Foundations CH 37 loss and grief

Maintain a comfortable and enviroment

A comfortable, clean, pleasant environment helps patients relax, promote good sleep patterns, and minimizes symptoms severity. Keep patient comfortable through frequent repositioning, making sure that bed linens are dry and controlling extraneous environmental noise and offensive odors. Consider non-pharmacological interventions such as massage therapy to increase patient comfort. Patient-preferred forms of complementary therapies offer noninvasive methods to increase comfort and well-being at the end of life

• Anticipatory Grief

A person experiences anticipatory grief before the actual loss or death occurs, especially in situations of prolonged or predicted loss such as caring for patients diagnosed with dementia or ALS. When grief extends over a long period of time, people absorb loss gradually and begin to prepare for its inevitability. They experience intense responses to grief before the actual death occurs and often feel relief when it finally happens. Another way to think about anticipatory grief is that it is a forewarning or cushion that gives people time to prepare or complete the tasks related to the impending death.

Promote dignity and self esteem

A sense of dignity includes a person's positive self-regards, the ability to find meaning in life and feel valued by others, and treatment by caregiver. Nurses promote a patient's self-esteem and dignity by respecting him or her as a whole person, not just as a diagnosis. Respecting and valuing the things that a patient care about validates the person and at the same time strengthens communication among the patient, family members, and the nurse. Allow them to make decision such as how and when to administer personal hygiene, diet preferences, and timing of nursing interventions. Provide privacy during nursing care procedures and be sensitive to when the patient and family need time alone together

Grief tasks model

Accepts the reality of the loss, experiences the pain of grief, adjusts to a world in which the deceased is missing. Emotionally relocates the deceased and moves on with life.

Trajectories of bereuvment

Common Grief Chronic Grief Chronic Depression Depression followed by improvement Resilience

Behaviors

Crying and frequent sighing Distance from people Absentmindedness Dream of the deceased Keeping the deceased's room intact Loss of interest in regular life events Wearing objects that belonged to the deceased.

Stages of dying

Denial: The person cannot accept the fact of the loss. It is a form of psychological protection from a loss that the person cannot yet bear. Anger: The person expresses resistance or intense anger at God, people, or situation. Bargaining: The person cushions and postpones awareness of the loss by trying to prevent it from happening Depression: The person realizes the full impact of the loss. Acceptance: The person incorporates the loss into life.

Cognitive (thought patterns)

Disbelief Confusion Problems making decisions Inability to concentrate Feeling the presence of the deceased

Physical sensation

Disbelief Confusion Problems making decisions Inability to concentrate Feeling the presence of the deceased

Culture

During times of loss and grief patients and families draw on the social and spiritual practices of their culture to find comfort, expressions, and meaning in the experience. Try to understand and appreciate each patient's cultural values related to loss, death, and grieving. In other cultures, behaviors such as public wailing and physical demonstrations of grief, including survivor body mutilation, show respect for the dead. Even urban and rural settings provide a framework of culture in which people draw strength from traditional practices. Culture extends beyond the geographic location of a person. Consider the influence of sexual orientation, socioeconomic status, and family make-up when assessing cultural influence on grief practices and death rituals.

Nature of the loss

Exploring the nature of a loss will help you understand the effect of the loss on the patient's behavior, health, and well-being. Encouraging patient to share information about the loss will help you better develop appropriate interventions that meet the individualized needs of your patients. Highly visible losses generally stimulate a helping response from others. A more provate loss such as a miscarriage brings less support from others. A sudden and unexpected death poses challenges different from those of a person in a debilitating chronic illness.

Physical sensations

Headaches Nausea and appetite disturbances Tightness in the chest Oversensitivity to noise Feeling SOB Muscle weakness Lack of energy Dry mouth

Normal Grief

common and universal reaction characterized by complex emotional, cognitive, social, physical, behavioral, and spiritual responses to loss and death. Some normal feeling of grief is disbelief, yearning, anger, and depression. Although manner of death increases risk to the survivor's normal grief response, it does not always determine how an individual will actually grieve. Helpful coping mechanisms for grieving people include hardiness and resilience, a personal sense of control, and the ability to make sense of and identify positive possibilities after a loss.

