LOSS

Loss is any situation (actual, potential, or perceived) in which a valued object is changed
or is no longer accessible to the individual. Because change is a major constant in life,
everyone experiences losses. Loss can be actual (e.g., a spouse is lost through divorce) or
anticipated (a person is diagnosed with a terminal illness and has only a short time to
live). A loss can be tangible or intangible. For example, when a person is fired
from a job, the tangible loss is income, whereas the loss of self-esteem is intangible.
Losses occur as a result of moving from one developmental stage to another. An
example of such a maturational loss is the adolescent who loses the younger child’s
freedom from responsibility. Other examples of losses associated with growth and
development are discussed later. A situational loss occurs in response to external events,
usually beyond the individual’s control
Dealing with an actual or impending loss-whether the experience is of the
magnitude of war, mass murder ,and natural disasters or divorce, homelessness ,or living
with chronic illness has long been part of the human experience.

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TYPES OF LOSS
Loss occurs when a valued object is changed or is no longer available. Not everyone
responds to loss in the same way because the significance of the lost object or person is
determined by individual perceptions. There are many types of loss, including:
• Actual loss: Death of a loved one, theft of one’s property
• Perceived loss: Occurs when a sense of loss is felt by an individual but is not
tangible to others
• Physical loss: Loss of an extremity in an accident, scarring
from burns, permanent injury
• Psychological loss: Such as a woman feeling inadequate after menopause and
resultant infertility
There are four major categories of loss: loss of external objects, loss of familiar
environment, loss of aspects of self, and loss of significant other.
Loss of an External Object
When an object that a person highly values is damaged, changed, or disappears, loss
occurs. The significance of the lost object to the individual determines the type and
amount of grieving that occurs. The valued object may be a person ,pet, prized
possession, or one’s home. The loss of a pet, especially for those who live alone, can be a
devastating loss.
Loss of Familiar Environment
The loss of a familiar environment occurs when a person moves to another home or a
different community, changes schools, or starts a new job. Also, a client who is
hospitalized or institutionalized experiences loss when faced with new surroundings. This
type of loss evokes anxiety caused by fear of the unknown.
Loss of Aspect of Self
Loss of an aspect of self can be physiological or psychological. A psychological aspect of
self that may be lost is ambition, a sense of humor, or enjoyment of life. An example of
physiological loss includes loss of physical function as a result of illness or injury. Loss

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also occurs when there is disfigurement or disappearance of a body part, such as having
an amputation or mastectomy. Loss of an aspect of self can result from illness, trauma, or
treatment methodologies (such as surgery).
Loss of Significant Other

The loss of a loved one is a significant loss. Such a loss can be the result of separation,
divorce, running away, moving to a different area, or death. Responses to loss are highly
individualized as each person perceives the meaning of loss differently. For example, the
death of a spouse is different for men and women “Men who are widowed react as if they
have lost a part of themselves, whereas women react as if they have been deserted or
abandoned” .

PHYSICAL REACTION

 Crying/Weeping
 Upset Stomach
 Loss of Appetite
 Dry Mouth
 Sleep Disturbances
 Anxiety
 Tightness in Chest
 Breathlessness
 High Blood Pressure
 Heart Palpitations
 Lowered Immune System
 Fatigue
 Missed Menstrual Cycle
 Complications to Pre-Existing Health Conditions
 Weight Loss

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GRIEF

Grief is a series of intense physical and psychological responses that occur following a
loss. It is a normal, natural, necessary, and adaptive response to a loss. “Grieving is a
walk through unknown territory. Familiar internal and external stabilities disappear in a
whirlwind of changing thoughts, feelings, and emotional flux”
Loss leads to the adaptive process of mourning, the period of time during which the grief
is expressed and resolution and integration of the loss occur. Bereavement is the period
of grief following the death of a loved one.
THEORIES OF THE GRIEVING PROCESS
There is no one comprehensive theory to explain the grief process, which may consist of
a series of phases. Several theories have allowed us to delineate predictable symptoms
and states in response to loss. When reviewing the following theories, remember that
everyone does not experience each phase in the order described. The theories of Erich
Lindeman, George L .Engle, John Bowlby , and J. William Worden are discussed
in the following sections.

