COPING WITH LOSS, DEATH AND GRIEVING

1. INTRODUCTION

Individuals are constantly experiencing loss. Episodes of personal crisis, natural

disaster, and terrorism result in the experience of loss. The nurse must be aware of the
many ways individuals react and adapt to losses. Individuals are faced with losses
throughout the life cycle. Growth and development would not continue to progress
without some losses. An understanding of the major concepts related to loss and
grieving is necessary for each nurse. Many people consider loss only in terms of death
and dying.

Loss and grief are experiences that affect not only clients and their families but
the nurses who care for them as well. The intense emotions associated with grief are
caused by very real, concrete losses. Death of a client, for example, leaves one feeling
powerless. Most nurses enter the profession with the intent of helping clients recover
from illness and move toward health promotion. It is frightening to learn that
knowledge, skill, and technology cannot always come together to result in cure. As a
nurse, you will have the opportunity to help clients and families face devasting losses
and accept the reality of impending death.

Providing care for clients in crisis and at the end of life requires knowledge and
caring to help bring comfort to clients and families even when hope for cure is gone.
Grief, or grieving is a subjective state that occurs in response to a loss. Grief
may be called grief work because the client must work through the phases and tasks,
expressing and accepting the feelings involved. If the client does not do this work,
dysfunctional grieving (also called unresolved grief or a morbid grief reaction) may
result, in which conscious grieving may be absent or delayed, distorted or exaggerated,
or prolonged (chronic). In dysfunctional grieving the client may deny the loss; deny
feelings related to the loss; experience impaired social relationships and functioning
exhibit depressed, withdrawn, or self-destructive behaviour; develop symptoms of a
physical or psychiatric illness; or continue to experience intense grief long after the
acute mourning period.

A client’s experience of the grief process is influenced by many factors,

including spiritual beliefs, culture, previous experiences of loss and grief, and social
 support. The client religion and customs can form a framework that provides solace,
support, and a means of expressing feelings. If the client lacks this support , however
his or her grief can be compounded and prolonged.

Grief can be experienced on many levels in response to different types of losses.

In addition to the loss of an individual person, object, life change, and so forth, a loss
on the community level can trigger deep and lasting grief. Community grieving refers
to grief shared by members of a community in response to a significant loss or change
such as a natural disaster, accident or crime in which many people are killed or injured,
a key individual is killed or dies, or there is severe or widespread destruction of
property. This type of grief can occur on a national level (sometimes called national
grief), as occurred in response to the assassinations of Dr. Martin Luther King, Robert
Kennedy, and John.F.Kennedy. Widespread grief shared among people in many
countries also can occur, for example, in response to terrorist attacks or the death of an
internationally known individual.

It has been described by various authors as a process that includes a number of

stages, characteristic feelings, experiences, and tasks. These include shock, being
stopped in one’s functioning, denial, numbness, developing awareness of the loss, and
preoccupation with the loss; feelings such as yearning, anger, ambivalence, depression,
despair and guilt; disorganisation; and tasks such as managing feelings, accepting the
loss, reorganizing relationships, and integrating the loss into one’s life.

Loss and grief work are significant stresses physically as well as emotionally,
and they can increase the client’s vulnerability to illness and even death.

2. TERMINOLOGIES

2.1 Aneurysm : A localized dilation of the wall of a blood vessels, usually

caused by atherosclerosis and hypertension, or less frequently,
by trauma, infection, or a congenital weakness in the vessel
wall.

2.2 Bereavement : Suffering the loss of a loved one. Bereavement is defined as the
objective state of having experienced the loss of a loved one.

2.3 Coping : Coping refers to the thoughts and actions we use to deal
with stress.
2.4 Death : the act of dying; the end of life; the total and permanent
cessation of all the vital functions of an organism. (Or) Death is
defined as the cessation of all vital functions of the body
including the heartbeat, brain activity (including the brain
stem), and breathing .

2.5. Denial : Denial is the refusal to acknowledge the existence or severity of

unpleasant external realities or internal thoughts and feelings.

2.6 Depression : Depression is a common mental disorder that presents with

depressed mood, loss of interest or pleasure, feelings of guilt or
low self-worth, disturbed sleep or appetite, low energy, and
poor concentration.

2.7 Euthanasia : Euthanasia refers to the practice of ending a life in a manner

which relieves pain and suffering. According to the House of
Lords Select Committee on Medical Ethics, the precise
definition of euthanasia is "a deliberate intervention undertaken
with the express intention of ending a life, to relieve intractable
suffering.

2.8 Grieving : Grieving is a multi-faceted response to loss, particularly to the

loss of someone or something to which a bond was formed.
(Or) To cause to be sorrowful; distress

2.9 Hospice : Hospice is a type of care and a philosophy of care that focuses
on the palliation of a terminally ill patient's symptoms. These
symptoms can be physical, emotional, spiritual or social in
nature.

2.10 Mourning : Mourning is, in the simplest sense, synonymous with grief over
the death of someone

2.11Palliative care: Palliative care (from Latin palliare, to cloak) is any form
of medical care or treatment that concentrates on reducing the
Severity of disease symptoms, rather than striving to halt,
delay, or reverse progression of the disease itself or provide a
cure.
 2.12 Resuscitation : the act of reviving a person and returning them to
consciousness; "although he was apparently drowned,
resuscitation was accomplished by artificial respiration" (or)
Restoration of life or consciousness to one who appears to be
dead.

2.13 Stress : Stress is the body's reaction to a change that requires a physical,
mental or emotional adjustment or response. (Or)

Stress can come from any situation or thought that makes you
feel frustrated, angry, nervous, or anxious.

2.14 Stroke : A stroke is an interruption of the blood supply to any part of the
brain. A stroke is sometimes called a "brain attack."

2.15 Violence : Violence is the expression of physical or verbal force against

self or other, compelling action against one's will on pain of
beinghurt.

