Coping with Loss, Death and Grief

CONCEPTS OF LOSS, GRIEF AND DEATH

People grieve in different ways, and there is no time line for completing the grief process.
The time of grieving often depend on significance of the loss, the length of the time the
person or object was known and loved, the anticipation or preparation for the loss, person’s
emotional stability, and maturity, and person’s coping ability.

No one expects to die. It is something that happens to someone else and someone else’s loved
ones. Yet it is one of two life events that all humans share, the other being birth. Dying Loss
is a part of life cycle. All people experience loss in form of change, growth and transition.
The experience of loss is painful, frightening and lonely, and it triggers an array of emotional
responses. People may vacillate between denial, shock, disbelief, anger, inertia, intense
yearning, loneliness, and sadness, loss of control, depression and spiritual despair.

Superimposed on normal losses associated with life cycle stages are potential losses of health,
a body part, self-image, self-esteem and even one’s life. When loss is not acknowledged or it
is cumulative, anxiety, depression and health problems may occur. Likewise people with
physical health problems, such as diabetes mellitus, AIDS, cardiac conditions, GI disorders
etc. tend to respond to these illnesses with feelings of grief.

Because health care usually focus on cure of disease and promotion of health, the death of
patient may represent a form of failure to health care providers. When nurses deal with
grieving families and dying patients, they are confronted with their own mortality (the
condition of being subjected to death) and other discomforting issues that accompany loss.
Such factors can affect quality of care. Technological advances in medicine have caused care
of those who are dying to become depersonalized and mechanical. In an attempt to humanise
the care of dying proponents of improved end of life care are looking to nurses. This highly
technological world calls for application of high touch interventions with dying. In other
words, appropriate care of dying is administered by compassionate nurses who are both
technically competent and able to demonstrate caring.

DEATH
Definition:-Death was defined in 1981 by the president commission for the study of ethical
problems in medicine and biomedical and behavioural research as: Death is present if an
individual has sustained (1) irreversible cessation of circulatory and respiratory functions. (2)
Irreversible cessation of all functions of entire brain, including the brain stem.

A Harvard university committee stated that the following characteristics must be present for
at least 24 hours before death can be declared:

 Lack of receptivity and responsiveness

 Lack of movement or breathing
 Lack of reflexes

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  Flat encephalogram

RIGHTS OF DYING PERSON

Right to be treated as a living human being until death.
Right to maintain a sense of hopefulness however changing its focus may be.
Right to express feelings and emotions about approaching death in his or her on
words.
Right to participate in decisions concerning care.
Right to expect continuing medical and nursing attention even though cure goals must
be change to comfort goals.
Right not to die alone.
Right to free from pain.
Right to have questions answered honestly.
Right not to be deceived.
Right to have from and for family in accepting death.
Right to die in peace and with dignity.
Right to retain individuality and not to be judged for decisions which may be contrary
with the belief of others.
Right to be cared by caring, sensitive and knowledgeable people who will attempt to
understand needs and will be able to gain some satisfaction in helping patient face his
or her death.

SIGNS OF APPROACHING DEATH

Although death is unique for each individual, common physical and psychological events
occur when death is approaching.
PHYSICAL EVENTS: Death usually occurs gradually over hours or days. Cells deteriorate
from underlying lack of sufficient oxygen; which leads to multisystem failure. The following
are signs of impending death that alert the nurse that client will die shortly.

CARDIAC DYSFUNCTIONS: Failing cardiac functions is one of the first sign that a
client's condition is worsening. At first, heart rate increases in a futile attempt to deliver
oxygen to cells. The apical pulse rate may reach 100 or more per minute. Cardiac output per
minute increases. This may diminish heart’s own oxygen supply which causes heart rate to
decrease and blood pressure to fall.

PERIPHERAL CIRCULATION CHANGES: Reduced cardiac output compromise

peripheral circulation and impair cellular metabolism & produces less heat. Skin become
pale, nail beds and lips may appear blue, client may feel cold.

PULMONARY FUNCTION IMPAIRMENT: Failure of heart pumping function causes

fluid to collect in pulmonary circulation. Breath sounds become moist and client cannot
exhale carbon dioxide adequately compounding state of hypoxia.

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CENTRAL NERVOUS SYSTEM ALTERATION: With hypoxia, brain is less sensitive to
accumulating levels of carbon dioxide, thus client may experience periods of apnoea. Pain
perception is decreased; client may stare blankly through partially opened eyes. Senses
become impaired. Hearing tends to be remaining intact.

RENAL IMPAIRMENT: Low cardiac output decreases the urine volume and waste
products accumulate.

GASTROINTESTINAL DISTURBANCE: Peristalsis decreases, causes intestinal contents

to accumulate. This stimulates vomiting centre inducing nausea and vomiting.

MUSCULOSKELETAL CHANGES: Reflexes become hypoactive. The client loses

control over sphincters leading to incontinence. Jaw and facial muscles relax. Tongue may
fall back.

PSYCHOLOGICAL EVENTS: If they have reached the stage of acceptance, some

terminally ill client looks forward to dying because it will end their suffering. Some seen to
forestall dying when they feel their loved ones are not prepared. This is waiting for
permission phenomenon.

NEAR DEATH EXPERIENCE: In this a person almost dies but is resuscitated; have been
reported for some time. People who experience near death experience report similar events
such as:

Floating above their bodies.

Moving rapidly toward a bright life.

Seeing familiar people who have already died.

Feeling warm and peaceful.

Being told that it is not time yet for them to die.

Regretting having to return to their resuscitated body.

NEARING DEATH AWARENESS: It is a phenomenon characterised by dying client’s

premonition of approximate time or date of death. In addition, just before death, client may
reach out, point or open their arms as if to embrace someone or call them by name.

LOSS
Loss is any situation, actual, potential, or perceived, in which a valued object is changed or is
no longer accessible to individual. Because change is major constant in life, everyone
experiences.

