Loss, Death, Grief Student

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Loss, Death, GriefFundamentals of Nursing

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  • NURS 3105

  • Chapter 36

  • Dealing with loss is inevitableNecessary lossMaturational lossSituational lossActual lossPerceived loss

    Ultimate loss

    Type of loss & perception of it influence depth/duration of grief response

  • Emotional response to loss

    Normal (uncomplicated)AnticipatoryDisenfranchisedAmbiguous ComplicatedExaggeratedDelayedMasked

  • Kbler-Ross Stages of Dying (DABDA):

    Wordens Grief Tasks ModelTask I: Accept the realityTask II: Experience the pain of griefTask III: Adjust to a world in which the deceased is missingTask IV: Emotionally relocate the deceased and move on

    Post Modern Grief Theories

    INDIVIDUALIZE the Grieving Process

    Bowlbys Attachment TheoryNumbingYearning and seekingDisorganization and despairReorganization

    DenialAngerBargainingDepressionAcceptance

  • Developmental StagePersonal RelationshipsMeaning of LossCoping StrategiesCognitions (Thought Patterns)Culture and Ethnicity

    Spiritual and Religious BeliefsHopePhysical SensationsSelf-Care

  • Anticipatory grievingCompromised family copingDeath anxietyFearImpaired comfortIneffective denialGrievingComplicated grievingRisk for complicated grievingHopelessnessPain (acute or chronic)Risk for lonelinessSpiritual distressReadiness for enhanced spiritual well-being

  • Dying with dignityPeaceful deathCompassionate careAdvocacyCommunication

    A GOOD DEATH.

  • Knowing patient needsEnsuring needs/preferences are metSymptom managementPromote meaningful interaction between patient/family/caregiverFacilitate peaceful death

  • HospiceInterdisciplinary approach to assess and address the holistic needs of patients and families to facilitate quality of life and a peaceful deathPalliative careActive total care of patients who have disease unresponsive to curative treatment [WHO]Control of pain, of other symptoms, and of psychological, social and spiritual problems is paramount

  • Affirms life and rewards death as a normal processNeither hastens nor postpones deathProvides relief from pain and other distressing symptomsIntegrates the psychological and spiritual aspects of careSupport system to assist in living actively to their potentialSupport system to family for coping and bereavement

  • Pre-active phase of dyingIncreased restlessness, confusionWithdrawal sociallyIncreased sleep/lethargyDecreased PO intakeSeeing persons who have already diedNeed to tie up loose endsBeginning to have pauses in breathingEdema

  • Circulatory ChangesCool skinMottling/cyanosisDecrease BPVariable HR

    CNS changesAgitationRestlessFatigueDrowsinessDisorientedImpaired swallowingImpaired communication

  • Respiratory changes Gurgling-Death RattlePulmonary congestionDyspneaCheyne-StokesShallow breathing

    Metabolic ChangesDecreased food/fluid intakeSlowed digestive processesElimination changesBowel/bladder incontinence

  • Recognize clinical manifestations of impending death

    Assess coping difficulties

    Communication

    Dignity and quality of lifeEnvironmentAbandonment and isolation

  • Pain Management/Comfortmost significant concern

    PsychosocialSupport for significant othersClear communication

    Interdisciplinary team management

    Table 36-2 (p. 721)

  • Maintain dignity and hope

    Nursing strategies that promote hope are often quiet simple:Be presentProvide holistic care that affirms the patients lifeMaintain dignity

  • The heart stops beatingBreathing stopsPupils become fixed and dilatedBody color becomes pale and waxen as blood settlesBody temperature dropsMuscles and sphincters relax (muscles stiffen 4-6 hours after death as rigor mortis sets in)Urine and stool may be releasedEyes may remain openThe jaw can fall openObservers may hear the trickling of fluids internally, even after death

  • Identify the patient. Use the hospital ID tag if available. Note the general appearance of the body. Test for response to verbal or tactile stimuli. Overtly painful stimuli are not required. Nipple or testicle twisting, or deep sternal pressure, are inappropriate and unnecessary. Listen for the absence of heart sounds and blood pressure; feel for the absence of carotid pulse.

