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Grief & Loss Concept Guide

Fall, 2023

Catherine Strength, Professor of Nursing

Office 5031 cstren@dcc.edu

Introduction: To provide care for patients experiencing loss, you will need to understand the key
concepts of loss, grief, death and dying, and end-of-life care.

WHAT IS LOSS?

Categories of Loss: Loss can be categorized in the following ways:

■ Actual loss includes the death of a loved one (or relationship), theft, deterioration, destruction,
and natural disaster. The loss can be identified by others, not just by the person experiencing it
(e.g., hair loss during chemotherapy).

■ Perceived loss is internal; it is identified only by the person experiencing it (e.g., a woman
diagnosed with a sexually transmitted infection may perceive herself as having lost her purity).

■ Physical loss includes (1) injuries (e.g., when a limb is amputated), (2) removal of an organ (e.g.,
hysterectomy), and (3) loss of function (e.g., loss of mobility).

■ Psychological losses challenge our belief system. Also known as perceived losses, they are
commonly seen in the areas of sexuality, control, fairness, meaning, and trust.

■ Some losses may be mixed. For example, after removal of a prostate gland, a man may feel
both the physical and psychological loss of sexuality.

■ External losses are actual losses of objects that are important to the person because of their
cost or sentimental value (e.g., jewelry, a home). These losses can be brought about by theft,
destruction, or disasters such as floods and fire.

■ Internal loss is another term for perceived or psychological loss.

Loss of Aspects of Self These losses include physical losses such as body organs, limbs, body
functions, and/or body disfigurement. Psychological and perceived losses in this category include
aspects of one’s personality, developmental change (as in the aging process), loss of hopes and
dreams, and loss of faith.

Environmental Loss involves a change in the familiar, even if the change is perceived as positive.
Examples include moving to a new home, getting a new job, and going to college. These losses can
be perceived or actual.

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Loss of Significant Relationships includes, but is not limited to, actual loss of spouses, siblings,
family members, or significant others through death, divorce, or separation (e.g., military
deployment).

Health Language/Terminology:

Whenever there is significant loss, there is grieving. Although grieving requires energy and can
interfere with health and delay healing, it is positive and essential to psychological healing after a
loss.

Grief is the physical, psychological, and spiritual responses to a loss. Grief (GT) is the total
response to the emotional experience of loss. Permits the pt. to cope w the loss & accept it. A
social process & is best shared.

■ Mourning consists of actions associated with grief (e.g., wailing, wearing black clothing).
These processes are normal and natural responses to a loss. Mourning (MB) is the behavioral
process through which grief is eventually resolved or altered.

■ Bereavement is the period of mourning and adjustment after a loss. Bereavement (BS) : The
subjective response experienced by the surviving loved ones.

Key Point: Although each person may express grief differently, some aspects of grief are shared by
almost everyone.

Effects on Grief

No two people ever grieve in the same manner because many factors play a role in the grieving
process. They include the following:

■ Significance of the Loss. The meaning the person has attached to the person or object lost will
be different for each person. The greater the attachment, the more difficult the grief will be.

■ Support System. People with strong emotional and psychosocial support typically have less
complicated grief.

■ Unresolved Conflict. Prolonged or dysfunctional (complicated) grief can occur with unresolved
conflict. A conflict (e.g., an argument) left unresolved may cause prolonged grief.

■ Circumstances of the Loss. The manner and circumstances of the death can leave the bereaved
feeling guilty, responsible, or unprepared. Violent deaths (e.g., homicide, suicide, accident) can
result in prolonged or dysfunctional (complicated) grief.

■ Previous or Multiple Losses. A person who has sustained several losses in a short period of time
may experience dysfunctional (or complicated) grief. In the hospital, you will frequently care for
patients with multiple losses; for example, a patient suffering a stroke with paralysis has lost his
mobility, independence, and familiar surroundings when moved to a skilled care facility.
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■ Spiritual/Cultural Beliefs and Practices. Spirituality and religious beliefs can help or hinder the
grieving process. One person might believe the deceased is in a place of contentment and
happiness, where all suffering is over. Another may believe that the deceased person will be
reborn into another form. Yet another may believe that death is final and there is no afterlife.
Most cultures engage in rituals (e.g., funerals) that allow the bereaved to openly express their
grief and pain whereas others may limit expressions of grief to private settings.

