Chapter 43: Loss, Grief and Dying
1. Explain the concepts of loss and grieving, including types of loss and grief reactions
a. Loss: inaccessibility or
... [Show More] change in a valued person, object, or situation.
i. Actual loss: loss tangible to both the person sustaining the loss and to others.
1. Ex: loss of a limb, a child, a valued object such as money, and a job
ii. Perceived loss: loss tangible only to the person sustaining it.
1. Loss of youth or growing up too quickly
iii. Physical loss: loss of life, limb, an object, person, pet, or job.
1. A person who loses an arm in an automobile crash suffers from both the
physical loss of the arm and the psychological loss that may be caused by
an altered self-image and the inability to return to his or her occupation
or other activities.
iv. Psychological loss: loss that affects a person’s self-image.
v. Anticipatory loss: loss behaviors displayed before the actual loss occurs.
1. Ex: diagnosis with breast cancer and getting a vasectomy and losing the
breast
vi. Maturational loss: is experienced as a result of natural developmental processes.
1. Ex: A first child may experience a loss of status when a sibling is born
2. Ex: The parent of a single child may experience a sense of loss when the
child begins school.
vii. Situational loss: experienced as a result of an unpredictable event
1. Ex: traumatic injury, disease, death, or national disaster
b. Grief: emotional response to loss.
i. Normal expressions of grief may be:
1. physical:(crying, headaches, difficulty sleeping, fatigue)
2. emotional:(feelings of sadness and yearning)
3. social:(feeling detached from others and isolating yourself from social
contact)
4. spiritual:(questioning the reason for your loss, the purpose of pain and
suffering, the purpose of life and the meaning of death).
ii. Dysfunctional grief: distorted or abnormal grief response, including
1. inhibited grief:(suppression of grief reaction)
a. manifest somatic (body) symptoms, such as abdominal pain or
heart palpitations.
2. unresolved grief:(lengthy or denied grief reaction).
iii. Abbreviated grief: short but genuine grief reaction.
iv. Anticipatory grief: grief reaction before actual loss.
v. Engel’s six stages are:
1. shock and disbelief
a. refusal to accept the fact of loss, followed by a stunned or numb
response: “No, not me.”
CHAPTER 43: LOSS, GRIEF AND DYING
2. developing awareness
a. physical and emotional responses such as anger, feeling empty,
and crying: “Why me?”
3. Restitution
a. rituals surrounding loss; with death, it includes religious,
cultural, or social expressions of mourning, such as funeral
services
4. resolving the loss
a. void left by the loss
5. Idealization
a. exaggeration of the good qualities of the person or object,
followed by acceptance of the loss and a lessened need to focus
on it
6. Outcome
a. dealing with loss as a common life occurrence
vi. Kübler-Ross five stages of reaction:
1. Denial and isolation
2. Anger
3. Bargaining
4. Depression
5. Acceptance
2. Describe the signs of impending death.
a. Difficulty talking or swallowing
b. Nausea, flatus, abdominal distention
c. Urinary or bowel incontinence or constipation
d. Loss of movement, sensation, and reflexes
e. Decreasing body temperature with cold or clammy skin
f. Weak, slow, or irregular pulse
g. Decreasing blood pressure
h. Noisy, irregular, or Cheyne–Stokes respirations
i. Restlessness or agitation
j. Cooling, mottling, and cyanosis of the extremities and dependent areas
i. Mottling: purpling of the skin
ii. Cyanosis: bluing of the skin
3. Compare and contrast the five emotional stages of dying defined by Kübler-Ross.
i. Stages can be flowed through backward and forward, no timeline
b. Denial: The patient denies the reality of death and may repress what is discussed.
i. Ex: patient may think, “They made a mistake in the diagnosis. Maybe they mixed
up my records with someone else’s.”
c. Anger: The patient expresses rage and hostility and adopts a “why me?” attitude:
i. Ex: “Why me? I quit smoking and I watched what I ate. Why did this happen to
me?”
d. Bargaining: The patient tries to barter for more time. Many patients put their personal
affairs in order, make wills, and fulfill last wishes, such as trips, visiting relatives, and so
forth. It is important to meet these wishes, if possible, because bargaining helps patients
move into later stages of dying.
i. ex: “If I can just make it to my son’s graduation, I’ll be satisfied. Just let me live
until then.”
e. Depression: The patient goes through a period of grief before death. The grief is often
characterized by crying and not speaking much
i. ex:“I waited all these years to see my daughter get married. And now I may not
be here to see her walk down the aisle. I can’t bear the thought of not being there
for the wedding—and of not seeing my grandchildren.”
f. Acceptance: When the stage of acceptance is reached, the patient feels tranquil. The
patient has accepted the reality of death and is prepared to die.
i. Ex: The patient may think, “I’ve tied up all the loose ends: made the will, made
arrangements for my daughter to live with her grandparents. Now I can go in
peace knowing everyone will be fine.”
