Chapter 45

Loss and Grief

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Loss

Loss is any situation in which a valued object is changed or is no longer accessible to the individual.

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Types of Loss

Maturational loss occurs as a result of moving from one developmental stage to another.

Situational loss occurs in response to external events.

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Types of Loss

Actual loss Perceived loss Physical loss Psychological loss

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Types of Loss

Categories of Loss• Loss of an external object• Loss of familiar environment• Loss of aspect of self• Loss of significant other

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Types of Loss

Loss as Crisis• Loss precipitates anxiety and a feeling of

vulnerability, which may lead to crisis.• When an individual is overwhelmed and his

or her usual coping mechanisms are no longer effective, crisis occurs.

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Types of Loss

All Americans experienced significant loss as a collective, as a result of a terrorist attack in the World Trade Center on September 11, 2001.

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Grief

Grief is a normal, natural, necessary, and adaptive response following a loss.• Bereavement is the period of grief following

a significant loss, especially death of a person or pet.

• Mourning is the period of time during which the grief is expressed.

• Mourning is an adaptive response to loss.

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Grief

Theories of the Grieving Process• Lindemann coined the phrase grief work.• Engle described three stages of mourning.

- Shock and Disbelief- Developing Awareness- Restitution and Resolution

• Worden identified four tasks in dealing with a loss.

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Grief

Types of Grief• Uncomplicated grief• Dysfunctional grief• Anticipatory grief

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Types of Grief

Persons experiencing dysfunctional grief do not progress through the stages of overwhelming emotions associated with grief, or they may fail to demonstrate any behaviors commonly associated with grief.

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Types of Grief

Disenfranchised grief is grief experienced in situations where grief is discouraged and social supports are absent.

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Types of Grief

Anticipatory grief is the occurrence of grief work before an expected loss.

Promotes adaptive grieving by freeing up the mourner’s emotional energy.

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Factors Affecting Grief

Developmental Considerations

• Childhood

• Adolescence

• Early Adulthood

• Middle Adulthood

• Older Adulthood

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Children

Concept of death varies with the child’s developmental level.

Children need to be included in mourning rituals as appropriate to their developmental level.

Children need explanations about death that are honest and comprehensible.

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Adolescence

Adolescents perceive themselves as being invulnerable and death as something that will not happen to them.

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Middle Adulthood

The death of peers forces acknowledgement of one’s own vulnerability to death.

Other losses during middle age are those associated with changes in employment and relationships.

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Older Adulthood

Most older adults recognize the inevitability of death.

Older adults commonly experience the loss of loved ones and friends, occupational role, material possessions, dreams and hopes, and physical and cognitive function.

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Factors Affecting Grief

Religious and cultural beliefs Relationship with the lost entity

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Factors Affecting Grief

Cause of Death• Anticipated death• Unexpected death• Traumatic death• Suicide

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Nursing Care of theGrieving Person

Assessment• Determination of the personal meaning of

the loss• Understanding that the stages of grief the

client is experiencing are not necessarily sequential

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Nursing Care of theGrieving Person

Nursing Diagnoses• Dysfunctional Grieving• Anticipatory Grieving

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Outcome Identification and Planning

Verbalization of feelings of grief Sharing grief with significant others Acceptance of the loss Renewal of activities and relationships

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Implementation

Listening to gain understanding of the significance of the client’s loss

A nonjudgmental, accepting attitude while the bereaved expresses anger

Appropriate referrals to community support groups

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Evaluation

Resolution of the loss is generally a process of life-long adjustment.

The nurse has a unique opportunity to lay the foundation for adaptive grieving.

Goals mutually established with client and family are the foundation for evaluation.

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Death

Stages of Death and Dying (Elizabeth Kubler-Ross)• Denial• Anger• Bargaining• Depression• Acceptance

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Ethical and Legal Issues Related to End of Life

End-of-Life Care Physician-Assisted Suicide

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Nursing Care Plan of the Dying Client

Assessment• Client’s and family’s knowledge about the

nature of terminal illness• Availability of support systems• Physical condition and symptoms• Emotional status including depression

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Assessment

Presence of advance directives for health care decisions

Concern about unfinished business Client priorities and preparation needs

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Nursing Diagnoses

Powerlessness Helplessness High Risk for Spiritual Distress Altered Family Processes

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Outcome Identification and Planning

Promoting an optimal quality of life Treating client and family respectfully Providing a safe environment Meeting the holistic needs and goals of

client and family

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Implementation

Sitting with the client, touching the client, and being physically present are often the most effective in communicating a caring, compassionate, and accepting attitude.

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Nursing Care Plan of the Dying Client

Implementation• Palliative Care

- Focus is on symptom management.- The most common symptoms are pain, dyspnea,

anxiety, and fatigue.

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Implementation

Physiological Needs• Nutrition• Breathing• Elimination• Comfort• Mobility

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Implementation

Promoting Comfort• Pain relief• Keeping client clean and dry• Providing a safe, nonthreatening

environment

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Implementation

Hospice Care• Concept of allowing individuals to die with

dignity and be surrounded by those who love them

• An interdisciplinary team is essential for delivering quality, compassionate care.

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Implementation

Psychosocial Needs• Clients may fear helplessness, dependence

on others, loss of abilities, mutilation, uncontrollable pain.

Spiritual Needs• Dying can be a time of spiritual crisis.

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Implementation

Support for the Family Learning Needs of Client and Family

• Client’s physical condition• Treatment regimen• How to handle medical crises• Emergency care

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Evaluation

Evaluating the death experience for the family and friends

Determining if the goals for a peaceful death and provision of a supportive environment were met

Discussing the process in order to assist in providing care for future dying clients

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Care After Death

Care of the Body• Physiological changes

- Algor mortis- Liver mortis- Rigor mortis

• Autopsy• Organ donation

Care of the Family

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Nurse’s Self-Care

Grief is a common experience for many nurses who are confronted with death and loss daily.

To cope with their own grief, nurses need support, education, and assistance in coping with the death of clients.