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Page 1: Grief & Grieving Process

Loss, Grief and Death

Elmer A. F. Conde

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Definition of Terms

• Loss- the absence of an object, person’s body part or function, or emotion that was formerly present.

• Grief – a form of sorrow that follows the perception or anticipation, loss of one or more valued or significant objects

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• Bereavement – the state of grieving during which a person goes through grief reaction. It is the experience of having lost something or someone by death.

Definition of Terms

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• Mourning – is the period of acceptance of loss and grief which the person learns to deal with the loss. This includes wakes, funeral rituals, memorial services, wearing of black/white dress, and defined time of social withdrawal or isolation.

Definition of Terms

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Types of Loss:

Loss of external object• Possession that is worn – out, misplaced,

stolen, or ruined by disaster or calamity

Loss of life• How one person views death (relief vs

loneliness)

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Loss of a known environment• Temporary or permanent relocation• Separation from a known or comfortable

environment• Hospitalization

• Loss of an aspect of life • Loss of a body part, physiologic function,

psychological function, emotions, self-concept, self confidence, power, love

Types of Loss:

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Loss of significant others• Loss of a parent, spouse, children,

siblings, colleagues, friends, neighbors, entertainment figures, well known people and actors.

Types of Loss:

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Types of Loss:

• Actual– Recognized by others

• Perceived– Experienced by one

person but cannot be verified by others

• Anticipatory– Experienced before

loss occurs– Can be actual or

perceived

• Situational – i.e., Loss of job,

death of child

• Developmental– i.e., Departure of

children from home

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Theories Affecting Grief

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Engel (1954) Phases of Grief

I. Shock and Disbelief • Person refuses to accept the loss• Stunned and numb responses (“Not

me?”, “No”)

II. Developing awareness• Presence of physical and emotional

responses (anger, feeling empty, crying, “Why me?”)

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III. Restitution• Involves rituals surrounding loss and

death• Religious, social, cultural expressions of

mourning such as funeral service.

IV. Resolving the loss• Dealing with the void/emptiness left by

the loss

Engel (1954) Phases of Grief

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V. Idealization• Exaggeration of the good qualities of the

person or object lost• Followed by the acceptance of the loss

and need to focus on the loss is lessened

VI. Outcome• Dealing with the loss a common life

occurrence

Engel (1954) Phases of Grief

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Bowlby (1980) Phases of Grieving Process

• Phase I: experiencing numbness and denying the loss

• Phase II: emotionally yearning for the lost loved one and protesting the permanence of death

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• Phase III: experiencing cognitive disorientation and emotional despair with difficulty functioning in the everyday world.

• Phase IV: reorganizing and reintegrating the sense of self to pull life back together.

Bowlby (1980) Phases of Grieving Process

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Rodebaugh, Schwindt & Valentine (1999) Process of

GriefI. Reeling • Person feels shock, disbelief and denial

II. Feelings• Person experiences anguish, guilt,

profound sadness, anger, lack of concentration, sleep disturbances, appetite changes

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III. Dealing• Person begins to adapt to the loss by

engaging in support groups, grief therapy, reading and spiritual guidance.

IV. Healing• Integrates loss a part of life, anguish is

lessen.• Does not imply that the person has

forgotten or accepted the loss.

Rodebaugh, Schwindt & Valentine (1999) Process of

Grief

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Phases of Death and Dying (Kobler Ross, 1969)

1. Denial & Isolation• Client denies he will die• may repress that is discussed or isolate

self from reality• Nursing Implications

– Support emotional needs without supporting denial

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• Nursing Implications– Offer to remain with clients, without

discussing reasons for behavior or need to cope with it until they bring it up

– Offer regressive care such as food, drinks and safety

Phases of Death and Dying (Kobler Ross, 1969)

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2. Anger• Express anger and retaliates to family

members, staff, physician or supreme being

• Becomes demanding and accusing • Maybe precipitated by guilt which will

lead to anxiety and low self-esteem.

Phases of Death and Dying (Kobler Ross, 1969)

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•May feel resentful and jealous to those who still have lost object or loved one.

•Nursing implications:–Provide anticipatory guidance

about feelings and their intensity experienced as a part of grief.

–Do not take anger personally.–Meet needs that cause angry

response.

Phases of Death and Dying (Kobler Ross, 1969)

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Phases of Death and Dying (Kobler Ross, 1969)

3. Bargaining• Client is willing to do anything to avoid loss

or change the prognosis.• Bargaining is commonly addressed to the

Supreme Being in an attempt to postpone death

• A positive way to maintain hope• Nursing implications:

– Nurses must provide information regarding the need for decision making.

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• A positive way to maintain hope• Nursing implications:

– Nurses must provide information regarding the need for decision making.

Phases of Death and Dying (Kobler Ross, 1969)

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Phases of Death and Dying (Kobler Ross, 1969)

4. Depression• Time for introspection• Quite and non-communicative, • May lose interest in appearance and

may become suicidal• May cope by doing unhealthy behaviors

such as drinking, smoking, drug use

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Phases of Death and Dying (Kobler Ross, 1969)

• Client struggles with painful realities of life and preparing for death

• Nursing implications:– Provide support and empathy– Support crying by offering touch that

communicates caring– Assess risk of harm to self and refer

accordingly.

