Grief Process, Death and Dying: Nur 102, Module G

Reading assignment : Potter and Perry, Chapter 30

1. LOSS

A. Actual loss
i. Any loss of a person or object that can no longer been felt, heard, known, or
experienced by an individual. (Death, amputation, Sensory loss,
independence, divorce)

B. Perceived loss
i. Any loss uniquely defined by the client. (confidence, self-esteem, group
status)

C.Maturational loss

i. Any change in the developmental process that is normally expected in a life

time. (Empty nest syndrome, loss of senses)

D. Situational loss
i. Any sudden unpredictable event (hurricane Katrina, recessional job loss,
chronic illness; financial loss, security, family role. Hospitalization; privacy,
modesty)

2. Grief

E. Grief is the emotional response to a loss

i. Based on spirituality, religious beliefs, individual

F. Coping with grief…

i. Mourning: the outward social expression of loss.

ii. Bereavement- grief and mourning together.

G.Kubler-Ross Stages of Dying (Grief)

i. Denial: the pt. acts like nothing happened. They refuse to accept that a loss
has occurred. May see outward expressions of this: deep sighs, listlessness,
cognitive impairment, refusal to comply with physicians orders.

ii. Anger: pt. may begin to recognize loss; they begin to strike out at
caregivers. Pt. is angry about loss. May become accusatory, demanding. Keep
in mind this is not personal or directed towards you.
 iii. Bargaining: Let’s make a deal. Trying to barter for more time. Postponing
awareness of dealing with loss.

iv. Depression: will see all classic symptoms of depression. They begin to realize
what all the loss will entail. They realize the total impact of the loss. May
exhibit suicidal thoughts or tendencies.

v. Acceptance: pt. begins to accept loss for what it is. Begin to look toward
future and accept loss for what it is. Less introverted, participate in more
activities in environments.

2. Death and Dying

i. Assisting the patient to “Live well” and “Die well”

A. Common Fears of the Dying Patient

i. Fear of Loneliness: pt knows they are dying and that caregivers are not. Fear
of actually moment of death being alone.

ii. Fear of Sorrow: Letting go of hopes and dreams, letting go of future.

Anticipatory grief. May have grief process of disease that is going to be long
term.

iii. Fear of the Unknown: death is an unknown state. We all have beliefs and
faiths but really don’t know. Fear about what will happen to your families.

iv. Fear of Loss of Self-concept and Body Integrity: Procedures that change body
appearance or function.

B. More Common Fears of the Dying Patient

i. Fear of Regression: going backwards. Not being able to take care of
self, cant do ADL’s.

ii. Fear of Loss of Self Control: similar to above. Cannot control emotions,
cannot control environment. Loss of independence.

iii. Fear of Suffering and Pain: Emotional pain, physical pain, social
withdrawal, altercation of relationships. Fear family will suffer.

3. Child’s Response to Illness and Death

C. Infant: birth to six months

i. No concept of death.

D. Toddler: 6 months to 2 years-old

i. May see death as reversible.
 E. Preschool: 2 years to 6 years
i. Curiosity; lots of questions. Want to understand. Expect regressions in this
age.

F. School Aged
i. More curios about biological side of death. May see death as punishment.
May take blame for death. May see some cognitive changes.

G. Adolescent
i. Understand death as permanent. May somatosize.

4. Factors Influencing Loss and Grief

H. Human development
i. Age of patient. Developmental stage they are in.

I. Psychosocial perspectives
i. Age, gender, status, race, intellect.

J. Socioeconomic status
i. May interfere with obtaining medical help, counseling, etc…

K. Personal relationships
i. Mother, father, child, sibling vs. second cousin or friend.

L. Nature of the loss

i. Sudden, expected, type of loss.

M. Culture and ethnicity

i. Some cultures are more expressive, some are quieter. Each culture has its
own beliefs on how to deal with loss.

N.Spiritual beliefs
i. Finding comfort in a higher power, certain rituals or rights associated with the
death.

ii. Cultural Backgrounds Affect Beliefs Concerning Death

iii. Nurses need to be in tune with patients’ spiritual needs

iv. Becoming familiar with cultural views will help…

5. Nursing Process & Grief:Assessment

 i. Should include family members, patient.

O. Type and Stage of Grief

P. Grief reactions
i. Assess how the pt is reacting not how you think they should be reacting.

ii. No two people grieve the same way; very individualized.

Q.Symptoms of normal grief-(Box 30-5, pg. 469, Potter & Perry)

R. End-of-life decisions
i. Decisions that relate to what that pt wants with regards to end of life care.

ii. Nurse should try to discuss this with pt. when possible.

iii. DNR, Living will, etc…

S. Nurse’s experiences
i. We each have to look inside when dealing with terminal patients. Need to
examine our own ideas on death and dying b/c it will affect care we give.

ii. Need to look out for our own emotional well being as well.

iii. Need to deal with personal phobias of death. Cannot put own personal
feelings above that of the client!

T. Client expectations
i. “what can I do to help you?”

ii. Discuss with family their expectations of the healthcare team.

6. Nursing Diagnoses

U.Anticipatory grieving

V. Dysfunctional grieving

W. Hopelessness

X. Powerlessness

Y. Spiritual distress
7. Planning
 Z. Goals and outcomes

1. Short-term: related to hospital

i. Getting through hospital stay, education, setting up care for ADL’s, etc…

2. Long-term: carry on to home.

i. Renewing relationships, getting through grieving process, etc…

AA. Setting priorities

i. Need to figure out what needs to be taken care of first. Ex: do not try to teach
if pt. is in level nine on pain chart.

BB. Continuity of care

i. Make sure pt. continues to receive any counseling, care, education they need
after they leave hospital setting.

