Ethics and Values, The Experience
of Loss, Death, and Grief, Stress and
Coping
Nursing ethics
Nursing ethics is a branch of applied ethics that concerns itself with activities
in the field of nursing. Nursing ethics shares many principles with medical
ethics, such as beneficence, non-maleficence and respect for autonomy. It
can be distinguished by its emphasis on relationships, human dignity and
collaborative care

The nature of nursing means that nursing ethics tends to examine the ethics
of caring rather than 'curing' by exploring the relationship between the
nurse and the person in care. arly work to define ethics in nursing focused
more on the virtues that would make a good nurse, rather than looking at
what conduct is necessary to respect the person in the nurse's care.
However, recently, the ethics of nursing has also shifted more towards the
nurse's obligation to respect the human rights of the patient and this is
reflected in a number of professional codes for nurses.
Nursing Code of Ethics



Provision 1
The nurse, in all professional
relationships, practices with
compassion and respect for the
inherent dignity, worth, and
uniqueness of every individual,
unrestricted by considerations of
social or economic status, personal
attributes, or the nature of health
problems.
Provision 2
The nurse's primary commitment is
to the patient, whether an
individual, family, group, or
community.
Provision 3
The nurse promotes, advocates for,
and strives to protect the health,
safety, and rights of the patient.



Provision 4
The nurse is responsible and accountable for individual nuring
practice and determines the appropriate delegation of tasks
consistent with the nurse's obligation to provide optimum
patient care.
Provision 5
The nurse owes the same duties to self as to others, including
the responsibility to preserve integrity and safety, to maintain
competence, and to continue personal and professional growth.
Provision 6
The nurse participates in establishing, maintaining, and
improving health care environments and conditions of
employment conducive to the provisiobn of quality health care
and consistent with the values of the profession through
individual and collective action.



Provision 7
The nurse participates in the advancement of the profession
through contributions to practice, education, administration,
and knowledge development.
Provision 8
The nurse collaborates with other health professionals and the
public in promoting community, national and international
efforts to meet health needs.
Provision 9
The profession of nursing value, for maintaining the integrity
of the prosession and its practice, and for shaping social
policy.
How to Deal With a Patient's Death



First, it is important to acknowledge the death - you may find
it helpful to share your feelings with colleagues, friends and
family.
You may also find it helpful, to some degree, to share feelings
of loss with members of the family of the deceased. Of course,
it is important to realise that the grief of the family must take
precedence, but sometimes family members can gain a great
deal of comfort from sharing experiences with someone who
has been involved with the care of their relative.
Too often in medicine we do not acknowledge events such as
this, and our own feelings get lost because we then become
involved with new cases and new situations.
Loss, Grief and Death
People are complex, biopsychosocial
beings. When they become ill,
undergo diagnosis for altered
health states, experience a loss,
or progress into the end stage of
life, their responses are the result
of the complex interaction of
biopsychosocial changes that
occur. Because we live in a
culture marked by dramatically
different responses to the
experiences of loss and grief,
nurses often feel inadequate in
planning interventions to
facilitate grief management and
the healing process.
Loss
The concept of loss can be defined in several ways. The
following definitions have been selected to familiarize the
student with the concept of loss:
 Change in status of a significant object
 Any change in an individual's situation that reduces the
probability of achieving implicit or explicit goals
 An actual or potential situation in which a valued object,
person, or other aspect is inaccessible or changed so that it is
no longer perceived as valuable
 A condition whereby an individual experiences deprivation of,
or complete lack of, something that was previously present
Types of Loss
A loss may occur suddenly (eg, death of a child due to an auto
accident) or gradually (eg, loss of a leg due to the progression
of peripheral vascular disease). It may be predictable or occur
unexpectedly. Loss has been referred to as actual (the loss has
occurred or is occurring), perceived (the loss is recognized
only by the client and usually involves an ideal or fantasy),
anticipatory (the client is aware that a loss will occur),
temporary, or permanent
For example..
“A 65-year-old married woman with the history of end stage
renal disease is told by her physician that she has
approximately 12 months to live. She may experience several
losses that affect not only her, but also her husband and family
members, as her illness gradually progresses.”
The losses may include a predictable decline in her physical
condition, a perceived alteration in her relationship with her
husband and family, and a permanent role change within the
family unit as she anticipates the progression of her illness and
actual loss of life.
Examples of Losses Identified by
Student Nurses
Loss of spouse, friend, and companion.
The client was a 67-year-old woman admitted to the psychiatric hospital for
treatment of depression following the death of her husband. During a group
discussion that focused on losses, the client stated that she had been
married for 47 years and had never been alone. She described her deceased
husband as her best friend and constant companion. The client told the
student and group that she felt better after expressing her feelings about her
losses
Loss of physiologic function, social role, and independence because of kidney
failure. A 49-year-old woman was admitted to the hospital for improper
functioning of a shunt in her left forearm. She was depressed and asked
that no visitors be permitted in her private room. She shared feelings of
loneliness, helplessness, and hopelessness with the student nurse as she
described the impact of kidney failure and frequent dialysis treatment on
her lifestyle. Once an outgoing, independent person, she was housebound
because of her physical condition and presented what her kidneys were
doing to her.
Grief

