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SEMINAR ON
COPING WITH LOSS ,
GRIEF & DEATH

SUBMITTED TO : SUBMITTED BY :

MRS. SINDHUMATHI MS . JAYAVARSHINI.S

Associate professor M.sc ( Nursing ) I- Year

CON- EIMS CON-EIMS

SUBMITTED ON :
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COPING WITH LOSS, GRIEF, DYING & DEATH

Introduction:

Life itself is a journey where one experiences a lot of things such as the feeling of happiness and sorrows, love
and caring, achievement, etc. Not only these, one experiences a series of loss and gain. Loss, grieving and death
are experienced by everyone at some time during their life. people may suffered the loss of valued relationships
through life changes, such as moving from one city to another, separation, divorce, death of parents, spouse or
friends. Loss and grief are experiences that affect not only the clients and their families but also the nurses who
for them as well. Loss and death are universal, yet individually unique events of human experiences. Coping
mechanisms determine people‘s ability to face and accepts loss and grief is the natural response to loss. Human
can anticipate death. Death can be an overwhelming experience that affects the dying persons and their families,
significant others, friends and caregivers. The style of dying reflects a person‘s style of living and attitudes about
death depends on a person‘s beliefs and emotional strength. Nurses assist the patients in understanding and
accepting loss so that life can continue. When patients do not do grief work after a loss, serious emotional,
mental and social may occurs. Care of dying patients and their families can be one of the most challenging
aspects of nursing care. Because is the final stage of human growth and development, it is essential that NURSES
be knowledgeable about the process of dying as they are about the process of birth.

Definition:

Loss: Loss is an actual or potential situation in which that is valued is changed, no longer available or gone. People can
experience the loss of body image, sense of well being, a job, personal possessions, beliefs, sense of self, and so on.

Grief: Grief is the natural response to loss. It is essential for good mental and physical health. It is a natural part of
human experiences

Dying: The process of undergoing death is known as dying.

Death:

 Apparent Death: The cessation of life as indicated by the absence of heartbeat or respiration.
 Legal Death: The total cessation/absence of activity in the brain and the central nervous system, cardio-vascular
system and the respiratory system as observed by a physician.

LOSS:
Loss comes in many forms based on the values and priorities learned within one‘s sphere of influence, including
one‘s family, friends, society and cultures. A person experiences loss in the absence of an object, person, body
parts or functions, emotions, or idea that was formerly present.

TYPES :

According to it, loss can be of different types. They are:-

1) Actual Loss.
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2) Perceived Loss.

3) Maturational Loss.

4) Situational Loss.

1.) Actual Loss: Actual loss is any loss of a person or object that can no longer be felt, heard, known, or
experienced by the individual.

E.g. Loss of arm, child, relationship, role at work, etc.

2.) Perceive Loss: Any loss that is tangible and uniquely defined by the grieving client. It may be less obvious to
others.

E.g. loss of confidence prestige.

3.) Maturational Loss: It includes any change in the developmental process that is normally expected during a
lifetime.

E.g. Mothers feeling of loss as a child goes to school for the first time

4.) Situational Loss: It includes any sudden, unexpected external event that is not predictable. Often this types
of loss includes multiple losses rather than a single loss, such as an automobile accident that haves a driver
paralysed, unable to return to work and grieving over the loss of the passenger in the accident.

Source of Loss:

There are many sources of loss:-

 Loss of an aspect of oneself. E.g. A body part, a physiological function, or a psycho logic attribute.
 Loss of an object external to oneself.
 Separation from an accustomed environment.
 Loss of a loved or valued person.

Factors Influencing Loss Experiences:

The factors influencing loss experiences are as follows:-

1) Childhood experiences.

2) Physical and emotional state.

3) Accumulated loss experience.

4) Visibility.

5) he grief.

6) Availability of resources.

7) Cultural factor.
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8) Relationship with the lost person.

Factors Affecting Loss:

The factors affecting loss are as follows:-

A. Development stage.

B. Religious & cultural beliefs.

C. Relationship with the loss object.

D. Cause of death.

A.) DEVELOPMENT STAGE:

 Depending on the client‘s place on the age, the grief response to a loss will be experienced differently.
 Nurses practice in many setting where children, adolescents and adults, as of growth and development,
experience changes that result in loss.
 E.g. A pregnant women to some degree experience loss after delivery of the first child even when the
child is healthy and normal.

Childhood:

 Children vary in the reaction to loss and in the ability to comprehend the meaning of death.
 It is important to understand the way a child‘s concept of death evolves, because the concept varies
developmental tasks.