TYPES OF LOSS

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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. An actual loss can be recognized by others.
Examples: - loss of a body part, child, relationship. Lost object that have been valued by a
client include any possession that is worn out, misplaced, stolen or ruined by disaster. A child
may grieve over the loss of a favourite toy.

PERCEIVED LOSS: Perceived loss is any loss that is uniquely defined by the grieving
client. It may be less obvious to others.

Example: - loss of confidence or prestige.

Perceived losses are easily overlooked or misunderstood, yet the process of grieffollows 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.

MATURATIONAL LOSS: It includes any change in development process that is normally

expected during the life time.

One example would be 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 change.

SITUATIONAL LOSS: It includes any sudden, unpredictable external event. Often this
type of loss include multiple type of losses rather than a single loss Such as an automobile
accident that leaves a driver paralysed, unable to return to work, and grieving over the loss of
the passenger in the accident.

Loss can be tangible or intangible. For e.g. when a person is fired from a job, the tangible loss
is income, whereas loss of self-esteem is intangible.

CATEGORIES OF LOSS

There are many sources of loss:-

Loss of an aspect of oneself: - loss of body part, loss of psychological function. The degree
to which these losses affect a person largely depends on the integrity of the person’s body
image.

Loss of object external to oneself: -loss of external objects includes: (a) loss of inanimate
object that have importance to the person, such as loss of money and (b) loss of animate (live)
object such as pets.

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Separation from a familiar environment: - separation from an environment and people
who provide security can result in sense of loss. Example the 6yrs old is likely to feel loss
when first leaving the usual environment to attend the school.

Loss of loved or valued person: - The loss of a loved one or valued person through illness,
separation or death can be very disturbing. The death of loved one is permanent and complete
loss. People may be uncomfortable talking about death and being around people who are
dying. There is tendency to consider extraordinary measures that prolong and preserve life.

Perception of loss (e.g. death) by children and adolescents and

potential development disruptions
Developmental Perception Potential development disruption
stage
Infancy, Not aware of If the mother or surrogate dies
toddler death, Is aware during the first 2 years of life,
of disruption in may have long lasting
normal routine, psychosocial problems
Can react to
family’s
expression of
grief
Preschool View death as a May have significant
temporary psychosocial problem if either
separation, able parent is lost at this stage,
to react to the especially between age 4 & 6,
gravity of death problems are especially likely if
in accordance the deceased parent is of same
with the reaction or opposite sex depending on
of parents or where the child is in relation to
other adults sex identification

School age Appreciate that May have nightmares, may

death is final and
inevitable,
fantasizes about
and tend to
personify death
Preadolescent and Recognize that death is
adolescent final, understand that
death is inevitable,
preadolescents tend to
worry about dying,
adolescent tend to deny
engage in death avoidance
behaviours, may experience
intense guilt and a sense of
responsibility for death
Loss of parent may interfere with
mastery of the young adulthood task of
forming an intimate relationship with
members of opposite sex

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 that death could happen
to them

GRIEF
Grief is a series of intense physical and psychological responses that occur following a loss. It
is manifested in variety of ways that are unique to an individual and based on personal
experiences, cultural expectation and spiritual beliefs. It is normal, natural, necessary and
adaptive response to a loss. Loss leads to the adaptive process of mourning, the period of time
during which the grief is expressed and resolution and integration of loss occur. Bereavement
is the period of grief following the death of a loved one.

Mourning:Coping with grief after a loss involves the process of mourning, the outward,
social expression of loss. It involves working through the grief until an individual accepts and
adapts to his or her expectations to go on in life without that which was lost. It is behaviour
determined by cultural mores and values.

Bereavement:It includes grief and mourning – the inner feelings and outward reactions of
the survivor. Survivors go through a bereavement period that is not linear. It is the period
during which the grief process unfolds.

TYPES OF GRIEF

A nurse’s knowledge on the types of grief, which are based on characteristics or signs and
symptoms of grief, allows for implementation of appropriate bereavement therapies.

Normal grief

Normal or uncomplicated grief consists of the normal findings, behaviours, and

reactions loss. These might include sorrow, anger, crying, loneliness, and temporarily
with drawl from activities. Often the normal grief response to a loss can prove
positive, helping one to mature and develop as a person. As people mature they
develop ways of dealing with losses and learn to maintain and enhance their feelings
of safety and security.

Anticipatory grief

The process of disengaging or “letting go” that occurs before an actual loss or death
has occurred is called anticipatory grief. For example, once e person or family
receives a terminal diagnosis, they begin the process of saying good bye and
completing life affairs. The process becomes more stressful when the client is unable
to make decisions due to deterioration in health. The family must weigh factors such
as client’s values and choices, the medical facts and probabilities, the burden of
treatment, the expected future quality of life for the client, and the limitations on their
own emotional resources.

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 When the actual process of dying is extended for a long time, person in the client’s
family may have few symptoms of grief once the death occurs. This seeming absence
of grief symptoms may result because the family has engaged in grief process over
time. By the time the actual moment of death arrives, much of the shock, denial and
tearfulness have already been experienced. There is risk in anticipatory grieving.
Family members may withdraw emotionally from the client too soon, leaving the
client with no emotional support as death approaches. There may also be
complications if the person who was thought to be near death survives. Family
members may then have difficulty reconnecting and may even be resentful that the
person has lived past life expectancy.

Complicated grief

When a person has a difficulty progressing through the normal phases or stages of
grieving, bereavement becomes complicated. In these cases bereavement appears to “go
wrong” and loss never resolves. This can threaten a person’s relationship with others.
Complicated grief includes 4 types:

 Chronic grief: Active acute mourning that is characterised by normal grief reactions
that do not subside and continue over very long periods of time. Person verbalise an
inability to “get past” the grief.
 Delayed grief: Characterised by normal grief reactions that are suppressed or
postponed and survivor consciously or unconsciously avoid the pain of the loss.
Active grieving is held back, only to resurface later, usually in response to a trivial
loss or upset. For e.g. a wife may only bereave a few weeks after the death of her
spouse, only to become hysterical and sad a year later when she attends a family
gathering. The extreme sadness is a delayed response to the death of her husband.
 Exaggerated grief: persons become overwhelmed by grief, and they cannot function.
This may be reflected in form of severe phobias or self-destructive behaviour such as
alcoholism, substance abuse, or suicide.
 Masked grief: Survivors are not aware that behaviours that interfere with normal
functioning are a result of their loss. For e.g. a person who has lost a pet may develop
alterations in eating or sleeping patterns.