Grief is a normal, appropriate
emotional response to an external
and consciously recognized loss. It is
usually time-limited and subsides
gradually.

The grief process is all-consuming,
having a physical, social, spiritual,
and psychological impact on an
individual that may impair daily
functioning. Feelings vary in
intensity, tasks do not necessarily
follow a particular pattern, and the
time spent in the grieving process
varies considerably from weeks to
years.
Precipitating Factors of Grief





Death in family
Separation
Divorce
Physical Illness
Work failure disappointments
Nursing Interventions:









Assess; specific loss, meaning of loss, coping skills, support
persons.
Accept the client; do not respond personally to the client.
Support adaptive responses; allow to express feelings
Support defense mechanism – reassure client that denial and
wanting to be alone is normal.
Help find constructive outlets of anger. Do not take clients
hostility personally. Do no retaliate.
Monitor for self destructive behaviors
Help express feelings: Ask how they feel
Meet needs
Allow as much decision making as possible to maintain
dignity by giving choices and alternatives.
Death is defined as:


"cessation of heart- lung
function, or of whole brain
function, or of higher brain
function.
"either irreversible cessation of
circulatory and respiratory
functions or irreversible
cessation of all functions of the
entire brain, including the brain
stem" - (The President's
Commission for the study of
Ethical problems in Medicine
and Biomedical and Behavioral
Research, US, 1983).
Responses to dying and death



lthough each person reacts to the knowledge of impending death or to loss
in his or her own way, there are similarities in the psychosocial responses
to the situation.
Kubler-Ross' (1969) theory of the stages of grief when an individual is
dying has gained wide acceptance in nursing and other disciplines.
The stages of dying, much like the stages of grief, may overlap, and the
duration of any stage may range from as little as a few hours to as long as
months. The process vary from person to person.
Some people may be in one stage for such a short time that it
seems as if they skipped that stage. Some times the person returns
to a previous stage
According to Kubler- Ross, the five stages of dying are:
 Denial
 Anger
 Bargaining
 Depression
 Acceptance

They are videly known in the acronym 'DABDA'.
Denial
On being told that one is dying, there
is an initial reaction of shock.
The patient may appear dazed at first
and may then refuse to believe the
diagnosis or deny that anything is
wrong.
 Some patients never pass beyond
this stage and may go from doctor
to doctor until they find one who
supports their position.
Anger




Patients become frustrated,
irritable and angry that they are
sick.
A common response is,” Why
me? ”
They may become angry at God,
their fate, a friend, or a family
member.
The anger may be displaced onto
the hospital staff or the doctors
who are blamed for the illness.
Bargaining
Depression
The patient may attempt to negotiate
with physicians, friends or even
God, that in return for a cure, the
person will fulfill one or many
promises, such as giving to
charity or reaffirm an earlier faith
in God.
The patient shows clinical signs of
depression- withdrawal,
psychomotor retardation, sleep
disturbances, hopelessness and
possibly suicidal ideation.
The depression may be a reaction to
the effects of the illness on his or
her life or it may be in
anticipation of the approaching
death.
Physical signs of dying









Dying is a different experience for everyone involved.
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
Loss of bowel or bladder control – caused by relaxing muscles in the pelvic
area
Skin becomes cool to the touch
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
Changes in body after death:



