The five stages, denial, anger, bargaining, depression and acceptance are a part of the framework that makes up our learning to live with the one we lost. They are tools to help us frame and identify what we may be feeling. But they are not stops on some linear timeline in grief.

1. GRIEF LOSS DEATH DYING
BY:
MR. ABHAY ARJPOOT

2. 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

3. GRIEF AND LOSS
Loss 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.

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

5. STAGES OF GRIEVING
Stages Behaviors
D Refuses to believe that loss is happening
A Retaliation
B Feelings of Guilt, punishment for sins
D Laments over what has happened
A Begins to plan (e.g. wills, prosthesis)

7. STAGES OF GRIEVING
DENIAL

8. STAGES OF GRIEVING
DENIAL: interventions

9. STAGES OF GRIEVING
ANGER
•“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.

10. STAGES OF GRIEVING
ANGER: 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.

11. STAGES OF GRIEVING
BARGAINING
• “Yes me, but…”
• The patient
attempts to
negotiate a
postponement with
God and is generally
kept a secret.

12. STAGES OF GRIEVING
BARGAINING: intervention
• Spend time with
patients
• Discuss importance
of valued objects
and people.

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

14. STAGES OF GRIEVING
DEPRESSION: intervention
• Be available
• Don’t attempt to
cheer person up
• Find out any
religious support

15. STAGES OF GRIEVING
ACCEPTANCE
• Restful time, but not
necessarily happy.
• Often begin putting their
life in order, sorting out
wills and helping others to
accept the inevitability.

16. STAGES OF GRIEVING
ACCEPTANCE: 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

17. 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

18. DEATH CONCEPT AMONG AGE
1-5 immobility and inactivity; wishes and
unrelated action responsible for action
5-10 final but can be avoided
9-12 understands own mortality and fears
death
12-18 fears and fantasizes avoidance
18- 45 increased attitude awareness
45-65 accepts mortality
Above 65 multiple meanings; encounters
and fears

19. FEARS OF DYING PERSON
FEAR OF LONELINESS
• Distancing by support people and
caregivers can occur
• Debilitation, pain, and incapacitation
• Hospital, a place that can be very
lonely
• Fear of dying alone

20. FEARS OF DYING PERSON
FEAR OF SORROW
• 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

21. FEARS OF DYING PERSON
FEAR OF THE UNKNOWN
• Death is an unknown state
• What will happen after death?
• What will happen to loved ones, those left
behind

22. FEARS OF DYING PERSON
LOSS OF SELF CONCEPT AND BODY
INTEGRITY
• Mutilation via therapy and body image
changes
• Loss of role or status
• Loss of standard of living

23. FEARS OF DYING PERSON
FEAR OF SUFFERING AND PAIN
• 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

24. 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

25. •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
TAKING CARE OF DYING PERSON
PHYSICAL LEVEL

26. • 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
TAKING CARE OF DYING PERSON
PSYCHOLOGICAL LEVEL

27. 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
TAKING CARE OF DYING PERSON
SOCIAL LEVEL

28. • 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
TAKING CARE OF DYING PERSON
INTELLECTUAL LEVEL

29. Palliative care
Palliative care is the prevention, relief,
reduction or soothing of symptoms of
disease or disorders throughout the
entire course of an illness, including care
of dying and bereavement follow-up for
the family.
- Ferrell & Coyle.

30.  Respects the goals, likes and choices of the dying
pt.
 Looks after medical, emotional, social, and
spiritual needs of the dying person.
 Supports the needs of the family members.
 Helps pt gain access to needed healthcare
providers and appropriate settings.
 Builds ways to provide excellent end of life
care

31.  Death declaration/ Death certificate by physician.
 Autopsy(written permission)
 Customs & principles are kept in mind.
 Positioning- body straitened & arms laid at
the side.
 Eyes are closed as in sleep.
 Dentures are removed & prop chin in position
with bandaging.
 Remove all appliances used for patient care(
e.g - catheter tubing's etc..)

32.  Remove all the appliances used for patient care. (e.g.
Catheter, tubing's, I,V.sets, etc)
 Remove ornaments and list them to relatives.
 All orifices are to be plugged with cotton to
prevent escape of body discharges.
 Prevention of spread of diseases (i.e sealing
body) Send body clean and neatly dressed.
 An identification tag for body.
 If relatives are present then body is handed over
them with proper written legal authority
permission.
 Maintain record of death and inform to
authority for register of deaths.

33. 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

34. NURSING RESPONSIBILITIES
• Provide relief from illness, fear and
depression
• Help clients maintain sense of security
• Help accept losses
• Provide physical comfort

35. 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

36. 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

37. PHYSICAL SIGNS OF DYING
Drowsiness – an increased need for sleep
and unresponsiveness
Withdrawal and decreased socialization
Skin becomes cool to the touch
Loss of bowel or bladder control

38. 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

39. PRONOUNCEMENT OF DEATH
•Absence of carotid
pulses
•Pupils are fixed and
dilated
•Absent heart sounds
•Absent breath sounds

40. • 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.
STAGES OF DECOMPOSITION
PALLOR MORTIS

41. • 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
STAGES OF DECOMPOSITION
ALGOR MORTIS

42. • 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.
STAGES OF DECOMPOSITION
RIGOR MORTIS

43. • 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
STAGES OF DECOMPOSITION
PUTREFACTION

44. POSTMORTEM CARE
• Needs to be done promptly, quietly,
efficiently, and with dignity
• Straighten limbs before death, if possible
• Place head on pillow

45. 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

46. POSTMORTEM CARE
• Grasp eyelashes and gently pull lids down
• Insert dentures
• Place clean gown on body and cover with
clean sheet

47. 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

48. 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