3. LOSS

3.1 Definition of loss:

Loss is any situation, either potential, actual, or perceived, wherein a valued object
or person is changed or is not accessible to the individual. Everyone experiences
losses because change is a major constant in life

3.2 Types of loss:

3.2.1 Actual loss:

An actual loss is any loss of a person or object that can no longer be felt, heard,
known, or experienced by the individual. Examples could include the loss of an
arm, child, relationship, or role at work. Lost objects that have been valued by a
client include any possession that is worn out, misplaced, stolen, or ruined by
disaster. For example, a child may grieve over the loss of a favourite toy or pet.
3.2.2 Perceived loss:
A perceived loss is any loss that is tangible and uniquely defined by the
grieving client. It may be less obvious to others. An example is the loss of
 confidence or prestige. Perceived losses are easily overlooked or misunderstood,
yet the process of grief follows the same sequencing and progression as actual
losses.
Individual interpretation makes a difference in how the perceived loss is
uniquely valued and the response that one will have during grieving.

3.2.3 Maturational loss:

A maturational loss includes any change in the developmental process that is
normally expected during a lifetime. One example would be a mother’s feeling of
loss as a child goes to school for the first time. Events associated with maturational
loss are part of normal life transitions, but the feelings of loss persist as grieving
helps a person cope with the change.

3.2.4 Situational loss:

It includes any sudden, unexpected, external event that is not predictable. Often
this type of loss includes multiple losses rather than a single loss, such as an
automobile accident that leaves a driver paralyzed, unable to return to work, and
grieving over the loss of the passenger in the accident.

The type of loss and the perception of the loss influence the degree of grief a
person experiences. Each individual responds to loss differently. It is incorrect to
assume that the loss of an object does not generate the same level of stress as loss
as a loved one.

The value an individual places on the lost object (e.g. a family pet) determines
the emotional response to the separation. As a nurse you must assess the special
meaning that a loss has for a client and its effect on the client’s health and well
being.

The type of loss and the perception of the loss influence the degree of grief a
person experiences. Each individual responds to loss differently. It is incorrect to
assume that the loss of an object does not generate the same level of stress as loss
of a loved one. The value an individual places on the lost object (e.g., a family pet)
determines the emotional response to the separation. As a nurse you must assess
the special meaning that a loss has for a client and its effect on the client’s health
and well being.

Hospitalization and chronic illness or disabilities are special circumstances that

have multiple associated losses. When persons enter a hospital, they lose their
privacy, control over body functions and their daily routines, their modesty and
any illusions that they may have about their personal indestructibility. A chronic or
debilitating illness adds concern over financial security. Furthermore, long-term
illness may require a job change, threaten independence, and force alterations in
lifestyle. Even a brief illness or hospitalization requires temporary shifts in family
role functioning. Chronic or debilitating illness may pose a major threat to the
stability of relationships.

Death is the ultimate loss. Although death is part of the continuum of life and a
universal and inevitable part of being human, it is also a mystical event that
generates anxiety and fear. Death ends the relationship that binds families and
individuals together and separates people from the physical presence of persons
who influence their lives. Even in the presence of a strong spiritual grounding,
facing death is often difficult for the dying person, as well as for the person’s
family, friends and caregivers.

A person’s terminal illness reminds close friends and associates of their own
mortality. Death is generally not part of most persons’ day-to-day experience.
Callahan (1995) suggests that talking about death has been banished from our
society, from our society, from our everyday lives, from our language, and even
our thinking. Feelings of guilt, anger, and fear arise when death must finally be
faced. It may cause family members and caregivers to withdraw at a time when the
dying person needs their love and support. The way a person approaches dying
will be influenced by personal fundamental beliefs and values, culture, spirituality,
and the quality of the emotional support available.
3.3 Categories of Loss:

3.3.1 Loss of Significant Other:

Losing a loved one is a very significant loss. Such a loss can result from
moving to a different area, separation, divorce, or death.

3.3.2 Loss of Aspect of Self:

Loss of an aspect of self can be physiological or psychological. Physiological

loss includes loss of physical function or loss resulting from disfigurement or
disappearance of a body part, as is the case with amputation or mastectomy.

Loss of a physical aspect of self can result from trauma, illness, or a treatment
methodology such as surgery. Psychological aspects of self that may be lost
include a sense of humor, ambition, or enjoyment of life. These feelings of loss
may result from life events such as losing a job or failing at a task that the
individual deems important.

3.3.3 Loss of an External Object:

Whenever an object that a person highly values is changed or damaged, or

disappears, loss occurs. The type and amount of grieving depends on the
significance of the lost object to the individual.

For instance, an individual who loses a family heirloom in a fire may react not
only to the lost financial value of the piece, but also to the lost sense of history and
heritage that the piece represented.

3.3.4 Loss of Familiar Environment:

The loss of a familiar environment occurs when a person moves away from
familiar surroundings, for instance to another home or a different community, to a
 new school, or to a new job. A client who is hospitalized or institutionalized may
also experience loss when faced with new surroundings. This type of loss evokes
anxiety related to fear of the unknown.

4. DEATH

4.1 Definition of Death:

Death is the termination of the biological functions that sustain a living

organism. The word refers both to the particular processes of life's cessation as well
as to the condition or state of a formerly living body.

4.2 Causes of death:

4.2.1 Unexpected Death:

The bereaved have particular difficulty in achieving closure when the loss
occurs as a result of an unexpected death. As Roach and Nieto(1997) state, any
death is a traumatic experience to the surviving loved ones, even an anticipated
death. Survivors are shocked and bereaved after an unanticipated death, such as an
aneurysm, heart attack, or stroke. Usually, the bereaved can work through the
grieving process without complications.

4.2.2 Traumatic Death:

Complicated grief is associated with traumatic death such as death by

accident, violence, or homicide. Survivors are not necessarily predisposed to
complications in mourning, but often have more intense emotions than those
associated with normal grief.

4.2.3 Traumatic Imagery:

It is imagining the feelings of horror felt by the victim or relieving the terror
of an incident. Traumatic imagery is a common occurrence in cases of traumatic
death. Such thoughts, coupled with intense grief, can lead to post-traumatic stress
 disorder (PTSD) in the survivors. Nurses’ awareness of the possibility of PTSD and
alertness for the presence of symptoms is important. Symptoms may include:

 Chronic anxiety
 Psychological distress
 Sleep disturbances, such as recurrent, terror-filled nightmares.