Lindemann
In 1944, after the Coconut Grove fire in Boston, in which over 400 people died,
Lindemann studied survivors of the disaster and their families. Lindemann coined the
phrase grief work, which is still used today to describe the process experienced by the
bereaved. During grief work, the person experiences freedom from attachment to the
deceased, becomes reoriented to the environment in which the deceased is no longer
present, and establishes new relationships (Lindemann, 1944). Lindemann’s classic
work is the foundation for current crisis and grief resolution theories. The accompanying
display provides a description of Lindemann’s concepts.

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LINDEMANN’S THEORY:REACTIONS TO NORMAL GRIEF
Somatic Distress
Episodic waves of discomfort in duration of 10–60 minutes ;multiple somatic complaints,
fatigue, and extreme physical or emotional pain.
Preoccupation with the Image of the Deceased
The bereaved experience a sense of unreality, emotional detachment from others, and an
overwhelming preoccupation with visualizing the deceased.
Guilt
The bereaved consider the death to be a result of their own negligence or lack of
attentiveness; they look for evidence of how they could have contributed to the death.
Hostile Reactions
Relationships with others become impaired owing to the bereaved’s desire to be left
alone, irritability, and anger.
Loss of Patterns of Conduct
The bereaved exhibit an inability to sit still, generalized restlessness and continually
search for something to do.

ENGLE
Grief is a typical reaction to loss of a valued object. There are three stages of mourning,
and progression through each stage is necessary for healing. The grieving process, which
may take several years for completion ,cannot be accelerated. The goal of the grieving
process is for the mourner to accept the loss and let go of the deceased. The
accompanying display provides an over view of Engle’s theory of grief.
ENGLE’S THEORY OF GRIEF:THREE STAGES OF MOURNING
Stage I: Shock and Disbelief
• Disorientation
• Feeling of helplessness
• Denial gives protection until person is able to face reality
Stage I can last from minutes to days.

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Stage II: Developing Awareness
• Emotional pain occurs with increased reality of loss
• Recognition that one is powerless to change the situation
• Feelings of helplessness
• Anger and hostility may be directed at others
• Guilt
• Sadness
• Isolation
• Loneliness
Stage II may last from 6 to 12 months.
Stage III: Restitution and Resolution
• Emergence of bodily symptoms
• May idealize the deceased
• Mourner starts to come to terms with the loss
• Establishment of new social patterns and relationships Stage III marks the beginning of
the healing process and may take up to several years.

BOWLBY
Bowlby stated that grief results when an individual experiences a disruption in
attachment to a love object. His theory proposes that grief occurs when attachment bonds
are severed. There are four phases that occur during grieving:
• Numbing
• Yearning and searching
• Disorganization and despair
• Reorganization (Bowlby, 1982)

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WORDEN
J. William Worden has identified four tasks that an individual must perform in order to
successfully deal with a loss:
• Accept the fact that the loss is real.
• Experience the emotional pain of grief.
• Adjust to an environment without the deceased.
• Reinvest the emotional energy once directed at the deceased into another relationship
Worden categorized the behavioral responses that grieving individuals experienced;

TYPES OF GRIEF
Grief is a universal, normal response to loss. Grief drains people, both emotionally and
physically. Because grief consumes so much emotional energy, relationships may be
impaired and health status may become altered. There are different types of grief
including uncomplicated (“normal”), dysfunctional, and anticipatory.
Uncomplicated Grief
Many individuals use the term normal grief. Engle (1961) proposed use of the term
uncomplicated grief to describe a grief reaction that normally follows a significant
loss. Uncomplicated grief runs a fairly predictable course that ends with the relinquishing
of the lost object and resumption of the previous life. Of course, the bereaved person’s
life is changed forever, but the person is able to regain the ability to function
“Expression of loss is often experienced by somatic symptoms that may range in
severity from minor to incapacitating”
Many grieving people experience feelings of anger or blame; these feelings may
be directed toward those perceived to have caused or contributed to the death. Often
the anger associated with grief is directed at one’s self, that is, expressed as guilt or
depression. Some survivors have a strong need to assign blame. If someone else can
be blamed, then the survivors can rid themselves of any responsibility. Those who are
experiencing grief must be provided an opportunity to express feelings—both positive
and negative—in order to alleviate guilt.