Rigor Mortis: body becomes
stiff within 4 hours after death as
a result of decreased ATP
production. ATP keeps muscles
soft and supple.
Algor Mortis: Temperature
decreases by a few degrees each
hour. The skin loses its elasticity
and will tear easily.
Livor Mortis: Dependant parts
of body become discolored. The
patient will likely be lying on
their back, their backside being
the 'dependant' body part. The
discoloration is a result of blood
pooling, as the hemoglobin
breaks down.
Hospice and palliative care



Hospice is a specialized program that addresses the needs of
the catastrophically ill and their loved ones particularly
accepte in US and West.
A team approach is provided in hospice that may involve
physicians, nurses, social workers, clergy, home health aids,
volunteers, therapists and family caregivers.
Hospice workers can help a dying person manage pain,
provide medical services and offer family support through
every stage of the process, from diagnosis to bereavement.
Components of hospice care programme
include the following:









Client and family as the unit of care
Co-ordinated home care with access to available inpatient and nursing
home beds
Control of symptoms(physical, sociological, psychological and spiritual)
Physician directed services
Provision of an interdisciplinary care team of physicians, nurses, spiritual
advisers, social workers and counselors.
Medical and nursing services available at all times
Bereavement follow up after a client's death
Use of trained volunteers for frequent visitation and respite support
Acceptance into the programme on the basis of health care needs rather
than the ability to pay
Palliative Care





Palliative care is the active total care of patients whose disease is not
responsive to curative treatment (World Health Organization).
The relief of suffering is one of the central goals of palliative care in
terminal illnesses.
Control of pain, of other symptoms and of psychological, social and
spiritual problems is paramount.
The goal of palliative care is the achievement of the best possible quality of
life for patients and their families.
Palliative care is a special care, which affirms life and regards dying as a
normal process, neither hastens nor postpones death, provides relief from
pain and other distressing symptoms, integrates the psychological and
spiritual aspects of patient care and offers a support system to help patients
live as actively as possible until death and helps the family cope during the
patient’s illness and in their own bereavement.
Palliative care is based on five major
principles





It respects the goals, likes and choices of the dying person.
It looks after the medical emotional, social and spiritual needs of the dying
person.
It supports the needs of the family members.
It helps gain access to needed health care providers and appropriate care
settings.
It builds ways to provide excellent care at the end of life
Identify the sources of stress

Stress management starts with identifying the sources of stress
in your life. This isn’t as easy as it sounds. Your true sources
of stress aren’t always obvious, and it’s all too easy to
overlook your own stress-inducing thoughts, feelings, and
behaviors. Sure, you may know that you’re constantly worried
about work deadlines. But maybe it’s your procrastination,
rather than the actual job demands, that leads to deadline
stress.
To identify your true sources of stress, look closely at
your habits, attitude, and excuses:



Do you explain away stress as temporary (“I just have a
million things going on right now”) even though you can’t
remember the last time you took a breather?
Do you define stress as an integral part of your work or home
life (“Things are always crazy around here”) or as a part of
your personality (“I have a lot of nervous energy, that’s all”).
Do you blame your stress on other people or outside events, or
view it as entirely normal and unexceptional?
Stress management strategy #1:
Avoid unnecessary stress





Learn how to say “no” – Know your limits and stick to them. Whether in your
personal or professional life, refuse to accept added responsibilities when
you’re close to reaching them. Taking on more than you can handle is a surefire
recipe for stress.
Avoid people who stress you out – If someone consistently causes stress in
your life and you can’t turn the relationship around, limit the amount of time
you spend with that person or end the relationship entirely.
Take control of your environment – If the evening news makes you anxious,
turn the TV off. If traffic’s got you tense, take a longer but less-traveled route.
If going to the market is an unpleasant chore, do your grocery shopping online.
Avoid hot-button topics – If you get upset over religion or politics, cross them
off your conversation list. If you repeatedly argue about the same subject with
the same people, stop bringing it up or excuse yourself when it’s the topic of
discussion.
Pare down your to-do list – Analyze your schedule, responsibilities, and daily
tasks. If you’ve got too much on your plate, distinguish between the “shoulds”
and the “musts.” Drop tasks that aren’t truly necessary to the bottom of the list
or eliminate them entirely.
Stress management strategy #2: Alter the situation




