LOSS, GRIEF AND DEATH
Loss, Grief, Dying
Class Objectives
The nursing student
will learn:
 nurses role in loss,
grief, death and
dying
 emotional reactions
to loss




Engles stages of
grief
Kubler-Ross Grief
and Death Reactions
legal and ethic
dilemmas with death
and dying
to create a nursing
care plan for a death
and dying patient.
Loss

Occurs when a
valued person,
object, or
situation is
changed
• Actual Loss
• Perceived loss
• Anticipated loss
• Physical loss
• Psychological
loss
Grief or Grieving-Grief is the
Emotional Reaction to Loss

Bereavement- state
of grieving during
which a person goes
through grief
reaction.

Mourning-period of
acceptance of loss
and grief during
which the person
learns to deal with
the loss.
Engels 6 Stages of Grief
Reaction




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
Shock and disbelief
Developing
awareness
Restitution
Resolving the loss
Idealization
Outcome
Kubler-Ross Grief and Death
Reactions

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
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Denial and isolation
Anger
Bargaining
Depression
Acceptance
Five Principles of Palliative Care(Hospice care)


Respects the goals,
likes and choices of
the dying pt.
Looks after medical,
emotional, social,
and spiritual needs of
the dying person



Supports the needs
of the family
members
Helps pt gain access
to needed healthcare
providers and
appropriate settings
Builds ways to
provide excellent end
of life care
Ethical and Legal Dimensions



Managed death,
Legalized physician
assisted suicide,
Physician
administered lethal
injections (aid in
dying) – create
ethical dilemmas.

Patients look to
nursing for
information, advice
and support.
The nurse patient relationship is
key to helping patient’s grieve
Advanced Directives

Living wills- provide
specific instructions
about the kinds of
health care that
should be provided
or foregone in a
particular situation

Durable power of
attorney- appoints
and agent the person
trusts to make
decisions in the
event of the
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




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Developmental
Family
Socioeconomic
Cultural
Religious
Cause of Death
Nursing Process

 Questions to ask
Assessing• What have you been told
determine the
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
you are coping
strategies and
• What is helping you get
resources.
through this?
Nursing Diagnoses



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
Impaired adjustment
Caregiver role strain
Decisional conflict
Ineffective coping
Ineffective denial




Anticipatory grieving
Dysfunctional
grieving
Hopelessness
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
care for the dying pts
and their families
and promote health
and preventing
illness of the family

Nursing Diagnosis
•
•
•
Impaired adjustment
r/t newly diagnosed
terminal illness
Caregiver role strain r/t
hospital discharged
dying pt because of
inadequate insurance.
Dysfunctional grieving
r/t inability to accept
death of infant no grief
resolution.
Nursing interventions



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Monitor patient for
anxiety
Monitor mood
changes
Communicate
willingness to
discuss death
Encourage pt and
family to share
feelings about death



Monitor pain
Facilitate obtaining
spiritual support for
pt and family
Include the family in
care decisions and
activities as desired.
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

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Muscle weakness
Respiratory changes
• Cheyne-Stokes
• Death Rattle
Sensory changes
Circulatory changes
Postmortem Care

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Nursing prepares the body for viewing
Identification
Who to notify
Jewelry and valuables
Dentures, glasses, prosthetics
Question
A.
B.
C.
D.
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:
Elevated B/P
Cheyne-Stokes respirations
Elevated pulse rate
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.
b.
c.
d.
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 inform her to refuse the test
Inform the MD of her statements
Educate her on the test’s benefits
Educate her on the procedure
Question #3

a.
b.
c.
d.
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 families MD
County court
City policy dept
County coroner.
Question #4

1.
2.
3.
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
Anger
Bargaining
Denial
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
Increases anxiety levels
Allows family members an avenue of escape
from the truth
Supports the family members’ decision for a
DNR
2.
3.
4.