NURSING CARE IN GRIEF AND LOSS

Grief and bereavement are universal experiences that people go through when they are dealing with a
loss in their lives. In end-of-life care, nurses must understand the fundamentals about grief, loss, and
bereavement on the part of patients and families, and also within themselves. Individuals each express
and cope with losses differently and a nurse should expect to see that when working with patients and
families at the end of life. According to ELNEC (2010), the role of the nurse includes three things: (1) the
nurse must facilitate the grieving process by assessing the grief; (2) the nurse must assist the patient
with issues and concerns related to the grief; and (3) the nurse must support the survivors.

Grieving is a normal response to a loss; grieving, as defined by the National North American Nursing
Diagnosis Association International, is "a normal, complex process that includes emotional, physical,
spiritual, social and intellectual responses and behaviors by which individuals, families, and communities
incorporate a loss into their daily lives".

Grief is a process that can begin long before the loss of a loved one. The patient and family can have
feelings of loss even as they anticipate an impending loss. As was discussed earlier, grief is the emotional
response to that loss. Similar to the stages of dying, individuals go through a process to help them
eventually cope and be able to live with that loss. This process has been referred to as “grief work” and
as with the stages of dying, people can go through the stages in varying order. People never get over
their loss, but find ways to live with the loss and without their deceased loved one (ELNEC, 2010).

A three-stage model of grief was developed by Corless (2010) and includes the following components:
notification and shock, experiencing the loss, and reintegration.
 The first stage, notification and shock, is when the individual first learns or acknowledges the
loss. They often feel shock and numbness and may isolate from others during this initial phase.
 In the second stage, the individual really experiences the loss both emotionally and cognitively.
A host of feelings can occur during this stage including; anger, sadness, emptiness, as well as
physical manifestations (insomnia, loss of appetite).
 The final stage is when the individual reorganizes and reintegrates into their life without the
person they have lost. This last stage characterizes the healing that should ideally take place at
the end of grief.

All losses impact on the client. Losses can occur as the result of an intrapersonal loss of self and one's
bodily image and extrapersonal losses like the loss of a pet, the death of a loved one including a child or
a spouse, the loss of a personal friendship as the result of a spat, and the loss of one's life savings.

Losses can be categorized and classified as an actual loss, a perceived loss, a situational loss, a
developmental or maturational loss and a necessary loss. These losses occur as the result of an actual
event, an event that is perceived by the client but not based in reality, a loss of a loved one, the loss of
one's youth, and a loss that is expected during the life span, respectively.

Grief and the types of grief can be categorized and classified as normal grief, dysfunctional complicated
grief, anticipatory grief, disenfranchised grief, and grief that occurs as the result of a public tragedy.
Examples of these types of grief include normal grief that is coped with in a healthy adaptive manner,
grief that is complicated and prolonged beyond what is normally expected, grief that occurs prior to the
actual loss, grief after a substance abuse overdose that kills a family member and one that is not shared
with others because the loss is socially unacceptable, and grief following a natural or man-made disaster
such as the World Center terrorism and a major flood, respectively.
Normal or uncomplicated grief
This type of grief symbolizes the most desirable and universal reaction to loss and is considered to be
normal Corless (2010). The individual will have physical, emotional, cognitive, and behavioral reactions
following the loss and will eventually move toward adjusting to it. The period of time for this can vary
from person to person and is dependent on the type of relationship, type of loss and individual factors
related to the bereaved. The nurse should support the family to take the time that they need for this
normal grief processes to happen.

Anticipatory grief

Anticipatory grief is grief that occurs before the loss of a loved one. Sometimes anticipatory grief starts
at the time of a terminal diagnosis and can proceed until the person dies. Both patients and family
members can feel anticipatory loss. For the patient, they can anticipate the loss of independence,
function or comfort. This can cause a lot of pain and anxiety if not given the proper support. For the
family, they often start grieving for the loss of their loved one before they die. Perhaps it is because they
bear witness to the pain or suffering they see their loved one go through or maybe they are also
envisioning their own life without their loved one in it. They start to think about all the things that they
still wanted to share with their loved one, who will likely not live long enough to do. This type of grief
has been shown to help cushion a person’s bereavement reaction (Corless, 2010).