Disenfranchised grief

Persons experience grief when a loss is experienced and cannot be openly acknowledged, or
publicly shared. An example includes the loss of a partner from HIV or AIDS, children
experiencing the death of a step parent, or the mother whose child dies in utero or at birth.

Common myths about grief:

1. Children grieve like adults.

2. Grief is the same after all types of death.
3. It takes two months to get over your grief.
4. All bereaved people grieve in the same way.

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 5. Your grief will decline over time without any upsurges.
6. When grief is resolved, it never comes up again.
7. You and your family will be the same after the death of a loved one.
8. It's not okay to feel sorry for yourself.
9. There is no reason to be angry at your deceased loved one.
10. Men and women grieve in the same ways.
11. Children need to be protected from grief and death.
12. You will have no relationship with your loved one after his or her death.
13. Parents usually divorce after a child dies.
14. Once your loved one has died, it is better not to focus on him or her but to put him or
her in the past and go on with your life.

SYMPTOMS COMMONLY EXPERIENCED DURING GRIEF

PHYSICAL PSYCHOSOCIAL COGNITIVE BEHAVIOURAL
REACTIONS REACTIONS REACTIONS REACTIONS

 Lossof  Profound sadness  Inability to  impulsivity

appetite  Helplessness concentrate  indecisive
 Weight loss  Hopelessness  forgetfulness  social
 Insomnia  Denial  impaired withdrawal
 Fatigue  Anger judgement  distancing
 Decreased  Hostility  decreased
libido  Guilt problem
 Decreased  Nightmares solving
immune  Ennui ability
function  Preoccupation
 Multiple with lost object
somatic  Loneliness
complaints

THEORIES OF GRIEVING PROCESS

Several theoretical models describe grieving. Some of the theories are discussed below:

THERESE RANDO
Therese Rondo’s Six R's
Researcher and Clinical Psychologist, ThereseRandom also has contributed a stage model of
the grief process that she observed people to experience while adjusting to significant loss.
She called her model the "Six R's":

 Recognize the loss: First, people must experience their loss and understand that it has
happened.

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  React: People react emotionally to their loss.
 Recollect and Re-Experience: People may review memories of their lost relationship
(events that occurred, places visited together, or day to day moments that were
experienced together).
 Relinquish: People begin to put their loss behind them, realizing and accepting that
the world has truly changed and that there is no turning back.
 Readjust: People begin the process of returning to daily life and the loss starts to feel
less acute and sharp.
 Reinvest: Ultimately, people re-enter the world, forming new relationships and
commitments. They accept the changes that have occurred and move past them.

ERICH LINDEMANN
In 1944, after the coconut grove fire in Boston, Lindeman studied survivors of the disaster
and their families. Lindeman coin the phrase grief work, which is still used today to describe
the process experienced by the bereaved. During grief work, the person experiences freedom
from attachment to the deceased, become reoriented to the environment in which the
deceased is no longer present, and establishes new relationships. Lindeman’s classic work is
the foundation for the current crisis and grief resolution theories. The accompanying display
provide a description of Lindeman’s concept

Lindeman’s theory: reactions to normal grief

 Somatic distress
Episodic waves of discomfort in duration 10 – 60 minutes; multiple somatic complaints,
fatigue, and extreme physical or emotional pain.
 Preoccupation with the image of the deceased
The person experiences a sense of unreality, emotional detachment from others, and an
overwhelming preoccupation with visualising the deceased.
 Guilt
The person consider the death to be a result of their negligence or lack of attentiveness,
they look for evidence how they would have contributed to the death.
 Hostile reactions
Relationship with others becomes impaired owing to the person’s desire to be felt alone,
irritability and anger.
 Loss of pattern of conduct
The person exhibit an inability to sit still, generalised restlessness and continually
searching for something to do.

L. Engel
Grief is a typical reaction to loss of a valued object. There are six stages of grief, and
progression through each stage is necessary for healing. The grieving process, which may
take several years for completion, cannot be accelerated. The goal of grieving process is for

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the mourner to accept the loss and let go to the deceased. The accompanying display provides
an overview of Engle’s theory of grief.

Engle’s theory of grief: six stages of grief

Stage 1: Shock and disbelief

Shock and disbelief are usually defined as refusal to accept the fact of loss, followed by a
stunned or numb response “No, Not me”

Stage 2: Developing awareness

It is characterised by physical and emotional responses such as anger, feeling empty and
crying: “why me”

Stage 3: Restitution

It involves the rituals surrounding loss, and with death, includes religious, cultural or social
expressions of mourning such as funeral services.

Stage 4: Resolving

Resolving the loss is dealing with the void left by the loss

Stage 5: Idealization

Idealization is exaggeration of the good qualities of the person or object lost, followed by
acceptance of the loss and a lessened need to focus on it.

Stage 6: Outcome

Outcome is the final resolution of the grief process, including dealing with loss as a common
life occurrence.

Bowlby
Bowlby’s attachment theory is the foundation for his theory on mourning. Attachment is
described as aninstinctive behaviour that leads to development of affection bond between
their children and their primary care givers. Attachment behaviour ensures our survival
because it keeps us in close contact with the persons who can offer us protection and support.

Bowbly described four phases of mourning.

