1. LOSS, GRIEF AND DEATH

2. 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.

3. Loss Occurs when a valued person, object, or situation is changed
Actual Loss
Perceived loss
Anticipated loss
Physical loss
Psychological loss
Actual loss can be recognized by others including the person sustaining the loss, ex: a person losing a limb, spouse, valued object, job etc.
Perceived loss- felt by the person but is intangible to others EX:
(loss of your youth, financial dependence.
Anticipatory loss- the person displays loss and grief behaviors for loss that has yet to take place. EX: families with terminally ill patients and serves to lessen the impact of actual loss
- ex.
Physical loss
loss of an arm from a car accident Physical loss
Psychological loss- caused by an altered self image and the inability to return to his or her occupation. A person who is scared by has not lost a limb may suffer from perceived and psychological loss of self image.

4. Grief or Grieving-Grief is the Emotional Reaction to Loss
Mourning-period of acceptance of loss and grief during which the person learns to deal with the loss.
Bereavement- state of grieving during which a person goes through grief reaction.
Grief occurs with loss caused by separation as well as with loss caused by death. (Many people who divorce experience grief, loss of a body part a job, a house or a pet.)
Bereavement- when a person neglects their own health to an extreme.
Mourning person- char. By a return to normal living habits.
(refers to Engel’s 6 stages of grief reaction)

5. Engels 6 Stages of Grief Reaction
Shock and disbelief
Developing awareness
Restitution
Resolving the loss
Idealization
Outcome
Shock and disbelief , “no not me”
Developing awareness “why me” crying, anger, feeling empty
Restitution – funeral services and rituals surrounding loss cultural influences come in to play here talk about funerals
Resolving the loss- dealing with the void left by loss.
Idealization- Exaggeration of good qualities of the person or object lost
Outcome- acceptance

6. Kubler-Ross Grief and Death Reactions
Denial and isolation
Anger
Bargaining
Depression
Acceptance
Kubler- Ross is considered the “pioneer” in the study of grief and death reactions.
More important than the stages of any grief reaction is the idea that grief is a process and it varies person to person
DENIAL and isolation- pt. Denies that he or she will die. “thy made a mistake in the dx, maybe they mixed my records with someone else.
Anger- the pt expresses rage and hostility in the anger stage and adopts a “why me” attitude, I quit smoking and I watched what I ate, Why did this happen to me?”
Bargaining- the pt tries to barter for more time. If I can just make it to my son’s graduation I will be satisfied. Just let me live until then” This is the stage wills are made, personal affairs are taken care of, final trips.”
Depression- period of grief before death. Characterized by crying and not speaking. “I waited all these years to see my daughter get married. AN d now I may not see my daughter get married. I may not be her to walk her down the aisle.I can’t bear the though to not being there.”
Acceptance- pt feels tranquil. She or he has accepted death and is prepared to die. “I’ve tied up all the loose ends- made my will , arrangements for my daughter to live with her grandparents. No I can go in peace.
Dysfunctional when person is not able to resume normal life. Unresolved or inhibited. IE peggy’s concerns for allison after jesse died no expression. Talk about people grieve in different ways

7. 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
Medical, emotional, social, and spiritual needs- focus on making sure there comfortable, not left alone
Supports the needs of the family members- helping with responsibilities of a care giving and supporting them through grief.
Builds ways to provide excellent end of life care- through education of care providers, appropriate health policies, adequate funding from insurers and gov
Page 879 box 33-2

8. 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.
“bill of rights page 877 box 33-1 “

9. The nurse patient relationship is key to helping patient’s grieve

10. Advanced Directives
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.

12. Do not resuscitate or No code orders
What is the difference between a DNR or a No code order
and
Comfort measures only order?
DNR Prevents the improper cardiopulmonary resuscitation which is designed to prevent unexpected death.
The order means simply that there are no attempts made to resuscitate.
Comfort measures only-goal of tx is to comfort pt. Allow dignified death and that further life sustaining efforts are not taken.