Adolescence:

 Most adolescents value physical attractiveness and athletic abilities.

 Grief may occur when the adolescent suffers the loss of body part and function.
 Because of the strong influence of peer groups, adolescents seek approval of their friends and they fear being
rejected if a loss affects their acceptance by others even though they have an intellectual understanding
of death, adolescents believe themselves to be invulnerable and thus, immune to death, they reject the
possibility of their own mortality.

Early adulthood:

 In young adult, grief is usually precipitated by the loss of role or status.

 E.g. Unemployment or the break- up of a relationship may cause significant grief for the young adult.
 The concept of death in this age group primarily a reflection of cultural values and spiritual beliefs.

Middle Adulthood:

 During middle adulthood, the potential for experiencing loss increases.

 The death of parents often occurs during this developmental phase.
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 As an individual ages, it can be especially threatening when peers die, because these death force
acknowledgement of one‘s own mortality.

Late Adulthood:

 During this stage, most individual recognise the inevitability of death.

 It is challenging for elders to experience the death of age-old friends or to find themselves the last one of their
children and grandchildren as sources of comfort and companionship.
 Cultivating friendships in all age groups helps prevent loneliness and depression.

B.) RELIGIOUS & CULTURAL BELIEFS:

 Religious and cultural beliefs can have a significant effect on an individual grief experience.
 Every cultural has certain religious beliefs about the significance of death, as well as rituals for care of the dying.
 Belief about an afterlife, a supreme being, redemption of the soul, and re-incarnation are important aspects that
can assist one in grief work. Relationship with the Loss Object
 In general, the more intimate relationship with the deceased, the more intense grief experience by the
bereaved.
 The death of child poses a particular risk for dysfunctional grieving.
 The death of a child generally thought to exceptionally painful because it upsets the natural order of things,
parents do not expect their children to die before them.
 The death of the parent or a sibling can pose a major challenge for the children. The child‘s feelings may often go
unrecognised by adult who fails to understand the child‘s need to mourn.

C.) CAUSES OF DEATH:

The intensity of grief response also varies according to the cause of death be unexpected, traumatic, or suicide.

Unexpected Death:

 The loss occurring as a result of an unexpected death poses particular difficulty for the bereaved in achieving
closure.
 As roach and Neito (1997) states, any death even an anticipated death, is traumatic experience to the surviving
loved ones.
 Unanticipated death such as a death from a heart attack, Aneurysm, or stroke leaves the survivors shocked and
bereaved.
 Most often the bereaved are capable of working through the grieving process without complication.

Traumatic Death:

 Complicated grief is associated with traumatic death such as death by homicide, violence, or accident.
 Although traumatic death does not necessarily pre-dispose the survivor to complications in mourning, survivors
often suffer emotions of greater intensity then those associated with the normal grief.

Suicide:
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 The loss of a loved one to suicide is frequently compounded by feeling of guilt among the survivors. They felt
guilty for failing to recognise clues that may have enabled the victim to receive help.
 These feelings of guilt and self-blame can transform into anger at the victim for inflecting such pain, at
themselves, and caregiver.
 Feeling of shame for having a suicide in the family may also be present.
 the negative stigma of suicide may prohibit the survivor for successfully resolving their grief.

LOSS AS CRISIS:

 Loss can be viewed as either a situational or a developmental crisis.

 Loss that occurs 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 are developmental crisis that can be anticipated and to
some extent prepared for.
 When caring for clients who are experiencing loss of functional ability resulting from acute or chronic illness,
who have experienced loss of a body part (E.g. Amputation of limb, mastectomy) or who are in the process of
dying, the nurse needs to consider the influence of these factors not only on the client, but also on the client‘s
family and loved ones. All persons concerned experience the loss and may exhibit different expressions of
grieving.

RESPONSES TO LOSS:

 The threat of illness precipitates coping behavior associated with loss.

 Dying patients must adapt to the loss of life, other patient must adjust to the loss of health or loss of a limb, a
blow to self- concept or a necessary change in the lifestyle.
 Regardless of the nature of loss, the dynamics of grief present themselves in some form.

