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UNIT X: Concept of Loss & Grieving and Death and Dying’

DEFINATIONS
Death
Death is a loss both for the dying person and for those who survive. Although death is
inevitable, it can stimulate people to grow in their understanding of themselves and others.

1. Assess the physiologic signs of death

Signs of Death
The traditional clinical signs of death were cessation of the apical pulse, respirations, and
blood pressure, also referred to as heart-lung death
Following guidelines for physicians as indications of death:
• Total lack of response to external stimuli
• No muscular movement, especially breathing
• No reflexes
• Flat encephalogram (brain waves).

2. Identify beliefs and attitude about death in relation to age

Development of the Concept of Death
Age Beliefs/Attitudes
Infancy–5 Does not understand concept of death.
years Infant’s sense of separation forms basis for later understanding of loss and
death.
Believes death is reversible, a temporary departure, or sleep.
5–9 years Understands that death is final. Believes own death can be avoided.
Associates’ death with aggression or violence
9–12 years Understands death as the inevitable end of life. Begins to understand own
mortality, expressed as interest in afterlife or as fear of death.
12–18 Fears a lingering death. May fantasize that death can be defied, acting out
years defiance through reckless behaviours (e.g., dangerous driving, substance
abuse). Seldom thinks about death, but views it in religious and philosophic
terms
18–45 Has attitude toward death influenced by religious and cultural beliefs.
years
45–65 Accepts own mortality. Encounters death of parents and some peers.
years Experiences peaks of death anxiety
65+ years Fears prolonged illness. Encounters death of family members and peers.
Sees death as having multiple meanings (e.g., freedom from pain, reunion
with already deceased family members).

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3. Discuss the various ways of helping the dying patient meet his/her
physiological, spiritual and emotional needs.
Meeting the Physiological Needs of the Dying Client
The physiological needs of people who are dying are related to a slowing of body processes
and to homeostatic imbalances. Interventions include
 Providing personal hygiene measures;
 Controlling pain;
 Relieving respiratory difficulties;
 Assisting with movement,
 Nutrition,
 Hydration, and elimination; and
 Providing measures related to sensory changes
Providing Spiritual Support
Spiritual support is of great importance in dealing with death. The nurse has a responsibility
to ensure that the client’s spiritual needs are attended to, either through direct intervention or
by arranging access to individuals who can provide spiritual care
Interventions may include
 Facilitating expressions of feeling,
 Prayer,
 Meditation,
 Reading, and discussion with clergy or a spiritual adviser.
It is important for nurses to establish an effective interdisciplinary relationship with spiritual
support specialists.
Emotional needs
The major nursing responsibility for clients who are dying is to assist the client to a peaceful
death. More specific responsibilities include the following:
• To minimize loneliness, fear, and depression
• To maintain the client’s sense of security, self-confidence, dignity, and self-worth
• To help the client accept losses
• To provide physical comfort.

4. Discuss care of the body after death.

7. Discuss important factors in caring for the body after death.
Post-mortems Care
Nursing personnel may be responsible for care of a body after death. Post-mortem’s care
should be carried out according to the policy of the hospital or agency

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• Make the environment clean and pleasant and to make the body appear natural and
comfortable
• All equipment, soiled linen, and supplies should be removed from the bedside
• Some agencies require that all tubes in the body remain in place; in other agencies, tubes
may be cut to within 2.5 cm (1 in.) of the skin and taped in place; in others, all tubes may
be removed.
• Normally the body is placed in a supine position with the arms either at the sides, palms
down, or across the abdomen.
• One pillow is placed under the head and shoulders to prevent blood from discoloring the
face by settling in it
• The eyelids are closed and held in place for a few seconds so they remain closed.
Dentures are usually inserted to help give the face a natural appearance. The mouth is
then closed.
• Soiled areas of the body are washed; however, a complete bath is not necessary, because
the body will be washed by the mortician
• Absorbent pads are placed under the buttocks to take up any faces and urine released
because of relaxation of the sphincter muscle
• A clean gown is placed on the client, and the hair is arranged. All jewellery is removed,
except a wedding band in some instances, which is taped to the finger
• The top bed linens are adjusted neatly to cover the client to the shoulders. Soft lighting
and chairs are provided for the family
• The body is wrapped in a shroud, a large piece of plastic or cotton material used to
enclose a body after death