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Phases of Death and Dying (Kobler Ross, 1969)

• Acceptance•Individuals accept the terms of loss

and death and begins to plan for it.•Reminiscence is common and good

outweighs that bad.•Life begins to stabilize and peaceful

acceptance that death is imminent.

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Nursing implications:– Offer opportunities to share feelings

verbally in writing or art or by tape recording.

– Allow and encourage review as often as clients want to talk.

– Show acceptance of liability of feelings– Assist in discussing future plans.

Phases of Death and Dying (Kobler Ross, 1969)

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a. communication patterns: use of therapeutic communication

b. proxemics and kinetheticsc. risk factors: death of a child, spouse,

parent; sudden, untimely death; multiple deaths, deaths by suicide, murder or manslaughter

Nursing Considerations:

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Nursing Considerations:

d. cultural variabilitye. susceptibility factors: low self-esteem,

mistrust, co-morbid disorders, previous suicidal threats and attempts, absent/unhelpful family

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Question 1A client’s family tells the nurse that their culture does not permit a dead person to be left alone before burial. Hospital policy states that after 6:00 PM when mortuaries are closed, bodies are to be stored in the hospital morgue refrigerator until the next day. How would the nurse best manage this situation?

1. Gently explain the policy to the family and then implement it.

2. Inquire of the nursing supervisor how an exception to the policy could be made.

3. Call the client’s primary care provider for advice.4. Move the deceased to an empty room and assign

an aide to stay with the body.

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Rationales 1

1. When possible, modifications of policy that demonstrate respect for individual differences should be explored.

2. Correct. When possible, modifications of policy that demonstrate respect for individual differences should be explored.

3. The primary care provider is in no position to modify the implementation of hospital policy.

4. Utilizing an empty room and a staff member for a deceased client is an inappropriate use of resources.

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Question 2

The shift changed while the nursing staff was waiting for the adult children of a deceased client to arrive. The oncoming nurse has never met the family. Which of the following greetings is most appropriate?

1. “I’m very sorry for your loss.”2. “I’ll take you in to view the body.”3. “I didn’t know your father but I am sure he was

a wonderful person.”4. “How long will you want to stay with your

father?”

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Rationales 2

1. Correct. This statement acknowledges the family’s grief simply.

2. Avoid statements that may be interpreted as overly impersonal.

3. Avoid statements that may be interpreted as false support.

4. Avoid statements that may be interpreted as harsh.

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Question 3An 82-year-old man has been told by his primary care provider that it is no longer safe for him to drive a car. Which statement by the client would indicate beginning positive adaptation to this loss?

1. “I told the doctor I would stop driving, but I am not going to yet.”

2. “I always knew this day would come, but I hoped it wouldn’t be now.”

3. “What does he know? I’m a better driver than he will ever be.”

4. “Well, at least I have friends and family who can take me places.”

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Rationales 3

1. This option does not demonstrate movement toward a goal of adaptation nor problem solving.

2. This option does not demonstrate movement toward a goal of adaptation nor problem solving.

3. This option does not demonstrate movement toward a goal of adaptation nor problem solving.

4. Correct. Adaptive responses indicate the client can put the loss into perspective and begin to develop strategies for coping with the loss.

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Question 4When asked to sign the permission form for surgical removal of a large but noncancerous lesion on her face, the client begins to cry. Which of the following is the most appropriate response?

1. “Tell me what it means to you to have this surgery.”

2. “You must be very glad to be having this lesion removed.”

3. “I cry when I am happy or relieved sometimes, too.”

4. “Isn’t it wonderful that the lesion is not cancer?

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Rationales 4

1. Correct. The nurse needs to assess and explore the meaning of the client’s crying.

2. Option 2 leaps to assumptions about the meaning of the tears and ignores the possibility of the client’s distress.

3. Option 3 suggests that the client has the same feelings as the nurse, which may not be correct.

4. Option 4 leaps to assumptions about the meaning of the tears and ignores the possibility of the client’s distress.

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Question 5A nursing care plan includes the desired outcome of “quality of life” for a client with a chronic degenerative illness who is likely to live for many more years. Which of the following is one example that would indicate the outcome has been met?

1. The client demonstrates having adequate financial resources to pay for health care for many more years.

2. The client spends the majority of his or her time in spiritual reflection.

3. The client has no signs or symptoms of preventative complications of the illness.

4. The client verbalizes satisfaction with current relationships with other persons.

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Rationales 5

1. Although being able to pay for care may appear to contribute to good quality of life, only the client’s expression of satisfaction can provide the data the nurse requires to evaluate the goal.

2. Although apparent spiritual peace may appear to contribute to good quality of life, only the client’s expression of satisfaction can provide the data the nurse requires to evaluate the goal.

3. Although the absence of physiological complications may appear to contribute to good quality of life, only the client’s expression of satisfaction can provide the data the nurse requires to evaluate the goal.

4. Correct: Quality of life is determined by the client and expressed in terms of his or her satisfaction with a variety of aspects of life.

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Thank You!!!