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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.
• 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
• 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, 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
• 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
• Developmental • Family • Socioeconomic • Cultural • Religious • Cause of Death
• Assessing- determine the adequacy of the pt’s and families, knowledge, perceptions, coping strategies and resources.
• Questions to ask – What have you been told about
your condition? – Have you had any previous
experience with this condition or death of a loved one?
– Tell me a little bit about how you are coping
– What is helping you get through this?
• 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.
• 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.
• 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.
• 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
• 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
– 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
• 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.
• 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