Complicated grief

Complicated grief may require professional assistance depending on its severity and can be further
classified into four different types as shown in Table 12.1. Individuals could be at risk for complicated
grief if they experience losses that are sudden or traumatic or resulting from suicide/homicide. If the
person has already had recent losses or previous losses from which they did not resolve their grief, it can
contribute to developing complicated grief reaction with the new loss. Lack of a support network or
concurrent stressors such as ailing health or relationships, also can contribute to this type of grief
(ELNEC, 2010).

Four Types of Complicated Grief

Type Characterized by
Chronic Grief Normal grief reactions that continue for an extended period of time.
Delayed Grief Normal grief reactions which are suppressed or postponed because the survivor
avoids the pain of loss (consciously or unconsciously).
Exaggerated Grief An intense reaction to the loss that can include thoughts of suicide, phobias or
nightmares.
Masked Grief Survivor is not aware that their behaviors are a result of the loss.

Disenfranchised grief
This type of grief is defined as grief that has not been validated or recognized (ELNEC, 2010). This type of
grief often develops in individuals who have lost loved ones to stigmatized illnesses, such as AIDS, or
through socially unacceptable ways, such as abortion. The loss of a previously severed relationship, such
as with divorce, can also contribute to this type of grief because the individual may not be able to mourn
as openly for that loved one due to the circumstances surrounding their relationship.

Unresolved grief
In this type of grief, the bereaved has failed to move through the stages of grief and accomplish the
work needed to come to terms with the loss (Corless, 2010). Many factors can contribute to the
manifestation of this type of grieving and can include: lack of formal closure (loved one’s body never
found or laid to rest), multiple or concurrent losses, or social isolation.

Manifestations of Grief

Physical manifestations: Emotional responses:

 feeling physically ill from the loss,  anxiety,
 headaches,  guilt,
 heaviness or pressure,  anger,
 tremors,  sadness,
 muscle aches,  feelings of helplessness,
 exhaustion  relief
 insomnia
Cognitive manifestations: Behavioral manifestations:
 inability to concentrate,  withdrawal,
 sense of confusion or disbelief,  impaired performance at work or school,
 preoccupation with the deceased  avoiding anything that reminds one of the
 hallucinatory experiences deceased,
 possessing constant reminders of the
deceased

Grief and the grieving process are characterized with suffering, despair, sleep impairments, pain,
distress, anger, detachment, guilt, and even personal growth.

There are theories and conceptual frameworks that provide nurses, and other health care providers,
with insight into grief, loss, the grieving process and ways that nurses can meet the needs of clients who
are affected with normal grief and unresolved complicated grief. These theories include those
summarized below:

Warden's Four Tasks of Mourning: This theory has four tasks that people go through after the loss of a
loved one. These four tasks are typically completed by the person after about a year of grieving. These
tasks are
 accepting the loss,
 coping with the loss,
 altering, modifying and changing the environment to cope with and accommodate for the
absence of the lost person, and
 resuming one's life while still having a healthy connection with the loved one.

Engel's Stages of Grieving: Engel's Stages of Grieving theory describes these steps in this proper
sequential order:
 Shock and disbelief
 Developing awareness
 Restitution
 Resolving the loss
 Idealization
 Outcome
The client denies the loss and refuses to accept the fact that the loss has actually occurred during the
shock and disbelief stage; during the developing awareness stage of this theory, the client discards the
previous denial and begins to develop an awareness and acknowledgement of the loss; the grieving
person works through the mourning process and they often perform spiritual and cultural rituals during
this stage; the resolution stage is characterized with the affected person's seeking out of social support
systems to resolve the grief after which the client may deify and idealize the lost one; the final stage of
Engel's theory is the outcome phase during which time the affected client will adjust to and cope with
the loss.

Sander's Phases of Bereavement: Sander's phases of bereavement in correct sequential order are:
 Shock
 Awareness of the loss
 Conservation and withdrawal
 Healing or the turning point
 Renewal

These phases are quite similar to those of Engel with some variations. For example, during the
conservation and withdrawal phase, the person will withdraw from others and attempt to restore their
physical and emotional wellbeing; and during the healing stage, the person will move from emotional
distress to the point where they are able to learn how to live without the loved one. During the renewal
phase, the person is able to independently live without the loved one.