The response to loss can be described in the following 4 phases:-

1. Shock and disbelief.

2. Development of awareness.

3. Restitution.

4. Resolution

SHOCK AND DISBELIEF:

 In the first stages of response to loss, patients demonstrate the behaviours characteristic of denial. They fail
comprehend and experience the rational meaning and emotional impact of the diagnosis.
 When such blatant denial occurs, it is apparent that the problem is so anxiety provoking to the patient that it
cannot be handled by the more sophisticated mental mechanisms of rational problem solving
 This ,phase of denial also may serve as the period during which the patient‘s resources, briefly blocked by the
shock can be regrouped for the battle ahead
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 Therefore stripping away the denial may render the patient helpless. Furthermore, although denial has been its
obvious hazard denial has been associated with higher rates of survival after myocardial infarction.

Nursing Management:

 The nurse recognizes and accepts the patient‘s illness by watching, monitoring, or changing dressings. In these
ways, the nurse communicates acceptance of the patient through tone of voice, facial expression and touch.
 The nurse must be able to reflect statement of denial back to the patient in such a way that allows the patient to
hear them and eventually to examine their incongruity and apply reality by saying something such as, ―In some
way you believe that having a heart attack will be helpful to you and ―It seems that it is hard for u to stay in
bed.
 By verbalizing what the patient is expressing, the nurse gently confronts behavior but does not cause anxiety
and anger by reprimanding and judging.
 In this phase the nurse supports denial by allowing for it but does not perpetuate it. Instead the nurse
acknowledges, accepts and reflects the patient‘s new circumstances.

DEVELOPMENT OF AWARENESS:

 In this second stage of loss, the patient‘s behaviour characteristically associated with anger and guilt.
 The anger may be expressed overtly and may be directed at the staff for oversight, tardiness and minor
insensitivities.
 In this phase the ugliness of reality has made its impact. Displacement of the anger onto others helps to soften
the impact of reality on the patient. Such behaviour often alienates the nurse and other personnel.
 The patient who does not demand has probably withdrawn into depression because of anger directed towards
self rather than others.
 The patient will demonstrate verbal and motor retardation, will likely have difficulty sleeping and may prefer to
be left alone.
 During this phase, the nurse is likely to hear irrational expression of guilt. Patient seek to answer the question,
―why me. They attempt to isolate this human imperfection and attribute the cause of the malady to themselves
on their past behaviour. Both the patient and their families may look for a person or object blamed.

Nursing Management:

 During the development of awareness, nursing intervention must be directed towards supporting the
patient‘s basic sense of self-worth and allowing and encouraging the direct expression of anger.
 The nurse should provide and respect the patient‘s need for privacy and modesty. The nurses need to guard
against verbal and non-verbal expression of pity.
 A non-defensive, accepting attitude will decrease the patient‘s sense of guilt, and the expression of anger
will avert some of the depression.

RESTITUTION:

 In this stage, the client asides the anger and resistance and begins to cope constructively with the loss.
 The client tries new behaviours that are consistent with the new limitations.
 The emotional level is one of the sadness, and time spent in crying is useful. As the patient adapts to a new
image, considerable time spent going over and over significant memories relevant to the loss. Behaviours in
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this stage include verbalization of fear regarding the future. Often this goes unexpressed and undetected
because they are unbearable for the family to hear.
 They worry about the future response of their mates to their changed bodies. The patient probably also
question a new role in the family.

Nursing Management:

 During restitution, nursing care should again be supportive so that adaptation can occur. Listening to the
patient for a lengthy period of time is necessary.
 If the patient is able to verbalize fears and questions about the future he/she will be better able to define
the anxiety and solve new problems.
 During this stage, the nurse may have the patient consider meeting someone who successfully adapted to
similar trauma.
 Friends may respond differently to the patient who has suffered a permanent disability than to a healthy
person.
 During this time the family had also been going through a similar process. They too have experienced shock ,
disbelief, anger and sadness.
 The nurse must also help the family by allowing them to ventilate their repulsion and fear and by showing
acceptance of these feelings.
 Through intensive listening, the nurse provides a sounding board and then redirects the members of the
family back to each other so that they can give and receive each other‘s supports.

RESOLUTION

 It is the stage of identity change.

 The patients may over identify themselves as invalids.
 They may discriminate against themselves and make derogatory remarks to test the acceptance of the
nurse.
 The patients are sensitive to the ways in which health care worker response to their bodies. A patient
may make negative remarks to test the acceptance of the nurse.
 As time passes and the patient adapts, the patient moves towards identification as person who has
certain limitations due to illness rather than as a cripple or an invalid.
 The patient no longer uses a defect as a basis of identity.
 Often the patient reflects on the crisis as a time of growth and maturation. Such a patient achieves a
sense of pride at accomplishing the different adaptation and is able to look back realistically on
successes and disappointments without discomfort.
 At this time, the patient may find it useful and gratification to help others by serving as a role model for
those people in the stage of restitution who are experiencing their own identity crisis.

