Understanding Grief and Loss in Nursing

Grief and Loss presented by clinical instructor Sharon Celestine. The purpose of this lecture is to discuss what is loss and what is grief. By the end of the class, the students, you will be able to examine the factors that are influencing the loss and grief responses in patients and their significant others to facilitate the grief process. In addition, you are going to be able to apply the nursing process when caring for a patient and your significant other who is experiencing grief, loss, and or debt. In addition, you will also be able to formulate and individualize plan of care for a dying patient. When we say that, we are going to, you as a student will have to come up with a format, what's going on, a plan of care to give care to a patient that's dying. You're also going to discuss the nurse's role when performing postpartum care. So to get into this discussion, we're going to first define what exactly is loss. What do we consider loss? Loss can be defined as the undesired change or the removal of a valuable object, person, or situation. So here I have some photos just so you understand again. When we talk about loss, we're not just talking about someone. It could be the loss of your home, it could be the loss of a loved one, loss of work, loss of something that's dear to you, loss of even your mobility as we get older, losing something, and again, the loss of someone. There are different categories of loss, actual versus perceived loss. When we talk about actual loss it includes the death of a loved one even a relationship that deterioration destruction and anything natural disaster the loss can be identified by others and not just by the person that's experiencing so everyone around you could see that okay this has happened this is loss and then when we talk about perceived loss it is internal it's what you as a person is experiencing as loss. It is identified only by the person that is experiencing it. Next, we have physical loss versus psychological loss. Physical loss includes injury, removal of an organ, function, a limb. An example of this is a limb that's been amputated or lost of mobility. This is a physical loss. Psychological loss challenge your brief belief system, trust in someone. Do I trust this person? I had a close friend, but she did something to me and now I no longer have this person as a friend. She betrayed my trust. This is a loss. It is a psychological loss. Note that some losses can be mixed after removal. For example, after removal of a prostate gland, a man may feel physical or psychological loss of sexuality. So this is a combination of both. As we continue with the different categories of loss, we have external versus internal loss. External loss are the actual loss of an object that are important to the person because of the cost or the sentimental value. For example, we have home, jewelry, and photos. These losses can be brought on by theft, destruction, and disasters such as flood and fire. Some of you guys were present during Hurricane Katrina or even Hurricane Ida. These were all external examples of external loss. Internal loss is another term for perceived or psychological loss. Again, it is what the person feels or that person perceived as a loss. Lost of aspect of self, this includes physical loss such as a body organ, limb, and body function or any type of disfigurement. Psychological and perceived loss in this category includes the aspect of one's personality, development. mental change related to aging process, loss of hope, dreams, and loss of faith. Again, this is what the person feels. Environmental loss. This loss involves changes in familiar even if the change is perceived or positive or even negative. For example, moving to a new country, moving into a new home, starting a new job, and going to college. These are all types of environmental laws. These laws can be perceived or it can be actual, meaning that you can actually see what's going on, it's actual, it's actual going on, or it's perceived, what you feel. Lost of a significant relationship. This includes loss of a spouse, sibling, family member, friend through death, divorce, and separation. Yes, even through divorce, you have actually lost a partner. Now we're going to discuss what is grief. Grief is the physical, psychological, and spiritual response to a loss. We previously discussed the different types of losing. Now, this is how you react to the loss. So you may have a process where you decide to mourn. And when we talk about mourning, it consists of the action associated with grief. For example, some people may cry if they lose someone. There are some cultures where they may wear a certain color during the time of their um after they have experienced a loss of a loved one they may wear black clothing then we have what is called the bereavement period and this is the period of mourning and it adjusts an adjustment after a loss there is no set period on how long a person should mourn or the bereavement period remember that mourning and bereavement it is subjective it is the response that the person who is survived by the lost what they are experiencing so again there's no set time you cannot tell someone oh you should only mourn for one month it's how that person it's how that person respond to the loss that they have experienced everyone expressed grief differently no two people ever grieve in the same manner because many factors play a role in the grieving process there are certain factors or consideration that a person may experience or based on the relationship that they have had with that person that determines how they grieve. So now we're going to discuss some of the different types of grief or bring awareness that there are different types of grief. So when we talk about uncomplicated, grief is just what it says uncomplicated. There's nothing attached. a person. let's say you lose something, there's nothing complicated about it. Then we have something like dysfunctional grief. When we talk about dysfunctional grief, again, just as it's stated, dysfunctional grief, meaning that the relationship that you may have had with the person has been