Seminar on

Coping with loss, grief

and death
(With annotated bibliography)

Submitted to, Submitted By,

Mrs. Sindu Santhosh Shimi Bhadran

Vice Principal 1st yr.M.sc Nursing

Vijaya College of Nursing. Vijaya College of

Nursing.

Submitted On

23-3-13

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 Index
Sl.no. Content Page number
1 Introduction 3
2 Loss
 Definition 3
 Types of loss 3-4
 Sources of loss 4-5
3 Grief 4
 Definition 5
 Types of grief response 5-6
 Stages of grieving 6- 9
 Grief reactions 10-11
 Tasks of grieving 11- 12
4 Developmental Perspectives of Loss and Grief 12
5 Factors influencing the Loss and Grief responses 13-14
6 Coping with Loss and Grief 14
7 Nursing management related to Loss& Grief 14- 15
8 Death
 Definition 16
 Signs of Impending Death 16
 Clinical signs of Death 16-17
 Theories of Dying and Grief 17
 Management
 Management of dying patient 18
 Symptom management 18
 Nursing management 18-20
 Ethical and legal issues 20
9 Conclusion 20
10 Research abstract 20-21
11 Annotated bibliography 21

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 Coping with Loss, Grief and Death
Introduction
Losing someone or something you love is very painful. After a significant loss, you may
experience all kinds of difficult and surprising emotions, such as shock, anger, and guilt. Sometimes
it may feel like the sadness will never let up. While these feelings can be frightening and
overwhelming, they are normal reactions to loss. Accepting them as part of the grieving process and
allowing yourself to feel what you feel is necessary for healing.

Nurses may interact with dying patient and their clients and their families or caregivers in a
variety of setting, from a fetal demise (death of an unborn child), to the adolescent victim of an
accident, to the elderly client who finally succumbs to a chronic illness. Nurses must recognize the
various influence on the dying process and be prepared to provide sensitive , skilled and supportive
care to all those affected.

Loss

Definition
Loss is an actual or potential situation in which something that is valued is changed, no longer
available, or gone.

People can experience the loss of body image, a significant other, a sense of well being, a
job, personal possessions, beliefs, or a sense of self. Illness and hospitalization often produce losses.

Types of Loss
1. Necessary loss
2. Actual loss
3. Perceived loss
4. Maturational loss
5. Situational loss
6. Anticipatory loss

Necessary loss

Necessary losses are something natural and positive. For eg. Growing up process. We
develop independence from our parents, start and leave school, change friends, begin career and
form relationships.

Actual loss

Actual losses are any loss of a person or a object that can no longer be felt, heard, known or
experienced by the individual. Examples include: the loss of body part, role at work.
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Perceived loss

It is experienced by the person but it is intangible to others. Examples are loss of confidence
or prestige.

Maturational loss

It is experienced as a result of natural developmental processes. Example : the first child may
experience a loss of status when her sibling is born.

Situational loss

Situational loss is experienced as a result of an unpredicted event, including traumatic injury,

disease, death or national disaster.

Anticipatory loss

It is experienced before the loss actually occurs. For eg. A women whose husband is dying
may experience before the loss actually occurs.

Sources of loss
There are many sources of loss:

a. Loss of an aspect of oneself- a body part, a physiologic function, or a psychologic

attribute
b. Loss of an object external to oneself
c. Separation from an accustomed environment, and
d. Loss of a loved or valued person

Aspect of self

The loss of an aspect of self changes a person’s body image, even though the image
the loss may not be obvious. A face scarred from a burn is generally obvious to people; loss
of part of the stomach or loss of ability to feel emotion may not be obvious. The degree to
which these losses affect a person largely depends on the integrity of the person’s body
image. Old age is the stage in life when people may experience many losses: of employment,
of usual activities, of independence, of health, of friends, and of the family.

External Objects

Loss of external objects include – a) loss of inanimate objects that have importance to the
person, such as the loss of money or the burning down of the family house b) loss of animate
objects such as pets.

Familiar environment

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 Separation from an environment and people who provide security a can result in a
sense of loss. The 6-year old is likely to feel loss when first leaving the usual environment to
attend school.