8. Role of the Chaplain

CC. Can be a member of the health care team

DD. Assist with religious practices

1. Perform rites

2. Provide prayer, support, and comfort

EE. Assist with mobilizing other support systems that are important to the
client

FF. Support family members

9. Implementation

i. Help promote healthy grief resolution. Help them move through the process
and adjust to loss. Deal with stressors in their life; make health care
decisions at this time.
 GG. Therapeutic communication: open ended statements, will learn more in
Mod. E. No topic that a dying client wants to talk about is off limits. CLIENT
NEEDS THAT OUTLET!

HH. Promoting hope: can be an energizing resource for anyone dealing with
loss. Have cheerful attitude, encourage positive coping mechanisms, offering
info about illnesses to dispel misconceptions, using external resources.

II. Facilitating mourning: Give them time to grieve, allow family to be

there as much as possible, allow family to help with care as much as possible.
10. List nursing strategies appropriate for grieving persons

JJ. Open ended statements

1. Patient sets the pace

KK. Accept any grief reaction

1. Be aware—nurse may be target of anger

LL. Remove barriers

1. Sensory barriers

2. Family members that are not in control of emotions

3. Social workers may help.

MM. Avoid giving advice

NN. Allow patient to talk

OO. Allow patient to express signs of hope

PP. Support hope by helping focus

11. Palliative Care

QQ. Palliative care defined:

The prevention, relief, reduction, or soothing of symptoms of disease or
disorders without affecting a cure.

1. Some aspects of Palliative Care

i. Symptom control assist with related symptoms of
illness, provide comfort.
 ii. Maintaining dignity and self-esteem attend to
client’s appearance, help keep self-esteem high,
keep family and pt well informed.

iii. Preventing abandonment and isolation answer call

lights promptly, talk and spend time with pt, use
caring touch when appropriate, keep family
involved and part of care, provide peaceful and
comfortable environment.

iv. Providing a comfortable and peaceful environment

preferential activities, clean room, lighting, temp,
etc…

12. Guidelines concerning Communicating Terminal Illness

RR. Physician tells patient

i. Patient has right to know prognosis, but we do not give it to them.

SS. The nurse:

i. Clarifies: answer any questions that may not have come up when the
initial diagnosis was given.

ii. Listens

iii. Fosters communication: between physician and patient/pt family.

iv. Allows expression of feelings

v. Facilitates grief through nursing process

vi. Is available

vii. Assists with goals

viii. Connects with resources

13. Support for the Grieving Family

TT. Primary caregivers

1. Information and education

2. Planning
14. Assist Family to Grieve

UU. Explain procedures and equipment

VV. Prepare them about the dying process

WW. Involve family and arrange for visitors

XX. Encourage communication

YY. Provide daily updates: Do not deliver bad news when only one family
member is present

ZZ. Resources
15. Choices of Care Setting

AAA. There are choices available for client/family

BBB. Assist in providing desired choices

CCC. Hospice care

1. Nurses role in hospice

16. Nursing strategies to meet physical and psychosocial needs of the
dying patient

DDD. Thorough pain control

EEE. Maintain independence

FFF. Prevent isolation

GGG. Spiritual comfort

HHH. Support the family

17. Signs/Symptoms of Approaching Death

III.Motion and sensation is gradually lost

JJJ.Increase in temperature
 KKK. Skin changes-cold, clammy: can become diaphoretic though.

LLL. Pulse-irregular, and rapid

MMM. Respirations-strenuous, irregular, Cheyne stokes

NNN. “Death rattle”: a lot of congestion in chest that moves around and
rattles as they are breathing.

OOO. Decrease Blood Pressure

PPP. Jaw and Facial muscles relax

QQQ. MOST POSITIVE SIGN OF DEATH=Absence of brain waves (Need two

MDs to sign off)
18. Nursing Care Postmortem (after death)

RRR. Tissue and Organ Donation: will want to talk to pt. and pt. family about
organ donations prior to death.
i. Heart, liver, kidney, lung, pancreas

ii. Non-vitals that can be harvested: long bones, corneas, middle ear bones, skin

iii. If pt is donor keep cardiovascular systems going. Call donor bank rep.

iv. All family members must agree to donation.

SSS. Autopsy: examination performed after a person’s death to confirm or

determine cause of death

TTT. Cultural issues (Table 30-10, pg. 481)

19. Postmortem Care

i. Nurse’s responsibility

ii. Family becomes client

iii. Know facility Policy and Procedure

iv. Seek support resources as appropriate

v. Proper documentation: DOCUMENT ALL EVENTS SURROUNDING CLIENT’S

DEATH.

20. Care of the Body after Death

 UUU. Procedural Guidelines (pg.481 in Potter & Perry)

1. Check orders

VVV. Family/sig others: allow them to say goodbye and have closure.

WWW. Equipment: remove equipment by protocol. IV, Catheters, etc…

remove from room.

XXX. Cleansing: clean bed if needed, clean trash, etc…

YYY. Hair care

ZZZ. Position/Cover: most of the time supine, covered with sheet.

AAAA. Environment: try to have nice clean environment for family to view
body after death.

BBBB. Viewing time: give family time to say goodbye. Do not rush family!
21. After the family leaves...

i. Some sort of identifying tag on the body.

ii. May have to wrap body certain way, go by policy for prep to travel to
morgue.

iii. Documentation: pg 480 box 30-9 Potter and Perry.

22. Nurses response to the dying patient

CCCC. Nurses grieve also

DDDD. Nurses personal view of life and mortality

EEEE. Common feelings: Frustrations, associated guilt, Sadness, anxiety.

FFFF. Coping methods: Attend viewings if possible, Send card or letter to

family, other nurses, personal support systems, positive stress management
techniques.
23. Evaluation

GGGG. Client Care

HHHH. Client expectations