Grief, Loss and Dying Flashcards
Loss
an actual or potential situation
where something of value is changed or. gone or no longer available
Types of Loss
Actual –
Perceived –
Anticipatory/Maturational -
Situational-
can be identified by others.A response to a situation: Death of loved one, theft, destruction, natural
disaster
experienced by 1 person but can’t be
verified by others (internal loss) psychological loss:
woman gives up career to stay home with children
preparing before loss happens; caregiver/spouse of. terminal patient
sudden, unpredictable external
events: accident, physical changes, loss of
income, life goals
EXAMPLES OF ACTUAL LOSS (5)
- Aspect of self- body parts, loss of function/mobility, organ
- External Objects- theft-house, job, finance, pet
- Familiar Environment- leaving home for nursing home,
getting a new job - Loved Ones- death, separation, illness, change in
personality - Developmental Loss- progression through life, different
stages of life
GRIEF (4)
Intense emotion
The physical, psychological and spiritual
responses to a loss
Grief process allows person to metabolize
the grief
begin resolution
Mourning –
consists of ACTIONS associated with grief such as wailing, wearing black clothing
Bereavement –
period of mourning and adjustment time after a loss. Encompasses both grief and mourning, includes the emotional responses and outward behaviors of a person experiencing loss
Factors that affect the grieving process (12)
Significance of the Loss – meaning attached to loss
Support System – people to lean on
Unresolved Conflicts – may lead to complicated grief
Circumstances of the Loss – manner of death, feel guilty,
unprepared, violent death
Previous Loss – sustained several losses in a short period
Spiritual/Cultural Beliefs and Practices – ability to express
grief
Timeliness of the Death – age of deceased, child too young
Factors
Age – each developmental age views loss differently
Sex – Men and Women grieve DIFFERENTLY!!!
Socioeconomic variables – economic hardships, loss of
loved one’s income, social security benefits, change in
lifestyle (couple > single, dual income > single income)
Coping mechanisms - Positive: seeking out others,
expressing feelings, support groups.
Negative: social
isolation, repressing feelings, refusal to acknowledge the
loss.
Types of Grief (4)
a.
b. Remember the subcategories
c.think of kamar instagram name
d
A. Uncomplicated (normal Grief): common, natural response to a loss,
experiences the feelings, behaviors, physical, and spiritual
responses of his/her culture. Intensity of grief will diminish over time
- ACCEPTS NEW INSIGHTS INTO OWN LIFE
-ACCEPTS LOSS
B. Complicated: prolonged or significantly difficult time moving forward after a loss.
- MORE THAN 1 DEATH
1a.CHRONIC
2b. MASKED
3c. -DELAYED
4d. EXTENDED LENGTH OF TIME
FEELINGS OF “STUCKNESS”
C. Disenfranchised: experiences a loss that is not socially supported or
acknowledged by the usual rites or ceremonies (Ex: miscarriage,
death of mistress)
D. Anticipatory: experienced before the loss occurs, Ex: caring for a
loved one with Alzheimer’s disease, terminal illness
Characteristics of complicated grief
- extended length of time engages in detrimental behavior
- often “stuck
- little time/ energy for normal life
s/s assessments of complicated grief 6
somatic sx
- aches and pain
- SOB
- tightness
- sleep disturbances
- no adl
- lower self esteem
(masked grief)
Engages in detrimental behavior: drinking, drug use,
isolation, poor self-care
(complicated grief )
(delayed
grief)
Person uses energy to suppress grief rather than
releasing it: avoidance of grief process
Medical Treatment for pts( 4)
Professional help required: possible in-house
treatment or outpatient
Medications – anti- depressants
Psychotherapist, psychiatrist
Grief support groups: widows, children,
parent, loss from trauma
Medications (3)
a.citalopram hydrobromide- Celexa
b.sertraline hydrochloride-
Zoloft)
c. anti-anxiety drugs: (lorazepam-Ativan)
Stages of Grief Using Grief Wheel
Model (6)
1.Shock and disbelief: refusing to believe
2.Developing Awareness: reality of loss begins,
anger, feeling of sadness
3.Restitution: funeral rites, ceremonies
4.Resolving the loss attempts to deal with painful
loss, accepts the grieving process that must be
gone through, work through it
5.Idealization: emphasis on the positive aspects of
the loved one
6.Outcome – positive or negative
“Magical thinking”
believe they are the
cause of events.
