Loss, Grieving, And Death

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Loss

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Is an actual or potential situation in which something that is valued is changed or no longer available. People can experience the loss of body image, a significant other, a sense of well being, a job, personal possessions, or beliefs.

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There are two general types of losses;
ACTUAL and PERCEIVED losses

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Actual; can be recognized by others

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Perceived

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Experienced by one person but cannot be verified by others.Psychologic losses are often perceived losses in that they are not directly verifiable. Example; A women leaves her employment to care for her children at home may perceive a loss in independence and freedom

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Anticipatory Loss

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Experienced before the loss actually occurs. For example; a woman whose husband is dying may experience actual loss in anticipation of his death

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Situational losses

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One's job, the death of a child, or the loss of functional ability because of acute illness or injury

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Developmental losses

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Losses that occur in the process of normal development, such as the departure of grown children from the home, retirement from a career, and the death of aged parents.

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Many sources of loss

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A] loss of an aspect of oneself-a body part, a physiologic functionn, or a psychologic attribute. B] Loss of and object external to oneself; C] Separation from an accustomed environment; D] Loss of a loved or valued person

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External Losses

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A] Loss of inanimate objects that have importance to the person, such as the loss of money or the burning down of a family's house; and B] Loss of animate [live] ofjects such as pets that provide love and companionship.

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Grief

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Is the total response to the emotional experience related to loss. Grief is manifested in thoughts, feelings, and behaviors associated with overwhelming distress or sorrow

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Bereavement

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The subjective response experienced by the surviving loved ones after the death of a person with whom they have shared a significant relationship.

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Mourning

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The behavioral process through which grief is eventually resolved or altered; it is often influenced by culture, spiritual beliefs, and custom. Grief and mourning are experienced not only by the person who faces the death or a loved one but also by the person who suffers other kinds of losses.

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Symptoms that accompany grief

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Anxiety, depression, weight loss, difficulties in swallowing, vomiting, fatigue,, headaches, dizziness, fainting, blurred vision, skin rashes, excessive sweating,menstrual disturbances, palpitations, chest pain, and dyspnea.

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Types of grief responses;
ABBREVIATED GRIEF

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Is brief but genuinely felt, This can occur when the lost object is not significantly important to the grieving person or may have been replaced immediately by another, equally esteemed object.

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Anticipatory Grief

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Is experienced in advance of the event such as the wife who grieves before her ailing husband dies.

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Disenfranchised grief

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Occurs when a person is unable to acknowledge the loss to other persons. [example; Not spoken about, suicide, abortion, or giving a child up for adoption]. Socially unsanctioned and may not be known to other people. [ Homosexuality or extramarital relationships].

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complicated Grief

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Unhealthy Grief, exists when the strategies to cope with the loss are maladaptive. Including prior traumatic loss, family or cultural barriers to the emotional expression of grief, sudden death, strained relationships between the survivor and the deceased, and lack of adequate support for the survivor.

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Unresolved or Chronic Grief

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Extended in length or severity. May deny the loss, or may grieve beyond the expected time.

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Inhibited Grief

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Many of the normal symptoms of grief are suppressed, and other effects, including somatic, are experienced instead.

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Delayed Grief

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When feelings are pruposely or subconsciously suppressed until a much later time.

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Exaggerated Grief

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A survivor who appears to be using dangerous activities as a method to lessen the pain of grieving may be experiencing exaggerated grief.

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Kubler-Ross's stages of Grieving

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Denial; Refuses to believe that loss is happening Anger; Client or family may direct anger at nurse or staff about matters that normally would not bother them; Bargaining Seeks to bargain to aviod loss; Depression Grieves over what has happened and what cannot be done; Acceptance, come to terms with loss.

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Engel's Stages of Grieving

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1]Shock and Disbelief 2] Developing awareness 3] Restitutuon 4] Resolving the loss 5] Idealization 6] Outcome

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Sanders described five phases of bereavement;

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Shock, awareness, conservation/withdrawl, healing, and renewal

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Martocchio described five clusters of grief

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Shock and disbelief; Yearning and protest; Anguish, Disorganization, and Despair;

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Rando has written extensively on the subject of grief, describing three categories

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Avoidance, Confrontation, and Accommodation

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complicated Grieving

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Extended time of denial , depression, severe physiologic symptoms, or suicidal thoughts.