Kubler Ross's Stages of Grieving: This theory is perhaps the most popular of all theories and conceptual
frameworks relating to grief and loss. This theory has five stages in this sequential order.
 Denial
 Anger
 Bargaining
 Depression
 Acceptance

Denial. On being told that one is dying, there is an initial reaction of shock. The patient may appear
dazed at first and may then refuse to believe the diagnosis or deny that anything is wrong.
Some patients never pass beyond this stage and may go from doctor to doctor until they find one who
supports their position.
Anger. Patients become frustrated, irritable and angry that they are sick. A common response is,” Why
me? ” They may become angry at God, their fate, a friend, or a family member. The anger may be
displaced onto the hospital staff or the doctors who are blamed for the illness.
Bargaining. The patient may attempt to negotiate with physicians, friends or even God, that in return
for a cure, the person will fulfill one or many promises, such as giving to charity or reaffirm an earlier
faith in God.
Depression. The patient shows clinical signs of depression- withdrawal, psychomotor retardation, sleep
disturbances, hopelessness and possibly suicidal ideation. The depression may be a reaction to the
effects of the illness on his or her life or it may be in anticipation of the approaching death.
Acceptance. The patient realizes that death is inevitable and accepts the universality of the experience.
Under ideal circumstances, the patient is courageous and is able to talk about his or her death as he or
she faces the unknown.

People with strong religious beliefs and those who are convinced of a life after death can find comfort in
these beliefs (Zisook & Downs, 1989).
Kubler Ross's Stages of Grieving are similar to other theories in terms of denial, anger, depression and
acceptance. The bargaining stage, however, is unique to Kubler Ross's Stages of Grieving. In this context,
bargaining entails the client's negotiation with their maker or higher power to delay their inevitable
death. For example, they may pray to their god to let them live long enough to be able to participate in a
major event like the birth of a grandchild, the graduation of a child, or the wedding of their god
daughter.

Assisting the Client in Coping with Suffering, Grief, Loss, Dying, and Bereavement

The defining characteristics of grief and loss can include altered immune responses, distress, anger,
sleep disturbances, blame, withdrawal, pain, panic, suffering and alterations with neuroendocrine
functioning, among other signs and symptoms.

Coping and coping mechanisms to grief can vary greatly among individuals. This coping can be impacted
by a number of factors and forces such as one's cultural background, spiritual or religious background,
the client's past experiences with losses, the person's level of growth and development which impacts
on one's perception of death and loss such as a lack of understanding about the finality of death, one's
level of social supports and interpersonal relationships, socioeconomic status, ethnicity, and the client's
perception of the gravity and severity of the loss.

Nurses assist the client with the grieving process and with coping with the suffering, grief, loss, death
and bereavement. As with all other nurse-client relationships, the nurse initiates the relationship by
establishing trust with the client and then encouraging the person to ventilate their feelings within the
trusting, supportive and nonjudgmental environment. The nurse also assists the client in terms of their
coping with grief and loss by encouraging the client to learn about and employ effective coping
strategies, by encouraging the family members and significant others to care for and support the
affected the client, and, when needed, the nurse makes referrals for the client so that available
community resources are utilized. Some of these referrals may include psychological, social, religious
and spiritual support, individual counseling, group and family therapy, and peer support groups in the
community to promote adaptive grieving and to prevent complicated grieving.

Complicated grieving is a failure of the client to go through the grieving process in a normal manner
without prolonged signs and symptoms and the resumption of the normal activities of daily living and
socialization within a reasonable amount of time. The client should be assessed for complicated grieving
and, at times, standardized tests and tools such as the Pathological Grief Items Checklist, the Hamilton
Rating Scale for Depression, the Hogan Grief Reaction Checklist, the Beck Depression Inventory, the
Texas Inventory of Grief, and the Social Adjustment Scale are used to more comprehensively assess the
client.

