THE CONCEPT OF LOSS

NURSING GOALS:

1. TO PROMOTE GOOD/ PLEASANT DYING THROUGH COMPASSIONATE and PALLIATIVE CARE

2. FACILITATE COPING WITH DISABILITY AND DEATH

LOSS

- is a change in a person’s situation that reduces the probability of achieving goals

- is when a person is without something he formerly possessed
- is an actual or potential situation is which a valued object, person or the like is inaccessible or
changed so that it is no longer perceived as valuable
- occurs when a valued person/ object/ situation is changed or made inaccessible, diminished or
removed
- is inevitable and inescapable – no one is exempt
- is an actual or potential situation is which a valued object, person or the like is inaccessible or
changed so that it is no longer perceived as valuable

1.) SELF LOSS a. Loss of psychologic self - includes the loss of self esteem or personal identity

b. Loss of sociocultural self - includes the loss of language, association, and the meaning of
one’s cultural heritage
-influence of other cultures
c. Loss of physical self - the extent, duration, and viability of the loss will influence how
the individual responds to loss
- loss of a limb or a part of the body
d. Loss of spiritual self - loss of hope, values, beliefs
- without hope, despair sets in and the patient gives up

2.) EXTERNAL LOSS a. Actual loss - can be recognized by others and the person sustaining the loss
- includes the loss of - e.g. loss of a limb, spouse, valued object ( money or job)
objects, possessions, loved
ones b. Perceived loss - felt by a person but intangible to others
- loss can occur through - e.g. loss of youth, financial independence, valued environment
separation, moving, - physical and psychological loss are directly related to actual or
promotion, or death perceived loss
c. Maturational loss - is experienced as a result of natural developmental processes
- e.g. loss that the 1st child flees when the new sibling is born; loss
that a stay at home parent feels when the child starts school
d. Situational loss - experienced as a result of an unpredictable event
- an event that did not allow a plan to happen
- e.g. traumatic injury, disease, death, natural disaster

e. Anticipatory loss - type of loss experienced before the loss really occurs
- a person displays loss and grief behaviors for a loss that has yet
to take place
- serves to lessen the impact of the actual loss
- e.g. families of patient with serious and life threatening illness

FACTORS INFLUENCING LOSS EXPERIENCE

1. Childhood experiences - can impact the way one perceives and reacts to a loss
- how parents handle losses can influence the child’s view of losing something
or someone
2. Significance assigned to the loss - related to objective and subjective value of the object

3. Physical and Emotional state - depends on the time of the loss which can have significant influence of one’s
response
4. Accumulated loss experience - can impact how a person responds to a current loss especially if there are
unresolved losser
- has the greatest impact
5. View loss as crisis - can be helpful to understand how a person experiencing the loss perceives his
ability to cope
6. Viability - can have a (+) or (-) effect

7. Duration and Timing - depends on the degree of goal disruption that results from the time spent in
resolving the loss
8. Abruptness and suddenness of the loss - more difficult to cope because of the lack of time to preprare

9. Financial impact - the longer and more extensive the loss the greater the expenses usually
involved
10. Availability of resources - both internal (ability to cope with challenges from the loss) and external
(support from family and friends)
11. Cultures

12. Relationship with the lost person

DYING

- an integral part of life

- it is as natural and predictable as being born
- universal and individually unique event of human experience
- occurs suddenly as a result of an accident, injury, pathologic crisis and after a prolonged
experience of debilitating illness
- it is the process of coming to an end

DEATH

- permanent cessation of all vital functions

- the end of human life
- it is an event (moment of death) and a state (that of being dead

CONCEPTS AND PRINCIPLES OF DEATH & DYING

1. Person may suspect or knows that he is dying

2. Make the client feel that they are not alone – lessen fear of death
3. Living life to the fullest in their own way
4. Life review
5. Facing death is individualized

REACTIONS TO DEATH AND DYING THROUGHOUT LIFE CYCLE

Developmental Stage Coping Reaction Nursing Implications

I. INFANCY TO TODDLER - no concept of death a. avoid admonishing behaviors

(0-1 yo) - impossible to comprehend absence of life b. stress that person will only return in
-egocentricity (self-centered, selfish) thought
- vague separation of fact and fantasy c. consistent staff assignment
- the dead still exists --- “Grandpa is dead. He went
to heaven.”
II. TODDLER ( 1-3 yo) -coping reactions a. avoid admonishing behaviors
1. Crankiness b. stress that person will only return in
2. Crying thought
3. Clingy c. consistent staff assignment
- according to parents’ emotional state
- greatest threats: PAIRS
P – painful intrusive procedures
A – altered rituals
I – immobilization
R – regression
S – separation
- persists on visiting the dead
- anxiety
- talks about the deceased as if nothing happened
III. PRESCHOOLER (3-6 yo) - preoperational thought a. explain that the soul goes to heaven
- magical thinking: “the dead lives underground” b. the more outward the grief, the less
- consequence: guilt, shame, punishment significant is the loss
- psychosexual development has a heavy influence c. ceremonies: tell child what to expect,
– focus primarily on opposite sex parent give choices
- God is viewed as a male human d. hold and reassure
- heaven, hell and holy spirit considered frightening e. explain that death is final:
- meaning of death : death is sleep and sleep is no breathing
death; recognize physical death as temporary and no eating
reversible no awakening
- coping reactions:
1. Giggling 3. Attracting attention
2. Joking 4. Regression
- greatest fear: parental separation
- unusual activities

