Concept of Loss ,Grieving

Death & Dying

Prepared by:
Rubina kousar
RN,RM,BScN Post RN
OBJECTIVES

1. Assess the physiologic signs of death.

2. Identify beliefs and attitude about death in
relation to age.
3. Discuss the various ways of helping the
dying patient meet his/her physiological,
spiritual and emotional needs.
4. List changes that occur in the body after
death.
5. Discuss care of the body after death
 OBJECTIVES

6. Define terms related to loss and grieving.

7. Discuss Kubler-Ross’ theory to assess
grieving behaviors.
8. Identify common manifestations of grief.
9. Describe how a nurse meets a dying
patient’s needs of comfort.
10.Discuss the legal implications of death.
 LOSS

 Loss is an actual or potential situation in which

something that is valued is changed or no longer
available. E.g. the loss of body image , Loss of job.
 Types of Loss

1. Actual Loss
– An actual loss can be recognized by others.
2. Perceived Loss :
– A perceived loss is experienced by one person but cannot
be verified by others. E.g. a woman who leaves her
employment to care for her children at home may
perceive a loss of independence and freedom.
3. Anticipatory loss:
– Anticipatory loss is experienced before the loss actually
occurs. E.g. a woman whose husband is dying may
experience actual loss in anticipation of his death.
 Grief

• Grief is the total response to the emotional

experience related to loss. Grief is manifested in
thoughts, feelings, and behaviors associated
with overwhelming distress or sorrow.
Bereavement & Mourning

Mourning
 Mourning is the behavioral
process through which grief is
eventually resolved or altered; it
is often influenced by culture,
spiritual beliefs, and custom.
 Bereavement is the
subjective response
experienced by the
surviving loved ones.
Manifestations of grief
• Verbalization of the loss
• Crying
• Sleep disturbance,
• Loss of appetite
• Difficulty concentrating.
• Complicated grieving may be characterized
by extended time of denial, depression, severe
physiological symptoms, or suicidal thoughts.
Nursing Strategies for Grieving
person
• Open ended statement
• Accept any grief reaction
• Avoid giving Advice
• Allow Patient to Talk
• Allow patient to express sign of hope
• Acknowledge the pain.
• Accept that grief can trigger many
different and unexpected emotions.
• Understand that grieving process will be
unique to every individual.
• Seek out face-to-face support from
people who cares about grieving person .
• Ask him/her to Support himself
emotionally by taking care of himself
physically.
 Thanatology
• Thanatology (study of death)
• The description of study of the
phenomena of death, needs of
terminally ill persons and their
families.
 What is death?

Death is a universal experience,

one that we will all eventually
face.
 Cont..

Functional death:
Functional death is the absence of a
heartbeat and breathing.

Brain death:
Brain Death occurs when the higher
brain center, the cerebral cortex, is
irreversibly destroyed(no possibility of
restoring brain function).
 Nursing strategies
to comfort dying
patient’s
• Pain control
• Emotional Support
• Prevent isolation
• Spiritual comfort
• Support the family
Physiologic Signs of
Death
 Physiological changes after
death Death
• Rigor mortis
• Stiffening of body that occurs about 2-4 hours
after death.
• Algor mortis
– Gradual decrease of body temperature after
death .
• Livor mortis
– Discoloration of body after death.
• Decomposition
– Tissue after death become soft and
eventually liquefied by bacterial
fermentation
 Development of the concept of death
AGE Belief / Attitude
INFANCY – 5 •Does understand concept of death
YEARS •Believes death is reversible, a temporary departure or sleep
5-9 •Understand that death is final
YEARS •Believes own death can be avoided
•Believes wishes or unrelated can be responsible for death
9-12 •Understand death as the inevitable end of life
YEARS •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 defined , acting
YEARS out defiance through reckless behaviors E.g. Dangerous driving.
•Seldom thinks about death, But views it in religious or philosophic terms
18 – 45 •Has attitude towards death influenced by religious and cultural belief.
YEARS
45- 65 •Accepts own mortality
YEARS •Encounter deaths of parents and some peers
•Experiences peak of death anxiety
65 + YEARS •Fear of prolong illness
•Sees death as having multiple meanings . E.g. Freedom from pain, Reunion
with family members
Understanding the Process
of Dying
Kubler-Ross’ 5 stages of death

