GRIEF LOSS

DEATH DYING

GRIEF AND LOSS

 LOSS = something of value is gone

 GRIEF = total response to emotional experience related to loss

 BEREAVEMENT = subjective response to by loved ones

 MOURNING = behavioral response

GRIEF AND LOSS

 Loss is a universal experience that occurs throughout the lifespan.

 Grief is a form of sorrow involving feelings, thoughts and behaviors caused by bereavement.

 Responses to loss are strongly influenced by one’s cultural background.

GRIEF AND LOSS

The grief process involves a sequence of affective, cognitive and psychological states as a person
responds to and finally accepts a loss.

STAGES OF GRIEVING

Stages Behaviors

D Refuses to believe that loss is

happening

A B Retaliation

D A Feelings of Guilt, punishment for sins

 DENIAL

 “No, not me…”

 After the initial shock has worn off, the next stage is usually one of classic denial, where they pretend that the
news has not been given.

 They effectively close their eyes to any evidence and pretend that nothing has happened.

DENIAL: interventions

 Do not interfere unless it becomes destructive

 Do not support denial; conversations should not include reality

 Continue to teach and encourage self care

activities.

 ANGER

 “Why me?”

 This stage often occurs in an explosion of emotion, where the bottled –up feelings of the previous stages are
expulsed in a huge outpouring of grief.

 Whoever is in the way is likely to be

blamed.

ANGER: intervention

 Give space allowing them to rail and below. The more the storm blows the sooner it will blow itself out.

 Try not to respond in “kind”

 When anger is destructive , it must be addressed directly. Remind the person of appropriate and inappropriate
behavior

 BARGAINING

 “Yes me, but…”

 The patient attempts to negotiate a postponement with God and is generally kept a secret.

BARGAINING: intervention

 Spend time with patients

 Discuss importance of valued objects and people.

 DEPRESSION
 The inevitability of the news eventually (and not before time) sinks in and the person reluctantly accepts that it
is going to happen.

DEPRESSION: intervention

 Be available

 Don’t attempt to cheer person up

 Find out any religious support

 ACCEPTANCE

 Restful time, but not necessarily happy.

 Often begin putting their life in order, sorting out wills and helping others to accept the inevitability.

ACCEPTANCE: intervention

 Plan care to allow the person with whom patient is comfortable to care for him or her

 It is important that you don’t withdraw

 DEATH

 heart – lung death, cessation of the apical pulse, respiration, and blood pressure. (traditional clinical signs of
death)

 Cerebral death ( higher brain death)

 Somatic death – determine by the absence of cardiac and pulmonary functions.

 Molecular death – determine by the cessation of cellular [Link] medical assembly -:

 CLINICAL SIGNS OF DEATH

IMPENDING DEATH:

- LOSS OF MUSCLE TONE.

-SLOWED CIRCULATION

-V/S CHANGES SENSORY IMPAIREMENT

IMMINENT DEATH:

-FIXE DILATED PUPILS

-LOSS OF REFLEXES AND MOVEMENT

- FASTER, WEAK PULSE

-DEATH RATTLE

DEATH CONCEPT AMONG AGE

AGE GROUP CONSIDERATION

 NEWBORN AND INFANT -NO CONCEPT OF DEATH

-SEPARATION ANXIETY

-REACTS MORE TO PAIN AND DISCOMFORT OF ILLNESS

AND IMMOBILIZATION

 TODDLER AND PRESCHOOLER -PERCEIVED DEATH AS LONG SLEEP

 SCHOOL AGE -AT AGE OF 9 YEARS OLD, A CHILD HAS REALISTIC CONCEPT OF
DEATH AS IRREVERSIBLE, UNIVERSAL (NO ONE ESCAPE),

INEVITABLE AND NATURAL

 ADOLESCENTS -BEGINS TO DEVELOP PHILOSOPHY OF LIFE AND DEATH

-MAY HAVE POORER OUTCOES THAN ADULTS BECAUSE OF

OTHER STRESSOR

 ADULTS -MIDDLE AGE ADULTS PERCEIVED DEATH AS OUT OF THE

DEATH CONCEPT AMONG AGE

1-5 immobility and inactivity; wishes and unrelated action responsible for action

5-10 final but can be avoided

9-12 understands own mortality and fears death

12-18 fears and fantasizes avoidance

18- 45 increased attitude awareness

45-65 accepts mortality

Above 65 multiple meanings; encounters and fears

 FEAR OF LONELINESS

 Distancing by support people and caregivers can occur

 Debilitation, pain, and incapacitation

 Hospital, a place that can be very lonely

 Fear of dying alone

 FEAR OF SORROW

 Sadness

 Letting go of hopes, dreams, the future

 Awareness of own mortality

 Grief about future losses

 Anticipatory grief that involves mourning, coping skills

 Grief related to diagnosis that has a long term effect on the body such as cancer

 Patient may feel well at time of diagnosis

 FEAR OF THE UNKNOWN

 Death is an unknown state

 What will happen after death?

