Loss, Grief, and Dying

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 Types of Loss
 Actual loss—can be recognized by others
 Perceived loss—is felt by person but intangible
to others
 Physical loss versus psychological loss
 Maturational loss—experienced as a result of
natural developmental process
 Situational loss—experienced as a result of an
unpredictable event
 Anticipatory loss—loss has not yet taken place

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 Definitions
 Grief – internal emotional reaction to loss
 Bereavement - state of grieving; person goes
through grief reaction
 Mourning – actions and expressions of that
grief, including the symbols and ceremonies
that make up the outward expressions of grief

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 Engel’s Six Stages of Grief
 Shock and disbelief
 Developing awareness
 Restitution
 Resolving the loss
 Idealization
 Outcome
 Page 1687

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 Definitions of Death

 Irreversible cessation of all functions of

circulatory and respiratory functions, or
 Irreversible cessation of all functions of the
entire brain, including the brainstem

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 Clinical Signs of Impending Death
 Difficulty talking or swallowing
 Nausea, flatus, abdominal distention
 Weak, slow, or irregular pulse
 Restless or agitation
 Bowel and bladder incontinence
 Loss of motion, sensation, reflexes
 Decreasing temperature, cold or clammy skin, cyanosis
 Lowered blood pressure
 Noisy or irregular respirations
 Cheyne-Stokes respirations

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Kubler-Ross’s Five Stages of Grief
 Denial and isolation
 Anger
 Bargaining
 Depression
 Acceptance
 Pages 1687 and 1689

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 Types of Grieving

 Normal grieving - began the thought that this

concept is normal and not pathological;
coined “grief work” which is the effort by a
grieving person to acknowledge the physical,
emotional, social, and spiritual pain
associated with bereavement and to integrate
the loss into the future

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 Types of Grieving
 Anticipatory grieving … the intellectual and
emotional responses and behaviors by which
individuals, families, and communities
attempt to work through the process of
modifying self-concept based on the
perception of potential loss

 Dysfunctional grieving… having trouble

dealing with grief that is unresolved or
inhibited; abnormal or distorted

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 Components of a Good Death
 Pain and symptom management
 Clear decision making
 Preparation for death
 Completion of life
 Contributing to others
 Affirmation of the whole person
 Good relationship with health care
professionals

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 Palliative Care

 Care of the whole person (heart, soul, mind,

spirit, and body)
 Dying is natural and personal
 Best quality of life is given
 Symptoms are aggressively managed
 Care should be provided in all settings

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 Advance Directives (Page 1691)

 Decide who will make decisions for the patient in

case he or she is unable
 Decide the kind of medical treatment the patient
wants or doesn’t want
 Decide how comfortable the patient wants to be
 Decide how the patient will be treated by others
 Decide what the patient wants loved ones to
know

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 Special Orders (Page 1694)

 Allow Natural Death

 Do-not-resuscitate (DNR), or no-code
 Comfort measures only
 Do not hospitalize

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 Living Will

 A legal document that allows you to give

instructions about the use of medical
treatments at the End of Life. Other names
for this type of document are “health-care
declaration” or “medical directive.”

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 Medical Power of Attorney

 A Medical Power of Attorney (or Durable

Power of Attorney for healthcare) is a written
document, in which you name a person
(proxy) to make decisions for you if you
become unable to do so.

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 Do Not Resuscitate
 A “Do Not Resuscitate” (DNR) order is written
instruction from a health care provider telling
health-care providers NOT to make resuscitative
attempts.
 A DNR order means that no attempts are to be
made to resuscitate a patient whose breathing or
heart stops.
 A DNR is a type of Advance Directive that is used
to help ensure that the wishes of the patient
and/or family concerning End of Life issues are
followed.

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Factors Affecting Grief and Dying
 Developmental considerations
 Family
 Socioeconomic factors
 Cultural
 Biological sex roles
 Religious influences
 Causes of death

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 Diagnosis
 Death anxiety
 Risk for caregiver role strain
 Readiness for enhanced coping

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 Needs of Dying Patients
 Physiologic needs—physical needs, such as
hygiene, pain control, nutritional needs
 Psychological needs—patient needs control
over fear of the unknown, pain, separation,
leaving loved ones, loss of dignity, loss of control
and unfinished business
 Intimacy needs—patient need ways to be
physically intimate that meets needs of both
partners
 Spiritual needs—patient needs to practice
religious faith
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 Developing a Trusting Nurse-Patient
Relationship

 Keep the lines of communication open

 Answer questions about dying
 Do not escape death questions
 Do not provide false reassurance

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 Providing Postmortem Care (Page 1567)

 Care of the body

 Care of the family
 Discharging legal responsibilities
 Death certificate issued and signed
 Labeling body
 Reviewing organ donation arrangements if
any
 Care of other patients
 Care for oneself
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 Postmortem Care of the Body

 Prepare body for discharge

 Place body in anatomical position, replace
dressings, and remove tubes (unless there is
an autopsy scheduled)
 Place identification tags on the body
 Follow local law if patient died of
communicable disease

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 Postmortem Care of the Family
 Listen to family’s expressions of grief, loss, and
helplessness
 Offer solace and support by being an attentive
listener
 Arrange for family members to view the body
 In the case of sudden death, provide a private
place for family to begin grieving
 It is appropriate for the nurse to attend the
funeral and make a follow-up visit to the family

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 Death Certificate
 Must be prepared for each person that dies
 Law specifies information
 Sent to local health department
 Must have a clinician’s signature (check state
law to see if nurse’s can sign death
certificate)
 Page 1696

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 Autopsy
 Page 1697

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 Organ Donation
 Organs retrieved from totally brain-dead patients but new
protocols exist for retrieval from non-heart beating
cadavers raise practice concerns
 Once brain death is confirmed, an organ donation
organization is contacted
 Louisiana Organ Procurement Agency (LOPA) - organ
procurement organization that serves the state of
Louisiana
 LOPA has two objectives: maintain and house the LA.
Donor Registry and organs and tissues are recovered for
transplant
www.LOPA.org

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 How Organ Donation Occurs

 The United Network for Organ Sharing

(UNOS) is a data base that keeps information
on people waiting for transplants. It retains
data that helps transplant teams match
donors with recipients
 Each person on the waiting list is entered
with information such as blood type, illness
status, tissue type, medical urgency, waiting
time, plus other criteria
www.UNOS.org

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 How Organ Donation Occurs

 One organ donor can save eight lives

 Potential organ donors include people of all ages
and medical histories
 Can be a living donor

www.UNOS.org

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UNOS List of Organs and Tissues
that can be Donated
 Heart
 Lungs
 Liver
 Kidneys
 Intestines
 Pancreas
 Nerves
 Bones
 Tendons
 Heart valves
 Corneas
 Skin
 Plus more
www.UNOS.org
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 It seems to be true!!

They get better before they die

If they tell you they are going to die,

they probably will

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 Communication
 Do not say:
 At least he’s old
 It was God’s will
 He’s better off anyway
 You’re young, you can have more children
 What you can say:
 I’m sorry
 This must be painful/difficult for you
 I’ll be with you/them
 Listen

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