LOSS,GRIEVING & DEATH

LOSS
Loss is an actual or potential
situation in which something that is
valued is changed or no longer
available.
People can experience the loss of body
image, a significant other, a sense of well-
being, a job, personal possessions, or
beliefs.
Illness and hospitalization often produce
losses.
 TYPES OF LOSS

There are two general types of loss, actual and perceived.

An actual loss can be recognized by others.
A perceived loss is experienced by one person but cannot
be verified by others. Psychological losses are often
perceived losses because they are not directly verifiable.
An anticipatory loss is experienced before the loss
actually occurs.
 SOURCES OF LOSS

There are many sources of loss:

 Loss of an aspect of oneself (a body part,
a physiological function, or a
psychological attribute )
 Loss of an object external to oneself;
 Separation from an accustomed
environment;
 Loss of a loved or valued person
 GRIEF, BEREAVEMENT, AND MOURNING
Grief is the total response to the emotional experience related to loss.
Grief is manifested in thoughts, feelings, and behaviors associated
with overwhelming distress or sorrow.
Bereavement is the subjective response experienced by the surviving
loved ones.
Mourning is the behavioral process through which grief is eventually
resolved or altered; it is often influenced by culture, spiritual beliefs,
and custom.
Grief and mourning are experienced not only by the person who faces
the death of a loved one but also by the person who suffers other
kinds of losses. Grieving permits the individual to cope with the loss
gradually and to accept it as part of reality. Grief is a social process; it
 MANIFESTATION OF GRIEF & BEREAVEMENT
 Working through one’s grief is important because bereavement may have
potentially devastating effects on health.
 Among the symptoms that can accompany grief are anxiety, depression,
weight loss, difficulties in swallowing, vomiting, fatigue, headaches,
dizziness, fainting, blurred vision, skin rashes, excessive sweating,
menstrual disturbances, palpitations, chest pain, and dyspnea.
 The grieving and the bereaved may experience alterations in libido,
concentration, and patterns of eating, sleeping, activity, and
communication.
 Although bereavement can threaten health, a positive resolution of the
grieving process can enrich the individual with new insights, values,
challenges, openness, and sensitivity. For some, the pain of loss, though
diminished, recurs for the rest of their lives.
 TYPES OF GRIEF RESPONSES
Abbreviated grief is brief but genuinely felt. This can occur when the
lost object is not significantly important to the grieving person or may
have been replaced immediately by another, equally esteemed object.
Anticipatory grief is experienced in advance of the event such a the
wife who grieves before her ailing husband dies. A young person may
grieve before an operation that will leave a scar. Because many of the
normal symptoms of grief will have already been expressed in
anticipation, the reaction when the loss actually occurs is sometimes
quite abbreviated.
Disenfranchised grief occurs when a person is unable to
acknowledge the loss to other people. Situations in which
this may occur often relate to a socially unacceptable loss
that cannot be spoken about.
such as suicide, abortion, or giving a child up for
adoption. Other examples include losses of relationships
that are socially unsanctioned and may not be known to
other people (such as homosexuality or extramarital
relationships).
Complicated grief (Unhealthy grief—
pathologic)when the strategies to cope with the
loss are maladaptive and out of proportion or
inconsistent with cultural, religious, or age-
appropriate norms. The disorder, referred to by
physicians as persistent complex bereavement
disorder, may be said to exist if the preoccupation
lasts for more than 6 months and leads to reduced
ability to function formally
Complicated grief may take several forms.
Unresolved or chronic grief is extended in length and severity. The
same signs are expressed as with normal grief, but the bereaved may
also have difficulty expressing the grief, may deny the loss, or may
grieve beyond the expected time.
With inhibited grief, many of the normal symptoms of grief are
suppressed and other effects, including somatic, are experienced
instead.
Delayed grief occurs when feelings are purposely or
subconsciously suppressed until a much later time.
A survivor who appears to be using dangerous activities
as a method to lessen the pain of grieving may
experience exaggerated grief.
 STAGES OF GRIEVING
KUBLER ROSS’S STAGES OF GRIEVING
STAGES BEHAVIORAL RESPONSES
Refuses to believe that loss is happening. Is unready to deal
Denial with practical problems, such as prosthesis after the loss of
a leg. May assume artificial cheerfulness to prolong denial.

