INTRODUCTION:

All people experience loss in the form of change, growth and transition but perhaps the most
painful one is the loss of a loved one. It may lead to physical, social and mental deterioration.
People grief in different ways and there is no timeline for completing the grief process.
Personal coping style, life experience with handling loss, as well as support from others,
makes a big difference in how someone responds to loss.
Dying was once considered to be normal part of life cycle whereas today it is often
considered to be a medical problem that should be handled by health care providers.
LOSS:
Loss is any situation, either actual, potential or perceived in which a valued object is changed
or is no longer accessible to individual. Because change is major constant in life, everyone
experiences.
Types of loss:
Actual loss: an actual loss is any loss of a person or object that can no longer be felt, heard,
known or experienced by the individual. Examples could include the loss of a body part,
child, relationship, or role at work. Lost objects that have been valued by a client include any
possession that is worn out, misplaced, stolen or ruined by disaster. For example, a child may
grieve over the loss of a favorite toy.
Perceived Loss
Perceived loss is any loss that is uniquely defined by the grieving client. It may be less
obvious to others. Example is loss of confidence or prestige.

Maturational Loss
It includes any change in development process that is normally expected during the life time.
One example would be mother’s feeling of loss as a child goes to school for the first time.
Events associated with maturational loss are part of normal life transitions, but the feelings of
loss persist as grieving helps a person cope with the change.
Situational Loss
It includes any sudden, unpredictable external event. Often this type of loss includes multiple
types of losses rather than a single loss. Such as an automobile accident that leaves a driver
paralyzed, unable to return to work, and grieving over the loss of the passenger in the
accident

CATEGORIES OF LOSS

Loss of an External Object

When an object that a person highly values is damaged, changed, or disappeared, loss occurs.
The significance of the lost object to the individual determines the type and amount of
grieving that occur.

Loss of Familiar Environment

The loss of familiar environment occurs when a person moves to another home or a different
community, changes school or starts a new job. Also a client who is hospitalized or
institutionalized experiences loss when faced with new surroundings. This type of loss
evokes anxiety due to fear of the unknown.

Loss of Aspect of Self

Loss of an aspect of self can be physiological or psychological. A psychological aspect of self
that may be lost is ambition, a sense of humor or enjoyment of life. Physiological loss of
aspect of self can result from illness, trauma, etc.

Loss of Significant Other

The loss of loved ones is a significant loss. Such a loss can be a result of separation, divorce,
running away, moving to a different area or death.

TERMINAL ILLNESS AND CARE

A terminal illness means a condition from which recovery is beyond reasonable
expectations. Such a diagnosis is devastating news. On learning they will die soon, the client
tends to experience several stages as they process the information.

STAGES OF DYING
Dr Elizabeth Kubler-Ross has described the stages through which many terminally-ill
patients progress. These are denial, anger, bargaining, depression and acceptance. These
stages may occur in progressive fashion or a person can move back and forth through the
stages. There is no specific time period for completion of stages.

Denial
The psychological defense mechanism, by which a person refuses to believe certain
information, helps people to cope initially with reality of death. Terminally-ill clients may
first refuse to believe that their diagnosis is accurate. They may speculate that test results are
wrong or their reports have been mixed-up with others reports.

Anger
Emotional response to feeling victimized occurs because there is no way to retaliate against
fate. Clients often displace their anger onto nurses, physicians, family members, even god.
They may express anger in less obvious way, e.g. overreacting to even slight annoyance.

Bargaining
A psychological mechanism for delaying the inevitable, involves a process of negotiation
usually with god or other high power. Usually, dying clients are willing to accept death but
want to extend their lives temporarily until some significant event takes place (e.g. child's
wedding).

Depression
Sad mood indicates the realization that death will come sooner rather than later. The sad
mood is a result of confronting social loss.

Acceptance
Attitude of complacency occurs after the clients have dealt with their losses and completed
unfinished business. Kubler described the unfinished business in two-ways. Literally it refers
to completing legal and financial matters to provide best security for survivors. It also refers
to addressing social and spiritual matters such as saying good bye to loved ones and making
peace with god. After tying up all the loose ends, dying clients feel prepare to die.