Denial:
• Denial is resisting the whole idea of
death ("No I'm not or she's not").
Anger:
• "Why me/her?" "Why not you?“
Bargaining:
• At this stage individuals are trying to
negotiate their way out of the Death.
Depression:
• The individual at this stage is overwhelmed
by a deep sense of loss.
 continued

Acceptance:
• People are fully aware that death is
impending
• In this stage individuals near death make
peace with death and may want to be left
alone.
• Persons in this stage are often
unemotional and uncommunicative.
 FIVE EMOTIONAL
STAGES
• Denial - or “no not me”
• Anger - or “why me?”
• Bargaining - or “Yes, but. . .”
• Depression - or “It’s me!”
• Acceptance - or “It’s part of life.
I have to get my life
in order.”
 DEAD BODY CARE

• After death the body undergoes many physical changes.so

care must be provided as early to prevent tissue damage/
disfigurement of body parts
• Purpose of dead body care
1. To prepare the body for morgue
2. To prevent discoloration or deformity of body
3. To protect the body from post mortem discharge
 PROCEDURE

• Care of dead body ,often depends upon the custom and

religious beliefs
• Nurses provide dignity and sensitivity to client and family
1. Check order for any specimen
2. Ask for special requests to family (E.g. shaving, special
gown)
3. Remove all equipment's , tubes supplies and dirty linens
4. Cleanse the body thoroughly , Apply clean sheets
5. Brush and comb the hairs
6. The eyelids are closed and held in place for a few seconds,
so they remain closed
7. Mouth should be closed
8. Remove all ornaments
9. Absorbent pads are placed under the buttocks to
take up any feaces and urine released because of
muscle sphincter relaxation.
10. All the orifices should be closed
11. Cover with clean sheet up to the chin
12. Apply name tag ( wrist, R-big toe)
13. Allow the family members to view the dead body
14. Hand over all the belongings to relatives
15. Do complete documentation in the nursing notes
– Time of death & actions taken to prevent death
– Who pronounced death
– Personal articles left on the body or given to family
16. Hand over the body to relatives/ sent to morgue
 Legal Implications of
Death
• The nurse’s role in legal issues related to death is
prescribed by the laws of the region and the policies of
the health care institution.

• ADVANCE HEALTH CARE DIRECTIVES

Advance health care directives include a variety of legal
and lay documents that allow persons to specify aspects
of care they wish to receive should they become unable
to make or communicate their preferences.
Legal Implications of
Death
• Types of Advance health Care Directives

1. The living will provides specific instructions about what

medical treatment the client chooses to omit or refuse
(e.g., ventilatory support).

2. The health care proxy, also referred to as a durable

power of attorney for health care,or witnessed statement
appointing someone else (e.g., a relative or trusted friend)
to manage health care treatment decisions when the client
is unable to do so.
Legal Implications of
Death
• AUTOPSY
– An autopsy or postmortem examination is an examination
of the body after death.
• CERTIFICATION OF DEATH
– The formal determination of death, must be performed by
a primary care provider
• DO-NOT-RESUSCITATE ORDERS (DNR)
– Primary care providers may order “no code” or “do not
resuscitate” (DNR) for clients who are in a stage of
terminal, irreversible illness or expected death.
Legal Implications of
Death
• EUTHANASIA
– Euthanasia is the act of painlessly putting to death people
suffering from incurable or distressing disease. It is
sometimes referred to as “mercy killing.”
• INQUEST
– An inquest is a legal inquiry into the cause or manner of a
death. When a death is the result of an accident, for
example, an inquest is held into the circumstances of the
accident to determine any blame
• ORGAN DONATION