grief process, death and dying

Grief Process, Death and Grief Process, Death and DyingDying

Plaut Plaut &&

RoarkRoark

Roark, 2004Roark, 2004

LOSSLOSS ActualActual PerceivedPerceived External ObjectsExternal Objects Known EnvironmentKnown Environment Significant OtherSignificant Other Aspect of SelfAspect of Self LifeLife


Kubler-Ross Stages of GriefKubler-Ross Stages of Grief DenialDenial AngerAnger BargainingBargaining DepressionDepression AcceptanceAcceptance


Death and DyingDeath and Dying Assisting the Assisting the

patient to “Live patient to “Live well” and “Die well” and “Die well”well”

What does this mean What does this mean to you?to you?


Common fears of the dying Common fears of the dying patientpatient

Fear of LonelinessFear of Loneliness Distancing by support people and Distancing by support people and

caregivers can occurcaregivers can occur Debilitation, pain, and incapacitationDebilitation, pain, and incapacitation Hospital, a place that can be very lonelyHospital, a place that can be very lonely Fear of dying aloneFear of dying alone


Fears of the dying clientFears of the dying client Fear of SorrowFear of Sorrow

SadnessSadness Letting go of hopes, dreams, the futureLetting go of hopes, dreams, the future Awareness of own mortalityAwareness of own mortality Grief about future lossesGrief about future losses Anticipatory grief that involves mourning, coping Anticipatory grief that involves mourning, coping

skillsskills Grief related to diagnosis that has a long term Grief related to diagnosis that has a long term

effect on the body such as cancereffect on the body such as cancer Patient may feel well at time of diagnosisPatient may feel well at time of diagnosis


Fears of the dying clientFears of the dying client Fear of the unknown:Fear of the unknown:

Death is an unknown stateDeath is an unknown state What will happen after death?What will happen after death? What will happen to loved ones, those What will happen to loved ones, those

left behindleft behind


Fears of the dying clientFears of the dying client Loss of self concept and body Loss of self concept and body

integrityintegrity Mutilation via therapyMutilation via therapy Body image changesBody image changes Loss of role or statusLoss of role or status Loss of standard of livingLoss of standard of living


Fears of the dying clientFears of the dying client Fear of RegressionFear of Regression

Ego is threatenedEgo is threatened Physical deterioration may occurPhysical deterioration may occur Mental deterioration may occurMental deterioration may occur Unable to care for selfUnable to care for self Become dependent on others for careBecome dependent on others for care


Fears of the dying clientFears of the dying client Fear of Loss of Self ControlFear of Loss of Self Control

Loose ability to control life decisionsLoose ability to control life decisions Loose ability to control ADL’sLoose ability to control ADL’s Loss of control of body functionsLoss of control of body functions Loss of control of emotionsLoss of control of emotions Loss of independenceLoss of independence


Fears of the dying clientFears of the dying client Fear of Suffering and PainFear of Suffering and Pain

May be many different types of pain or May be many different types of pain or suffering such as physical, emotional, suffering such as physical, emotional, social, or spiritual in naturesocial, or spiritual in nature

Altered relationships with othersAltered relationships with others Anxiety related to the disease and Anxiety related to the disease and

consequences of the diseaseconsequences of the disease


Child’s Response to Illness and Child’s Response to Illness and DeathDeath

InfantInfant ToddlerToddler PreschoolPreschool School AgedSchool Aged AdolescentAdolescent


Cultural Backgrounds Affect Cultural Backgrounds Affect Beliefs Concerning DeathBeliefs Concerning Death

Beliefs, attitudes, and values that stem from Beliefs, attitudes, and values that stem from the patient’s cultural background will strongly the patient’s cultural background will strongly influence their reaction to loss, grief, and deathinfluence their reaction to loss, grief, and death

Expressions of grief are governed by what is Expressions of grief are governed by what is acceptable by the family and within the acceptable by the family and within the cultural contextcultural context

Comfort may be found through spiritual beliefs, Comfort may be found through spiritual beliefs, and finding comfort in specific rites, rituals, and finding comfort in specific rites, rituals, and practicesand practices


Cultural Backgrounds Affect Cultural Backgrounds Affect Beliefs Concerning DeathBeliefs Concerning Death

Organized religious practicesOrganized religious practices Nurses need to be in tune with Nurses need to be in tune with

patients’ spiritual needspatients’ spiritual needs Becoming familiar with cultural views Becoming familiar with cultural views

will help…will help… Can you name some cultural practices Can you name some cultural practices

associated with loss, grief, and death?associated with loss, grief, and death?


