COPING WTH LOSS,DEATH AND

GRIEVING
Prepared by
KISHORE SINGH
RATHORE

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 What is
loss
• Loss can be defined as the undesired change or removal of a
valued object ,person or situation.

• Types
• necessary loss
Necessary losses are something natural and positive
• Start and leave school, change friends

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 actual loss
eg . Loss of body part ,role at work

Perceived loss
Any loss that is uniquely defined by The grieving client
eg. Loss of confidence or prestige

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• Maturational loss
• anychange in the development process that is
normally expected during a life time
• Loss of external objects
• Loss of life
• Loss of known environment

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• Grief is the physical ,psychological and
spiritual responses to loss.
mourning is the psychlogicalprocess
through which the individual passes on to
successful adaptation to the loss of a
valued object.

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 Normal grief
eg; crying,sorrow ,anger

Anticipatory grief
process of disengaging or letting go that occurs before
an actual loss of death has occurred
Complicated grief
difficulty in
progressing through
normal process
of grieving
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• chronic grief
• masked grief
Disenfranchised
Person experiences grief when a loss is
experienced and cannot be openly
acknowledged,socially sanctioned or
publicly shared
Eg .loss of partner from AIDS

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• Human development
• Psychological perspectives of loss and grief
• Socioeconomic status
• Personal relationships
• Nature of loss
• Amount of support for bereaved
• Culture and ethinicity
• Spiritual beliefs

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• MODEL OF SUCCESSFUL GRIEVING; ENGEL
(1964)

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 William worden’s theory
• 1. realizing that loved one is gone
• In the hours and days after a significant loss,the grieving
person typically feels numb hand unable to accept
the fact of the loss,this numbness is thought to be an
helpful form of denail.
• 2.experiencing the pain
• once the grieving person has accepted the reality
of loss,the feelingand emotions that surface are intense
and can change rapidly. This makes the person feel out
of control

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3 Adjusting to the environment without the
deceased:
.This means performing activities alone ,such as going for
walk or shopping, that were once shared or taking on roles
and responsibilities that the deceased previously held

4 Investing emotional energy:

Initially all energy is focused on the deceased: thinking
about the person, talking about her, reliving memories and
so on. When the person’s energy begins to flow toward
others or to different or former interest, the healing
process is in progress.
•
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 Death and dying

• Death
in 1981,the president’s commission for the study of ethical
problems in medicine , behavioral and biomedical
research defined death as an individual has sustained
either irreversible cessation of circulatory and respiratory
functions or irreversible cessation of all functions of the
entire brain ,including brain stem.

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A person is dead when, according to ordinary standards
of medical practice, there is irreversible cessation of the
person’s spontaneous respiratory and circulatory
functions. (Patient is pulseless, apnoeic and unresponsive
to verbal stimuli for a period of at least 2 – 5 minutes).
• If artificial means of support that a person's spontaneous
respiratory and circulatory functions have ceased, the
person is dead when according to ordinary standards of
medical practice, there is irreversible cessation of all
spontaneous brain function.

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SENSORY SYSTEM
• Hearing - usually last sense to
disappear
• Touch - decreased sensation
- decreased perception of touch and
pain
• Taste - decreased with disease
progress.
• Smell - decreased with disease
progress.
• Sight -blurring of vision
• blink reflex absent
• eyelids remain half open
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INTEGUMENTARY SYSTEM
• Cold clammy skin
• cyanoses on nose, nail beds
• RESPIRATORY SYSTEM
• Increased respiratory rate
• cheyne stroke respiration (alternating periods of apnoea,
deep and rapid breathing)
• Irregular breathing gradually slowing down to terminal
gasps (guppy breathing)
• Noisy wet sounding (death rattle)

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URINARY SYSTEM
• Gradual decrease in urinary output
• Urinary incontinence or unable to urinate
• GASTROINTESTINAL SYSTEM
• Accumulation of gas
• Distension and nausea
• Loss of sphincter control
• Possible cessation of GI function
• Bowel movement may occur before imminent death
or at the time of death

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 MUSCULOSKELETAL SYSTEM
• Gradual loss of ability to move
• Loss of gag reflex
• Sagging of jaw results in loss of facial muscle tone, dysphagia,
difficulty in speaking
• CADIOVASCULAR SYSTEM
• Increased heart rate: later slowing
• Irregular rhythms
• Decreased blood pressure
• Weakening of pulse

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A variety of feelings and emotions affect the dying
patients at the end
of life care. They are
• Altered decision making
• Fear of loneliness
• fear of pain
• Helplessness
• Restlessness
• Anxiety
• Impending doom
• Grief

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 ASPECTS OF END OF LIFE
CARE

• Palliative care
• Preparation at the end of life
care
• Advanced directives
• Understanding CPR and DNR
• Hospice care

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 PALLIATIVE CARE
• The palliative care means taking care of the whole
person-body, mind and spirit, heart and soul.