Loved ones

The loss of a loved person or valued person through illness, divorce, separation, or
death can be very disturbing. In some illnesses, a person may undergo personality changes
that make friends and family feel they have lost that person.

Grief

Definition
Grief is an internal emotional reaction to loss. It is manifested in thoughts, feelings,
and behaviors associated with overwhelming distress or sorrow.

For example, many people who divorce experience grief. Loss of a body part , a job,
a house or a pet may cause grief.

Mourning is the actions and expressions of that grief, including the symbols and
ceremonies (including a funeral or final celebration of life) that makes up the outward
expressions of grief.

Bereavement is the subjective response experienced by the surviving loved ones

after the death of a person with whom they have shared a significant relationship.

Types of grief responses

a. A normal grief reaction may be abbreviated or anticipatory.

Abbreviated grief is brief but genuinely felt. The lost object may not have been sufficiently
important to the grieving person or may not have been replaced immediately by another,
equally esteemed object.

Anticipatory grief is experienced in advance of the event. The wife who grieves before her
ailing husband dies in anticipating the loss.

b. Disenfranchised grief

It occurs when a person is unable to acknowledge the loss to other persons. Situations in
which this may occur often relate to a socially unacceptable loss that cannot be spoken out,
such as suicide, abortion, or giving a child up for adoption.

c. Dysfunctional grief or unhealthy grief

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It may be unresolved or inhibited. Many factors can contribute to dysfunctional grief,
including a prior traumatic loss and the circumstances of the present loss. Other influences
include family or cultural barriers to the emotional expression of grief.

i. Unresolved grief

It is extended in length and severity. The same signs are expressed as with normal grief but
may grieve beyond the expected time.

ii. Inhibited grief

Many of the normal symptoms of grief are suppressed, and other effects, including somatic,
are experienced instead.

Stages of grieving
KUBLER-ROSS’S STAGES OF GRIEVING (Kubler-Ross’s theory)

focuses on behavior

In 1969, psychiatrist Elisabeth Kübler-Ross introduced what became known as the “five
stages of grief.” These stages of grief were based on her studies of the feelings of patients
facing terminal illness, but many people have generalized them to other types of negative
life changes and losses, such as the death of a loved one or a break-up.

STAGE BEHAVIORAL RESPONSES NURSING

IMPLICATIONS

1. Denial  refuses to believe that loss is  verbally support client’s

happening ; unready to deal with denial for its protective function
practical problems as prosthesis after ; examine your own behavior to
loss of leg ; may assume artificial ensure that you do not share in
cheerfulness to prolong denial client’s denial

 client or family may direct anger  help client understand that

2.Anger at nurse or hospital staff, about matters anger is a normal response to
that normally would not bother them ; feelings of loss &
resist the loss & may act out to powerlessness ; avoid
everyone & everything in the withdrawal or retaliation with
environment anger, do not take anger
personally ; deal with needs
underlying any angry reaction ;

provide structure & continuity

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3. Bargaining  seeks to bargain to avoid loss ;
attempts to make deals in a subtle or
overt manner to prevent the loss
 grieves over what has happened
& what cannot be ; may talk freely
4. Depression
(reviewing past losses such as job or
money), or may withdraw ; loss is
realized & the full impact of its
significance is apparent
 comes to terms with loss ; may
5. Accepta have decreased interest in
nce surroundings & support persons ;
may wish to begin making plans
(will, altered living, prosthesis,
arrangements) ; person feels at
peace; the final “letting go”
ENGEL’S STAGES OF GRIEVING(Engel’s theory)
STAGE BEHAVIORAL RESPONSES
1. Shock and  Refusal to accept loss
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to promote feelings of security ;
allow clients as much control as
possible over their lives
 listen attentively, and
encourage client to talk to relieve
guilt & irrational fear ; if
appropriate, offer spiritual support
 allow client to express
sadness ; communicate non-
verbally by sitting quietly
with- out expecting
conversation ; convey caring
by touch ; help support
persons understand
importance of being with the
client in silence
 help family & friends under-
stand client’s decreased
need to socialize & need for
short, quiet visits ;encourage
client to participate as much
as possible in the treatment
program
 Disbelief  stunned feelings
 intellectual acceptance but emotional denial

