! GRIEFLOSSDEATHDYINGGERALD REY O. COQUIA, RNACLC COLLEGE TACLOBAN

GRIEF AND LOSS 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

GRIEF AND LOSSLoss is a universal experience that

occurs throughout the lifespan.Grief is a form of sorrow involving

feelings, thoughts and behaviors caused by bereavement.

Responses to loss are strongly influenced by one’s cultural background.

GRIEF AND LOSSThe grief process involves a sequence of affective, cognitive and psychological states as a person responds to and finally accepts a loss.

STAGES OF GRIEVINGStages Behaviors

D

A

B

D

A

Refuses to believe that loss is happening

Retaliation

Feelings of Guilt, punishment for sins

Laments over what has happened

Begins to plan (e.g. wills, prosthesis)

STAGES OF GRIEVINGDENIAL• “No, not me…”• After the initial shock has worn off,

the next stage is usually one of classic denial, where they pretend that the news has not been given.• They effectively close their eyes to

any evidence and pretend that nothing has happened.

STAGES OF GRIEVINGDENIAL: interventions• Do not interfere unless it becomes

destructive• Do not support denial; conversations

should include reality• Continue to teach and encourage

self care activities.

STAGES OF GRIEVINGANGER

•“Why me?”•This stage often occurs in an explosion

of emotion, where the bottled –up feelings of the previous stages are

expulsed in a huge outpouring of grief. •Whoever is in the way is likely to be

blamed.

STAGES OF GRIEVINGANGER: interventions

•Give space allowing them to rail and below. The more the storm blows the

sooner it will blow itself out.•Try not to respond in “kind”

•When anger is destructive , it must be addressed directly. Remind the person

of appropriate and inappropriate behavior.

STAGES OF GRIEVINGBARGAINING• “Yes me, but…”• The patient

attempts to negotiate a postponement with God and is generally kept a secret.

STAGES OF GRIEVINGBARGAINING: intervention• Spend time with

patients• Discuss importance

of valued objects and people.

STAGES OF GRIEVINGDEPRESSIONThe inevitability of the news eventually (and not before time) sinks in and the person reluctantly accepts that it is going to happen.

STAGES OF GRIEVINGDEPRESSION: intervention• Be available• Don’t attempt to

cheer person up• Find out any

religious support

STAGES OF GRIEVINGACCEPTANCE• Restful time, but not

necessarily happy.• Often begin putting their

life in order, sorting out wills and helping others to accept the inevitability.

STAGES OF GRIEVINGACCEPTANCE: intervention• Plan care to allow the

person with whom patient is comfortable to care for him or her • It is important that you

don’t withdraw

DEATH "cessation of heart- lung

function, or of whole brain function, or of higher brain function.

"either irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain, including the brain stem

DEATH CONCEPT AMONG AGE1-5 immobility and inactivity; wishes and

unrelated action responsible for action5-10 final but can be avoided9-12 understands own mortality and fears

death12-18 fears and fantasizes avoidance18- 45 increased attitude awareness45-65 accepts mortalityAbove 65 multiple meanings; encounters

and fears

FEARS OF DYING PERSON

• Distancing by support people and caregivers can occur

• Debilitation, pain, and incapacitation• Hospital, a place that can be very

lonely• Fear of dying alone

FEAR OF LONELINESS

FEARS OF DYING PERSON

• Sadness• Letting go of hopes, dreams, the future• Awareness of own mortality• Grief about future losses• Anticipatory grief that involves mourning,

coping skills• Grief related to diagnosis that has a long

term effect on the body such as cancer• Patient may feel well at time of diagnosis

FEAR OF SORROW

FEARS OF DYING PERSON

• Death is an unknown state• What will happen after death?• What will happen to loved ones, those left

behind

FEAR OF THE UNKNOWN

FEARS OF DYING PERSON

• Mutilation via therapy and body image changes• Loss of role or status• Loss of standard of living

LOSS OF SELF CONCEPT AND BODY INTEGRITY

FEARS OF DYING PERSON

• Ego is threatened• Physical deterioration may

occur• Mental deterioration may

occur• Unable to care for self• Become dependent on others

for care

FEAR OF REGRESSION

FEARS OF DYING PERSON

• May be many different types of pain or suffering such as physical, emotional, social, or spiritual in nature• Altered relationships with others• Anxiety related to the disease and

consequences of the disease

FEAR OF SUFFERING AND PAIN

TAKING CARE OF DYING PERSON•The role of the nursing staff is fundamentally supportive•Accept the physical and

mental state he is in•Show him that they will not

abandon him•Responds to the persons

needs in a physical, psychological, social and

intellectual level

TAKING CARE OF DYING PERSON

•Biological needs, reduction and control of pain

•Pain is a subjective experience•Acute pain: usually temporary•Chronic pain: interrupts normal

everyday functioning•Medication is more effective in the

context of a holistic intervention

PHYSICAL LEVEL

TAKING CARE OF DYING PERSON

• Feelings of anger, sadness, depression are part of a wider process of “anticipatory grief”,

useful for the patient’s psychological preparation to die

• Nursing staff has to comprehend and the person to express these feelings

• The only way for the person to reconcile with these feelings is to talk to someone who is

willing to listen • Support has to respond to the person’s need

for safety, autonomy and self-control

PSYCHOLOGICAL LEVEL

TAKING CARE OF DYING PERSON

• Emotional and social withdrawal• Need of emotional withdrawal co-exists with

the need of belonging to an accepting and supportive social environment

• When family/medical nursing staff keep their distance in order to protect themselves, the

person experiences a “social death”, which is sometimes more painful than the actual death• Nursing staff must treat the dying person

without fear, encourage relatives to be close to him, act as a liaison with the outside world