Only when this problem is identified and the survivors are encouraged to
express their intense feelings will they be able to move through the normal, adaptive
grieving process.

4.2.4 Suicide:

The loss of a loved one to suicide is frequently compounded by feelings of

guilt by the survivors for failing to recognize clues that may have permitted the
victim to receive help. The feelings of guilt and self-blame can change into anger at
the victim for inflicting such pain. Having a suicide in the family may evoke feelings
of shame. Survivors may be prohibited from successfully resolving their grief by the
negative stigma of suicide.

4.3 Stages of Dying and Death:

Elizabeth Kubler-Ross (1969, 1974) identified in her classic works five stages of
dying that are experienced by clients and their families. Every client does not move
through each stage sequentially. These stages are experienced for varying lengths of
time and in varying degrees. The client may express denial, and then, a few minutes
later, express acceptance of the inevitable, and then express anger. An important
value of Kubler-Ross work is that it has increased sensitivity to the dying client’s
needs.

4.3.1 Denial
 During the first stage of dying, the initial shock can be very overwhelming,
making denial a useful tool of coping. It is an essential, protective mechanism that
may last for only a few minutes or may manifest for months.
 In some clients, denial manifests as “doctor shopping” (not to imply that second
opinions are not sometimes up or mistake in the diagnostic tests. In other clients,
 denial manifests as simply avoiding the issue. Their daily routines are the same as
though nothing in their lives has changed. Given time, most people will eventually
move past the stage of denial.
 Clients may choose to be selective in the use of denial. For example, clients try to
protect certain family members or friends from the truth by using denial. Clients
may also use denial from time to time to set aside thoughts of illness and death in
order to focus on living

4.3.2 Anger

 Anger often follows the initial stage of denial. The client’s security is threatened
by the unknown, with the normal daily routines becoming disrupted. This stage is
typically very difficult for family and caregivers because they often feel useless in
terms of helping their loved one through the situation. Since the client has no
control over the situation, anger is the response. The anger may be directed at self,
God, others, the environment, and the health care system.
 In the client’s eyes, whatever is done is not right thing. Family members may be
greeted with silence or with outbursts of anger. Their response, in turn, may be
anger, guilt, or despair.

4.3.3 Bargaining

 The client attempts to postpone or reverse the inevitable by bargaining. The

client’s bargaining represents an attempt to postpone death and usually has self-
imposed limitations.
 For example, a client may ask to live long enough to see the first grandchild in
exchange for giving money to a charity. Most clients bargain in silence or in
confidence with their spiritual leader. It is not uncommon for a client to live long
enough for some special event (a wedding or birth), then die shortly afterward.

4.3.4 Depression
  Depression resulting from the realization that death can no longer be delayed is
different from dysfunctional depression because it helps the client detach from life
and makes it easier to accept death. Depression in this sense is a therapeutic
experience for the dying person.
 Clients sometimes feel abandoned, as persons who were once friends begin to visit
less and less, sometimes severing ties with the client even before death; this may
compound the client’s feelings of depression and hopelessness.
4.3.5 Acceptance

 Every dying client may not reach the final stage, acceptance. Peace and
contentment comes with acceptance. The client often expresses feeling that all that
could be done has been done. It is important to reinforce the client’s feelings and
sense of personal worth. Many clients will make an effort to get all of their personal
and financial affairs in order.
 Sleep is required to fill a physical and emotional need, not to avoid reality. The
client may limit visitors to those people with whom he feels comfortable and safe.
The most significant forms of communication at this time are touch and moments
of silence.

4.4 Legal Considerations

 The Patient Self -Determination Act (PSDA) is part of the Omnibus Budget
Reconciliation Act (OBRA) of 1990. This act provides a legal means for individuals
to specify the circumstances under which life-sustaining measures should or should
not be rendered to them. The act applies to hospitals, home health agencies, long –
term care facilities, hospice programs, and certain health maintenance organizations
(HMOs).

 In many states, just signing these documents may not be adequate for carrying out
client wishes. They may also need to indicate their desires regarding intubation,
 artificial feeding, blood transfusions, chemotherapy, surgery, and transfer to the
hospital (for residents in skilled care facilities).

 Although a durable power of attorney for health care and living will are legal
documents, they do not prevent resuscitation (support measures to restore
consciousness and life). The medical record must have a written do-not-resuscitate
(DNR) order from a physician if this is in agreement with the client’s wishes and
with the advance directives. In the absence of such an order, resuscitation will be
initiated.

 In many states a Health Care Surrogate Law is implemented when there is no

advance directive. This law varies from state to state but basically provides a legal
means for certain individuals to make decisions for the client when the client
cannot do so. The spouse is the first person who would act in the interests of the
client. Then children in the event there is no spouse.

4.5Ethical Considerations:

 Death is often fraught with ethical dilemmas that occur almost daily in health care
settings. Ethics committees in many health care agencies develop and implement
policies to deal with end -of-life issues.
 Ethical decision making is a complex issue. Determining the difference between
killing and allowing someone to die by withholding life-sustaining treatment
methods is one of the most difficult dilemmas.
 The American Nurses Association (ANA) distinguishes mercy killing (Euthanasia
or assisted suicide) and relieving pain. Euthanasia is viewed as unethical, whereas
pain relief is a central value in nursing.
  The ANA’s position is that increasing doses of medication to control pain in
terminally ill clients is ethically justified, even at the expense of maintaining life.
(ANA, 1992).

4.6 Nursing care of the dying client:

 Assessment:

 A thorough assessment of the client’s holistic needs is the basis for nursing
interventions. Assessment of the dying client includes an ongoing collection of
data regarding the strengths and limitations of the dying person and the family.

 To gather a complete database that allows accurate analysis and identification of

appropriate nursing diagnosis for dying clients and their families, the nurse first
needs to recognize the states of awareness manifested by the client and family
members.
 Three types of awareness that have been described are closed awareness, mutual
pretense, and open awareness.

 In closed awareness, the client is not made aware of impending death. The
family may choose this because they do not completely understand why the
client is ill or they believe the client will recover. The primary care provider may
believe it is best not to communicate a diagnosis or prognosis to the client.
Nursing personnel are confronted with an ethical problem in this situation.

