3 Types of Loss
- Necessary Loss
- Maturational Loss
- Situational Loss
Necessary Loss
Loss that is a natural part of life
May eventually be replaced by something different or better
Some are permanent and threaten security and belonging (death of loved one, divorce, loss of independence)
Maturational Loss
a type of necessary loss. all normally expected life changes throughout the lifespan
Examples of maturational loss
children leaving home for preschool, college
loss of favorite grade school teacher as you progress through school
loss of grandparents and elderly parents
Situational Loss
sudden unpredictable external events that bring about loss
ex. trauma and permanent disability
Actual Loss
When a person can no longer feel, hear, see or know a person or object.
Ex. loss of body part, loved one, job or valued object.
Perceived Loss
Uniquely defined by the person experiencing the loss and is less obvious to other people.
Ex. loss of confidence, status and daily routines
Perceive losses are easily
overlooked d/t their internal nature
Examples of losses during hospitalization
Access to familiar people Loss of familiar environment Loss of privacy Loss of control over body functions Loss of daily routines Loss (long-term or temporary): (Family role, relationships and daily activities)
Grief
the emotional response to a loss, manifested in ways unique to an individual and based on personal experiences, cultural expectations and spiritual beliefs
Mourning
- outward social expressions of grief and the behavior associated with loss
- culturally influenced and learned behaviors
Bereavement
includes the responses of both grief and mourning
Normal (uncomplicated) grief
feelings of acceptance, disbelief, yearning, anger and depression are displayed in normal bereavement grief.
Coping mechanisms for grieving people include
- Hardiness and resilience
- Personal sense of control
- The ability to make sense of and identify positive possibilities after a loss
Anticipatory Grief
the unconscious process of disengaging or “letting go” before the actual loss or death occurs
Characteristics of Anticipatory Grief
- Experience responses to grief (shock, denial and tearfulness) before the actual death occurs; possibly feeling relief when the death finally happens.
- Gives people time to prepare and accept what is coming.
- May cause added stress d/t emotional roller coaster of dealing w/ a terminal illness/diagnosis
Disenfranchised Grief
Experienced when a persons relationship to the deceased person is not socially sanctioned or cannot be openly shared, or seems of lesser significance.
Examples of disenfranchised grief
Death of an ex-spouse
A gay partner
A pet
Death from a stigmatized illness such as alcoholism or during the commission of a crime.
Ambiguous Loss
Type of disenfranchised grief, when the lost person is physically present but not psychologically available such as severe dementia or brain injury.
Complicated Grief
Prolonged or significantly difficult time moving forward after a loss.
Characteristics of Complicated Grief
Chronic disruptive yearning for the deceased
Trouble accepting the death and trusting others
Feels excessively bitter, emotionally numb or anxious about the future
Chronic Grief
normal grief response however it extends for a longer period of time (years to decades)
Exaggerated Grief
self-destructive or maladaptive behavior
Delayed Grief
avoiding the full realization of the loss because it is so overwhelming.
may be triggered by a secondary loss
Masked Grief
behaving in ways that interfere with normal functioning but is unaware that the disruptive behavior is a result of the loss
Theories of Grief and Mourning
- no “normal” theoretical descriptions of a persons experience w/ grief/loss
- educating grievers about the cyclical pattern of grief prepares them for difficult days among better days
- there are psychological, physical and social reactions to loss.
Five Stages of Grief: Dynamic Process
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
Stage 1 of Grief: Denial
cannot accept the fact of the loss
Stage 2 of Grief: Anger
resistance and possibly intense anger at God, other people or the situation
Stage 3 of Grief: Bargaining
making “deals” with God or loved ones that they will live differently if hey can be sparred the grief
Stage 4 of Grief: Depression
feeling overwhelmingly sad, hopeless and lonely
Stage 5 of Grief: Acceptance
incorporates the loss into life.
finds ways to move forward
Bowlby’s Four Stages of Mourning
- Numbing
- Yearning and Searching
- Disorganized and despair
- Reorganization
Stage 1 of Mourning: Numbing
feeling “stunned”.
protects the person from the full impact of the loss.
lasts a few hours to a week or more.
Stage 2 of Mourning: Yearning and Searching
- (separation anxiety) inner intense yearning for lost individual or object.
- includes SOB, chest tightness, lethargy, insomnia and loss of appetite.
- can last for months
Stage 3 of Mourning: Disorganization and despair
person endlessly examines why the loss occurred or expresses anger at anyone deemed responsible finally coming to terms that the loss is permanent
Stage 4 of Mourning: Reorganization
Accepts change and assumes unfamiliar roles, acquires new skills, and builds new relationships.
May take a year or more.
Factors Influencing Grief: Human Development
age and stage of development.
toddlers through older age.
Factors Influencing Grief: Personal Relationships
social support, ability to accept help from others
Factors Influencing Grief: Nature of the Loss
highly visible, private loss, sudden and unexpected death
Factors Influencing Grief: Coping Strategies
emotional disclosure, venting, talking about feelings, expressing anger, OR focusing on positive emotions and optimistic feelings.
Factors Influencing Grief: Socioeconomic Status
paying for medical expenses or objects of loss
Factors Influencing Grief: Culture and Ethnicity
physical demonstrations of grief, rituals, life-sustaining treatments during terminal illness
Factors Influencing Grief: Spiritual and Religious Beliefs
helps dying people find meaning.
faith in a higher power, linked to more positive attitudes towards death.
Spiritual Distress
inability to feel hopeful or see any favorable outcome
Designing Plans of Care
- requires the use of professional standards including the nursing code of ethics.
- explore w/ patients their plans for end of life care.
