CHAPTER 17: LOSS, GRIEF, AND DEATH
LOSS: As in any situation, either actual, potential, or perceived wherein a valued
object or person is changed or is no longer accessible to the individual.
Maturational loss: loss that occurs as a result of moving from one
developmental stage to another (ie working after you complete school)
TYPES OF LOSS:
A LOSS CAN BE TANGLIBLE OR INTANGLIBLE
Tangible loss- Income
Intangible- Self-esteem
ACTUAL LOSS: loss of someone or something (ie death of a loved one, theft of
property.)
ANTICIPATED LOSS: ie diabetic faced with losing foot(amputation)
PERCEIVED LOSS: sense of loss felt by an individual but not tangible to others
(loss of self-esteem because of rejection)
PHYSICAL LOSS: loss of a part or aspect of the body (ie loss of extremity)
PSYCHOLOGICAL LOSS: emotional loss (ie women feeling inadequate after
menopause)
SITUATIONAL LOSS: loss that takes place that a person has no control over (loss
of a job when company goes bankrupt or the company transfers.)
4 CATEGORIES OF LOSS:
1. Loss of external object 2. Loss of familiar object
3 Loss of aspect of self
4 Loss of significant other
GRIEF: A series of intense physical & psychological response that occurs
following a loss.
Mourning: The adaptive process that a person experiences after a loss, the period
where grief is expressed.
Bereavement: the period of grief following the death of a loved one.
Erick Lindemann’s Theory of “Grief Work” describes the process experienced by
the bereaved. The person experiences freedom from attachment to the
deceased, becomes reoriented to the environment & establishes new
relationships.
Angle Theory: is that the grieving process occurs in stages:
 Stage 1: shock & disbelief
 Stage 2: developing awareness
 Stage 3: restitution & resolution
TYPES OF GRIEF:
UNCOMPLICATED “normal grief”: A grief reaction that normally follows a
significant loss
PHYSICAL REACTIONS:
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Loss of appetite
Insomnia
Fatigue
Decreased Libido
Restlessness
PSYCOSOCIAL REACTIONS:
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Helplessness
Hopelessness
Denial
Anger etc. (listed on page 311)
DYSFUNCTIONAL GRIEF: these individuals do not progress through the steps of
overwhelming emotions & fail to demonstrate any behaviors commonly
associated with grief. They remain isolated & do not return to their normal
lifestyle pattern. They continue to focus on the deceased & they usually need
professional help.
Several Forms of dysfunctional grief:
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Chronic- inability to conclude grieving
Delayed- when grief does not take place at time of loss
Exaggerated- when grief is experienced as overwhelming
Masked-when grief is covered up by maladaptive behaviors
ANTICIPATORY GRIEF: is the occurrence of grief BEFORE an expected loss usually
occurs.
DYSFUNCTIONAL GRIEF: grief that is not openly acknowledged, socially
sanctional, or publicly shared (ie loss of a pet)
FACTORS THAT AFFECT LOSS & GRIEF:
Development Stage: grief is experienced differently depending on where the
persons place is on the age/development continuum.
 CHILDHOOD: children who grieve need an explanation about death.
infant/toddler not aware of what death is
are aware of disruption of normal routine
can react to families expression of grief
 PRESCHOOL:
Views death as temporary separation
Is able to react to the gravity of death in accordance with the reactions
of parents & others.
 SCHOOL-AGE:
Appreciates that death is final & inevitable
Fantasizes about & tends to personify death (ie the boggie man)
 PREADOLESCANCE/ADOLESCANCE:
Recognizes that death is final
Understands that death is inevitable
 EARLY ADULTHOOD:
Grief is usually precipitated by the loss of a role or status.
 MIDDLE ADULTHOOD:
Potential for experiencing loss increases
Death of a peer might threaten their own mortality
 LATE ADULTHOOD:
Individuals recognize that death is inevitable
FACTORS THAT INFLUENCE ONES PERCEPTION OF GRIEF INCLUDE:
 Religious & cultural beliefs (life after death etc.)
 Relationship with the lost object- the more intimate the relationship
with the deceased the more intense the grief is expressed
 Loss of a child- is exceptionally painful, it interfers with natural order
(parents usually die before their children)
 CAUSE OF DEATH:
 Unexpected- poses difficulty for the bereaved in achieving closure(death
from MI, CVA etc)
 Traumatic death- survivors suffer emotions of greater intensity than
those associate with normal grief(the bereaved re-live the terror of the
incident or imagine the feelings of horror felt by the victim.
 Suicide- survivors suffer feelings of guilt.
NURSING CARE OF GREIVING CLIENTS (read on own)
DEATH: the last stage of life
 Health care providers must come to terms with their own mortality &
feelings about death in order to care for the dying patients & they need
to know the ethical issues involved.
LEGAL CONSIDERATIONS:
 ADVANCED DIRECTIVES- (NOT WRITTEN IN STONE) any written
instruction, including a living will or durable power of attorney for health
care that is recognized under state law. (applies to hospital, LTCF, HH
agencies, hospice programs, etc)
 LIVING WILL/DURABLE POA: does not preclude the need for
resuscitation. The medical record MUST have DNR order from MD
(missie dercole) if this is in agreement with the clients wishes & with the
advanced directives.
 HEALTH CARE SURROGATE LAW: it provides a legal means for specific
individuals to make decisions for the client when the client can no
longer do so.
 the law has developed a hierarchy of individuals who would act in the
interest of the client. Spouse first followed by children.
ETHICAL CONSIDERSTIONS: ethical decision making is a complex issue.