2. Developing  reality of loss begins to penetrate consciousness

Awareness  anger may be directed at hospital, nurses, etc.
 crying and self blame

3. Restitution  rituals of mourning (funeral)

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
person
 thinks over and talks about memories of the dead
person

 produces image of dead person that is almost devoid

5. Idealization of undesirable features
 represses all negative & hostile feelings toward
deceased
 may feel guilty & remorseful about past inconsiderate
or unkind acts to deceased
 unconsciously internalizes admired qualities of
deceased
 reminders of deceased evoke fewer feelings of sadness
 reinvests feelings in others

6. Outcome  behavior influenced by several factors :

a. importance of lost object as source of support
b. degree of dependence on relationship
c. degree of ambivalence toward deceased
d. number & nature of other relationships
e. number & nature of previous grief experiences
(which tend to be cumulative)

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MARTOCCHIO’S CLUSTERS OF GRIEF (martocchio’s theory):

Martocchio, a nurse researcher, defined grieving as the process of moving the process of moving
through the pain of loss. She identified manifestations of grief as a series of clusters that describe the
nature of grieving process.

STAGE BEHAVIOR RESPONSES

1. Shock and  feeling of numbness immediately following the

Disbelief death of a loved one
 bereaved may feel depressed, angry, guilty, & sad
 disbelief & denial may persist even though the loss
has been accepted intellectually
 anger the bereaved feel may be directed at the
deceased for having died, at God, at others whose
2. Yearning loved ones are still alive, or at the caregivers
and Protest  the bereaved may begin to fear their own mental
deterioration & withdraw from sharing their
thoughts & feelings with others
 when the reality of the loss is genuinely admitted,
depression can set in
 weeping is common at this time
3. Anguish,  bereaved lose interest & motivation in pursuing the
Disorganization, future, are unable to make decisions, & lack
confidence & purpose
& Despair  activities that were once enjoyed with the deceased
are now without attraction.
 coping strategies such as excessive drinking may
compromise health

4. Identification  bereaved may take on the behavior, personal traits,

in habits, & ambitions of the deceased.
 they may also experience the same symptoms of
Bereavement physical illness

5.  achieving stability & a sense of reintegration can

Reorganizatio take a period of time that ranges widely, from less
n and than a year to several years.
 bereaved are able to experience a sense of well-
Restitution being & can resume most normal patterns of
functioning.

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Grief reactions
 Are the emotional reactions to loss
 Frequently run very high as everyone confronts the possibility of the end of the
patient’s life and the change death will bring
Normal grief reactions include a whole range of physical, emotional, and cognitive behaviors
Normal physical grief reactions include:

• Feelings of hollowness in the stomach

• Tightness in the chest
• Heart palpitations
• Weakness
• Lack of energy
• Gastrointestinal disturbances
• Weight gain or loss
• Skin reactions

Normal emotional grief reactions include feelings of:

• Emotional numbness
• Relief
• Sadness
• Fear
• Anger
• Guilt
• Loneliness
• Abandonment
• Despair
• Ambivalence

Normal cognitive grief reactions include:

• Disbelief
• Confusion
• Inability to concentrate
• Preoccupation with or dreams of the deceased
• There are many different reactions to normal grief
o Some people will make a conscious effort to deal with the loss
o Others will deny what is happening and avoid dealing with the loss
Complicated Grief
When grief reactions occur over long periods of time, are very intense, or interfere with the
survivor’s physical or emotional well-being, they become symptoms of complicated grief
• There are 4 categories of complicated grief reactions:

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  Chronic grief is characterized by normal grief reactions that do not subside and
continue over very long periods of time
 Delayed grief is characterized by normal grief reactions that are suppressed or
postponed. The survivor consciously or unconsciously avoids the pain of the loss
 In exaggerated grief, the survivor may resort to self-destructive behaviors such as
suicide
 In masked grief, the survivor is not aware that the behaviors that interfere with
normal functioning are a result of the loss

