Loss, Grief, and Dying

Types of LossTypes of Loss

• Actual loss — can be recognized by others

• Perceived loss — is felt by person but intangible to others

• Physical loss versus psychological loss

• Maturational loss — experienced as a result of natural developmental process

• Situational loss — experienced as a result of an unpredictable event

• Anticipatory loss — loss has not yet taken place

DefinitionsDefinitions

• Grief — emotional reaction to loss

• Bereavement — state of grieving; person goes through grief reaction

• Mourning — acceptance of loss; person learns to deal with loss

Engel’s Six Stages of GriefEngel’s Six Stages of Grief

• Shock and disbelief

• Developing awareness

• Restitution

• Resolving the loss

• Idealization

• Outcome

Kubler-Ross’s Five Stages of GriefKubler-Ross’s Five Stages of Grief

• Denial and isolation

• Anger

• Bargaining

• Depression

• Acceptance

Clinical signs of Impending DeathClinical signs of Impending Death

• Inability to swallow

• Pitting edema

• Decreased gastrointestinal and urinary tract activity

• Bowel and bladder incontinence

• Loss of motion, sensation, reflexes

• Elevated temperature, cold or clammy skin, cyanosis

• Lowered blood pressure

• Noisy or irregular respiration

• Cheyne-Stokes respirations

Three Definitions of DeathThree Definitions of Death

• Traditional heart-lung — irreversible cessation of spontaneous respiration and circulation

• Whole brain — irreversible cessation of all functions of the entire brain

• Higher brain — irreversible loss of all “higher” brain function

Components of a Good DeathComponents of a Good Death

• Pain and symptom management

• Clear decision-making

• Preparation for death

• Completion

• Contributing to others

• Affirmation of the whole person

Five Principles of Palliative CareFive Principles of Palliative Care

• Respects goals, likes, and choices of the dying person and his loved ones

• Looks after the medical, emotional, social, and spiritual needs of the dying person

• Supports the needs of family members

• Helps to gain access to needed healthcare providers and care setting

• Builds ways to provide excellent care at end of life

Advance DirectivesAdvance Directives

• Decide who will make decisions for the patient in case he or she is unable.

• Decide the kind of medical treatment the patient wants or doesn’t want.

• Decide how comfortable the patient wants to be.

• Decide how the patient will be treated by others.

• Decide what the patient wants loved ones to know.

Special OrdersSpecial Orders

• Do-not-resuscitate (DNR) or no-code

• Comfort measures only

• Do-not-hospitalize

Factors Affecting Grief and DyingFactors Affecting Grief and Dying

• Developmental considerations

• Family

• Socioeconomic factors

• Cultural influences

• Religious influences

• Causes of death

Developing a Trusting Nurse-Patient RelationshipDeveloping a Trusting Nurse-Patient Relationship

• Explain the patient’s condition and treatment.

• Teach self-care and promoting self-esteem.

• Teach family members to assist in care.

• Meet the needs of dying patient.

• Meet family needs.

Needs of Dying PatientsNeeds of Dying Patients

• Physiological needs — physical needs, such as hygiene, pain control, nutritional needs

• Psychological needs — patient needs control over fear of the unknown, pain, separation, leaving loved ones, loss of dignity, loss of control, unfinished business, isolation

• Sexual needs — patient needs ways to be physically intimate that meets needs of both partners

• Spiritual needs — patient needs to practice religious faith

Providing Postmortem CareProviding Postmortem Care

• Care of the body

• Care of the family

• Discharging legal responsibilities

• Death certificate issued and signed

• Labeling body

• Reviewing organ donation arrangements if any

• Care of other patients

Postmortem Care of the BodyPostmortem Care of the Body

• Prepare body for discharge.

• Place body in anatomical position, replace dressings, and remove tubes (unless there is an autopsy scheduled).

• Place identification tags on the body.

• Follow local law if patient died of communicable disease.

Postmortem Care of the FamilyPostmortem Care of the Family

• Listen to family’s expressions of grief, loss, and helplessness

• Offer solace and support by being an attentive listener.

• Arrange for family members to view the body.

• In the case of sudden death, provide a private place for family to begin grieving.

• It is appropriate for the nurse to attend the funeral and make a follow-up visit to the family.