Chapter 43: Loss, Grieving, and Death

What is unresolved grief?

(Also: Chronic Grief) Grief that is extended in length or 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 expected time.

The Dying Person's Bill of Right's (Part 1)

**These were created at a workshop, "The Terminally Ill Patient and the Helping Person," in Lansing Michigan sponsored by the South Western Michigan Inservice Education Council and conducted by Amelia Barbus (1975), Associate Professor of Nursing, Wayne State University. -I have the right to be treated as a living human until I die. -I have the right to maintain a sense of hopefulness, however changing its focus may be. -I have the right to be cared for by those who can maintain a sense of hopefulness, however changing this may be. -I have the right to express my feelings and emotions about my approaching death in my own way.

What is the nurses role in the grief process?

-Explore and respect ethnic, cultural, religious, and personal values. -Teach what to expect in the grief process. -Encourage the client to express and share grief with support people. -Teach family members to encourage the client's expression of grief. -Encourage the client to resume activities on a schedule that promotes physical and psychologic health.

The Dying Person's Bill of Right's (Part 3)

-I have the right to have my questions answered honestly. -I have the right to retain my individuality and not be judged for my decisions, which may be contrary to the belief of others. -I have the right to expect that the sanctity of the human body will be respected after death. -I have the right to be cared for by caring, sensitive, knowledgeable people who will attempt to understand my needs and will be able to gain some satisfaction in helping me face my death.

The Dying Person's Bill of Right's (Part 2)

-I have the right to participate in decisions concerning my care. -I have the right to expect continuing medical and nursing attention even though "cure" goals must be changed to "comfort" goals. -I have the right to not die alone. -I have the right to be free of pain.

Strategies in helping clients die with dignity

-Identify personal feelings about death -Focus on client's needs -Talk to the client or family about how the client usually copes with stress -Establish communication relationship -Determine what client knows about illness -Respond with honesty and directness -Make time to be available

How can a nurse assist the client to a peaceful death?

-Minimize loneliness, fear, and depression -Maintain the client's sense of security, self-confidence, dignity, and self-worth -Help the client accept losses -Provide physical comfort

WHO: Definition of palliative care for children

-Palliative care for children is the active total care of the child's body, mind and spirit, and also involves giving support to the family. -It begins when illness is diagnosed, and continues regardless of whether or not a child receives treatment directed at the disease. -Health providers must evaluate and alleviate a child's physical, psychological, and social distress. -Effective palliative care requires a broad multidisciplinary approach that includes the family and makes use of available community resources; it can be successfully implemented even if resources are limited -It can be provided in tertiary care facilities, in community health centres and even in children's homes

List the World Medical Assembly guidelines for death

-Total lack of response to external stimuli -No muscular movement, especially during breathing -No reflexes -Flat encephalogram -In instances of artificial support, absence of brain waves for at least 24 hours

WHO: Palliative Care (Part 2)

-integrates the psychological and spiritual aspects of patient care -offers a support system to help patients live as actively as possible until death -offers a support system to help the family cope during the patients illness and in their own bereavement

WHO: Palliative Care (Part 1)

-provides relief from pain and other distressing symptoms -affirms life and regards dying as a normal process -intends neither to hasten or postpone death

WHO: Palliative Care (Part 3)

-uses a team approach to address the needs of patients and their families, including bereavement counseling, 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

List the Kübler-Ross stages of grief

1) Denial 2) Anger 3) Bargaining 4) Depression 5) Acceptance

What are factors affecting the significance of the loss?

1) Importance of the lost person, object, or function. 2) Degree of change required because of the loss 3) The persons' beliefs and values

List Sander's phases of bereavement

1) Shock 2) Awareness of loss 3) Conservation/withdrawal 4) Healing: the turning point 5) Renewal

List Engel's stages of grieving

1) Shock and disbelief 2) Developing awareness 3) Restitution 4) Resolving the loss 5) Idealization 6) Outcome

Six Dimensions of Hospice Palliative Care

1) Valuing 2) Connecting 3) Empowering 4) Doing for 5) Finding meaning, and 6) Preserving Integrity

What is complicated grief?