IV. SCHOOLER (6-12 yo) - concrete operations – thinks logically; deals a. allow to achieve independence
best with actual objects and people but can b. anticipatory explanations
relate concepts & compare events; develops an c. explain what is happening and what can
awareness and understanding; daydream of be done(be realistic)
other people’s feelings and point of view
- coping reactions:
1. nightmares
2. rituals
3. daydreaming
- fears: darkness and being alone
- better understanding to casualty
- prone to self reference (privacy and
understanding)
- death is final (5-9 yo): best can be avoided;
possibility of life after death
- understands own mortality (9-12 yo): death is
reversible but beginning to see its finality;
personification of death, naturalistic and
physiologic explanation
V. ADOLESCENTS (13-17 yo) - formal operations - answer honestly, be direct
- abstract - respect privacy
- death: religious and philosophical terms - allow self-control and independence
- adult approach with remnants of magical - structure hospital admission
thinking - acceptance and non-judgmental attitude
- life is fragile but feels immortal - role model
- inevitable, universal, permanent - allow ventilation of feelings
- rejects death
- coping reactions:
1. maturational crisis
2. body image is more important
3. alienate self from fears
4. fears lingering death
5. talks about loss
6. silent and withdrawn
7. undisturbed by events
8. extremely angry, lack of fulfillment of
adult roles
9. idealistic view of the world: horrified and
angry over practical matters, fear of the
unknown, funeral rites
- Adolescents’ response to grief:
D – despair, depression, denial
W – withdrawn
A – anger and aggression
R – repression
F – frustration
S – silence
- other risky behaviors:
Independence vs. dependence
Development vs. deterioration
VI. YOUNG ADULTS (18-30 yo) - coping reactions: a. patient group support
1. rage
2. disappointment
3. frustration
- unwelcome intrusion

VII. MIDDLE ADULTS (30-60 - unmet goals

yo) - threat to emotional integrity
- concern: consequence of own death and that of
others
- pain
VIII. LATE ADULTS (60 and - philosophic rationalization: a. religious belief for comfort
above) Life is over b. help prepare for own death
When time runs out c. reminiscing
- new life d. care and comfort
- rest and peaceful reflection e. be present at death
- fear:
1. prolonged illness
2. freedom from pain
3. reunion

SUMMARY OF COPING BEHAVIORS:

a. THE GRIEVING CHILD

PRE-SCHOOLER (2-5)

R – regression
E – express little concern
S – separation fear
T – temporary state

EARLY SCHOOLER (6-9)

C – cry
A – anxious often
B – better understanding of death
G – grasp is unclear: cause and effect

LATE SCHOOLER (9-12)

D – distancing and day dreaming

R – realistic view
A – afraid to leave home
G – grades are poor
S – separation anxiety

ADOLESCENT

S – substance abuse
A – angry and aggression
D – drastic behavior

b. THE GRIEVING ADULT

18-35 yo – influenced by religious and cultural beliefs (priest/ minister)

45-65 yo – accepts own mortality

Encounters death of parents

Experiences death - anxiety

GRIEVING PROCESS

- is the process of psychological, social, and somatic reaction to a perceived loss (emotional
reaction to a loss)
- is said to be a natural reaction often expected to any kind of loss
 - is the total response to the emotional experience of the loss and is manifested in thoughts,
feelings and behaviors.
- a normal subjective emotional response to loss, essential for good mental, and physical health
- better termed as “STATES” since grief is dynamic

GRIEF

- a mental suffering
- sharp sorrow
- painful
- subjective and individualized
- follow loss
- accompanies mourning

DISENFRANCHISED GRIEF

- is briefly over a loss that is not or cannot be acknowledged openly, mourned publicly or socially
supported

3 Categories of circumstances that can result in disenfranchised grief

1. a relationship has no legitimacy

2. the loss itself is not recognized
3. the griever is note recognized

MOURNING

- is the period of acceptance of loss and grief during which the person learns to deal with the loss
- characterized by a return to more normal living habits

BEREAVEMENT

- is the state of grieving during which a person goes through grief reactions (state of having
suffered a loss)

- bereaved people often neglect their health to an extreme

General Characteristics of Grief Stages

a. reactions to grief and dying are similar

b. stages of reactions overlap an vary among individuals

Normal Grief Reactions

1. denial
2. sadness
3. anger
4. fear
5. anxiety

Symptoms of Grief

Physically drained
Emotionally out of control
No appetite
Prone to disease
Easy fatigability
Neglect work, physical appearance, personal hygiene
Loudness
Guilt – a person who is guilty cannot move on
Lack of interest
Zombie effect – existing without life
Thinking is unclear
Forgetful
 Cry continuously
Sighing
Lack of interest in sex and alterations in libido

FACTORS THAT AFFECT GRIEF AND DYING

1. Age - the younger the individual is, the lesser the easier the grief
- children do not understand death on same levels as adults do
- death of parent can retard a child’s development – regression
- Nursing implication: prepare oneself for inevitable death

2. Family role - death of child – devastating to the family

- loss of a spouse – protect the children
- loss of parent – eldest sibling feels the need to be strong and therefore may not grieve
openly
- Nursing implication: Give time to talk and be listened to
Allow family to enough time to accept reality of the situation
Allow family to express themselves in non-judgmental way
3. Socioeconomic factors - bereaved family suffer more if there is no life insurance
(economic loss) - loss of home, support system especially if death of spouse may lead to down income

4. Cultural influences/ culture - varies from culture to culture, person to person

- e.g. male: expected to be emotionally supportive
Female: expected to be weak and needs support
- in western culture families, grief is a private matter, shared by the family only but
others may display emotion.
5. Religious influences/ - faith and religious practices play important role in expression of grief and provide
religion comfort and solace to the person experiencing the loss.