Death
Death was defined in 1981 by the president commission for the study of ethical problems in
medicine and biomedical and behavioral research as: Death is present if an individual has
sustained (1) irreversible cessation of circulatory and respiratory functions. (2) irreversible
cessation of all functions of entire brain, including the brainstem.
A Harvard University committee stated that the following characteristics must be present for
at least 24 hours before death can be declared:
 Lack of receptivity and responsiveness
 Lack of movement or breathing
 Lack of reflexes
 Flat encephalogram.

SIGNS OF APPROACHING DEATH

Although death is unique for each individual, common physical and psychological events
occur when death is approaching.

Physical events:
The following are signs of impending death that alert the nurse that client will die shortly.
 Cardiac Dysfunctions
Failing cardiac functions is one of the first signs that a client's condition is worsening. At
first, heart rate increases in a futile 1 attempt to deliver oxygen to cells. The apical pulse rate
may reach 100 or more per minute. Cardiac output per minute increases, this may diminish
heart's own oxygen supply which causes heart rate to decrease and blood pressure to fall.
 Peripheral Circulation Changes
Reduced cardiac output compromises peripheral circulation and impairs cellular metabolism
and produces less heat. Skin becomes pale, nail beds and lips may appear blue, client may
feel cold.
 Pulmonary Function Impairment
Failure of heart pumping function causes fluid to collect in pulmonary circulation. Breath
sounds become moist and client cannot exhale carbon dioxide adequately compounding state
of hypoxia.
 Central Nervous System Alteration
With hypoxia, brain is less sensitive to accumulating levels of carbon dioxide, thus client may
experience periods of apnea. Pain perception is decreased, client may stare blankly through
partially opened eyes. Senses become impaired. Hearing tends to be remain intact.
 Renal Impairment
Low cardiac output decreases the urine volume and waste products accumulate.
 Gastrointestinal Disturbance
Peristalsis decreases, causes intestinal contents to accumulate. This stimulates vomiting
center inducing nausea and vomiting.
 Musculoskeletal Changes
Reflexes become hypoactive. The client loses control over sphincters leading to incontinence.
Jaw and facial muscles relax. Tongue may fallback.
Psychological Events:
If they have reached the stage of acceptance, some terminally-ill clients look forward to
dying because it will end their suffering. Some seen to forestall dying when they feel their
loved ones are not prepared. This is waiting for permission phenomenon.
 Near Death Experience
People who experience near death experience report similar events such as:
 Floating above their bodies.
 Moving rapidly toward a bright life.
 Seeing familiar people who have already died.
 Feeling warm and peaceful.
 Being told that it is not time yet for them to die
 Regretting having to return to their resuscitated body.
 Nearing Death Awareness
It is a phenomenon characterized by dying client's premonition of approximate time or date
of death. In addition, just before death, clients may reach out, point or open their arms as if to
embrace someone or call them by name.

GRIEF:

Grief is a series of intense physical and psychological responses that occur following a loss. It
is manifested in variety of ways that are unique to an individual and based on personal
experiences, cultural expectation and spiritual beliefs. It is normal, natural, necessary and
adaptive response to a loss. "Grieving is a walk through unknown territory. Familiar internal
and external stabilities disappear in a whirlwind of changing thoughts, feelings and emotional
flux." Loss leads to the adaptive process of mourning, the period of time during which the
grief is expressed and resolution and integration of loss occurs. Bereavement is the period of
grief following the death of a loved one.

MOURNING:

Coping with grief after a loss involves the process of mourning, the outward, social
expression of loss. It involves working through the grief until an individual accepts and
adapts to his or her expectations to go on in life without that which was lost. It is a behavior
determined by cultural norms and values.

BEREAVEMENT:

It includes grief and mourning: The inner feelings and outward reactions of the survivor.
Survivors go through a bereavement period that is not linear. It is the period during which the
grief process unfolds.

TYPES OF GRIEF

A nurse’s knowledge on the types of grief, which is based on characteristics or signs and
symptoms of grief, allows for implementation of appropriate bereavement therapies.

Normal Grief
Normal or uncomplicated grief consists of the normal findings, behaviors, and reactions to a
loss. These might include resentment, sorrow, anger, crying, loneliness, and temporarily
withdrawal from activities. Often the normal grief response to a loss can prove positive,
helping one to mature and develop as a person. As people mature they develop ways of
dealing with losses and learn to maintain and enhance their feelings of safety and security.