A form of grief in which the individual's strategies to cope with the loss are maladaptive. The disorder may be said to exist if the preoccupation lasts for more than 6 months and leads to a reduced ability to function formally.

Acceptance (Kübler-Ross)

A grief stage in which the individual has come to terms with the reality of his or her(or a loved one's) imminent death. May have decreased interest in surroundings and support people. May wish to begin making plans.

What factors influence the loss and grief responses?

A number of factors affect a person's response to a loss or death. These factors include age, significance of the loss, culture, spiritual beliefs, gender, socioeconomic status, support systems, and the cause of the loss or death.

What is a perceived loss?

A perceived loss is experienced by one person but cannot be verified by others. ***Psychological losses are often perceived losses in that they are not directly verifiable.

Anger (Kübler-Ross)

A person expresses resistance and sometimes feel intense anger at God, other people, or the situation. Client or family may direct anger at nurse or staff about matters that normally would not bother them.

What is the nurses role in diagnosing a dying client?

A range of nursing diagnoses, addressing both physiological and psychosocial needs, can be applied to the dying client.

What is bereavement?

A subjective response of a person who has experienced the loss of a significant other through death.

Age

Age affects a person's understanding and reaction to loss. With familiarity, people usually increase their understanding and acceptance of life, loss, and death.

What are contributing factors to unresolved grief?

Ambivalence towards the lost person, a perceived need to be brave and in control, endurance of multiple losses, extremely high emotional value invested in the dead person, uncertainty about the loss, and lack of support systems.

What is actual loss?

An actual loss can be recognized by others.

What is mourning?

An adjustment process which involves grief or sorrow over a period of time and helps in the reorganization of the life of an individual following a loss or death of someone loved.

What is an anticipatory loss?

An anticipatory loss is experienced before the loss actually occurs.

What are the symptoms of grief?

Anxiety, depression, weight loss, difficulties in swallowing, vomiting, fatigue, headaches, dizziness, insomnia, fainting, blurred vision, skin rashes, excessive sweating, menstrual disturbances, palpitations, chest pain, and dyspnea.

Early and middle adulthood

As people grow they come to experience loss as a part of normal development. Coping with the death of an aged parent has even been viewed as an essential developmental task of the middle-aged adult. The middle aged adult can experience losses other than death. For example, losses resulting from impaired health or body function and losses of various role functions can be difficult for the middle aged adult. How the middle-aged adult responds to such losses is influenced by previous experiences with loss, the person's sense of self-esteem. and the strength and availability of support.

Resolving the loss (Engel's)

Attempts to deal with painful void. Still unable to accept new love object to replace lost person or object. May accept more dependent relationship with support person. Thinks over and talks about memories of lost object.

Outcome (Engel's)

Behavior influenced by several factors: importance of lost object as source of support, degree of dependence on relationship, degree of ambivalence towards lost object, number and nature of other relationships, and number and nature of previous grief experiences.

Sensory impairment

Blurred vision Impaired senses of taste and smell **Hearing is the last to go

What is abbreviated grief?

Brief, but genuinely felt; lost object may not have been sufficiently important to the grieving person/ may have been replaced immediately by another, equally esteemed object.

What are some definitions and signs of death?

Cessation of: Apical pulse Respirations Blood pressure Referred to as heart-lung death

What is anticipatory grief?

Characterized by the presence of grief in anticipation of death or loss; the actual death comes as a confirmation of knowledge of a life-limiting condition.

Childhood

Children differ from adults not only in their understanding of loss and death but also in how they are affected by the loss of others. The loss of a parent or other significant other can threaten the child's ability to develop. Some adults may assume that children do not have the same need as an adult to grieve the loss of others. Children experience the same emotions of grief as adults. In situations of crisis and loss, children are often pushed aside or protected from the pain. They can feel afraid, abandoned, and lonely.

What types of grief might a nurse encounter in a clinical setting?

Clients may be experiencing grief related to declining health, loss of a body part, terminal illness, or the impending death of self or a significant other. It is important for the nurse to understand the significance of loss and develop the ability to assist clients as they work through the grieving process.