Holistic care

Hospice care is a philosophy and model for the care of terminally ill patients and their families at the end of life. It gives priority to managing a patient's pain and other symptoms; comforts; quality of life; and attention to physical, psychological, social, and spiritual needs and resources. Patient accepted into a hospice program usually have less than 6 months to live. Hospice programs are built on the following core beliefs and services: Patient and family are the unit of care Coordinated home care with access to inpatient and nursing home beds when needed Symptoms management Physician-directed services Provision of an interdisciplinary care team Medical and nursing services available at all times Bereavement follow-up after patient's death Use of trained volunteers for visitation and respite support To be eligible for home hospice care, a patient must have family caregiver to provide care when the patient is no longer able to function alone. Hospice team offer 24-hour accessibility and coordinate care between the home and inpatient setting. As a patient's death comes closer, the hospice team provides intensive support to the patient and family

Support the grieving family

In palliative and hospice care patients and family members constitute the unit of care. When a patient becomes debilitated or approaches the end of life, family members also suffer. They describe caregiving at the end of life as unpredictable, frightening, and anguishing. Often family members face challenging and complex situations long before their loved one is actively dying. Educate family members in all settings about the symptoms that the patient will likely experience and the implications for care. Family members who have limited prior experience with death do not know what to expect. They may need personal time with the nurse to share their concerns, ask about treatment options, validate perceived changes in the patient's status, or explore the possible meaning of patient behavior. Provide information privately and stay with the family as long as needed or desired. Reduce family member anxiety, stress, or fear by describing what to expect as death approaches. Do not try to predict the time of death; instead use your assessments to help family members anticipate what is happening. Be compassionate and sensitive in how you share information. Mottling is an expected sign as a body begins shutting down instead of when a person gets closer to death we see mottling. In the time immediately following death determine the family's needs. Some families want to touch or hold the deceased, others will not. After death help the family make decisions such as notification of a funeral home, transportation of family members and collection of the patient's belonging. Nurses primary source of family support. When uncertain about what a family member prefers for support, pose simple questions and offer suggestions for assistance.

Dual process models

Loss-Oriented: grief work, indwelling on the loss, breaking connections with the deceased person, and resisting activities to move past the grief. Restoration-Oriented: attending to life changes, finding new roles or relationships, coping with finances, and participating in distractions, which provides balance to the loss oriented state.

Management symptoms

Managing the multiple symptoms commonly experienced by chronically ill or dying patients remains a primary goals of palliative care nursing. Uncontrolled symptoms cause patients' and families' distress, discomfort, and suffering, which often the dying experience. Despite the availability of effective treatment options for pain, many patients suffer with avoidable pain at the end of life because of misconceptions by the nurse or family. Maintain an ongoing assessment of the patient's pain and response interventions. Reassure the family repeatedly of the need for pain control even if the patient does not appear in pain. You are responsible to advocate for change if the patient does not obtain relief from the prescribed regimen. Remain alert to the potential side effects of opioid administration: constipation, nausea, sedation, respiratory depression, or myoclonus.

Protect against abandonment and isolation

Many patients with terminal illness fear dying alone. Patients feel more hopeful when others are near to help them. Nurses in institutional settings need to answer call lights promptly and check on patients often to reassure them that someone is close at hand. Some family members who have a difficult time accepting a patient's impending death cope by making fewer visits. When family members do visit, inform them of the patient's status and share meaningful insights or encounters that you have had with the patient. Suggest that a family member stay through the night if possible. Make exceptions to visiting policies, allowing family members to remain with patients who are dying at any time. Record contact information for them so you can reach them at any time.

Attachment theory

Numbing: Protects the person from the full impact of the loss. Yearning and Searching: Emotional outbursts of tearful sobbing and acute distress, common physical symptoms in this stage: tightness in chest and throat, SOB, a feeling of lethargy, insomnia, and loss of appetite. Disorganization and despair: Endless examination of how and why the loss occurred or expressions of anger at anyone who seems responsible for the loss. Reorganization: Accepts the change, assumes unfamiliar roles, acquire new skills, builds new relationships, and begins to separate himself or herself from the lost relationship without feeling that he or she is lessening its importance.