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Nurses play an important role in assisting mourners to develop and understand the normal
grieving process and the complex feelings exhibited when grief becomes more
complicated. Nurses with a sound knowledge base of both normal grief and dysfunctional
grief will be better prepared to assist the survivors than nurses who believe that all grief is
the same.
Dysfunctional Grief
Persons experiencing dysfunctional grief do not progress through the stages of
overwhelming emotions associated with grief, or they may fail to demonstrate any
behaviors commonly associated with grief. The person experiencing pathologic grief
continues to have strong emotional reactions, does not return to a normal sleep pattern or
work routine, usually remains isolated, and has altered eating habits. The bereaved may
have the need to endlessly tell and retell the story of loss but without subsequent healing.
The pathologically grieving person is unable to reestablish a routine. Visits to the
gravesite or mausoleum may be made often or not at all. Schattner (2000) refers to a type
of dysfunctional grief as unspoken grief that “can lead to a variety of unresolved grief
symptoms and isolation from support of friends, family, and activities” .
Dysfunctional grief is a demonstration of a persistent pattern of intense grief that does not
result in reconciliation of feelings. A person experiencing chronic grief continues to focus
on the deceased, may overvalue objects that belonged to the deceased, and may engage
in depressive brooding.
Several factors predispose a person to experience dysfunctional grieving, including:
• Uncertain, sudden, or overcomplicated circumstance surrounding the loss
• A loss that is socially unspeakable or socially negated (e.g., suicide)
• A relationship with the deceased characterized by ambivalence or excessive dependency
Anticipatory Grief
Anticipatory grief is the occurrence of grief work before an expected loss. Anticipatory
grief may be experienced by the terminally ill person as well as family. This phenomenon
promotes adaptive grieving by freeing up the mourner’s emotional energy. Although
anticipatory grieving may be helpful in adjusting to the loss, it may also result in some

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disadvantages .For example, for the dying client, anticipatory grieving may lead to family
members’ distancing themselves and not being available to provide support. Also, if the
family members have separated themselves emotionally from the dying client, they may
seem cold and distant, thus, not meeting society’s expectations of mourning behavior.
This response can prevent the mourners from receiving their own much needed support
from others.

FACTORS AFFECTING GRIEF

The experience of grief is individual and is influenced by various factors. Factors that
influence grief include the person’s developmental level, religious and cultural beliefs,
relationship to the lost object, and the cause of death.
Developmental Considerations
Depending on a client’s development level, the grief response to a loss will be
experienced differently. Nurses practice in many settings in which children, adolescents,
and adults, as a result of growth and development, experience changes that result in loss.
For example, a pregnant woman will, to some degree, experience loss after delivery, even
delivery of a normal healthy infant. Certain kinds of loss at key developmental points
may have a profound effect on a person’s ability to work through grief, as well as
possible inadequate achievement of the developmental task.
Childhood
Children vary in their ability to comprehend the meaning of death. It is important to
understand how a child’s concept of death evolves, because it varies with developmental
level and may affect mastery of developmental tasks Well-meaning adults often try to
protect children from the realities of death by excluding them from mourning rituals.
However, children need to be included as appropriate to their developmental level,
“or they may feel abandoned and left to face their fear alone” . Children who are grieving
need explanations about death that are honest and in language that can be comprehended
for suggestions on talking to children about death.

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Adolescence
Most adolescents value physical attractiveness and athletic abilities. Grief may occur
when the adolescent suffers the loss of a body part or function. Because of the strong
influence of peer groups, adolescents seek approval of their friends and fear being
rejected if a loss affects their acceptance by others (e.g., grief after a disfiguring
accident is usually intense in adolescents). Even though they have an intellectual
understanding of death, adolescents feel they are immune to death and therefore do not
accept the possibility of their own mortality. This perception is caused by the sense of
invulnerability that normally occurs during adolescence.
Early Adulthood
In the young adult, grief is usually precipitated by loss of role or status. For example,
unemployment or breakup of a relationship causes significant grief for the young adult.
The concept of death in this age group is primarily a reflection of cultural values and
spiritual beliefs.