school-age children grief
Interventions (6)
For disorganization:
For reorganization
BE THERE !!! : overwhelming process
LISTEN !!! : with acceptance, grieving people do not
hear advice, can not be cheered up
Normalize the process: normal for everyone
For protest/anger: utilize TCT, support systems, good
health habits, avoidance of drugs and alcohol
For disorganization: encourage personal counseling,
support groups, may need help putting event in
perspective, spiritual/religious support
For reorganization: career counseling, educational
programs promoting patient well-being, social
activities, journal writing
Types of Death (2)
Heart(Lung Death):
-Irreversible cessation of
spontaneous respirations
and circulation
-No respirations
-No pulse or BP and ECG
shows no heartbeat
activity
-Cells no longer capable of
life, necrosis of organs
occur
- longterm care/ dnr
Higher (Brain death)
-Irreversible cessation of all higher brain
functions
-Electroencephalogram (EEG) shows no brain
wave activity
-Cerebral cortex and brain stem are
irreversibly destroyed
- machine keeps pt alive
- doctor make choice
- accidents/ several mi/icu
Organ, Eye, Tissue Donation
Recovery of organs,
eyes, or/and tissues to
enhance or save the lives
of others.
Patient request, use of
donor card (driver
license), honor his/her
request but may not if
strong family objection
5 stages of Dying
Individual Proceess.
a. denial
b.anger
c. bargaining
d. depression
e. acceptance
Denial ( define / nursing interventions)
Just found out about terminal illness/ Stunned, shock, emotions overwhelming, act like a
“zombie”
assume artificial cheerfulness
Nursing interventions: Active listening, responses
translated into feelings “ This must be very difficult for you
to understand and come to terms with”. Offer silence,
just be with patient, encourages patient to express their
thoughts and feelings. Help establish support system
Anger ( define/ nursing interventions)
“why me?’’
Nursing interventions: Don’t take anger personally.
Be there (power in presence). Allow patient to
express themselves, anger not rational. Help
patient find an outlet for anger – journal writin
Bargaining ( define/ nursing interventions)
Asking intervention by another – 2nd opinion doctor, new
treatment options(holistic, research/trial meds), God
- Attempting to negotiate a trade with God or Fate
-Trying to delay the inevitable
Nursing interventions: Listen and offer support. Patient
and family probably getting exhausted at this stage due to
the grief process. Encourage talking. Ask about
spiritual support
Depression ( define/ nursing interventions)
“down” time, expected sadness, change in interactions
Sets in when defense mechanisms (denial, bargaining)
are no longer working
Great sense of loss, no longer deny illness or the
situation.
Nursing interventions: Allow patient to express their
feelings. Be there without having to carry on a
conversation. Allow time to grieve, do not chit chat
about unimportant things. Use sense of touch
Acceptance/Nursing Interventions
Moves forward, moving toward resolution, come to terms
with situation
Only begins when shock of loss is over
Considered a stage of relative peace
Contemplate past and review accomplishments in their life
Making funeral plans
Patient feels at peace and are ready to go, they are tired
Nursing interventions: Encourage memories/stories.
Look at pictures. Assist family members who are
struggling with acceptance. Power of presence –
hand holding, sitting close
End of life (dying) issues-
Quality of Life
Physiologic Well-being
Psychological Well-being
Social Well-being
Spiritual Well-being
Physiologic well-being (2)
Cachexia (malnourished, poor health, weakness and emaciation)
Fatigue, increase sleep to conserve energy,
decrease appetite or desire for food, cognitive
changes, decreased functional abilities
Cachexia
(malnourished, poor health, weakness and emaciation)
Psychological Well-Being (4)
Life threatening time for the patient. Encourage
patient to make decisions regarding his/her
care and what they want to accomplish.
Fears surrounding the dying process
Struggle to maintain control of life
Decreased enjoyment in leisure activities
Social Well-Being (5) for dying pts
Roles and relationships begin to change
Caregiver role increases (stress increases, self-
neglect)
Affection/intimacy needs are increased, sexual
function decreased
Financial issues – burden d/t advancing disease,
exhausted health care benefits, worried how bills will
be paid, not wanting to leave loved ones in debt.
Going into public places may be difficulty d/t change
in appearance. Body image and self-esteem become
a concern
Spiritual Well- Being (4)
Becoming a priority
Dealing with religious faith, questioning higher
power, “where do I go from here?”
Meaning of pain and suffering
Feeling hopeless and powerless over his/her
fate
physiologic effect of dying process
( senses )3
HEARING IS THE LAST TO GO!
vision blurred
impaired taste
sagging of tongue
physiologic effect of dying process
skin
Peripheral
drenching
mucous membrane
extreme pallor
physiologic effect of dying process
respiratory
cheyne stokes
rapid , shallow, irregular , dyspnea
noisy (gurgles), non productive cough
physiologic effect of dying process central nervous system
muscle tone decrease
agitation
LOC changes
Children - Preschool (6)
Does not comprehend the concept of
death
Believes death is reversible/temporary,
or the person is sleeping
Fears separation
Behavior changes may occur with eating,
sleeping patterns, fussiness, bed wetting
or elimination accidents during the day
Believes own death can be avoided
Associates death with aggression or
violence
Childhood - age 5 years and up (5)
Beginning to understand that death is
permanent
Believes that death can happen but not to
themselves or anyone they know
“Magical thinking” – believe they are the
cause of events
May express an interest in the afterlife:
Where is Grandpa right now? What is he
doing? Are Grandma and Grandpa together
with my dog?