Client or family may direct anger at nurse or staff about

Anger
matters that normally would not bother them.
Seeks to bargain to avoid loss (e.g., “let me just live until
Bargaining
and then I will be ready to die”).
Grieves over what has happened and what cannot be. May
Depression talk freely (e.g., reviewing past losses such as money or job),
or may withdraw.
Comes to terms with loss.
May have decreased interest in surroundings and support
Acceptance people.
May wish to begin making plans (e.g., will, prosthesis, altered
 ENGEL’s STAGES OF GRIEVING
STAEGES BEHAVIOURAL RESPONSES
Shock and Refuses to accept loss. Has stunned feelings.
Disbelief Accepts the situation intellectually, but denies it emotionally.
Developing Reality of loss begins to penetrate consciousness.
Awareness Anger may be directed at agency, nurses, or others.
Restitution Conducts rituals of mourning (e.g., funeral).
Attempts to deal with painful void.
Still unable to accept new love object to replace lost person or object.
Resolving the loss May accept more dependent relationship with support person.
Thinks over and talks about memories of the lost object.
Produces image of lost object that is almost devoid of undesirable features.
Represses all negative and hostile feelings toward lost object.
May feel guilty and remorseful about past inconsiderate or unkind acts to
Idealization lost person.
Unconsciously internalizes admired qualities of lost object. Reminders of lost
object evoke fewer feelings of sadness. Reinvests feelings in others.
Behavior influenced by several factors: importance of lost object as source
of support, degree of dependence on relationship, degree of ambivalence
Outcome toward lost object, number and nature of other relationships, and number
 SANDER’s PHASE OF BEREAVEMENT
Phase Description Behavior Responses
Feelings of confusion, Disbelief, Confusion, Restlessness, Regression
unreality, and disbelief that and helplessness,
the loss has occurred. They Physical : dryness of mouth and throat,
Shock are often unable to process sighing, weeping, sleep disturbance, loss of
normal thought sequences. appetite.
Phase may last from a few Psychological : egocentric phenomenon,
minutes to many days. preoccupation with thoughts of the deceased,
psychological distancing
Friends and family resume Separation anxiety, Conflicts, Acting out,
normal activities. The Prolonged stress
Awareness of
bereaved experience the full Physical : anger, guilt, frustrated, cry,
Loss
significance disturb sleep, fear of death
of their loss. Psychological: oversensitivity, disbelief and
denial, decrease Sense of presence
Feel a need to be alone to Withdrawal, Despair, Diminished social
conserve both physical and support, Helplessness
Conservation/
emotional energy. May Physical : weakness, fatigue , more sleep, a
Withdrawal
experience despair and weak immune system
helplessness. Psychological: hibernation, obsessional
 During this phase, the Assuming control, Identity restructuring,
bereaved move from Relinquishing roles.
Healing: distress about living Physical : increased energy, sleep/immune
The turning without their loved one to system restoration
point learning to live more Psychological : forgiving, forgetting,
independently. searching for meaning , hope

In this phase, survivors New self-awareness ,Accept responsibility ,

move on to a new self- learn to live without
awareness, an acceptance Physical : functional stability, revitalization,
of responsibility for self, caring for physical needs
Renewal
and learning to live without Psychological: living for oneself, loneliness,
the loved one. anniversary reactions, reaching out to
others, time for the process of
bereavement
 STAGE OF GRIEF
Martocchio (1985) described five clusters of grief :
1. Shock and Disbelief.
2. Yearning and protest.
3. Anguish.
4. Disorganization.
5. Despair.
Identification in bereavement; and reorganization and
restitution—and maintained that there is no single correct way,
nor a correct timetable, by which a person progresses through
the grief process.
 FACTORS INFLUENCING THE LOSS & GRIEF
RESPONSES

Several factors affect a person’s response to a loss or death.

These factors include :
Age Gender
Significance of the loss Socioeconomic status
Culture Support systems
Spiritual beliefs Cause of the loss or death
Nurses can learn general concepts about the influence of these
factors on the grieving experience, but the constellation of these
factors and their significance will vary from individual to individual.
 DYING AND DEATH
The concept of death is developed over time, as the
person grows, experiences various losses, and thinks
about concrete and abstract concepts. In general,
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.
The reaction of any person to another person’s
impending or real death, or to the potential reality of his
or her own death, depends on all the factors regarding
loss and the development of the concept of death.
 Concept of Death
AGE CONCEPT
Infancy–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.
5–9 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
9–12 years Understands death as the inevitable end of life. Begins to understand own
mortality, expressed as interest in afterlife or as fear of death.
12–18 years Fears a lingering death. May fantasize that death can be defied, acting out
defiance through reckless behaviors (e.g., dangerous driving, substance
abuse). 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.
18–45 years Has attitude toward death influenced by religious and cultural beliefs.

