Chapter 37

The Experience of Loss, Death,

and Grief

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 Scientific Knowledge Base: Loss

 Developing a personal understanding of your

own feeling about grief and death will help you
better serve your patients
 Actual losses
 Necessary losses
• Maturational losses
• Situational losses
 Perceived losses

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 Case Study
 Mrs. Kelly is 79 years old and is in end-stage heart
disease secondary to diabetes mellitus. Her mobility has
declined greatly because of shortness of breath, poor
food intake, decreased strength, and lack of oxygen. She
takes pain medication for severe back and joint pain and
has trouble with constipation.
 She is now in the intensive care unit for chest pain and
congestive heart failure.
 Mrs. Kelly no longer wants to be hospitalized for her
medical conditions, and she wants to go home to
die. Mrs. Kelly is being evaluated for home hospice care
and will temporarily receive home care.
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 Scientific Knowledge Base: Grief

 Grief is a normal but bewildering cluster of

ordinary human emotions arising in response to
a significant loss, intensified and complicated by
the relationship to the person or the object lost.
 Normal (uncomplicated)
 Anticipatory
 Disenfranchised (ambiguous)
 Complicated (chronic, exaggerated, delayed, masked)

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 Case Study (Cont.)

 Mrs. Kelly lives with her husband of 54

years. Her daughter, Lilly, lives near her parents
and visits them every day. Lilly does not agree
with the plan to begin hospice care. She cannot
accept her mother's plan to “give up.”
 Mr. Kelly does not understand hospice and is not
sure if he will be a good caregiver.

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 Quick Quiz!

1. You are caring for a patient who is depressed

because the only child has gone away to
college. The nurse will assess this type of
depression as:
A. actual loss.
B. perceived loss.
C. situational loss.
D. maturational loss.

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 Theories of Grief and Mourning
 Knowledge of grieving
theories assists you in
how to help a grieving
person
 Support the
complexity and
individuality of grief
responses

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 Case Study (Cont.)

 Nursing student Jennifer Brown will be caring for

the Kelly family as she learns how to give care in
the home. Before Jennifer meets the Kelly family
for the first time, she reviews the information
essential for making a thorough assessment.
 Jennifer worries that she will be asked questions
for which she has no answer. She feels more
comfortable talking about heart disease than
about end-of-life decisions and care.

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 Nursing Knowledge Base

 Organizations that assist in end-of-life care

 End-of-Life Nursing Consortium (ELNEC)
 American Nurses Association (ANA)
 American Society of Pain Management Nurses
 American Association of Critical Care Nurses

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 Factors Influencing Loss and
Grief

Human development Personal relationships

Nature of loss Coping strategies

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 Factors Influencing Loss and
Grief (Cont.)

Socioeconomic status Culture and ethnicity

Spiritual and religious beliefs Hope

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 Critical Thinking

 Be familiar with commonly experienced

responses to loss.
 Integrate theory, prior experience, subjective
experiences, and self-knowledge.
 Use Professional Standards:
 Nursing Code of Ethics
 Dying Person’s Bill of Rights
 ANA Scope and Standards of Hospice and Palliative
Nursing

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 Assessment

 Through the patient’s eyes

 Be present
 Use active listening, silence, therapeutic touch
 Use open, honest communication
 Ask open-ended questions
 Grief variables
 Grief reactions

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 Diagnosis

 Nursing diagnoses relevant for patients

experiencing grief, loss, or death include:
 Compromised family coping
 Death anxiety
 Grieving
 Complicated grieving
 Risk for complicated grieving
 Hopelessness
 Pain (acute or chronic)
 Spiritual distress

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 Planning

 Goals and outcomes

 Based on nursing diagnosis
 Setting priorities
 Encourage patient to share their priorities for care
 Give priority to a patient’s most urgent physical or
psychological needs
 Maintain an ongoing assessment to revise the plan of
care according to patient needs and preferences
 Teamwork and collaboration

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 Case Study (Cont.)

 Jennifer will ensure that Mrs. Kelly's pain is well

managed before asking about her other priorities
for care. Jennifer knows that many families have
never given end-of-life care, so she plans to
provide teaching for their priority concerns.

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 Implementation: Health Promotion

 Health promotion
 Focus on coping and optimizing health
 Palliative care
 Primary goal is to help patients and families achieve
the best possible quality of life
 Hospice care
 Care of terminally ill patients
 Manage pain, provide comfort, ensure quality of life
 Adheres to patient wishes

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 Implementation: Health Promotion
(Cont.)
 Use therapeutic communication
 Helps earn trust
 Use open-ended questions
 Provide psychological care
 Manage symptoms
 Promote dignity and self-esteem
 Maintain a comfortable and peaceful
environment

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Implementation: Health Promotion
(Cont.)
 Promote spiritual
comfort and hope
 Protect against
abandonment and
isolation
 Support the grieving
family

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 Implementation: Health Promotion
(Cont.)
 Assist with end-of-life decision making
 Support and educate patients and families as they
identify, contemplate, and decide the best journey to
the end of life
 Facilitate mourning
 Provide bereavement care
 Care after death
 Ensure respect for the body

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 Case Study (cont’d)
Intervention
Involve the Kelly family in a
discussion about symptom
recognition and management.
Offer the Kelly family a chance
to ask questions.
Explain that setting easily
achievable goals helps give
hope.
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Rationale
Even with poor prognosis, social
supports and prompt symptom
relief improve quality of life.
Clarifying expectations better
prepares individuals to face
changes.
Restructuring goals to be more
short term and achievable helps
to give hope.
21
 Evaluation

 Through the patient’s eye

 Patient outcomes
 Ask questions
 Short- and long-term acheivements

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 Quick Quiz!

2. As a first-year nursing student, you are assigned to

care for a dying patient. To best prepare you for this
assignment, you will want to:
A. complete a course on death and dying.
B. control your emotions about death and dying.
C. compare this experience to the death of a family
member.
D. develop a personal understanding of your own
feelings about grief and death.

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 Case Study (Cont.)

 Jennifer asks Mr. Kelly and Lilly about any

changes they see in Mrs. Kelly. They report that
Mrs. Kelly has less activity tolerance, that she is
able to rest with oxygen in place, and that Mrs.
Kelly’s family asks about her pain before Mrs.
Kelly states it.
 Jennifer observes family members’ caregiving
and level of comfort and involvement. She notes
that after 1 week, Mrs. Kelly’s family is more at
ease with caregiving activities.

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 Case Study (Cont.)

 Jennifer asks Mrs. Kelly to describe her feelings

after sharing stories and life review with family.
 After 2 weeks Jennifer notices that the Kelly
family has begun to look forward to sharing
these stories, and they are becoming at ease
with Mrs. Kelly’s decision and their role in
palliative care.

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