Occurs when a person, object or situation of value changes or is no longer inaccessibleMay be positiveMarriage or BirthMay be negativeDivorce, death, job loss
types of loss
- Actualrecognized by others as well as by the person sustaining the lossExamples include loss of a child, spouse, jobPerceived lossfelt by the person but is intangible to othersExamples include loss of youth, financial independence
- Maturational loss (Necessary loss)Experienced as the result of natural developmental processesOldest sibling feels a loss when the second child is born
- Situational lossexperienced as a result of an unpredictable eventincludes traumatic injury, disease, death, or national disasterAnticipatory lossperson displays loss and grief behaviors for a loss that has yet to happenexample-families with patients with life-threatening illnessescan lessen the impact of the actual loss
Defined as an emotional reaction to lossOccurs with loss caused by separation or deathDeath of a family member or loss of a limb may cause grief
State of grieving during which a person goes through a grief reaction-experienced by both the patient and the family Can have profound health consequences that may lead to additional care
- Period of acceptance of loss and grief Person learns to deal with the loss Social expressions of grief Religious ceremonies Funerals/Wake
- Actions and expressions of grief include outward expressions of grief, including symbols, ceremonies, funeral, wake
- Shock and disbelief Refusal to accept the fact of loss Followed by a stunned or numb response “No, not me”Developing awareness Physical and emotional responses Include anger, feeling empty and crying “Why me?”
- Restitution Rituals surrounding loss With death it involves religious, cultural, or social expressions of mourning Resolving the loss Dealing with the void left by the loss
- Idealization Exaggeration of the good qualities that the person or object had Followed by the acceptance of the loss and a lessened need to focus on it Outcome Dealing with the loss as a common life occurrence
types of grief
- Normal Uncomplicated Anticipatory Grief over impending loss Can be helpful if seen as an opportunity for preparation of impending death
- Disenfranchised Person’s feelings do not meet societal norms Ambiguous grief Person may be physically present but not is not psychologically present Person is gone but no body to provide closure
- Not meeting societal norms inmate, former spouse, abortion
- Complicated Prolonged, difficult time moving forward Chronic Exaggerated Delayed Masked
Loss of relationship impacts grief, depending on the type of relationship that was lost Type of Loss Permanent or Temporary Visible or Private Coping Variables in culture, spiritual and religious beliefs or socioeconomic status HOPE
factors that affect grief and dying
Age Family Socioeconomic Position Cultural and Gender Influences Religious Influences Cause of Death
- Family roles have important impact on a person’s reaction to and expression of grief Death of a child is devastating for the family Guilt can be big burden for parents of a child who has died.
- Person who loses a spouse may feel they need “to be strong” for the children
- Children need to grieve Loss of parent by middle aged adult helps prepare for loss of spouse and accept eventual death Older people lose spouse and friends-reminisce about life, put purpose of life in perspective and prepare for their own death
- Terminally ill children and siblings ask questions about death in an attempt to understand it Death of a parent or other significant person can slow child’s development or cause regression
- Children do not understand death on the same level as adults
- Bereaved family may suffer more if there is no health insurance or pension after death of the family provider Loss of loved one and also economic loss
- May be economic loss, loss of home, community, and support system
Cultural and Gender Influences
- Western culture-grief is private shared only with family Internalize feelings European Least likely to accept and want life support
- Mexican-Americans Positive about life support and generally want this treatment Feel treatment would not be suggested if the case was truly hopeless Korean-Americans Positive about life support Did not want such technology personally Decision about life support made by the family
- African Americans Generally acceptable to withhold or withdraw life support Most likely to want to be kept alive on life support Deep distrust of healthcare system and feel it is based on the ability to pay
- Males Stoic Not cry in public Emotionally supportive
- Females Cold if not grieve in public Weak and need support
- Ethnic traditions affect how people grieve
Play important part in expression of grief Provide comfort and solace to those experiencing loss Some may blame God and turn away from their faith Some become more involved in their religion, sometimes even returning to their faith
Cause of Death
Grief response depends on cause of death Accidental death associated with feelings of bad luck-leads to enormous guilt response Some feel death is a punishment from God –especially death by disease.Death of a child because of an accident causes tremendous guilt by parents/caregiver Death while defending a country is considered honorable.
Definitions of Death
- Irreversible cessation of circulatory and respiratory functions Irreversible cessation of all functions of the entire brain, including brain stem
- Definition has been gray area at times over history
Signs of Approaching Death
- Inability or difficulty swallowing Pitting edema Decreased gastrointestinal and urinary tract activity Bowel and bladder incontinence Loss of motion, sensation, and reflexes
- Elevated temperature, but cold or clammy skin; cyanosis (Mottling)Lowered blood pressure Noisy or irregular respiration
stages of death
- Studied by Kubler-Ross Look at psychological response to death Five stages Stages may overlap Duration of stages varies between people
- First Stage-Denial and Isolation Patient denies that he/she is dying May repress what is discussed May isolate themselves from reality
- Second Stage-Anger Rage and hostility“Why me?”