Assist with end of the life decision making

Patient s and families must decide which treatments to continue and which to forgo, to enroll in hospice or stay in the hospital, or to transfer to a nursing home, in-patient unit, or home. Even after the decision to enroll in hospice, questions arise about symptoms management, artificial nutrition and hydration, in-patient unit, or home. You are able to support and educate patients and families as they identify, contemplate, and ultimately decide how to best journey to the end of life. Nurses often provide options that family members do not know are available and are advocates for patients and family members making decision at the end of life in the form of an advanced directive. Although this has increased patients'' level of autonomy, it has not reduced the number of deaths that occur in the hospital.

Palliative care

Patients and families can benefit greatly from the specialized approach of palliative care. This holistic method to prevent and reduce symptoms promotes quality of life and whole-person well-being through care of the mind, body, and spirit. Palliative care focuses on the prevention, relief, reduction, or soothing of symptoms of disease or disorders throughout the entire course of an illness. The primary goal of palliative care is to help patients and families achieve the best possible quality of life. It is appropriate both for patients still receiving aggressive treatment with hope of achieving a cure and for patients who have forgone any life extending treatment. It is important that you help patients and their families understand the distinction because often misunderstanding the purpose of palliative care causes patient to refuse it. When the goals of care change and cure for illnesses become less likely, the focus shifts to more palliative care strategies and ideally transition to hospice care, more specialized form of palliative care for the dying.

Promote spiritual comfort and hope

Patients are comforted when they have assurance that some aspect of their lives will transcend death; therefore, helping patients make connections to their spiritual practice or cultural community can be a useful intervention. Draw on the resources of spiritual care providers in an institutional setting or collaborate with the patient's own spiritual or religious leaders and communities. The spiritual concept of hope takes on special significance near the end of life.

Provide pyshcocial care

Patients at the end of life experience a range of psychological symptoms, including anxiety, depression, powerlessness, uncertainty, and isolation. Worry or fear is common in many patients and often heightens their perception of discomfort and suffering. You can alleviate some of it by providing information to them about their condition, the course of their disease, and benefits and burdens of treatment options.

DIsenfranchised grief

People experience disenfranchised grief when their relationship to the deceased person is not socially sanctioned, cannot be shared openly, or seems of lesser significance. The person's loss and grief do not meet the norms of grief acknowledged by his or her culture, thereby cutting the grieving person off from social support and the sympathy give to people with more socially acceptable losses. Ambiguous loss: Sometimes people experience losses that are marked by uncertainty. Can occur when the lost person is physically present but not psychologically available, as in cases of severe dementia or brain injury. Ambiguous losses are particularly difficult to process because of the lack of finality and unknown outcomes.

Rando R process

Recognizing: the loss Reacting: to the pain of separation Reminiscing Relinquishing: Old attachments Readjusting: to life after loss Reminiscence: of the relationship by mentally or verbally anecdotally reliving and remembering the person and past experiences.

Social economical

Socioeconomic status influences a person's grief process indirect and direct ways. Because of role changes, a newly widowed mom finds herself working several jobs to make ends meet and does not find time to initiate self-care or allow herself to grieve the loss of her husband. With limited resources, activities that support healthy grief work such as buying a tree to plant in honor of the deceased or travel to a support group may be realistic

Compilacated grief

Some people do not experience a normal grief process. In complicated grief a person has a prolonged or significantly difficult time moving forward after a loss. He or she experiences a chronic and disruptive yearning for the deceased; has trouble accepting the death and trusting others, and feels excessively bitter, emotionally numb, or anxious about the future. Loss associated with homicide, suicide, sudden accidents, or the death of a child has the potential to become complicated.

Coping strategies

The losses that patients face from the time they were children formulate the coping skills they will use when faced with larger and more painful losses in adult hood. These coping strategies such as talking, journaling, and sharing their emotions with others may be healthy and effective. They maybe unhealthy and ineffective such as increased use of alcohol, drugs and violence. Nurses need to support by assessing a patient's coping strategies, educating about new and healthy strategies, and encouraging use of these strategies

Therapeutic Communication

This patient-centered approach allows you to respond to patient's rather than react and encourages the sharing of important information. Open-ended questions invite patients to elaborate on their thoughts and encourage them to tell their story Use active listening, learn to be comfortable with silence, and use prompt to encourage continued conversation. Remain supportive by letting patients and family member s know that feelings such as anger are normal by saying "I see that you're upset right now, and that's understandable". If a patient chooses not to share feeling or concerns, express a willingness to be available at any time. Do not avoid talking about a topic. When you sense that a patient wants to talk about something, make time to do so as soon as possible. Help family members access other professional resources.

