1. DEATH & DYING GRIEF & LOSS

2. Loss -Occurs when a valued person, object, or situation is changed
Types of Losses
-actual loss
-perceived loss
-anticipatory loss
Actual loss can be recognized by others including the person sustaining the loss, ex: a person losing a limb, spouse, valued object, job etc.
Perceived loss- felt by the person but is intangible to others EX:
(loss of your youth, financial dependence.
Anticipatory loss- the person displays loss and grief behaviors for loss that has yet to take place. EX: families with terminally ill patients and serves to lessen the impact of actual loss– for example
Physical loss-loss of an arm from a car accident
Psychological loss- caused by an altered self image and the inability to return to his or her occupation. A person who is scared by has not lost a limb may suffer from perceived and psychological loss of self image.

3. Grief or Grieving- Grief is the Emotional Reaction to Loss
Mourning-
a period of acceptance of loss and grief during which the person learns to deal with the loss
Bereavement-
a state of grieving during which a person goes through a grief reaction
Grief occurs with loss caused by separation as well as with loss caused by death. (Many people who divorce experience grief, loss of a body part a job, a house or a pet.)
Bereavement- when a person neglects their own health to an extreme.
Mourning person- char. By a return to normal living habits.
(refers to Engel’s 6 stages of grief reaction)

4. Engels: 6 Stages of the Grief Reaction
Shock and Disbelief
Developing Awareness
Restitution
Resolving the Loss
Idealization
Outcome
Shock and disbelief , “no not me”
Developing awareness “why me” crying, anger, feeling empty
Restitution – funeral services and rituals surrounding loss
Resolving the loss- dealing with the void left by loss..
Idealization- Exaggeration of good qualities of the person or object lost
Outcome- acceptance

5. When I must leave you for a little while Please do not grieve and shed wild tears And hug your sorrow to you through the years But start out bravely with a gallant smile; Reach out your hand in comfort and in cheer And I in turn will comfort you and hold you near; And never, never be afraid to die, For I am waiting for you in the sky!

6. Stages of the Grief and Loss/ Death & Dying Process
Denial
Anger
Bargaining
Depression
Acceptance
Kubler- Ross is considered the “pioneer” in the study of grief and death reactions.
More important than the stages of any grief reaction is the idea that grief is a process and it varies person to person
DENIAL and isolation- pt. Denies that he or she will die. “thy made a mistake in the dx, maybe they mixed my records with someone else.
Anger- the pt expresses rage and hostility in the anger stage and adopts a “why me” attitude, I quit smoking and I watched what I ate, Why did this happen to me?”
Bargaining- the pt tries to barter for more time. If I can just make it to my son’s graduation I will be satisfied. Just let me live until then” This is the stage wills are made, personal affairs are taken care of, final trips.”
Depression- period of grief before death. Characterized by crying and not speaking. “I waited all these years to see my daughter get married. AN d now I may not see my daughter get married. I may not be her to walk her down the aisle.I can’t bear the though to not being there.”
Acceptance- pt feels tranquil. She or he has accepted death and is prepared to die. “I’ve tied up all the loose ends- made my will , arrangements for my daughter to live with her grandparents. No I can go in peace.

7. Five Principles of Palliative Care (Hospice Care)
respect the goals, likes and choices of the dying patient
look after medical, emotional, social, and spiritual needs of the dying person
support the needs of the family members
help the patient gain access to needed healthcare providers and appropriate settings
build ways to provide excellent end of life care
Medical, emotional, social, and spiritual needs- focus on making sure there comfortable, not left alone
Supports the needs of the family members- helping with responsibilities of a care giving and supporting them through grief.
Builds ways to provide excellent end of life care- through education of care providers, appropriate health policies, adequate funding from insurers and gov

8. Ethical and Legal Dimensions
-managed death
-legalized physician assisted suicide
physician- administered lethal injections create ethical dilemmas
patients look to nurses for information, advice and support

9. Advanced Directives
Living Wills- provide specific instructions about the kinds of health care that should be provided or foregone in a particular situation
Durable Power of Attorney-
appoints an agent the person trusts to make decisions in the event of the appointing person’s subsequent incapacity

10. Factors That Influence Death and Dying
Developmental
Family
Socioeconomic
Cultural
Religious
Cause of Death
Developmental- death of a parent can retard a child’s development.
Children may not understand death but their sense of loss is great.
Family- roles with in the family are identified, for ex. The oldest child may feel the need to be strong.
Socioeconomic- if one has no health or life insurance or pension , the family can experience the loss of the person as well as the economic loss. This may result into loss of house, community, and support system.
Cultural influences-
Western culture grief is private matter that is only shared with family.
Religion- May play an important role is expression of grief and provide comfort.
Cause of Death- sudden, disease (AIDS), accidental death, death from war, violent deaths, suicides).

11. Nursing Process Questions to Ask
What have you been told about your condition?
Have you had any previous experience with this condition or death of a loved one?
Tell me about how you are coping
What is helping you get through this?
Assessing- determine the adequacy of the patient’s and family’s knowledge, perceptions, coping strategies and resources
Knowledge- Objective is to id. Whether or not the knowledge of the pt and family possess will allow them to make informed decisions.
Perceptions- object is to discover if pt and fx have unrealistic expectations
Coping objective see if family and pt are using effective coping strategies.
Resources- assess adequacy of the human financial and spiritual resources avail.

12. Nursing Process Planning- the patient and family will:
demonstrate freedom in
expressing feelings
identify and use effective
coping strategies
accept need for help as appropriate
make healthcare decisions reflecting personal values and goals

13. Nursing Process Implementing- the family
the nurse’s aim is to care for the dying patient and their families as well as to promote health and prevent illness in
the family
Nursing Diagnoses
impaired adjustment r/t newly diagnosed terminal illness
caregiver role strain r/t hospital discharged dying pt because of inadequate insurance.
dysfunctional grieving r/t inability to accept death of infant

14. Nursing Interventions
Monitor anxiety
Monitor changes in mood/affect
Communicate willingness to discuss death
Encourage patient and family to share feelings about death
Monitor pain
Facilitate obtaining spiritual support for patient and family
Include the family in care decisions and activities as desired

15. Nursing Process Evaluating
does the plan of nursing care for the dying patient meet the outcome of a comfortable, dignified death?
do family members resolve their grief after a suitable time of mourning and resume meaningful life roles and activities?

16. Question #1
A referral for bereavement resources to enhance care
Interventions for a pt in isolation and inner thought
Assessment skills to determine fear and anxiety
Therapeutic skills to enhance communication
A nurse caring for a 15 y/o pt. with terminal CA has assessed that the pt. is very quiet and has not expressed his feelings. The nurse will need to implement:
D therapeutic skills to enhance communication

17. Question #2
A pt who has ovarian CA with metastasis to the liver complains of increased pain and dysphasia. A physician orders a barium enema. The patient states, “I don’t want this test. What should I do?” The nurse should
Encourage her to refuse the test
Inform the MD of her statement
Educate her on the test’ s benefits
Educate her on the procedure
b. Inform the MD of the statements