Grief/Loss and Death

What are the six types of loss?

"Actual loss; perceived loss; physical and psychological loss; maturational loss; situational loss; and anticipatory loss."

What is actual loss?

A loss that can be recognized by others — something tangible that is gone.

What is perceived loss?

A loss that is real to the person experiencing it but may not be recognized by others — for example a financial loss or loss of self-image.

What is physical and psychological loss?

"Physical loss involves something concrete like an extremity; psychological loss involves self-image — for example; women who undergo mastectomy may experience a significant loss of self-image."

What is maturational loss?

Loss that results from natural developmental processes — for example children leaving home as they grow up.

What is situational loss?

Usually unpredictable loss caused by a specific event — such as a traumatic injury or the sudden death of a loved one.

What is anticipatory loss?

Loss that is expected because a loved one has been ill for a long time — the person knows the loss is coming but is never fully ready for it.

What is grief?

The internal emotional reaction to loss — the feelings a person has in response to a specific loss.

What are the four normal expressions of grief and examples of each?

"Physical (crying; headaches; insomnia); emotional (sadness and yearning); social (detachment and isolation); and spiritual (questioning reason; purpose; and meaning)."

What is mourning?

The actual outward behaviors and expressions that occur in response to loss — including cultural symbols like wearing black or covering mirrors. It is the action of grief.

What is bereavement?

The state of grieving — the overall condition of experiencing loss. Mourning is the expression; bereavement is the state.

How are mourning and bereavement different?

Mourning refers to the outward behaviors and expressions of grief; bereavement is the state of grieving. They are related but different.

What are the five types of grief?

"Anticipatory grief; uncomplicated grief; complicated or prolonged grief; disenfranchised grief; and unresolved grief."

What is anticipatory grief?

Grief experienced before the actual loss occurs — when a person knows a loved one is terminally ill and the loss is coming.

What is uncomplicated grief?

A range of emotions after a loss that moves progressively toward acceptance — the grieving process moves in the expected direction without becoming incapacitating.

What is complicated or prolonged grief?

An intense grief response that lasts more than one year — the person cannot move through the grieving process and remains significantly affected.

What is disenfranchised grief?

Grief over a loss that cannot be openly acknowledged or shared with others — for example; grieving the death of someone in a secret relationship or grieving a pregnancy loss that was kept private.

What is unresolved grief?

"Grief following traumatic and unexpected losses — such as the death of a child or a suicide — where the lack of answers or closure makes it very difficult to move toward acceptance. These are usually prolonged and not fully resolved."

Why is suicide particularly associated with unresolved grief?

Because survivors often cannot reconcile what happened or find answers — the lack of closure and the unanswered questions make it very difficult to reach acceptance.

What are the five stages of grief according to Elisabeth Kübler-Ross?

"Denial; anger; bargaining; depression; and acceptance."

What is the denial stage of grief?

Refusing to believe the loss has occurred even when witnessed directly — it is a normal protective response.

What is the anger stage of grief?

Feeling anger toward God; others; or even the person who died — it is a normal and expected response; even if it seems unreasonable.

What is the bargaining stage of grief?

"Making promises or deals — often with God — in exchange for the loved one's survival or more time. Example: If you let them live; I will do whatever you want."

What is the depression stage of grief?

A period where the person has not fully accepted the loss and may struggle significantly to function or cope.

What is the acceptance stage of grief?

Reaching a point of coming to terms with the loss — the person can continue with their life; even though they still feel the loss at times.

Is the grieving process the same for every person?

No — not any two people will go through the stages the same way. The process is different for every individual.

What are the two legal definitions of death?

"Irreversible cessation of all functions of circulatory and respiratory functions; OR irreversible cessation of all functions of the entire brain including the brainstem."

What is brain death?

When the entire brain including the brainstem has irreversibly ceased all functions — the body may continue to function only with the support of machines.

Who determines death — the nurse or the physician?

The physician determines and pronounces death. The nurse's role is to support the patient and family — it is not the nurse's decision.

What does establishing death require in terms of clinical examinations?

Two separate clinical examinations are required to certify death.