GRIEF AND THE FAMILY

1. DENIAL
initially support and then strive to increase the development of awareness
2. ISOLATION
- listen and spend designated time consistently with the family personally
- offer the person and the family opportunity to express their emotions
-reflect on past losses and acknowledge loss behavior
3. DEPRESSION
- begin with simple problem solving and move towards acceptance
- enhance self worth through positive reinforcement
- identify the level of depression and indication of suicidal behavior or ideas
-be consistent and establish regular time to speak with the person and family
4. ANGER
- allow for crying to replace their energy
- listen and communicate
-encourage concern, support from significant others as well as professional support
5. GUILT
- listen and communicate
- allow crying
- promote more direct expression of feelings
- explore methods to resolve grief
6. FEAR
- help the person and family recognize the feelings
- explain that this will help cope with life
- explore the person’s and family’s attitudes about loss, death etc
7. REJECTION
- allow for verbal expression of this feeling state to diminish the emotional strain
- recognize that the expression of anger may create for rejection of self to significant others

Effects of grief in the family

1. Worsening marital tension

Gender roles: husband is the provider, wife is the nurturer

2.Sexual intimacy affected

 Caring for the couple:

a. familiarize with grieving process

b. counseling
c. wife’s behavior is not a form of rejection
d. husband is trying to be strong
e. open communication
f. never judge how a family chooses to mourn

Impact on surviving children (family therapy)

a. daddy does not want to play ball anymore

b. child is unable to verbalize sadness, fear of death
c. attention seeker, somatic complaints, suicide

STAGES OF PARENTAL GRIEF

1. SHOCK
- disbelief, confusion, restlessness
2.DEPRESSION
months of emotional numbness
preoccupation with thoughts of the deceased
consult doctor for antidepressants
3.ANXIETY
Loneliness
Communication breakdown
Sleep disturbance
4.HOSTILITY
- accuses mate
- anger with God – God is uncompassionate
- expresses anger in improper manner
5.GUILT
- angry at child for dying
- anger and guilt feed on each other (will to die)

RECONCILIATION
- increased energy & sleep restoration, physical healing, forgetting, searching for
meaning & hope
7. RELIEF
- painlessness, strengthens marriage
- improves parenting skills & closer sibling bond

DIFFERENT SIGNS OF IMPENDING DEATH

A. Clinical Death
1. function stops
2. apnea
3. patient will go into coma
B. Biologic Death
1. organs cease to function
2. no PR, RR
3. brain and heart stops
C. Cerebral Death
1. affects the cerebrum
2. irreversibly unconscious
D. Brain Death
1. cerebral panecrosis (extensive tissue death)
E. Social Death
1. the time when the physician pronounces death

DIFFERENT CLINICAL SIGNS OF DEATH

1. Loss of muscle tone

- incontinence
- dysphagia
- dysphasia
 - loss of gag reflex
- decreased GI motility, inspite incontinence
- decreased body movement
2. Decreased circulation
- skin becomes cyanotic
- cold and clammy feet, hands, ears, nose
3. Changes in v/s – everything goes down
- breathing is shallow, irregular, abnormally slow, does mouth breathing causing dry mucous
membrane and lips to crack
- eyes: pupils dilate, doll’s eye
- swallowing and yawning until the last breath
4. Flat ECG

GRIEF ACCORDING TO DIFFERENT THEORISTS

A. KUBLER-ROSS

STAGE DEFINITION EXAMPLE NURSING RATIONALE

RESPONSIBILITIES
1.) Denial Patient uses denial to protect “Hindi kaya nagkamali Support patient denial. It serves as
- temporary defense himself against the ang doctor sa Patient needs time protective
mechanism anguish and despair aking before facing death function;
of his situation; refuse diagnosis?” Do not force acceptance of patient
to believe that loss is truth needs time
happening. before
An adoptive coping facing
mechanism to delay death.
the pain and shock
until the patient is
better able to deal
with the reality.
Patient is unready to deal
with practical
problems.
“No, not me!”
2.) Anger and Rage These feelings are projected “Bakit ako? Sa milyo- Help patient understand that
on to family are care milyong tao ako anger is a normal
givers who are able to pa ang natamaan response to feelings
continue with life and ng cancer.” of loss and
activities. powerlessness
“Why me?” created by the
impending death.
Provide structure and
continuity in
patient’s care – this
increases patient’s
feelings of security.
The nurse should not take
anger personally or
label patient as
ungrateful or
uncooperative. It
will isolate patient
and family further
and increase guilt
and anxiety.

An attempt to postpone dying until “Hinihingi ko sa Nurse needs to listen attentively, encourage
certain tasks are completed. Diyos na patient to talk. Talking can relieve
These requests are usually made to mabigyan guilt and irrational fears.
God and provide a way for the pa ako ng In some situations, it is advisable to refer the
patient to deal with the anim na patient to member of the clergy.
situation in small increment. taon, Be patient and allow expression of feelings
“If only…’ makita ko and support realistic and positive
man lang hope.
anak ko
 makagradu
ate.”
Occurs when the patient realizes that “Wala akong gana Do not avoid the patient. - - Patient has the
he is about to lose many things. sa lahat ng reason to be sad and must be allowed
E.g. family, job, control and life itself. Gawain. to express sadness. This time the
“What’s the use” – this realization Para saan patient needs a listening ear and
produces profound sadness and pa ang pag- support from the nurse.
depression. aayos ng Don’t try to cheer the patient up.
sarili.” Communicate nonverbally.
- sitting quietly with patient
and not expecting
conversation; conveying
caring by touch; being with
the patient in silence is very
important because it
increases self worth.
Insincere reassurance/ encouragement of
unrealistic hopes should be avoided.