- assess patients’ and family members’ understanding of treatment options to implement a mutually developed care plan
Nursing Process: Assessment
- use both psychological and physical assessment skills to assess a patient’s unique grief response
- encourage patient to tell his/her story
A trusting, helping relationship w/ grieving patients and family members is
essential
Personality, coping style and culture can shape:
- attitudes about self-disclosure
- sharing emotions
- talking about illness, fears and death
What questions may help guide culturally competent, individualized care?
What is the most important thing I can do for you at this time?
Are your needs being addressed in a timely manner?
Are you getting the care for which you hoped?
Would you like me to help you in a different way?
Do you have a specific requests that I have not met?
Possible Nursing Diagnosis
Compromised family coping Death anxiety Fear Impaired comfort Ineffective denial Grieving Complicated grieving Hopelessness Risk for loneliness Spiritual distress
The dying patient’s care plan focuses on
comfort
preserving dignity
quality of life
A patient at the end of life has diagnoses related to physical changes including
Impaired urinary elimination Bowel incontinence Acute pain Nausea Ineffective breathing pattern
Teamwork and Collaboration RT Loss, death and Grief
Spiritual care Pain specialists Hospice Palliative care Social workers Nutritionists Grief care specialists
Health promotion consists of
of facilitation successful coping and optimizing physical, emotional and spiritual health while helping patients and families deal with disappointments, frustrations and anxieties along the way
Palliative care and Hospice benefit people who
Face chronic life-threatening illness.
It is important to make the distinction between the two.
Palliative Care
Focuses on prevention, relief, reduction, or soothing of symptoms of disease or disorders throughout the entire course of an illness including care of the dying and bereavement follow-up for the family.
Primary goal of palliative care is
to help patients and families achieve the best possible quality of life.
Care is for patients of any age
Palliative Care includes
complex chronic illnesses such as CHF and COPD
Hospice
a philosophy of care for the terminally ill and their families.
NOT a place, but a patient and family-centered approach to care
Hospice services are available in
home, hospital, extended care, or nursing home settings.
W/ hospice care, priority is given to
pain control, comfort, quality of life and attention to physical, psychological, social, and spiritual needs and resources.
Nurses promote patient
dignity, self-esteem, maintain a comfortable and peaceful environment, assist with ethical decision making and facilitate mourning.
Patients accepted into hospice usually have less than
6-12 months to live.
Therapeutic Communication
Use open-ended questions; invite patients to expand on their thoughts
Avoid false reassurance
Do not avoid discussion of sensitive issues
Do your best to make time when a patient needs to talk
Feelings of sadness, denial, or anger are normal
Patients at the end of life experience a range of psychological symptoms including:
Anxiety Depression Altered body image Denial Powerlessness Uncertainty Isolation
Attending to the patient’s physical appearance promotes
dignity and self-esteem
ex. cleanliness, absence of body odors, oral care and attractive clothing
A clean, pleasant environment helps patients
relax, promotes good sleep patterns, and minimizes symptom severity.
How can a nurse maintain a comfortable and peaceful environment for the patient?
Frequent repositioning Make sure bed linens are dry Control extraneous environmental noise Control offensive odors Consider non-pharmacological interventions
How can a nurse promote spiritual comfort and hope?
Use resources such as spiritual care
Be present and provide holistic care
Protect against abandonment and isolation
Support the grieving family
Assist with end-of-life decision making
Facilitate mourning
How can a nurse protect against patient feelings of abandonment and isolation?
Answer call lights promptly; check on patients often
Find simple and appropriate care activities for the family to perform
Make exception to visiting policies
Encourage family members to stay around the clock
How can the nurse support the grieving family?
Educate family members in all setting about symptoms the patient is likely to experience B. 37-8 p. 764
Allow family members to vent their feelings/concerns
Assist with End-of-Life decision Making
During the dying process, check on family members frequently
Facilitate Mourning
Organ or tissue donation
The appearance of a live-looking body may confuse the family during life-support while waiting for organ procurement
In the event the patient has left no instructions for donation,
the family either gives or denies the request at the time of death.
Performing an autopsy
Usually at the discretion of the coroner or medical examiner.
Performed according to law in the event of homicide, suicide, accidental causes, or deaths occurring during incarceration.
The nurse must be certain the family has not
requested or arranged an autopsy before discontinuing indwelling lines and tubes (central lines, breathing tubes, etc.)
Providing safe and appropriate postmortem care
The care of the body after death in a manner consistent with the cultural and religious beliefs of the patient.
Documenting the occurrence of a death
Relevant in risk management or legal investigations.
Also validates success in meeting patient goals, changes in treatment or expected outcomes.
Nursing Process: Evaluation
Success is measured by the relationship you have built with the patient and/or family.
Refer back to the established goals/outcomes
Include family members in the evaluation process.
Many times nurses do not recover from one emotionally draining situation before they encounter another which leads to
feelings including frustration, anger, guilt, sadness or anxiety
Frequent or prolonged exposure to grief and loss places nurses at risk for
compassion fatigue.
compassion fatigue
physical, emotional, and spiritual exhaustion resulting from seeing patients suffer, leads to nurses inability to empathize or show compassion with suffering people.
Nurses’ Self-care strategies
Talking with friends, spiritual care, close colleague helps recognize grief and reflect on the meaning of caring for dying patients.
Stress management techniques help restore energy and enjoyment in caring for patients.
Nurses who practice self-care are more likely to
experience professional and personal growth and find meaning in their work
Other Self-care strategies for nurses
Caring for your physical health: Eat right Engage in relaxing activities Laughing and getting enough sleep Daily gratitude reflections Deep breathing Meditation Listening to music
Receiving recognition for valuable contributions to the quality of patients’ lives contributes greatly to
job satisfaction.
