Loss, Grief and Dying • Abnormal or Distorted

• Unresolved – trouble expressing feelings; denies feelings

Loss
– when something of value is changed or made inaccessible
• Unresolved – extends over a long period
so that its value is diminished or removed • Inhibited – suppresses feelings but presents somatic
• Actual Loss – recognized by others symptoms
→ E.g.: loss of a limb
Interventions in Grieving
• Perceived Loss – intangible to others • Interpersonal skills to demonstrate empathy
→ E.g.: loss of youth • Encourage verbalization
• Physical Loss • Respond to inquiries honestly
• Psychological loss • Promote grief work through each stage of grieving
→ E.g.: diminished body image • Appropriate referrals
• Maturational Loss – result of natural development • Alert about patient who is moving through grief work
→ E.g.: kids growing up
• Situational Loss – result of an unpredictable event Death and Dying

→E.g.: trauma, accident, death, natural disaster • Death –

• Anticipatory loss – feeling the loss before it happens; →Heart-Lung Death – irreversible cessation of
E.g.: mourning for the terminally ill spontaneous respiration and circulation
→Whole brain death – irreversible cessation of all
Grief functions of the entire brain
– emotional reaction to a loss
→Higher Brain death – irreversible loss of all “higher”
• Bereavement – state of grieving w/ grief reaction brain functions, cognitive functions
→ May neglect health to extremes • Signs of impending death:
• Mourning – period of acceptance of a loss → Inability to swallow
→ Return to normal habits → Pitting edema
→ Decreased GIT & UT activity
Grief Reactions → Bowel & bladder incontinence
• Engel (1964) → Loss of motion, sensation & reflexes
→Shock and disbelief – refusal to accept → Elevated temperature but cold & clammy skin;
cyanosis
→Developing awareness – anger, emptiness → Low BP
→Restitution - rituals → Noisy/irregular respiration
→Resolving the loss – dealing with void → Cheyne-Stokes respiration

→Idealization – exaggeration of good qualities Dying Person’s Bill of Rights

→Outcome – resolution of grief I have to the right to--
• Kubler- Ross (1969) 1. be treated as a human being until I die.
2. maintain a sense of hopefulness, however changing its
→Denial and isolation focus may be.
→Anger 3. be cared for by those who can maintain a sense of
hopefulness, however changing its focus may be.
→Bargaining 4. express my feelings and emotions about my approaching
→Depression death in my own way.
→Acceptance 5. participate in decisions concerning my care.
• Stages of Grief & Related Grief Work 6. expect continuing medical and nursing attention even
though “cure goals” must be changed to “comfort
→ Denial – support initially then assist in awareness when
goals.”
ready
7. not die alone.
→ Isolation – listen and spend time
8. be free from pain.
→ Depression – problem solving then positive 9. have my questions answered honestly.
reinforcement 10. be not deceived.
→ Anger – allow crying and release of energy; listen; 11. die in peace and dignity.
support system 12. retain my individuality and not be judged for my
→ Guilt – listen; allow crying; help express feelings decisions, which may be contrary to the beliefs of others.
→ Fear – help recognize feelings; explore attitude toward 13. discuss and enlarge my religious and/or spiritual
loss experiences, whatever these may mean to others.
→ Rejection - allow expression; watch for rejection of 14. expect that the sanctity of the human body will be
self/others respected after death.
15. be cared for by caring, sensitive, knowledgeable
Normal Grief people who will attempt to understand my needs and will
• Abbreviated – short but genuine be able to gain some satisfaction in helping me face my
death.
• Anticipatory – before actual loss
Death and Dying (Kozier)
Dysfunctional Grief AGE Beliefs
Infancy NO clear concept of Death • Common law right of self determination and
to 5 It is Reversible, temporary constitutionally supported right to privacy
years sleep • Nurse identifies and supports legally valid decision
old
maker; clarifies goal of treatment; advocate for patient
prescho- death is permanent and family; documents end of life care preferences,
ol -may believe that he is written record of communication, wills, durable power of
responsible attorney for healthcare, medical advance directive
-death is a punishment
5 to 9 Understands DEATH is FINAL Advance Directives
years but can be AVOIDED • Allow indv to state in advance their choices would be for
9-12 Death is INEVITABLE healthcare
years Understands own mortality
12-18 Fears a lingering Death
• LIVING WILLS – specific instructions about kinds of
healthcare that should be provided or foregone in
18-45 Attitude is influenced by
specific situations
religion
45-65 Experiences peak of death • DURABLE POWER OF ATTORNEY – appoints an agent to
anxiety make decisions in the event of subsequent incapacity
65 and Death as multiple meanings • Self-Determination Act of 1990 – requires all hospitals to
 inform their patients about advance directives