 Symptoms of complicated grief include:

 Intense longing and yearning for the deceased
 Intrusive thoughts or images of your loved one
 Denial of the death or sense of disbelief
 Imagining that your loved one is alive
 Searching for the person in familiar places
 Avoiding things that remind you of your loved one
 Extreme anger or bitterness over the loss
 Feeling that life is empty or meaningless

• When complicated grief is suspected, referral for specialized help is warranted

Tasks of the Grieving
• After a major loss, there are typically 4 tasks the bereaved must complete before they will
effectively deal with their loss
 These tasks apply to the many losses that precede the death, as well as to
the death itself
 While the tasks are interdependent, they are not necessarily completed in
sequence
1. Accepting the reality of the loss
 For many, realization and acceptance that the loss or death has actually
occurred can be a major hurdle
 If such individuals spent little or no time at the bedside after the death realizing
what happened, they may continue for months to deny that anything has occurred
 Denial can be unwavering. Some bereaved may even continue to look for the
person, waiting for his or her telephone call and/or return
 Until such people realize that the person has died, they cannot begin to resolve
what has happened and move on
2. Experiencing the pain caused by the loss
 Knowing that the death has occurred is not enough
 To be able to move on, the bereaved need to experience the pain caused by
their loss
 As this can be very distressing, many who are bereaved try to avoid the pain, and
physicians frequently try to blunt it with medication
 While this may be necessary for temporary management of destructive reactions,
if overdone, medication may prolong both the grief reactions and the pain
associated with the loss

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3. Adjusting to the new environment after the loss
 Once they have realized what has happened and the pain that the loss has caused,
the bereaved need to recognize the significance of their losses and the changes
to their lives
4. Rebuilding a new life
Finally, as grief proceeds, the bereaved need to reinvest their energy into new
activities and relationships
Developmental Perspectives on Loss and Grief

AGE BELIEFS / ATTITUDES

Infancy – 5 years  does not understand concept of death

 infant’s sense of separation forms basis for later understanding of loss & death
 believes death is reversible, a temporary departure, or sleep
 emphasizes immobility & inactivity as attributes of death

 understands that death is final

5 to 9 years  believes own death can be avoided
 associates death with aggression or violence
 believes wishes or unrelated actions can be responsible for death
9 to 12 years
 understands death as the inevitable end of life
 begins to understand own mortality, expressed as interest in afterlife or as fear
of death
 expresses ideas about death gathered from parents & other adults

 fears a lingering death

 may fantasize that death can be defied, acting out defiance through reckless
12 to 18 years behaviors (dangerous driving, substance abuse)
 seldom thinks about death, but views it in religious & philosophic terms
 may seem to reach “adult” perception of death but be emotionally unable to
accept it
 may still hold concepts from previous developmental stages

 has attitude toward death influenced by religious & cultural beliefs

18 to 45 years

 accepts own mortality

45 to 65years  encounters death of parents & some peers
 experiences peaks of death anxiety
 death anxiety diminishes with emotional well-being

65 years +  fears prolonged illness

 encounters death of family members and peers
 sees death as having multiple meanings (freedom from pain, reunion with
already deceased family members)