■ Timeliness of the Death. The death of a child or a young person is almost universally more
difficult to accept than the death of an older person. In addition to the loss of the person, there is
a sense of unfairness because of the loss of potential—of what the child might have become or
achieved.

Dr.Kübler-Ross’ 5 Stages of Dying (DABDA):

Denial Stage: Patient: “No, not me!” Nurse:

Anger Stage: Patient: “Why, me?” Nurse:

Bargaining Stage: Patient: If you will do this, then I will…” or “Yes, but…” Nurse:

Depression Stage: Patient: “What’s the use? It is me!” Nurse: Allow the pt. to express

sadness.

Acceptance Stage: Patient: “I’ve tied up all loose ends and can go in peace.” or “It’s my death
and part of my life.” Nurse:

Facts about the Stages of D & D

• Pts. can move back and forth through the stages, possibly extending over a long period of
time.

• Also, some pts. can get stuck in a stage.

• Unresolved grief can cause complications.

• Remember that grief is essential for normal physical and emotional health.

Developmental Stages of Grief

Adults

Older Adults

Types of Grief

Uncomplicated

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Dysfunctional

Chronic

Masked

Delayed

Disenfranchised

Anticipatory

Stages of Dying

To help dying patients and their families understand the dying process, your theoretical
knowledge base must include information on both physiological and psychological processes.

Physiological Stages of Dying

The dying process is unique to each person. However, people experience many similar symptoms
as they approach the end of life. Fewer than 10% of patients die suddenly and unexpectedly, as
in an accident or massive heart attack. Ninety percent die after a long illness, progressively
deteriorating until entering an active dying phase at the end.

One to Three Months Before Death The dying person begins to withdraw from the world and
people. Sleep increases; it becomes difficult for the body to digest food, especially meat; and
appetite and food intake decrease. Liquids are preferred. Anorexia and the resulting ketosis may
be protective, as they can diminish pain and increase the person’s sense of well-being.

One to Two Weeks Before Death A host of physical changes indicates the body is beginning to
lose its ability to maintain itself. Cardiovascular deterioration brings reduced blood pressure,
changes in pulse and skin color (e.g., a yellowish pallor), and extreme pallor of the extremities.
Temperature fluctuates and perspiration increases. Respiratory rate may increase or decrease;
during sleep, the dying person may experience brief periods of apnea. Congestion may cause a
rattling sound and/or a nonproductive cough.

Days to Hours Before Death Often a surge of energy brings mental clarity and a desire to eat and
talk with family members. However, as death approaches, patients tend to become dehydrated
and have difficulty swallowing, which results in decreased blood volume. The tissues of the
tongue and soft palate sag, and the gag reflex declines, so secretions accumulate in the
oropharynx and/or bronchi. Often the mucous membranes become dry and tacky, and lips
become cracked. Dehydration during the last hours of dying is thought not to cause distress and
perhaps to stimulate endorphin release (

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■ Respirations—Breathing may be shallow, rapid, or irregular: Periods of apnea may lengthen to

10 to 30 seconds before breathing resumes.

■ Congestion causes a “death rattle” that can be quite loud.

■ Cheyne–Stokes respirations may occur. This is a cyclic pattern consisting of a 10- to 60-second
period of apnea and then a gradual increase in depth and rate of respirations. Respirations
gradually become slow and shallow, and then the cycle begins again with apnea.

■ Peripheral circulation decreases, and the person perspires and feels “clammy.”

■ Blood pressure decreases; pulse may be hard to detect.

■ Extremities become cool and mottled; the underside of the body may be much darker.

■ Decreased circulation also results in reduced kidney function and decreased urinary output.

■ Elimination—As peristalsis slows, the patient may retain feces. Urine output decreases and
urine often becomes more concentrated and foul smelling. Sphincters relax, and bowel and
bladder incontinence can occur.

