1. LOSS, DEATH: GRIEF AND THE GRIEVING PROCESS

2. Loss, Death, Grieving
Nursing by its nature is involved in all processes of life: from birth to death. Nurses interact daily with clients and families experiencing loss and grief.

3. GRIEF AND THE GRIEVING PROCESS
The unique function of the nurse is to assist the individual sick or well in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would have perform unaided if he had the necessary strength, will, or knowledge, and to do this in such a way as to help him gain independence as rapidly as possible (Henderson, 1966).

4. GRIEF AND THE GRIEVING PROCESS
Loss-the removal or absence or an important object or subject from an individual’s life; it is state of being without something one has had. Loss can be actual or potential.
The more individuals have invested emotionally in a person, object, or aspect of self, the more threatened they are likely to feel as they anticipate that loss.

5. GRIEF AND THE GRIEVING PROCESS
Loss may be
Actual
Perceived
about external objects
about known Environment
about significant others
about an aspect of Self
of Life

6. GRIEF AND THE GRIEVING PROCESS
Grief –the normal response to and personal experience of loss of something that is critical to one’s sense of wellbeing. It is a profound, holistic stat that affects how a person think, eats, sleeps, and makes it through the day.
Grief is a painful response that involves strong emotions such as rage, despair, and fear.

7. GRIEF AND THE GRIEVING PROCESS
A grieving person may also present with the feeling of chocking, shortness of breath, need for sighing, insomnia, confusion, absentmindedness, confusion and difficulty in concentration.

8. GRIEF AND THE GRIEVING PROCESS
Types of grief that may be expressed are:
Abbreviated grief-brief but genuine
Disenfranchised grief-grief that cannot be acknowledged openly
Complicated grief-unhealthy grief; inhibited, delayed, exaggerated, unresolved/chronic

9. GRIEF AND THE GRIEVING PROCESS
Loss may be personal, group or multiple.
Mourning-is the behavioural process though which grief is eventually resolved or altered; it the cultural patterning of a bereaved person’s grief. Cultures provide various ways for individuals to convey their grief to others through culturally sanctioned attitudes and customs.
Bereavement denotes the period during which the grief process unfolds, ending with the reorganization of the individual’s life.

10. Kubler-Ross Stages of Grief
The Stages
Manifestations
Denial
Anger
Muscular weakness, clammy sensation, inability to think, feel, or move; may report having dreams in which the deceased was alive
Anger towards the deceased, towards God, caregivers and jealousy towards those who still have their loved ones alive

11. Kubler-Ross Stages of Grief
Bargaining
Depression
Acceptance
Manifestations
Trying to postpone the inevitable shopping for Rx, bargains with God for a better life.
One withdraws from the world, talks less, turns visitors away; refuses food, medication etc.
Comes to terms with the situation, may want to say last words to close relations

12. Engel’s Stages of Grieving
Shock and disbelief
Developing awareness
Restitution
Resolving the loss
Idealization
outcome

13. Expression of Grief
There is no single correct way nor a correct timetable by which a person progresses through the grieving process and no individuals are responding to the same loss cannot be expected to follow the same pattern or schedule in resolving their grieve, even while they support each other.

14. GRIEF AND THE GRIEVING PROCESS
The nature and extent of grief is influenced by
Age
Nature of the loss
Cultural and spiritual beliefs
Gender roles
Socio-economic status/social support systems

15. The Dying Patient
Loss is an element of dying just as it is for bereavement. Individuals with fatal diagnoses experiences losses. These may include:
Loss of being a healthy person functioning in the society
Loss of independence, self esteem and integrity.
Loss of job
Loss of the ability to live without interruptions of frequent hospitalization and painful treatments.
Loss of friends and love ones

16. Fears of the dying client
These loses may arouse fears in the patient
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

17. Fears of the dying client
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

18. Fears of the dying client
Fear of the unknown:
Death is an unknown state
What will happen after death?
What will happen to loved ones, those left behind

19. Dying with Dignity Dying Persons’ Bill of Rights (look for)
Promotion of comfort
Maintenance of independence
Prevention of loneliness and isolation
Promotion of spiritual comfort
Support for the grieving family
Hospice Care

20. Approaching Death: Some Physical Changes
Dying person turns toward light - sees only what is near
Can only hear what is distinctly spoken
Touch is diminished - response to pressure last to leave
Dying person might turn toward or speak to someone not visible to anyone else
Eyes may remain open even if unconscious
Person might rally just before dying

21. Approaching Death: Some Physical Changes
Temperature may increase or decrease
Pulse may be fast, irregular, weak, difficult to find
Respirations may be rapid, shallow, noisy, Cheyne-Stokes
BP decreases
Peripheral circulation is impaired

22. Approaching Death: Some Physical Changes
Thirst; dry mouth
Sight fails
Asphagia
Mental alertness varies
Hearing- supposed to be last sense to be lost
Relaxation of muscles

23. Approaching Death: Some Physical Changes
Pupils might react sluggishly or not at all to light
Pain might be significant
Assess for pain if person unable to talk: restlessness, tight muscles, facial expressions, frowns
Provide pain medication as needed

24. Approaching Death: Some Physical Changes
Death is the end, as we know it, for that person
We can only support, listen therapeutically,
Make the person as physically comfortable as possible
We can also use our knowledge and expertise to strengthen, support, and prepare the family

25. Some Changes After Death
Physical Changes After Death
Pupils- Fixed and dilated
Algor Mortis- Rapid cooling of the body
Rigor Mortis- Stiffening of the body, develops 2-4 hours after death
Livor Mortis- Purple discoloration of skin in dependent areas

26. Some Changes After Death
Certification of death by the physician
performance of last offices