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Children

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The loss of a parent or other significant person can threaten the child's ability to develop, and regression sometimes results. Assisting the child with the grief experience includes helping the child regain the normal continuity and pace of emotional development.

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Middle aged Adult

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The loss of a parent through death seems a more normal occurrence compared to the death of a younger person. Coping with the death of an aged parent has even been viewed as an essential developmental task of the middle-aged adult.

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Sander's Phases of Bereavement

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Shock, Awareness of loss, Conservation/withdrawal, Healing;the turning point, Renewal

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Late Adulthood

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For older adults, the loss through death of a lifelong mate is profound. Although individuals differ in their ability to deal with such a loss, research suggests that health problems for widows and widowers increase following the death of the spouse

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A number of factors affect the significance of the loss;

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1] Importance of the lost person, object, or function
2] Degree of change required because of the loss
3] The person's beliefs and values
More than fearing death,some may fear loss of control or becoming a burden.

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Socioeconomic Status

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A pension plan or insurance, for example, can offer a widowed or disabld person a chioce of ways to deal with a loss; a person who is confronted with both severe loss and economic hardship may not be able to cope with either,

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Support System

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People closest to you are often the first to recognize and provide needed emotional, physical, and functional assistance. However, because many people are uncomfortable or inexperienced in dealing with losses, the usual support people may instead withdraw from the grieving individual.

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Cause of Death

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Individuals and societal views on the cause of a loss or death may significantly influence the grief response. A loss or death that is beyond the control of those involved may be more acceptable than one that is preventable, such as a drunk driving accident. Injuries or deaths occurring during respected activities, such as "in the line of duty" are considered honorable.

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Assessing [nursing assessment of the client experiencing a loss includes three major components;

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1] Nursing History
2] Assessment of personal coping resources, and
3] Physical assessment.
During the routine health assissment of every client, the nurse poses questions regarding previous and current losses.

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Implementing; The skills most relevant to situations of loss and grief;

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Attentive listening, silence, porn and closed questioning, paraphrasing, clarifying and reflecting feelings, and summarizing

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Implementing; Less helpful to clients are respnses that ;

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Give advice and evaluation, those that interpret and analyzi, and those that give unwarrented reassurance. To ensure dffective communication, the nure=se must make an accurate assissment of what is appropriate for the client.

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Knowledge;

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Client's understanding of the implications of the loss

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Self-care abilities;

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Skill in caring for self based on any physical abilities that may have been altered by the loss.

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Current Coping;

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Stages in the grieving or bereavement process

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Client; Current manifestations of the grief response;

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Adaptive or maladaptive signs and symptoms; cultural or spiritually based behaviors.

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Client; Role expectations;

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Client's perception of the need to return to work or family roles.

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Family;
Knowledge;

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Various family members' perception of the loss

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Family;
Support people's availability and skills;

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Sensitivity to the client's emotional and physical needs; ability to provide an accepting environment.

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Family; Role expectations;

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Family perception of client's need to return to work or family roles

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Community; Resources;

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Availability and familiarity with possible sources of assistance such as grief support groups, religious or spiritual centers, counseling services, physical care providers.

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Facilitating Grief Work;

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Explore[values of family, religion, Ethnic, Cultureal, personal expressions of grief]
Teach [client what to expect, saddness,guilt, fear, loneliness]
Encourage [sharing fellings]
Teach [family members to encourage the clients expression of grief
Encourage [Client to resume normal activities on a schedule that promotes physical and psychologic health.

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Dying and Death

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The nurse's knowledge of these developmental stages helps ot understanding some of the client's responses to a life-threatening situation.

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Responses To Dying and Death
Grieving

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Include denial, guilt, anger,despair, feelings of worthlessness, crying, and inability to concentrate. they may extend to thoughts of suicide, delusions, and hallucinations.

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Fear;

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The feeling of disruption that is related to an identifiable source [in this case someones death], may also be present. Many of the characteristrics seen in a fearful person are similar to those of grieving and include crying, immoblity, increased pulse and respirations, dry mouth, anorexia, difficulty sleeping, and nightmares.

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Hopelessness

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Occurs when the person perceives no solutions to a problem-when the death becomes inevitable and the person is unable to see how to move beyond the death. The nurse may observe apathym pessimism, and inability to make decisions. A person who does perceive a solution to the problem but does not believe that it is possible to implement the solution may be said to experience.[powerlessness]

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POWERLESSNESS

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This loss of control may be manifested by anger, violence, acting out, or depression and passive behavior.