Possible Nursing Diagnosis related with grief and loss

1. Anticipatory grieving related to perceived
 potential loss of loved one
 loss of body part or function
 loss of psychosocial well-being
 loss of social role
perceived impending death (of self)
2. Dysfunctional grieving related to
 multiple past or current issues
 lack of resolution of previous grieving response
 difficulty or inability of freely expressing feelings
  inadequate social support system
 unresolved guilt to the deceased
3. impaired adjustment related to
 disability requiring lifestyle change
 impaired cognition
 ineffective denial
 inadequate social support system
4. Social isolation related to
 inadequate personal resources
 altered wellness state
 inability to engage in a satisfying social relationship

Supporting the Client in Anticipatory Grieving

As previously mentioned, grief can be categorized and classified as normal grief, dysfunctional
complicated grief, anticipatory grief, disenfranchised grief, and grief that occurs as the result of a public
tragedy. Anticipatory grief is grief that is experienced prior to an actual loss. Anticipatory grieving gives
the client and the family members the opportunity to begin the grieving process before a client is
actually lost.

Anticipatory grieving can occur as the result of a terminal illness, the anticipated loss of a bodily part as
the result of a planned surgical procedure and other losses.

Informing the Client of Expected Reactions to Grief and Loss

Clients typically react in different ways to grief and loss. Nurses assess these reactions and they also
educate and inform the client about these reactions and how they are the normal results of the grieving
process when indeed they are. This acknowledgement and the support of the nurse can help the client
to understand that they are not alone and that they are experiencing normal feelings, signs and
symptoms of grief.

Providing the Client with Resources to Adjust to Loss/Bereavement

As previously mentioned, clients who are experiencing loss and bereavement can often be helped with
resources such as individual therapy, group therapy and peer support groups in the community.

Evaluating the Client's Coping and Fears Related to Grief and Loss

Nurses evaluate the client's coping and their fears related to grief and loss. Some of the expected
outcomes for these clients can include:
 The client will be free of complicated grieving
 The client will verbalize and express their true feelings
 The client will seek the help and support of others
 The client will identify their own strengths and weaknesses
 The client will utilize effective coping mechanisms
 The client will resume their normal life in one year of less
 The client will discuss the meaning of their loss
 CARE OF THE DYING CLIENT

Birth and death are two aspects of life, which will happen to everyone. Dying and death are painful and
personal experiences for those that are dying and their loved ones caring for them. Death affects each
person involved in multiple ways, including physically, psychologically, emotionally, spiritually, and
financially. Whether the death is sudden and unexpected, or ongoing and expected, there is information
and help available to address the impact of dying and death.

Death is defined as the "cessation of heart- lung function, or of whole brain function, or of higher brain
function.” It is "either irreversible cessation of circulatory and respiratory functions or irreversible
cessation of all functions of the entire brain, including the brain stem" - (The President's Commission for
the study of Ethical problems in Medicine and Biomedical and Behavioral Research, US, 1983).

Physical signs of dying.

Dying is a different experience for everyone involved.

 Confusion – about time, place, and identity of loved ones; visions of people and places that are not
present
 A decreased need for food and drink, as well as loss of appetite
 Drowsiness – an increased need for sleep and unresponsiveness
 Withdrawal and decreased socialization
 Loss of bowel or bladder control – caused by relaxing muscles in the pelvic area
 Skin becomes cool to the touch
 Rattling or gurgling sounds while breathing or breathing that is irregular and shallow, decreased
number of breaths per minute, or breathing that switches between rapid and slow
 Involuntary movements (called myoclonus), changes in heart rate, and loss of reflexes in the legs
and arms also mean that the end of life is near

Changes in body after death:

 Rigor Mortis: body becomes stiff within 4 hours after death as a result of decreased ATP production.
ATP keeps muscles soft and supple.
 Algor Mortis: Temperature decreases by a few degrees each hour. The skin loses its elasticity and
will tear easily.
 Livor Mortis: Dependant parts of body become discolored. The patient will likely be lying on their
back, their backside being the 'dependant' body part. The discoloration is a result of blood pooling,
as the hemoglobin breaks down.
 Decomposition: Tissues after death become soft and eventually liquified by bacterial fermentation.
The hotter the temperature, the more rapid the change. So bodies are stored in cool places /
embalming.

