Grief Process, Death and
Dying
Plaut
&
Roark
LOSS
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Actual
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Perceived
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External Objects
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Known Environment
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Significant Other
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Aspect of Self
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Life
Roark, 2004
Kubler-Ross Stages of Grief
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Denial
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Anger
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Bargaining
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Depression
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Acceptance
Roark, 2004
Death and Dying
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Assisting the patient
to “Live well” and
“Die well”
What does this mean to
you?
Roark, 2004
Common fears of the dying patient
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Fear of Loneliness
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Distancing by support people and caregivers
can occur
Debilitation, pain, and incapacitation
Hospital, a place that can be very lonely
Fear of dying alone
Roark, 2004
Fears of the dying client
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Fear of Sorrow
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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
Roark, 2004
Fears of the dying client
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Fear of the unknown:
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Death is an unknown state
What will happen after death?
What will happen to loved ones, those left
behind
Roark, 2004
Fears of the dying client
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Loss of self concept and body integrity
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Mutilation via therapy
Body image changes
Loss of role or status
Loss of standard of living
Roark, 2004
Fears of the dying client
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Fear of Regression
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Ego is threatened
Physical deterioration may occur
Mental deterioration may occur
Unable to care for self
Become dependent on others for care
Roark, 2004
Fears of the dying client
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Fear of Loss of Self Control
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Loose ability to control life decisions
Loose ability to control ADL’s
Loss of control of body functions
Loss of control of emotions
Loss of independence
Roark, 2004
Fears of the dying client
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Fear of Suffering and Pain
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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
Roark, 2004
Child’s Response to Illness and
Death
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Infant
Toddler
Preschool
School Aged
Adolescent
Roark, 2004
Cultural Backgrounds Affect Beliefs
Concerning Death
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Beliefs, attitudes, and values that stem from the
patient’s cultural background will strongly
influence their reaction to loss, grief, and death
Expressions of grief are governed by what is
acceptable by the family and within the cultural
context
Comfort may be found through spiritual beliefs,
and finding comfort in specific rites, rituals, and
practices
Roark, 2004
Cultural Backgrounds Affect Beliefs
Concerning Death
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Organized religious practices
Nurses need to be in tune with patients’
spiritual needs
Becoming familiar with cultural views will
help…
Can you name some cultural practices
associated with loss, grief, and death?
Roark, 2004
Support the client
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Nurses can help to identify coping mechanisms,
and encourage effective coping mechanisms
Allow client/family to visit the chapel if desired
Allow family members around
Client may have problems with conflicting
feelings that do not align with culture or
religious practices-nurse can evaluate coping
and guide the client to appropriate interventions
Roark, 2004
Role of the Chaplain
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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
Roark, 2004
Nurses response to the dying
patient
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Nurses grieve also
Nurses need to come to terms with personal
meanings of life and death
Best prepared to work with terminal clients
when the nurse has been given the time to
come to terms with own mortality
Common feelings
Develop personal/professional support systems
Roark, 2004
Rationale for Communicating
Truthfully about Terminal Illness
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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
Roark, 2004
Communicating Terminal Illness,
continued
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The nurse:
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Clarifies what was said
Listens to concerns
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
Roark, 2004
List nursing strategies appropriate
for grieving persons
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Open ended statements
Patient sets the pace
Accept any grief reaction
Be aware—nurse may be target of anger
Remove barriers
Avoid giving advice
Allow patient to talk
Allow patient to express signs of hope
Support hope by helping focus
Roark, 2004
Assist Family to Grieve
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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
Roark, 2004
Choices of Care Setting
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Families have choices of where to care for
the dying loved one
Ask the patient and family preferences
Support whatever the choice
Hospital, Home/Hospice
Roark, 2004
Elements of Hospice Care
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Home care coordinated with hospital
Control of symptoms holistically
Physician directed care
Utilization of variety of health care
professionals
Bereavement follow up care
Acceptance based on need, not $
Roark, 2004
Nursing strategies to meet physical
and psychosocial needs of the
dying patient
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Thorough pain control
Maintain
independence
Prevent isolation
Spiritual comfort
Support the family
Roark, 2004
Signs/Symptoms of Approaching
Death
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Motion and sensation is gradually lost
Increase in temperature
Skin changes-cold, clammy
Pulse-irregular, and rapid
Respirations-strenuous, irregular, Cheyne stokes
“Death rattle”
Decrease Blood Pressure
Jaw and Facial muscles relax
MOST POSITIVE SIGN OF DEATH=Absence of brain
waves (Need two MDs to sign off)
Roark, 2004
Nursing care after death
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Autopsy: examination performed after a
person’s death to confirm or determine
cause of death
For tissue and organ removal:
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Keep CV system going
Call donor bank representative
Must be agreed on by all family members
Or, patient decision before death
Roark, 2004
Nursing care after death
Legally, a person is considered dead when there is
a lack of brain waves even though other body
organs continue to function
This definition allows for harvesting of organs and
tissue for donation
Vital organs are: heart, liver, kidney, lung,
pancreas
Non-vital organs are: eye corneas, long bones,
middle ear bones, and skin
Roark, 2004
Deceased patient, before viewing
the body
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Check orders for special requests
Remove equipment
Remove supplies
Change soiled linens and cleanse patient
Use room deodorizer
Place patient in supine position, with small pillow
under head
Insert dentures
Roark, 2004
Deceased patient, before viewing
the body continued
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Remove valuables and give to family
Stay with family, if requested
After the family leaves:
 Tag patient according to hospital/agency policy
 Wrap body in shroud
 Put ID tag on shroud
 Transfer to morgue
 Document
Roark, 2004
Describe response of family to
dying process
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Related to cultural background
Unresolved grief issues
Emotions
Requests
Physical symptoms may occur
Reorganization
Individualized grief patterns
Roark, 2004
Behavioral responses that obstruct
the expression of grief
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Sudden, unexpected death
Lengthy illness resulting in death
Loss of a child
Perception that the death was preventable
Unsteady relationship with deceased
Mental illness of survivor
Lack of social support
Roark, 2004
Thanatology
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Thanatology= study of death
The description of study of the
phenomena of death, and of psychological
mechanisms for coping with death
Roark, 2004
Thank you
Roark, 2004