What are the five medical criteria used to certify death?

"Cessation of breathing; no response to deep painful stimuli; lack of reflexes (gag or corneal); lack of spontaneous movement; and a flat encephalogram (flat brain waves)."

What are the three components of a good death?

"Death on the patient's own terms; pain-free; and with dignity."

What role do nurses play in supporting a good death?

"A critical role — nurses advocate for the patient's wishes; manage pain; ensure dignity; and support both the patient and family throughout the dying process."

What is the nurse's responsibility if a patient requests pain medication even when it may hasten death?

If the medication is ordered; the nurse can administer it to keep the patient comfortable — the goal is comfort and dignity; not to cause death. If a nurse is not comfortable with this; they should find someone who is so the patient does not suffer.

What are the signs of approaching death?

"Difficulty talking or swallowing; nausea; flatus; and abdominal distention; bowel or bladder incontinence; loss of movement and sensation; decreased body temperature; weak and slow pulse with decreased blood pressure; altered and noisy respirations; cooling and mottling of extremities; and restlessness; agitation; and decreased LOC."

What is mottling of the skin and what does it indicate?

A cooling; blotchy discoloration of the skin (especially extremities) caused by decreased circulation — it can be a sign of approaching death but is not always definitive.

What is a death rattle?

Noisy; labored respirations that occur near death — a pattern where the patient breathes in; stops; and then breathes again. Not all patients experience this.

What is Cheyne-Stokes respiration in the context of approaching death?

An irregular breathing pattern near death — the patient breathes in; stops for a period; then breathes again — it indicates altered breathing near death.

Who typically determines what when and how a patient is told about a terminal illness?

The healthcare provider (HCP) usually determines this — though all healthcare team members need to be informed when death is impending.

Why must nurses be aware of cultural differences when communicating about terminal illness?

In some cultures the family is told first and they decide what to tell the patient — not all cultures value direct disclosure to the patient.

How should nurses approach enabling hope in a dying patient?

Do not give false hope. Avoid saying everything will be okay if it implies the patient will recover when they will not. Be honest while still being supportive and compassionate.

What is palliative care?

"A service that focuses on comfort; pain management; and symptom control — but continues aggressive treatment aimed at treating the underlying disease. It is usually provided in a hospital setting."

What is hospice care?

"A service focused on comfort; pain relief; and quality of life for patients with a terminal illness — generally a prognosis of six months or less. Hospice does NOT pursue aggressive treatment or a cure."

What is the key difference between palliative care and hospice?

Palliative care continues aggressive treatment for the disease while managing comfort. Hospice stops curative treatment and focuses entirely on comfort and dignity.

Can hospice care be provided in a hospital?

Yes — some hospice care occurs in the hospital; but it is usually provided in the patient's home. Hospice also provides mental health support for the family.

How long does hospice follow up with a family after a patient's death?

Hospice typically follows up with the family for one year after the patient's death to support mental health and address depression or grief.

What is advance care planning (ACP)?

The process of making decisions about the kind of healthcare a person wants — or does not want — in specific situations; documented before incapacitation.

What is a living will?

A legal document that provides specific instructions about what kinds of health care should or should not be provided in specific situations — written while the patient is still alive and competent.

What is a durable power of attorney for healthcare?

A legal document that appoints a trusted person (agent) to make healthcare decisions on behalf of the patient if they become incapacitated.

When should advance directives ideally be obtained?

Well before they are needed — once a patient has dementia; they can no longer sign these documents. To get decision-making authority at that point; a family member must go through the court system to obtain legal guardianship.

What does DNR stand for and what does it mean?

Do Not Resuscitate — if the patient's vital signs stop; no resuscitation efforts will be initiated.

What does AND stand for and what does it mean?

Allow Natural Death — a term used interchangeably with DNR; meaning the patient is allowed to die without resuscitation.

What does DNI mean?

Do Not Intubate — CPR and medications may still be given; but the patient is not to be placed on a ventilator or have a breathing tube inserted.

What does comfort measures only mean?

All interventions are focused solely on the patient's comfort and dignity — no life-prolonging measures are taken.