Hospice and palliative care

Hospice is a specialized program that addresses the needs of the catastrophically ill and their loved ones
particularly accepte in US and West. A team approach is provided in hospice that may involve physicians,
nurses, social workers, clergy, home health aids, volunteers, therapists and family caregivers.
Hospice workers can help a dying person manage pain, provide medical services and offer family
support through every stage of the process, from diagnosis to bereavement. Components of hospice
care program include the following:

 Client and family as the unit of care

 Co-ordinated home care with access to available inpatient and nursing home beds
 Control of symptoms(physical, sociological, psychological and spiritual)
 Physician directed services
 Provision of an interdisciplinary care team of physicians, nurses, spiritual advisers, social workers
and counselors.
 Medical and nursing services available at all times
 Bereavement follow up after a client's death
 Use of trained volunteers for frequent visitation and respite support
 Acceptance into the program on the basis of health care needs rather than the ability to pay

Palliative Care

Palliative care is the active total care of patients whose disease is not responsive to curative treatment
(World Health Organization). The relief of suffering is one of the central goals of palliative care in
terminal illnesses. Control of pain, of other symptoms and of psychological, social and spiritual problems
is paramount. The goal of palliative care is the achievement of the best possible quality of life for
patients and their families.

Palliative care is a special care, which affirms life and regards dying as a normal process, neither hastens
nor postpones death, provides relief from pain and other distressing symptoms, integrates the
psychological and spiritual aspects of patient care and offers a support system to help patients live as
actively as possible until death and helps the family cope during the patient’s illness and in their own
bereavement.

Palliative care is based on five major principles (Foley and Carver, 2001):
 It respects the goals, likes and choices of the dying person.
 It looks after the medical emotional, social and spiritual needs of the dying person.
 It supports the needs of the family members.
 It helps gain access to needed health care providers and appropriate care settings.
 It builds ways to provide excellent care at the end of life.

MANAGING DEATH ANXIETY

Some of the commonly used techniques to deal with death anxiety.

Spirituality. Religion is a prime source of strength and sustenance to many people when they are dealing
with death. Different religious theories explain the inevitability and even necessity of death from
different perspectives.
 According to the Gita, soul is not destructible but immortal. It says that death of the body is certain
and irrelevant but eternal Self or the universal Self is immortal, therefore there should be no grief
over what is inevitable, even necessary. It further explains that the Self instead of dying, merely goes
on to take a new body and start the process all over again, therefore it is pointless to worry about
the discarding of the present body
 In The Bible death has been viewed as “Blessed are the dead who die in the Lord from now
on…….that they may rest from their labors, and their works follow them (Revelations, ch. 14, verse
13)”.
 Islamic belief says- death as the begining of eternal life. Every individual will be questioned about his
deeds in this life and he will be awarded Heaven or Hell based on His judgement.

Existential Approaches in Management of Death Anxiety

 Death anxiety is inversely proportional to life satisfaction (Yalom, 1980).

 When an individual is living authentically, anxiety and fear of death decrease (Richard, 2000).
Recognition of death plays a significant role in psychotherapy, for it can be the factor that helps us
transform a stale mode of living into a more authentic one (Yalom, 1980). Confronting this
realization produces anxiety.
 Frankl (1969) also contends that people can face pain, guilt, despair and death in their
confrontation, challenge their despair and thus triumph. It also postulates that a distinctly human
characteristic is the struggle for a sense of significance and purpose in life.

Existential therapy provides the conceptual framework for helping the client challenge the meaning in
his or her life.

Management of dying patient

Cassen (1991) suggests seven essential features in the management of the dying patient:
 Concern: Empathy, compassion, and involvement are essential.
 Competence: Skill and knowledge can be as reassuring as warmth and concern.
 Communication: Allow patients to speak their minds and get to know them.
 Children: If children want to visit the dying, it is generally advisable; they bring consolation to dying
patients.
 Cohesion: Family cohesion reassures both the patient and family.
 Cheerfulness: A gentle, appropriate sense of humor can be palliative; a somber or anxious
demeanor should be avoided.
 Consistency: Continuing, persistent attention is highly valued by patients who often fear that they
are a burden and will be abandoned; consistent physician involvement mitigates these fears.

