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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