Reframe problems. Try to view stressful situations from a more
positive perspective. Rather than fuming about a traffic jam, look at it
as an opportunity to pause and regroup, listen to your favorite radio
station, or enjoy some alone time.
Look at the big picture. Take perspective of the stressful situation.
Ask yourself how important it will be in the long run. Will it matter in a
month? A year? Is it really worth getting upset over? If the answer is
no, focus your time and energy elsewhere.
Adjust your standards. Perfectionism is a major source of avoidable
stress. Stop setting yourself up for failure by demanding perfection. Set
reasonable standards for yourself and others, and learn to be okay with
“good enough.”
Focus on the positive. When stress is getting you down, take a moment
to reflect on all the things you appreciate in your life, including your
own positive qualities and gifts. This simple strategy can help you keep
things in perspective.
Stress management strategy #3: Adapt to the
stressor




Reframe problems. Try to view stressful situations from a more positive
perspective. Rather than fuming about a traffic jam, look at it as an
opportunity to pause and regroup, listen to your favorite radio station, or
enjoy some alone time.
Look at the big picture. Take perspective of the stressful situation. Ask
yourself how important it will be in the long run. Will it matter in a month?
A year? Is it really worth getting upset over? If the answer is no, focus your
time and energy elsewhere.
Adjust your standards. Perfectionism is a major source of avoidable
stress. Stop setting yourself up for failure by demanding perfection. Set
reasonable standards for yourself and others, and learn to be okay with
“good enough.”
Focus on the positive. When stress is getting you down, take a moment to
reflect on all the things you appreciate in your life, including your own
positive qualities and gifts. This simple strategy can help you keep things in
perspective.
Stress management strategy #4: Accept the things you can’t
change




Don’t try to control the uncontrollable. Many things in life are beyond
our control— particularly the behavior of other people. Rather than
stressing out over them, focus on the things you can control such as the
way you choose to react to problems.
Look for the upside. As the saying goes, “What doesn’t kill us makes us
stronger.” When facing major challenges, try to look at them as
opportunities for personal growth. If your own poor choices contributed to
a stressful situation, reflect on them and learn from your mistakes.
Share your feelings. Talk to a trusted friend or make an appointment with
a therapist. Expressing what you’re going through can be very cathartic,
even if there’s nothing you can do to alter the stressful situation.
Learn to forgive. Accept the fact that we live in an imperfect world and
that people make mistakes. Let go of anger and resentments. Free yourself
from negative energy by forgiving and moving on.
Stress management strategy #5: Make time for fun and
relaxation




Set aside relaxation time. Include rest and relaxation in your daily
schedule. Don’t allow other obligations to encroach. This is your time to
take a break from all responsibilities and recharge your batteries.
Connect with others. Spend time with positive people who enhance your
life. A strong support system will buffer you from the negative effects of
stress.
Do something you enjoy every day. Make time for leisure activities that
bring you joy, whether it be stargazing, playing the piano, or working on
your bike.
Keep your sense of humor. This includes the ability to laugh at yourself.
The act of laughing helps your body fight stress in a number of ways.
Stress management strategy #6: Adopt a healthy lifestyle





Exercise regularly. Physical activity plays a key role in reducing and
preventing the effects of stress. Make time for at least 30 minutes of
exercise, three times per week. Nothing beats aerobic exercise for releasing
pent-up stress and tension.
Eat a healthy diet. Well-nourished bodies are better prepared to cope with
stress, so be mindful of what you eat. Start your day right with breakfast,
and keep your energy up and your mind clear with balanced, nutritious
meals throughout the day.
Reduce caffeine and sugar. The temporary "highs" caffeine and sugar
provide often end in with a crash in mood and energy. By reducing the
amount of coffee, soft drinks, chocolate, and sugar snacks in your diet,
you’ll feel more relaxed and you’ll sleep better.
Avoid alcohol, cigarettes, and drugs. Self-medicating with alcohol or
drugs may provide an easy escape from stress, but the relief is only
temporary. Don’t avoid or mask the issue at hand; deal with problems head
on and with a clear mind.
Get enough sleep. Adequate sleep fuels your mind, as well as your body.
Feeling tired will increase your stress because it may cause you to think
irrationally.
Healthy ways to relax and recharge














Go for a walk.
Spend time in nature.
Call a good friend.
Sweat out tension with a good workout.
Write in your journal.
Take a long bath.
Light scented candles.
Savor a warm cup of coffee or tea.
Play with a pet.
Work in your garden.
Get a massage.
Curl up with a good book.
Listen to music.
Watch a comedy.