Nursing Care of Dying Patient

 Creating a peaceful environment to the patient’s liking.

 Preparing instructions about whom to call (usually not all) when death occurs.
 Give the relatives time to witness what is happening.
 Creating and using rituals that can help mark the occasion in the respectful way.
 When death occurs, families should encouraged to take whatever time they need to feel what has
happened, and say their goodbyes. There is no need to rush the body to a funeral home, and some
families want to stay with the body for a period of time after death.

Meeting physical needs:

 A patient in the terminal stages of a disease, is given all the nursing care possible to ensure the most
comfort and freedom from pain. Physical comfort is important as well as emotional and spiritual
comfort.
Meeting nutritional need:
 Patients suffer discomfort due to decreased gastrointestinal activity.
 Nutrients and fluids are given intravenously when they are not tolerated orally.
 Sips of water is given as long the swallowing reflex is present.
 When there is a problem gauze soaked with water may be placed in the patient’s mouth for him to
suck and moisten the mouth.

Meeting special needs:

 Mucus that collects in the throat is removed by placing the patient in a lateral position, wiping it
way, or by suctioning.
 Frequent oral hygiene is done to keep the mouth free of dried secretions, and feeling fresh to the
patient.
 Vaseline or cream is applied to the lips to keep them soft.
 The nostrils are kept cleans and lubricated as necessary.
 The eyes are cleaned with cotton balls miostened with normal saline.
 Lubricating drops or ointment may be applied to the eyes.
 The patient may perspire profusely even though the skin feels cool.
 Bath the patient and change the linen needed.
 Light weight bed covering should be used. Heavy covering seems to be uncomfortable to dying
patients.
 Urinary and fecal incontinence often occur due to relaxing of the sphincter muscles. Pads are used
to keep the bed linen from being soiled. The patient is checked frequently and pads or linen changed
as necessary. The patient’s skin is washed and dried each time it is soiled.
 Frequent change of position (make sure the position permits each breathing)
 Pain is a great problem in some diseases. The doctor orders sufficient medication to control pain. It
must be given as frequently as permitted. If it does not adequately control the pain, inform the
doctor.
 Nursing measures for pain are used to make the patient comfortable on a minimum of medication.
 Dimness and shadows are confusing and increase a sense of loneliness. So we have to provide
adequate light facility to the patient.

Meeting Emotional Needs:

 Touch is an important method of communication with a dying person. The patient appropriates
some one holding his hand or playing a hand on an arm, his head or some other part of the
body. It conveys a feeling of caring and concern. Quiet, encouraging conversation to the patient
is helpful.
 Speak in a normal voice to the patient or to others in his presence.
 Do no speak in a whisper in the patient’s presence. It is very distressing to most sick people.
 Hearing is believed to the last sense to disappear. Weeping is disclosed in the patient’s presence
or nearby.

Symptom Management

1. Assessment of the severity of the symptoms.

2. Evaluation for the underlying cause.
3. Addressing the social, emotional and spiritual aspects of the symptom.
4. Discussing the treatment options with the patient and family.
5. Using therapies designed as around the clock interventions for chronic symptoms.
6. Reevaluating the control of the symptom periodically.
Signs of Impending Death