May or may not show sadness
Adolescent (5)
Although teens look mature, often lack
emotional maturity
Believe they are immortal/invincible.
(nothing can hurt them)
May fantasize that death can be defied;
act out reckless behaviors.
Seem to reach adult perception of
death, but emotionally unable to accept
it.
May feel responsible to take care of
grieving others and avoid grieving
themselves (help Mom feel better with
loss of Dad)
Adulthood (6)
Concerns relate to deaths of
others/friends/family members.
Through life experiences and
developmental growth develops a
personalized sense of mortality
Understand death is inevitable
Accepts own mortality: preparing for
death – Will, HCP, financial security
Encounters death of friends/ family
members- parents
Experiences death anxiety at times:
anxious
about illnesses, own well-being
Older Adult (4)
Fears prolonged illness
Encounters death of friends, peers and family
members
Views death as having multiple meanings-
freedom from pain/reunion with deceased friends
and family members
Fears becoming a burden, loss of independence
(physical and functional losses)
Cultural Beliefs (Asian/ western/African
Western cultures: Funerals, memorial services, and burials are common practices. There might be religious or secular ceremonies to honor the deceased.
Asian cultures: Practices like ancestor worship, burning of offerings, and specific mourning periods are common.
African cultures: Traditional ceremonies, communal mourning, and rituals involving music and dance are often part of the grieving process.
Nursing Care of the Dying Patient
Oxygen needs
Integument care
Nutrition/Fluids
Elimination
Sleep, rest and activity
Psychological care
Oxygen needs = 02 nasal cannula/mask/ raise head of the bed, bronchodilators, antianxiety, morphine, sedation occurs before
Integument care =Positioning: Reposition the patient regularly to prevent pressure ulcers. Use supportive devices like pillows and cushions to relieve pressure on bony prominences.
Skin Care: Keep the skin clean, dry, and moisturized. Use gentle, non-irritating products. Be mindful of fragile skin, and avoid friction during repositioning.
Pain Management: Administer pain relief as needed. Painful wounds or pressure ulcers should be managed effectively.
Nutrition/Fluids=Hydration: Offer small sips of water or ice chips if the patient is conscious and able to swallow. Intravenous hydration might be considered in certain cases.
Comfort Foods: Provide favorite foods if the patient desires, even if they are not part of a typical medical diet. Focus on providing comfort and pleasure in eating.
Elimination= Toileting Assistance: Provide assistance with toileting as needed, ensuring the patient’s dignity and privacy are respected.
Incontinence Management: Use absorbent pads or briefs to manage incontinence. Provide gentle peri-care to maintain hygiene and prevent skin irritation.
Sleep, rest and activity= Create a calm, quiet, and soothing environment to promote rest and sleep. Use dim lighting, soft music, or nature sounds to enhance relaxation.
Mobility: Assist the patient with position changes to prevent discomfort. Encourage gentle range-of-motion exercises to prevent muscle stiffness.
Psychological care=Provide emotional support to both the patient and their family. Be present, listen actively, and offer reassurance.
Spiritual Support: Respect the patient’s spiritual and religious beliefs. Offer the opportunity for spiritual counseling or the presence of a chaplain if desired
antianxiety medication 2 think of mary
alprazolam (xanax)
lorazepam ( ativan)
Raxanol
under tongue, IM, SQ, Rectally/ opiod narcotic.
“Terminal Secretions” death rattle ( 2 placements)
air passing through secretions accumulated in oropharynx, bronchi or both
Terminally ill pt the focus is on the pt
comfort not that the morphine depresses VS n PR
Anti-emetics –(2)
prochlorperazine(Compazine)
ondansetron(Zofran)
anticholinergic & antispasmodic agents
atropine, methscopolamine, hyoscyamine (levsin - last few hours of life)
Integument (5)
explain diuretics
Integument Care
Bathe, lotions, oral care
T & P
Diuretics (furosemide – Lasix) for edema
Elevate feet prn, float heels
Change linens prn
Nutrition
Anti-emetics –
prochlorperazine(Compazine),
ondansetron(Zofran)
Fluids as desired, poor appetite
Wet lips and mouth with swabs of cool
water
Dysphagia/Aspiration precautions
Elimination
Fiber as tolerated if still taking po
Stool softener (constipation d/t pain meds)
Bedpan/commode in reach
Foley Catheter prn
Incontinence Care – loss of sphincter
control, avoid skin breakdown
Sleep/rest/activity
Pain control – morphine po or SL, pillows,
wedges
Position changing, prevent skin
breakdown
Activity as tolerated
Increase sleep/bedrest/recliner
Psychological Care (7)
Be there
Be supportive
Avoid “I know how you feel”
Play soft music, nature sounds
low lights
Answer all questions honestly
Explain care
Observe non-verbal cues
Postmortem care
- Confirming the Death:
Medical Confirmation: A qualified healthcare professional confirms the death and issues the necessary legal documents such as a death certificate. - Notifying Authorities:
Legal Notification: Inform the appropriate legal authorities about the death if required by local laws and regulations. - Preparing the Body:
Gentle Handling: Treat the body with care and respect, maintaining the person’s dignity at all times.
