Loss, Death, and Grieving

By : Ibne Amin
Lecturer , INS
Khyber Medical University,Peshawar
 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. Discuss care of the body after death.
5. Discuss the legal implications of death.
6. Describe how a nurse meets a dying patient’s needs of
comfort.
7. Discuss important factors in caring for the body after death.
8. List changes that occur in the body after death.
 Objectives

9. Define terms related to loss and grieving.

10. Discuss Kubler-Ross’ theory to assess grieving
behaviors.
11. Identify common manifestations of grief
12. Discuss the effects of multiple losses on the grief
process
13. Apply the nursing process to grieving clients.
 Introduction

Birth and death are two aspects of life, which will happen to
everyone.

Dying and death are painful and personal experiences for

those that are dying and their loved ones caring for them.

Death affects each person involved in multiple ways,

including physically, psychologically, emotionally,
spiritually, and financially.
 Definition

Death is defined as “The irreversible cessation of all vital

functions especially as indicated by permanent stoppage of
the heart, respiration, and higher brain function”

Death is the cessation or permanent termination of all the

biological functions that sustain a living organism.

Dying means “approaching death”

 Physiologic signs of death

The four main characteristic changes are ;

• Loss of muscle tone
• Slowing of the circulation
• Changes in the vital signs
• Sensory impairment.
The following guidelines for physicians as indications of death.
1. Total lack of response to external stimuli
2. No musscular movement(esp breathing)
3. No reflexes
4. Flat encephalogram.
 Beliefs and attitudes about death in
relation to age relation to age
• Infancy to 5 years; Does not understand concept of
death,belives death is reversible, temporary departure or
sleep.
• 5 to 9 years; Understand death is final, believes own
death can be avoided, believes wishes and unrelelated
actions can be responsible for death.
• 9 to 12 years; Begin to understand own mortality,
expressed in after life and fear of death.
 Conti….
• 12 to 18 years; May still hold concept from previous
developmental stages, may seem to reach “adult’’ perception
of death but be emotionally unable to accept it.
• 18 to 45 years; Has attitude towards death influenced by
religious and cultural beliefs.
• 45 to 65 years; Accepts own mortality. encounters death of
parents and some peers experiences.
• 65 years +; Fears prolonged illness, sees death as having
multiple meanings,(eg,freedom from pain, reunion with
already deceased family
 Dying Patients
We may help the dying patient meet his/her

• Physiological Needs
• Spiritual Needs
• Emotional Needs
 Meeting physiologic needs of the dying
patient.
• Providing personal hygiene measures
• Controlling pain
• Relieving respiratory difficulties
• Assisting with movement,nutrition,hydration and
elimination.
• Providing comfort to the patient and relieving pain.
 Spiritual support

• Identify patient spiritual needs

• Respect the beliefs of patients
• Be willing to listen and discuss issues of spirituality.
• Demonstrate empathy
• Provide a supportive presence
• Refer to community resources or spiritual leaders
• Acknowledge and provide for the rituals
 Emotional support

• Compassion (desire to help)

• Responsiveness to emotional needs
• Maintain a positive attitude
• Expressing empathy
• Attending wishes
• Being present.
 Physical Changes After Death

– Pupils- Fixed and dilated

– Algor Mortis- Rapid cooling of the body
– Rigor Mortis- Stiffening of the body, develops 2-4
hours after death
– Livor Mortis- Purple discoloration of skin in
dependent areas
 Care After Death
• Death declaration/ Death certificate by physician.
• Autopsy(written permission)
• Customs & principles are kept in mind.
• Positioning- body straitened & arms laid at the side.
• Eyes are closed as in sleep.
• Dentures are removed & prop chin in position with
bandaging.
• Remove all appliances used for patient care( e.g - catheter
tubing's etc..)
 Care After Death
• Remove all the appliances used for patient care. (e.g. Catheter,
tubing's, I,V.sets, etc)
• Remove ornaments and list them to relatives.
• All orifices are to be plugged with cotton to prevent escape of
body discharges.
• Prevention of spread of diseases (i.e sealing body)
• Send body clean and neatly dressed.
• An identification tag
• If relatives are present then body is handed over them with
proper written legal authority permission.
• Maintain record of death and inform to authority for register of
deaths. for body.
 Legal aspects of death

Federal and state law require that institutions develop policies

and procedures for certain events that occur after death.

1.Requesting organ or tissue donation

2. Autopsy
3.Certifying and documenting the occurrence of a death.
4.Providing safe and appropriate post mortem care.
 Legal aspects of death
Death must be certified by a physician
In unusual death,an autopsy(postmortem examination)may be
required.
Request family member consent and signature for autopsy. Several
reasons for a death becoming a case for the coroner:
– Death by suspicious means or not under a doctor’s care
– Death resulting from an accident
– Client has been hospitalized for less than 24 hours

• Dying Persons’ Bill of Rights

• Passive euthanasia
• California Law (1976)- “Right to Die” bill
• California Natural Death Act
 Loss

Loss occurs when a valued person, object, or situation is

changed.
OR
Loss can be defined as the undesired change or removal of
a valued object ,person or situation

Loss is a universal experience that occurs throughout the

lifespan.
 Types of loss

1. Actual Loss can be recognized by others including

the person sustaining the loss, ex: a person losing a
limb, spouse, valued object, job etc.
2.Perceived loss felt by the person but is intangible to
others loss of your youth, financial dependence, loss
of confidence or prestige.
3. Anticipated loss the person displays loss and grief
behaviors for loss that has yet to take place. EX:
families with terminally ill patients and serves to
lessen the impact of actual loss
 Grief

Grief is an emotional response to a loss.