Anticipatory Grief
The process of disengaging or "letting go" that occurs before an actual loss or death has
occurred is called anticipatory grief. For example, once a person or family receives a terminal
diagnosis, they begin the process of saying good bye and completing life affairs. The process
becomes more stressful when the client is unable to make decisions due to deterioration in
health. Unless guided by a client’s explicit decision regarding end of life care, the family
assumes the responsibility of deciding whether to continue life sustaining measures. When
the actual process of dying is extended for a long time, person in the client's family may have
few symptoms of grief once the death occurs. This seeming absence of grief symptoms may
result because the family has engaged in grief process over time. By the time the actual
moment of death arrives, much of the shock, denial and tearfulness have already been
experienced

Complicated Grief
When a person has a difficulty progressing through the normal phases or stages of grieving,
bereavement becomes complicated. In these cases bereavement appears to "go wrong" and
loss never resolves. This can threaten a person’s relationship with others. Complicated grief
includes four types:
 Chronic Grief
Active acute mourning that is characterized by normal grief reactions that do not subside and
continue over very long periods of time. Person verbalizes an inability to "get past" the grief.
 Delayed Grief
Characterized by normal grief reactions that are suppressed or postponed and survivor
consciously or unconsciously avoids the pain of the loss. Active grieving is held back, only to
resurface later, usually in response to a trivial loss or upset. For example, a wife may only
bereave a few weeks after the death of her spouse, only to become hysterical and sad a year
later when she attends a family gathering. The extreme sadness is a delayed response to the
death of her husband.
 Exaggerated Grief
Persons become overwhelmed by grief, and they cannot function. This may be reflected in
form of severe phobias or self-destructive behavior such as alcoholism, substance abuse, or
suicide.
 Masked Grief
Survivors are not aware that behaviors that interfere with normal functioning are a result of
their loss. For example, a person who has lost a pet may develop alterations in eating or
sleeping patterns.

Disenfranchised Grief
Persons experience grief when a loss is experienced and cannot be openly acknowledged,
socially sanctioned, or publicly shared. An example includes the loss of a partner from HIV
or AIDS, children experiencing the death of a step parent, or the mother whose child dies at
birth.

THEORIES OF GRIEVING PROCESS

Several theoretical models describe grieving. Some of the theories are discussed below:
Therese Rando
Therese Rando's Six R's: Researcher and clinical psychologist, Therese Rando contributed a
stage model of the grief process that she observed people to experience while adjusting to
significant loss. She called her model the "Six R's".
 Recognize the loss: First, people must experience their loss and understand that it has
happened.
 React: People react emotionally to their loss.
 Recollect and re-experience: People may review memories of their lost relationship
(events that occurred, places visited together, or day-to-day moments that were
experienced together).
 Relinquish: People begin to put their loss behind them, realizing and accepting that
the world has truly changed and that there is no turning back.
 Readjust: People begin the process of returning to daily life and the loss starts to feel
less acute and sharp.
 Reinvest: Ultimately, people re-enter the world, forming new relationships and
commitments. They accept the changes that have occurred and move past them.

Erich Lindemann
Lindemann's theory: Reactions to normal grief
1. Somatic distress: Episodic waves of discomfort in duration 10-60 minutes; multiple
somatic complaints, fatigue, and extreme physical or emotional pain.
2. Preoccupation with the image of the deceased: The bereaved experiences a sense of
unreality, emotional detachment from others, and an over-whelming preoccupation
with visualizing the deceased.
3. Guilt: The bereaved consider the death to be a result of their negligence or lack of
attentiveness, they look for evidence how they would have contributed to the death.
4. Hostile reactions: Relationship with others becomes impaired owing to the bereaved's
desire to be felt alone, irritability and anger.
5. Loss of pattern of conduct: The bereaved exhibit an inability to sit still, generalized
restlessness and continually searching for something to do.