 With mutual pretense, the client, family and health personel know that the
prognosis is terminal but do not talk about it and make an effort not to raise the
subject. Sometimes the client refrains from discussing death to protect the family
from distress. The client may also sense discomfort on the part of health
personnel and therefore not bring up the subject. Mutual pretense permits the
client a degree of privacy and dignity, but it places a heavy burden on the dying
person, who then has no one in whom to confide.

 With open awareness, the client and others know about the impending death and
feel comfortable discussing it, even though it is difficult. This awareness
provides the client an opportunity to finalize affairs and even participate in
planning funeral arrangements.
 Not all people are comfortable with open awareness. Some believe that terminal
clients acquire knowledge of their condition even if they are not directly
informed. Others believe that clients remain unaware of their condition until the
end. It is difficult, however to distinguish what clients know from what they are
willing to accept or acknowledge.

 Nursing care and support for the dying client and family include making an
accurate assessment of the physiologic signs of approaching death. The four
main characteristics changes are loss of muscle tone, slowing of the circulation,
changes in respirations, sensory impairment.

 Clinical manifestations list indications of impending clinical death.

Loss of muscle tone:

 Relaxation of the facial muscles (e.g. the jaw may sag.)

 Difficulty speaking
 Difficulty swallowing and gradual loss of the gag reflex
 Decreased activity of the gastrointestinal tract, with subsequent nausea,
accumulation of flatus, abdominal distension, and retention of faeces, especially
if narcotics or tranquilizers are being administered.
 Possible urinary and rectal incontinence due to decreased sphincter control.
 Diminished body movement.
Slowing of the circulation

 Diminished sensation
 Mottling and cyanosis of the extremities.
 Cold skin, first in the feet and later in the hands, ears, and nose (the client,
however, may feel warm if there is a fever)
 Slower and weaker pulse.
 Decreased blood pressure.

Changes in respirations
  Rapid, shallow, irregular or abnormally slow respirations
 Noisy breathing referred to as the death rattle, due to collecting of mucus in the
throat.
 Mouth breathing, dry oral mucous membranes.

Sensory impairment

 Blurred vision
 Impaired senses of taste and smell

 Nursing diagnosis:

 The nurse’s assessment of the dying client may lead to several diagnoses. One
NANDA-approved nursing diagnosis that is applicable for many dying clients is
Powerlessness, that is, “the perception that one’s own action will not
significantly affect an outcome; a perceived lack of control over a current
situation or immediate happening” (NANDA, 2003).
 Another response experienced by the dying is described by the diagnosis
Hopelessness, “a subjective state in which an individual sees limited or no
alternatives or personal choices available and is unable to mobilize energy on
own behalf” (NANDA, 2003).
 The client may also exhibit Death Anxiety, “apprehension, worry, or fear related
to death or dying” (NANDA, 2003).
 In addition risk for caregiver role strain and interrupted family process.

 Planning/outcome identification:

» The major goals of nursing care are the physical, emotional, and mental comfort
of the client. The goals of nursing care for the dying client are the same as those
goals developed for all clients who are unable to meet their own needs.
 » The dying client should be treated as a unique individual worthy of respect,
instead of a diagnosis to be cured.
» Many dying clients do not fear death but are anxious about a painful death or
dying alone.
» Promoting optimal quality of life includes treating the client and family with
respect and providing a safe environment for expressing their feelings.
» Planning should focus on meeting the client’s and family holistic needs, as
specified in the Dying Person’s Bill of rights.
» When planning care, the nurse should make every effort to be sensitive to the
rights of the dying client.
» Planning care for a dying client:
 Schedule time to spend with the client.
 Identify areas of special concern to the client and make referrals when
appropriate (e.g. social worker consult for information on equipment rental).
 Promote and protect individual self0esteen and self-worth.
 Balance the client’s needs for assistance and independence
 Meet the physiological needs of the client and family.
 Respect the client’s confidentiality.
 Provide factual information to the client and family and answer all questions.
 Offer to contact clergy or other spiritual leader.

 Implementation

The first priority is to communicate caring to the client and family. Powell found
that the presence of a comforting nurse made a tremendous difference to the
client. Laduke (2001) suggests holding a client’s or family member’s hand and
saying “I will not leave you.” This assurance of the nurse’s presence is a powerful
way to show caring.
The nurse should approach the client in denial with understanding and the
knowledge that moving between the stages of dying is enhanced by a trusting
 nurse-patient relationship. Establishing rapport facilities the client’s verbalization
of feelings. A safe environment established by the nurse allows the client to
express those feelings being experienced.

 Terminally ill clients are often given palliative care, or care that relieves
symptoms, such as pain, but does not alter the course of disease. A primary aim
of palliative care is to help the client feel comfortable, safe and secure. Holding
the client’s hand and listening are therapeutic measures.

 Physiological Needs - Physiological needs are essential for existence, according

to Maslow’s hierarchy of needs. Therefore, they must be met before all other
needs. Areas that are often problematic for the terminally ill client are
respirations; fluids and nutrition; mouth, eyes, and nose; mobility; skin care; and
elimination.

 Respiration - Oxygen is frequently ordered for the client experiencing laboured

breathing. Suctioning may be needed to remove secretions that the client is
unable to swallow.

 Fluids and nutrition - Dying clients almost universally refuse food and fluids. It
is believed that the dying client does not feel thirst and hunger. Although the
issue of permitting dehydration in terminally ill clients is often met with great
resistance, the literature supports the concept that forced nutrition has
questionable value and may even exacerbate the client’s condition. The
American Diet Association, the American Medical Association, and the ANA
agree that it is ethically, legally, and professionally acceptable to discontinue
nutritional support if that is the terminally ill client’s request.

 Mouth, eyes, and Nose - The only documented side effect of dehydration in the
terminally ill client is oral discomfort. The administration of oxygen and mouth
breathing both increase the need for meticulous oral care. Apply petroleum jelly
to the lips. To maintain the client’s comfort, oral care must be given every 2 to 3
hours.
 If the eyes become irritated due to dryness, artificial tears will alleviate this
discomfort. A cotton ball should be used to gently wipe the eye from inner to
outer canthus (one wipe per cotton ball) to remove any discharge.

