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1. UNIT X: Concept of Loss &
Grieving and Death and Dying
Prepared by: Merub Alexander
(RN, BScN)
GULFREEN NURSING COLLEGE

2. Objectives:
• At the end of this unit, learners will be able to:
1. Assess the physiologic signs of death.
2. Identify beliefs and attitude about death in relation to age.
3. Discuss the various ways of helping the dying patient meet his/her
physiological, spiritual and emotional needs.
4. Discuss care of the body after death.
5. Discuss the legal implications of death.
6. Describe how a nurse meets a dying patient’s needs of comfort.
7. Discuss important factors in caring for the body after death.

3. 8 . List changes that occur in the body after death.
9. Define terms related to loss and grieving.
10. Discuss Kubler-Ross’ theory to assess grieving behaviors.
11. Identify common manifestations of grief
12. Discuss the effects of multiple losses on the grief process
13. Apply the nursing process to grieving clients

4. • Everyone experiences loss, grieving, and death during his or her life.
People may suffer the loss of valued relationships through life
changes, such as moving from one city to another; separation or
divorce; or the death of a parent, spouse, or friend.

5. • Loss: is an actual or potential situation in which something that is
valued is changed or no longer available. People can experience the
loss of body image, a significant other, a sense of well-being, a job,
personal possessions, or beliefs. Illness and hospitalization often
produce losses.
• Grief: is the total response to the emotional experience related to
loss. Grief is manifested in thoughts, feelings, and behaviors
associated with overwhelming distress or sorrow.

6. • Bereavement: is the subjective response experienced by the
surviving loved ones.
• Mourning: is the behavioral process through which grief is
eventually resolved or altered; it is often influenced by culture,
spiritual beliefs, and custom. Grief and mourning are experienced not
only by the person who faces the death of a loved one but also by the
person who suffers other kinds of losses.

7. DEATH
• The irreversible cessation of all vital functions especially as y
permanent stoppage of the heart, respiration, and higher brain
function.
• Death is cessation or permanent termination of all the biological
function that sustain a living organism.
• Dying mean approaching death.

8. Physiological sign of death:
The four main changes are:
• Loss of muscle tone.
• Changes in the vital signs.
• Slowing of circulation.
• Sensory impairment.
The following guidelines for physicians as indications of death:
• Total lack of response to external stimuli.
• No muscular movement (especially breathing)
• No reflexes.
• Flat encephalogram.

9. Belief and attitude about death in relation to
age:
• Infancy to 5 year: Does not understand concept of death ,believes
death is reversible, temporary departure or sleep.
• 5 to 9 year: Understand death is final , believes own death can be
avoided , believes wishes and unrelated actions can be responsible
for death.
• 9 to 12 years: Begins to understand own mortality, expressed in after
life and fear of death.
• 12 to 18 years: May still hold concept from previous developmental
stages, may seen to reach “adult” perception of death but
emotionally unable to accept it.

10. • 18 to 45 year: Has attitude towards death influenced by religious and
cultural believes.
• 45 to 65 years: Accepts own mortality. Encounters death of parents
and some peers experience.
• 65 years+ : Fear prolong illness, sees death as having multiple
meanings, (eg, freedom from pain, reunion with already decreased
family.

11. Dying Patient:
We may help dying patient meet his/her
• Physiological needs.
• Spiritual needs.
• Emotional needs.

12. Meeting Physiological Needs Of Dying Patients:
• Providing personal hygiene measures.
• Controlling pain.
• Relieving respiratory difficulties.
• Assisting with movements, nutrition, hydration and elimination.
• Providing comfort to the patient and relieving.

13. Spiritual support:
• Identify patient spiritual needs.
• Respect the beliefs of patients.
• Be willing to listen and discuss issues of spirituality.
• Demonstrate empathy.
• Provide a supportive presence.
• Refer to community resources of spiritual leaders.
• Acknowledge and provide for the rituals.

14. • Emotional support:
• Compassion( desire to help).
• Responsiveness to emotional needs.
• Maintain a positive attitude.
• Expressing empathy.
• Attending wishes.
• Being present.

15. Physical changes after death:
• Pupil : fixed and dilated.
• Algor mortis: rapid cooling of body.
• Rigor mortis: stiffing of the body, develops 2-4 hours after death.
• Livor mortis: purple discoloration of skin in dependent areas.

16. Care after death:
• Death declaration/ death certificate by physician.
• Autopsy( written permission).
• Customs & principles kept in mind.
• Positioning- body straitened & arms are laid at the side.
• Eyes are closed as in sleep.
• Dentures are removed & prop chin in position with bandaging.
• Remove all appliances used for patient care (e.g. catheter tubing etc.)