Spiritual and religious beliefs

To never offend a patient and to offer high quality care, you must assess your patient's beliefs and practices and encourage patients to draw on their spiritual resources in a higher power, communities of support, friends, a sense of hope and meaning in life, and religious practices. Spirituality affects the patient's ability cope with loss as well. Caring for the patient in a holistic approach, which includes the spirit, ensure that you are providing patients with the best possible individualized care. Hope, a multidimensional concept considered to be a component of spirituality, energizes and provides comfort to individuals experiencing personal challenges. Hope gives a person the ability to see life as enduring or having meaning or purpose. Maintaining a sense of hope depends in part on a person having a strong relationships and emotional connectedness to others. On the other hand, spiritual distress often arises from a patient's inability to feel hopeful or foresee any favorable outcomes. Spirituality and hope play a vital role in a patient's adjustment to loss and death.

Personal relationships

When loss involves another person, the quality and meaning of the lost relationship influence the grief response. When a relationship between two people was very rewarding and well connected, the survivor often finds it difficult to move forward after death. Grief work is hampered by regret and a sense of unfinished business, especially when people are closely related but did not have a good relationship at the time of death. Social support and the ability to accept help from others are critical variables in recovery from loss and grief.

Exagerated grief

-A person with an exaggerated grief response often exhibited self-destructive or maladaptive behavior, obsession, or psychiatric disorders. Suicide is a risk for these individuals

Chronic grief

-A person with chronic grief experiences a normal grief response, except that it extends for a longer period of time. This can include years to decades of intense grieving.

Delayed grief

-A person's grief response is usually delayed or postponed because the loss is so overwhelming that the person must avoid the full realization of the loss. A delayed grief response is

• Loss of a significant other

-Close friends, family members, and pets fulfill psychological, safety, love, belonging, and self-esteem needs.

Types of Loss: Loss of possessions or objects

-Extent of grieving depends on values of object, sentiment attached to it, or its usefulness

Factor Influencing Loss and Grief • Multiple factors influence the way a person perceives and responds to loss.

-Human development Patient age and stage of development affect the grief response. Toddlers cannot understand loss or death but often feel anxiety over the loss of objects and separation from parents. Common expressions of grief include changes in eating and sleeping patterns, bowel and bladder disturbances, and increased fussiness. School-Age children understand the concepts of permanence and irreversibility but do not always understand the causes of a loss. Some have intense periods of emotional expression and experience changes in eating, sleeping, and level of social engagement. Young Adults undergo many necessary developmental losses related to their evolving future. They leave home, begin school or a work life, or form significant relationships. Illness or death disrupts the young adult's future dreams and establishment of an autonomous sense of self. Midlife: experience major life transitions such as caring for aging parents, dealing with changes in marital status, and adapting to new family roles. Older adults: older adults the aging process leads to necessary and developmental losses. Experience age discrimination, especially when they become dependent or are near death, but they show resilience after a loss as a result of their prior experiences and development coping skills.

• Loss of an aspect of self

-Illness, injury, or developmental changes result in loss of a valued aspect of self, altering personal identity and self concept

• Loss of known environment:

-Loss occurs through maturational or situational events or by injury/illness. Loneliness in an unfamiliar setting threatens self-esteem, hopefulness, or belonging.

• Loss of life

-Loss of life grieves those left behind. Dying people also feel sadness or fear pain, loss of control, and dependency on others

masked grief

-Sometimes a grieving person behaves in ways that interfere with normal functioning but is unaware that the disruptive behavior is a result of the loss and ineffective grief resolution.

Situational loss

-Sudden, unpredictable external events bring about situational loss. (for example, automobile accident sustains an injury with physical changes that make it impossible to return to work or school, leading to loss of function, income, life goals, and self-esteem).

Necessary loss

-They learn to expect that most necessary losses eventually are replaced by something different or better. -However, some losses cause them to undergo permanent changes in their lives that threaten their sense of belonging and security.

Actual loss:

-actual loss occurs when a person can no longer feel, hear, see, or know a person or object. (for example, the loss of a body part, death of a family member, or loss of a job).

Mourning

-coping with grief involves a period of mourning, outward, social expressions of grief and the behavior associated with loss. - Most mourning rituals are culturally influenced, learned behaviors.

