Coping wth loss,death and grieving

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COPING WTH LOSS,DEATH AND GRIEVING
Prepared by
Salman habeeb

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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 psychlogical process
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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Williamworden’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 artificialmeans 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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Dying person’s bill of rights
FromAmerican Journal of nursing, 75(1)99
• I have the right to be to be treated as a living human being until idie.
• I have the right to maintaina sense of hopefulness, however changing its
focus may be.
• I have the right to be cared for bythose who canmaintaina sense of
hopefulness, however changingthis may be.
• I have the right to express my feelings and emotions and my approaching
death in my own way.

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• I have the right to participate in decisions concerning my care.
• I have the right to expect continuing medical and nursing attention.
• I have the right not to die alone.
• I have the right to be free from pain.
• I have the right to have my questions answered honestly.
• I have the right not to be deceived.
• I have the right to have help from and for my family in accepting my
death.
• I have the right to die in peace and dignity.

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• Ihave the right to retain my individualityand not be judged by my
decisions, whichmaybe contrary to the beliefs of others.
• Ihave the right to discuss and enlarge my religious or spiritual
experiences, regardless of what they meanto others.
• Ihave the right to expect that the sanctity of the humanbody willbe
respected after death.
• Ihave the right to becared for bycaring, sensitive, knowledgeable
people whowill attempt to understand myneeds andwill be ableto
gainsome satisfactionin helpingface mydeath.

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• SENSORY SYSTEM
• Hearing - usuallylast 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
• -blinkreflex absent
• -eyelids remain half open

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• INTEGUMENTARY SYSTEM
• -Cold clammy skin
• -cyanoses on nose, nailbeds
• RESPIRATORY SYSTEM
• -Increased respiratory rate
• -cheyne stroke respiration (alternating periods of apnoea, deep and
rapidbreathing)
• -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
• -urinaryincontinence or unableto 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
• -saggingof jawresults in loss of facialmuscle 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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ASPECTSOF END OF LIFE CARE
• Palliative care
• Preparation at the end of life care
• Advanceddirectives
• 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
• palliativecare 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.
• Palliativecare looks after the medical, emotional, socialand 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 hisor her life and find peace.
• Palliativecare supports the need of family members, helping them with the
responsibilities of care giving and even supporting them asthey grieve

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• Palliativecare helps togain access to neededhealthcare
providers and appropriate care settings involving various kinds of
trained providers in differentsettings, tailored to theneeds of the
patientand his or her family.
• Palliativecare builds a way to provide excellent care at theend of
life througheducation of care providers, appropriate health
policies, and adequatefundingfrom 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 alldeaths 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 patientmay ultimatelydie,they are likely to
spend most of their last year of life in theirown homebeing cared
for by close familymembers. Whenthepatientand thefamily’s
hopes are focussed on allowing thepatientto die in his or her
own home ,the nurses need to be acutelysensitive to theshifting
needs of the caring family.

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.
• GRIEVING LOSSES
• Learning that persons illness hasbecome terminal can bring about intense
feelings of anger, fear grief, regret and other strong emotions.
• Encourage thepatientsTalkingabout 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 affairsinclude locating and organizing important legal
and financialdocuments, such aswill, marriage and birth certificates,
social security card, insurancepolicies, bank statements and investment
summaries.
• Some people also find it helpful to plan some aspects of their own
funeral. This canbe done with set of written instructions or talkingto
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 asrereading 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 illpatients and their families. Include counselling to patient and
family members
• The patient’s and family’s preferences , individual needs related to spiritual
TO BERESPECTED
• Eg: Giving anointment.

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• Advance directives are thelegaldocumentsthatexplain thekind
of medical treatmentwould want and would not wantif patient
become unableto make thesedecisions for yourself.
• Advance directives protect client’s rights and preferences for the
medical treatmentand diminish theburden of family members
and theother caregivers makingdecision for client

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Types of advance directive
• LIVING WILL
A type of advance directive inwhich the individual documents
treatment preferences. . A living will can include
• Whether client want the medical team to use cardiopulmonary
resuscitation(CPR) and or artificiallife support such asmechanical
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 isa legal document through whichthe signer appoints
and authorizesanother individual tomake decisionson
his or her behalfwhen he/she is nolonger ableto speak
for him/herself.
• Once patientchoose a healthcare agent he can stillmake
your own decisionsabouthis 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 healthcare providers not to attempt CPR
and it isoften 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
• Unlikeother advance directives that are written and signed by the
individual, aDNR order must be completed and signed by doctor or
other healthcare provider.

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Providing comfort
• Use foam cushionsto makebeds and chairs more comfortable
and help thepatientto change positions frequentlyand change
thebed linensas necessary.
• Elevate thepatient’s head or turn the patienton his or her side to
help make breathingeasier.
• Use blankets to help keep theperson warm & gently rub the
person’s hand, feetor soak the handsand feet in warm water.

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Controlling pain
• Controllingpain is an important part of dying comfortably and
peacefully.
• Administer medicationsaround the clock ina timely mannerand
on a regular basis to provide constant relief rather than waiting
untilthe painis unbearable.
• Concentratedmorphine solutioncan be very effectiveby
delivered by the sublingualroute.
• In case of uncontrolled pain, palliative sedation

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HOSPICE CARE
• Hospice is not a place but a concept of care thatprovides compassion,
concern, and support for dying. Hospice and palliativecare are frequently
used interchangeably. Hospice existsto provide support and care for
person in the last phases of the incurable diseases so that they might liveas
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 has6 months or less to live

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• Comparing palliative care and hospice
care
• Although theterm palliative care and hospice care are
sometimes used interchangeably, they have slightlydifferent
meanings
• Palliativecare starts muchearlier in a disease process where as
hospice is traditionally is limitedto the projected last six months
of life.

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LEGAL AND ETHICAL ISSUES
AFFECTING END OF LIFE CARE
• ORGAN AND 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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RESEARCH STUDIES

Coping wth loss,death and grieving

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