Assessing: Three types of awareness

Closed awareness: Client not aware of impending death Mutual pretense: Client, family, and health personnel know the prognosis is terminal but do not talk about it Open awareness: Client and others know about the impending death and feel comfortable discussing it

When is a client eligible for hospice care?

Commonly, clients are eligible for hospice care or hospice insurance benefits when certified by a physician to be likely to die within 6 months.

What are some manifestations of complicated grieving?

Complicated grieving may be characterized by extended time of denial, depression, severe physiological symptoms, or suicidal thoughts.

Restitution (Engel's)

Conducts rituals of mourning.

Culture

Culture influences an individual's reaction to loss. How grief is expressed is often determined by the customs of the culture. Some cultural groups value social support and the expression of loss. In some groups, expressions of grief through wailing, crying, physical prostration, and other outward demonstrations are acceptable and encouraged. Other groups may frown on this demonstration as a loss of control, favoring a more quiet and stoic expression of grief.

Denial (Kübler-Ross)

Defense mechanism by which people refuse to believe or even to perceive painful realities. May assume artificial cheerfulness to prolong denial.

Slowing of the circulation

Diminished sensation Mottling and cyanosis of the extremities Cold skin, first in the feet and later in the hands, ears, and nose (the client may feel warm if there is a fever) Slower and weaker pulse Decreased blood pressure

Conservation/withdrawal (Sander's)

During this phase, survivors feel a need to be alone to conserve and replenish both physical and emotional energy. The social support available to the bereaved has decreased and they may experience despair and helplessness.

Healing: the turning point (Sander's)

During this phase, the bereaved more from distress about living without their loved one to learning to live more independently.

After the client dies

Encourage the family to view the body May wish to clip a lock of hair as a remembrance Children should be included in the events surrounding the death if they wish family or friends wish to view the body: -Make the environment as clean and as pleasant as possible -Make the body appear naturaI and comfortable -All equipment, soiled linen, and supplies should be removed from the bedside -Follow agency policy when caring for tubes

Specific interventions for spiritual support

Facilitating expressions of feeling Prayer Meditation Reading Discussion with appropriate clergy or spiritual advisor **It is important for the nurse to establish an effective interdisciplinary relationship with spiritual support specialists

Care of the body after death (Part 1)

Follow policy of the hospital or agency Check the client's religion rituals and make every attempt to comply Place the body in a supine position Place arms either at sides, palm down, or across the abdomen Place one pillow under the head and shoulders Close the eyelids for a few seconds Insert dentures Close mouth

Awareness of loss (Sander's)

Friends and family resume normal activities. The bereaved experience the full significance of their loss.

What is disenfranchised grief?

Grief or mourning that persons experience when they incur a loss that is not or cannot be openly acknowledged, publicly mourned, or socially supported. Situations in which this occur often relate to a socially unacceptable loss that cannot be spoken about, such as suicide, abortion, or giving a child up for adoption.

What is hospice care?

Hospice care focuses on support and care of the dying person and family, with the goal of facilitating a peaceful and dignified death. Hospice care is always provided by a team of both health professionals and non-professionals to ensure a full range of care services.

What is hospice care based on?

Hospice care is based on holistic concepts, emphasizes care to improve quality of life rather than cure, supports the client and family through the dying process, and supports the family through bereavement.

Renewal (Sander's)

In this phase, survivors move on to a new self-awareness, an acceptance of responsibility for self, and learning to live without the loved one.

Cause of loss or death

Individual and societal views on the cause of a loss or death may significantly influence the grief response. Some diseases are considered "clean," whereas others may be viewed as repulsive and less unfortunate. A loss or a death that is beyond the control of those involved may be more acceptable than one that is preventable, such as a drunk driving incident. Injuries or deaths that occur during respected activities, such as "in the line of duty," are considered honorable, whereas those occurring during illicit activities may be considered the individual's just rewards.

What is loss?

Loss is an actual or potential situation in which something that is valued is changed or no longer available. There are two general types of loss: actual and perceived.