 Most difficult dilemma is determining the difference between killing &
allowing someone to die by withholding life sustaining measures.
 EUTHANASIA IS VIEWED AS UNETHICAL
STAGES OF DYING:
Elizabeth Kubler Ross identified 5 stages of dying. Clients experience these
stages in varying degrees & for varying lengths of time. Not all moves sequentially
through each stage
 DENIAL: this stage is primarily when individuals “dr shop” or insist that
there was a mix-up or mistake (ie this cant be happening to me)
 ANGER: the client feels powerless & they have no control of the
situation so they become very angry. Anger may be directed at GOD,
themselves, or others. (ie why me? I go to church)
 BARGAINING: client attempts to postpone or reverse the inevitable &
sometimes it is not uncommon for the client to live long enough for the
event & then die shortly after (ie let me live long enough to see my
grandchild graduate)
 DEPRESSION: when the client realizes that the loss can no longer be
delayed. Friends/family begin to visit less & less & this will compound
their feelings & hopelessness. ( ie go away I just want to lie here in bed
whats the use!)
 ACCEPTANCE: not everyone reaches this stage. Reinforcement of the
clients feelings & sense of personal worth are important during this
stage. Client sleeps more, not to avoid reality but because of the
physical & emotional need for sleep. (ie I feel ready, at least I am more
at peace now)
NURSING CARE OF THE DYING CLIENT: read on own
Remember: terminally ill clients are given palliative care (does not alter the
course of the disease) palliative care is symptomatic
RELIGION AND DYING ISSUES
RELIGION:
JUDAISM:
 LIFE SUPPORT WITHDRAWL: allowed under right circumstances (ie when
life support is used to impede death)
 DEATH: suicide is forbidden, buried within 24 hours, NO cremation
 ORGAN DONATION: permitted except Orthodox Jews, autopsy
permitted
ISLAM:
 LIFE SUPPORT WITHDRAWL: permitted only if only serving to prolong
death
 DEATH: suicide forbidden
 ORGAN DONATION: permitted, autopsy permitted
CATHOLICISM/ORTHODOXY:
 LIFE SUPPORT WITHDRAWL: controversial/permitted if clients condition
is hopeless.
 DEATH: prayers are offered at time of death
 ORGAN DONATION: permitted, cremation, autopsy permitted
PROTESTANISM:
 LIFE SUPPORT WITHDRAWL: permitted if clients condition is hopeless.
 DEATH: prayers are offered at time of death
 ORGAN DONATION: permitted but rejected by Baptists & Pentecostal,
burial, cremation, & autopsy are all permitted.
JEHOVAHS WITNESS:
 LIFE SUPPORT WITHDRAWL: permitted if serving only to prolong death
or if quality of life is nonexistent.
 DEATH: suicide is not approved
 ORGAN DONATION: individuals choice, autopsy permitted only if legally
necessary.
MORMONS:
 LIFE SUPPORT WITHDRAWL: client or family decision
 DEATH: cremation is discouraged, autopsy is family decision
 ORGAN DONATION: family decision
HOSPICE CARE: the goal is control symptoms of terminal patients: provide pain
relief. Hospice focuses on quality of life over quanity.
 Type of care for terminally ill clients
 Allows clients to die with dignity
 No more aggressive medical treatments
RESPITE CARE: provides rest & relief for family members caring for patient.
IMPENDING DEATH:
 Clients may exhibit signs of impending death then rally for several days.
 Some clients need permission to die from a loved one
PHYSICAL SIGNS INCLUDE:
 Cheyne-Stokes Respirations: breathing with periods of apnea altered
with periods of dyspnea. “death rattle” is secretions in the respiratory
tract.
 Skin is cool, possibly pale, cyanotic, jaundice, or mottled.
 Pulse is rapid, irregular, weak & thread
 Cold cyanotic extremities & irregular respirations indicate death within 1
to 2 hours
 Confusion & lethargy
 Pupils fixed & dilated
 Client may “talk” to dead loved ones
 Last sense to go is HEARING
 Heart stops beating & within a few minutes cerebral death occurs.
IF PATIENT DIES AT HOME (page 326):
IMPORTANT: DO NOT CALL AMBULANCE OR 911!!!
CARE AFTER DEATH:
POST-MORTEM CARE:
 Given immediately after death but before the body is moved
 Before the family comes: remove all IVs, Foleys, put on a clean gown &
cover them to their neck.
ALGOR MORTIS:
 Body temp decreases  lack of skin elasticity
LIVER MORTIS:
 Bluish-purple discoloration of skin usually at pressure points
 Elevate head to prevent discoloration associated with pooling of blood
RIGOR MORTIS: (2-4 hours after death)
 Body stiffens because of contraction of muscles
 Close eyelids, close mouth (don’t put dentures in)
 Position body in natural position
 Get body to morgue as soon as possible
AFTER FAMILY VIEWS BODY:
 Place I.D. tags on (toe, wrist, & shroud)
 Place body in the shroud
 Transport body to morgue according to agency policy until it is
transported to mortuary.
 Nursing responsibility: return deceased possessions to family (clothing,
hearing-aid, jewelry etc.)
LEGAL ASPECTS:
 MD determines cause of death
 Autopsy: may be mandated where there is unusual death (family must
give consent)
ORGAN DONATION: organs used for transplantation:
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Kidney
Lungs
Heart
Liver
Pancreas
Skin
Corneas
Bones
When family consents time is of an essence, donor team should be notified
CARE OF FAMILY:
 Provide support
 Be informative
 Help family & be sensitive to their needs
NURSE’S SELF- CARE
 Take time to cry with family
 Don’t try to be “supernurse”