What must a nurse check before responding to a patient with no vital signs?

The nurse must check the patient's chart to see if there is a DNR order and what type of care is required — starting CPR on a patient with a DNR can result in legal consequences.

What happens if a patient or family verbally states there is a DNR but no written document is present?

All life-saving measures must be performed — a verbal DNR is not sufficient. The written; signed document must be present and on the chart.

What is terminal weaning?

The withdrawal of mechanical ventilation when support is deemed futile — the ventilator is removed from a patient who is no longer benefiting from it.

What must nurses do when educating families about terminal weaning?

Educate the family that removing the ventilator does not guarantee immediate death — the patient may continue to breathe on their own after it is removed; possibly for hours or days.

What is the nurse's role in managing a patient during terminal weaning?

"Managing sedation and analgesia to ensure the patient is comfortable and pain-free; and supporting the family emotionally throughout the process."

Can a patient refuse to eat and drink?

Yes — patients have the right to voluntarily stop eating and drinking as part of their end-of-life choices.

What is the nurse's role when a patient voluntarily stops eating and drinking?

"Ensure it is truly a voluntary choice; honor the patient's preferences; and support both the patient and family through this decision."

What is active euthanasia?

An act that brings about death — for example; administering a lethal dose of a drug to end a person's life. Active euthanasia is generally illegal in the United States.

What is passive euthanasia?

"Allowing death to occur through omission — such as withdrawing life-sustaining treatment (removing a ventilator) or withholding treatment (declining surgery that would extend life). Passive euthanasia is considered ethically and legally distinct from active euthanasia."

Is administering ordered pain medication that may hasten death considered active euthanasia?

No — giving ordered pain medication to relieve suffering is not considered active euthanasia because the intent is comfort; not to cause death.

How many U.S. states allow assisted suicide as of this lecture?

Five states allow assisted suicide; with specific circumstances required.

What four things should a nurse assess when caring for a grieving or dying patient and family?

"Adequacy of knowledge base (do they understand what is happening); realism of expectations and perceptions; adequacy of coping strategies; and adequacy of available resources."

What should a nurse do if a family member does not understand why a treatment is or is not being given?

Make sure they understand the patient's condition and all available treatment options — education and explanation are key nursing responsibilities.

What six elements define a trusting nurse-patient and nurse-family relationship in end-of-life care?

"Non-judgmental listening; vigilance to the patient's need to talk; not avoiding questions; using open-ended questions; being open to both the patient's and nurse's own feelings; and not providing false reassurances."

Why are open-ended questions important in end-of-life care?

Open-ended questions allow patients to express their fears; emotions; thoughts; and anticipations — they cannot be answered with a simple yes or no; which encourages deeper sharing.

What should a nurse say if a patient asks please help me to die?

"The nurse cannot help the patient die; but can say: I can't help you die; but I am here for you and I will make you as comfortable as I can. Then communicate with the physician."

What should a nurse say if a patient says please go away?

Respect the request while ensuring safety — say I'll be back in 10 minutes so the patient knows someone is still there for them and will return.

What is the NURSE framework for responding to a patient's emotion?

"Name the emotion (e.g. It sounds like you are worried about the future); Understand the emotion (e.g. You have been through so much already); Respect or praise the patient (e.g. I'm so impressed with how you've dealt with so many ups and downs); Support the patient (e.g. I am here for you no matter what the future holds); and Explore the emotion (e.g. You seem more worried than usual — can you tell me more about it?)."

What should a nurse focus on rather than long-term promises when a patient says they cannot handle more setbacks?

Focus on the immediate present — offer to make today; the next hour; or even the next 10 minutes better. Patients know the long-term outcome; small moments of comfort can make a significant difference.

What are the physical care needs of a dying patient that nurses must continue to address?

"Symptom management; hygiene; pain management; nutrition; fluids; movement; elimination; and respiratory care — basic care continues even as death approaches."

What are the psychological needs of a dying patient?

"Fear of the unknown; pain management; fear of separation; unfinished business; fear of facing death alone; loss of dignity; and loss of control."

What is the nurse's role when a patient expresses fear of the unknown about death?