Physiologic Changes Signs/Symptoms Intervention

Cardiac and Circulation Changes
Decreased blood Skin may become mottled and Provide good skin care. Turn patient every 2-
perfusion discolored. Mottling and cyanosis 3 hours if this does not cause discomfort.
of the upper extremities appear to Lotion to back and extremities. Support
indicate impending death versus extremities with soft pillows.
such changes in the lower
extremities.
Decreased cerebral Decreased level of consciousness Orient patient gently if tolerated and this is
perfusion or terminal delirium. not upsetting. Allow pt. to rest.
Drowsiness/disorientation
Decrease in cardiac Tachycardia Comfort measures. Space out activities.
output and Hypotension
intravascular volume Central and peripheral cyanosis
and peripheral cooling.
Urinary function
Decreased urinary Possible urinary incontinence. Keep patient clean and dry. Place a Foley if
output Concentrated urine. skin starts to break down or if patient is
large and difficult to change diapers or if
caregiver unable to provide diaper and linen
changes.
Food and Fluids
Decreased interest in Weight loss/dehydration Do not force fluid or foods.
food and fluid. Provide excellent mouth care.
Swallowing difficulties Food pocketed in cheeks or Soft foods and thickened fluids (e.g. nectar)
mouth/choking with as tolerated. Stop feeding patient if choking
eating/coughing after eating or pocketing food.
Skin
Skin may become Patches of purplish or dark pinkish Keep sheets clean and dry-avoid paper chux
mottled or discolored. color can be noted on back and directly to skin. Apply lotion as tolerated.
posterior arms/legs.
Decubitus ulcers may Red spots to bony prominences Relieve pressure to bony prominences or
develop from pressure are first signs of Stage I decubiti other areas of breakdown with turning and
of being bedbound, and open sores may develop. positioning Q2 hrs if tolerated. If patient has
decreased nutritional increased pain or discomfort with position
status. changes, decrease the frequency.
Special mattress as needed.
Duoderm or specialized skin patch to Stage I-
II ulcers. Change Q5-7 days or as needed.
Goals of wound care for Stage III and IV
decubiti should be to promote comfort and
prevent worsening rather than healing since
healing most likely will not occur.

Consider application of specialized products

such as charcoal or metronidazole paste
 (compounded) if odors are present.

Respiratory
Retention of secretions Noisy respirations – usually no Head of bed up at 45 degrees. Can fold small
in the pharynx and the cough or weak cough. soft pillow or towel behind neck for extra
upper respiratory support.
tract.
Dyspnea Shortness of breath Oxygen at 2-3 liters may help for some
patients and often helps families to feel
better. Link to Dyspnea module
Cheyne-Stokes Notable changes in breathing. A gentle fan blowing toward the patient may
respirations provide relief.
Educate families that this is normal as the
Definition patient is dying.

General changes
Profound weakness Drowsy for extended periods. This is normal. Educate family.
and fatigue. Sleeping more.
Disoriented with More withdrawn and detached This is normal. Educate family.
respect to time and a from surroundings. May appear to
severely limited be in a comatose-like state.
attention span.
Patient may speak to Family may think these are If patient appears frightened may need to
persons who have hallucinations or a drug reaction. treat with medication. Otherwise, educate
already died or see family that this is normal and common.
places others cannot
see.

Quick look at the signs of dying:

 Loss of appetite
 Decreased oral fluid intake and decreased thirst.
 Increasing weakness and/or fatique
 Decreasing blood perfusion, including decreased urine output, peripheral cyanosis and cool
extremities.
 Neurologic dysfunction, including delirium, lethargy and coma and changes in respiratory patterns.
 Loss of ability to close eyes.
 Noisy breathing as pharyngeal muscle relax.
 In particular, neurologic dysfunction can sometimes result in terminal delirium. Which can include a
mounting syndrome of confusion, hallucinations, delirium, myocardial jerks and seizures prior to
death.
 Pitting edema develops, especially of the extremities and sacrum
 Movement and sensation are gradually lost.
 Temperature elevation will be there, but the skin feels cold and clammy.
 Pulse becomes irregular, weak and fast.
 BP falls as the peripheral circulation decreases.
 The skin cyanosed as circulation decreases.
 Respiration become noisy
 Reflexes disappear
 Urine decreases
 Pain usually subsides
 Mental alertness varies
 Jaw and facial muscles relax with the expression becoming peaceful.

The major focus of most dying patients is the avoidance of pain. Controlling pain in terminally ill patients
requires attention to the following:
 Potential etiology of pain
 Use of medications
 Use of nonpharmacologic methods

Nursing care of a dying individual

The person who deals with the dying patient must commit (Schwartz and Karasu, 1997) to:

 Deal with mental anguish and fear of death,

 Try to respond appropriately to patient’s needs by listening carefully to the complaints and
 Be fully prepared to accept their own counter transferences, as doubts, guilt and damage to their
narcissism are encountered.

Management of the dying patient often elicits anxiety in nursing staff. Education and role playing can
improve perspective taking and empathetic skills, respect each other’s point of view as well as
appreciate the situation of patient and their families.

 Developing a sense of control and efficacy.