Cleaning: Cleanse the body gently, removing any medical equipment, tapes, or adhesives.
Rigor Mortis: Be aware of rigor mortis (stiffening of the body after death) and handle the body appropriately.
Positioning: Position the body in a natural, relaxed state, often with the eyes and mouth closed. - Personal Belongings:
Cataloging: Note down and secure the deceased person’s personal belongings. These items are usually handed over to the family or next of kin. - Preparation of the Room:
Privacy: Provide a private, quiet environment for the family to spend time with the deceased if they wish.
Comfort: Ensure the room temperature is comfortable for family members and visitors. - Contacting the Family:
Sensitivity: Inform the family and loved ones with empathy and sensitivity. Be prepared to offer emotional support and answer their questions. - Organ and Tissue Donation:
Respect Wishes: If the deceased person was an organ donor, ensure that their wishes are respected and coordinate with the appropriate medical personnel. - Documentation:
Record Keeping: Maintain accurate records of the procedures performed, including details of the body’s condition, personal belongings, and any other relevant information. - Cultural and Religious Considerations:
Respect Customs: Be aware of and respect the deceased person’s cultural and religious practices, which might include specific rituals or ceremonies. - Transfer of the Body:
Funeral Home: Coordinate with the funeral home or mortuary for the transfer of the body. Ensure all necessary paperwork is completed. - Emotional Support:
Family and Staff: Offer emotional support to family members and healthcare staff who might be affected by the loss. - Follow-Up:
Support Services: Provide information about grief counseling and support services available to the family and healthcare staff.
Purpose of Autopsy
Examination of body after death
To determine exact cause of death, learn more
about disease (dementia- plaque)
Consent may be required
Detailed internal and external evaluation
of the body, removes body organs
(replaced afterward) and tissue samples
Assisting the family to cope with
death of….
Newborn –
Child –
Young adult –
Middle adult –
Elderly –
Newborn – allow parents to hold infant, give
items (name band, lock of hair, footprint)
Child – be present, answer questions, allow
parents to be with child AATs, bond created
caring for child
Young adult – help dispel grief energy safely,
support groups
Middle adult – address needs of the children
Elderly – life accomplishments
Nurse dealing with grief (productive vs unproductive )
Productive responses
Talk and express feelings
Help family/ patient grieve
Tx with dignity
Acknowledge the loss of life
Unproductive responses
Repressing feelings
Avoiding patient, family, or staff
Advance Directives
Living will
Health Care Proxy
Molst Forms
Living will
Specific instructions regarding medical tx client
requests and refuses
Health Care Proxy
Appoints someone to manage healthcare treatment
decisions when patient is unable
MOLST forms – tell what should and should not be
done for pt (IV hydration, IV ABT use, tube
feedings, hospitalization). Bright pink in color.
Do Not Resuscitate
DNR (may also see DNR/DNI)
If resp or cardiac arrest, no resuscitation
Goal: keep pt comfortable; allow a dignified
death
No further life-sustaining measures
Must have MD order
Palliative Care
does not have to be near death or hospice. not aggressive measures/only on symptoms. Dont cure
Also known as “comfort care”
Used in chronic disease care
Promotes the best possible quality
Any form of care or tx that focuses on reducing
the severity of disease symptoms, rather than
trying to delay or reverse the progression of
the disease itself or provide a cure
of life during the illness
Relieves symptoms, provide support
Not Hospice care, can be offered at any time
Purpose of Autopsy
Examination of body after death
To determine exact cause of death, learn more
about disease (dementia- plaque)
Consent may be required
Detailed internal and external evaluation
of the body, removes body organs
(replaced afterward) and tissue samples
Hospice Care
Interventions are designed to aid in comfort/pain management
Offer the highest possible quality of life dignity at the end of life,
face death with dignity
Focus is on terminally ill patients who no longer seek treatment
to cure them and who are expected to live for six months or
less
Plan of care attends to the whole person and family –
addressing the physical, psychological, social and spiritual
needs.
Provide an interdisciplinary team approach to care – nurses,
social worker, physician, spiritual support, pharmacist
consultant
Bereavement services for caregivers/family for up to 13 months
after death of loved one