The nares may become dry and crusted. Oxygen given by cannula can further
irritate the nares. A thin layer of water soluble jelly applied to the nares will help
alleviate discomfort. The elastic strap of the oxygen cannula should be applied
too tightly, in case it causes discomfort.

 Mobility- Mobility decreases as the client’s condition deteriorates. The client

requires more assistance as he becomes less able to move about in bed. Physical
dependence increases the risk of complications related to immobility, such as
atrophy and pressure ulcers. Reposition the client at least every 2 hours. Maintain
body alignment with the use of pillows and other supportive equipment and use
positioning techniques to facilitate ease of breathing.

 Skin Care - Prevention of pressure ulcers is a priority. They are painful, can
cause secondary complications, and are costly to treat. Two preventive measures
are passive range-of-motion exercises and regular repositioning. Bed baths are
adequate if the client cannot get into the tub or sit in a shower chair.

 Elimination - Side effects of pain medications and a lack of physical activity

may cause constipation. For clients with adequate oral intake, foods with high-
fiber content and fluids can be effective preventive measures. A commode with
padded arms can be more comfortable than a toilet.

 Comfort - The primary activities for promoting physical comfort include pain
relief, keeping the client dry and clean, and providing a safe, nonthreatening
environment. The nurse who has a caring, respectful attitude increases the
client’s psychological comfort.

 Physical environment –The client’s comfort can be significantly increased by a

soothing physical environment. Soft lighting may enhance vision. Complying
with the client’s request for a nightlight is also helpful in creating a pleasant and
nonthreatening environment. Help eliminate environmental odors by ensuring
adequate ventilation, daily cleaning of the room, removal of leftover food, and
frequent linen changes.
 Psychosocial needs – Death presents a threat to one’s psychological integrity, as
well as to one’s physical existence. The dying person is often tethered to tubes
and electronic gadgetry in an intensive care unit. The client is held locked up in a
tangle of technology and is kept at a distance from the supportive presence and
touch of family and friends.

Technology cannot replace concern, touch, compassion, or human

companionship. By their presence, nurses and family can humanize the dying
person’s environment. Invite and encourage families to participate in the client’s
care, if they desire to do so and the client is willing. Well groomed appearance is
important. Combing and brushing the hair not only improves appearance but is
also a comforting and relaxing activity for many clients.

 Spiritual needs – Nurses have the opportunity to play a major role in promoting
the dying client’s spiritual comfort. Dying persons may experience confusion,
anger at their god, crises of faith, or other types of spiritual distress. Dying is a
personal and often a lonely process. Therapeutic nursing interventions that
address the spiritual needs of the dying client include:
 Use touch
 Play music
 Pray with the client
 Communicate empathy
 Contact clergy, if requested by the client
 Read religious literature aloud, at the client’s request.

 Support for the family – the presence of the nurse is extremely important. It
shows support and caring not only for the client but for the family as well.
Family members may have increased guilt because of feelings of helplessness.
Laduke (2001) suggests encouraging family members to speak to, touch, read to,
sing to, pray with, or just sit with the client. This can give family members a
sense of purpose, ease feelings of helplessness, and provide more pleasant
memories in the future.
The relationship with the family does not always end with the client’s death.
Staff members may attend visitations, funerals or memorial services. If a hospice
was involved, the family may participate in a bereavement support program. If
 the client was a resident in a long term care facility, family members may return
to visit other residents with whom they became acquainted.

5. GRIEF

5.1 Definition of Grief:

Grief is a series of intense psychological and physical responses occurring after a

loss. These responses are necessary, normal, natural and adaptive responses to the
loss.

5.2 Stages of Grief:

Three stages of grief generally recognized are shock, reality and recovery.

 Shock stage
The period of shock may last from only days to a month or more. The person may
describe feeling “numb”. It is an emotional numbness rather than a physical one.
 Reality stage
A painful experience begins when the individual consciously realizes the full
meaning of the loss. Anger, guilt, fear, frustration, and /or helplessness may be the
expressed reactions.
 Recovery stage
During the last stage, recovery, the loss is integrated into the reality of the
individual’s life. The person exhibits adaptive behaviours and begins to live again,
doing things that were formerly enjoyed.

5.3 Types of Grief:

Grief is a normal, universal, response to loss. Grief drains people, both

physically and emotionally, and relationships often suffer. Different types of grief
include uncomplicated (“normal”), anticipatory, dysfunctional, and
disenfranchised grief. Nurses assist many individuals to understand the normal
grieving process. Nurses who understand all types of grief are better prepared to
assist others.
 Uncomplicated Grief-
Uncomplicated grief is what many individuals would refer to as normal grief.
Engle (1961) proposed the term uncomplicated grief to describe the grief reaction
normally following a significant loss.

Uncomplicated grief has a fairly predictable course that ends with relinquishing
the lost object and resuming the duties of life.

The grieving person may feel angry, hopeless, or sad and may express feelings
of depression. A person who is grieving may experience loss of appetite, weight
loss, insomnia, restlessness, indecisiveness, impulsivity, and inability to concentrate
or carry out daily activities.

 Anticipatory Grief-
Anticipatory grief is the occurrence of grief before an expected loss actually
occurs. Anticipatory grief may be experienced by both the person’s family and the
terminally ill person. This process promotes early grieving, freeing emotional
energy for adapting once the loss has occurred. Although anticipatory grieving
may be helpful in adjusting to the loss, it also has some potential disadvantages.

For example, in case of the dying client, the family members may distance
themselves and not be available for support. Also, if the family members have
separated themselves emotionally from the dying client, they may seem cold and
distant and, thus, not meet society’s expectations of mourning behaviour.

 Dysfunctional grief-

Dysfunctional grief is a demonstration of a persistent pattern of intense grief that

does not result in reconciliation of feelings. The person experiencing dysfunctional
(or pathological) grief does not progress through the stages of grief. The
dysfunctionally grieving person cannot re-establish a routine. The professional
 caregiver must be aware of these behaviours and refer the pathologically grieving
person to professional counselling.