L Engle
Stage 1: Shock and disbelief-Shock and disbelief are usually defined as refusal to accept the
fact of loss, followed by a stunned or numb response: "No, not me"
Stage 2: Developing awareness-It is characterized by physical and emotional responses such
as anger, feeling empty and crying: "why me"
Stage 3: Restitution-It involves the rituals surrounding loss, and with death, includes
religious, cultural or social expressions of mourning such as funeral services
Stage 4: Resolving-Resolving the loss is dealing with the void left by the loss
Stage 5: Idealization-Idealization is exaggeration of the good qualities of the person or object
lost, followed by acceptance of the loss and a lessened need to focus on it.
Stage 6: Outcome-Outcome is the final resolution of the grief process, including dealing with
loss as a common life occurrence

Bowlby
Bowlby described four phases of mourning.
1. Numbing
It may last from a few hours to a week or more and may be interrupted by periods of
extremely intense emotions. It is the briefest phase of mourning. The grieving person may
describe this phase as feeling "stunned" or "unreal". Numbing may serve to protect the body
from the onslaught or consequences of a loss.
2. Yearning and searching:
It arouses emotional outburst of sobbing and acute distress in most persons. The phase is
painful but must be endured. Parkes has explained that it is necessary for the bereaved person
to experience the pain of grief in order to get the grief work done. Then, anything that
continually allows the person to avoid or suppress the pain can be expected to prolong the
course of mourning. Common physical symptoms are tightness in the chest and throat,
shortness of breath, feeling of weakness and lethargy, insomnia and loss of appetite. This
phase may last for months or years.
3. Disorganization and Despair
In this phase, an individual may endlessly examine how and when the loss occurred. It is
common for the person to express anger at anyone who might be responsible. Gradually, this
examination gives the way to an acceptance that loss is permanent.
4. Reorganization
This phase may require as much as a year or more, the person begins to accept unaccustomed
roles, acquire new skills, and build new relationships. Persons experiencing this phase must
be encouraged to untie themselves from their old relationship, while not devaluating it or
feeling that in doing so they are lessening its importance.

Worden
Task 1: To Accept the Reality of the Loss
Even when a death has been expected, there is always some period of disbelief and surprise
that the event has really happened. This task involves the process required to accept that the
person or object is gone and will not return.
Task 2: To Work through the Pain of Grief
Even though people respond to loss differently, it is impossible to experience a loss and work
through a grief without emotional pain. Individual who deny or shut off the pain prolong their
grief.
Task 3: To adjust to the Environment in which the Deceased is missing
According to Worden, a person does not realize the full impact of a loss for at least 3 months.
At this point many friends and I associates stop railing and the person is left to ponder the full
impact of loneliness. People completing this task must take on I roles formerly filled by the
deceased, including some task that they never fully appreciated.
Task 4: To Emotionally Relocate the Deceased and Move on with Life
The goal of this task is not to forget the deceased or give-up the relationship with the
deceased but to have the deceased take a less, new prominent place in a person's emotional
life. This is often the most difficult task to complete because people fear if they make other
attachments they will forget their loved one or become disloyal. A person completes this
stage after realizing that it is possible to love other people without loving the deceased person
less.