Bereavement

-encompasses both grief and mourning and includes the emotional responses and outward behaviors of a person experiencing loss. -The bereaved should be encouraged to talk about the loss and reassured that the feelings are normal and that major decisions should be postponed.

Maturational loss

-form of necessary loss and includes all normally expected life changes across the life span. A toddler experiences separation anxiety from mom when starting preschool. A grade school child does not want to lose her favorite teacher and classroom. A college student does not want to leave his campus community. Maturational losses associated with normal life transitions help people develop coping skills to use when they experience unplanned, unwanted, or unexpected loss.

Perceived loss:

-uniquely defined by the person experiencing the loss and is less obvious to other people. (For example, some people perceive rejection by a friend to be a loss, which create a loss of confidence or changes their status in the social groups). -Perceived loss are easy to overlook by others because they are experienced so internally and individually, but they are as painful as an actual loss and grieved in the same way.

Facilitate mourning

Helpful strategies for assisting grieving persons include the following: Help the survivor accept that the loss is real. Discuss how the loss or illness occurred or was discovered, when, under what circumstances, who told him or her about it, and other factual topics to reinforce the reality of the event and put it in perspective. Support efforts to adjust to the loss. Use a problem solving approach. Have survivors make a list of their concerns or needs, help them prioritize, and lead them step by step through a discussion of how to proceed. Encourage survivors to ask for help. Encourage establishment of new relationships. Reassure people that new relationships do not mean that they are replacing the person who has died. Encourage involvement in nonthreatening group social activities. Allow time to grieve. A return to sadness or the pain of grief is often worrisome. Openly acknowledge the loss, provide reassurance that the reaction is normal, and encourage the survivor to reminisce. Interpret "normal" behavior. Being distractible, having difficulty sleeping or eating, and thinking that they have heard the deceased's voice are common behaviors following loss. These symptoms do not mean that an individual has an emotional problem or is becoming ill. Provide continuing support. Survivors need the support of a nurse with whom they have bonded for a time following a loss, especially in home care or hospice nursing. Attachment for a period of time after the death is appropriate and healing for both the survivor and the nurse. Be alert for signs of ineffective, potentially harmful coping mechanisms such as alcohol and substance abuse or excessive use of OTC analgesics or sleep aids.

Patient outcomes

The short and long term outcomes that signal a family's recovery from a loss guide your evaluations. • Short-term outcomes indicating effectiveness of grief intervention include talking about the loss without feeling overwhelmed, improved energy level, normalized sleep and dietary patterns, reorganization of life patterns, improved ability to make decision, and finding it easier to be around other people. • Long-term achievements include the return of a sense of humor and normal life patterns, renewed or new personal relationships, and decrease of inner pain.

Grief

• 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. • No two people grieve the same loss the same way, nor do they journey through grief in the same way. • Grief work is very hard and requires enormous amounts of energy from the griever. • Grief can diminish, and healing can occur when the pain of loss is less.

Cultural aspects of care

• African American Care of the body after death depends on the African American's country of origin and degree of American acculturation. The mourning period is relatively short, with a memorial service and a public viewing of the body or a wake before burial. Organ donation and autopsy are allowed. • Chinese Death is regarded as a negative life events, and there is no concept of an afterlife. The dead are treated with the same respect as the living and may be buried with good and other artifacts. Members of an extended family usually stay with the deceased fro up to 8 hours after death. The oldest son or daughter bathes the body under direction of an older relative or a temple priest. • Hispanics Honoring family values and roles is essential in providing care and making decisions at the end of life. Mexican-American cultures often use special objects such as amulets or rosary beads, alternative healing practices, and prayer. • Native American Native American encompasses diverse tribal groups with differing practices, traditions, and ceremonies. Traditional Navajos do not touch the body after death. Care of the body in the large Navajo tribe includes cleansing the body. • Islamic The deceased's body is ritualistically washed, wrapped, cried over, prayed for, and buried as soon as possible after death. The eyes and mouth are closed, and the face of the deceased is turned toward Mecca. The proximity of loved ones after death is important since it is believed that the soul stays with the body until it is buried. • Buddhist Death is preferred at home, and a person's state at the time of death is important. Individuals usually minimize emotional expressions and maintain a peaceful, compassionate atmosphere. Buddhists recommend not touching the body after death to give the deceased a smoother transition to the afterlife. People often say prayers while touching and standing at the head of the deceased. • Hindu The body is placed on the floor with the head facing north. People of the same gender handle the body after death. There are no general prohibitions against autopsy. Bodies are cremated after death to purify by fire • Jewish Usually the burial occurs within 24 hours but not on the Sabbath. Some but not all types of Judaism avoid cremation, autopsy, and embalming