Nursing Management:

 The goal of nursing care during resolution stage is to help the patient attach a sense of self-esteem to a rectified
identity.
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 Nursing intervention centered on helping the patient find the degree of dependence that is needed and can be
accepted.
 The nurse must accept and recognize with the patient that periods of vacillation between the independence and
dependence will occur.
 Certainly, the nurse can support and reinforce the patient‘s growing sense of pride in rehabilitation.

GRIEF

Grief:

It is the total response to the emotional experience related to loss which is manifested in thoughts, feelings & behavior
associated with overwhelming distress and sorrow.

Bereavement:

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

It is the behavioural process through which grief is eventually resolved or altered. It is often influenced by cultural,
religious experiences, and customs.

THEORIES OF GRIEVING PROCESS :

Several theoretical models describe grieving. The theories of Erich Lindemann , George. L. Eagle, John Bowlby and J.
William Worden.

A.] LINDEMANN:

Following the Coconut Grove Fire in Boston in 1944, Lindemann studied survivors and their families. He coined the
phrase ―Grief WorK which is still used today to describe the process experienced by the bereaved.

He also found that during grief work, the person experienced the freedom from attachment from the deceased and
become re-oriented to the environment where the deceased is no longer present and established a new relationship.

His classic work is the basis of current crisis and grief resolution theories.

Lindemann(1944), Roach & Neito (1997) describe Lindemann‘s theory of a person‘s reaction to normal grief as:-

a. Somatic Distress.

b. Pre-occupation with the image of the deceased.

c. Guilt.

d. Hostile reaction.

e. Loss of pattern of conduct

a. somatic distress :
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The bereaved experience episodic waves of discomfort in durations, of 10-60 minutes, multiple somatic complaints,
fatigue, extreme physical and emotional pain.

b. pre-occupation with the image of the deceased:

The person experienced a sense of unreality, emotional detachment from others, and overwhelming pre-occupation
with visualizing the deceased. Guilt:  The person consider the death to be a result of their own negligence or lack of
attentiveness, they look for the evidence of how they have contribute to death.

c. hostile reaction:

The person relationship with others become impaired owing to bereaves desire to be left alone and bereaves feeling of
irritability and anger.

d) loss of pattern of conduct:

The person exhibit generalized restlessness and inability to sit stilled, they continually search for something to do.

B.] BOWLBY:

According to Bowlby, grief result when a person experiences a disruption in attachment to a love object. His theory
proposes that grief occurs when the attachment bond are severed.

The four phases of grieving as cited by him are:-

 Numbness.
 Yearning & Searching.
 Disorganization & Despair.
 Re-organization.

C]WORDEN:

He has identified four tasks that an individual must perform in order to successfully deal with a loss.

 Accept the fact that the loss is real.

 Experience the emotional pain of grief.
 Adjust to the environment without the deceased.
 Re-invest the emotional energy once directed at the deceased into another relations

D.] ENGLE:

Grief is a typical reaction to loss of a valued object. According to him, there are three stages of mourning and
progression through each stage is necessary for healing.

Stage 1: Shock and Disbelief:

 Disorientation.
 Feeling of helplessness.
 Denial, which provide protection until the person is able to face the reality.

Stage 2: Developing Awareness:

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 Guilt.
 Sadness.
 Isolation.
 Loneliness.
 Feeling of helplessness.
 Possible anger and hostility towards others.
 Increasing emotional pain in response to increasing reality to loss.

Stage 3: Restitution & Resolution :

 Emergence of bodily symptoms.

 Possible idealization of the deceased.
 Beginnings of coming to terms with the loss.
 Establishment of new social pattern and relationships.

TYPES OF GRIEF:

Grief is a universal, normal response to loss. Grief drains people both emotionally and physically. Because it so much
emotional energy, relationships may suffer.

There are different types of grief. They are:-

1. Uncomplicated Grief.

2. Dysfunctional Grief.

3. Anticipated Grief.

4. Disenfranchised Grief.

1.) Uncomplicated Grief:

 Uncomplicated grief is what many individual would refer to as normal grief.

 Engle also proposed the use of uncomplicated grief to describe a grief reaction that normally follows a
significant loss.
 Uncomplicated grief runs a fairly predictable course that also ends with the relinquishing of the lost object and
the resumption of the duties of life.
 Many grieving people experience feelings of anger or blame and it may be directed towards those perceived to
have caused or contribute to the death.
 Often the anger associated with the grief is directed one‘s self i.e. expressed as guilt or depression.
 Even though the bereaved have done nothing to cause to death, they often believe that somehow they should
have been able to prevent it.