FACTORS AFFECTING LOSS AND GRIEF

The way an individual perceives a loss and responds to it during bereavement is heavily
influenced by many factors.
Human Development:
Persons of different ages and stages of development will show different and unique
symptoms of grief. For example, toddlers are unable to understand loss or death, but they feel
great anxiety over loss of object and separation from parents. School age children experience
grief over the loss of a body part or function. They often associate misdeeds with causing
death. Middle age adults usually begin to re-examine life and sensitive to their own physical
changes. Older adults often experience anticipatory grief because of aging and loss of self-
care abilities.
Psychosocial Perspective of Loss and Grief:
Loss and death are universal life experiences that each person faces. Death is an
overwhelming experience that affects everyone involved in loss situation or in death of
individual. According to psychologist, the valuing of individual is unique, learned response
of a specific culture and society. An individual's expression of grief evolves as the person
matures. Personal experiences shape the coping mechanisms that the individual uses to deal
with stressors
Socioeconomic Status:
Socioeconomic status influences a person's ability to obtain options and use support
mechanism when coping with loss. Generally an individual feels greater burden from a loss
when there is lack of financial, educational or occupational resources. For example, a client
with limited finances may not be able to replace a home lost in a fire or may not be able to
purchase necessary medications to manage a newly diagnosed disease.
Personal Relationship:
When loss involves a loved one, the quality and meaning of relationship are critical in
understanding a person’s grief experience. When a relationship between two individuals is
very close and well-connected, it can be very difficult for the one left behind to cope. The
support that the client receives from the family and friends is based in part on their
relationship with members of their social network and the manner and circumstances of their
loss.
Nature of the Loss:
The ability to resolve grief depends on meaning of the loss and the situation surrounding the
loss. The ability to accept help from others influences whether the bereaved will be able to
cope effectively. The visibility of the loss influences the support a person receives.
Culture and Ethnicity:
Interpretation of a loss and the expression of loss arise from cultural background and family
practices. When individuals lose control over their life aspects due to illness, their basic core
belief systems are critical components that they can and often do hold on to. Culture affects
how clients and their support system or families respond to loss.
Spiritual Beliefs:
Individuals' spirituality significantly influences their ability to cope with the loss. A person's
faith in higher power or influence, the community of fellowship with friends, their sources of
hope and meaning in life, and the use of religious rituals and practices are just some of the
spiritual resources a client may depend upon during a loss. Loss can, sometimes, cause
internal conflicts about spiritual beliefs and meaning of life..

RELATIONSHIP BETWEEN LOSS, GRIEF AND DEPRESSION

Grief and depression are different. It is possible to grieve without being depressed, but many
of the feelings are similar.

Symptoms that suggest a bereaved person is also depressed include:

1. Intense feelings of guilt not related to the bereavement
2. Thoughts of suicide or a preoccupation with dying
3. Feelings of worthlessness
 4. Markedly slow speech and movements, lying in bed doing nothing all day
5. Prolonged or severe inability to function (not able to work, socialize or enjoy any
leisure activity)
6. Prolonged hallucinations of the deceased or hallucinations unrelated to the
bereavement.

COPING WITH LOSS, DEATH AND GRIEF

Just as people feel grief in many different ways, they handle it differently, too. Coping can be
adaptive or maladaptive.
Adaptive Coping
Adaptive coping helps the person to deal effectively with event and minimizes distress
associated with it. Some people reach out for support from others and find comfort in good
memories. Others become very busy to take their minds off the loss.
Maladaptive Coping
It can result in unnecessary distress for the person and other associated with person. Some
people become depressed and withdraw from their peers or go out of the way to avoid the
places or situations that remind them of the person who has died.
Possible causes of maladaptive coping:
Adjustment disorder:
It occurs in persons who do not adapt or experience more than 3 losses. Loss may be
development transition or situational.
Acute Stress Disorder:
While experiencing an extreme traumatic loss (physical assault, death, and injury) a person
might show major changes in behavior, thought and emotions. This disorder is characterized
by numbness, detachment, absence of emotional responsiveness, feeling of unreality, etc.
Dissociative Disorders:
Dissociative amnesia-Usually follows great loss. It involves an inability to remember
significant events.
Dissociative fugue-Involves suddenly leaving home and going on a journey.
Dissociative identity disorder-Involves possession of at least two distinct personalities. The
transition from one personality to other is sudden.
Depersonalization-Involves sense of being cut off or detached from one's self.

Coping Strategies
In coping with the loss and grief, people tend to use one of the three main coping strategies:
Appraisal-focused, problem focused and emotional focused.
 Appraisal-focused Coping
It occurs when the persons modify the way they think for example, employing denial or
distracting themselves from the problem. People may alter the way they think about the
problem by altering their goals and values, such as by seeing humor in a situation.

 Problem-focused
People using these strategies try to deal with the cause of their problem. They do this by
finding information on the problem and taming new skills to manage the problem. Men often
prefer problem-focussed coping. Problem-focused coping mechanism may allow an
individual greater perceived control over their problem.
  Emotional-focused
These involve releasing pent-up emotions, distracting oneself, managing hostile feelings,
meditating, using simple relaxation procedures, etc. Women prefer emotional-focused
response. Emotional-focused coping may, more often, lead to a reduction in perceived
control.