 Disenfranchised Grief:
Disenfranchised grief is described as grief not openly acknowledged, socially
sanctioned, or publicly shared. When an individual either is reluctant to recognize
the sense of loss and develops guilt feelings or feels pressured by society to “get on
with life”, grief can become disenfranchised. An example of disenfranchised grief
is extreme sadness over the loss the loss of a pet when this mourning might be
viewed by others as excessive or inappropriate. A mother’s sadness over a
miscarriage might also be considered disenfranchised grief because a lengthy
period of mourning may not be publicly expected despite the mother’s intense
feelings of loss and despair.

6. FACTORS AFFECTING LOSS AND GRIEF:

Variables affecting the intensity and duration of grieving are:

 Developmental stage
 Religious and cultural beliefs
 Relationship with the lost object

6.1 Developmental Stage:

Depending on the client’s place on the age/development continuum, the grief

response to a loss will be experienced differently. For example, a pregnant woman
will, to some degree, experience loss after delivery of a first child (loss of freedom,
independence, and self-focused life), even when the child is normal and healthy.

 Childhood Children vary in their reactions to loss and in the ability to

comprehend the meaning of death. It is important to understand the way a child’s
concept of death evolves, because the concept varies with developmental tasks.
 Children who are grieving need honest explanations about death using terms they
can understand.

 Adolescence Physical attractiveness and athletic abilities are valued by most

adolescents. Because adolescents seek approval of their peer group. When the
adolescent suffers the loss of a body part or function, grief includes fear of being
rejected. After a disfiguring accident, grief is usually very intense.

 Early adulthood In the young adult, grief is often precipitated by loss of role or
status. For example, significant grief may be caused by unemployment or the
breakup of a relationship. The concept of death in this age group primarily reflects
spiritual beliefs and cultural values.

 Middle adulthood The potential for experiencing loss increases during middle
adulthood. The death of parents often occurs during this developmental phase. As
an individual age, it can be especially threatening when peers die, because these
deaths force acknowledgement of one’s own mortality.

 Late adulthood Most individuals recognize the inevitability of death during the
late adulthood. It is challenging for elders to experience the death of age-old
friends or find themselves the last one of their peer group left living. Older adults
often turn to their children and grandchildren as sources of comfort and
companionship. Cultivating friendships in all groups helps prevent loneliness and
depression.

6.2 Religious and cultural beliefs

An individual’s grief experience is significantly affected by religious and cultural

beliefs. Every culture has rituals for care of the dying and beliefs about the
significance of death. Other beliefs regarding an afterlife, redemption of the soul, a
Supreme Being, and reincarnation can assist the individual in grief work.

6.3Relationship with the loss object.

 Generally the grief experienced is more intense the more intimate the relationship
was with the deceased. The risk for dysfunctional grieving is particularly great
after the death of a child.

The death of a child is generally thought to be exceptionally painful because it

upsets the natural order of things; parents do not expect their children to die before
them. Parents experiencing grief usually have intense responses and reactions.

7. NURSING CARE OF THE GRIEVING CLIENT

Assessment:

 Determining the personal meaning of the loss is the beginning of a thorough

assessment of the grieving client and family.
 The person’s progress through the grieving process is another key assessment area.
The stages of grieving are not necessarily mastered sequentially, but instead
individuals may move back and forth through the stages of grief.
 Interview the client and family using honest and open communication. Listen
carefully, and observe the client’s responses and behaviours. Assume a neutral
perspective and be alert for nonverbal cues. Summarize and validate any
impressions you form with the client and family so that appropriate nursing
diagnosis can be made. Other health care workers will contribute to your database,
including physicians, social workers, and members from pastoral care.
 Coping resources – determine what behaviours and outside resources typically help
clients cope with difficulties. Ask open-ended questions or statements to enable the
client to provide details: “tell me how you find ways to adjust when times get
difficult” or “tell me whom you go to when you are experiencing difficult times.”
Use of direct questions may help you determine if activities such as relaxation
exercises, meditation, reading or exercise help clients deal with stressors. These
coping resources may become invaluable in your plan of care.
 Grief behaviours – assessment of the client and family includes consideration of the
stages of grief and the type of behaviours they exhibit, while you observe the
client’s behaviour, you can assess the effects of the loss. No two people grieve have
exactly the same way. However, most persons who grieve have at least some
outward signs and symptoms that associated with grief.
 The symptoms of normal grief are
 Feelings
- Sadness
- Anger
- Guilt or self reproach
- Anxiety
- Loneliness
- Fatigue
- Helplessness
- Shock/numbness (lack of feeling)
- Yearning
- Emancipation/ relief

 Cognition(thought patterns)
- Disbelief
- Confusion
- Preoccupation about the deceased
- Sense of the presence of the deceased
- Hallucinations
- Hopelessness (I’ll never be OK again”)

 Physical sensations:

- Hollowness in the stomach

- Tightness in the chest
- Tightness in the throat
- Oversensitivity to noise
- Sense of depersonalization (“nothing seems real”)
- Feeling short of breath
- Muscle weakness
- Lack of energy
 - Dry mouth

 Behavoirs

- Sleep disturbances
- Appetite disturbances
- Absentminded behaviour
- Dreams of the deceased
- Sighing
- Crying
- Carrying objects that belonged to the deceased.

Nursing Diagnosis:

 The presence of one or two defining characteristics is usually insufficient to make

an accurate diagnosis. Be vigilant and carefully review the data you have and
consider competing diagnoses. For example, if a client whi is dying manifests
crying and tearfulness, displays anger, and reports nightmares, this could signal
several possible nursing disgnoses because these characteristics are common to
more than one diagnosis. Possibilities include pain, ineffective coping and spiritual
distress.
 The North American Nursing Diagnosis Association defines Dysfunctional
grieving as “extended, unsuccessful use of intellectual and emotional responses by
which individuals, families, communities attempt to work through the process of
modifying self concept based upon the perception of loss”.
 The other grieving diagnosis is Anticipatory Grieving, defined as “intellectual and
emotional responses and behaviours by which individuals, families and
communities work through the process of modifying self-concept based on the
perception of potential loss.
 Some of the diagnoses are common to grieving, such as anxiety or imbalanced
nutrition, spiritual distress, social isolation, powerlessness, ineffective denial,
ineffective coping and caregiver role strain.
 Planning / outcome identification

o When planning for the grieving client, it is important to clarify the expected
outcomes. Some expected goals for the person experiencing grief are:
 Accept the loss.
 Verbalize feelings of grief.
 Share grief with significant others.
 Renew activities and relationships.