1) Numbing: it may last from few hours to a week or more and may be interrupted by
periods of extremely intense emotions. It is the briefest phase of mourning. The
grieving person may describe this phase as feeling “stunned” or “unreal”. Numbing
may serve to protect the body from the onslaught or consequences of a loss.
2) Yearning and searching: it arouses emotional outburst of sobbing and acute distress
in most persons. The phase is painful but must be endured. Parks has explained that it
is necessary for the bereaved person to experience the pain of grief in order to get the

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 grief work done. Then, anything that continually allows the person to avoid or
suppress the pain can be expected to prolong the course of mourning. Common
physical symptoms are tightness in the chest and throat, shortness of breath, feeling of
weakness and lethargy, insomnia and loss of appetite. This phase may last for months
or years.
3) Disorganisation and despair: in this phase, an individual may endlessly examine
how and when the loss occurred. It is common for the person to express anger at
anyone who might be responsible. Gradually, this examination gives the way to an
acceptance that loss is permanent.
4) Reorganisation: This phase may require as much as a year or more, the person
begins to accept unaccustomed roles, acquire new skills, and build new relationships.
Persons experiencing this phase must be encouraged to untie themselves from their
old relationship, while not devaluating it or feeling that in doing so they are lessening
its importance.
Worden

Worden’s four task of mourning imply that persons who mourn can be actively involved in
helping themselves and can be assisted by outside intervention. Although time varies greatly
in individuals, the task typically requires a minimum of a full year to work through.

Task 1: To accept the reality of the loss: Even when a death has been expected, there is
always some period of disbelief and surprise that the event has really happened. This
task involves the process required to accept that the person or object is gone and will
not return.

Task 2: To work through the pain of grief: Even though people respond to loss differently,
it is impossible to experience a loss and work through a grief without emotional pain.
Individual who deny or shut off the pain prolong their grief.

Task 3: To adjust to the environment in which the deceased is missing: According to

worden, a person does not realize the full impact of a loss for at least 3 months. At
this point many friends and associates stop calling and the person is left to ponder the
full impact of loneliness. People completing this task must be taking on roles formerly
filled by the deceased, including some task that they never fully appreciated.

Task 4:To emotionally relocate the deceased and move on with life : The goal of this task
is not to forget the deceased or give up the relationship with the deceased but to have
the deceased take a less, new prominent place in a person’s emotional life. This is
often the most difficult task to complete because people fear if they make other
attachments they will forget their loved one or become disloyal. A person completes
this stage after realizing that it is possible to love other people without loving the
deceased person less

FACTORS AFFECTING LOSS AND GRIEF

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The way an individual perceives a loss and respond to it during bereavement is heavily
influenced by many factors.

Human development: Persons of different ages and stages of development will show
different and unique symptoms of grief. For e.g. toddlers are unable to understand loss or
death, but they feel great anxiety over loss of object and separation from parents. School age
children experience grief over the loss of a body part or function. They often associate
misdeeds with causing death. Middle age adults usually begin to re-examine life and sensitive
to their own physical changes. Older adults often experience anticipatory grief because of
aging and loss of self-care abilities.

Psychosocial perspective of loss and grief: loss and death are universal life experiences that
each person faces. According to psychologist, the valuing of individual is unique, learned
response of a specific culture and society. An individual’s expression of grief evolves as the
person matures. Personal experiences shape the coping mechanisms that the individual use to
deal with stressors. As psychologist frequently explains the coping mechanism that was
effective in past are repeated as first response to the pain of a loss. When older coping
strategies are unsuccessful, new coping mechanisms are attempted.

Socioeconomic status: Socioeconomic status influence a person’s ability to obtain options

and use support mechanism when coping with loss. Generally an individual feels greater
burden from a loss when there is lack of financial, educational or occupational resources. For
e.g. a client with limited finances may not be able to replace a home lost in a fire or may not
be able to purchase necessary medications to manage a newly diagnosed disease.

Personal relationship: when loss involves a loved one, the quality and meaning of
relationship are critical in understanding a person’s grief experience. It has been said that to
lose your parents is to lose your past; to lose your spouse is to lose your present and to lose
your child is to lose your future. When a relationship between two individual is very close
and well connected, it can be very difficult for the one left behind to cope. The support that
the client receives from the family and friends is based in part on their relationship with
members of their social network and the manner and circumstances of their loss.

Nature of the loss: the ability to resolve grief depends on the meaning of the loss and the
situation surrounding the loss. The ability to accept help from others influences whether the
person will be able to cope effectively. The visibility of the loss influences the support a
person receives.

Culture and ethnicity: interpretation of a loss and the expression of loss arise from cultural
background and family practices. When individual lose control over their life aspects due to
illness, their basic core belief systems are critical components that they can and often do hold
on to. Culture affects how clients and their support system or families respond to loss. For
e.g. in western hemisphere, the grieving process is usually personal and private, with
individual showing restrained emotions. However ceremonies surrounding a person’s death
offer time for grief resolution and reminiscing. In eastern nations such as china, respect for
dead is shown by wailing and physical demonstration of grief for a specified period of time.

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Spiritual beliefs: individual’s spirituality significantly influences their ability to cope with
loss. A person’s faith in higher power or influence, the community of fellowship with friends,
their sources of hope and meaning in life, and the use of religious rituals and practices are just
some of the spiritual resources a client may depend upon during a loss. Loss can sometime
cause internal conflicts about spiritual beliefs and meaning of life...

Relationship between loss, grief and depression

Grief and depression are different. It is possible to grieve without being depressed, but many
of the feelings are similar.

However, about 33 per cent of affected people also have a depressive illness one month after
the loss, and 15 per cent are still depressed a year later.

Symptoms that suggest a person is also depressed include:

 Intense feelings of guilt.

 Thoughts of suicide or a preoccupation with dying.
 Feelings of worthlessness.
 Markedly slow speech and movements, lying in bed doing nothing all day.
 Prolonged or severe inability to function (not able to work, socialise or enjoy any
leisure activity).
 Prolonged hallucinations of the deceased.

Coping With loss, death & grief

Just as people feel grief in many different ways, they handle it differently, too. Coping can be
adaptive or maladaptive.