SOCIAL LEVEL

TAKING CARE OF DYING PERSON

•Need to evaluate his life as meaningful, important, useful

•Nursing staff should stand by him without being judgmental, let him

decide where he wants to spend his last days, and interact with him

as a person who LIVES

INTELLECTUAL LEVEL

NURSING RESPONSIBILITIES• Nurses need to take time to analyze their

own feelings about death before they can effectively help others with terminal illness• Understand that you may experience grief• Nurses have to be strong to control their

feelings to be able to tolerate pain, illness, and death, and to keep their distance

NURSING RESPONSIBILITIES• Provide relief from illness, fear and

depression• Help clients maintain sense of security• Help accept losses• Provide physical comfort

ROLE OF THE CHAPLAIN• Can be a member of the health care

team• Assist with religious practices• Perform rites• Provide prayer, support, and comfort• Assist with mobilizing other support

systems that are important to the client• Support family members

COMMUNICATING WITH CLIENT

• Right to know• Time frame• Nurse needs to assess whether or not

the patient/family have been told and what was told to them• THE PHYSICIAN WILL TELL THE CLIENT

FIRST, NOT THE NURSE

COMMUNICATING WITH CLIENT• Clarifies what was said• Listens to concerns• Fosters communication between MD,

client, and family• Allows patient to express loss• Facilitate grief through nursing process• Be available for patient• Assist patient to identify needs/hopes

for remainder of life• Connect patient with proper resources

ASSIST FAMILY• Explain procedures and equipment• Prepare them about the dying process• Involve family and arrange for visitors• Encourage communication• Provide daily updates• Resources• Do not deliver bad news when only one

family member is present

PHYSICAL SIGNS OF DYING• Confusion – about time,

place, and identity of loved ones; visions of people and places that are not present• A decreased need for

food and drink, as well as loss of appetite

PHYSICAL SIGNS OF DYINGDrowsiness – an increased need for sleep

and unresponsiveness

Withdrawal and decreased socializationSkin becomes cool to the touchLoss of bowel or bladder control

PHYSICAL SIGN OF DYING• Rattling or gurgling sounds while breathing

or breathing that is irregular and shallow, decreased number of breaths per minute, or breathing that switches between rapid and slow

• Involuntary movements (called myoclonus), changes in heart rate, and loss of reflexes in the legs and arms also mean that the end of life is near

PRONOUNCEMENT OF DEATH•Absence of carotid

pulses•Pupils are fixed and

dilated•Absent heart sounds•Absent breath sounds

STAGES OF DECOMPOSITION

• paleness of death• almost immediately after death a body of a

person with light skin will begin to grow very pale. this is caused by a lack of blood in the Capillary region of the blood vessel.

PALLOR MORTIS

STAGES OF DECOMPOSITION

• cool of death• after death a human body will no longer be

working to keep warm, and as a result will start cooling

• about an hour postmortem (after death) a human body will have decreased around 2 degrees celcius, and will continue to decrease one degree celcius until it reaches the temperature of the environment around it

ALGOR MORTIS

STAGES OF DECOMPOSITION

• death stiffness• about three hours after death a chemical

change in the muscles of a human corpse causes the limbs of the corpse to become stiff and difficult to move.

RIGOR MORTIS

STAGES OF DECOMPOSITION

• decomposition of proteins in a process that results in the eventual breakdown of cohesion between tissues and the liquefaction of most organs. It is caused due to bacterial or fungal decomposition of organic matter and results in production of noxious odors

PUTREFACTION

POSTMORTEM CARE

• Needs to be done promptly, quietly, efficiently, and with dignity

• Straighten limbs before death, if possible• Place head on pillow

POSTMORTEM CARE

•Remove tubes•Replace soiled dressings•Pad anal area•Gently wash body to remove discharge•Place body on back with head and shoulders

elevated

POSTMORTEM CARE

• Grasp eyelashes and gently pull lids down• Insert dentures• Place clean gown on body and cover with

clean sheet

POSTMORTEM CARE•Note time of death and chart•Notify attending physician•Chart any special directions•Notify family members•Allow time with loved one•Gather eyeglasses and other belongings•Prepare necessary paperwork for body removal

POSTMORTEM CARE• Call funeral home (or other appropriate personnel)

for body transport• Note on chart• What personal artifacts were released with the

body• What belonging were released• Who received the belongings

• Tag or provide body identification as per policy