Grief and loss Lecture notes (completed)
Loss, Death & Grief
Introduction
Objectives
1. Classify the types of loss experienced throughout life
2. Compare the types of grief
3. Explain characteristics of a person experiencing grief
4. Develop a nursing care plan for a patient and family experiencing loss and grief.
5. Prioritize interventions for symptom management in patients at the end of life
6. Discuss the criteria for palliative and hospice care
7. Summarize care of the body after death.
How Nurses Impact Grief
Nurses play a crucial role in supporting patients and families during the grieving process through education, empathy, and direct care.
Types of Grief
1. Expected grief: Grief experienced before the loss occurs, often due to anticipation.
2. Normal grief: Typical emotional responses following a loss that align with societal expectations.
3. Prolonged and/or difficult grief: Grief that extends over a long time and may complicate the healing process.
4. Disenfranchised grief: Grief that is not publicly acknowledged or socially sanctioned, often leading to isolation.
5. Anticipatory grief: Grieving that occurs when a loss is anticipated, allowing emotional preparation for the event.
6. Complicated grief: Grief that is intense and persists beyond normal expectations, potentially leading to mental health issues.
Theories of Grief & Loss
Knowledge of theories can assist the nurse in caring for grieving patients and their families:
Kübler-Ross’ Stages of Grief:
Denial: Refusal to accept the truth of loss.
Anger: Frustration and helplessness manifest as anger.
Bargaining: Attempting to negotiate ways to reverse the loss.
Depression: Deep sorrow and withdrawal from others.
Acceptance: Coming to terms with the loss.
Bowlby’s Attachment Theory: Emphasizes the bonds between Children and their caregivers; loss disrupts these bonds and induces grief.
Factors Influencing Grief & Loss
Factors that can influence an individual's grieving process:
Development: Age and developmental stage can impact how loss is perceived and processed.
Relationships: The nature of the deceased relationship affects grief intensity.
Nature of Loss: The circumstances and perceived significance of the loss.
Coping/Support: Available support systems and individual coping mechanisms.
Socioeconomic Status (SES): Access to resources and support can influence grief experiences.
Culture and Religion: Cultural and religious beliefs shape the grieving process and rituals.
Hope: Maintaining a sense of hope or purpose can aid in coping with loss.
Organizational Support
Organizations that assist with end-of-life issues:
End of Life Nursing Consortium (ELNEC)
American Nurses Association (ANA)
National Hospice and Palliative Care Organization (NHPCO)
American Society of Pain Management Nurses (APSMN)
Hospice vs. Palliative Care
Palliative Care: Focus on life-extending treatments for chronic conditions with an emphasis on symptom management.
Hospice Care: For patients with a prognosis of 6 months or less. Focus on symptom management without life-extending treatments and can be provided in various settings (home, nursing home, inpatient units).
Assessment
Assessing a grieving patient requires a broad understanding of:
Patient’s perspective: Understanding their perception of illness and prognosis.
Distressing symptoms: Identifying symptoms that cause the patient the most distress.
Social support systems: Evaluating the patient's support network.
Cultural/Religious/Spiritual beliefs: Important factors that influence coping and grieving processes.
Grief reactions: Observing emotional and behavioral responses to loss.
Environmental factors: Contextual factors affecting patient wellbeing.
Nursing Diagnoses
Common nursing diagnoses related to grief and loss include:
Death Anxiety: Fear about the process and implications of dying.
Pain: Physical discomfort affecting wellbeing.
Impaired Coping: Difficulty in managing emotional responses.
Dysfunctional Grief: Inability to process loss healthily.
Anticipatory Grief: Grief experienced before an expected loss.
Hopelessness: A feeling of despair regarding the future.
Fatigue: Physical or emotional exhaustion.
Impaired Breathing: Respiratory issues affecting comfort.
Planning - Patient Specific
Characteristics of effective planning in nursing include:
Realistic Goals: Set achievable goals based on the patient's situation.
Collaborative Approach: Work with the healthcare team and family to create a unified care plan.
Setting Priorities: Identify urgent needs first, such as pain management or emotional support.
Physical and Psychological Needs: Address both physical symptoms and emotional concerns.
Planning - Concept Map
Nursing Diagnosis: Hopelessness
Signs: Frequent sighing, negative outlook, expressionless demeanor.
Nursing Diagnosis: Chronic Pain
Symptoms: Swollen, painful toes, severe back pain.
Interventions for Chronic Pain:
Administration of pain medications, around-the-clock management, use of non-pharmacological methods (e.g., massage).