5.) Acceptance Comes when the patient “Malapit na akong Direct activities toward maintaining the
acknowledges and mamatay. patient’s self worth and ensuring that
recognizes that death is Do not give patient is not alone.
inevitable. Time of peace me Encourage the patient to participate as much
and contentment. anymore as possible in his or her treatment
- the patient accepts oxygen – program.
it after having the time Spend time with patient and convey caring.
gone through the has come to It can relieve patient’s feelings of
other stages; he be with my loneliness or fear.
may become creator. I Suggest for a visit of a priest – last sacrament
increasing am ready to (SOS)
detached and show go don’t
readiness to go. delay me.”
“Yes, it is me.”

B. JOHN HARVEY (1998)

1. Shock, outcry denial

2. Intrusion of thoughts, distractions and obsessive review of the loss
3. Confiding in others as a way to emote and to cognitively restructure an
account of the loss

C. RODEBAUGH, SCHWINDT & VALENTINE (1999)

1. Reeling – the person feels shock, disbelief or denial

2 . Feeling – the person experiences anguish, guilt, profound sadness, anger, lack of concentration
3 . Dealing – the person begins to adapt to the loss by engaging in support
groups, grief therapy, reading and spiritual guidance.
4. Healing – the person integrates the loss as part of life acute anguish lessens.

D. WORDEN’S BASIC TASK OF GRIEF AND MOURNING (1990)

1. to accept the reality of the loss

2. to experience the pain of grief or loss
3. to adjust to an environment in which the deceased is missing
4. to withdraw emotional energy and reinvent it in other relation

E. LINDEMANN’S 3 BASIC TASK OF GRIEF (1944)

1. Emancipation - stress
2. Readjustment – struggles, bear pain of separation
3. Reinvestment – grief work, successful mourning

F. RANDO’S 7 TASK OF DYING (1992)

 1. Preserving emotional balance.
2. Preserving self image
3. Preparing for the future
4. Pain and symptom control
5. Managing stress
6. Managing relationship with caregivers.
7. Managing relationship with significant others (SO)

Rando’s prerequisite for working with the dying

1. A personal confrontation with death in the sense of having started to come to quits
with one’s own mortality.
2. An understanding of the grief process and an appreciation for the total experience of
the dying patient.
3. Effective listening skills and the ability to appropriately respond
non-verbally as well as verbally.

4. A commitment to giving part of oneself to the dying person and

working with families after death when appropriate.
5. A knowledge of one’s own personal limits, knowing when there is to get away from
death and now to avoid burnout.
6. Appreciation of the total experience.

G. GEORGE ENGEL

1. SHOCK AND DISBELIEF

- refusal to accept loss

- stunned feelings
- intellectual acceptance but emotional denial
2. DEVELOPING AWARENESS
- reality of loss begins to penetrate awareness
- anger may be directed at hospital nurses etc
- crying and self blame
3. RESTITUTION
- rituals of mourning
4. RESOLVING THE LOSS
- attempts to deal with painful void
- still unable to accept new love object to replace lost person
- may accept more dependent relationship with support
- thinks over and talks about memories of the dead person
5. IDEALIZATION
- is the exaggeration of the good qualities that the person or object had
followed by acceptance of the loss and develops a lessened need to focus on it.
- produces image of dead persons that is almost devoid of undesirable features.
- represses all negative and hostile feelings towards the deceased
- unconsciously internalizes admired qualities of the deceased
- reinvest feelings in others
6. OUTCOME
- the final resolution of the grief process including dealing with loss as a common life occurrence
- behavior influenced by several factors:
a. importance of the lost object as source of support
b. degree of dependence on relationship
c. degree of ambivalence toward the deceased
d. number and nature of other relationships
e. number and nature of previous grief experience

H. JOHN BOULBY

1. Numbness and Protest

- anger directed at deceased for having died

- unacknowledged loss
2. Disequilibrium
- preoccupation
- intense weeping
 - anger
- ambivalence
- guilt
3. Disorganization and Despair
- depression sits in, unable to make decisions, lack of confidence
- fear
- aimless
- restless
- somatic complaints
- 2H - helplessness and hopelessness
4. Reorganization
- achieving stability and sense of reintegration
- reinvestment
- acceptance
- reminiscing

DYSFUNCTIONAL GRIEVING

- when the person cannot move on with normal activities

- does not allow a person to adjust to situation
- state in which an individual or group experiences prolonged unresolved grief and engage in
detrimental activities

ABBREVIATED GRIEF

- is brief but genuinely felt

ANTICIPATED GRIEF

- is experienced in advance of the event

- occurs before the actual loss

UNHEALTHY GRIEF

- is pathologic, dysfunctional grief

FACTORS CONTRIBUTING TO DYSFUNCTIONAL GRIEF

a. prior to traumatic loss in childhood

b. circumstances of the present loss
c. family or cultural barriers

TYPES OF DYSFUNCTIONAL GRIEF

a. Unresolved grief
- is prolonged in terms of length and severity
- bereaved has difficulty accepting/ expressing grief
- denies the loss
b. Inhibited grief
- suppressed symptoms/ reactions

FACTORS LEADING TO DYSFUNCTIONAL GRIEVING

1. client fails to grieve following death of a loved one – does not cry, absent himself at the funeral
2. the client becomes recurrently symptomatic on the anniversary of the loss, during holidays esp
Xmas
3.the client avoids visiting the grave & refuses to participate in religious memorial services of a loved one
4.the client develops persistent guilt and lowered self esteem
5. even after prolonged period, the client continues to search for the lost person
6. the client is unable to discuss the deceased with equanimity even after a long period of time
7. the client experiences physical symptoms similar to those of the person who died after the normal
period of grief
8. client’s relationships with friends and relatives worsen following the death