45–65 years Accepts own mortality. Encounters death of parents and some peers .
Experiences peaks of death anxiety. Death anxiety diminishes with
 DEFINITIONS AND SIGNS OF DEATH
The traditional clinical signs of death were cessation of the apical pulse , respirations,
and blood pressure, also referred to as heart-lung death. However, since the advent
of artificial means to maintain respirations and blood circulation, identifying death is
more difficult.
In 1968, the World Medical Assembly (Gilder, 1968) adopted the following guidelines
for physicians as indications of death:
Total lack of response to external stimuli
 No muscular movement, especially breathing
 No reflexes
 Flat encephalogram (brain waves).

In instances of artificial support, absence of brain waves for at least 24 hours

indicates death. Only then can a physician pronounce death, and only after this
pronouncement can life-support systems be shut off.
 DEFINITIONS AND SIGNS OF DEATH
Another definition of death is cerebral death or higher brain
death, which occurs when the higher brain center, the
cerebral cortex, is irreversibly destroyed. In this case, there is
a clinical syndrome characterized by the permanent loss of
cerebral and brainstem function, manifested by absence of
responsiveness to external stimuli, absence of cephalic
reflexes, and apnea. An isoelectric electroencephalogram for
at least 30 minutes in the absence of hypothermia and
poisoning by central nervous system depressants, supports
the diagnosis (Stedman’s Medical Dictionary for the Health
Professions and Nursing, 2012).
DEATH-RELATED RELIGIOUS AND CULTURAL
PRACTICES

Cultural and religious traditions and practices associated with

death, dying, and the grieving process help people cope with
these experiences. Nurses are often present through the dying
process and at the moment of death. Knowledge of the client’s
religious and cultural heritage helps nurses provide
individualized care to clients and their families, even though
they may not participate in the rituals associated with death.
In some cultures, people prefer a peaceful death at home rather
than in the hospital. Members of certain ethnic groups may
request that health professionals not reveal the prognosis to
dying clients.
NURSING MANAGEMENT
 ASSESSMENT
To gather a complete database that allows accurate
analysis and identification of appropriate nursing diagnoses
for dying clients and their families, the nurse first needs to
recognize the states of awareness manifested by the client
and family members.
In cases of terminal illness, the state of awareness shared
by the dying person and the family affects the nurse’s
ability to communicate freely with clients and other health
care team members and to assist in the grieving process.
Three types of awareness that have been described are
Closed awareness, Mutual pretense, and Open
awareness
 ASSESSMENT
 In closed awareness, the client is not made aware of
impending death. The family may choose this because they
do not completely understand why the client is ill or they
believe the client will recover.
 With mutual pretense, the client, family, and health care
personnel know that the prognosis is terminal but do not
talk about it and make an effort not to raise the subject.
 With open awareness, the client and others know about
the impending death and feel comfortable discussing it,
even though it is difficult. This awareness provides the
client an opportunity to finalize affairs and even participate
in planning funeral arrangements.
 Manifestation of Death/Dying
Relaxation of the facial muscles (e.g., the jaw may sag), Difficulty
speaking, Difficulty swallowing and gradual loss of the gag reflex.
Decreased activity of the gastrointestinal tract, with subsequent
LOSS OF MUSCLE TONE
nausea, accumulation of flatus, abdominal distention, and
retention of feces, especially if narcotics or tranquilizers are being
administered, Possible urinary and rectal incontinence due to
decreased sphincter control. Diminished body movement
Diminished sensation, Mottling and cyanosis of the extremities,
SLOWING OF THE
Cold skin, first in the feet and later in the hands, ears, and nose
CIRCULATION
(the client, however, may feel warm if there is a fever). Slower
and weaker pulse, Decreased blood pressure
Rapid, shallow, irregular, or abnormally slow respirations, Noisy
CHANGES IN
breathing, referred to as the death rattle, due to collecting of
RESPIRATIONS
mucus in the throat. Mouth breathing, dry oral mucous
membranes
 DIAGNOSIS
A range of nursing diagnoses, addressing both physiological and
psychosocial needs, can apply to the dying client, depending on the
assessment data. Diagnoses that may be particularly appropriate for
the dying client are:
 Fear,
 Hopelessness, and
 Powerlessness.
In addition,
 Risk for Caregiver Role Strain and
 Interrupted Family Processes
are not uncommon diagnoses for caregivers and family members.
 PLANNING
Major goals for dying clients are:
 Maintaining physiological and psychological comfort
 Achieving a dignified and peaceful death, which includes
maintaining personal control and accepting declining health
status.
Planning for Home Care
People facing death may need help accepting that they have
to depend on others. Some dying clients require only minimal
care; others need continuous attention and services. People
need help well in advance of death, in planning for the period
of dependence. They need to consider what will happen and
 IMPLEMENTING