5. Discuss the legal implications of death.

6. Describe how a nurse meets a dying patient’s needs of comfort.
Palliative care:
• provides relief from pain and other distressing symptoms;
• affirms life and regards dying as a normal process;
• intends neither to hasten nor postpone death;
• integrates the psychological and spiritual aspects of client care;
• offers a support system to help clients live as actively as possible until death;
• offers a support system to help the family cope during the client’s illness and in their own
bereavement;
• uses a team approach to address the needs of clients and their families, including
bereavement counselling, if indicated;
• will enhance quality of life, and may also positively influence the course of illness;
• is applicable early in the course of illness, in conjunction with other therapies that are
intended to prolong life, such as chemotherapy or radiation therapy, and includes those
investigations needed to better understand and manage distressing clinical complications

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8. List changes that occur in the body after death.

Rigor mortis
Is the stiffening of the body that occurs about 2 to 4 hours after death. Rigor mortis starts in
the involuntary muscles (heart, bladder, and so on), then progresses to the head, neck, and
trunk, and finally reaches the extremities.
Algor mortis
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. Simultaneously, the skin loses its
elasticity and can easily be broken when removing dressings and adhesive tape
livor mortis,
After blood circulation has ceased, the red blood cells break down, releasing haemoglobin,
which discolours the surrounding tissues. This discoloration, referred to as livor mortis,
appears in the lowermost or dependent areas of the body

9. Define terms related to loss and grieving

Grief
Grief is the total response to the emotional experience related to loss. Grief is manifested in
thoughts, feelings, and behaviours associated with overwhelming distress or sorrow
Bereavement is the subjective response experienced by the surviving loved ones. Mourning
is the behavioural process through which grief is eventually resolved or altered; it is often
influenced by culture, spiritual beliefs, and custom
TYPES OF GRIEF RESPONSES
Abbreviated grief is brief but genuinely felt. This can occur when the lost object is not
significantly important to the grieving person or may have been replaced immediately by
another, equally esteemed object
Anticipatory grief is experienced in advance of the event such as the wife who grieves
before her ailing husband dies. A young person may grieve before an operation that will leave
a scar
Disenfranchised grief occurs when a person is unable to acknowledge the loss to other
people. unacceptable loss that cannot be spoken about, such as suicide, abortion, or giving a
child up for adoption
Unhealthy grief—that is, pathologic or complicated grief— exists when the strategies to
cope with the loss are maladaptive and out of proportion or inconsistent with cultural,
religious, or age-appropriate norms.
Complicated grief may take several forms. Unresolved or chronic grief is extended in
length and severity. The same signs are expressed as with normal grief, but the bereaved may
also have difficulty expressing the grief, may deny the loss, or may grieve beyond the

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expected time. With inhibited grief, many of the normal symptoms of grief are suppressed
and other effects, including somatic, are experienced instead. Delayed grief occurs when
feelings are purposely or subconsciously suppressed until a much later time.

Loss
Loss is an actual or potential situation in which something that is valued is changed or no
longer available. People can experience the loss of body image, a significant other, a sense of
well-being, a job, personal possessions, or beliefs. Illness and hospitalization often produce
losses.

Types and Sources of Loss

There are two general types of loss, actual and perceived
An actual loss can be recognized by others
A perceived loss is experienced by one person but cannot be verified by others.
Psychological losses are often perceived losses because they are not directly verifiable. For
example, a woman who leaves her employment to care for her children at home may perceive
a loss of independence and freedom..
An anticipatory loss is experienced before the loss actually occurs. For example, a woman
whose husband is dying may experience actual loss in anticipation of his death
Sources of Loss
There are many sources of loss:
(a) loss of an aspect of oneself— a body part, a physiological function, or a psychological
attribute;
(b) loss of an object external to oneself;
(c) separation from an accustomed environment; and
(d) loss of a loved or valued person.

10. Discuss Kubler-Ross’ theory to assess grieving behaviours.

Many authors have described stages or phases of grieving, perhaps the most well known of
them being Kübler-Ross (1969), who described five stages: denial, anger, bargaining,
depression, and acceptance
Client Responses in Kübler-Ross’s Stages of Grieving
Stage Behavioural Responses
Denial Refuses to believe that loss is happening.
Is unready to deal with practical problems, such as
prosthesis after the loss of a leg.
May assume artificial cheerfulness to prolong denial
Anger Client or family may direct anger at nurse or staff about matters that
normally would not bother them
Bargaining Seeks to bargain to avoid loss (e.g., “let me just live until and then I will be
ready to die”).