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Nurses

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To be an effective, nurses must come to grips with their own attitudes toward loss, death, and dying, because these attitudes will directly affect their ability to provide care.

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Guidelines for physicians as indications of death.

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1] Total lack of response to external stimuli 2] No muscular movement, especially breathing 3] No reflexes 4] Flat encephalogram [brain waves]

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Artificial Support

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Absence of brain waves for an least 24 hours is an indication of death. Only then can a physician pronouncement can life-support systems be shut off.

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Cerebral Death or High Brain Death

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Which occurs when the higher brain center, the cerebral cortex, is irreversibly destroyed.In this case, there is "a clinical syndrome characterized by the permanent loss of cerebral and brainstem function ect....]

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Three types of awareness that have been described are 1] Closed Awareness 2] Mutual Pretense, and 3] Open Awareness

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In cases of terminal illness, the state of awareness shared by the dying person and the family affects the nurse's ability to communicate freely with clients and other health care team members. and to assist in the grieving process.

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Closed Awareness

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The client is not made aware of impending death. The family may choose this because they do not completely understand why the client is ill or they believe the client will recover. The primary care provider may believe it is best not to communicate a diagnosis or prognosis to the client. Nurses are confronted with this ethical problem?

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Mutual Pretense

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The client, family, and health personnel know that the prognosis is terminal but do not talk about it and make an dffort not to raise the subject.Sometimes the client refrains from discussing death to protect the family from distress. Mutual pretense permits the client a degree of privacy and dignity, but it places a heavy burden on the dying person, who then has no one to whom to confide.

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Open Awareness

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The client and others know about the 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 the funeral arrangements.

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Accurate Assessment of the physiologic signs of approaching death.

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1] Loss of muscle tone 2] Slowing of circulation 3] Changes in respirations, and sensory impairment. 4] Clinical Manifestations lists indications of impending clinical death.

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Hearing

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The last sense to go.

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Planning
[Major goals for dying clients]

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A] Maintaining physiologic and psychologic comfort and B] Achieving a dignified and peaceful death, which includes maintaining personal control and accepting declining health status.

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Implementing

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-To minimize loneliness, fear, and depression
-To maintain the client's sense of security, self-confidence, dignity, and self-worth
-To help the client accept losses
-To provide physical comfort

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Dying People

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Dying People ofter strive for self-fulfillment more than for self-preservation, and may need to find meaning in continuing to live while suffering. Part of the nurse's challenge, then , is to support the client's will and hope.

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Palliative Care

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An approach that improves the quality of life of clients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assissment and treatment of pain and other problems, physical, psychosocial and spiritual.

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Meeting the Physiologic Needs of the Dying Client

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The physiologic 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, and elimination; and providing measures related to sensory changes.

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Rigor Mortis

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Stiffening of the body that occurs 2 to 4 hours after death. It results from a lack of adenosine triphosphate [ATP], which causes the muscles to contract, which inturn immobilizes the joints. Rigor Mortis starts in the involuntary muscles [heart, bladder, andso on], Then progresses to the head, neck, and trunk, and finally reaches the extremities.Rigor Mortis usually leaves the body about 96 hours after death.

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Algor Mortis

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Is the gradual decrease of the body's temperature after death. When blood circulation terminates and the gypothalamus ceases to function, body temperature falls about 1 C [1.8 F] per hour until it reaches room temperature.

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Livor Mortis

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This discoloration; referred to as livor mortis, appears in the lowermost or dependent areas of the body.

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Tissue

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Tissue after death become soft and eventually liquefied by bacterial fermintation. The hotter the temp., the more rapid the change. Therefore, bodies are often stored in cool places to delay this process.

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shroud

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A large piece of plastic or cotton material used to enclose a body after death. Identification is then applied to the outside of the shroud. Mislabeling can create legal problems if the body is inappropriately identified and prepared incorrectly for burial or a funeral.

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Evaluating--

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--Listening to the client's reports of feeling in control of the environment surrounding death, such as control over pain relief, visitation of family and support people, or treatment plans
---Observing the client's relationship with significant others
--Listening to the client's thoughts and feelings related to hopelessness or powerlessness