Death and Dying

* Moving from one city to another
* Separation
* Divorce
* Death of a parent, spouse, or friend

People may suffer the loss of valued relationships through life changes, such as

•Decreasing health

•Loss of a body part

•Terminal illness

•Impending death of self or a significant other

In clinical setting, the nurse encounters clients who may be experiencing grief related to:

•Personal Crisis (e.g. Divorce, Separation, etc.)

•Natural Disaster (e.g. Earthquakes, floods, hurricanes)

The nurse may also work with clients in community setting who are grieving losses, related to:

LOSS

Is an actual or potential situation in which something that is valued is changed, no longer available, or gone

• Body image

• Significant other

• A sense of well-being

• A job

• Personal possessions

• Beliefs

\- A sense of self

Death 2

__________ is a fundamental loss, both for the dying person and for those who survived

Although it is inevitable for everyone, it is a lonely experience that each person ultimately faces alone

Death 3

__________, like loss, can stimulate people to grow in perception of both themselves and others

Death

can be viewed not simply as loss of life, but as the dying person’s final opportunity to experience life in ways that bring meaning and fulfillment

Actual Loss

• Type of Loss

• Can be identified by others

• **Can arise either in response to or in anticipation of a situation**

Perceived Loss

• Is experienced by one person but cannot be verified by others

• Psychologic losses are often perceived losses, in that they are not directly verifiable

1\.Loss of one aspect of oneself

•A body part

•A physiologic function

•A psychologic attribute



2\.Loss of an object external to oneself

3\.Separation from an accustomed environment

4\.Loss of loved one or valued person

Sources of Loss

* Actual
* Perceived

Types of Loss

* Situational
* Maturational

Divisions of Loss

Situational Loss

abrupt, unexpected loss e.g. fire, snatching

Maturational

•Division of loss

•Occurs in the process of normal development

•Expected loss, occurs gradually

EX:

»Babinski reflex of a baby disappears once he learns how to walk

»Death of aged parent

Grief

•is the **total response** to the emotional experience related to loss

•is manifested in thoughts, feelings, and behaviors associated with overwhelming distress or sorrow

Bereavement

•Is the subjective response experienced by the surviving loved ones after the death of a person with whom they have shared a significant relationship

Mourning

•Is the behavioral process through which grief is eventually resolved or altered

•Often influenced by culture, religious experience, and custom

* Denial
* Anger
* Bargaining
* Depression
* Acceptance

Stages of Grieving (by Elizabeth Kubler-Ross)

Denial

•refuses to believe that the loss is happening

•is unready to deal with practical problem, such as prosthesis after loss of leg

•May assume artificial cheerfulness to prolong denial

\
–Nursing Implications

•Verbally support client’s denial for its protective function

•Examine your own behavior to ensure that you don’t share in client’s denial

Anger

•Client or family may direct anger at nurse or hospital stuff, about matters that normally would not bother them

•Patients become frustrated, irritable, and angry that they are sick

\
–Nursing Implications:

•Help client understand that anger is a normal response to feelings of loss and powerlessness

•Avoid withdrawal or retaliation with anger, do not take anger personally

•Provide structure and continuity to promote feelings of security

•Allow clients as much control as possible over their lives

Bargaining

•Seeks to bargain to avoid loss

•May express feeling of guilt or fear of punishment for past sins, real, or imagined

•The patient may attempt to negotiate with physicians, friends, or even God that in return for a cure, the person will fulfill one or many promises, such as giving charity or reaffirm an earlier faith in God

\
–Nursing Implications:

•Listen attentively, and encourage client to talk to relieve guilt, and irrational fear

•It appropriate, offer spiritual support

Depression

•Grieves over what has happened and what cannot be

•May talk freely (e.g. reviewing past losses such as money or job), or may withdraw

•The patient shows clinical signs of depression –

• withdrawal, psychomotor retardation, sleep disturbance, hopelessness, and possibly suicidal ideation

\
–Nursing Implication:

•Allow client to express sadness

•Communicate nonverbally by sitting quietly without expecting conversations

•Convey caring by touch

•Help support person understand the importance of being with client in silence

Acceptance

•Comes to terms with loss

•May have decreased interest in surrounding and support persons

•May wish to begin making plans (e.g. will, prosthesis, altered living arrangements)

\
–Nursing Implications:

•Help family and friends understand the client’s decreased need to socialize and need for short, quiet visits

•Encourage client to participate as much as possible in the treatment program

* Chronic
* Delayed
* Exaggerated
* Masked
* Disenfranchised

Types of Dysfunctional Grieving

Dysfunctional Grieving

Exceeds the normal (1 year) span of time for grieving

**Chronic**

type of dysfunctional grieving, cannot get over the loss

Delayed

• type of dysfunctional grieving, consciously / unconsciously suppressed the feeling

• Late / after some time before expressing

Exaggerated

• type of dysfunctional grieving, cannot function effectively

• Overwhelming feeling

• Catatonia (motionless, same position for a long time)

Masked

• Type of dysfunctional grieving, No awareness on the part of the person involved but depression (somehow suppressed) interferes with normal activities

Disenfranchised

• Type of dysfunctional grieving, Prohibition or expression of feelings as dictated by norms / culture

* Physiological (clinical, brain, cellular)
* Situational (natural/expected, sudden, unexpected, suicide)

Types of Death

Dead

•End of Life

•Vital organs and functions ceases

Death

* the last developmental task

Legal Death

person./patient is declared dead by a physician/doctor

Death with Dignity

* philosophical thought that a person should die naturally without use of respirators to prolong life

Thanatology

• Study of death in relation to medical psychology realm / field

Mummification

* halts the process of decay

Putrefication

* bacteria start to attack corpse after 3-4 days especially if unattended

* Human development
* Psychological perspective
* Socio-economic status
* Personal Relations
* Nature of loss (anticipatory, sudden)
* Culture and Ethical
* Spiritual

Factors Affecting Grieving

Toddlers

–have Separation Anxiety (don’t want to leave parents) accompanied by Strangers / Anxiety

–They live in fantasies / imagination – they don’t grieve by crying

Older kids

see death as a reality

Adults

–Accept death of parents but not of own spring

Algor Mortis (cold)

* decreasing body temp
* Body temperature decreases by 1°C every hour until it reaches room temperature
* This is due to failure of hypothalamus to function

Livor Mortis (color)

•Discoloration of the body

•The red blood cells break down, releasing hemoglobin, which discolors the surrounding tissues

•Is apparent in areas where pressure is applied (person’s back if in supine position)

**Embalming**

reverses the process through injection of chemicals into body to destroy the bacteria

Postmortem Care

•Care given to the dead body

•To clean the patient’s body and prepare it for removal from the hospital after death

•Nursing gives care from womb to tomb

* Preserve (natural position; anatomical position, arms flexed at chest)
* Protect (from damage)
* Present (aesthetic presentation for family)

Purposes of Postmortem Care

“Why me?”

Anger stage common response

Older People

Embrace death as a destination

Euthanasia

•Mercy killing

•Types:

* Passive Euthanasia
* Active Euthanasia

Euthanasia Types

Passive Euthanasiaa

Type of Euthanasia, You don’t help so the patient dies

Active Euthanasiaa

Type of Euthanasia, You do something to kill

1 year

normal span of time for grieving