Coping with Loss, Grieving

and Death

MARISSA S. FERNANDEZ, RN, MAN

 Definition of terms:
 Loss – is an actual or potential situation in which a valid object,
person or the like is inaccessible or changed so that it is no longer
perceived a valuable.
 Bereavement – is the subjective response to a loss through the death
of a person with whom there has been significant relationship.
 Grief – is the total response to the emotional experience of the loss
and is manifested in thoughts, feelings and behaviour.
 Mourning – is the behavioural process through which grief is
eventually resolved or altered, it is often influenced by culture and
custom.
 Development Concept of Death:
 1). Infancy to 5yrs
 = does not understand concept of death
 = believes death is reversible, temporary departure or sleep.
 2.) 5 – 9 years
 = understand that death is final
 = believes on death is final
 = associates death with aggression or violence
 3.) 9 – 12 years old
 = understand death as the inevitable end of life
 = begins to understand own mortality
 4.) 12 – 18 years old
 = fears of lingering death
 = may fantasize that death can be defied, acting out defiance through
reckless behaviour.
 = views death in religious and philosophic terms.
 5.) 18 – 45 years old
 = has attitude towards death that is influenced by religious and
cultural beliefs.
 6.) 45 – 65 years old
 = accepts own mortality
 = encounters death of parents and some peers
 = encounters peak of death anxiety
 7. 65 years above
 = fears of prolonged illness
 = encounters death of family members and peers
 = sees death as having multiple meanings,
 - example: freedom from pain, reunion with already deceased
family members.
 Stages of Grieving: (Kubler-Ross)
 1. Denial
 = refuses to believe that loss is happening
 = is unready to deal with practical problems
 = may assume artificial cheerfulness.
 2. Anger
 = client or family may direct anger at a nurse or hospital about matters that normally
would not bother them.
 3. Bargaining
 = Seeks to bargain to avoid loss
 = may express feeling of guilt or fear of punishment for past sins, real or imagined.
 4. Depression
 = grieves over what has happened and what can not be
 = may talk freely or withdraw
 5. Acceptance
 =comes to terms with loss
 = may have decreased interest I surroundings and support persons
 = may wish to begin making plans.
 Five Cluster of Grief: ( Martocchio)
 1. Shock and disbelief
 = a feeling of numbness following the death of a love one.
 2. Yearning and protest
 = the anger that the bereaved feel may be directed at the deceased for
having died, at GOD, at others whose love ones are still alive, or at
caregivers.
 3. Anguish, disorientation and despair
 = when the reality of the loss is genuinely admitted, depression can set in.
Weeping is common. The bereaved lose interest and motivation in pursuing
the future and lack of confidence and purpose.
 4. Identification and bereavement
 = the bereaved may take on the behaviour, personal traits, habits and
ambitions of the deceased. Sometimes they may also experience the same
symptoms of physical illness.
 5. Reorganization and restitution
 = achieving stability and sense of reintegration can take a period of time
that ranges widely, from less than a year to several years.
 Stages of Grieving: (Engel)
 1. Shock and disbelief
 = refusal to accept loss
 = stunned feelings
 = intellectual acceptance but emotional denial
 2. Developing awareness
 = reality of loss begins to penetrate awareness
 = anger may be directed at hospital, nurses etc.
 = crying and self blame
 3. Restitution
 = rituals or mourning
 4. Resolving the loss
 = attempts to deal with painful void
 = still unable to accept new love object to replace lost person
 = may accept more dependent relationship with support
 = thinks over and talks about the memories of dead person
 5. Idealization
 = produces the image of dead persons that it almost devoid of
undesirable features
 = represses all negative and hostile feelings toward the deceased
 = unconsciously internalizes admired qualities of the deceased
 = reinvest feelings in others
 6. Outcome
 = Behaviour influenced by several factors
 a. importance of the lost object as source of support
 b. degree of dependence on relationship
 c. degree of ambivalence toward deceased
 d. number and nature of other relationship
 e. number and nature of previous grief relationship
 Symptoms of Grief:
 1. repeated somatic distress
 2. tightness in the chest
 3. choking or shortness of breath
 4. sighing
 5. empty feeling in the abdomen
 6. loss of muscular power
 7. intense subjective distress
 Assisting Clients with their Grief:
 1. provide opportunity for the persons to “tell their story”
 2. recognize and accept the varied emotions that people express
to the significant loss
 3. provide support for the expression of difficult feelings, such as
anger and sadness
 4. include children in their grieving process
 5. encouraged the bereaved to maintain established relationships
 6. acknowledge the usefulness of mutual-help groups
 7. encourage self-care by family members particularly, the primary
caregivers
 8. acknowledge the usefulness of counselling for especially difficult
problems.
 Nursing Diagnosis: Clients with Grief and Loss
 1. Anticipatory grieving related to:
 = perceived potential loss of loved one
 = perceived loss of body parts of function
 = perceived loss of physiopsychosocial well-being
 = perceived potential loss of social role
 = perceived impending death of self
 2. Dysfunctional grieving related to:
 = multiple past or current losses
 = lack of resolution of previous grieving response
 = unresolved guilt related to the deceased
 = lack of adequate social supports
 = unconscious gain from others to maintain grieving
 = difficulty or inability to express feelings freely
 3. Impaired adjustment related to:
 = disability requiring change in lifestyle
 = inadequate or unavailable support systems
 = impaired cognition
 = ineffective denial
 4. Social isolation related to:
 = inability to engage in satisfying personal relationships
 = inadequate social resources
 = alterations in physical appearance
 = altered state of wellness
 Signs of Impending Clinical Death:
 A. Loss of muscle tone
 1. relaxation of facial muscles (the jaw may sag)
 2. difficulty in speaking
 3. difficulty in swallowing and gradual loss of the gag reflex
 4. decreased activity of the GIT
 5. possible urinary and rectal incontinence
 6. diminished body movements
 B. Slowing of circulation
 1. diminished sensation
 2. mottling and cyanosis of the extremities
 3. cold skin, first in the feet and later in the hands, ears and nose
 C. Changes in vital signs
 1. decelerated and weaker pulse
 2. decreased blood pressure
 3. rapid, shallow, irregular or abnormally slow respirations;
Cheyne-stroke respirations; noisy breathing (death rattle); mouth
breathing.
 D. Sensory impairment
 1. blurred vision
 2. impaired sense of taste and smell