Coping Skills and Coping Resources

Coping resources are options or strategies that help determine what can be done, as well as
what is stake. Coping resources include economic assets, abilities and skills, defensive
techniques, social supports and motivation. Other coping resources include health and energy,
spiritual support, positive beliefs, problem-solving and social skills, social and material
resources and physical well-being.
 Spiritual Belief
Spiritual belief and viewing oneself positively can serve as a basis of hope and can sustain a
person’s coping efforts under most adverse circumstances.
 Social Skills
Social skills facilitate solving of the problem involving other people, increase the likelihood
of getting cooperation and support from others and give individual greater social control.
 Material Asset
Material assets refer to money and goods and services that money can buy. Obviously
monetory resources greatly increase a person's coping options in almost any situation.
 Knowledge and Intelligence
Knowledge and intelligence are other coping resources that allow people to see different
ways of dealing with loss and grief.
 Coping resources also include a strong ego identity, commitment to social network,
cultural stability, a stable system of values and thoughts. People who generally cope
successfully have a varied array of personal resources, which include following
abilities:
1. The ability to seek pertinent information
2. The ability to share concerns and find consolation when needed
3. The ability to redefine a situation so as to make it more solvable
4. The ability to consider alternatives and examine consequences
5. The ability to use humor to defuse a situation.

GRIEF COUNSELING AND GRIEF THERAPY

The way the individuals and families cope with dying, death, grief, loss, and bereavement is
as unique as a fingerprint. The response to the death of a family member, relative, or close
friend places one in the category of "bereaved." Those who are bereaved experience grief, a
person's response or reaction to loss, which encompasses physical, psychological, social, and
spiritual components. How one copes with other life events and adapts to one's present and
future is also part of the grieving process.
 In grief counseling and grief therapy (1991), the clinician and researcher William J
Worden, PhD, makes a distinction between grief counseling and grief therapy. He
believes counseling involves helping people facilitate uncomplicated, or normal grief
to a healthy completion of the tasks of grieving within a reasonable timeframe. Grief
therapy, on the other hand, utilizes specialized techniques that help people with
abnormal or complicated grief reactions and helps them resolve the conflicts of
separation.
  Today, ethics committees in hospitals and long-term care facilities are available to
help families and health care providers arrive at common ground. Traumatic and
violent deaths have also changed the bereavement landscape. What had helped
individuals and families in the past in many situations has eroded and the grief and
bereavement specialist, or the persons, agencies, and organizations providing those
services, is doing so in many cases out of default. Grief counseling is used not only by
individuals and families, but in many situations by schools, agencies, and
organizations, and in some cases by entire communities affected by death.

Goals of Grief Counseling

 Accepting the loss and talking about it
 Identifying and expressing feelings related to the loss (anger, guilt, anxiety,
helplessness, sadness)
 Living without the deceased and making decisions alone
 Separating emotionally and forming new relationships
 The provision of support
 Identifying ways of coping that suit the bereaved. Explaining the grieving process.

Approaches Used
Each counselor or therapist has his or her own techniques that he or she utilizes because they
are effective, although counselors often defer to other techniques that suit a particular person
much better based on the individual's circumstances. Counseling and therapy techniques
include art and music therapy, meditation, creation of personalized rituals, bibliotherapy,
journaling, communication with the deceased (through writing, conversations, etc.), bringing
in photos or possessions that belonged to the person who has died, role playing, bearing
witness to the story of the loved one, confiding in intimates, and participating in support
groups. The "empty chair" or Gestalt therapy technique is also an approach widely used by
grief counselors and grief therapists. This technique involves having an individual talk to the
deceased in an empty chair as if the deceased person were actually sitting there; afterward,
the same individual sits in the deceased person's chair and speaks from that person's
perspective. The dialogue is in first person, and a counselor or therapist is always present.
The internet also provides a number of sites that address the topic of grief and provide links
to counseling services and organizations.

