee,
milk, and citric acid juices.

Constipation Give preventive care, which is most effective: increase fluid intake; include bran,
whole grain products, and fresh vegetables in diet; encourage exercise.
Administer prophylactic stool softener.
Assess for fecal impaction.
 SYMPTOMS NURSING IMPLICATIONS
Diarrhea Confer with physician to change medication if possible.
Provide low-residue diet.
Urinary Incontinence Protect skin from irritation or breakdown.
Indwelling urinary catheter or condom catheters may be used.
Inadequate Nutrition Serve smaller portions and bland foods, which may be more palatable.
Allow home-cooked meals, which may be preferred by client and gives the
family a chance to participate.

Dehydration Remove factors causing decreased intake; give antiemetics, apply topical
analgesics to oral lesions.
Reduce discomfort from dehydration; give mouth care at least every 4 hours;
offer ice chips or moist cloth to lips.
Ineffective breathing patterns, Treat or control underlying cause.
e.g. dyspnea, shortness of Maximize client’s oxygenation, e.g. position client upright, provide
breath supplemental oxygenation, maintain a patent airway, reduce anxiety or fever.
Administer medications such as bronchodilators, inhaled steroids, or
narcotics to suppress cough and ease breathing and apprehension.
CARE OF TERMINALLY ILL
 HEALTH PROMOTION
¡ Although a return to full function will not be an
expected outcome for a terminally ill client or even
a person who experiences significant disability,
there is always the goal of enabling the client to
return to optimal physical and emotional
functioning.
 THERAPEUTIC COMMUNICATION

¡ Nursing care of the grieving client and family

begins with establishing a caring presence and
determining the significance of their loss.
 PROMOTING HOPE
¡ Affective Dimension – Show empathic understanding of the
client’s strength.
¡ Cognitive Dimension – Offer information about the illness and
correct any misunderstanding or misinformation.
¡ Behavioral Dimension – Assist the client in using personal
resources and making use of external supports to balance
need for independence with healthy interdependence and
dependence.
¡ Affiliative Dimension – Encourage clients to foster supportive
relationship with others.
¡ Temporal Dimension – Focus on short-term goals as life
expectancy diminishes.
¡ Contextual Dimension – Encourage development of achievable
goals
 FACILITATING MOURNING
¡ Help the client accept that loss is real.
¡ Support efforts to live without the deceased person
or in the face of disability.
¡ Encourage establishment of new relationships.
¡ Allow time to grieve.
¡ Interpret “normal” behavior
¡ Provide continuing support.
¡ Be alert for signs of ineffective coping.
 PALLIATIVE CARE
¡ Provide relief from pain and other distressing symptoms
¡ Affirm life and regard dying as a normal process
¡ Neither hasten nor postpone death
¡ Integrate psychological and spiritual aspects of client
care.
¡ Offer a support system to help clients live as actively as
possible until death.
¡ Offer a support system to help families cope during the
client’s illness and their own bereavement.
¡ Enhance the quality of life.
 HOSPICE CARE
¡ Alternative care deliver y model for the terminally ill.
¡ Components of hospice care programs
§ Client and family as the unit of care.
§ Coordinated home care with access to available inpatient and nursing
home beds.
§ Control of symptoms (physical, sociological, psychological and
spiritual)
§ Physician-directed services
§ Provision of an interdisciplinary care team of physicians, nurses,
spiritual advisers, social worker and counselors.
§ Medical and nursing services available at all times.
§ Bereavement follow-up after a client’s death.
§ Use of trained volunteers for frequent visitation and respite support.
§ Acceptance into the program on the basis of health care needs rather
than the ability to pay.
 CARE AFTER DEATH
¡ Post mortem care is the care provided to a patient
immediately after death.
¡ Postmortem care serves several purposes,
including:
§ Preparing the patient for viewing by family
§ Ensuring proper identification of the patient prior to
transportation to the morgue or funeral home
§ Providing appropriate disposition of patient's
belongings.
§ Maintaining vital organs, if donation is planned.
Rigor Mortis
¡ The stiffening of the body that occurs about 2 to 4 hours
after death.

Algor Mortis
¡ The gradual decrease of the body’s temperature after
death.

Livor Mortis
¡ Discoloration of the skin caused by breakdown of the red
blood cells; occurs after blood circulation has ceased;
appears in the dependent areas of the body.
 CARE OF THE BODY AFTER DEATH

¡ Special Consideration

1. Follow institutional procedure for certain events

that occur after death like organ donation.
Example legal consent for donation, expenses, how
donation affects burial or cremations
2. Autopsy (surgical dissection of body after death)
to be done to determine the exact cause and
circumstances of death or questionable cause of
death
Equipment:
¡ Bath Towel Wash cloths
¡ Wash basin Scissors
¡ Shroud Kit Bed linen
¡ Cotton balls
¡ Death Certificate Forms
¡ 2Pieces Name Tag
 PROCEDURE

1. Confirm that the health care provider(physician)

certified and documented the time of death and action
taken.
2. Determine if the physician requested an autopsy is
required for death that occur in certain circumstances.
3. Validate the status of request for organ transplant
or tissue donation. Maintain sensitivity to personal,
religious and cultural beliefs in this process.
4. Provide sensitive and dignified nursing care to
patient and family.
a. Elevate the head of the bed as soon as possible
affect the face.
b. Collect ordered specimens.
c. Ask if family wishes to participate in preparation
of the body.
d. Ask about family request for body preparation
such as wearing a special clothing or religious
artefacts'.
e. Remove all equipment, tubes and indwelling
lines.
f. Cleanse the body thoroughly, maintaining
safety standard for body fluid and contamination.
g. Close eyes by gently holding them shut, leave
dentures in the mouth to maintain facial shape,
place arm on the side
h. Cover/ wrap body with a shroud.
i. Apply identifying name tag according to agency
policy.
THANK YOU!