2.) Dysfunctional Grief:

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 It is a demonstration of a persistent pattern of intense grief that does not result in reconciliation of feelings.
 Persons experiencing dysfunctional grief do not progress through the stages of overwhelming emotions
associated with grief and many fails to demonstrate the behaviour commonly associated with grief.
 The person experiencing pathological grief continues to have strong emotional reactions, does not return to a
normal sleep pattern, or work routine; usually remains isolated and displays altered eating habits.
 The bereaved may have the need to endlessly tell and retell the story of loss but without subsequent telling.
 A person experiencing the dysfunctional grief continues to focus on the deceased, may overvalued objects that
belongs to the deceased and may engage in depressive brooding.
 The professional caregiver must be aware of these behaviors and refer the pathologically grieving person to
professional counselor.

3.) Anticipatory Grief:

 It is the occurrence of grief work before an expected loss actually loss.

 Anticipatory grief can be experienced by the terminally ill person as well as the person‘s family.
 This phenomenon promotes adaptive grieving and therefore frees up the mourner‘s emotional energy necessary
for problem solving.
 Although anticipatory grieving may be helpful in adjusting to the loss, it also has some potential disadvantages.
 E.g. In case of dying patient, anticipatory grieving may lead to family members distancing themselves and not
being available to provide supports. Also if the family members have separated themselves emotionally from the
dying client they may seem cold and distant and thus not meet the society‘s expectation of mourning
behaviour.
 This response can in turn prevent the mourner‘s from receiving their own much needed supports from others.

4.) Disenfranchised Grief:

The grief that is not openly acknowledged, socially sanctioned, or publicly shared.

Grief can become disenfranchised when an individual either is reluctant to recognize the sense of loss and develops
guilt feelings or feels pressured by the society to ―get on to life.

E.g. 1) Extreme sadness over the loss of a pet, and when this mourning might be viewed by others as excessive or
inappropriate.

2) A mother‘s sadness over a miscarriage might also considered disenfranchised grief as a lengthy period of
mourning may not be publicly expected despite the mother‘s intense feelings of loss and despair.

SYMPTOMS OF NORMAL GRIEF:

1. Feeling:
 Sadness.
 Anger.
 Guilt.
 Anxiety.
 Loneliness.
 Fatigue.
 Helplessness.
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 Shock/Numbness.
 Yearning.
 Relief/Emancipation.
2. Cognition:
 Disbelief
 Confusion
 Pre-occupation about the deceased
 Hallucination
 Hopelessness (I‘ll never be ok)
3. Physical sensation :
 Hollowness in the stomach.
 Tightness in the chest , throat.
 Oversensitivity to noise.
 Feeling of shortness of breath.
 Muscle weakness.
 Lack of energy.
 Dry mouth.
4. Behaviour:
 Sleep disturbances.
 Appetite disturbances.
 Absent minded behaviour.
 Sighing.
 Crying.
 Carrying object that belongs to the deceased

NURSES GRIEF:

 Nurses may also experience grief when working specially with the dying patients as a results, this role in
supporting the grieving patients and family can become complicated.
 So, when caring for clients experiencing grief, it is important for the nurses to assess your own emotional well-
being.
 Self-reflection, which is a part of critical thinking, become a valuable tool in asking whether her personal sadness
is related to caring for the client or to resolved personal experience from the past.
 It is not wrong to have a personal feelings and emotions. However, it is appropriate to put her personal family
situation before the patient.
 Part of being a professional is to know when to get away of the situation and to care of oneself.

DYING & DEATH:

STAGES OF DYING:

The purpose of knowing about the stages of grief and dying is to recognize what emotions and behaviour can occur and
to plan interventions accordingly as they appear.

The stages are as follows:-

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1. Denial.

2. Anger.

3. Bargaining.

4. Depression.

5. Acceptence.

1.) Denial:

Reaction – “No-Not Me”―There Must Be A Mistake .

It served as a buffer to the patient to shield oneself until the individual is able to mobilize alternate defences.

2) Anger:

Reaction-―”Why Me”

In this stage the patient /client may developed anger and react hostilely which is directed towards the caregivers or the
love ones.

3 ) Bargaining:

Reaction- ―Yes, But

In this stage, bargaining is often made with God. It is an attempt to postpone death and is a positive way to maintain
hope.