■ Muscles throughout the body relax, causing the face to “droop.”

■ Vision blurs; the eyes may be open or partially open but unseeing. Instead, the patient may see
things that are not visible to others.

■ Cognition—In the final hours of life, many patients become restless and agitated. This response
may be caused by medications, liver failure, cerebral hypoxia, renal failure, stool impaction,
distended bladder, increased pain, or unresolved emotional or spiritual issues.

Near to the time of death, some people unexpectedly become more coherent and energized for a
time. Others become less communicative, quiet, and withdrawn (Emanuel, Ferris, von Gunten, et
al., 2015; Scott, 2016). Fatigue is common.

Nursing Process

Factors Influencing Grief & Loss

Nursing Process and Grief:

Assessment: Develop a trusting relationship, Active Listening, Empathy/Open communication,

Clarify, Conversations about meaning of loss often lead to other areas assessment, Coping style,
Nature of family relationships, social support systems, Nature of the loss.

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Diagnoses: Anticipatory grieving, Compromised family coping, Death anxiety, Fear, Impaired
comfort, Ineffective denial, Grieving, Complicated grieving, Risk- prone health behavior, Risk for
complicated grieving, Hopelessness, Pain (acute or chronic), Risk for loneliness, Spiritual distress,
Readiness for enhanced spiritual well-being, Interrupted family processes

Planning: Focus of care for the dying patient, Comfort, preserving dignity & quality of life,
Providing family with emotional, social, and spiritual support

Implementation: Health Promotion: Providing palliative care in acute and restorative settings,
providing hospice care, using therapeutic communication, providing psychosocial care, Managing
symptoms.

Evaluation

Validation questions of achievement of patient goals/expectations: (Prior to patient death.)

What’s the most important thing I can do for you at this time?

Are your needs being addressed in a timely manner?

End-of-Life Care

Palliative Care

Hospice Care

Clinical Manifestations: Signs of Impending Death

I. Loss of Muscle Control

II. Slowing of Circulation

III. Changes in Respirations

IV. Sensory Impairment

Implementation: Care After Death Federal and state laws apply to certain events after death,
Documentation, Organ and tissue donation, Autopsy

Postmortem Care

Identify the pt. using double identifiers.

Adhere to appropriate infection control procedures, i.e., clean gloves, etc.

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Treat with respect. Check for any cultural or religious practices, minister requests, etc.

Follow the hospital policy for care i.e., remove lines, tubes etc. if no autopsy, or a coroner's case,
etc.

Unless otherwise ordered, remove the pts. clothes, and other personal affects and secure and
document contents.

All these measures are performed prior to offering the patient's loved one's to view the
deceased patient. (The starred ** procedure would not be performed if the loved one's or no
one chooses to view the deceased.)

Close pt. eyelids.

Leave dentures in or insert. Close mouth.

Place pt. supine, with wrists crossed palms down on abdomen or at the sides of the pt., with one
pillow beneath the head and shoulders.

Wash soiled or bloody areas only.

Place waterproof pads under perineal area.

**Place in clean gown, comb hair, if possible, cover with clean sheet to neck.

Clean the environment, remove all equipment, soiled linens, & supplies.

Offer for loved ones to view the pt.:

Describe how the pt. looks or how they may feel i.e., cold, etc.

Allow for religious or cultural customs.

Have fly. sign funeral home release, sign for personal affects, etc.

After the significant others leave the room, obtain a shroud or postmortem pack, and a morgue
stretcher.

Loosely tie the crossed wrists and label shroud tags with patient identification information, attach
one tag to the toe, a wrist, and to the outside of the shroud.

Place the body onto morgue stretcher with blue pads under perineal area.

Wrap the body with the shroud and tie the ties around neck, around hips, and around ankles.

Cover shrouded body with a sheet and transfer to morgue with funeral home release and death
certificate.

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Document that post-mortem care given, etc.

Nurse’s Presence:

Compassion Fatigue

Rev. F23 CBS

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