4. Identify ethical and legal issues in end-of-life care, including advance directives, physician
orders, assisted suicide, and euthanasia.
a. Advance Directive: written directive that allows people to state in advance what their
choices for health care would be if certain circumstances should develop
i. For anyone 18 and older
ii. Provides instructions for future treatment
iii. Appoints a Health Care Representative
iv. Does not guide Emergency Medical Personnel
v. Guides inpatient treatment decisions when made available
1. a living will
a. provide specific instructions about the kinds of health care that
should be provided or foregone in particular situation
2. durable power of attorney
a. appoints an agent the person trusts to make decisions in the event
of subsequent incapacity
vi. 5 wishes:
1. The person I want to make care decisions for me when I can’t
2. The kind of medical treatment I want or don’t want
3. How comfortable I want to be
4. How I want people to treat me
5. What I want my loved ones to know
b. POLST form: A Physician Order for Life-Sustaining Treatment form is a medical order
indicating a patient’s wishes regarding treatments commonly used in a medical crisis
i. POLST form must be completed and signed by a healthcare professional
ii. cannot be filled out by a patient
iii. These forms are always completed in close consultation with the patient to ensure
that the patient’s values and goals of care are accurately represented.
1. Physician Order for Life-Sustaining Treatment (POLST) Form:
a. For persons with serious illness—at any age
b. Provides medical orders for current treatment
c. Guides actions by Emergency Medical Personnel when made
available
d. Guides inpatient treatment decisions when made available
c. Euthanasia: mercy killing; the deliberate termination of the life of a person
i. Active euthanasia: is taking specific steps to cause a patient’s death
1. doing something to end a patient’s life
a. (e.g., administers a lethal dose of medication)
ii. Passive euthanasia: is defined as withdrawing medical treatment with the
intention of causing the patient’s death.
1. not doing something to preserve a patient’s life. In assisted suicide
a. (e.g., a prescription for a lethal dose of barbiturates)
d. Assisted suicide: making a lethal combination of drugs available to a patient wishing to
die or administering a lethal injection or carbon monoxide
1. The ANA Code for Ethics states that the nurse:
a. “should provide interventions to relieve pain and other
symptoms in the dying patient consistent with palliative care
practice standards and may not act with the sole intent to end
life”
e. Orders:
i. Do Not Resuscitate (DNR) order, or No Code:
1. patient or surrogate has expressed a wish that there be no attempts to
resuscitate the patient. Means that no attempts are to be made to
resuscitate a patient whose breathing or heart stops
ii. Slow Code (or “Show Code”):
1. should be called in the case of cardiopulmonary or respiratory arrest,
calling a code and resuscitating the patient are to be delayed until these
measures will be ineffectual.
iii. Allow Natural Death (AND) order:
1. Easier for families to authorize doing something positive rather than
preventing something
a. (i.e., a resuscitative effort) that is usually perceived to be helpful.
iv. Do Not Intubate (DNI) order
v. Comfort Measures Only order:
1. which indicates that the goal of treatment is a comfortable, dignified
death and that further life-sustaining measures are no longer indicated.
vi. Do Not Hospitalize order:
1. Often used for patients in long-term care and other residential settings
who have elected not to be hospitalized for further aggressive treatment.
vii. Terminal Weaning:
1. withdrawal of life-sustaining therapy with the understanding that death
may result, generally after a decision is made that the therapy in question
is medically futile or disproportionately burdensome
a. A nurse’s role in terminal weaning:
i. participate in the decision-making process by offering
helpful information about the benefits and burdens of
continued ventilation
ii. provide a description of what to expect if terminal
weaning is initiated.
iii. supporting the patient’s family and managing sedation
and analgesia are critical nursing responsibilities.
viii. Palliative Sedation:
1. the lowering of patient consciousness with medication for the express
purpose of limiting the patient’s awareness of suffering that is intractable
and intolerable
5. Explain six factors that affect loss, grief, and dying
a. Developmental Considerations
i. Children: do not understand death on the same level as adults do
1. their sense of loss is just as great
2. likely to talk about and ask questions about death in an attempt to
understand it
3. needs to go through the same grief reactions as adults to accept such a
loss and maintain emotional well-being.
4. death of a parent or another significant person can retard a child’s
development or may cause the child to regress developmentally.
ii. Middle-aged adult:
1. Death of a parent helps to prepare the adult for the loss of a spouse or
significant other and to accept his or her own eventual death.
iii. Older adults:
1. may lose a spouse or friends and relatives their own ag [Show Less]