Grief variables

• Conversations about the meaning of loss to a patient often leads to other important areas of assessment, including the patient's coping style, the nature of family relationships, social support systems, the nature of the loss, cultural and spiritual beliefs, life goals, family grief patterns, self-care, and sources of hope. • Knowing the commonly experienced reactions to grief and loss and grief theories guides your critical thinking and assessment skills. Focus your assessment on how a patient is reacting to loss or grief and not on how you believe that patient should be reacting.

Goals and outcomes

• During planning establish realistic goals and expected outcomes on the basis of nursing diagnoses. • Consider patient's own resources such as physical energy and activity tolerance, family support, and coping style. • The goals of care for a patient experiencing loss are either short or long term, depending on the nature of the loss and the patient's condition. • A possible goal for your woman with advanced breast cancer is "will maintain a sense of control" with a following potential expected outcomes: Patient participates in all treatment decisions Patient identifies a minimum of three ways to maintain a parental role in care of her young child Patient communicates a minimum of three treatment side effects or concerns to the health care team.

Assesment

• During the assessment process thoroughly assess each patient and critically analyze finding to ensure that you make patient-centered clinical decisions required for safe nursing care. • A trusting, helping relationship with grieving patients and family members is essential to the assessment process.

Health promotion Patient teaching strategies

• Encourage patient to set realistic goals and identify ways to achieve them. • Identify ways that patient can maintain usual daily routines that provide comfort and sense of normalcy. • Demonstrate forms of complementary therapy that patient can sue for symptom management • Discuss ways that patient can maintain a sense of control over end-of-life planning and maintain a realistic outlook • Discuss patient's needs for presence of particular support people or for solitude. • Identify methods to facilitate safety and ease in managing activities of daily living as patient's abilities change.

Setting priorities

• Encourage patients and family members to share their priorities for care at the end of life. Patients at the end of life or with advanced chronic illness are more likely to want their comfort, social, or spiritual needs met rather than pursuing medical cures. • Give priority to a patient's most urgent physical or psychological needs while also considering his or her expectations and priorities. • When a patient has multiple nursing diagnoses, it is not possible to address them all simultaneously. The chronic pain experienced by the patient is often the first focus. Until her pain is under control, it will not be possible for her to feel more energized, eat well, or regain her sense of hopefulness.

Care after death

• Federal and state laws require institutional to develop policies and procedures for certain events that occur after death: requesting organ or tissue donation, performing an autopsy, certifying and documenting the occurrence of a death, and providing safe and appropriate postmortem care. • Make requests for organ and tissue donation at the time of every death. The person requesting organ or tissue donation provides information about who can give consent legally, which organs or tissues can be donated, associated costs, and how donation affects burial or cremation. • If deceased has not left behind instructions concerning organ and tissue donation, the family fives or denies consent at the time of death. • Family members give consent for an autopsy to determine the exact cause and circumstances of death or discover the pathway of a disease. • Autopsy within 24 hours of hospital admission of death. • Documentation of a death provides a legal records of the event. Physicians or coroners signs some medical forms such as a request for autopsy, but the RN gathers and records much of the remaining information surrounding a death. • Nurses also usually witness or delegate the signing of forms. • Family members deserve and expect a clear description of what happened to their loved one, especially in cases of sudden, unusual, or unexpected circumstances. Give only factual information in a nonjudgmental, objective manner and avoid sharing your opinion. • Maintaining the integrity of cultural and religious rituals and mourning practices at the time of death gives survivors a sense of fulfilled obligations and promotes acceptance of the patient's death. • The nurse coordinates patient and family care during and after a death. Become familiar with applicable policies and procedures for postmortem care because they vary across settings or institutional. • Death procedures physical changes in the body quite quickly, thus you need to perform postmortem care as soon as possible to prevent discoloration, tissue damage, or deformities.