FACTORS THAT CONTRIBUTE TO UNRESOLVED GRIEF AFTER DEATH

1. ambivalence towards the lost person

- intense feelings of both love and hate
 - the bereaved is often fears discovering unacceptable negative feelings
2. a perceived need to be brave and in control
- fear of losing control in front of others
3. endurance of multiple losses
4. extremely high emotional value inverted in the dead person
- failure to grieve in this instance helps the bereaved avoid the reality of the loss
5. uncertainty about the loss
- e.g. when a loved one is missing in action
6. lack of support persons
7. subjection to socially unacceptable loss that cannot be spoken about
- e.g. suicide, abortion, giving up child for adoption

TYPES OF DYSFUNCTIONAL GRIEVING

Possible complicated outcomes of grief.
1. Persevering, unusually intense or distorted occurrences of - delayed or prolonged grief
normal grief symptoms. - alternation in relationships in relationships with friends and
relatives
2. Syndromes of depression, distortions, and problems. - hostility against specific person somehow connected with the
death
- phobias about illness or death
3. Diagnosable mental or physical disorder. - agitated depression, insomnia and feeling of worthlessness

4. Suicide

RISK FACTORS OF OCCURRENCE OF DYSFUNCTIONAL GRIEVING

1. Sudden unanticipated death especially when it is traumatic, violent.
2.Ambivalence, marked dependence or co-dependence in the relationship with the deceased
3. Perceived lack of social support
4. Liabilities of the mourners.
5. Loss of a child.
6. Perception of the death or suffering preventable.

CHANGES THAT OCCUR WHILE APPROACHING DEATH AND AFTER DEATH

A. Facial appearance, sight, speech, and - facial muscle relaxes, cheeks become flaccid, facial structure changes to distress;
hearing frowns
- pale ashy skin, sunken gazing eyes
- sight gradually fails, eyes remain half open or gazing (cover or wet eyes with NSS
to prevent drying
- pupils are fixed, do not react to light
- speech becomes difficult, confused and finally impossible
- hearing is retained being the last sense to be lost
B. Skin and Musculo-Skeletal System - muscles relax, patient is increasingly losing capability to move
- lips lose reflexes, sensation, ability to move following death, muscles become
fixated
- Rigor Mortis – stiffening of the body few hours following death; starts from the
jaw and progressing down the body
- immediately following death movements of the body occur
- as death approaches, skin becomes pale, cool with excessive or profuse
perspiration (diaphoresis)
- increased or uncontrolled temperature – the thermoregulating center fails.
- following death, body cools rapidly initially then gradually reaches environment
temperature
- Clinically dead – RR and HR stops
- Biologically alive – patient remains alive for a period of 3-4 minutes after the
heart ceased to beat. Once grace period passes, biologic death occurs,
resuscitation is useless; brain is severely damaged.
C. Respiratory System - breathing patter will change and becomes irregular (Cheyne Stokes), rapid and
shallow or very slow
- 10-30 seconds period of no breathing (apnea) while asleep
D. Central Nervous System - the patient will spend more and more time sleeping and at times difficult to arouse
(results from the body’s slowing metabolism
- reflexes are gradually lost
- there is restlessness – owing to need of oxygen because the blood circulation is
 slowing
- consciousness is lost and reflexes are absent
E. Circulatory System - changes occur due to alteration in temperature, RR, PR as circulatory system
gradually fails
- rapid irregular PR progresses to death
- following death (Postmortem Hypostasis) bruise-like reddish or bluish
discoloration
F. Gastrointestinal & Genitourinary Systems - n/v, weight loss is common
- impaction, urine retention, distention, bladder and bowel incontinence maybe
present
- decreasing peristalsis prevents stomach from emptying intestinal contents;
stomach distends
- impaction occurs due to lack of energy needed to evacuate bowel
- incontinence is due to relaxation of anal and bladder sphincters.

NURSING PROCESS IN DEATH AND DYING

Assessment of Patient and Family experiencing loss/ dying and death
O’Toole’s Phases of Living-Dying and related tasks
1. The living with illness phase – at the time the illness was 1st diagnosed
2. The active dying phase
3. The time of death
4. The follow-up of bereavement phase

The Living with illness phase (key tasks of patient and family at their phase)
1.The need to obtain and gain understanding and information regarding the illness process – include
information about medical and nursing treatment and what to expect and what the patient and family need
to do.
2.The need for assistance and information about limitation imposed by the illness and what resources
are available to assist them.
3. A period of adjustment as family members develop new roles.
4. The patient and family need to develop trusting relationship with their caregivers.
5. The need for assistance in maintaining hope while dealing with the reality with the disease process and
the implication of the threat to life.
6. The family’s needs to develop strategies to meet the needs of the ill person to retain as much control
over his or her life as possible.
7. The patient and family need to discover coping patterns that will assist in limiting their awareness of
the impact of losses and conserve energy so that living can continue
8. The need to maintain and/or restore relationships with significant persons, the need to tie up loose ends
9. The time to some degree to recognize and resolve unfinished business
10. The caregivers need to develop a system that permits them to care for themselves and continue living
fully as possible

Patient/ Family tasks of the active dying phase

1. if the patient is cared for at home, the caregivers will need instructions on the care of
the terminally ill
2. the family caregiver needs to regulate emotions to attend to personal needs, the dying
person’s needs and the family system needs
3. the patient and family will experience the pain of separation as the patient begins to
withdraw
4. the need to remain sufficiently engaged to provide care, comfort nd presence to the
dying person and other family member
5. the time of completion of significant issues of reconciliation and forgiveness
6. as far as possible, the time to accept or recognize the earth life is ending
7. the need for some form of acknowledgment of the bonds of the dying person to those who
remain and some formalization of the creation of memories.
8. the dying person’s needs for assurance that he or she will be remembered

Tasks at the time of death

1. Assessment of the need and wish of the family to be present at the time of death
2. The patient should not be left alone at the time of death
 3. Assessment of who the patient/ family wanted to be present, such as clergy, other family
members or friends
4. The family’s need for information about what to expect at the time of death
5. The family’s needs for assistance in notifying the appropriate person about the death such as
the funeral home.
5. The family’s need for permission to remain along patient’s body after death.