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Factors influencing the Loss and Grief responses
A number of factors affect a person’s response to a loss or death. It include the following:
1. Age:
Age affects a person’s understanding of and reaction to loss. With familiarity, people usually
increase their understanding and acceptance of life, loss, and death. Coping with other of life’s
losses, such as the loss of pet, the loss of youth or a job, can help people anticipate the more severe
loss of death of loved ones teaching them successful coping strategies.
2. Significance of loss
The significance of loss depends on the perceptions of the individual experiencing the loss. A
number of factors affect the significance of the loss:
 Importance of the lost person, object or function
 Degree of change required because of the loss
 The person’s belief and values.
3. Culture
Culture influences an individual’s reaction to loss. How grief is expressed is often determined by
the customs of the culture.
 In cultures where several generations and extended and extended and extended family
members either reside in the same household or are physically close, the impact of the
family member’s death may be softened because the role of the deceased are quickly
filled by other relatives.
 Some persons have adopted the belief that grief is a private matter and remain
unidentified.
 Some cultural groups value social support and the expression of loss. In some groups,
the expression of grief through wailing, crying, physical prostration, and other outward
demonstrations are acceptable and encouraged.
4. Spiritual Beliefs
Spiritual beliefs and practices greatly influence both a person’s reaction to loss and subsequent
behavior. Most religious groups have practice related to dying, and these are important to the
client and support people.
5. Gender
The gender roles into which many people are socialized in the United States and Canada affect
their reactions at time of loss. Men are frequently expected to “be strong” and show very little
emotion during grief, whereas it is acceptable for women to show grief by crying.
6. Socioeconomic status
The socioeconomic status of an individual often affects the support system available at the time
of a loss. A pension plan or insurance, for example, can offer a widowed or disabled person a
choice of ways to deal with a loss.
7. Support system
The person closest to the grieving individual are often the first to recognize and provide needed
emotional, physical and functional assistance
8. Cause of loss or death

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Individual and societal views on the cause of a loss or death may significantly influence the grief
response. A loss or death that is beyond the control of those involved may be more acceptable than
one than is preventable, such as drunk driving accident.
Coping with grief and loss

Healthy lifestyle
 Take good care of yourself.
 Try to get enough sleep
 Eat a good balance of healthy foods
 Avoid using alcohol and un prescribed drugs for relief.
• Exercise
 Physical activity can help you cope and will help keep you healthy.
 Do any kind of physical activity that you have enjoyed in the past or try a new one.
 Doing the activity with others may be even more helpful.
• Support from family and friends
 People need support from others for their losses.
 Do not hesitate to accept or even ask for the help or support you need..
• Grief support groups
 Grief support groups are available in many communities and also on-line.
 Some groups are open to anyone. Others may be restricted, e.g., a group for young widows..
• Rituals
 A ritual is an activity that is done to remember and honor the person who died. It may be
related to your cultural traditions
 Some examples: lighting candles on special dates to remember the deceased, sharing a
memory dinner to celebrate the life of the deceased.
• Writing or journaling
 Writing or journaling about your grief experience can help you express your feelings and the
importance of your loss.
• Nature
 Spending time in nature can be soothing and healing.
Nursing management related to loss and grief
Assessment

 Identify behaviors suggestive of the grieving process

Manifestations of grief are strongly influenced by factors such as age, gender, and culture.
 Assess stage of grieving being experienced by patient or significant others: denial, anger,
bargaining, depression, and acceptance.
 Assess the influence of the following factors on coping: past problem-solving abilities,
socioeconomic background, educational preparation, cultural beliefs, and spiritual beliefs.
 Assess whether the patient and significant others differ in their stage of grieving.
 Identify available support systems, such as the following: family, peer support, primary
physician, consulting physician, nursing staff, clergy, therapist or counselor, and professional
or lay support group.
 Identify potential for pathological grieving response.
 Evaluate need for referral to social security representatives, legal consultants, or support
groups.

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 It may be helpful to have patients and family members plugged into these supports as
early as possible so that financial considerations and other special needs are taken care of
before the anticipated loss occurs.
 Observe nonverbal communication.
Body language may communicate a great deal of information, especially if the patient
and his or her family is unable to vocalize their concerns.