 Encouraging peer groups for families coping with bereavement.
 Developing increased resourcefulness in dealing with death related situations.
 Recognizing that a moderate level of death anxiety is acceptable.
 Improving our understanding of pain and suffering will also improve communication and effective
interactions.

Ethical and Legal Issues

The contemporary practice of palliative care raises important ethical issues that deserve thoughtful
consideration.

Patients have a right to refuse Life-sustaining treatment, even if they die as a consequence (Stanley,
1992). Here the patient must have the ability to comprehend the available choices and their risks and
benefits, to think rationally and to express a treatment preference.

Informed consent and refusal to life-sustaining treatment has three elements:

 adequate information must be conveyed to the patient,
 the patient must be able to decide, and
 the patient must have freedom from coercion.
LIFE AFTER DEATH

Near Death Experience

NDE is an altered state of consciousness usually occurring after traumatic injury and almost invariably
involve risk of life. Some people belief that they were actually “in death”. They report that after “dying”
they left their body and floated away, become enveloped in a dark tunnel, and then enter a soothing
light, later when they come back to life they are able to recall the events that occurred when they were
dead. Apparently, during the episode their entire past flashes before them.

Hallucinations caused by hyperactivation of amygdala-hippocampus-temporal lobe a response of oxygen

starved brain, have been proposed as a physiological explanation.
After effects of NDEs include: increase in spirituality, concern for others, appreciations of life and
decrease in fear of death, materialism, and competitiveness.

Reincarnation

Since 1960s, Stevension and Pasricha have systematically investigated hundreds of cases of children,
who claim to remember their previous life.

These children show atypical behavioural and emotional patterns consistent with their claims.

Various explanations like fantasy, fraud, cryptamnesia, paramnesia, socio-cultural expectations have
been proposed, but their data is in favour of reincarnation hypothesis.

CRYONICS

Cryonics is the preservation of the dead body to be revived, till the time, medical technology advances
to do so.
The main arguments against cryonics are:
 Reflects denial of the inevitable.
 There is no way to preserve bodies so that their organ will resume functioning when they are
thawed (Darwin and Wowk, 1992).
 Immortality does not yet fall within the province of technology (Shermer, 1992).
 NURSING CARE OF THE DEAD

Death is one of the two aspects of life that will happen to everyone. Whether the death is sudden and
unexpected, or ongoing and expected, nurses should provide information and help to address the
impact of death to the dying and to the family.

After death the body undergoes many physical changes. So care must be provided as early to prevent
tissue damage /disfigurement of body parts.

Signs of Death
 Absence of heartbeat and respirations.
 Fixed pupils
 Skin color turns to a waxen pallor and extremities may darken.
 Body temperatures drops
 Muscles and sphincters relax, sometimes resulting in release of stool or urine

Points to Remember
 Respect the dead body. Avoid unnecessary exposure and irrelevant conversations.
 The body should be identified properly.
 Clothing’s, jewelry and other valuables or belongings must be kept and cared for properly.
 As it is unavoidable to handle human fluids, always protect yourself with the appropriate PPE.

Common steps in providing nursing care for the dead:

1. The patient has pronounced dead by the doctor, place the body in dorsal position with only a small
pillow under the head.
2. Straighten the body.
3. See that dentures are placed in the mouth if patient has any
4. Remove all appliances; catheters, drainage tubings, Venoclysis sets, etc.
5. Close the eyes and mouth when open.
6. Eyes—bring upper lid down to the lower and apply gentle pressure over it for a while.
7. Mouth—bring the jaws together by placing a rolled towel under the chin.
8. Remove extra bed linen. Leave one sheet to cover the body.
9. Bathe the body using the Lysol solution to rinse.
10. Change surgical dressings p.r.n. Pack anus with cotton. Vagina (if female). If there is any discharge
from the nose and mouth, pack them too. Use forceps.
11. Place the diaper.
12. Full hands over the chest. Pad wrists with cotton and the tie the 2 wrists together with bandage.
Attach one tag to the wrist.
13. Pad the ankles and tie them together.
14. Put on the shroud. Wrap body with a sheet well. Attach the other tag at the center
15. Cover the prepared body with a sheet and notify the head nurse or call for the messenger to take
the body to the morgue.