Symptoms of normal grief

• Feelings Sorrow Fear Anger Guilt Anxiety Loneliness Fatigue Helplessness Yearning Relief

Theories of grief and morning

• Grief theorists describe the physical, psychological, and social reactions to loss. Remember that people who vary from expected norms of grief or theoretical descriptions are not abnormal. • Criticism exists for the stages and task theories because they fail to capture the complexity and diversity of the experience. • Consider a widow several weeks of feeling less sad and depressed. If unprepared for the cyclical nature of grief, she may be taken off guard by her strong grief reaction to a phone call for her husband or a commercial advertising his favorite candy.

Physical changes hours or days before death

• Increased period of sleeping/unresponsiveness • Coolness and color changes in extremities • Bowel or bladder incontinence • Decreased UO; dark colored urine • Restlessness, confusion, or disorientation • Decreased intake of food or fluids • Congestion/ increased pulmonary secretion • Altered breathing • Decreased muscle tone, relaxed jaw muscles, sagging mouth • Weakness and fatigue

Loss

• Life provides each person with multiple opportunities to grieve a los or change. • The loss can be of tangible things such as a body part or function, relationship, or possession. They can also be intangible such as the loss of self-esteem, confidence, or a dream. • The experience of loss starts early in life and continue until death. • Children develop independence from the adults who raise them and as they begin and leave school, change friends, begin careers, and form new relationships. • From birth to death people form attachments and experience loss. Illness can also be a source of loss. • How one grieves depends on cultural norms, belief systems, support systems, and personal faith.

Grief reaction

• Most grieving people show some common outward signs and symptoms. • Assess the family's response to loss and recognize that sometimes they are dealing with their grief at a different pace.

Planning

• Nurses provide holistic, physical, emotional, social, and spiritual care to patients experiencing grief, death or loss. • The care of plan for the dying patient focuses on comfort; preserving dignity and quality of life; and providing family member with emotional, social, and spiritual support.

Through the patient eyes

• One of the best things that you can do for patients and families is to be present. By using the skills of active listening, silence, and therapeutic touch, you can establish a trusting relationship with your patients. • This trusting relationship will help you explore with patients their unique responses to grief or their preferences for end-of-life care, which may include advance directives. • Patients with advanced chronic illness and their families eventually face end-of-life care decision and should discuss the content of any advance directives together. • Speak to patients and family members using honest and open communication, remembering that cultural practices influence how much information the patient shares. • Keep open mind, listen carefully, and observe the patient's verbal and nonverbal responses. • The use of pauses, gentle questioning, and silence honors the patient's privacy and readiness to talk. Talk to patients and family members in private, and quiet settings. • As you gather assessment data, summarize and validate your impressions with the patient or family member. • Because of the importance of symptom management and priority of comfort in end-of-life care, prioritize your initial assessment to encourage patients to identify any distressing symptoms.

Grief Considerations in Older Adults

• There is little evidence that grief experiences differ because of age alone. Responses to loss are more likely related to the nature of the specific loss experience and individual differences. • Increased age increases the likelihood that older adults have faced multiple losses. Older adults residing in communal living situations experiences many losses as friends die. • Many older adults exhibit resilience. Others around them can learn from their courage and ability to respond to life challenges graciously, accepting life with integrity and wholeness • Older adults are at risk for complicated grieving as a result of multiple losses, potential for cognitive impairment, or decreased physical resources. The risk include depression, loneliness, and accompanying functional decline. • Physical decline caused by chronic illness sometimes leads to grief over lost health, function, and roles. • Pain is often undertreated in older adults, particularly in people with dementia or cognitive impairments. Side effects of pain medications are usually more pronounced in older adults. • Older adults benefit from the same therapeutic techniques as people in other age-groups. Reliving depression and maintaining physical function are therapeutic goals for grieving older adults.

Documentation of end of life care

• Time and date and all actions taken to respond to the impending death • Name of HCP certifying the death • People notified of the death and person who comes to declare time of death • Name of person making request for organ or tissue donation • Special preparation of the body • Medical tubes, devices, or lines left in or on the body • Personal articles left on and secured to the body • Personal items given to the family with description, date, time, to whom given • Location of body identification tags • Time of body transfer and destination • Any other relevant information or family requests that help clarify special circumstances • Verify with health care agency