4 )Depression:

Reaction ―Yes, Me

It is a stage patient goes into a stage of sadness and grief and it is the time of introspection. Usually request only
significant others to be with them. The patient struggles with the realities of life and preparing for death.

5 ) Acceptance:

Reaction ―I am Ready.

The patient resolved to the fact that death is imminent. Peaceful acceptance and positive feeling are often present.

THE DYING PERSON’S BILL OF RIGHTS:

1. I have the right to be treated as a living human being until I die.

2. I have a right to maintain a sense of hopefulness, however changing its focus may be.
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3. I have the right to be cared for by those who can and emotions about my approaching death in my own way.
4. I have the right to participate in decision concerning my care.
5. I have the right to expect continuing medical nursing attention even though ‗CURE‘ goals must have change to
COMFORT goals
6. I have the right not to die alone.
7. I have the right to be free from pain.
8. I have the right to have my questions answered honestly.
9. I have the right not to deceive.
10. I have the right to have help from and for my family in accepting my death.
11. I have the right to die in peace and in dignity.
12. I have the right to retain my individuality not to be judged for my decisions which may contrary to the beliefs of
others.
13. I have the right to expect that the sanctity of the human body will be respected after death.
14. I have the right to be cared for my caring, sensitive, knowledgeable people who will attempt to understand my
needs and will be able to gain some satisfaction in helping me face my death.

Nursing Care of Dying Patient:

Physiological Needs:

According to Maslow‘s Hierarchy of needs, physiological needs must be met before others, because they are essential
for existence.

Areas that are often problematic for the terminally ill client are respirations, fluids & nutrition, mouth, eyes and nose,
mobility, skin care and elimination.

Respiration:

 Oxygen is frequently ordered for the client experiencing laboured breathing. Suctioning may be needed to
remove secretions that the client is unable to swallow.

Fluids & Nutrition:

 The refusal of food and fluids is almost universal in dying clients. It is believed that the client is not feeling thirst
and hunger.
 Although the issue of permitting dehydration in terminally ill clients is often met with great resistance.
 Artificial nutrition often increases the client agitation leads to increased use of limb restraints and increases the
risk of aspiration pneumonia.
 Hospice nurses have indicated that withholding artificial nutrition is not painful. Regardless, in every situation,
the client the client‘s own wishes must always take precedence.
 If the comatose client has not previously made his wishes known, family members must be given accurate and
truthful information.
 For the person in irreversible coma, withholding artificial nutrition does not causes death rather it allows life to
take its natural course and it should be discontinue to support nutritionally if the client request.

Mouth:

 Oral discomfort is the only documented side effect of dehydration in the terminally ill client.
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 Both the administration of oxygen and mouth breathing increase the need for meticulous oral care.
Caregiver can use saliva substitutes and moisturizers to alleviate discomfort.
 Regular brushing of teeth should be encouraged and the tongue must also be given the same attention as is
the rest of the mouth.
 Ice chips and sips of favourable beverages should be offered frequently and petroleum jelly applied to the
lips.
 Oral care must be given every 2-3 hrs to maintain the client‘s comfort.

Eyes:

 Due to the dryness the eyes may become irritated and artificial tears can alleviate this discomfort
 Therefore wiping off the tears from inner to outer cantus to remove the discharges.

Nose:

The nares may become dry and crusted. Oxygen given by the cannula can further irritate the nares. So, a thin layer
of water soluble jelly applied to the nares will be helpful to alleviate discomfort.

Mobility:

 As the client‘s condition deteriorates, mobility decreases. Te client become less able to move about in bed
or to get out of the bed and requires more assistance.
 Therefore physical dependence increases the risk of complication related to immobility. E.g Atrophy
&pressure ulcer.

NURSING MANAGEMENT:

 Frequently re-positioning according to the patient and considering the underlining condition of the patient
such as arthritis & lung disease.
 Passive range of motion exercise should be done 2 times (twice) a day to prevent stiffness and aching of the
joints.
 Using a wheelchair can also increase the client‘s environmental space, giving the client more mobility,
control, and independence.

Skin Care:

 Prevention of pressure ulcer is the priority. These are painful and can cause secondary complication such as
sepsis and are costly to treat.
 In addition to the care of the pressure point keeping the skin clean moisturized promotes healthy tissue.
 The skin should be inspected twice daily.
 Gentle massages with soothing lotion are comforting.
 Bed bath are adequate if the client cannot get into the tub or sit in the shower chair.