Some of these expected outcomes will take a long time to achieve, and some must
be achieved before others are mastered. For example, to accept the loss, the person
must begin to share grief with others by verbalizing those feelings. Two of the
expected outcomes are discussed below.

Acceptance of loss – individuals are able to reach some acceptance and resolution of
feelings about the loss only by going through grief work. Often people try to find
some meaning in their situations. This search involves introspection, for which
spiritual support may be therapeutic.

Renewal of activities and relationships – the basis of grief work revolves around
accepting the fact that the needs met by key people in life can be met by other
people in other ways. Knowing that the deceased cannot be replaced, healing must
occur so that new relationships may begin.

Implementation

 Basic to therapeutic nursing care is an understanding of the significance of the loss

to the client. The nurse must spend time listening to understand the client’s
perspective. Even if the client does not respond according to the nurse’s belief
system or expectations, the nurse must demonstrate acceptance.
 The nurse’s nonjudgmental, accepting attitude is essential during the bereaved
expression of all feelings, including anger and despair.
 The nurse avoids personalizing and using defensive behaviours by by
communicating an understanding of the client’s anger. The expression of grief is
not only appropriate but also essential for therapeutic resolution of the loss.

 Grieving people need reassurance, support and counselling. One mechanism of

support on a long term basis is support groups. The nurse must be informed about
the availability of such groups within the community in order to make appropriate
referrals. Members of support groups have experienced similar losses.

 Discussions in support groups decrease the feelings of loneliness and social

isolation that are so common in the grief experience.

 Health promotion – although a return to full function will not be an expected

outcome for a terminally ill client or even a person who experiences significant
disability or other loss of function, there is always the goal of enabling the client
to return to optimal physical and emotional functioning. This does not mean the
client and family will not experience sadness or other disturbing emotions, but
that they will cope with the stressors in their life. You will assist clients in
learning to deal with their loss, to make effective decisions about their health care,
and to adjust to any disappointment, frustration, and anxiety created by their loss.

 Therapeutic communication – nursing care of a grieving client and family begins

with establishing the significance of their loss. This is difficult if the client is
unwilling or unable to express feelings or is experiencing shock or denial.

- It is important for you to use therapeutic communication strategies that enable the
client to discuss the loss and work with you in findings ways to resolve it.
- Use open ended questions that allow clients to freely share their thoughts and
concerns. Too often the use of closed questions result in the client discussing only
what you presume is the problem.
- If a client chooses not to share feelings or concerns, you should convey a
willingness to be available when needed.
- It is important to recognize that some clients will not discuss feelings about their
loss. Be observant for expressions of anger, denial, depression, or guilt.
Remember it is important to know your own feelings before encouraging clients to
express their anger.
 Facilitating mourning - these strategies you can use to help clients move through
uncomplicated grief. These guidelines are equally helpful for persons who
mourning a death, facing death, and grieving over an actual situational loss.
 Help the client accept that the loss is real
 Support efforts to live without the deceased person or in the face of disability.
 Encourage establishment of new relationships.
 Allow time to grieve.
 Interpret “normal” behaviour.
 Provide continuing support.
 Be alert for signs of ineffective coping.

Evaluation:

 Client care: You will care for clients and families at every phase of the grief
response. This requires you to maintain aware of signs and symptoms of grief,
even when clients are not specifically seeking care directly related to a loss. These
same signs and symptoms offer criteria to evaluate whether a client is able to deal
with a loss and progress through the grief process. The goal of terminally ill client
and family is participation in the process of life review.
 Client expectations : maintain open communication with clients to allow them to
evaluate their nursing care. Clients who have developed a good relationship with a
nurse will feel comfortable in discussing their perceptions of “how things are
going.” When caring for a terminally ill client, take the time to frequently ask the
family about their level of satisfaction.
  People follow their own time schedule for grief work. Because it takes months or
years for grief resolution, nurses usually do not have the opportunity to know
when the bereaved family completes its grieving work.

 The foundation for evaluation is the goals mutually established with client and
family. It is important for nurses to teach grieving individuals that resolution of
the loss is generally a process of lifelong adjustment.

8. COPING WITH LOSS AND GRIEF:

In order for you, as a nurse, to provide the necessary support clients and families
require during loss, it is necessary to understand how people normally cope with
grief and loss. Your nursing interventions will involve reinforcement of these
coping strategies or introduction of approaches that help clients learn new
strategies.

HOPE:

 It is the anticipation of a continued good, an improvement, or lessening of

something unpleasant. It is a multidimensional concept that is energizing.
 A person often reveals hope through an expression of expectations for life, the
present, and the future. Often in terminal illness a client focuses hope on
milestones (e.g. a child’s high school graduation or the completion of an important
project at work), significant events (e.g. an upcoming anniversary), or for the
relief of pain or other disabling symptoms.
 A person’s spiritual distress is often based on their definition of hope or lack of
hope. The existence and maintenance of hope depend on a person having strong
relationships and a sense of emotional connectedness to others.

SYNTHESIS
 When you care for a client who has experienced a loss, successful critical thinking
requires a synthesis of knowledge, experiences with loss and grief, and
information gathered from client’s and families.
 Each client enters the health care setting at a different developmental, spiritual,
and cultural place and with different expectations. You will learn to consider all of
these factors when providing a comprehensive plan of care.

KNOWLEDGE

 Knowledge of the grief process will help you understand the responses and needs
of your client and family. You must also have a clear understanding of the nature
of the loss, how the loss affects their lives.
 Applying knowledge of therapeutic communication principles enables you to
explore the loss thoroughly with a client to understand all influential factors.
 Principles of caring and an understanding of family dynamics will enable you to
provide compassionate care.