1) Adaptive coping:-Help the person to deal effectively with event and minimize
distress associated with it. Some people reach out for support from others and find
comfort in good memories. Others become very busy to take their minds off the loss.
For some people, it can help to talk about the loss with others. Some do this naturally
and easily with friends and family, while others talk to a professional therapist.
2) Maladaptive coping:-Itcan result in unnecessary distress for person and other
associated with person. Some people become depressed and withdraw from their
peers or go out of the way to avoid the places or situations that remind them of the
person who has died. For e.g. Some people may not feel like talking about it much at
all because it's hard to find the words to express such deep and personal emotion or
they wonder whether talking will make them feel the hurt more. This is fine, as long
you find other ways to deal with your pain. People sometimes deal with their sorrow
by engaging in dangerous or self-destructive activities. This isn't really dealing with
the pain, only masking it, which makes all those feelings build up inside and only
prolongs the grief.

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Possible consequences of maladaptive coping

1) Adjustment disorders: it occurs in persons who do not adapt or experience more

than 3 losses. Loss may be development transition or situational.
2) Acute stress disorder: while experiencing an extreme traumatic loss (physical
assault, death, and injury) a person might show major changes in behaviour, thought
and emotions. This disorder is characterised by numbness, detachment, absence of
emotional responsiveness, feeling of unreality etc.
3) Dissociative disorders
a) Dissociative amnesia: usually follow great loss. Involve an inability to
remember significant events
b) Dissociative fugue : involve suddenly leaving home and going on a
journey
c) Dissociative identity disorder: involve possession of at least two
distinct personalities. The transition from one personality to other is
sudden
d) Depersonalization: involve sense of being cut off or detached from
one’s self.

Coping strategies

In coping with loss and grief, people tend to use one of the three main coping strategies
appraisal focussed, problem focussed and emotional focussed.

1) Appraisal focussed coping: It occur when the person modifies the way they
think, for example: employing denial or distracting oneself from the problem.
People may alter the way they think about the problem by altering their goals
and values, such as by seeing humour in a situation.
2) Problem focussed coping: People using these strategies try to deal with the
cause of their problem. They do this by finding information on the problem
and learning new skills to manage the problem. Men often prefer problem
focussed coping. Problem focussed coping mechanism may allow an
individual greater perceived control over their problem.
3) Emotional focussed coping: These involve releasing pent up emotions,
distracting one-self, managing hostile feelings, meditating, using simple
relaxation procedures etc. Women prefer emotional focussed response.
Emotional focussed coping may more often lead to a reduction in perceived
control.

Coping skills and coping resources

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Coping resources are options or strategies that help determine what can be done, as well as
what is stake. Coping resources include economic assets, abilities and skills, defensive
techniques, social supports and motivation. Relationship between the individual, family
group and society are critically important. Other coping resources include health and energy,
spiritual support, positive beliefs, problem solving and social skills, social and material
resources and physical wellbeing.

Spiritual belief and viewing oneself positively can serve as a basis of hope and can sustain a
person’s coping efforts under most adverse circumstances.

Problem solving skills include the ability to search for information, identify the problem,
weigh alternatives and implement plan of action.

Social skills facilitate solving of the problem involving other people, increase the likelihood
of getting cooperation and support from others and give individual greater social control.

Material asset refer to money and goods and services that money can buy. Obviously
monetary resources greatly increase a person’s coping options in almost any situation.

Knowledge and intelligence are other coping resources that allow people to see different
ways of dealing with loss and grief.

Coping resources also include a strong ego identity, commitment to social network, cultural
stability, a stable system of values and thoughts. People who generally cope successfully
have a varied array of personal resources, which include following abilities

2) The ability to seek pertinent information

3) The ability to share concerns and find consolation when needed
4) The ability to redefine a situation so as to make it more solvable
5) The ability to consider alternatives and examine consequences
6) The ability to use homer to defuse a situation

Hope can be found in all aspects of life as a force that help person cope. It has a purpose and
gives direction and gives reason for being. The existence and maintenance of hope depend on
person having strong relationship and sense of emotional connectedness to others.
Hopefulness offers an ability to see life as enduring and having sustained meaning or
purpose.

Grief counselling and grief therapy

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In Grief Counselling and Grief Therapy (1991), the clinician and researcher William J.
Worden, Ph.D., makes a distinction between grief counselling and grief therapy. He believes
counselling involves helping people facilitate uncomplicated, or normal, grief to a healthy
completion of the tasks of grieving within a reasonable time frame. Grief therapy, on the
other hand, utilizes specialized techniques that help people with abnormal or complicated
grief reactions and helps them resolve the conflicts of separation. He believes grief therapy is
most appropriate in situations that fall into three categories: (1) The complicated grief
reaction is manifested as prolonged grief; (2) the grief reaction manifests itself through some
masked somatic or behavioural symptom; or (3) the reaction is manifested by an exaggerated
grief response.

Today, ethics committees in hospitals and long-term care facilities are available to help
families and health care providers arrive at common ground. Traumatic and violent deaths
have also changed the bereavement landscape. What had helped individuals and families in
the past in many situations has eroded and the grief and bereavement specialist, or the
persons, agencies, and organizations providing those services, is doing so in many cases out
of default. Grief counselling is used not only by individuals and families, but in many
situations by schools, agencies, and organizations, and in some cases by entire communities
affected by death.

Goals of grief counselling

 Copingaccepting the loss and talking about it.

 Identifying and expressing feelings related to the loss (anger, guilt, anxiety,
helplessness, sadness).
 Living without the deceased and making decisions alone.
 Separating emotionally and forming new relationships.
 The provision of support.
 Identifying ways of coping that suit person. Explaining the grieving process.

NURSING MANAGEMENT

ASSESSMENT : To gather a complete database that allows accurate analysis and

identification of appropriate nursing diagnosis for dying clients and their families, the nurse
first need to recognise the state of awareness manifested by client and family members. In
case of terminal illness the state of awareness shared by dying person and family affect the
nurse’s ability to communicate freely with client and other health care team members and to
assist in grieving process. Three types of awareness that have been described are:

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  Closed awareness: In closed awareness, the client is not made aware of impending
death. The client may choose this, they don’t completely understand why client is ill
or they believe the client will recover.
 With mutual pretense: The client, family and health personnel know that the
prognosis is terminal but don’t talk about it and make an effort not to raise the
subject..
 With open awareness: The client and others know about 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
arrangement.