13. Factors that influence Grief and Dying
Developmental
Family
Socioeconomic
Cultural
Religious
Cause of Death
Developmental- death of a parent can retard a child’s development.
Children may not understand death but their sense of loss is great.
Family- roles with in the family are identified, for ex. The oldest child may feel the need to be strong.
Socioeconomic- if one has no health or life insurance or pension , the family can experience the loss of the person as well as the economic loss. This may result into loss of house, community, and support system.
Cultural influences-
Western culture grief is private matter that is only shared with family.
Religion- May play an important role is expression of grief and provide comfort.
Cause of Death- sudden, disease (AIDS), accidental death, death from war, violent deaths, suicides).

14. Nursing Process 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?
Assessing- determine the adequacy of the pt’s and families, knowledge, perceptions, coping strategies and resources.
Knowledge- Objective is to id. Whether or not the knowledge of the pt and family possess will allow them to make informed decisions.
Perceptions- object is to discover if pt and fx have unrealistic expectations
Coping objective see if family and pt are using effective coping strategies.
Resources- assess adequacy of the human financial and spiritual resources avail.
Cultural influences

15. Nursing Diagnoses Impaired adjustment Caregiver role strain
Decisional conflict
Ineffective coping
Ineffective denial
Anticipatory grieving
Dysfunctional grieving
Hopelessness
Ineffective management of therapeutic regimem
Problem or etiology can be loss
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16. 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.
Must have trusting relationship
Needs of both patient and family are psychological, physiological and spiritual. Sexual needs also
May feel sexual needs are inappropriate. Choice between both. Can be a form of expression of love, caring acceptance.
Hospice role.
Accept beliefs of others role is to provide comfort. Not to change or convert

17. Implementing
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.

18. Nursing interventions
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.

19. Evaluating
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.

20. Nurses grieve too.

21. Clinical Signs of Impending Death
Muscle weakness
Respiratory changes
Cheyne-Stokes
Death Rattle
Sensory changes
Circulatory changes
Muscles. Difficulty with speech, swallowing, movement, incontinence, jaw sags
Respiratory. Cheyne stokes. Alternating deep/shallow breathing with temporary apnea. Death rattle is noisy due to increases secretions. Breathing becomes through mouth vs nose.
Sensory vision blurrs, taste and smell decline
Circulatory mottling, cyanosis in extremities, cold skin decreased b/p, slow pulse, poor or decreases sensation.

22. Postmortem Care Nursing prepares the body for viewing Identification
Who to notify
Jewelry and valuables
Dentures, glasses, prosthetics
In hospital. Leave on bracelet for id. Clean the body and area for family viewing. Remove tubes, IVs, cover and position straighten room.
Notify Life center for organ donation
Hospice if involved.
Coroner
Family
Physician
Who pronounces?
Care of the family offer a cup of coffee/tea
Care of roommate or other patients.
Family gone place body in schroud and tag on the ankle transport to morgue or wait for funeral home to pick it up.

23. 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:
Elevated B/P
Cheyne-Stokes respirations
Elevated pulse rate
Flushed skin

24. Question #1
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
A referral for bereavement resources to enhance care
Interventions for a pt in isolation and inner thought
Assessment skills to determine fear and anxiety
Therapeutic skills to enhance communication
D therapeutic skills to enhance communication

25. 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 inform her to refuse the test
Inform the MD of her statements
Educate her on the test’s benefits
Educate her on the procedure
b. Inform the MD of the statements

26. Question #3
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 families MD
County court
City policy dept
County coroner.
Count coroner

27. Question #4
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
Anger
Bargaining
Denial
Depression
Bargaining

28. Question #5
The process of viewing the body after death best supports which of the following statements?
Provides the resolution of the death experience for most families
Increases anxiety levels
Allows family members an avenue of escape from the truth
Supports the family members’ decision for a DNR