Death and Grief Study Notes

Loss and Death

  • Loss: Actual or potential situation where something valued is changed or no longer available.
  • Affects everyone and leads to grief.
  • Nurses help clients deal with the loss of people, roles, health, body parts, or even life itself.
  • Death is a fundamental loss, both for the dying person and their survivors.

Types of Loss

  • Actual Loss: Recognized by others (e.g., death of a patient).
  • Perceived Loss: Experienced by one person but cannot be verified by others (e.g., loss of self-confidence).
  • Anticipatory Loss: Experienced before the loss occurs; can be actual or perceived (e.g., terminal illness of a loved one).

Types of View

  • Situational: Unexpected (e.g., loss of a job, death of a child).
  • Developmental: Expected part of life (e.g., departure of children from home).

Sources of Loss

  • Loss of an aspect of oneself: Losing hope after a failure
  • Loss of an object external to self: Losing a necklace from a deceased parent
  • Separation from the accustomed environment: Transferring to a new school
  • Loss of a loved one: Death of a sibling

Bereavement, Grief, and Mourning

  • Bereavement: Subjective response by surviving loved ones.
  • Grief: Total response to the emotional experience of loss.
  • Mourning: Behavioral process through which grief is resolved or altered.

Types of Grief Responses

  • Abbreviated Grief: Brief but genuinely felt; strong coping mechanisms (managing to move forward quickly).
  • Anticipatory Grief: Experienced in advance of the event (e.g., grieving while someone is in hospice; moving on quickly).
  • Disenfranchised Grief: Occurs when a person is unable to acknowledge the loss of the person (e.g., a secret relationship ends, but you can’t tell anyone).
  • Complicated Grief: Strategies to cope with the loss are maladaptive.
    • Unhealthy, maladaptive, unresolved, or chronic.
      • Unresolved/Chronic Grief: Never processed.
      • Inhibited Grief: Hiding emotion.
      • Delayed Grief: Denial or suppressed grief.
      • Exaggerated Grief: Too intense, could lead to self-harm.
Manifestations of Grief
  • Normal Manifestations: Verbalization of the loss, crying, sleep disturbance, loss of appetite, difficulty concentrating.
  • Complicated Grieving: Expanded time of denial, depression, severe physiologic symptoms, suicidal thoughts.

Factors Influencing Loss and Grief Response

*Culture: Death of nuclear family member in culture with extended family may soften impact. Private versus social grieving
*Spiritual Beliefs: Most religious groups have practices related to dying. Knowledge of cultural and religious heritage allow nurses to assist families
*Age
*Culture
*Gender
*Socioeconomic support system
*Causes of death

Death-Related Religious and Cultural Practices

  • Help people cope with death.
  • Beliefs and attitudes, rituals vary.
  • Beliefs about preparation of body, autopsy, organ donation, cremation, and prolonging life are affected by religion.

Death-Related Legal Issues

  • Advance healthcare directives.
  • Do-not-resuscitate orders.
  • Organ donation.
  • Euthanasia, aid in dying.

Engel's 6 Stages of Grief Reaction

  1. Shock and disbelief
  2. Developing awareness
  3. Restitution - calming
  4. Resolving the loss
  5. Idealization - see in a positive way
  6. Adaptive - result of what you are after your loss / move on or still grieving

Kubler-Ross Stages of Grief and Dying

  1. Shock
  2. Denial
  3. Anger
  4. Fear
  5. Bargaining
  6. Depression
  7. Acceptance
  8. Forgiveness
  9. Renewal
  10. Serenity

Mustachio’s Manifestation of Grief and Bereavement

  • Shock and disbelief
  • Yearning and protest (bargaining and anger)
  • Anguish, disorganization, and despair (bargaining)
  • Identification and bereavement (acceptance)
  • Reorganization and restitution (acceptance and forgiveness)

Rando’s Three Broad Categories

  1. Avoidance - “I’ve got too much work to do to wallow in this stuff.”
  2. Confrontation (with the reality of death) - “Everything I see reminds me of her and can set me off.”
  3. Reestablishment - “Last week when I got the award, I thought about my dad and how proud he would have been.”

Sender’s (1998) Five Phases of Bereavement

  1. Shock - confused, unreal, disbelief
  2. Awareness of loss - conflict, stress, separation anxiety
  3. Conservation/ Withdrawal - despair, hopelessness, isolation
  4. Healing - acceptance
  5. Renewal - acceptance, revitalization

Death Definition and Signs

  • Total lack of response to external stimuli
  • No muscular movement
  • No reflexes
  • Flat encephalogram
3 Types of Awareness
  1. Closed awareness - client not aware of impending death
  2. Mutual pretense - client, family, and health personnel know prognosis is terminal but do not talk about it
  3. Open awareness - Client and others know about the impending death and feel comfortable discussing it.

Nursing Process

Assessment

  • Accurate assessment of the physiological signs of approaching death
  • Assist family to prepare
    1. Fear
    2. Hopelessness
    3. Powerlessness
    4. Risk of caregiver

Diagnosing

Planning

  1. Maintain physiologic and psychologic comfort
  2. Achieve a dignified and peaceful death
  3. Dying at home requires able and giving caregivers
  4. Outpatient hospice referral
  5. Planning for home care

Implementing

  • Minimal for some, continuous for others
  • Period of dependence
  • Client should consider how and where he or she would like to die
Helping Clients Die with Dignity
  • Determine what client knows about illness
  • Respond with honesty and directness
  • Make time to be available
Hospice and Palliative Care
  • Hospice - quality, not length, of life
  • Palliative care - comfort, not cure
  • End-of-life care - are provided in the final weeks of life

Post Mortem Care

  • To clean and prepare the patient's body before it is transported to the morgue
    1. Confirm the patient has been declared dead
    2. Identify the body, label it, and gather belongings
      • Do not remove wedding rings unless necessary
    3. Ask visitors to step out if needed
    4. Follow hospital policies
    5. Clean the body, close eyes and mouth, position body properly
Stages of Decomposition
  • Pallor Mortis: Paleness of death. Almost immediately after death, the body of a person with light skin will begin to grow very pale. This is caused by a lack of blood in the capillary region of the blood vessel.
  • Algor Mortis: Cool of death. After death, a human body will no longer be working to keep warm and as a result will start cooling. About an hour postmortem (after death)….
  • Rigor Mortis: Stiffening of body 2-4 hours after death.
  • Putrefaction: Decomposition of proteins in a process that results..
  • Liver Mortis: Discoloration in dependent areas. The blood pools.