Therapeutic Interventions

(i) Establish rapport with patient and significant others; try to maintain continuity in care providers.
Listen and encourage patient or significant others to verbalize feelings.
(i) Recognize stages of grief; apply nursing measures aimed at that specific stage.
(i) Provide safe environment for expression of grief.
(i) Minimize environmental stresses or stimuli. Provide the mourners with a quiet, private
environment with no interruptions.
(i) Remain with patient throughout difficult times. This may require the presence of the care
provider during procedures, difficult discussions, conferences with other family members or other
members of the health care team.
(i) Accept the patient or the family's need to deny loss as part of normal grief process.
(i) Anticipate increased affective behavior.
(i) Recognize the patient or family's need to maintain hope for the future.
(i) Provide realistic information about health status without false reassurances or taking away hope.
(i) Recognize that regression may be an adaptive mechanism.
(i) Discuss possible need for outside support systems (i.e., peer support, groups, clergy).
(i) Help patient prioritize importance of rehabilitation needs.
(i) Encourage patient's or significant others' active involvement with rehabilitation team.
(i) Continue to reinforce strengths, progress.
(i) Recognize patient's need to review (relive) the illness experience.
(i) Recognize that each patient is unique and will progress at own pace.
Cultural, religious, ethnic, and individual differences affect the manner of grieving.
Carry out the following throughout each stage:
(i) Provide as much privacy as possible.
(i) Allow use of denial and other defense mechanisms.
(i) Avoid reinforcing denial.
(i) Avoid judgmental and defensive responses to criticisms of health care providers.
(i) Do not encourage use of pharmacological interventions.
(i) Do not force patient to make decisions.
(i) Provide patient with ongoing information, diagnosis, prognosis, progress, and plan of care.
(i) Involve the patient and family in decision making in all issues surrounding care.
(i) Encourage significant others to assist with patient's physical care.
(i) When the patient is hospitalized or housed away from home, facilitate flexible visiting hours and
include younger children and extended family.

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 Death
Definition

Death is defined as:

"Cessation of heart- lung function, or of whole brain function, or of higher brain function.

"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).

Signs of Impending Death

1. Loss of muscle tone
 relaxation of the facial muscles (jaw may sag)
 difficulty speaking
 difficulty swallowing & gradual loss of the gag reflex
 decreased activity of the GIT, with subsequent nausea, accumulation of flatus, abdominal
distention, & retention of feces
 possible urinary & rectal incontinence due to decreased sphincter control
 diminished body movement
2. Slowing of the Circulation
 diminished sensation
 mottling & cyanosis of the extremities
 cold skin, first in the feet & later in the hands, ears, & nose (however, client may feel warm
due to elevated temperature.)
3. Changes in Vital Signs
 decelerated & weaker pulse
 decreased BP
 rapid shallow, irregular, or abnormally slow respirations; Cheyne-stokes respirations; noisy
breathing, referred to as the death rattle, due to collecting of mucus in the throat; mouth
breathing, which leads to dry oral mucous membranes
4. Sensory impairment
 Blurred vision
 Impaired senses of taste & smell (hearing is the last sense to disappear)
Clinical signs of Death

- cessation of the apical pulse, respirations, & blood pressure

1. Total lack of response to external stimuli

2. No muscular movement, especially breathing
3. No reflexes
4. Flat encephalogram for 24 hours.

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 5. Flat ECG despite performing CPR.
Cerebral death

 Occurs when the higher brain center, the cerebral cortex, is irreversibly destroyed.
 It is believed that the cerebral cortex, which holds the capacity for thought, voluntary
action, & movement of the individual.

Body Changes
Rigor Mortis -
 the stiffening of the body that occurs about 2 to 4 hours after death due to lack of
(ATP) Adenosine Triphosphate, which is not synthesized because of a lack of
glycogen in the body. ATP is necessary for muscle fiber relaxation. Its lack causes
the muscles to contract, which in turn immobilizes the joints.
 starts in the involuntary muscles (heart, bladder, etc.) then progresses to the head,
neck, trunk, & finally reaches the extremities.
 rigor mortis leaves the body about 96 hours after death

Algor Mortis
 Gradually decrease of the body’s temperature after death.
 When blood circulation terminates & the hypothalamus ceases to function, body
temperature falls about 10 C per hour until it reaches room temperature.
 Simultaneously, skin loses its elasticity & can easily be broken when removing
dressing & adhesive tapes

Livor Mortis
 After blood circulation has ceased, skin becomes discolored. The RBC breakdown,
releasing hemoglobin, which discolors the surrounding tissues. Appears in the
lowermost or dependent areas of the body

Theories of Dying and Grief

Theories of Death and Dying
 Glaser And Strauss’ Theory
 Pattison’s Theory
 Kubler-Ross’s Theory

Theories of Grief and Grieving

 Lindemann’s Theory
 Bowlby’s Theory
 Engel’s Theory
 Parkes’s Theory
 Martocchio’s Theory