17. • Remove ornaments and list them relatives.
• All orifices are to be plugged with cotton to prevent escape of body
discharges.
• Prevention of spread of diseases (i.e. sealing body).
• Send body clean and nearly dressed.
• An identification tag.
• If relatives are present then body is handed over them with proper
written legal authority permission.
• Maintain record of death and inform to authority for register of death
for body.

18. Legal aspects of death:
• Federal and state law require that institutions develop policies and
procedures for certain events that occur after death.
• Requesting organ or tissue donation.
• Autopsy.
• Certifying and documenting the occurrence of a death.
• Providing safe and appropriate post mortem care.

19. • Death must be certified by physician
In unusual death, an autopsy (postmortem examination) may be
required.
• Request family members consent and signature for autopsy.
• Several reasons for a death becoming a case for the coroner:
oDeath by suspicious means or not under a doctor’s care.
oDeath resulting from an accident.
oClient has been hospitalized for less than 24 hours.

20. Loss:
• Loss occurs when a valued person, object or situation is changed.
• Loss can be defined as the undesired changes or removal of a valued
objects, person or situation.
• Loss is a universal experience that occurs throughout the lifespan.

21. Types of loss:
• Actual Loss: An actual loss can be recognized by others including the
person sustaining the loss, ex: a person losing a limb, spouse, valued
objects, job etc.
• Perceived Loss: A perceived loss is experienced by one person but
cannot be verified by others. Psychological losses are often perceived
losses because they are not directly verifiable. For example, a woman
who leaves her employment to care for her children at home may
perceive a loss of independence and freedom.

22. • Anticipating Loss: An anticipatory loss is experienced before the loss
actually occurs. For example, a woman whose husband is dying may
experience actual loss in anticipation of his death.

23. Grief
• Grief is emotional response to loss.
• Grief is form of sorrow involving feelings, thoughts and behaviours
caused by bereavement.
• Grief is physical , psychological and spiritual responses to loss.
• Grief is a “ set of cognitive ,emotional and social difficulties that
follow the death of a loved one.”
• The grief process involves a sequence of effective, cognitive and
psychological states as a person responds to and finally accepts a loss.

24. Loss & Grieving:
• Loss: Something of value is gone.
• Grief: Total response to emotional experience related to loss.
• Bereavement: Subjective response to by loved ones.
• Mourning: Behavioral response.

25. Functions of Grief:
• To make the outer reality of loss in to an internally accepted reality.
• To lessen the emotional attachment to the lost person or object.
• To make it possible for the bereaved person to become attached to
other people or objects.

26. Types of Grief:
• Anticipatory grief
• Normal or common grief
• Complicated grief
• Disenfranchised grief
Common grief reaction: A grief reaction is a set of psychological
and somatic( body) symptoms that results from extreme sorrow or loss.
These reactions fall into four different categories:
oThought patterns.
oPhysical sensations
oEmotions
oBehaviors.

27. Common Clinical Manifestations Of Grief:
• Shock and disbelief.
• Sadness
• Guilt
• Anger
• Fear
• Disorganized behaviors
• Physical symptoms
• Anorexia, GI issues, SOB etc.

28. Stages of grief:
• Kubler-Ross, in extensive research with terminally ill patients,
identified five stages of feelings and behaviors that individuals
experience in response to a real, perceived or anticipated loss.
• Kubler-Ross stages of grieving( 1969):
oDenial
oBargaining
oDepression
oAcceptance

29. Denial and isolation:
• Denial is a conscious or unconscious refusal to accept facts,
information, reality, etc, relating to the situation concerned. It’s a
defense mechanism and perfectly natural.
Anger:
• Anger can manifest in different ways. People dealing with emotional
upset can be angry with themselves, and /or with others, especially
those close to them. “why me? And its not fair!” are comments often
expressed during anger stage.

30. Bargaining:
• Traditionally the bargaining stage for people facing death can involve
attempting to bargain with whatever God the person believes in. For
examples “ can we still be friend?..” when facing a break-up .
Bargaining rarely provides sustainable solution, especially if it’s a
matter of life or death.
Depression:
• During this stage, the full impact of loss is experienced. The sense of
loss is intense and feelings of sadness and depression prevail. This is a
time of quite desperation and disengagement from all association
with the lost entity.

31. Acceptance:
• The final stage brings a feeling of peace regarding the loss that has
occurred. It is a time of quite expectation and resignation. The focus
is on the reality of loss and its meaning for the individuals affecting by
it. Reaching this stage of mourning is a gift not afforded to everyone.

32. • For nursing care plan read the nursing management in the book.