Terminal Illness Do-Not-Resuscitate or No-Code Orders

• Illness in which death is expected • DNR or No code – no attempts are to be made to
• MD decides what, when and how px should be told resuscitate a px who stops breathing or whose heart
stops breathing
• RN, clergy, other health care professionals may be
involved in discussing px’s condition w/ him or her • Standard of care still obligates healthcare professionals
to attempt resuscitation if px stops breathing or his heart
• Breaking the “bad news”:
stops
→ Sit face-to-face in a private place
→ Ask how much is already known • Nurses should clarify patient’s code status if probable
→ Ask how much is wanted to be known results of resuscitation are negligible or has reason to
→ Give info in “small chunks” and ask if understood believe that patient would not want to be resuscitated
→ Let reactions come
Comfort measures only and other Special Orders
→ Summarize, ask questions, set a new appointment
• Comfort-measures-only order - Comfortable, dignified
death and life sustaining measures not indicated
• Impact on Patient
→ Pxs pick up nonverbal cues • Do-not-hospitalize order – patient s in nursing homes and
→ Pxs should be allowed to go through grieving process residential settings who have elected not to be
→ Competent pxs may refuse or consent to any or all hospitalized for further aggressive treatment
treatments • Nurses should be familiar with pertinent federal and state
→ Should know rights laws and institutional policy as well as forms to indicate
• Impact on Family preferences of patients on end-of-life-care
→ Family should participate in planning px care
Other Ethical and Legal Issues
→Healthcare personnel should be available for
discussion and to offer support • Terminal Weaning - Gradual withdrawal of mechanical
→ Family may want to participate in planning memorial ventilation from a patient with terminal illness or an
services irreversible condition with a poor prognosis
• Assisted Suicide – Making lethal combination of drugs
Palliative Care available to patient wishing to die
• Taking care of the whole person – body, mind, spirit, • Active Euthanasia - administering lethal injection at the
heart and soul patient’s request
• Dying – natural and personal
• GOAL – best quality of life by aggressive mgmt of • Passive Euthanasia – allow disease to progress naturally
symptoms to death
***ANA – assisting in suicide and participating in active
• Also called “Hospice Care”
euthanasia – violation of Nurses’ Code
Hospice Care • Death Certificate – US law reqt; prepared for each px; RN
• standard of care for terminally ill cancer clients should ensure physician signed the certificate
• Symptom control • Organ Donation – fill out an organ donation card; RN
• Pain management reviews options and provide consent forms to interested
• Providing comfort and dignity clients
• 24 hour – 7 day coverage • Autopsy – examination of organs and tissues of body
• Services given based on client’sneed not on ability to pay after death; MD obtains permission; RN may assist in
explaining reasons for autopsy
Ethical and Legal Dimensions
• Patients w/ legal and moral right to consent to and refuse Good Dying
any and all indicated therapies • “Last Acts Project” – focuses on improving care for dying
patients
• 8 key elements of end-of-life-care
→ State advance directive policies- living will, power of
atty.
→ Location of death
→ Hospice use
→ Hospital end-of-life services
→ Care in ICU
→ Pain among nursing home residents
→ State pain policies
→ Palliative care certified physicians and nurses

6 Major Components of a Good Death

• Pain and symptoms management
• Clear decision making
• Preparation for death
• Completion
• Contributing to others
• Affirmation of the whole person

FACTORS THAT AFFECT GRIEF AND DYING

• Age
• family relationships
• socioeconomic position
• cultural and religious influences
• person’s reaction to and expression of grief
• Cause of death

Nurse as Role Model

• Nurses need to take time to analyze their own
feelings about death before they can effectively
help others with terminal illness
• Grief after patient death is natural ; nurse should address
personal health needs
 NURSING PROCESS FOR GRIEVING FAMILIES → Wrap the body in a shroud
→ Bring the body to the morgue for cryonics (cooling)
Assessing
• Adequacy of knowledge
• Realism of expectations
• Adequacy of coping strategies
• Adequacy of resources
• Physical response

Diagnosing
• Impaired adjustment
• Caregiver role strain
• Decisional conflict
• Ineffective coping
• Ineffective denial
• Anticipatory grieving
• Dysfunctional grieving
• Hopelessness
• Ineffective Therapeutic Regimen Management

Implementing
• Developing a Trusting Nurse-Patient Relationship
• Explaining the Patient’s Condition and Treatment
• Teaching Self-Care and Promoting Self-Esteem
• Teaching Family Members to Assist in Care
• Meeting the Needs of Dying Patients
• Meeting Family Needs
• Providing Postmortem Care

Evaluating
• Plan of nursing care is effective if patients meet the
outcome of a comfortable, dignified death and family
members resolve their grief after a suitable time of
mourning and resume meaningful life roles and activities

Post Mortem Care

• Body Care after death
→ Make the body appear natural
→ Remove all equipment and supplies from the bedside
→ Place the body in supine position (arms at the sides,
palms down)
→ Place one pillow under head to prevent face
discoloration
→ Close eyelids, insert dentures and close the mouth
→ Wash soiled parts of the body
→ Watch out feces and urine discharge
→ Remove all jewelry and place in a safe storage
→Allow Significant Other to view the patient’s body
→ Apply 3 ID tags (wrist, ankle and over the shroud)