NURSING MANAGEMENT

Assessment
To gather a complete database that allows accurate analysis and identification of appropriate
nursing diagnosis for dying clients and their families, the nurse first needs to recognize the
state of awareness manifested by client and family members. In case of terminal illness the
state of awareness shared by dying person and family affect the nurse's ability to
communicate freely with client and other health care team members and to assist in grieving
process.
Nursing care and support for dying client and family include making an accurate
assessment of physiological signs of approaching death. In addition to signs related to client's
specific disease, certain other physical signs are indicative of impending death. The four main
characteristics are: loss of muscle tone, slowing of circulation, changes in respiration and
sensory impairment. As death approaches, the nurse assists the family and other significant
people to prepare. Depending in part on knowledge of the person's state of awareness, the
nurse asks questions that help identifying ways to provide support during period and before
death. In particular, the nurse need to know what the family expect to happen where the
person dies so accurate information can be given at appropriate death.

Diagnosing:
A range of nursing diagnosis, addressing both physiological and psychological needs, can be
applied to dying client, depending on assessment data. Diagnoses that may be particular to
dying clients are:
 Impaired adjustment related to newly diagnosed terminal illness
 Caregiver role strain related to hospital discharged dying patient because of
inadequate insurance Decisional conflict related to repeated hospitalizations.
 Ineffective coping related to inability to accept death.
 Ineffective denial.
 Anticipatory grieving.

Planning:
 Maintaining physiological and psychological comfort
 Achieving a dignified and peaceful death which includes maintaining personal control
and accepting declining health status. When planning care with these clients, the
dying person's bill of rights can be useful guide.

Implementation:
•To minimize loneliness, fear and depression
•To maintain clients sense of security, self-confidence, dignity and self-worth
•To help the client accept losses
•To provide physical comfort.

HOSPICE AND PALLIATIVE CARE

The hospice movement was founded by physician Saunders in London in 1967. Hospice care
focuses on support and care of dying person and family with goal of facilitating a peaceful
and dignified death. Hospice care is based on holistic concepts, emphasizes care to improve
quality of life rather than cure, support the client, and family through the dying process and
support the family through bereavement. The condition of client usually deteriorates and
attention needs to be focused on caregiver to ensure that they are receiving support and
resources as these changes occur. If the hospice team meets regularly, these needs can be
discussed and interventions initiated. Physical needs are usually apparent, but emotional and
behavioral signs are often more subtle
The principles of hospice care can be carried out in a variety of settings, the most common
being home and hospital based unit. Services focus on symptom control and pain
management. Hospice care is always provided by a team of both health professionals and non
professionals to ensure a full range of care services.

PALLIATIVE CARE

Palliative care is specialised, interdisciplinary care for patient with serious, life limiting or
chronic debilitating illness. It involves comprehensive management of the patient’s physical,
psychological, social and spiritual needs. As described by WHO, is an approach that
improves the quality of life of clients and their families facing the problem associated with
life-threatening illness, through prevention and relief of suffering by means of early
identification and impeccable assessment and treatment of pain and other problems, physical,
psychosocial and spiritual. The origin of palliative care is hospice care. However unlike
hospice care, palliative care occurs anytime during a patient's illness, even if life expectancy
extends to years and aggressive or curative treatment is being pursued. Palliative care:
 Provides relief from pain and other distressing symptoms
 Affirms life and regards dying as a normal process
 Intends neither to hasten or nor postpone death
 Integrates psychological and spiritual aspects of client care
 Offers a support system to help the client live as actively as possible until death
 Offers support system to help family cope during client's illness
 Uses a team approach to address the needs of client
 Will enhance the quality of life.
.
Principles of Palliative Care
1. Palliative care respects the goals, likes and choices of the dying person and his or her
loved ones, helping them to understand the illness and what can be expected from it,
and to figure out what is most important during this time.
2. Palliative care looks after the medical, emotional, social and spiritual needs of dying
person, with a focus on making sure he or she is comfortable, not left alone, and able
to look back on his or her life and find peace.
3. Palliative care supports the needs of family members, helping them with the
responsibilities of caregiving and even supporting them as they grieve.
4. Palliative care helps to gain access to needed health care providers and appropriate
care settings, involving various kinds of trained providers in different settings,
tailored to the needs of the patient and his or her family.
5. Palliative care builds ways to provide excellent care at the end of life, through
education of care providers, appropriate health policies and adequate funding from
insurers and government.