Nursing care and support for dying client and family include
making an accurate assessment of physiological signs of approaching death. In
addition to signs related to client’s specific disease, certain other physical signs are
indicative of impending death. The four main characteristics are – loss of muscle tone,
slowing of circulation, changes in respiration and sensory impairment. As death
approaches, the nurse assists the family and other significant people to prepare.
Depending in part on knowledge of the person’s state of awareness, the nurse ask
questions that help identifying ways to provide support during period and before
death. In particular, the nurse need to know what the family expect to happen where
the person dies so accurate information can be given at appropriate death.

ASSESSMENT INTERVIEW: Ask spouse, partner, or significant others:

 Have you ever been close to someone who was dying before?
 What you have been told about what may happen when death occurs?
 Do you have questions about what may happen at time of death?
 How do you think you would like to say good bye?
 How you are taking care of yourself during these times?
 Whom can you turn to for help at this time?
 Is there anyone you would like us to contact?

DIAGNOSING: A range of nursing diagnosis, addressing both physiological and

psychological needs, can be applied to dying client, depending on assessment data. Diagnoses
that may be particular to dying client are:

 Impaired adjustment related to newly diagnosed terminal illness.

 Caregiver role strain related to hospital discharged dying patient because of
inadequate insurance.
 Decisional conflict related to repeated hospitalizations.
 Ineffective coping related to inability to accept death.
 Ineffective denial
 Anticipatory grieving
 Dysfunctional grieving
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  Hopelessness

PLANNING: Major goals for dying clients are:

 Maintaining physiological and psychological comfort.

 Achieving a dignified and peaceful death which includes maintaining personal control
and accepting declining health status. When planning care with these clients, the
dying person’s bill of rights can be useful guide.

IMPLEMENTING: The major nursing responsibility for the client who is dying is to
assist the client to peaceful death. More scientific responsibilities are following:

 To minimize loneliness, fears and depression.

 To maintain client’s sense of security, self-confidence, dignity and self-worth.
 To help the client accept losses.
 To provide physical comfort.

HELPING CLIENT DIE WITH DIGNITY:

Nurse Need to ensure that client is treated with dignity i.e. with honour and respect. Dying
client often feels they have lost control over their lives and over life itself. Helping client
dying with dignity involve maintaining their humanity, consistent with their values, beliefs
and culture. Although it is natural for people to be uncomfortable discussing death. Steps can
be taken to make such discussion easier for both nurse and client. Strategies include the
following :

 Identify your personal feelings about death.

 Focus on client’s needs. It is important the nurse should not impose fears and beliefs
on client and family.
 Talk to the client or family about how client cope with stress.
 Establish a communicative relationship that shows concern for and commitment to the
client.
 Determine what client knows about illness and prognosis.
 Respond with honesty and directness to client’s questions about death.
 Make time to be available to client to provide support, listen and respond.

HOSPICE AND PALLIATIVE CARE:

The hospice movement was founded by physician Saunders in London in 1967. Hospice care
focuses on support and care of dying person and family with goal of facilitating a peaceful
and dignified death. Hospice care is based on holistic concepts, emphasises care to improve
quality of life rather than cure, support the client, and family through the dying process and
support the family through bereavement. The condition of client usually deteriorates and
attention needs to be focussed on caregivers to ensure that they are receiving support and
resources as these changes occur. If the hospice team meets regularly, these needs can be
discussed and interventions initiated. Physical needs are usually apparent, but emotional and
behavioural signs are often more subtle.The principles of hospice care can be carried out in

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variety of settings, the most common being home and hospital based unit. Services focus on
symptom control and pain management. Commonly clients are eligible for hospice care or
hospice insurance benefits when certified by a physician to be likely to die in 6 months.
Hospice care is always provided by a team of both health professionals and non-professionals
to ensure a full range of care services.

PALLIATIVE CARE:

Palliative care is specialised, interdisciplinary care for patient with serious, life limiting or
chronic debilitating illness. It involves comprehensive management of the patient’s physical,
psychological, social and spiritual needs. As described by WHO, “is an approach that
improves the quality of life of clients and their families facing the problem associated with
life threatening illness, through prevention and relief of suffering by means of early
identification and impeccable assessment and treatment of pain and other problems, physical,
psychosocial and spiritual”. The origin of palliative care is hospice care. However unlike
hospice care, palliative care occurs any time during a patient’s illness, even if life expectancy
extends to years and aggressive or curative treatment is being pursued. Palliative care:

 Provide relief from pain and other distressing symptoms.

 Affirms life and regards dying as a normal process.
 Intends neither to hasten or nor postpone death.
 Integrates psychological and spiritual aspects of client care.
 Offers a support system to help the client live as actively as possible until death.
 Offers support system to help family cope during client’s illness.
 Uses a team approach to address the needs of client.
 Will enhance the quality of life.
This care may differ from hospice care in that the
client is not necessarily believed to be imminently dying. Both hospice and palliative
care can include end of life care.

5 Principles of palliative care:

 Palliative care respect the goals, likes and choices of the dying person and his or her
loved ones, helping them to understand the illness and what can be expected from it,
and to figure out what is most important during this time.
 Palliative care looks after the medical, emotional, social and spiritual needs of dying
person, with a focus on making sure he or she is comfortable, not left alone, and able
to look back on his or her life and find peace.
 Palliative care supports the needs of family members, helping them with the
responsibilities of caregiving and even supporting them as they grieve.
 Palliative care helps to gain access to needed health care providers and appropriate
care settings, involving various kinds of trained providers in different settings,
tailored to needs of the patient and his or her family.

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  Palliative care build ways to provide excellent care at end of life, through education of
care providers, appropriate health policies and adequate funding from insurers and
government.