Middle Adulthood
During middle adulthood the potential for experiencing loss increases. The death of
parents begins to occur. As an individual ages, it can be especially threatening for peers
to die because their death forces acknowledgment of one’s own vulnerability to death.
Other losses frequently experienced during middle age are those associated with changes
in employment and relationships (e.g., divorce), children leaving home, and decreasing
functional abilities.
Older Adulthood
During late adulthood, most individuals recognize the inevitability of death. Most older
adults experience numerous losses as they age. Losses commonly experienced
by the elderly include loss of :
• Loved ones and friends
• Occupational role as a result of retirement
• Material possessions

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• Dreams and hopes.

RELIGIOUS AND CULTURAL BELIEFS

Religious and cultural beliefs can have a significant effect on an individual’s grief. Every
culture has certain religious beliefs about the significance of death, as well as rituals
for care of the dying Beliefs about an after-life, faith in God, redemption of the soul, and
reincarnation are important aspects that often assist one in grief work.

RELATIONSHIP WITH THE LOST OBJECT

It is usually more difficult to cope with the loss of an ambivalent relationship as such
relationships are characterized by many “if only” and “I should have” thoughts.
“Unfinished business” and regrets about the deceased make coping with their loss more
problematic.“The greater the dependency on and importance of the lost object, the greater
the risk for ineffective coping” When individuals of stormy relationships have time to
work on issues prior to the death, grieving is usually facilitated. In general, the more
intimate the relationship with the deceased, the more intense the grief experienced by
the bereaved. The death of a child poses a particular risk for dysfunctional grieving to
occur. The death of a parent or a sibling can pose a major challenge for children. The
child’s feelings may often go unrecognized by adults who fail to understand the
child’s need to mourn.

CAUSE OF DEATH
The intensity of the grief response changes according to the cause of death, be it
unexpected, traumatic, or a suicide.

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Unexpected Death
The loss occurring with an unexpected death poses particular difficulty for the bereaved
in achieving closure Unanticipated death, such as a death resulting from a natural
disaster or other tragedy (e.g., airplane crash), leaves survivors shocked and bereaved.

Traumatic Death
Complicated grief is associated with traumatic death such as death by homicide, suicide,
or an accident. Although traumatic death does not necessarily predispose the survivor to
complications in mourning, survivors suffer emotions of greater intensity than those
associated with normal grief. When loved ones die violently, the grievers may suffer
from traumatic imagery, that is, the reliving the terror of the incident or imagining the
feelings of horror felt by the victim. Traumatic imagery is a common occurrence with
traumatic death. Such thoughts, coupled with intense grief, can lead to post-traumatic
stress disorder (PTSD).Nurses must be aware of the possibility of PTSD and be
alert for the presence of symptoms, which may include:
• Sleep disturbances, such as recurrent, terror-filled nightmares
• Psychological distress
• Chronic anxiety
Suicide
The loss of a loved one to suicide is frequently compounded by feelings of blame in the
survivors. They feel guilty for failing to recognize clues that may have enabled the victim
to receive help. These feelings of guilt and self-blame can be transformed into anger at
the victim for inflicting such pain, at themselves, and at caregivers. Feelings of shame for
having a suicide in the family may also be present

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PHYSICAL SYMPTOMS
Here are some of the commonly reported symptoms:

 Pain
 Sleep difficulties
 Poor appetite or overeating
 Shakiness or trembling
 Disorientation
 Migraines or headaches
 Dizziness
 Dry mouth
 Crying
 Numbness
 Shortness of breath
 Exhaustion

DEATH

Death is viewed as something to be avoided at all costs; medicine, with its technological
advances, pursues immortality. These scientific advances do not change the fact that
death is a part of every human existence.
End-Of-Life (EOL) Care
It is something that happens to someone else and to someone else’s loved ones. Yet it is
one of two life events that all humans share, the other being birth. Dying was once
considered to be a normal part of the life cycle. Today it is often considered to be a
medical problem that should be handled by health care providers. Technologic advances
in medicine have caused care of those who are dying to become depersonalized and

