Medical-Surgical Nursing: An Integrated Approach, 2E Chapter 9

LOSS, GRIEF, AND DEATH

Loss

Any situation —actual, potential, or perceived —wherein a valued object or person is changed or is no longer accessible to the individual.

Types of Loss

Actual (loss of someone or some thing). Perceived (felt by an individual but not

tangible to others, e.g. loss of self-esteem).

Physical (loss of part or aspect of the body).

Psychological (emotional loss, e.g. a woman’s feelings after menopause).

Categories of Loss

Loss of External Object.

Loss of Familiar Environment.

Loss of Aspect of Self (Physiological or Psychological).

Loss of Significant Other.

Grief

A series of intense physical and psychological responses that occur following a loss.

A normal, necessary, and adaptive response to a loss.

Mourning & Bereavement

Mourning is the period of time during which grief is expressed and resolution and integration of loss occur.

Bereavement is the period of grief following the death of a loved one.

Theories of the Grieving Process

Erich Lindemann George L. Engle John Bowlby William Worden

Leading theoretical models describinggrieving have been devised by:

Lindemann Theory

Somatic distress. Preoccupation with the image of the

deceased. Guilt. Hostile reactions. Loss of patterns of conduct.

Erich Lindemann coined the phrase grief work and described typical grief reactions:

Engle Theory

Three Stages of Mourning Stage I: Shock and Disbelief (disorientation,

helplessness, denial). Stage II: Developing Awareness (guilt, sadness,

isolation, anger and hostility). Stage III: Restitution and Resolution (bodily

symptoms, idealization of the deceased, beginning of coming to terms with loss, establishment of new social patterns and relationships).

Bowlby Theory

Four Stages of Mourning Numbness. Yearning and searching. Disorganization and despair. Reorganization.

Worden Theory

Four Tasks to Deal with Loss Successfully Accept the fact that the loss is real. Experience the emotional pain of grief. Adjust to an environment without the deceased. Reinvest the emotional energy once directed at the

deceased into another relationship.

Types of Grief

Uncomplicated (a grief reaction that normally follows a significant loss).

Dysfunctional (intense grief that does not result in reconciliation of feelings).

Anticipatory (occurrence of grief work before loss actually occurs).

Disenfranchised (grief that is not openly acknowledged, socially sanctioned, or publicly shared, e.g. grief over the loss of a pet).

Factors Affecting Loss and Grief

Developmental Stage. Religious and cultural beliefs. Relationship with the lost object. Cause of death.

Nursing Care of the Grieving Client

Nursing care for the grieving follows the standard five-part model:

Assessment. Nursing Diagnosis. Planning/Outcome Identification. Implementation. Evaluation.

Death & Legal Considerations

The Patient Self-Determination Act (PSDA, 1990) was intended to provide individuals with legal means to determine the circumstances under which life-sustaining treatment should or should not be provided to them.

Many states also have a Health Care Surrogate Law, implemented in the absence of advance directives.

Death & Ethical Considerations

Death is often fraught with ethical dilemmas.

Many health care agencies have ethics committees to develop and implement policies to deal with end-of-life issues.

Important distinctions must be made between pain relief and euthanasia.

Stages of Dying and Death

Denial. Anger. Bargaining. Depression. Acceptance.

Assessment of the Dying Client

Client and family goals and expectations. Client’s awareness of terminal nature of

the illness. Availability of support systems. Current stage of dying. History of previous positive coping skills. Client perception of unfinished business

to be completed.

Physiological Needs of the Dying Client

Respirations. Fluids and nutrition. Mouth, eyes, and nose. Mobility. Skin care. Elimination. Comfort. Physical environment.

Hospice

A type of care for the terminally ill, founded on the concept of allowing individuals to die with dignity, surrounded by those who love them.

Clients enter hospice care when aggressive medical treatment is no longer an option or when client refuses further medical intervention.

Signs of Impending Death

Lungs become unable to provide adequate gas diffusion.

Heart and blood vessels become unable to maintain adequate tissue perfusion.

The brain ceases to regulate vital centers. Cheyne-Stokes respirations (irregular breathing) and

“death rattle” (noisy respirations caused by secretions accumulating in larynx and trachea) signal imminence of death.

Care After Death

Treat the body with respect and dignity. Bathe and put a clean gown on the body. Remove dressings and tubes. Place the client in body alignment with

extremities straight. Place dentures in the mouth, if client normally

wore them. Comb client’s hair.

Legal Aspects Following Death

Autopsy (examination of the body after death by pathologist to ascertain cause of death).

Organ Donation.

Care of the Family

Informing the family as to the circumstances of the death.

Providing information about viewing the body.

Offering to contact support people. Sometimes assisting in decision making

regarding a funeral home and removal of the dead person’s belongings.

Nurse’s Self-Care

Dealing with dying clients is stressful. Nurses must face their grief.

Unresolved grief is called shadow grief. Nurses often carry shadow grief which, if not released, can cause illness and burnout.

Signs of Shadow Grief

Loss of energy, spark, joy, and meaning in life.

A feeling of being powerless to make a difference.

Increased smoking or drinking.

Unusual forgetfulness. Constant criticism

directed at others.

Constant inability to get work done.

Uncontrolled outbursts of anger.

Perception of clients and their families as objects.

Surrender of hobbies or interests.

Coping with Shadow Grief

Take time to cry with and for clients.

Get physical: run, walk, bicycle, play tennis.

Ask colleagues to help with tasks; avoid being “Supernurse.”

Connect to place of worship; pray.

Look for joy in work. Laughter is a great healer.

Create a caring circle of friends.

Listen to music.