Nursing Diagnosis: Fatigue
Symptoms: Lack of energy, chronic arthritis pain leading to bed rest.
Intervention Strategies:
Schedule rest periods, encourage physical therapy, facilitate discussions about feelings of fatigue.
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements
Symptoms: Reduced appetite, feelings of giving up, recent weight loss.
Interventions:
Encourage social activities related to meals, identify easily prepared foods, facilitate meal delivery services.
Interventions
Recommendations for nursing interventions in end-of-life care:
Manage physiological symptoms initially.
Provide psychosocial care: Focus on emotional support and therapeutic communication.
Health promotion and teaching: Educate patients and families about the process.
Promote dignity: Respect their wishes and privacy.
Maintain a peaceful environment: Reduce stress and anxiety for the patient.
Support the grieving family: Provide them with information and emotional support.
Dying Person's Bill of Rights
Rights for individuals at the end of life include:
To be treated as a living human until death.
To maintain hopefulness, shifting its focus if necessary.
To have caregivers who also maintain a sense of hope.
To express thoughts and feelings about approaching death in their own way.
To participate in decision-making regarding their care.
To have medical and nursing attention continue even if goals shift from "cure" to "comfort."
To not die alone.
To be free from pain.
To have questions answered honestly.
To retain individuality despite differing beliefs from others.
To expect respect for the sanctity of the human body after death.
To receive care from compassionate and knowledgeable staff who seek to understand needs and assist them in facing death.
Physical Changes Hours or Days Before Death
Observable signs that may occur shortly before death include:
Increased sleep and unresponsiveness.
Circulatory changes (coolness and color changes of extremities).
Possible bowel or bladder incontinence.
Decreased urine output, possibly dark-colored.
Symptoms of restlessness, confusion, or disorientation.
Reduced intake of food or fluids, difficulty swallowing.
Increased pulmonary secretions leading to noisy breathing (death rattle).
Altered breathing patterns (apnea or Cheyne-Stokes respiration).
Decreased muscle tone and relaxed jaw muscles.
Profound weakness and fatigue.
Managing EOL Symptoms
Pain: Understand different causes and collaborate to find effective treatments (pharmacological and non-pharmacological).
Skin discomfort: Maintain skin care to minimize irritation.
Mucous membrane discomfort: Regular oral care to combat dryness.
Fatigue: Provide rest and encourage energy conservation.
Anxiety: Create a supportive environment for emotional expression.
Nausea: Identify causes and apply treatments as necessary.
Constipation/Diarrhea: Address dietary and medicinal interventions timely.
Urinary incontinence: Ensure accessibility to toilets/manage hygiene needs.
Ineffective breathing patterns: Positioning can facilitate easier respiration; oxygen can be administered as needed.
Noisy breathing: Manage secretions and improve comfort through positioning and hydration efforts.
Care After Death
Organ procurement:
Eligibility and consent
Timing
Coordination
Autopsy
Purpose
Types
Consent
Post Mortem Care
Steps for post-mortem care:
Confirm Death: Accurately assess and document death.
Prepare the Environment: Ensure privacy and gather necessary supplies.
Care for the Body: Includes proper positioning, cleansing, and dressing.
Remove Medical Devices: Such as tubes, lines, and dressings.
Document & Legal Considerations: Properly document events surrounding death and notify relevant personnel.
Support the Family: Provide emotional support, information, and assistance during the transition.
Prepare for Transfer: Including shrouding and tagging the body, ensuring personal items are handled respectfully.
Religion/Culture Post-Mortem Care Considerations
Different religions and cultures have specific practices regarding the care of the body after death:
Christianity: Body treated with respect, prayer may accompany preparation.
Islam: Body must be washed (Ghusl), shrouded in white cloth, and treated with utmost respect.
Judaism: Similar respect with ritual washing (Tahara) and dressing in a white shroud (Tallit).
Hinduism: Body washed and dressed; prayers and offerings often included.
Buddhism: Practices may include ritual washing and treatment of the body with respect.
Native American: Practices vary widely, often involving rituals that respect the deceased.
African Traditional Religions: Similar variation in practices, often including rituals to honor the deceased.
Burial Timing Considerations
Traditional practices regarding burial timing vary:
Christianity: Typically within 3-7 days after death, varying by denomination.
Islam: Ideally as soon as possible, usually within 24 hours after death.
Judaism: Same urgency as Islam, generally within 24 hours after passing.
Hinduism: Usually within 24 hours; cremation is common.
Buddhism: Burial/cremation generally occurs within a few days.
Native American and African Traditions: Vary widely, often involving specific ceremonies and rituals.