Acknowledge the fear without providing false reassurance — allow the patient to express their feelings and honor their cultural or spiritual beliefs about what happens after death.

What should a nurse do when a patient reports loss of control?

Allow the patient to make as many choices as possible — preserving some control restores a sense of dignity.

Why is dying alone considered one of the most difficult psychological aspects of death?

"Dying without family or loved ones present — as seen during COVID-19 — leaves patients completely isolated in their final moments; which is considered one of the most distressing experiences."

What is a nurse's responsibility for care of the body after death?

"Clean the environment; position the body to appear natural and comfortable with a pillow under the head; place dentures in the mouth (before rigor mortis sets in); change linens and wash the body if needed; put a clean gown on; comb the hair; remove tubes if permitted; and close the eyelids."

Why must dentures be placed in the mouth promptly after death?

Once rigor mortis sets in the jaw cannot be moved — dentures must be placed before this occurs.

Why is it important to close the patient's eyes after death?

To maintain dignity and avoid distressing the family when they view the body.

What should the room look like when the family comes to view the body?

"The environment should be clean; the body positioned naturally; tubes removed if allowed; linens changed; and the patient made as presentable as possible."

What is the nurse's responsibility regarding care for the family after a patient's death?

"Listen; offer solace and support; arrange for the family to view the body; allow adequate time and space for grieving; provide guidance in making plans; attend the funeral if appropriate; and follow up."

Who is responsible for ensuring the death certificate is signed?

The nurse is responsible for ensuring the physician's signature is on the death certificate.

Who must sign the death certificate?

The clinician (physician) who cared for the patient; and the pathologist or coroner if required.

What is the mortician's legal responsibility regarding the death certificate?

The mortician assumes responsibility for completing and filing the death certificate with the proper authorities.

What organs and tissues can be donated?

"Corneas; heart; lungs; pancreas; liver; kidneys; intestines; ligaments; veins; bones; skin; and heart valves."

Does having organ donation marked on a driver's license legally bind the family to honor that decision?

No — the family may choose not to honor it. The family's decision carries significant weight; even if the patient previously indicated a wish to donate.

What is the nurse's role in organ donation?

Review organ donation options with the family and provide consent forms. A designated staff member at most facilities handles organ donation conversations after a death.

Why must the family make organ donation decisions quickly?

"Once the decision is made; multiple teams are activated — a harvesting team and transplant teams at receiving facilities — and organs must be implanted very quickly. Things move rapidly after consent."

When is organ donation typically discussed with the family?

After the patient has died — a designated person on staff will approach the family to discuss donation options.

What is an autopsy?

An examination of the organs and tissues of the body after death to determine the cause of death.

Who gives consent for an autopsy?

The closest family members give or refuse consent — the healthcare provider obtains permission.

When is an autopsy automatically required regardless of family consent?

"When death is caused by accident; suicide; homicide; or illegal therapeutic practice — the coroner must be notified."

Can the coroner order an autopsy even if the family refuses?

Yes — if there is reason to suspect the death was not natural; the coroner can override the family's wishes and order an autopsy.

When does a patient who dies in the hospital typically NOT need an autopsy?

If they died under the care of a physician in the hospital; an autopsy is generally not required unless there are suspicious circumstances.

What is The Pause in end-of-life nursing care?

A moment of silence offered to the healthcare team after a patient's death — honoring both the patient and the efforts of the team. It is supported by NIH guidelines and helps reduce burnout and unresolved grief.

What is debriefing after a patient death and who participates?

"A structured meeting of the team after a difficult patient death — nurses; respiratory therapists; the hospital chaplain; and a support counselor review what happened; what went well; and what could have been done differently; without judgment."

What is the purpose of debriefing after a patient death?

"To allow the team to process emotions; reduce feelings of frustration and helplessness; acknowledge what went well; identify what could be done differently; and support each other — especially new nurses experiencing their first patient death."

What should a nurse do if their facility does not provide debriefing after a patient death?

Seek counseling through HR or their director — facilities should offer counseling after the death of a patient; and nurses should ask for it if it is not automatically provided.