Basic Nursing:Foundations of Skills & Concepts: Loss, Grief, and Death

Basic Nursing:Foundations of
Skills & Concepts

Chapter 17
LOSS, GRIEF,
AND DEATH
Loss
 Any situation —actual, potential, or

perceived —wherein a valued object or
person is changed or is no longer
accessible to the individual.
Types of Loss
 Actual (loss of someone or some thing).

 Perceived (felt by an individual but not
tangible to others, e.g. loss of self-
esteem).
 Physical (loss of part or aspect of the
body).
 Psychological (emotional loss, e.g. a
woman’s feelings after menopause).
Categories of Loss
 Loss of External Object.
 Loss of Familiar Environment.
 Loss of Aspect of Self (Physiological or

Psychological).
 Loss of Significant Other.

Grief
 A series of intense physical and

psychological responses that occur
following a loss.
 A normal, necessary, and adaptive

response to a loss.
Mourning & Bereavement
 Mourning is the period of time during

which grief is expressed and resolution
and integration of loss occur.
 Bereavement is the period of grief

following the death of a loved one.
Theories of the Grieving
Process
Leading theoretical models describing

grieving have been devised by:
 Erich Lindemann
 George L. Engle
 John Bowlby
 William Worden
Lindemann Theory
Erich Lindemann coined the phrase grief

work and described typical grief reactions:
 Somatic distress.
 Preoccupation with the image of the
deceased.
 Guilt.
 Hostile reactions.
 Loss of patterns of conduct.
Engle Theory
 Three Stages of Mourning

 Stage I: Shock and Disbelief (disorientation,
helplessness, denial).
 Stage II: Developing Awareness (guilt, sadness,
isolation, anger and hostility).
 Stage III: Restitution and Resolution (bodily
symptoms, idealization of the deceased, beginning of
coming to terms with loss, establishment of new
social patterns and relationships).
Bowlby Theory
 Four Stages of Mourning

 Numbness.
 Yearning and searching.
 Disorganization and despair.
 Reorganization.
Worden Theory
Four Tasks to Deal with Loss Successfully

 Accept the fact that the loss is real.
 Experience the emotional pain of grief.
 Adjust to an environment without the deceased.
 Reinvest the emotional energy once directed at
the deceased into another relationship.
Types of Grief
 Uncomplicated (a grief reaction that normally

follows a significant loss).
 Dysfunctional (intense grief that does not result
in reconciliation of feelings).
 Anticipatory (occurrence of grief work before
loss actually occurs).
 Disenfranchised (grief that is not openly
acknowledged, socially sanctioned, or publicly
shared, e.g. grief over the loss of a pet).
Factors Affecting Loss and Grief
 Developmental Stage.
 Religious and cultural beliefs.
 Relationship with the lost object.
 Cause of death.
Nursing Care of the Grieving
Client
Nursing care for the grieving follows the

standard five-part model:
 Assessment.
 Nursing Diagnosis.
 Planning/Outcome Identification.
 Implementation.
 Evaluation.
Death & Legal Considerations
 The Patient Self-Determination Act

(PSDA, 1990) was intended to provide
individuals with legal means to determine
the circumstances under which life-
sustaining treatment should or should not
be provided to them.
 Many states also have a Health Care
Surrogate Law, implemented in the
absence of advance directives.
Death & Ethical Considerations
 Death is often fraught with ethical

dilemmas.
 Many health care agencies have ethics
committees to develop and implement
policies to deal with end-of-life issues.
 Important distinctions must be made
between pain relief and euthanasia.
Stages of Dying and Death
 Denial.
 Anger.
 Bargaining.
 Depression.
 Acceptance.
Assessment of the Dying Client
 Client and family goals and expectations.

 Client’s awareness of terminal nature of
the illness.
 Availability of support systems.
 Current stage of dying.
 History of previous positive coping skills.
 Client perception of unfinished business
to be completed.
Physiological Needs of the
Dying Client
 Respirations.
 Fluids and nutrition.
 Mouth, eyes, and nose.
 Mobility.
 Skin care.
 Elimination.
 Comfort.
 Physical environment.
Hospice
 A type of care for the terminally ill,

founded on the concept of allowing
individuals to die with dignity,
surrounded by those who love them.
 Clients enter hospice care when
aggressive medical treatment is no
longer an option or when client refuses
further medical intervention.
Signs of Impending Death
 Lungs become unable to provide adequate gas

diffusion.
 Heart and blood vessels become unable to maintain
adequate tissue perfusion.
 The brain ceases to regulate vital centers.
 Cheyne-Stokes respirations (irregular breathing) and
“death rattle” (noisy respirations caused by secretions
accumulating in larynx and trachea) signal imminence
of death.
Care After Death
 Treat the body with respect and dignity.

 Bathe and put a clean gown on the body.
 Remove dressings and tubes.
 Place the client in body alignment with
extremities straight.
 Place dentures in the mouth, if client normally
wore them.
 Comb client’s hair.
Legal Aspects Following Death
 Autopsy (examination of the body after

death by pathologist to ascertain cause of
death).
 Organ Donation.
Care of the Family
 Informing the family as to the

circumstances of the death.
 Providing information about viewing the
body.
 Offering to contact support people.
 Sometimes assisting in decision making
regarding a funeral home and removal
of the dead person’s belongings.
Nurse’s Self-Care
 Dealing with dying clients is stressful.

Nurses must face their grief.
 Unresolved grief is called shadow grief.

Nurses often carry shadow grief which, if
not released, can cause illness and
burnout.
Signs of Shadow Grief
 Loss of energy, spark,  Constant inability to get

joy, and meaning in life. work done.
 A feeling of being  Uncontrolled outbursts of
powerless to make a anger.
difference.  Perception of clients and
 Increased smoking or their families as objects.
drinking.  Surrender of hobbies or
 Unusual forgetfulness. interests.
 Constant criticism
directed at others.
Coping with Shadow Grief
 Take time to cry with and  Connect to place of

for clients. worship; pray.
 Get physical: run, walk,  Look for joy in work.
bicycle, play tennis. Laughter is a great
 Ask colleagues to help healer.
with tasks; avoid being  Create a caring circle of
“Supernurse.” friends.
 Listen to music.

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Basic Nursing:Foundations of

Skills & Concepts

 Any situation —actual, potential, or

 Actual (loss of someone or some thing).

 Loss of External Object.

 Loss of Familiar Environment.

 Loss of Aspect of Self (Physiological or

 Loss of Significant Other.

 A series of intense physical and

 A normal, necessary, and adaptive

 Mourning is the period of time during

 Bereavement is the period of grief

Leading theoretical models describing

Erich Lindemann coined the phrase grief

 Three Stages of Mourning

 Four Stages of Mourning

Four Tasks to Deal with Loss Successfully

 Uncomplicated (a grief reaction that normally

Nursing care for the grieving follows the

 The Patient Self-Determination Act

 Death is often fraught with ethical

 Client and family goals and expectations.

 A type of care for the terminally ill,

 Lungs become unable to provide adequate gas

 Treat the body with respect and dignity.

 Autopsy (examination of the body after

 Informing the family as to the

 Dealing with dying clients is stressful.

 Unresolved grief is called shadow grief.

 Loss of energy, spark,  Constant inability to get

 Take time to cry with and  Connect to place of

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