Support the clientSupport the client Nurses can help to identify coping mechanisms, Nurses can help to identify coping mechanisms,

and encourage effective coping mechanismsand encourage effective coping mechanisms Allow client/family to visit the chapel if desiredAllow client/family to visit the chapel if desired Allow family members around Allow family members around Client may have problems with conflicting Client may have problems with conflicting

feelings that do not align with culture or feelings that do not align with culture or religious practices-nurse can evaluate coping religious practices-nurse can evaluate coping and guide the client to appropriate and guide the client to appropriate interventionsinterventions


Role of the ChaplainRole of the Chaplain Can be a member of the health care teamCan be a member of the health care team Assist with religious practicesAssist with religious practices Perform ritesPerform rites Provide prayer, support, and comfortProvide prayer, support, and comfort Assist with mobilizing other support Assist with mobilizing other support

systems that are important to the clientsystems that are important to the client Support family membersSupport family members


Nurses response to the dying Nurses response to the dying patientpatient

Nurses grieve alsoNurses grieve also Nurses need to come to terms with personal Nurses need to come to terms with personal

meanings of life and deathmeanings of life and death Best prepared to work with terminal clients Best prepared to work with terminal clients

when the nurse has been given the time to when the nurse has been given the time to come to terms with own mortalitycome to terms with own mortality

Common feelingsCommon feelings Develop personal/professional support Develop personal/professional support

systemssystems


Rationale for Communicating Rationale for Communicating Truthfully about Terminal Truthfully about Terminal

IllnessIllness Right to knowRight to know Time frameTime frame Nurse needs to assess whether or Nurse needs to assess whether or

not the patient/family have been told not the patient/family have been told and what was told to themand what was told to them

THE PHYSICIAN WILL TELL THE THE PHYSICIAN WILL TELL THE CLIENT FIRST, NOT THE NURSECLIENT FIRST, NOT THE NURSE


Communicating Terminal Communicating Terminal Illness, continuedIllness, continued

The nurse:The nurse: Clarifies what was saidClarifies what was said Listens to concernsListens to concerns Fosters communication between MD, client, Fosters communication between MD, client,

and familyand family Allows patient to express lossAllows patient to express loss Facilitate grief through nursing processFacilitate grief through nursing process Be available for patientBe available for patient Assist patient to identify needs/hopes for Assist patient to identify needs/hopes for

remainder of liferemainder of life Connect patient with proper resourcesConnect patient with proper resources


List nursing strategies List nursing strategies appropriate for grieving appropriate for grieving

personspersons Open ended statementsOpen ended statements Patient sets the pacePatient sets the pace Accept any grief reactionAccept any grief reaction Be aware—nurse may be target of angerBe aware—nurse may be target of anger Remove barriersRemove barriers Avoid giving adviceAvoid giving advice Allow patient to talkAllow patient to talk Allow patient to express signs of hopeAllow patient to express signs of hope Support hope by helping focusSupport hope by helping focus


Assist Family to GrieveAssist Family to Grieve Explain procedures and equipmentExplain procedures and equipment Prepare them about the dying processPrepare them about the dying process Involve family and arrange for visitorsInvolve family and arrange for visitors Encourage communicationEncourage communication Provide daily updatesProvide daily updates ResourcesResources Do not deliver bad news when only one Do not deliver bad news when only one

family member is presentfamily member is present


Choices of Care SettingChoices of Care Setting Families have choices of where to Families have choices of where to

care for the dying loved onecare for the dying loved one Ask the patient and family Ask the patient and family

preferencespreferences Support whatever the choiceSupport whatever the choice Hospital, Home/HospiceHospital, Home/Hospice


Elements of Hospice CareElements of Hospice Care Home care coordinated with hospitalHome care coordinated with hospital Control of symptoms holisticallyControl of symptoms holistically Physician directed carePhysician directed care Utilization of variety of health care Utilization of variety of health care

professionalsprofessionals Bereavement follow up careBereavement follow up care Acceptance based on need, not $Acceptance based on need, not $