.The goal of palliative care not to give cure to the

disease condition but to reduce the pain and side
effects and to improve the quality of life

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 PRINCIPLES OF PALLIATIVE
CARE
Palliative care respects the goals, likes, and choices of the dying
person and his or her loved ones and helping them to understand the
illness and what can be expected from it, and to figure out what is
most important during the time.
• Palliative care looks after the medical, emotional, social and
spiritual needs of the dying person with a focus on making sure he
or she is comfortable, not left alone, and able to look back on his or
her life and find peace.
• Palliative care supports the need of family members, helping them
with the responsibilities of care giving and even supporting them as
they grieve

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Palliative care helps to gain access to needed health care
providers and appropriate care settings involving various
kinds of trained providers in different settings, tailored to
the needs of the patient and his or her family.
• Palliative care builds a way to provide excellent care at
the end of life through education of care providers,
appropriate health policies, and adequate funding from
insures and the government

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 THE PALLIATIVE CARE TEAM

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HOSPITALS
• Despite the economic and human costs associated with death in
the hospital settings, as many as 50%of all deaths occur in the
acute care settings. It is clear that many patients will continue to
opt for hospital care or default will find themselves in hospital
settings at the end of life care.

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Where ever the patient may ultimately die, they are likely
to spend most of their last year of life in their own home
being cared for by close family members. When the
patient and the family’s hopes are focussed on allowing
the patient to die in his or her own home ,the nurses need
to be acutely sensitive to the shifting needs of the caring
family.

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 .

GRIEVING LOSSES
• Learning that persons illness has become terminal can
bring about intense feelings of anger, fear grief, regret and
other strong emotions.
• Encourage the patients Talking about feelings and
concerns with family, friends and caregivers can help
bring comfort.
• Inform It is normal to grieve and mourn the loss of your
abilities, the loved ones you will leave behind, and the
days you will not have.

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Setting patient affairs include locating and organizing
important legal and financial documents, such as will,
marriage and birth certificates, social security card,
insurance policies, bank statements and investment
summaries.
• Some people also find it helpful to plan some aspects
of their own funeral. This can be done with set of written
instructions or talking to family or close friends about
your wishes.
• As we approach the end of your life there may be
certain things you wish to accomplish in the time you
have left. such as rereading a favourite book or spending
time with those who are important to you.
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 RELIGION AND
SIRITUALITY
The spirituality is a key component of comprehensive nursing for
terminally ill patients and their families. Include counselling to
patient and family members
• The patient’s and family’s preferences , individual needs related to
spiritual
TO BE RESPECTED
• Eg: Giving anointment.

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Advance directives are the legal documents that explain
the kind of medical treatment would want and would not
want if patient become unable to make these decisions for
yourself.
• Advance directives protect client’s rights and
preferences for the medical treatment and diminish the
burden of family members and the other caregivers
making decision for client

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 Types of advance
LIVING WILL
directive
A type of advance directive in which the individual
documents treatment preferences. . A living will can
include
• Whether client want the medical team to use
cardiopulmonary resuscitation(CPR) and or artificial
life support such as mechanical ventilator, if
breathing or heart stops.
• Whether client want to receive a feeding tube, if
you cannot be fed otherwise?
• Whether client want certain procedures such as
dialysis.
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 DURABLE POWER OF ATTORNEY FOR
HEALTH CARE

It is a legal document through which the signer

appoints
and authorizes another individual to make decisions
on
his or her behalf when he/she is no longer able to
speak
for him/herself.
• Once patient choose a health care agent he can still
make your own decisions about his medical care:

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 UNDERSTANDING CPR AND DNR
A DNR order is a type of advance directive and it is the
written physician’s order instructing health care
providers not to attempt CPR and it is often requested
by patient and family. A ‘no code ‘or DNR order
allows the person to die with comfort measures only and
without the interference of the technology
• Unlike other advance directives that are written and
signed by the individual, a DNR order must be
completed and signed by doctor or other health care
provider.

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 Providing comfort

Use foam cushions to make beds and chairs more

comfortable and help the patient to change positions
frequently and change the bed linens as necessary.
• Elevate the patient’s head or turn the patient on his or
her side to help make breathing easier.
• Use blankets to help keep the person warm & gently rub
the person’s hand, feet or soak the hands and feet in warm
water.

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 Controlling
pain
Controlling pain is an important part of dying
comfortably and peacefully.
• Administer medications around the clock in a timely
manner and on a regular basis to provide constant relief
rather than waiting until the pain is unbearable.
• Concentrated morphine solution can be very effective
by
delivered by the sublingual route.
• In case of uncontrolled pain, palliative sedation

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 HOSPICE
CARE
Hospice is not a place but a concept of care that provides
compassion, concern, and support for dying. Hospice and
palliative care are frequently used interchangeably.
Hospice exists to provide support and care for person in
the last phases of the incurable diseases so that they might
live as fully and as comfortable as possible.
• Criteria for hospice care
• 1.the patient must desire the services;
• 2.a physician must certify that the patient has 6 months
or less to live

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Comparing palliative care and hospice
care
• Although the term palliative care and hospice care are
sometimes used interchangeably, they have slightly
different meanings
• Palliative care starts much earlier in a disease process
where as hospice is traditionally is limited to the
projected last six months of life.

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 LEGAL AND ETHICAL ISSUES
AFFECTING END OF LIFE
• ORGAN
CAREAND TISSUE DONATON
• TERMINAL WEANING
• EUTHANASIA

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 NURSING MANAGEMENT: END OF LIFE CARE

• TO REDUCE THE PAIN

• TO PREVENT DEHYDRATION
• FOR DYSPNOEA
• TO PREVENT SKIN BREAKDOWN
• FOR WEAKNESS AND FATIGUE
• FOR ANOREXIA ,NAUSEA AND VOMITING
• PSYCHOSOCIAL CARE

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 ANY
DOUBT………………………………………………………?

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