Elimination:

 Constipation may occur due to the side effects of the analgesics and the lack of physical activities.
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 Fluids and foods with high fibre contained can be effective preventive measures for the client with
adequate oral intake.
 It can also be alleviated by maintaining a scheduled time for bowel elimination and administering
suppositories if necessary
 The client may have incontinence of bladder and bowel, so the nurse need to check the client frequently,
clean the skin the peri-wash, apply a moisture barrier after each incontinence episode.
 Comfort
 Pain relief
 Keep the patient clean and dry.
 Provide a safe and non threatening environment.
 Provide a respectful, careful attitude to provide psychological comfort by establishing good rapport.

Physical environment:

 A soothing physical environment can significantly increase the clients comfort

 Adequate lighting enhances vision without causing discomfort associated with harsh, glaring light. Provide night
light if patient requires
 As the client circulation slightly sluggish, the body temperature will fall, so providing a light weight comforters
will be helpful to warmth without adding uncomfortable weight.
 Provide quite and calm environment.( even the phone can be removed if patient find it disturbing.

Psychosocial needs:

 Death presents a threat to not only ones physical existence but to ones psychological integrity.
 Even though in the presence of the nurse, the family members should be encouraged and invited to participated
in the clients care, if they desire to do so and the client is willing
 Maintain a well groomed appearance is important. cutting the nails, shaving the beard will help to promote
patients dignity.
 Combing and brushing the hair not only improves appearance but is also a comforting and relaxing activity for
many clients.

Spiritual needs:

The nurses play a major role in promoting the dying clients spiritual comfort. Dying persons are among the most
vulnerable members of the human family.

 Communicate empathy.
 Play music.
 Use touch.
 Pray with the client.
 Contact clergy if requested by the client.
 Read religious literature aloud, at the patient request.

Support for the family:

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 The family member needs to be involved in the care of their dying lived one.
 Guilt may be increased by the feeling of powerlessness.
 Involving the family members in the treatment is a helpful intervention
 The families facing the impending death of the loved one require much support from the nurses and the care
givers.
 Being with the family members is extremely important
 Provide assistance and guidance if the family members have limited coping skills and inadequate supporting
system.
 She must be supportive and non judgmental

LEGAL CONSIDERATION DURING DEATH:

 The Patient Self Determination Act (PSDA) was incorporated into the Omnibus budget reconciliation Act (OBRA)
of 1990.
 The Act was intended to provide a legal means for individuals to determine the circumstances under which life
sustaining treatment should or should not be provided to them. The individuals choice are validated by
advanced directives .
 An advanced directive is any written instruction including a living will or durable power of attorney for health
care that is recognised under state law( Taylor 1995) .
 The act applied to hospitals, long term care facilities , home care agencies, hospice programs, and certain health
maintenance organisations (HMOS) .
 All the clients entering into the healthcare system through this organisation must be given information regarding
the complete care. It is necessary not only to inform about the care but also the need to indicate the wishes in
regarding to artificial feeding, intubation, chemotherapy, surgery, blood transfusion etc.
 Although the living will and durable power of attorney for health care are legal documents, they do not preclude
the need for resuscitation
 The medical record must have a written DNR (Do-Not-Resuscitate) order from a physician if this is in agreement
with the client wishes and with the advanced directives. In the absence of this order resuscitation is not
initiated.

ETHICAL CONSIDERATION DURING DYING :

 Death is often fraught with ethical dilemmas that occur almost daily in health care settings.
 Many health care agencies have ethics committees to develop and implement policies to deal with and to end-
to-life issues
 Ethical decision making is a complex issue. One of the most ethical dilemmas is determining the difference
between killing and allowing someone to die with holding life-sustaining treatment methods.
 The ANA distinguish reliving pain and mercy killing( euthanasia or assisted suicide)
 Pain relief is a central value in nursing, where as euthanasia is viewed as unethical.
 The ANA‘s position is that increasing dose of medication to control pain in terminally ill client is ethically justified
even at the expenses of maintaining life.

CARE OF THE BODY AFTER DEATH:

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Body changes:

Rigor Mortis:

 The stiffening of the body that occurs about 2-4 hrs after death.  It results from the lack of Adenosine
Triphosphate (ATP), which is not synthesized because of the lack of glycogen in the body.
 Its lack causes the muscles to contract, which in turn immobilizes the joints.
 Rigor mortis starts in the involuntary muscles (heart, bladder, and so on) then progresses to the head, neck and
trunk, and finally reaches the extremities.
 Because the deceased families often wants to view the body, and because it is important that the deceased
appear natural and comfortable, nurses need to position the body, place dentures in mouth, and close the eyes
and mouth before rigor mortis sets in. Rigor mortis usually leaves the body about 96 hrs. After death.