Grief is a form of sorrow involving feelings, thoughts and
behaviors caused by bereavement.
Grief is the physical ,psychological and spiritual responses to
loss.
Grief is a “set of cognitive, emotional and social difficulties that
follow the death of a loved one.
The grief process involves a sequence of affective, cognitive and
psychological states as a person responds to and finally accepts a
loss.
It is a normal, natural, necessary, and adaptive response to a loss.
 Loss & Grieving

• LOSS Something of value is gone

• GRIEF Total response to emotional experience
related to loss
• BEREAVEMENT Subjective response to by loved
ones
• MOURNING Behavioral response
 Functions of Grief

• To make the outer reality of the loss in to an internally

accepted reality
• To lessen the emotional attachment to the lost person or
object
• To make it possible for the bereaved person to become
attached to other people or objects
 Types Of Grief

1. ANTICIPATORY GRIEF
2. NORMAL OR COMMON GRIEF
3. COMPLICATED GRIEF
4. DISENFRANCHISED GRIEF
 Common Grief Reactions

A grief reaction is a set of psychological and somatic (body)

symptoms that results from extreme sorrow or loss.
These reactions fall into four different categories:
I. Thought Patterns
II. Physical Sensations
III. Emotions
IV. Behaviours.
 Common Clinical Manifestion of Grief
• Shock and disbelief
• Sadness
• Guilt
• Anger
• Fear
• Disorganised behavior
• Physical symptom
• Anorexia , GI issues, SOB etc.
 Stages Of Grief
Kubler-Ross, in extensive research with terminally ill patients,
identified five stages of feelings and behaviours that
individuals experience in response to a real, perceived or
anticipated loss.

• Kubler-Ross Stages of Grieving (1969)

– Denial
– Anger
– Bargaining
– Depression
– Acceptance
 Kubler-Ross Stages of Grieving

1. Denial and Isolation

• Denial is a conscious or unconscious refusal to accept
facts, information, reality, etc., relating to the
situation concerned. It's a defence mechanism and
perfectly natural.
 Kubler-Ross Stages of Grieving

2.Anger
• Anger can manifest in different ways. People dealing
with emotional upset can be angry with themselves,
and/or with others, especially those close to them.
“Why me?” and It’s not fair!” are comments often
expressed during anger stage
 Kubler-Ross Stages of Grieving

3. Bargaining
Traditionally the bargaining stage for people facing
death can involve attempting to bargain with
whatever God the person believes in. For example
"Can we still be friends?.." when facing a break-up.
Bargaining rarely provides a sustainable solution,
especially if it's a matter of life or death.
 Kubler-Ross Stages of Grieving

4. Depression
• During this stage, the full impact of the loss is
experienced. The sense of loss is intense and feelings
of sadness and depression prevail. This is a time of
quiet desperation and disengagement from all
association with the lost entity.
 Kubler-Ross Stages of Grieving

5.Acceptance
The final stage brings a feeling of peace regarding the
loss that has occurred. It is a time of quiet
expectation and resignation. The focus is on the
reality of the loss and its meaning forthe individuals
affected by it.Reaching this stage of mourning is a gift
not afforded to everyone.
 Nursing Implications

• Nursing care involves providing comfort ,maintaining

safety ,addressing physical and emotional
needs ,and teaching coping strategies to terminally ill
patients and their families .
• More than ever ,the nurse must explain what is
happening to the patient and the family and be a
confident who listens to them talk about dying.
 Nursing Implications

• Hospice care , attention to family and individual

psychosocial issues ,and symptom and pain
management are all part of the nurse's
responsibilities.
• The nurse must also be concerned with ethical
considerations and quality-of-life issues that affect
dying people
 Nursing Implications

• Of utmost importance to the patient is assistance

with the transition from living to dying,
maintaining and sustaining relationships,
finishing well with the family, and accomplishing
what needs to be said and done.
• In the hospital, in long-term care facilities, and in
home settings, the nurse explores choices and
end-of-life decisions with the patient and family.
 Nursing Implications

• Referrals to home care and hospice services, as well

as specific referrals appropriate for the management
of the situation, are initiated.
• The nurse is also an advocate for the dying person
and works to uphold that person's rights. The use of
living wills and advance directives allows the patient
to exercise the right to have a"good death or to die
with dignity.
 References

• Kozier & Erb’s Fundamental of Nursing Book, 8th

edition.
• Potter and Perry (2005) “Fundamentals of nursing”
published by most by an imprint of Elsevier, 6th
edition. New Delhi. Page no 1068 – 1071 
• www.google.com
THANK YOU