Family Tasks after death

1. If the patient died at home, the family needs assistance with the preparation of the body.
2. They may need assistance in arranging funeral/ memorial rituals meaningful to them and the
deceased.
They may want and need encouragement to use this period to reminisce about the “good days”.

DATA ANALYSIS: NURSING DIAGNOSIS

Diagnostic Title Possible Etiologies
1. Anxiety - Financial insecurity, fear of own death, loneliness
- Threat to self concept, change in health status/ socioeconomic status/ role functioning and
threat to death
2. Role Performance Altered - Changes in social involvement due to life – threatening illness
3. Hopelessness - Failing physical condition, abandonment
4. Denial - Threat to life
5. Powerlessness - Health care environment, illness-related regimen
6. Grieving, Anticipating - Potential loss of significant person/ object/ body part
7. Social Interaction, Impaired - Poor communication skills, self concept disturbance, absence of significant others, altered
thought processes
8. Social Isolation - Alteration in physical appearance, state of wellness or altered mental status
9. Grieving, Dysfunctional - Actual or perceived object loss
- Lack of family support

Needs of the Dying Patient and their corresponding Nursing Interventions throughout the Living-Dying Continuum
PHYSICAL NEEDS MOUTH a. Remove dentures – they obstruct breathing, contributes to n/v
b. Lubricate patient’s lips – mouth and lips become dry due to elevated
temperature

EYE a. When vision fails communicate more with speech and touch
b. Keep room comfortably illuminated, prevent shining light to patient’s
eye – because patient’s eyes are glazed and dry
c. If eyes are open during the terminal stage, protect them with NSS and
eye pads.
SKIN a. Back rubs to promote circulation
b. Frequent turning of patient gently – prone to bedsores due to lack of
adequate adipose tissues to cushion bony prominences.
c. Continue ROM exercises gently
d. Always keep skin dry from diaphoresis

NUTRITION a. Administration of IVF as ordered to replace fluid loss during n/v and
diaphoresis
b. NGT feeding

PHYSICAL NEEDS ELIMINATION a. Laxative

b. Manual removal of impacted stool
c. Irritation may occur due to incontinence – skin care and application of
soothing ointment around anus and perineum
d. For urinary retention – catheterization may be necessary and care of
catheter
e. Measure I and O
POSITIONING a. Elevate head part for easier breathing
& b. Oxygen therapy
AIRWAY c. If patient is unconscious, flat on bed with head turned to the sides to
 facilitate drainage of mucus from the mouth and throat
d. Suction secretions gently
SAFETY a. Protect patient from harm:
- put side rails up
- precaution on use of hot water bag
- NGT insertion for tube feeding to prevent aspiration
REST

Needs of the Dying Patient and their corresponding Nursing Interventions throughout the Living-Dying Continuum

EMOTIONAL NEEDS Grieving is the a. Show kindness, thoughtfulness, gentleness

normal b. Be sensitive to their needs through sensitive listening, caring, touch, empathy,
response and soothing presence
to loss c. Love can be expressed through kind, compassionate care of patient

SPIRITUAL NEEDS Asking the a. The lost leg of earthly journey of the patient should be characterized by peace
Clergy with God, with other people and himself.
to visit

BODY CHANGES AFTER DEATH

A. LIVOR MORTIS

- discoloration of the skin after death due to the cessation of blood circulation
- cyanotic skin, gravitational pooling
- dependent lividity
- RBC hemolysis or breakdown releasing hgb which discolors surrounding tissues
- onset: 30 minutes
- peak: 6 hours
B. RIGOR MORTIS

- is the stiffening of the body due to chemical changes, contracted muscles and
joint immobility
- etiology: lack of ATP (adenosine triphosphate)
- onset: 2-4 hours
- care following rigor mortis:
1. position body
2. place dentures
3. close eyes and mouth
C. ALGOR MORTIS

- gradual decrease of body temperature after death

- blood circulation stops – hypothalamic functions stops
- RBC hemolysis – BT falls about 1ºC (1.8ºF) until it reaches room temperature
- blood circulation stops
- decreased skin elasticity
- tissue softens
- bacterial fermentation eventually resulting to liquefaction

POST MORTEM CARE

1. Position body:

a. Close eyelids and mouth

b. Put back dentures
c. Remove all attachments
d. Clean the body – bath or “labar”
e. Lysol bath for some patients
2. Make a list of valuables for endorsement and place in a bag
3. Make the environment as clean and as pleasant as possible
4. Make the body appear natural and comfortable
5. Remove all equipment and supplies from the bedside
6. Remove soiled linens so the room is free from odors
7. Place the body in supine position, arms at sides and palms down
8. Place one pillow under the head and shoulders to prevent blood from discoloring the face
 9. Place absorbent pads under the buttocks to take up any feces and urine released because of relaxation
of the sphincter muscle
10 Provide clean gown, brush/ comb the hair
11. Allow the family to view the patient’s body
12. Apply ID tags, one to the ankle and one to the wrist
13. Wrap the body in shroud or white linen apply another ID tag to the outside of the shroud
Bring the body to the morgue for cooling (cyanosis)
Note:

*** While the patient is dying, listen to what they are saying and maintain confidentiality
*** Pray with him and call for the clergy
*** Reassure family to lessen grieving

PROCEDURAL ACTIVITIES THAT MUST BE COMPLETED AT THE TIME OF CLIENT’S DEATH

Pronouncement of death
Death Certificate – it documents the time and cause of death
Request for post mortem examination (autopsy) – with written consent from next of kin if required by law
Request for organ or tissue donation – if client is medically judged to be a suitable donor
Determination of funeral home – the family selects the mortician to embalm or cremate

DEVELOPMENTAL IMPACT OF LOSS AND DEATH

Age Developmental Stage Concept of Death Impact of Loss
0 - 1 ½ years Trust vs. Mistrust Self centered and center of the world Separation
1½-3 Autonomy vs. Shame Unable to think correctly about abstract Disappearance
and Doubt concept
3–5 Initiative vs. Guilt Very temporary Fear of not being loved
5 – 12 Industry vs. Inferiority Concrete and logical (thinks logically Punishment for not measuring
about its causes) up to expectations
Threat of bodily harm
13 – 18 Identity vs. Role Poor orientation Threat to independence
Confusion Abstract thinking Signs of being different from
peers
Young adult 18-25 Intimacy vs. Isolation Abstract Description of lifestyle
Separation
Adulthood 25 – 45 Generativity vs. Abstract philosophies Description of lifestyle
Stagnation
Maturity 45 - death Integrity vs. Despair New life, rest and peaceful reflection Separation
Part of life cycle

PHASES OF LIFE THREATENING ILLNESS

1. PREDIAGNOSTIC PHASE

- the client recognizes symptoms and risk factors of illness

- the client recognizes some element of risk and selects strategies to cope with
this perceived threat
2. ACUTE PHASE

- the client faces a diagnosis of life threatening illness

- the client now must make a series of decisions
3. CHRONIC PHASE

- the client is struggling with the disease and its treatment

- this period is punctuated by a series of illness-related crisis
4. TERMINAL PHASE

- the disease has progressed to a point in which death is inevitable

EXPECTED OUTCOME - remembering the loved one without emotional pain and reinvesting emotional
energy in life so that the capacity to move is not lost.
BENEFICIAL WAYS IN WHICH DEATH AFFECTS OUR PERCEPTION OF LIFE

1. it gives us an appreciation for living

2. it gives us sense of real existence, individual existence
3. it gives us meaning to courage and integrity, allowing us to express our conviction effectively
4. it provides us with the strength to make major decisions
5. it shows us the importance of ego-transcending achievements
6. it allows us to see our achievements as being significant

THE GRIEVING PERSON MUST ACCOMPLISH THE FOLLOWING TASKS:

1. face the pain – acknowledging the loss and its impact in changing roles
2.permit the emotional expression of the full range of feeling – talking about the reality of loss
3.achieve emancipation from bondage to the deceased (beginning to incorporate the reality of the loss
4. adjust to an altered environment
5. renew or form new relationships
6. be able to live with memories

CARE FOR NURSE CARE GIVER

a. nurses who work w/ the terminally ill and with bereaved person develop a heightened empathy and
identification with their patients
b. nurses take emotional grief and form bonds that demand grief response
c. nurses are susceptible to all the emotion of grief: frustration, sadness, guilt, anxiety, depression,
helplessness, anger

DIFFERENT ROADBLOCKS TO NURSES GRIEVING

1. Social negation of the loss and isolation from support – the nurse is left alone to grieve or to go on as if
nothing important has occurred.
2. Professionalism: nurses are expected to be strong
3. Ambivalence and feelings of guilt toward the dead person, can result if the nurse had mixed feelings
about the patient – if the patient was a difficult person to care for, the nurse may even feel a sense of relief
when death occurs.
4. Nurses often have a need to be in control or may suppress their feelings
5. Multiple losses can be overwhelming
6. Old, unresolved losses suffered by the nurse can be reawakened.

STRATEGIES FOR NURSES’ SURVIVAL – NURSES’ RESPONSIBILITIES TO TAKE STEPS

TO CARE FOR THEMSELVES

Take regular meals or time-outs from the patient care area and consider rotating out of high-stress nursing
area.
Identify specific patients that are most difficult, so that they can be anticipated and counteracted.
3.knowledge physical needs as key factor in stress reduction.
4.Integrate decompression routines into daily life. Before leaving the work area, take moment to
review the day and set it aside before going alone.
5. Engage in life affirming activities e.g. spend time with lively healthy children
6. View losses as an opportunity to re-evaluate and grow.
7. Avoid the rescuer or “savior complex”: recognize limits.
8. Recognize the need for support and do not hesitate to ask for it.
9. Say “I choose” rather than “I should”
10. Develop the skills of setting limits and feeling ok about saying “no”.
11. Laugh and play in the face of tragedy without guilt.
12. Seek consultation on a regular basis.

NURSES’ BLOCKS TO A HELPING RELATIONSHIP

1. unwillingness to share the dying experience.