MEETING THE PHYSIOLOGICAL NEEDS OF DYING CLIENT:

The physiological needs of people who are dying are related to a slowing of body processes
and to homeostatic imbalances. Interventions include providing personal hygiene measures,
controlling pain, relieving respiratory difficulties, assisting with movement, nutrition,
hydration, elimination and providing measures related to sensory changes.

 Pain control is essential to enable client to maintain some quality of their life. Drugs
which can be given are – morphine, heroin, and methadone.

PROVIDING SPIRITUAL SUPPORT:

Spiritual support is of great importance in dealing with death. The nurse has a responsibility
to ensure that client’s spiritual needs are attended. She should not impose her own religious
belief on client. Specific interventions include facilitating expressions of feelings, prayer,
meditation, reading and discussion with appropriate clergy or a spiritual advisor.

FACILITATE MOURNING:

1) Help client accept that loss is real.

2) Support efforts to live without deceased person or in face of disability.
3) Encourage establishment of new relationship.
4) Allow time to grieve.
5) Interpret normal behaviour.
6) Provide continuing support.
7) Be alert for signs of ineffective coping

SUPPRTING THE FAMILY:

The most important aspect of providing support to family members of dying client involves
using therapeutic communication to facilitate their expressions of feelings. When nothing can
reverse the inevitable dying process, the nurse can provide an empathetic and caring
presence. Family members should be encouraged to participate in care of dying person as
they wish to and are able.

CARE OF BODY AFTER DEATH

Caring for the deceased body & meeting the needs of grieving family are nursing
responsibilities. The body of deceased need to be treated in a way that respects the sanctity of
human body. Nursing care include maintaining privacy and preventing damage to body.

Physiological changes: several physical changes occur after death. The body temperature
decreases with a resultant lack of elasticity (Algermortis). Therefore, the nurse must use

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caution when removing tapes from the body to avoid skin breakdown. Another physiological
change, liver mortis, is bluish purple discoloration i.e. a by-product of R.B.Cs destruction.
This discoloration occurs in dependent areas of body. Therefore the nurse should elevate the
head to prevent discoloration from pooling of blood. Approximately 2 – 4 hours after death,
rigor mortis occurs, this is stiffening of body due to contraction of skeletal and smooth
muscles. To prevent disfiguring, as soon as possible after death, the nurse should close the
eyelids, insert dentures, close mouth and position the body in natural position.

Steps

1) Gather equipment (Organises procedure)

 Disposable gloves, gowns and other protective clothing
 Plastic bag for hazardous waste disposable
 Washbasin, washcloth, warm water, bath towel
 Clean gown
 Absorbent pads
 Body bag or shroud kit
 Paper tape and gauze dressing
 Suitable receptacle for patient’s belongings
 Valuable envelope
 Identification tags
2) Wash hand. (Reduces spread of micro-organisms)
3) Don clean gloves. (Protect nurse from contamination)
4) Close patient’s eyes and mouth if needed. (Provide a normal appearance)
5) Remove all tubing’s and other devices from patient’s body. (Make patient look more
peaceful)
6) Place patient in supine position (Allows access for procedure). Elevate head (Prevent
discoloration). Do not place one hand on top of other (This can lead to discoloration).
7) Replace soiled dressing with clean ones. (avoid odour)
8) Bathe patient as necessary. (Reduces odour)
9) Brush or comb hairs. (Give more normal appearance)
10) Apply clean gown. (Prepare body for viewing)
11) Care for valuables and personal belongings. (for legal issues)
12) Allow family to view body and remain in room. (Provide emotional support). A sheet
or light blanket placed over body with only head and upper shoulder exposed will
maintain dignity and respect for deceased.
13) After family has left the room, attach a special label if patient has contagious disease.
(Protect those who handle the body)
14) Await arrival of ambulance or transfer to morgue.
15) Document procedure and disposition of patient’s body as well as belongings and
valuables. (for legal purpose)

Documentation

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Documentation is the final validation of the success of application of nursing process for the
client with a loss or who is in grieving process. Without clear, precise and accurate notes in
nursing notes of the chart, communication breakdown will impede progression through the
grieving process. Furthermore the specific description of all events will allow for greater
continuity of care between shifts. Remember golden rule of nursing “if it is not written, it is
not done”. Following is the list of contents that are to be document by a nurse:
1)
Time of death and actions taken to prevent the death if applicable.
2)
Who pronounced the death of the client?
3)
Any special preparation and any type of donation, including time &
staff.
4)
Who was called and who came to the hospital – donor organization,
morgue, funeral home and individual family members making any
decision.
5)
Personal articles left on the body and taped to skin or tubes left in.
6)
Personal items given to family – specific names and description of
items.
7)
Time of discharge and destination of body.
8)
Location of name tags on the body.
9)
Special request by the family.
10)
Any other personal statement that might be needed to clarify the
situation.

Ethical and legal dimensions

Multiple treatment opinions and sophisticated life support technologies may make it
difficult to draw a line between promoting life and needlessly prolonging the dying
process. In these cases, health care decision making is complicated for patients and
health care professional alike. The increased popularity of “managed death” concept
and call to legalize physician assisted suicide and physician administered lethal
injections pose new ethical challenges. As patient and family struggle with end of life
treatment decision, they are increasingly looking to nurses for information, advice and
support. Patient has legally and morally protected right to consent to and refuses any
and all indicated medical therapies. A discussion of nurse’s ethical and legal
responsibilities in end of life care follows :
Advance directives: decisions about health care are becoming increasingly complex.
Patients, family members, and health care professionals alike are voicing frustration
as they grapple with complex decision about prolonging life. Some of most difficult
cases involve patient who are no longer able to indicate their treatment preferences.
Two kinds of advance treatment directives can minimize difficulties by allowing
individual to state in advance what their choices would be for health care should
certain circumstances develop. Living wills provide specific instructions about kind of
health care they should be provided or foregone in a particular situation. A durable
power of attorney for health care appoints an agent the person trust to make decision
in the event of the appointing person’s subsequent incapacity.
Assisted suicide and direct voluntary euthanasia: euthanasia may be simply
defined as good dying. Until recently, most societies maintained that the distinction