Nursing strategies to meet Nursing strategies to meet physical and psychosocial physical and psychosocial needs of the dying patientneeds of the dying patient

Thorough pain Thorough pain controlcontrol

Maintain Maintain independenceindependence

Prevent isolationPrevent isolation Spiritual comfortSpiritual comfort Support the familySupport the family


Signs/Symptoms of Signs/Symptoms of Approaching DeathApproaching Death

Motion and sensation is gradually lostMotion and sensation is gradually lost Increase in temperatureIncrease in temperature Skin changes-cold, clammySkin changes-cold, clammy Pulse-irregular, and rapidPulse-irregular, and rapid Respirations-strenuous, irregular, Cheyne stokesRespirations-strenuous, irregular, Cheyne stokes ““Death rattle”Death rattle” Decrease Blood PressureDecrease Blood Pressure Jaw and Facial muscles relaxJaw and Facial muscles relax MOST POSITIVE SIGN OF DEATH=Absence of brain MOST POSITIVE SIGN OF DEATH=Absence of brain

waves (Need two MDs to sign off)waves (Need two MDs to sign off)


Nursing care after deathNursing care after death Autopsy: examination performed after Autopsy: examination performed after

a person’s death to confirm or a person’s death to confirm or determine cause of deathdetermine cause of death

For tissue and organ removal: For tissue and organ removal: Keep CV system goingKeep CV system going Call donor bank representativeCall donor bank representative Must be agreed on by all family membersMust be agreed on by all family members Or, patient decision before deathOr, patient decision before death


Nursing care after deathNursing care after deathLegally, a person is considered dead when Legally, a person is considered dead when

there is a lack of brain waves even though there is a lack of brain waves even though other body organs continue to functionother body organs continue to function

This definition allows for harvesting of This definition allows for harvesting of organs and tissue for donationorgans and tissue for donation

Vital organs are: heart, liver, kidney, lung, Vital organs are: heart, liver, kidney, lung, pancreaspancreas

Non-vital organs are: eye corneas, long Non-vital organs are: eye corneas, long bones, middle ear bones, and skinbones, middle ear bones, and skin


Deceased patient, before Deceased patient, before viewing the bodyviewing the body

Check orders for special requestsCheck orders for special requests Remove equipmentRemove equipment Remove suppliesRemove supplies Change soiled linens and cleanse patientChange soiled linens and cleanse patient Use room deodorizerUse room deodorizer Place patient in supine position, with small Place patient in supine position, with small

pillow under headpillow under head Insert denturesInsert dentures


Deceased patient, before Deceased patient, before viewing the body continuedviewing the body continued

Remove valuables and give to familyRemove valuables and give to family Stay with family, if requestedStay with family, if requested

After the family leaves:After the family leaves: Tag patient according to hospital/agency Tag patient according to hospital/agency

policypolicy Wrap body in shroudWrap body in shroud Put ID tag on shroudPut ID tag on shroud Transfer to morgueTransfer to morgue DocumentDocument


Describe response of family to Describe response of family to dying processdying process

Related to cultural backgroundRelated to cultural background Unresolved grief issuesUnresolved grief issues EmotionsEmotions RequestsRequests Physical symptoms may occurPhysical symptoms may occur ReorganizationReorganization Individualized grief patternsIndividualized grief patterns


Behavioral responses that Behavioral responses that obstruct the expression of griefobstruct the expression of grief Sudden, unexpected deathSudden, unexpected death Lengthy illness resulting in deathLengthy illness resulting in death Loss of a childLoss of a child Perception that the death was Perception that the death was

preventablepreventable Unsteady relationship with deceasedUnsteady relationship with deceased Mental illness of survivorMental illness of survivor Lack of social supportLack of social support


ThanatologyThanatology Thanatology= study of deathThanatology= study of death The description of study of the The description of study of the

phenomena of death, and of phenomena of death, and of psychological mechanisms for coping psychological mechanisms for coping with deathwith death

Thank youThank you


grief process, death and dying

Documents

dying clientfear of

dying clientfear of

cultural backgrounds

common fears

cultural practices

cultural views

cultural contextcomfort

spiritual beliefs