2. forgetting the emotional experience of the dying: fear loneliness, abandonment
3. irritation and hostility to the dying’s frequent calls
4. failure to seek support
5. elephant communication
6. use of technical language or social chitchat

LEGALITIES RELATED TO DEATH

BILL OF RIGHTS OF THE DYING PATIENT

I have the right …

1. to be treated as a living human being until I die

2. to maintain a sense of hopefulness
3. to be cared for by those who can maintain a sense of hopefulness
4. to express my feelings and emotions and my approaching death in my own way
5. to participate in decisions concerning my care
6.to expect continuing medical and nursing attention eventhough cure goals must be changed to comfort
goals
7. not to die alone
8. to be free from pain – give placebo
9. to have my questions answered honestly
10. not be deceived
11. to have help from and for my family in accepting my death
12. to die in peace and dignity
13.to retain my individuality and not be judged by my decisions which may be contrary to the beliefs of
others
14. to discuss and enlarge my religious and spiritual experience regardless of what they mean to
others
15. to expect that the sanctity of the human body will be respected after death
16. to be cared fro by caring, sensitive, knowledgeable people who attempt to understand my needs
and will be able to gain some satisfaction in helping me face my death. The nurses’ role in legal
issues related to death is prescribed by the laws of the region and the policies of the health care institution
(e.g. NGT, ET)

ADVANCE HEALTH CARE DIRECTIVES

-include a variety of legal documents that allow persons to specify aspect of care
to receive should they become unable to make or communicate their preferences

2 Types

a. Living will
- provides specific instructions about what medical treatment the
client chooses to omit or refuse (e.g. ventilatory support)

b. Health care proxy

- a durable power of attorney for health care

- a notarized or witnessed statement appointing someone else to

manage health care treatment decisions when the client is unable
to do so.
2. AUTOPSY

- an examination of the body after death to determine the exact cause of death
- the organs and tissues of the body are examined
- consent is necessary by the decedent (before death) or the next of kin
- after autopsy, hospitals cannot retain any tissue or organ without the
permission of the person who consented the autopsy

3. CERTIFICATION OF DEATH

- pronouncement must be performed by a physician

- usually signed by the attending physician and filed with the local health or other government
office
- the family is usually given a copy to use for legal matters such as insurance claims

4. DO NOT RESUSCITATE ORDER (DNR) OR NO CODE

- for clients who are in terminal stage, irreversible illness & expected death
- a written order is generally written when the client or proxy has expressed the wish for no
resuscitation in the event of a respiratory or cardiac arrest

5. EUTHANASIA

- act of painless putting to death persons suffering from incurable and distressing disease
6. ORGAN DONATION

- people 18 years or older with sound mind may make a gift of all or any part of
their own bodies for the following purposes:
a. medical or dental education
b. research and advancement of medical/ dental science
c. therapy of transplantation
*** card is usually carried by the person who signed it

DEATH-RELATED RELIGIOUS AND CULTURAL PRACTICES

- various cultural and religious traditions and practices associa-ted with death, dying and grieving
process help an individual cope with those experiences

- nurses are often present through the dying process and at the moment of death so knowledge of
the client’s religious and cultural heritage help nurses provide individualized care to client’s and their
families

1. Many cultures prefer a peaceful death at home rather than in the hospital

2. Members of some ethnic group may request that health professionals do not reveal the prognosis
to dying client because they believe that the person’s last days should be free of worry. Other
cultures prefer that a family member (preferable male) be told the diagnosis so that the client will
be tactfully informed by the designated family member in gradually or not at all. Nurses all need
to determine whom to call, and when as the impending death draws near

BELIEFS AND ATTITUDES

Autopsy may be prohibited, opposed, discouraged by Eastern Orthodox, Muslims, Jehovah’s Witness
and Orthodox Jesus
Organ donation is prohibited by the Jehovah’s Witness and Muslims
Cremation is discouraged and opposed by Mormons, Eastern Orthodox, Islamic and Jewish faiths
Hindus prefer cremation and cast ashes in a holy river
Christians use medical means to prolong life and the Jewish faith generally opposes prolonging life
after irreversible brain damage
Buddhists permit euthanasia

*** Nurses need to be knowledgeable about the client’s death-related rituals such as last rites, chanting at
bedside and the like.

RECOGNIZING DEATH SIGNS

Traditional signs of Death

----- cessation of apical pulse, respiration and BP – referred as heart-lung death

Cerebral death or Brain death – occurs when the higher brain center or the cerebral cortex is irreversibly
destroyed

1968 WORLD MEDICAL ASSEMBLY Adopted the following guidelines for physicians as indication of
death:

1. total lack of response to external stimuli

2. no muscular movement especially breathing
3. no reflexes
4. flat encephalogram (brain waves)

Care of the body

- the body of the deceased needs to be treated in a way that respects the sanctity of the human
body
- nursing care includes maintaining privacy and preventing damage to the body

SPECIAL CONSIDERATION WITH PEDIATRIC CLIENT

*** Dying infants or newborn should be baptized using emergency baptism

Nurses role in facilitating healthy grieving:

1. CREATING MEMORY

- the greatest gift that nurses can give to grieving families is the gift of memory
- through simple gestures nurses can create an environment that facilitates bonding and provide
tangible keepsakes that will comfort families for a lifetime

2. QUIET TIME

- all parents deserve the opportunity to have quiet time alone with their infants to promote

quality family time

3. HOLDING THE INFANT

- strongly encourage bereaved parents to see and hold their children regardless of the physical
deformity or malformation present
- the nurse should also encourage parents to seethe entire body by unwrapping blankets and
pointing out the positive features of the child.

4. NAMING THE CHILD

- parents may be reluctant to use a chosen name for a baby who has died, encourage them to
do so.
- the name will identify that child as a person, a little person to be remembered and loved as
integral part of the family

5. PROVIDING KEEPSAKE

- following the infant’ s death, tangible memories provide the greatest source of comfort for
parents
- helpful keepsakes may include birth certificates, foot prints, crib card, name bracelet, cord
clamp, unwashed diaper, infant’s hat, blanket, ultrasound, fetal heart strip, photos, video
tapes and pedia book
- a memory book is a nice way to organize these keepsakes