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Depression Grieves over what has happened and what cannot be.
May talk freely (e.g., reviewing past losses such as money or job), or may
withdraw.
Acceptance Comes to terms with loss.
May have decreased interest in surroundings and support people.
May wish to begin making plans (e.g., will, prosthesis, altered living
arrangements).

11. Identify common manifestations of grief

Manifestations of Grief
The nurse assesses the grieving client or family members following a loss to determine the
phase or stage of grieving. Physiologically, the body responds to a current or anticipated loss
with a stress reaction. The nurse can assess the clinical signs of this response
Manifestations of grief considered normal include verbalization of the loss, crying, sleep
disturbance, loss of appetite, and difficulty concentrating. Complicated grieving may be
characterized by extended time of denial, depression, severe physiological symptoms, or
suicidal thoughts.

12. Discuss the effects of multiple losses on the grief process

Complicated grief after a death may be inferred from the following data or observations:
• The client fails to grieve; for example, a husband does not cry at, or absents himself from,
his wife’s funeral.
• The client avoids visiting the grave and refuses to participate in memorial services, even
though these practices are a part of the client’s culture.
• The client becomes recurrently symptomatic on the anniversary of a loss or during
holidays.
• The client develops persistent guilt and lowered self-esteem.
• Even after a prolonged period, the client continues to search for the lost person. Some
may consider suicide to affect reunion.
• A relatively minor event triggers symptoms of grief.
• Even after a period of time, the client cannot discuss the deceased with composure; for
example, the client’s voice cracks and quivers, and eyes become teary.
• After the normal period of grief, the client experiences physical symptoms similar to
those of the person who died.
• The client’s relationships with friends and relatives worsen following the death.

13. Apply the nursing process to grieving clients

Assessing
Nursing assessment of the client experiencing a loss includes three major components: (1)
nursing history, (2) assessment of personal coping resources, and (3) physical assessment.
During the routine health assessment of every client, the nurse poses questions regarding
previous and current losses. The nature of the loss and the significance of such losses to the
client must be explored.

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Diagnosing
NANDA International nursing diagnoses (Herdman & Kamitsuru, 2014) relating specifically
to grieving include the following:
• Interrupted Family Processes if the loss has such impact on the individual and family that
usual effective roles and interactions are negatively affected
• Risk-Prone Health Behaviour if the client has great difficulty placing the loss in
appropriate perspective to his or her other life activities
• Risk for Loneliness related to the loss of relationships with others.

Planning
The overall goals for clients grieving the loss of body function or a body part are to adjust to
the changed ability and to redirect both physical and emotional energy into rehabilitation. The
goals for clients grieving the loss of a loved one or thing are to remember them without
feeling intense pain and to redirect emotional energy into one’s own life and adjust to the
actual or impending loss

Implementing
Besides using effective communication skills, the nurse implements a plan to provide client
and family teaching and to help the client work through the stages of grief
 Explore and respect the client’s and family’s ethnic, cultural, religious, and personal
values in their expressions of grief
 Teach the client or family what to expect in the grief process, such as that certain
thoughts and feelings are normal (acceptable) and that labile emotions, feelings of
sadness, guilt, anger, fear, and loneliness
 Encourage the client to express and share grief with support people. Sharing feelings
reinforces relationships and facilitates the grief process
 Teach family members to encourage the client’s expression of grief, not to push the client
to move on or enforce his or her own expectations of appropriate reactions
 Encourage the client to resume normal activities on a schedule that promotes physical and
psychological health

Evaluating
Evaluating the effectiveness of nursing care of the grieving client If outcomes are not
achieved, the nurse needs to explore why the plan was unsuccessful. Such exploration begins
with reassessing the client in case the nursing diagnoses were inappropriate. Examples of
questions guiding the exploration include these:
Examples of questions guiding the exploration include these:
• Do the client’s grieving behaviors indicate dysfunctional grieving or another nursing
diagnosis?
• Is the expected outcome unrealistic for the given time frame?
• Does the client have additional stressors previously not considered that are affecting grief
resolution?
• Have nursing orders been implemented consistently, compassionately, and genuinely
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