CEBU TECHNOLOGICAL UNIVERSITY
In consortium with
CEBU CITY MEDICAL CENTER- COLLEGE OF NURSING
FUNDAMENTALS OF NURSING PRACTICE
MODULE 3.12: DEATH AND DYING
LOSS, GRIEVING and DEATH
Loss – actual or potential situation in which
something that is valued is changed or no longer
available.
Death – a loss both for the dying person and for
those who survive.
Types of Loss
● Actual loss – can be recognized by others
● Perceived loss – experienced by one person but
cannot be verified by others.
● Anticipatory loss – experienced before the loss
actually occurs.
● Situational loss
● Developmental loss – losses that occur in the
process of normal development
Sources of loss
 Loss of an aspect of one self
 Loss of an object external to oneself
 Separation from an accustomed environment
 Loss of a loved or valued person
 Grief, Bereavement and Mourning
Grief
 the total response to the emotional experience
related to loss. It permits the individual to cope
with the loss gradually and to accept it as part of
reality.
 It is a social process.
Bereavement
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 the subjective response experienced by the
surviving loved ones.
Mourning
 the behavioral process through which grief is
eventually resolved or altered; often influenced
by culture, spiritual beliefs and custom.
Types of Grief
● Abbreviated grief – short-lived grief response.
● Anticipatory grief – experienced in advance of
the event.
● Disenfranchised grief – occurs when a person is
unable to acknowledge the loss to other person.
Complicated grief – exists when the strategies to
cope with the loss are maladaptive. It may exists for
6 months and leads to reduced ability to function
formally.
Factors can contribute to complicated grief:
1) Traumatic loss
2) Strained relationships between the survivor and
the deceased
3) Family or cultural barriers to the emotional
expression of grief
4) Lack of adequate support for the survivor
Forms of complicated grief:
▪ Unresolved or Chronic grief – extended in
length and severity.
▪ Inhibited grief – many of the normal symptoms
of grief are suppressed and other effects.
▪ Delayed grief – occurs when feelings are
purposely or subconsciously suppressed until a
much later time.
 CEBU TECHNOLOGICAL UNIVERSITY

In consortium with

CEBU CITY MEDICAL CENTER- COLLEGE OF NURSING

FUNDAMENTALS OF NURSING PRACTICE

MODULE 3.12: DEATH AND DYING

▪ Exaggerated grief – a survivor who appears to ANGER  individual recognizes

be using dangerous activities as a method to that denial cannot
lessen the pain of grieving. continue

Complicated grief after a death may be inferred  the person is very

from: difficult to care due to
misplaced feelings of
1. Fails to grieve rage and envy

2. Avoids visiting the grave & refuses to  Any individual that

participate in memorial services, even though symbolizes life or
these practices are part of the client’s culture. energy is subject to
projected resentment
3. Client’s relationship with friends & relatives
and jealousy.
worsen following the death.

4. Develops persistent guilt and lowered self-

BARGAINING  the hope that the
individual can
esteem
somehow postpone or
5. Even after a prolonged period, the client delay death
continues to search for the lost person.
 Usually the
6. Even after a period of time, the client is unable negotiation for an
to discuss the deceased with compassion. extended life is made
with a higher power in
Factors contribute to unresolved grief after a death: exchange for a
reformed lifestyle
a) Ambivalence toward the lost person
DEPRESSION  dying person begins to
b) Perceived need to be brave and in control understand the
certainty of death
c) Endurance of multiple losses
 the individual may
Kübler-Ross’s Five Stages of Grief become silent, refuse
visitors and spend
DENIAL  usually only a much of the time
temporary defense for crying and grieving
the individual
 allows the dying
 generally replaced person to disconnect
with heightened themselves from
awareness of things of love and
situations and affection
individuals that will be
left behind after death  not recommended to
attempt to cheer an
individual up that is in

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 CEBU TECHNOLOGICAL UNIVERSITY

In consortium with

CEBU CITY MEDICAL CENTER- COLLEGE OF NURSING

FUNDAMENTALS OF NURSING PRACTICE

MODULE 3.12: DEATH AND DYING

this stage or are physically close, the impact of family

member’s death may be softened because the role
ACCEPTANCE  final stage comes with
of the deceased are quickly filled by other relatives.
peace and
understanding of the 3. Spiritual beliefs → most religious groups have
death that is
practices related to dying, & these are often
approaching
important to the client & support people.
 want to be left alone
→to provide support at a time of death, nurses need
 feelings and physical to understand the client’s particular beliefs &
pain maybe non- practices.
existen
4. Gender→men are frequently expected to “be
 the end of the dying strong”& show little emotion during grief, whereas it
struggle
is acceptable for women to show grief by crying.

→ gender roles affect the significance of body image

Factors Influencing the Loss & Grief Responses
1. Age → affects person’s understanding & reaction
to loss.
a) Childhood – children differ from adults not only
in their understanding of loss & death but also
in how they are affected by the loss of others.
b) Early & Middle Adulthood – response to such
losses is influenced by;previous experiences
with loss,person’s sense of self-esteem strength
& availability of support
c) Late adulthood – losses experienced by older
adults include loss of health,
mobility,independence and work role.
Factors affecting the significance of loss
a. importance of the lost person, object, or function
b. degree of change required because of loss
c. person’s belief and values
2. Culture → where several generations & extended
family members either reside in the same household
changes to clients.
5. Socioeconomic status → it often affects the
individual’s support system available at the lime of a
loss.
6. Support system → the people closest to the
grieving individual are often the first to recognize &
provide needed emotional, physical & functional
assistance.
Cause of Loss or Death
a) a loss or death that beyond the control of those
involved may be more acceptable than the one that
is preventable.
b) injuries or death that occur during respected
activities are considered honorable whereas those
occurring during illicit activities may be considered
the individual’s just rewards.
Facilitating Grief Work
1. Explore & respect the client’s ethnic, cultural,
religious and personal values in their expression
of grief.