The major nursing responsibility for clients who are dying is to assist
the client to a peaceful death. More specific responsibilities include
the following:
 To minimize loneliness, fear, and depression
 To maintain the client’s sense of security, self-confidence, dignity,
and self-worth
 To help the client accept losses
 To provide physical comfort.
 HELPING CLIENTS DIE WITH DIGNITY
Nurses need to ensure that the client is treated with dignity, that is,
with honor and respect. Dying clients often feel they have lost control
over their lives and over life itself. Helping clients die with dignity
involves maintaining their humanity, consistent with their values,
beliefs, and culture. By introducing options available to the client and
significant others, nurses can restore and support feelings of control.
Some choices that clients can make are the location of care (e.g.,
hospital, home, or hospice facility), times of appointments with health
professionals, activity schedule, use of health resources, and times of
visits from relatives and friends.
Clients want to manage the events preceding death so they can die
peacefully. Nurses can help clients to determine their own physical,
psychological, and social priorities. Dying people often strive for self-
 HOSPICE AND PALLIATIVE CARE
The hospice movement was founded by the physician Cecily Saunders in London,
England, in 1967.
Hospice :
Hospice care focuses on support and care of the dying person and family, with the
goal of facilitating a peaceful and dignified death. Hospice care is based on holistic
concepts, emphasizes care to improve quality of life rather than cure, supports the
client and family through the dying process, and supports the family through
bereavement.
Palliative care
As described by the World Health Organization, is an approach that improves the
quality of life of clients and their families facing the problem associated with life
threatening illness, through the prevention and relief of suffering by means of early
identification and impeccable assessment and treatment of pain and other problems,
physical, psychosocial and spiritual.
 PALLIATIVE CARE
Palliative care provides relief from pain and other distressing symptoms :
 Affirms life and regards dying as a normal process;
 Intends neither to hasten nor postpone death;
 Integrates the psychological and spiritual aspects of client care;
 Offers a support system to help clients live as actively as possible until death
 Offers a support system to help the family cope during the client’s illness and in their
own bereavement
 Uses a team approach to address the needs of clients and their families, including
bereavement counseling, if indicated
 Will enhance quality of life, and may also positively influence the course of illness
 Is applicable early in the course of illness, in conjunction with other therapies that are
intended to prolong life, such as chemotherapy or radiation therapy, and includes those
investigations needed to better understand and manage distressing clinical
complications.
 MEETING THE NEEDS OF THE DYING
CLIENT

a. Physiological Needs
b. Spiritual Support
c. Supporting the Family
POSTMORTEM CARE
 POSTMORTEM CARE
Rigor mortis
Rigor mortis is the stiffening of the body that occurs about 2 to 4
hours after death. Rigor mortis starts in the involuntary muscles
(heart, bladder, and so on), then progresses to the head, neck, and
trunk, and finally reaches the extremities hours after death.
Algor mortis
Algor mortis is the gradual decrease of the body’s temperature after
death. When blood circulation terminates and the hypothalamus
ceases to function, body temperature falls about 1°C (1.8°F) per hour
until it reaches room temperature. Simultaneously, the skin loses its
elasticity and can easily be broken when removing dressings and
adhesive tape.
Livor mortis
POSTMORTEM CARE
After blood circulation has ceased, the red blood cells break down,
releasing hemoglobin, which discolors the surrounding tissues. This
discoloration, referred to as livor mortis, appears in the lowermost or
dependent areas of the body.
Mortician
Soiled areas of the body are washed; however, a complete bath is not
necessary, because the body will be washed by the mortician (also
referred to as an undertaker), a person trained in care of the dead.
Absorbent pads are placed under the buttocks to take up any feces
and urine released because of relaxation of the sphincter muscles. A
clean gown is placed on the client, and the hair is arranged
 POSTMORTEM CARE

Shroud
a large piece of plastic or cotton material used to enclose
a body after death. The body is wrapped in a shroud.
Identification is then applied to the outside of the shroud.
 EVALUATION
To evaluate the achievement of client goals, the nurse collects data
in accordance with the desired outcomes established in the planning
phase.
Evaluation activities may include the following:
 Listening to the client’s reports of feeling in control of the
environment surrounding death, such as control over pain relief,
visitation of family and support people, or treatment plans
 Observing the client’s relationship with significant others
 Listening to the client’s thoughts and feelings related to
hopelessness or powerlessness.