LOSS, GRIEF AND DEATH

Loss, Grief, Dying

Class Objectives

The nursing student  Engles stages of

will learn: grief
 nurses role in loss,  Kubler-Ross Grief
grief, death and and Death Reactions
dying  legal and ethic
 emotional reactions dilemmas with death
to loss and dying
 to create a nursing
care plan for a death
and dying patient.
Loss
 Occurs when a • Physical loss
valued person,
object, or
• Psychological
loss
situation is
changed
• Actual Loss
• Perceived loss
• Anticipated loss
Grief or Grieving-Grief is the
Emotional Reaction to Loss
 Bereavement- state  Mourning-period of
of grieving during acceptance of loss
which a person goes and grief during
through grief which the person
reaction. learns to deal with
the loss.
Engels 6 Stages of Grief
Reaction
 Shock and disbelief
 Developing
awareness
 Restitution
 Resolving the loss
 Idealization
 Outcome
Kubler-Ross Grief and Death
Reactions

 Denial and isolation

 Anger
 Bargaining
 Depression
 Acceptance
Five Principles of Palliative Care-
(Hospice care)
 Respects the goals,  Supports the needs
likes and choices of of the family
the dying pt. members
 Looks after medical,  Helps pt gain access
emotional, social, to needed healthcare
and spiritual needs of providers and
the dying person appropriate settings
 Builds ways to
provide excellent end
of life care
Ethical and Legal Dimensions
 Managed death,  Patients look to
 Legalized physician nursing for
assisted suicide, information, advice
 Physician and support.
administered lethal
injections (aid in
dying) – create
ethical dilemmas.
The nurse patient relationship is
key to helping patient’s grieve
Advanced Directives

 Living wills- provide  Durable power of

specific instructions attorney- appoints
about the kinds of and agent the person
health care that trusts to make
should be provided decisions in the
or foregone in a event of the
particular situation appointing person’s
subsequent
incapacity.
Do not resuscitate or No code
orders

What is the difference between a

DNR or a No code order
and
Comfort measures only order?
Factors that influence Grief and
Dying
 Developmental
 Family
 Socioeconomic
 Cultural
 Religious
 Cause of Death
Nursing Process

 Questions to ask
 Assessing-
determine the • What have you been told
about your condition?
adequacy of the pt’s
• Have you had any previous
and families, experience with this condition
knowledge, or death of a loved one?
perceptions, coping • Tell me a little bit about how
strategies and you are coping
resources. • What is helping you get
through this?
Nursing Diagnoses
 Impaired adjustment  Anticipatory grieving
 Caregiver role strain  Dysfunctional
 Decisional conflict grieving
 Ineffective coping  Hopelessness
 Ineffective denial  Ineffective
management of
therapeutic regimem
Planning expected outcomes

 The pt and family will achieve:

• Demonstrate freedom in expressing
feelings
• Identify and use effective coping
strategies.
• Accept need for help as appropriate
• Make healthcare decisions reflecting
personal values and goals.
Implementing

 The nurses aim is to  Nursing Diagnosis

care for the dying pts • Impaired adjustment
and their families r/t newly diagnosed
and promote health terminal illness
and preventing • Caregiver role strain r/t
hospital discharged
illness of the family dying pt because of
inadequate insurance.
• Dysfunctional grieving
r/t inability to accept
death of infant no grief
resolution.
Nursing interventions

 Monitor patient for  Monitor pain

anxiety  Facilitate obtaining
 Monitor mood spiritual support for
changes pt and family
 Communicate  Include the family in
willingness to care decisions and
discuss death activities as desired.
 Encourage pt and
family to share
feelings about death
Evaluating

 The plan of nursing care for dying pts. meets

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.
Nurses grieve too.
Clinical Signs of Impending
Death
 Muscle weakness
 Respiratory changes
• Cheyne-Stokes
• Death Rattle
 Sensory changes
 Circulatory changes
Postmortem Care
 Nursing prepares the body for viewing
 Identification
 Who to notify
 Jewelry and valuables
 Dentures, glasses, prosthetics
Question

A nurse is caring for a pt who is dying

of terminal cancer. While assessing
the pt. for signs of impending death,
the nurse should observe the pt for:
A. Elevated B/P
B. Cheyne-Stokes respirations
C. Elevated pulse rate
D. Flushed skin
Question #1
• A nurse caring for a 15 y/o pt with terminal
CA has assessed that the pt. is very quiet
and has not expressed his feelings. The
nurse will need to implement
1. A referral for bereavement resources to enhance
care
2. Interventions for a pt in isolation and inner
thought
3. Assessment skills to determine fear and anxiety
4. Therapeutic skills to enhance communication
Question #2

 A pt who has ovarian CA with metastasis to

the liver complains of increased pain and
dysphasia. A physician orders a barium
enema. The patient states, “I don’t want this
test. What should I do?” The nurse should
a. A inform her to refuse the test
b. Inform the MD of her statements
c. Educate her on the test’s benefits
d. Educate her on the procedure
Question #3

 A 39 y/o pt who is apparently dead is

brought to the hospital by ambulance. A
concerned neighbor found the pt alone in
the apartment in this condition. The
tentative cause of death is suicide. Even
though the family has refuse an autopsy,
an autopsy can be ordered by the
a. A families MD
b. County court
c. City policy dept
d. County coroner.
Question #4
 You overhear a patient state, “If you make me
well, God, I will try to be a better person.” You
know that this type of statement is one of the
stages of grieving known as
1. Anger
2. Bargaining
3. Denial
4. Depression
Question #5
 The process of viewing the body after death
best supports which of the following
statements?

1. Provides the resolution of the death

experience for most families
2. Increases anxiety levels
3. Allows family members an avenue of escape
from the truth
4. Supports the family members’ decision for a
DNR