Algor Mortis:

 It is the gradual decrease of body temperature after death.

 When blood circulation terminates and hypothalamus ceases to function, body temperature falls about 1degree
centigrade (1.8 F) per hour until it reaches room temperature.
 Simultaneously, the skin loses its elasticity and can easily be broken when removing dressing or adhesive tape.

Livor Mortis:

 After the blood circulation has ceased, the skin become discoloured. Red blood cells break down, releasing
haemoglobin, which discolours the surrounding tissues. This discoloration is known as LIVOR MORTIS
 Tissues after death become soft and eventually liquefied by bacterial fermentation. The hotter the
temperature, the more rapid the changes.
 Therefore, bodies often stored in cool place to delay the process.
 Embalming reverse the process through injection of chemicals into the body to destroy the bacteria.

LEGAL ASPECTS OF DEATH:

 Of many legal ramifications of human death, the most basic for the nurses is that death must be certified by
a physician.
 In circumstances of unusual death, an autopsy (post-mortem examination) may be required. Nurses have a
responsibility to be aware of the legal ramifications of death in the jurisdiction in which they practice.

NURSING INTERVENTION:

 Nursing personnel may be responsible for the care of a body after death.
 Make the environment clean and pleasant as possible and to make the body appear natural and comfortable.
 Remove all the equipments and supplies from the bedside.
 Remove the soiled linen in order to make the room free from odour.
 Care of the body may be influenced by religious law, the nurse should check the client‘s religion and make very
attempt to comply.
 The body should be placed in a supine position with the arm either at the sides, palms down, or across the
abdomen.
 The wrist band should be left on unless it is too tight.
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 A pillow should be placed under the head and the shoulders to prevent blood from discolouring the face by
settling in it.
 The eyelids are closed and held in place for a few seconds so that they remain closed.
 Dentures are usually inserted to help give the face a natural appearance.
 The mouth should be closed (a role towel under the chin will hold it closed).
 Soiled areas of the body are washed or a complete bath should be given.
 Absorbent pads are placed under the buttocks to take up any faeces and urine released because of the
relaxation of the sphincter muscles.
 A clean gown should be placed on the client, and the hair is brushed and combed.
 All the jewelleries are removed except the band in some instances, which is taped to the finger.
 The top bed linen should be adjusted neatly to cover the client till the shoulders.
 All the client‘s valuables including clothing are listed and placed in a safe storage area for the family to take
away or to handover it to them.
 After the body has been viewed by the family, additional identification tags are applied, one to the ankle and
one to the wrist if the client‘s wrist identification band was not left in place.
 The body should be wrapped in a shroud (a large rectangular or square piece of plastic a cotton material used to
enclose a body after death).
 Another identification tag should be applied to the outside of the shroud.
 Then the body should be taken to the morgue for cooling, if arrangement has not been made to have a
mortician pick it up from the client‘s room or the client should be hand over to the family members after
recordin g and reporting.

CONCLUSION:

By acquiring the above knowledge of the clients in the state of LOSS, GRIEF, DEATH and DYING the group will be able
to appreciate the nursing practice in managing such a client.

BIBLIOGRAPHY:

BOOK :

1. Potter & Perry‘s ―Basic Nursing; Essentials For practice‖ 5th edition, published by Mosby, 2004, Noida, New
Delhi. Page No. 39-40
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2. Kozier, Erb, Blais & Wilkinson‘s ―Fundamental of Nursing‖ 5th edition, published by Addison-Wesley, New York.
Page No. 852-874

3. Carol Taylor, Carol Lillis, Priscilla Le Mone‘s ―Foundation Of Nursing, The Art & Science of Nursing Care‖ 4th
edition, published by J.B.Lipincott, 2001, Philadelphia. Page No. 726-750

4. Barbara Christensen, Elaine Kockrow‘s ―Foundation of Nursing‖ 2nd edition, published by Mosby, Chicago,
London Page No. 1569-1585

5. Hudak‘s ―Critical Care Nursing: A Holistic Approach‖ 6th edition, published by J.B.Lipincott Company.1994,
Philadelphia. Page No. 9-21

NET REFERENCE :

6. www.answer.com

7. www.google.com

JOURNALS :

8. The ICFAI Journal of Healthcare Law May 2006.

9. The ICFAI Journal of Healthcare Law, November 2007.

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