    Look and listen for the absence of spontaneous respirations. Record the position of the pupils and the absence of pupillary light reflex. Record the time at which your assessment was completed.

  • InpatientNurse determines death has occurred & contacts HCP/hospice nurse to pronounceFederal and state laws require institutions to:Request organ or tissue donationPerform an autopsyCertify and document the occurrence of a deathProvide safe and appropriate postmortem carePostmortem careFamily assist?Family time with patientTransport of body to morgue

  • Continue to maintain dignity and respect of the bodyAllow for observation of cultural and religious practicesDocumentationBox 36-9Care of the survivors/caregivers

    *Loss, grief, and death affect ALL of usBut we often want to avoid it Saving the patient at all costWestern culture dont remind me of MY mortalityPatients and families have great difficulty accepting and managing loss and death. Alongside our duty to prevent illness and injury lies our potential to help patients and families navigate loss and grief and to have a positive death experience

    Experiencing and dealing with loss is inevitable. Throughout our lives, we grieve the loss of many things.

    Necessary losses are a part of life. These cause us to undergo some type of change. When a loss occurs, oftentimes it can be replaced by something different or better. (divorce, change in level of independence

    Maturational losses are a type of necessary loss that occur across the life span. Should equip us with coping skills to deal with unexpected losses

    Situational lossUnexpected suddenMVC, loss of limb, etc.Unnecessary losses are uniquely defined by the person experiencing the loss and are less obvious to other people.

    An actual loss occurs when a person can no longer feel, hear, or know a person or object.A perceived loss is defined by the person experiencing the loss. This is often less obvious to others but is real to that person.

    Death is the ultimate loss, and it is part of the continuum of life.

    *Manifested many ways

    Normal: common universal reaction to loss with complex emotional, cognitive, social, physical, behavioral and spiritual responses.

    Disengaging or letting go before the actual loss/death occursprolonged & predicted loss

    Disenfranchised = marginal / unsupported grief---relationship to deceased is not socially sanctioned, not openly shared or given less significance.

    `````Ambiguous lost person is physically present but not psychologically available.

    Complicated occurs when people do not experience a normal grief process. Prolonged or significantly difficult time moving forward after loss

    ``````exaggerated: exaggerated grief response with self-destructive or maladaptive behavior, obsessions or psych disorders. High risk for suicide. `````delayed: unsually delayed or postponedloss is too overwhelming to deal with and avoids fully realizing loss`````masked: behavior interferes with normal functioning, but individual does not recognize or is not aware tha the behavior is a result of loss

    *

    In addition to numerous diagnoses related to physical symptoms at the end of life, nursing diagnoses relevant for patients experiencing grief, loss, or death are listed on the slide.

    **The Institute of Medicine defined a good death a one that is free from avoidable suffering for patients, families and caregivers in general accordance with the patients and families wishes; and reasonably consistent with clinical, cultural, and ethical standards. ********Dignity Allow for reminiscing Speak to patientCont to explainPersonal hygiene and elimination

    ***Documentation of a death provides a legal record of the event. Some medical forms, such as a request for autopsy, must be signed by a physician or coroner, but the registered nurse gathers and records much of the remaining information surrounding a death. Nursing documentation becomes relevant in risk management or legal investigations into a death, underscoring the importance of accurate, legal reporting. Documentation also validates success in meeting patient goals or provides justification for changes in treatment or expected outcomes.

    A human body deserves the same respect and dignity as a living person and needs to be prepared in a manner consistent with the patients cultural and religious beliefs. Health care providers need to understand the makeup of a family network and to know which individuals should be involved in end-of-life decisions and care. After death assist the family with decision making such as notification of a funeral home, transportation of family members, and collection of the patient's belongings. DOCUMENTATION Nurses are a primary source of family support. Remember that, because of differing responses to grief, some family members prefer to be alone at the time of a death, whereas others want to be surrounded by a support community. When uncertain about what a family member prefers for support, pose simple questions and offer suggestions for assistanceFamily members deserve and expect a clear description of what happened to their loved one**

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