Management

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Management of dying patient

Cassen (1991) suggests seven essential features in the management of the dying patient:

1. Concern: Empathy, compassion, and involvement are essential.

2. Competence: Skill and knowledge can be as reassuring as warmth and concern.
3. Communication: Allow patients to speak their minds and get to know them.
4. Children: If children want to visit the dying, it is generally advisable; they bring consolation
to dying patients.
5. Cohesion: Family cohesion reassures both the patient and family.
6. Cheerfulness: A gentle, appropriate sense of humor can be palliative; a somber or anxious
demeanor should be avoided.
7. 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.

Symptom Management

The management of individual symptoms in terminally ill follows a general stepwise approach

 Assessment of the severity of the symptoms.

 Evaluation for the underlying cause.
 Addressing the social, emotional and spiritual aspects of the symptom.
 Discussing the treatment options with the patient and family.
 Using therapies designed as around the clock interventions for chronic symptoms.
 Reevaluating the control of the symptom periodically.

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 non pharmacologic methods

Nursing management of a dying patient

Therapeutic communication

Effective listening techniques & communication of concern & understanding help client move
through the grieving process

1. Use open-ended questions

 Allows client to speak about concerns
2. Schedule adequate time with client and family to promote open communication
3. Provide a private location for the interview conducive to sharing of perceptions
4. Words & actions should convey acceptance of all grief reactions
5. Acknowledge grief through touching the client & expressing concern to evoke client’s trust
& build self-esteem

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6. Convey willingness to be available when needed if client chooses not to share feelings or
concerns
7. Avoid erecting barriers to communication
(denying client’s grief, providing false reassurance, avoiding discussion of the problem &
focusing on caregiver’s needs instead of the client’s needs).

Maintenance of self esteem

1. Listen, respond quickly & positively to requests, maintain confidentiality & privacy &
provide comfort & support
2. Implement comfort measures in a caring, unhurried manner to reinforce client’s feelings
of self-worth & dignity & to decrease the fear of rejection, isolation, & sense of
hopelessness
3. Make client believe that his opinions are valuable in decisions that will affect the course
of his dying
4. Give attention to client’s appearance, show an attitude of respect & helpfulness rather
than encourage dependence or feelings of guilt
Promotion of return to life
1. Encourage clients to participate in decisions about relationships & resources for the
future
2. Identifying usual lifestyle practices helps bring a sense of closure to the loss
3. Hospice Care - based on holistic concepts that emphasize care to improve the quality
of life rather than cure
Promotion of comfort
1. Relief of pain is critically important, the sooner the dying client obtains pain relief, the
more energy the client can direct toward maintaining quality in the remainder of his life
2. Provide personal hygiene measures, control pain, relieve respiratory difficulties, assist
with movements, nutrition, hydration & elimination improves comfort
Promotion of spiritual comfort
1. Support client in his expression of the philosophy he has chosen for his life
2. Attentive listening encourages client to express feelings, clarify them, & accept his fate
3. Praying silently with the client
4. Make referrals for spiritual counseling
5. Facilitate expression of feeling, prayer, meditation, reading, & discussion with
appropriate clergy / spiritual advisor
Care of the Body
 Placed in supine position with arms at the side, palms down, or across the abdomen
(to make the body look as natural & comfortable as possible)
 Place a small pillow or folded towel under the head (to prevent discoloration from
blood).
 Gently hold eyelids close for a few seconds to make it remain closed.
 Insert client’s dentures to maintain the normal facial features
 Place a rolled-up towel under the chin to keep mouth closed Wash any soiled body
parts, dress the body in a clean gown, and cover the body upto the shoulder with
clean linen
 Place absorbent pads under the perineal & rectal area to collect any oozing feces or
urine
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  Remove all jewelries & present it and any valuables to the family
 If the wedding band is left in place, tape it securely to the finger
 Allow family members to enter the room when body is prepared

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

Conclusion

The stages of mourning are universal and are experienced by people from all walks of life. Mourning
occurs in response to an individual’s own terminal illness or to the death of a valued being, human or
animal. Coping with loss is a ultimately a deeply personal and singular experience — nobody can
help you go through it more easily or understand all the emotions that you’re going through. But
others can be there for you and help comfort you through this process. The best thing you can do is
to allow yourself to feel the grief as it comes over you. Resisting it only will prolong the natural
process of healing.