 Indications of Death:
 1. total lack of response to external stimuli
 2. no muscular movement
 3. no reflexes
 4. flat encephalogram (EEG). Most indicator of death
 Nursing Interventions for the Dying Client:
 1. Assist the client achieved the dignified and peaceful death
 a. provide relief from loneliness, fear and depression
 b. maintain the client’s sense of security, self-confidence, dignity
and self worth
 c. maintain hope
 d. help client to accept his losses
 e. provide physical comfort
 2. Maintain physiologic and psychologic comfort
 a. personal hygiene measures
 b. pain control ( highest priority when caring for dying clients)
 c. relief of respiratory difficulties
 d. measures related to sensory changes
 3. Provide spiritual support
 a. search for meaning
 b. sense of forgiveness
 c. need for love
 d. need for hope
 Hospices are healthcare facilities designed to care for terminally ill
clients and their families by providing supportive and palliative
resources.
 Nursing Diagnosis: Dying Clients
 1. Fear related to:
 = knowledge deficit
 = lack of social support in threatening situation
 = negative impact to survivors
 2. Hopelessness related to:
 = prolonged restriction of activity resulting in isolation
 = deteriorating physiologic condition
 = terminal illness
 = long-term stress
 = perceived significant loss of loved one, youth, influence
 3. Powerless related to:
 = chronic debilitating illness
 = terminal illness
 = institutional environment
 = interpersonal behaviour of others
 Care of Body After Death
Body Changes:
1. Rigor Mortis
= is the stiffening of the body that occurs about 2-4 hours after death
= results from lack of adenosine triphosphate (ATP), which is not synthesized
due to lack of oxygen in the body
= position the body, place dentures in the mouth and close the eyes and
mouth before rigor mortis sets in.
2. Algor Mortis
= is the gradual decrease of the body’s temperature after death
= when blood circulation terminates and the hypothalamus ceases to
function, body temperature falls about 1*C (1.8*F) per hour until it reaches room
temperature.
3. Livor Mortis
= discoloration of the skin after death, after circulation ceased. The red blood
cells breakdown, releasing hgb which discolors the surrounding tissues.
 Nursing Interventions for the Body after death:
 1. make the environment as clean and as pleasant as possible
 2. make the body natural and comfortable
 3. remove all equipment and supplies from bedside
 4. remove soiled linens, so the room is free from odors.
 5. place the body in supine position, the arms at the sides, palms down.
 6. place one pillow under the head and shoulders to prevent blood from discoloring the
face.
 7. close the eyelids, insert dentures and close the mouth.
 8. wash soiled areas of the body.
 9. place absorbent pads under the buttocks to take up any feces and urine released
because of relaxation of the sphincter muscles.
 10. place clean gown, brush/cob the hair
 11. removes all jewelries. All the client’s valuables are listed and placed in safe storage
area for the family to take away.
 12. apply the identification tags, one to the ankle and one to the wrist.
 13. wrap the body in shroud; apply another identification to the outside of the shroud.
 14. bring the body to the morgue.