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mechanical. In an attempt to humanize care of the dying, proponents of improved EOL
care are looking to nurses.“Nurses spend more time with patients who are facing the end
of life (EOL) than any other member of the health care team”. In 1997, the Institute of
Medicine (IOM) made six recommendations for improving EOL care

IMPROVING END-OF-LIFE CARE:IOM RECOMMENDATIONS

1. Create and facilitate patient and family expectations for reliable, skillful, and
supportive care.
2. Ask health care professionals to commit themselves to improving care for dying
patients and using existing knowledge to prevent and relieve pain and other symptoms.
3. Address deficiencies in the health care system through improved methods for
measuring quality, tools for provider accountability, revised financial systems to
encourage better coordination of care, and reformed drug prescribing laws.
4. Develop medical education to ensure practitioners have relevant attitudes, knowledge,
and skills to provide excellent EOL care.
5. Make palliative care a defined area of expertise, education, and research.
6. Pursue public discussion about the modern experience of dying, options available to
dying patients and families, and community obligations to those nearing death.

Kübler-Ross’s Stages of Dying and Death

Stage Example
First stage: Denial Verbal: “This can’t be happening to me!”
Behavioral: Client is diagnosed with terminal lung cancer; client
continues to smoke two packs of cigarettes daily.
Second stage: Anger Verbal: “Why me?”
Behavioral: Client strikes out at caregivers.
Third stage: Bargaining Verbal: Client prays, “Please, God, just let me live long

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 enough to see my grandchild graduate.”
Behavioral: Client tries to “make deals” with caregivers.
Fourth stage: Depression Verbal: “Go away. I just want to lie here in bed.
What’s the use?”
Behavioral: Client withdraws and isolates self.
Fifth stage: Acceptance Verbal: “I feel ready. At least, I’m more at peace now.”
Behavioral: Client gets financial or legal affairs in order. Client says
goodbye to significant others.

Denial
In the first stage of dying, the initial shock can be overwhelming. Denial, which is an
immediate response to loss experienced by most people, is a useful tool for coping. It
is an essential and protective mechanism that may last for only a few minutes or may
manifest itself for months.
Anger
The initial stage of denial is followed by anger. The client’s security is being threatened
by the unknown. All the normal daily routines have become disrupted. The client has no
control over the situation and thus becomes angry in response to this powerlessness. The
anger may be directed at self, God, and others. Often the nurse is the recipient of the
anger when the client lashes out
Bargaining
The anticipation of the loss through death brings about bargaining through which the
client attempts to postpone or reverse the inevitable. The client promises to do something
(such as be a better person, change lifestyle) in exchange for a longer life.

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Depression
When the realization comes that the loss can no longer be delayed, the client moves to the
stage of depression. This depression is different from dysfunctional depression in that it
helps the client detach from life to be able to accept death.
Acceptance
The final stage of acceptance may not be reached by every dying client. However, “most
dying persons eventually accept the inevitability of death. Many want to talk about their
feelings with family members . . Verbalization of emotions facilitates acceptance. With
acceptance comes growing awareness of peace and contentment. The feeling that all that
could be done has been done is often expressed during this stage. Reinforcement of the
client’s feelings and sense of personal worth are important during this stage

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BIBLIOGRAPHY

B T. Basavanthappa ,fundamentals of nursing.

Sue C. DeLaune, Fundamentals of nursing.

Potter A Perry, Basic Nursing- Essentials for practice, Elsevier publication.

Sorensen & Lueckmann’s ,Basic nursing.

Sheila L. Videbeck , Mental Health Nursing.

JOURNALS

Oxford journal of nursing

Journal of Christian Nursing

NET REFERANCE

www.wikipedia.com

www.ask.com

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 SEMINAR ON

COPING WITH LOSS,GRIEF

AND DEATH
SUBMITTED TO,
Mr . Subash
Senior Lecturer
Vijaya College Of Nursing.

SUBMITTED BY,
Mr . Arun.K.S
1 st yaer MSc Nursing
Vijaya College Of Nursing.

SUBMITTED ON,
5 – 1- 2011.

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