Research abstract

An Empirical Examination of the Stage Theory of Grief

Context The stage theory of grief remains a widely accepted model of bereavement adjustment still
taught in medical schools, espoused by physicians, and applied in diverse contexts. Nevertheless, the
stage theory of grief has previously not been tested empirically.

Objective To examine the relative magnitudes and patterns of change over time postloss of 5 grief
indicators for consistency with the stage theory of grief.

Design, Setting, and Participants Longitudinal cohort study (Yale Bereavement Study) of 233
bereaved individuals living in Connecticut, with data collected between January 2000 and January
2003.

Main Outcome Measures Five rater-administered items assessing disbelief, yearning, anger,
depression, and acceptance of the death from 1 to 24 months postloss.

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Results Counter to stage theory, disbelief was not the initial, dominant grief indicator. Acceptance
was the most frequently endorsed item and yearning was the dominant negative grief indicator from
1 to 24 months postloss. In models that take into account the rise and fall of psychological
responses, once rescaled, disbelief decreased from an initial high at 1 month postloss, yearning
peaked at 4 months postloss, anger peaked at 5 months postloss, and depression peaked at 6 months
postloss. Acceptance increased throughout the study observation period. The 5 grief indicators
achieved their respective maximum values in the sequence (disbelief, yearning, anger, depression,
and acceptance) predicted by the stage theory of grief.

Conclusions Identification of the normal stages of grief following a death from natural causes
enhances understanding of how the average person cognitively and emotionally processes the loss of
a family member. Given that the negative grief indicators all peak within approximately 6 months
postloss, those who score high on these indicators beyond 6 months postloss might benefit from
further evaluation.

Bibliography
Books

1. Basheer. P ‘Concise Textbook of Advanced Nursing Practice’ 1st edition Emees

Publishers Page no. 638-641

This book explained about Loss and types of Loss in deeper way. But this book gives only
the outline of coping with Loss and Grief.

2. Bolander.V ‘Sorenson and Luckmann’s Basic Nursing’ 3rd edition W.B Saunders
Company Philadelphia Page no: 1533-1543

This book clearly explained the theories of dying and grieving in a specific way in different
sub headings. This book gives adequate information regarding the nursing management of dying
patient. But it fails to explain the different stages of grieving as a separate topic and is mingled in
theories.

3. Kosier.B ‘Fundamentals of Nursing- Concepts, Process and Practice’ 7th edition

Pearson Education Philadelphia Page No: 1032-1047

The author explained about the definitions of Loss and Grief in an easily understanding
manner. He gives importance to the factors influencing the Loss and Grief. This book was not able
to give clear idea about death and dying person.

4. Taylor ‘Fundamental of Nursing’ 7th edition Lippincott Williams and Williams

Philadelphia Page no: 1545-1569

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 This book explained the developmental perspectives of Loss and Grief in different age
groups. This helps to learn the grief reactions at different age groups. This book gives general idea
regarding the nursing management of Loss, Grief and Death.

Net Reference

5. http://endlink.lurie.northwestern.edu/last_hours_of_living/part_three.pdf

This site gives information regarding assessment of grief, grief reactions and task of grieving by
clear points.

6. http://www.ucdmc.ucdavis.edu/hr/hrdepts/asap/Documents/Coping_with_Grief.pdf

This site gives information regarding coping mechanism of loss and grief. It also explains the
classification of grief by different heading.

Net Journal

7. Paul K ‘Journal of American medical Association’ vol.297 published by American

Medical Association

Research abstract is based on An Empirical Examination of the Stage Theory of Grief. This
research is based on the examination of consistency with the stage theory of grief. It is a
Longitudinal cohort study of 233 bereaved individuals living in Connecticut, with data collected
between January 2000 and January 2003

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