Impending clinical death

Loss of muscle tone Slowing of the circulation Changes in respirations Sensory impairment

Late adulthood

Losses experienced by older adults include loss of health, mobility, independence, and work role. Limited income and the need to change one's living accommodations can also lead to feelings of loss and grieving. For older adults, the loss through death of a longtime mate is profound. Although individuals differ in there ability to deal with such a loss, research suggests that health problems for widows and widowers increase following the death of the spouse.

What would be considered normal manifestations of grief?

Manifestations of grief that would be considered normal include verbalization of the loss, crying, sleep disturbance, loss of appetite, and difficulty concentrating.

What is inhibited grief?

Many of the normal symptoms of grief are suppressed and other effects, including somatic, are experienced instead.

What is cerebral death?

Occurs when cerebral cortex is irreversibly destroyed Permanent loss of cerebral and brainstem function -Absence of responsiveness to external stimuli -Absence of cephalic reflexes -Apnea Isoelectric EEG for at least 30 minutes in the absence of hypothermia and poisoning by CNS depressants

What is delayed grief?

Occurs when feelings and are purposely or subconsciously suppressed until a much later time.

What is palliative care?

Palliative care, as described by the World Health Organization, is approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

What is exaggerated grief?

Persons become overwhelmed by grief, and they cannot function. This is reflected in the form of severe phobias or self-destructive behaviors such as alcoholism, substance abuse, or suicide.

Algor mortis

Post-mortem cooling of the body, about 1°C (1.8°F) per hour until it reaches the surrounding temperature. Simultaneously, the skin loses its elasticity and can easily be broken when removing dressings and adhesive tape.

What are contributing factors to complicated grief?

Prior traumatic loss, family or cultural barriers to the emotional expression of grief, sudden death, strained relationships between the survivor and the deceased, and lack of adequate support for the survivor.

Idealization (Engel's)

Produces image of lost object that is almost devoid of all undesirable features. Represses all negative and hostile feelings towards lost objects. May feel guilty and remorseful about past inconsiderate or unkind acts towards lost person. Reminders of lost person provoke fewer feelings of sadness. Reinvests feelings in others.

Changes in respirations

Rapid, shallow, irregular, or abnormally slow respirations Noisy breathing, referred to as the death rattle, due to collecting of mucus in the throat Mouth breathing, dry oral mucus membranes

Developing awareness (Engel's)

Reality of loss begins to penetrate consciousness. Anger may be directed at agency, nurses, or others.

Shock and disbelief (Engel's)

Refuses to accept loss. Has stunned feelings. Accepts the situation intellectually, but denies it emotionally.

Loss of muscle tone

Relaxation of facial muscles Difficulty speaking Difficulty swallowing and gradual loss of the gag reflex Decreased activity of the GI tract, with subsequent nausea, accumulation of flatus, abdominal distention, and retention of feces, especially if narcotics or tranquilizers are being administered.

Rigor mortis

Rigor mortis is the stiffening of the body that occurs about 2 to 4 hours after death as a result of lack of ATP. It starts with involuntary muscles and works to head, neck trunk then extremities. Rigor mortis usually leaves the body about 96 hours after death. **Because the deceased person's family often wants to view the body, and because it is important that the deceased appear natural and comfortable, nurses need to place the body in an anatomic position, place dentures in the mouth, and close the eyes and mouth before rigor mortis sets in.

Bargaining (Kübler-Ross)

Seeks to bargain to avoid loss.

Familiar environment

Separation from an environment and people who provide security can result in a sense of loss.

Diagnosing: The Dying Client

Some examples of appropriate nursing diagnoses for a dying client: -Stress related to recent changes in self-care and decision to accept hospice services -Feelings of helplessness/hopelessness -Anticipatory Grieving r/t perceived impending death -Fear of the dying process, loss of physical and/or mental abilities -Concern about impact of death on SO/family -Inner conflict about beliefs, meaning of life/death -Financial concerns; lack of preparation (e.g., will, power of attorney, funeral) -Ineffective coping -Readiness for enhanced coping

Spiritual beliefs

Spiritual beliefs and practices greatly influence both a person's reaction to loss and subsequent behavior. Most religious groups have practices related to dying, and these are often important to the client and support people. To provide support at a time of death, nurses need to understand the client's particular beliefs and practices.