- Third Stage-Bargaining Barter for more time Time to put personal affairs in order Fulfill last wishes Important to meet these wishes so the patient may move forward
- Fourth Stage-Depression Period of grief before death Characterized by crying and not speaking much
- Fifth Stage-Acceptance Patient feels tranquil Accepted death and prepared to die
- Palliative Care
- Taking care of the whole person including body, mind, spirit, heart, and soul Sees dying as natural and personal Goal-to give patients with life-threatening illness the best quality of life by aggressive management of symptoms without having a curative effect on the underlying illness
- Hospice- care provided for people with terminal illness. Usually terminal within 6 months.
- Hospice Care Priority is shifted to managing pain and other symptoms Focus on patient comfort Usually with life expectancy less than six months but not always Shift to hospice care when dying appears to be closer.
Ethical and Legal Issues
- Multiple treatment options and sophisticated life-support technologies make it hard to decide between promoting life and prolonging the dying process This complicates the decision making process for patients and health-care professionals.
- Patients Have legal and moral right to consent or refuse any and all indicated medical therapies Legal foundations for the freedom to choose include common law right of self-determination and constitutionally supported right of privacy.
- Ethical challenge – physician assisted suicide; Dr. Kevorkian
- Advanced Directives Allow individuals to state in advance their wishes for health care should certain circumstances develop Include Living Wills and Durable Power of Attorney for Healthcare.
- Patient Self-Determination Act of 1990All hospitals required to inform patients about advanced directives Advance directives vary from state to state Nurses need to be aware of state and federal laws concerning these directives.
Do Not Resuscitate Orders
- Also known as No-Code Orders Means no attempts are made to resuscitate the patient who stops breathing or whose heart stops beating If there is not a Do Not Resuscitate Order healthcare professionals are obligated to attempt resuscitation.
- Do not get yourself into predicament of “show code” or “slow code”. Delay calling a code until resuscitation measures will be ineffective.Possible charge of negligence. Most hosp have policies forbidding use of “slow code”.
Required by US Law for each person who dies Sent to local health department Mortician assumes responsibility for handling and filing the death certificate Physician’s signature is required as well as the pathologist, coroner and others in special cases
- Patients can express wish to donate organs using donor consent card Family of deceased may also decide to donate organs Can be donated from brain dead or non-heart beating cadavershttp://www.donatelifeohio.org/
- What all can be donated? Skin, heart, kidneys, pancreas, corneas, bone marrow, lungs.
- Examination of the organs and tissues after death Closest surviving family member has authority to decide if there is an autopsy Coroner must be called when patient dies in hospice care at home. Funeral home will not move body until cleared by coroner.
- Death by accident, suicide, homicide, or illegal therapeutic practice-coroner must be notified according to law Coroner will then decide if autopsy necessary even if family has refused Death within 24 hours of admission to a health care facility must be reported to the coroner.
Meeting the Psychological Needs of the Dying Patient
- Patients have fear of facing death alone Nurse needs to support patient by:Indicating presence Give them your full attention Show that you care Encourage presence of family Encourage reminiscing.
- Fears of the patient: pain, separation, unknown, leaving loved ones, loss of dignity, loss of control, unfinished business, isolation-being alone.
Meeting the Spiritual Needs of the Dying Patient
Nurse should contact the dying patient’s clergy for patient support and comfort Patient needs to feel their lives had meaning Patient need to feel hope even though they are dying.
And Finally, the Most Prevalent Question on the Nurse’s Mind
What do I do once my patient has died?Nursing responsibilities Caring for the body Caring for the family Completing legal paperwork.
caring for the body
- Prepare the body for discharge Body should be positioned in the normal anatomical position to avoid pooling of blood Tubes are removed Dressings may be changed.
- It is not necessary to wash the body Some cultures see washing the body as the final thing that can be done for the loved one and should be allowed to do so If there is an autopsy-all tubes should be left in place.
Completing Legal Paperwork
- Nurse is legally responsible for placing identification tags on the body - Place on garment and ankle Make sure the patient’s belongings are labeled including dentures May need to take them to the morgue Review and act on organ donation requests, if necessary.
- Determine who will sign death certificate Calling the funeral home if required It is important to make sure the death certificate gets where it needs to go because it can delay burial/cremation.