EXPERIENCE

» Most of us have experienced some type of loss: loss of a friend, a family pet, a
beloved family member. Personal experience with loss prepares you to understand
what loss means and to anticipate the emotional experience a client is feeling.
» When you have previously cared for clients experiencing loss or those who have
died, the lessons are invaluable.
» Reflect upon those experiences and consider how you might apply what you have
learned to care for your next client.

ATTITUDES

 Risk taking, self-confidence, and humility are key attitudes that will help you to
make accurate judgements and decisions about your clients. Many nurses become
anxious when caring for clients who grieve.
 Being with a client or family who is mourning requires a personal risk. One must
learn to accept client’s discomfort in the interest of being supportive.
 Humility helps you to put aside personal assumptions about how loss might be
interpreted by the client and to remain open to hearing and understanding the
client’s beliefs, thoughts, and concerns.

STANDARDS

 You are ethically bound to provide the best quality care to clients at all times. You

must be diligent and sensitive in maintaining the client’s physical integrity,

preserving modesty and dignity, administering comfort measures and guarding
confidentiality.
 Living wills are legal documents that state individual’s wishes regarding life

support, organ donation, and other considerations regarding their death.

 The intellectual standards of significance and relevance are important when caring

for clients suffering loss.

Other documents such as A Patient’s Bill of rights and The Dying Person’s Bill of
Rights are honoured at hospitals and often posted in prominent areas.

- I have the right to be treated as a living human being until I die.

- I have the right to maintain a sense of hopefulness, however changing its focus
may be.
- I have the right to be cared for by those who can maintain a sense of
hopefulness, however changing this might be.
- I have the right to express my feelings and emotions about my approaching
death in my own way.
- I have the right to participate in decisions concerning my care.
- I have the right not to die alone.
- I have the right to be free from pain.
- I have the right to have my questions answered honestly.
 - I have the right not to be deceived.
- I have the right to die in peace and dignity.
- I have the right to have help from and for my family in accepting my death.
- I have the right to expect that the sanctity of the human body will be respected
after death.

9. CONCLUSION

Therapeutic communication is important nursing intervention to assist the grieving

and dying client in coping with loss. Evaluation of nursing care for the grieving and
dying client is ongoing and is based on identifiable behavioural changes through
the grieving process. Nurses who work with critically and terminally ill clients
experience loss and grief.

10. BIBLIOGRAPHY
BIBLIOGRAPHY:

 Berman. Synder. Kozier & Erb’s, “Fundamentals of Nursing”, 8th edition, 2008,

Dorling Kindersley publishers, Pg.no: 1081-1097.

 Carol Taylor. Lillis. Lemone. Lynn, “Fundamentals of Nursing”, 6th edition, Volume

I, 2008, Lippincott Williams & Wilkins Publishers, Pg.no: 273-281, 287-292.

 Delaune.Ladner, “Fundamentals of Nursing Standards and practice”, 3rd edition,

2006, Thomson Delmar publishers, Pg.no: 481-503.

 Harkreader.Hogan.Thobaben, “Fundamentals of Nursing”, 3rd edition, 2007,

Saunders Elsevier publishers, Pg.no:1172-1195.

 Harkreader.Hogan, “Fundamentals of Nursing”, 2nd edition, 2007, Elsevier

publishers, Pg.no:1110-1119.

 Craven.Hirnle, “Fundamentals of nursing”, 5th edition, 2007, Lippincott Williams

&Wilkins, Pg.no: 1314 -1335.

 Potter. Perry, “Fundamentals of Nursing”, Volume I, 5th edition, 2001, Mosby

publishers, Pg.no: 613-640.

 Potter. Perry, “Basic Nursing”, essentials for practice, 5th edition, 2003, Mosby

publishers, Pg.no: 506-522.

 Potter. Perry, “Fundamentals of Nursing”, Sixth edition, Elsevier publishers,

Pg.no: 389-409.

 Potter. Perry, “Basic Nursing”, theory& practice, 3rd edition, 1995, Mosby

publishers, Pg.no: 493-511.

 Barbara Kozier.Erb.Berman burke, “Fundamentals of Nursing”, Concepts, process,

& practice, 2nd edition, 2006, Pg.no: 1071-1091.

 Wilkinson & Van Leuven, “Fundamentals of Nursing”, thinking and doing,

Volume 2, first edition, 2008, Jaypee Publishers, Pg.no: 158-176.

 Potter. Perry, “Basic Nursing”, a critical thinking approach, 4th edition, Mosby

Publishers, Pg.no: 389-409.

 Lois White, “Foundations of Nursing”, 2nd edition, 2005, Thomson Delmar

publishers, Pg.no: 234-253.

 Tyler.Lillis.Lemone.Lymn, “Fundamentals of Nursing”, Volume II, 6th edition,

2009, Lippincott Williams and Wilkins, Pg.no: 983-998.

 Janet Weber & Jane Kelley, “ Heath assessment in nursing”, 3rd edition, Lippincott

Williams and Wilkins, Page. no: 890

 Hudak. Barbara. Gallo, Morton, “Critical care nursing”, a holistic approach, seventh

edition, Lippincott Williams and Wilkins, page no: 26-28.

 Louise Rebraca Shives, “Basic concepts of psychiatric Mental Health Nursing”,

seventh edition, Lippincott Williams and Wilkins, page no:75-87.

 Judith. M. Schultz, Sheila, “Lippincott Manual of Psychiatric Nursing care plans”,

8th edition, Lippincott Williams and Wilkins, page no: 350-357.

JOURNALS:

 Alison Palmer, “American association of nurse anaesthetist’s journal”, coping

with death and dying, Volume 73, Issue 5, October 2005, Pg.no:25-27.
 Whitaker. C. M." American Journal of Nursing”, Death before birth, Feb 1986,

Pg.no: 157-158.

WEBSITES:

 www.helpguide.org/mental/grief_loss.htm

 www.mayoclinic.com/health/grief/MH00036

 en.wikipedia.org/wiki/Grief_ counselling

 www.medicinenet.com/

 books.google.co.in/

 onlinelibrary.wiley.com

 www.selfhealingexpressions.com/course_overview_4.shtml

 www.jpnonline.com

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