 What will happen to loved ones, those left behind

 LOSS OF SELF CONCEPT AND BODY INTEGRITY

 Mutilation via therapy and body image changes

 Loss of role or status

 Loss of standard of living

 FEAR OF REGRESSION

 Ego is threatened

 Physical deterioration may occur

 Mental deterioration may occur

 Unable to care for self

 Become dependent on others for care

 May be many different types of pain or suffering such as physical, emotional, social, or spiritual in nature

 Altered relationships with others

 Anxiety related to the disease and consequences of the disease

 TAKING CARE OF DYING PERSON

 The role of the nursing staff is fundamentally supportive

 Accept the physical and mental state he is in

 Show him that they will not abandon him

 Responds to the persons needs in a physical, psychological, social and intellectual level

 TAKING CARE OF DYING PERSON

PHYSICAL LEVEL

 Biological needs, reduction and control of pain

 Pain is a subjective experience

 Acute pain: usually temporary

 Chronic pain: interrupts normal everyday functioning

 Medication is more effective in the context of a holistic intervention

 TAKING CARE OF DYING PERSON

PSYCHOLOGICAL LEVEL

 Feelings of anger, sadness, depression are part of a wider process of “anticipatory grief”, useful for the patient’s

Psychological preparation to die

 Nursing staff has to comprehend and the person to express these feelings

 The only way for the person to reconcile with these feelings is to talk to someone who is willing to listen

 Support has to respond to the person’s need for safety, autonomy and self-control

 TAKING CARE OF DYING PERSON

SOCIAL LEVEL

 Emotional and social withdrawal

 Need of emotional withdrawal co-exists with the need of belonging to an accepting and supportive social environment

 When family/medical nursing staff keep their distance in order to protect themselves, the person experiences

a “social death”, which is sometimes more painful than the actual death
 Nursing staff must treat the dying person without fear, encourage relatives to be close to him, act as a liaison with

the outside world

 TAKING CARE OF DYING PERSON

INTELLECTUAL LEVEL

 Need to evaluate his life as meaningful, important, useful

 Nursing staff should stand by him without being judgmental, let him decide where he wants to spend his

last days,and interact with him as a person who LIVES

 NURSING RESPONSIBILITIES

 Nurses need to take time to analyze their own feelings about death before they can effectively help others

with terminal illness

 Understand that you may experience grief

 Nurses have to be strong to control their feelings to be able to tolerate pain, illness, and death, and to keep their distance

 Provide relief from illness, fear and depression

 Help clients maintain sense of security

 Help accept losses

 Provide physical comfort

 ROLE OF THE CHAPLAIN

 Can be a member of the health care team

 Assist with religious practices

 Perform rites

 Provide prayer, support, and comfort

 Assist with mobilizing other support systems that are important to the client

 Support family members

COMMUNICATING WITH CLIENT

 Right to know

 Time frame

 Nurse needs to assess whether or not the patient/family have been told and what was told to them

 THE PHYSICIAN WILL TELL THE CLIENT FIRST, NOT THE NURSE

COMMUNICATING WITH CLIENT

 Clarifies what was said

 Fosters communication between MD, client, and family

 Allows patient to express loss

 Facilitate grief through nursing process

 Be available for patient

 Assist patient to identify needs/hopes for remainder of life

 Connect patient with proper resources

ASSIST FAMILY

 Explain procedures and equipment

 Prepare them about the dying process

 Involve family and arrange for visitors

 Encourage communication

 Provide daily updates

 Resources

 Do not deliver bad news when only one family member is present

 PHYSICAL SIGNS OF DYING

 Confusion – about time, place, and identity of loved ones; visions of people and places that are not present

 A decreased need for food and drink, as well as loss of appetite

 Drowsiness – an increased need for sleep and unresponsiveness

-Withdrawal and decreased socialization Skin becomes cool to the touch Loss of bowel or bladder control

 Rattling or gurgling sounds while breathing or breathing that is irregular and shallow, decreased number

of breaths per minute, or breathing that switches between rapid and slow

 Involuntary movements (called myoclonus), changes in heart rate, and loss of reflexes in the legs and arms

also mean that the end of life is near

 PRONOUNCEMENT OF DEATH

 Absence of carotid pulses

 Pupils are fixed and dilated

 Absent heart sounds

 Absent breath sounds

 PALLOR MORTIS

 paleness of death

 almost immediately after death a body of a person with light skin will begin to grow very pale. this is caused by a

lack of blood in the Capillary region of the blood vessel.

 ALGOR MORTIS

 cool of death

 after death a human body will no longer be working to keep warm, and as a result will start cooling

 about an hour postmortem (after death) a human body will have decreased around 2 degrees celcius,

and will continue to decrease one degree celcius until it reaches the temperature of the environment around it

 RIGOR MORTIS

 death stiffness

 about three hours after death a chemical change in the muscles of a human corpse causes

the limbs of the corpse to become stiff and difficult to move.

 PUTREFACTION

 decomposition of proteins in a process that results in the eventual breakdown of cohesion between tissues and the

liquefaction of most organs. It is caused due to bacterial or fungal decomposition of organic matter and

results in production of noxious odors

 POSTMORTEM CARE

 Needs to be done promptly, quietly, efficiently, and with dignity

 Straighten limbs before death, if possible

 Place head on pillow

 Remove tubes

 Replace soiled dressings

 Pad anal area

 Gently wash body to remove discharge

 Place body on back with head and shoulders elevated

 Grasp eyelashes and gently pull lids down

 Insert dentures
 Place clean gown on body and cover with clean sheet

Note time of death and chart

 Notify attending physician

Chart any special directions

 Notify family members

Allow time with loved one

 Gather eyeglasses and other belongings

 Prepare necessary paperwork for body removal

 PHYSICIAN CERTIFY DEATH

 OPTION FOR ORGAN DONATION

 CHECK FOR SPECIMEN ORDERS

 REMOVE ALL EQUIPMENT

 CLEAN BODY THOROUGHLY

 POSTION ACCORDING TO PROTOCOL

 APPLY NAME TAG, DOCUMENT.