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 CEBU TECHNOLOGICAL UNIVERSITY

In consortium with

CEBU CITY MEDICAL CENTER- COLLEGE OF NURSING

FUNDAMENTALS OF NURSING PRACTICE

MODULE 3.12: DEATH AND DYING

2. Teach the client or family what to expect in the b. Cerebral death or higher brain death – occurs
grief process. when the higher brain center, the cerebral cortex, is
irreversibly destroyed.
3. Encourage client to express & share grief with
support people. → there is a clinical syndrome characterized by:

4. Teach family members to encourage the client’s  permanent loss of cerebral & brainstem
expression of grief. function

5. Encourage the client to resume normal  absence of responsiveness to external stimuli

activities on a schedule that promotes physical
& psychological health.  absence of cephalic reflexes

Providing Emotional Support  apnea

1. Use silence & personal presence along with Death related to Cultural & Religious Practices
techniques of therapeutic communication.
1. Some culture, people prefer a peaceful death at
2. Acknowledge the grief of the client’s family & home rather than in the hospital
significant others.
2. Beliefs & attitudes about death, its cause & the soul
3. Offer choices that promote client autonomy. vary among cultures. Unnatural deaths, or “bad
deaths”, are sometimes distinguished from “good
4. Provide information regarding how to access deaths”.
community resources.
3. Beliefs about preparation of the body, autopsy,
5. Suggest additional sources of information & organ donation, cremation, and prolonging life are
help. closely allied to the person’s religion.

Definitions & Signs of Death ▪ Nurses need to be knowledgeable about the

client’s death-related rituals (last rites).
a) Heart – Lung Death (Traditional clinical signs of
death) ▪ Nurses need to ask family members about their
preference & verify who will carry out these
→ cessation of apical pulse, respirations & BP activities.

→ 1968, the World Medical Assembly adopted the ▪ In cases of terminal illness, the state of
following guidelines for physicians as indication of awareness shared by the dying person & the
death: family affects the nurse’s ability to
 total lack of response to external stimuli communicate freely with clients & other health
care team members & to assist in the grieving
 no muscular movement, especially
process.
breathing
Types of awareness:
 no reflexes
● Closed awareness – the client is not made aware
 flat encephalogram (brain waves)
of impending death.

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 CEBU TECHNOLOGICAL UNIVERSITY

In consortium with

CEBU CITY MEDICAL CENTER- COLLEGE OF NURSING

FUNDAMENTALS OF NURSING PRACTICE

MODULE 3.12: DEATH AND DYING

● Mutual pretense – the client, family & health
personnel know that the prognosis is terminal but do
not talk about it and make an effort not to raise the
subject.
● open awareness – the client and others know
about the impending death and feel comfortable
discussing it, even though it is difficult.
Helping Client Die with Dignity
− the gradual decrease of the body’s temperature after
death.
− when blood circulation terminates & the
hypothalamus ceases to function, body temperature
falls about 1⁰C (1.8⁰F) per hour until it reaches room
temperature.
− simultaneously the skin loses it elasticity & can easily
be broken when removing dressings & adhesive tape.

 Nurses need to ensure that the client is treated with
dignity, with honor and respect.
 Helping clients die with dignity involves maintaining
their humanity, consistent with their values, beliefs
and culture.
Hospice and Palliative Care
− After blood circulation has ceased, the RBC breaks
down, releasing hemoglobin, which discolors the
surrounding tissues. This discoloration referred to as
livor mortis appears in the lowermost or dependent
areas of the body.
Postmortem care should be carried out according to
the policy of the hospital or agency.

Hospice care – focuses on support and care of the
dying person and family, with the goal of facilitating a
peaceful and dignified death.
Palliative care – (WHO) an approach that improves
the quality of life of clients and their families facing the
problem associated with life-threatening illness, through
the prevention and relief of suffering by means of early
identification & impeccable assessment & treatment of
pain & other problems, physical, psychosocial, & spiritual.
Post-mortem Care
a) Rigor mortis
− the stiffening of the body that occurs about 2 – 4
hours after death.
− starts in the involuntary muscles (heart, bladder & so
on), then progresses to the head, neck & trunk and
finally reaches the extremities.
▪ all equipment, soiled linen, & supplies should be
removed from the bedside.
▪ some agencies require that all tubes in the body
remain in place, in other agencies, tubes maybe cut
to within 2.5 cm (1 in) of the skin & taped in place; in
others, all tube may be removed.
▪ Soiled areas of the body are washed, however, a
complete bath is not necessary, because the body
will be washed by the mortician (undertaker), a
person trained in care of the dead.
▪ In the hospital after the body has been viewed by the
family, the deceased wrist ID tag is left on and
additional ID tags are applied.
▪ The body is wrapped in a shroud, a large piece of
plastic or cotton material used to enclose a body
after death.
▪ ID is then applied to the outside of the shroud.

− usually leaves the body about 96 hours after death. ▪ Nurses have a duty to handle the deceased with
dignity and to label the corpse appropriately.
b) Algor mortis

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