MEETING THE PHYSIOLOGICAL NEEDS OF DYING CLIENT

The physiological needs of people who are dying are related to a slowing of body processes
and to homeostatic imbalances- Interventions include providing personal hygiene measures,
controling pain, relieving respiratory difficulties, assisting with movement, nutrition,
hydration, elimination and providing measures related to sensory changes.

 Providing Spiritual Support

Spiritual support is of great importance in dealing with death. The nurse has a responsibility
to ensure that clients spiritual need are attended. She should not impose her own religious
belief on client. Specific interventions include facilitating expressions, feelings, prayer,
meditation, reading and discussion with appropriate clergy or a spiritual advisor
.
 Facilitate Mourning
Help client accept that loss is real, support efforts to live without deceased person or in
face of disability, encourage establishment of new relationship, allow time to grieve,
interpret normal behavior, provide continuing support, be alert for signs of ineffective
coping.
  Supporting the Family
The most important aspect of providing support to the family members of dying client
involves using therapeutic communication to facilitate their expressions of feelings. When
nothing can reverse the inevitable dying process, the nurse can provide an empathetic and
caring presence. Family members should be encouraged to participate in care of dying person
as they wish to and are able.

 Care of Body after Death

Caring for the deceased body and meeting the needs of grieving family are nursing
responsibilities. The body of deceased needs to be treated in a way that respect the sanctity of
human body. Nursing care includes maintaining privacy and preventing damage to the body.

CONCLUSION:

Death is inevitable. Everyone, one day or the other will go through this process. In a
technology improvised world where the health care delivery focuses mainly on health
promotion, is the nurse who must be competent enough to able to cope physically and
mentally inorder to achieve the best in people while they go through the process of loss,
grieving and the breavemnet period.
BIBLIOGRAPHY

1. Brar NK, Rawat HC. Textbook of advanced nursing practice: coping with loss, death
and grief. 1st ed. New Delhi, India: Jaypee brothers medical publishers (p) ltd; 2015.
p. 886-903.
2. Sadock BJ, Sadock VA. Kaplan and Sadock’s synopsis of psychiatry: death, dying
and bereavement. 10th ed. Philadelphia, USA: Lippincott Williams and wilkens
publishers; 2003. p. 64-67
3. Stuart GW. Principles and practices of psychiatric nursing: psychological care of
patients with terminal illness. 9th ed. Haryana, India: Elsevier, a division of reed
Elsevier pvt India ltd; 2011. p. 729-733
Internet:
1. Jordan S. Coping with loss-bereavement and grief. 2015. Available at:
http://www.nhma.org. Accessed on October 16, 2016.
2. Goldberg J. grief. Coping with grief. 2016. Available at: http://www.m.webmd.com .
Accessed on October 16, 2016.
 ASSAM DOWNTOWN UNIVERSITY

FACULTY OF NURSING
CLASS PRESENTATION

ON

DEATH AND GRIEVING, COPING WITH LOSS

SUBJECT – ADVANCED NURSING PRACTICE

SUBMITTED TO: SUBMITTED BY:

MS.MRIDUSMITA NATH AMANDA KHARSAMAI

LECTURER 1ST YR. M.Sc. NURSING

FACULTY OF NURSING ROLL NO- 02

ASSAM DOWNTOWN UIVERSITY ASSAM DOWNTOWN UNIVERSITY

SUBMITTED ON: 08/11/2021

 CONTENT

1. INTRODUCTION
2. LOSS
3. CATEGORIES OF LOSS
4. TERMINAL ILLNESS AND CARE
5. STAGES OF DYING
6. SIGNS OF APPROACHING DEATH
7. GRIEVE
8. MOURNING
9. BEREAVEMENT
10. TYPES OF GRIEVE
11. THEORIES OF GRIEVING PROCESS
12. FACTORS AFFECTING LOSS AND GRIEVE
13. RELATIONSHIP BETWEEN LOSS, GRIEVE AND DEPRESSION
14. COPING WITH LOSS, GRIEVE AND DEATH
15. GRIEVE COUNSELING AND GRIEVE THERAPY
16. NURSING MANAGEMENT
17. HOSPICE AND PALLIATIVE CARE
18. MEETING THE PSYCHOLOGICAL NEEDS OF THE DYING CLIENT
19. CONCLUSION
20. BIBLIOGRAPHY