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between killing and allowing dying was morally relevant. This meant that withholding
or withdrawing medically ineffective or disproportionately burdensome therapies was
morally and legally justified even when this hastened or directly caused a patient’s
death. On the other hand killing a patient by administering a lethal injection or carbon
monoxide- even when performed with compassionate intent at the request of a patient
– was deemed both immoral and illegal. Some are questioning the validity of this
distinction today, and there are efforts to legalize assisted suicide and active
euthanasia in numerous countries. It is important for the nurses to understand the
argument for and against assisted suicide and direct voluntary euthanasia. These are
briefly listed:-
 Arguments in favour of assisted suicide and direct voluntary euthanasia
 It is beneficent and compassionate act.
 It respects autonomy by preserving the patient’s control of the manner,
method, and timing of death.
 It takes the matter outside the reach of medical power and scrupulosity.
 It prevent the injustice that allows some patients to choose death by refuse of
life support measures, while denying others the right to do so by active
euthanasia.
 In a pluralistic society, euthanasia must be accepted, whatever its intrinsic
morality, because state has no moral justification for intruding into such
private decisions.
 Arguments against assisted suicide and direct voluntary euthanasia
 It undermines the value of, and respect for, all human life.
 Guidelines cannot avoid “sliding down the slippery slope” to involuntary
euthanasia and selective devaluation of the lives of most the most vulnerable
among us.
 Euthanasia should be unnecessary because the major reason for requesting it –
intolerable pain and fear of overtreatment – can now be handled by better
palliative care, analgesia, and advance directives.
 A focus of euthanasia will deviate attention from others valuable palliative
techniques.
 If euthanasia is legal, it is predicted patient will feel a subtle pressure to
conform so as to relieve the economic and emotional burdens they impose on
family and friends.
 Euthanasia is socially destructive: it undermines treatment in physicians and
health care professionals, desensitize society to killing, and imperils the
ground already gained in legitimizing passive euthanasia.
 Do – Not – Resuscitate or no code orders
To prevent the improper use of CPR, which is designed to prevent unexpected
death, some physicians will write do not resuscitate (DNR), or no code, on the
chart of a patient if the patient or surrogate has expressed a wish that there be no
attempt to resuscitate the patient in the event of CPR. Many physicians are
reluctant to write these orders, especially when this issue is source of conflict
between patient and family or between individual family members. In these cases,

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 a physician who believes the patient will not benefit from resuscitative measures
may verbally indicate to nurses that only a slow code should be called i.e. in case
of cardiopulmonary arrest, calling a code and resuscitating the patient are to be
delayed until t, these measures will be ineffectual. Slow codes are never good
practice and many health care institutions now have policies forbidding their use.
It is likely that a nurse could be charged negligent in the event of slow code and
resultant patient death.
 Comfort measures only and other special orders :
A do not resuscitate order means simply that no attempt are to be made to
resuscitate a patient who stops breathing or whose heart stop beating. When a
discussion is taking place about resuscitation, it is appropriate to take question
aggressive treatment in general, for e.g. the use of dialysis, blood transfusion,
antibiotics and other medications. Whereas some patients may want aggressive
treatment and such treatment is medically beneficial, other patients may be at a
point in their illness at which they chose to terminate all life sustaining measures.
Nurses should be familiar with pertinent federal state law and the policies in their
institution or agency concerning the withholding or withdrawing the life
sustaining treatment. Nurses should also be familiar with the forms used to
indicate patient’s preferences about end of life care. A comfort measure only order
is written to indicate that goal of treatment is comfortable, dignified death and that
further life sustaining measures are no longer indicated. A do not hospitalise order
is being used by patients in nursing homes and other residential settings who have
elected not to be hospitalized for further aggressive treatment.
 Terminal weaning :
Terminal weaning is gradual withdrawal of mechanical ventilation from a patient
with a terminal illness or an irreversible condition with poor prognosis. In some
cases competent patient decide that they wish their ventilator support ended.
Although it may be expected that a patient will not be able to survive the weaning,
death is never a certain outcome, and it is not unusual for a patient to initiate
spontaneous respiration once ventilator support is withdrawn and live for several
hours to several days. Nursing role in terminal weaning is to participate in
decision making process by offering helpful information about the benefits and
burdens of continued ventilation and a description of what to expect if terminal
weaning is initiated.
 Death certificate:
Law requires that a death certificate be prepared for each person who dies. The
law specifies what information needs to be supplied. Death certificate are send to
local health departments, which compiles many statistics from the information.
The mortician assumes the responsibility for handling and filling the death
certificate with proper authorities. A physician’s signature is required on the
certificate, as well that of pathologist, the coroner, and other in special cases. The
nurse’s responsibility is to ensure that a death certificate has been signed by the
physician.
 Organ donation :

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 Patients who express a wish to donate functional organs, such as heart, cornea,
liver, lungs and kidneys, can fill out an organ donor consent card. The family of a
deceased patient also may decide to donate the patient’s functional organs. The
nurse should be able to review options and provide consent forms to interested
patients and their families.
 Autopsy :
 An autopsy is an examination of the organs and tissues of a human body after death.
Consent for autopsy is a legal requirement. The closest surviving family member or
member usually have the authority to determine whether an autopsy to be performed.
Some religious groups prohibit autopsies for legal purposes.
 It is commonly the physician’s responsibility to obtain permission for an autopsy.
Sometimes, the patient may grant this information before death. The nurse can assist
by explaining the reason for an autopsy. Many relatives find comfort when they are
told that the knowledge gained from an autopsy may contribute to advances in
medical science as well as establish the exact cause of death. If death is caused by
accident, suicide, homicide or illegal therapeutic practice, the coroner must be
notified, according to law. The coroner may decide that an autopsy is advisable and
order that one be performed, even though the patient’s family has refuse consent.

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