Shock (Sander's)

Survivors are left with feelings of confusion, unreality, and disbelief that the loss has occurred. They are often unable to process the normal thought sequences. Phase may last from a few minutes to many days.

Depression (Kübler-Ross)

The client grieves over what has happened and what cannot be. May talk freely or may withdraw.

Gender roles and grief

The gender roles into which many people are socialized in the United States affect their reactions at times of loss. Men are frequently expected to "be strong" and show very little emotion during grief, whereas it is acceptable for women to show grief by crying. Gender roles also affect the significance of body image changes to clients. A man might consider his facial scar to be "macho," but a woman might consider hers ugly. Thus the woman, not the man, would see the change as a loss.

Finding meaning

The hospice palliative care nurse assists the person and family to find meaning in their lives and their experience of illness.

Valuing

The hospice palliative care nurse believes in the intrinsic worth of others, the value of life and that death is a natural process.

Connecting

The hospice palliative care nurse establishes a therapeutic connection (relationship) with the person and family through making, sustaining and closing the relationship.

Preserves integrity

The hospice palliative care nurse preserves the integrity of self, person and family.

Doing for

The hospice palliative care nurse provides care based on best practice and/or evidence-based practice in the following areas: pain and symptom management, coordination of care, and advocacy.

Empowering

The hospice palliative care nurse provides care in a manner that is empowering for the person and family.

Loved ones

The loss of a loved one or valued person through illness, divorce, separation, or death can be very disturbing. The death of a loved one is a permanent and complete loss.

Aspect of self

The loss of an aspect of self changes a person's body image, even though the loss may not be obvious. The degree to which these losses affect a person largely depends on the integrity of the person's body image.

Providing spiritual support

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. Nurses need to be aware of their own comfort with spiritual issues and be clear about their own ability to interact supportively with the client.

Planning

The overall goals for clients who are 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 who are 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.

Support system

The people closest to the grieving individual are often the first to recognize and provide needed emotional, physical, and functional assistance. However, because many people are uncomfortable or inexperienced in dealing with losses, the usual support people may instead withdraw from the grieving individual. In addition, support may be available when the loss is first recognized, but as the support people return to their usual activities, the need for ongoing support may be unmet. Sometimes, the grieving individual is unable or unready to accept support when it is offered.

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.

Significance of the loss

The significance of a loss depends on the perceptions of the individuals experiencing the loss. One person may experience a great sense of loss over a divorce; another may find it only mildly disrupting. For older people who have already encountered many losses, an anticipated loss such as their own death may not be viewed as highly negative, and they may be apathetic about is instead of reactive. More than fearing death, some may fear the loss of control or becoming a burden.

Socioeconomic status

The socioeconomic status of an individual often affects the support system available at the time of a loss. A pension plan or insurance, for example, can offer a widowed or disabled person a choice of ways to deal with a loss; a person who is confronted with both severe loss and economic hardship may not be able to cope with either.

What is grief?

The total response to the emotional experience related to loss.

Assessing: Nurse's role

To gather a complete database that allows accurate analysis and identification of appropriate nursing diagnoses for dying clients and their families, the nurse first needs to recognize the states of awareness manifested by the client and family members. In cases of terminal illness, the state of awareness shared by the dying person and the family affects the nurse's ability to communicate freely with clients and other health care team members and to assist the grieving process.

Supporting the family

Use therapeutic communication Provide an empathetic and caring presence Explain what is happening and what to expect Have a calm and patient demeanor Encourage to participate in the physical care as they are able: -Assist with bathing -Speak or read to the client -Hold hands Support those who feel unable to care for or be with the dying Show an appropriate waiting area if they wish to remain nearby May be therapeutic for the family to verbally give permission to the client to "let go" when ready

Care of the body after death (Part 2)

Wash soiled areas of the body Place absorbent pads under the buttocks Place a clean gown on the client Brush and comb the hair Remove all jewelry except a wedding band which is taped to the finger Adjust the top bed linen to cover the client to the shoulder Provide soft lighting and chairs for the family

Loss of external objects

a) Loss of inanimate objects that have importance to the person. b) Loss of animate (live) objects such as pets that provide love and companionship.