dysfunctional. Not because the person passes that it's going to change the fact. It's still considered dysfunctional. Let's say there was some abuse going on and that person passed away. the person, the survivor, they may have some type of dysfunctional grief. Chronic grief. When we talk about chronic grief, last week a parent died, this week another parent died, and then maybe another week someone else died. It's just continuous, chronic, something that's going on and on. Mass grief, as we know, there are times when you're not dealing with the Delayed grief, let's say the person was ill. They passed away, you wasn't expecting it. It may be, you may not feel it right away, but eventually you do. Disenfranchised grief, again, disenfranchised, you're disconnected. Anticipatory grief, meaning that the person was ill over a period of time, you knew that this was coming. So again, there are different types of grief that we all or our patient may experience. There are different factors that affect grief. The type of relationship you have with the person can affect grief. So let's go over this now. The significance of loss. This means that the person has attached to the person or object loss will be different from each person. For example, you can have a mother with two children and both of those children may experience a different type of grief, although it's the same parent. Because the relationship that they had with this particular person may be a little bit different. The greater the attachment, the more difficult the grief will be. There are some times where kids are more attached to one parent than the other. So again, this is a factor that may affect the way that they grieve. Support system. People with strong emotional and psychosocial support system typically have less complicated grief. Unresolved conflicts. Sometimes we see this a lot, especially if the parents, you may have some type of dysfunction going on within the family dynamics. It may cause prolonged or dysfunctional grief can occur with unresolved conflicts. You didn't resolve the conflict, so it's there. A conflict left unresolved may prolong grief. circumstances of grief the manner or circumstances of the death can lead to bereaved feeling guilty responsible or unprepared sometimes let's just say I think I was looking at a movie recently and the parent bought the son a motorbike he went out on the motorbike and he had an accident and he died again based on those circumstances she may feel guilty she may feel a certain type of way because she was the one that actually bought her son the motorcycle. A violent death, murder, suicide, or accident, it can result in a prolonged, complicated grief. Previous or multiple loses. A person who has sustained several loss in a short period of time may experience complicated or dysfunctional grief. Spiritual, cultural beliefs and practices. With that, what we see is spiritual and religious belief can help or hinder the grieving. process. For example, some believe that the deceased is in a place of happiness where others may believe that the deceased is reborn, yet another may believe that that is final and there is no life after. So it all depends on the person's spiritual or cultural beliefs that can also affect the grieving process. The timelessness of the debt. The debt of a child or young person is almost universal, more difficult to accept. than the death of an older person meaning that most cultures they believe that the children should be burying the parents and not the parents burying the children so again this also plays a factor in the way that a patient or a person is affected by grief now let's go into talking about the different stages of grief and so according to Elizabeth Kubler-Ross there are five stages of grieving. It's denial. anger, bargaining, depression, and acceptance. When we talk about denial, during this stage here, denial may entail refuting the reality of the loss or any associated feeling. This stage may involve being numb, disbelief in response to the news of a loss. It may serve as an emotional buffer to prevent someone from feeling or from feeling overwhelmed. So you would see that they would have things like, may say things like, not me, this cannot be happening. They're in denial. Anger, during this stage an individual may direct their anger towards the person who died, the doctors, family members, or religious entities. As nurses working in the hospital, you may see this a lot. You may hear the family member saying, it's the doctor's fault. It's this. This replaces the numbness of shock and denial. It is important to address the anger. The description, they may say again, why me? Why is this happening to me? Bargaining. Bargaining, it involves thoughts such as, I will do anything if you take away the pain. This stage may come at a point within the grieving process. It is frequently accompanied by guilt. usually takes form of bargaining with God or higher power. And again, you would see the patient may say, if only I can live until my daughter's wedding, I'll give up, you know, I'll give an example of something. God, please, you know, please allow me to live. Please allow me to see my 50th birthday. Please allow me. This is in the bargaining stage. Next, depression. At this point, a person may experience feelings of emptiness and intense sadness. They may also withdraw from daily activities that they once enjoyed. While this stage is difficult, it is a necessary step towards healing. Acceptance. This is the final stage of the grieving process. Acceptance does not mean that people feel okay about the loss. Rather, it means that they realize the loss is their new reality. they understand that while life will not continue as it did before, it will go on. Please understand that individuals may not experience every stage or go through the stages in linear order. In addition, individuals may experience two or more stages at the same time. So again, although we call it the five stages of grieving, it does not occur one after the other and it does not con... continue at one at a time. It could be you experiencing two at a time or it could be in different steps. What are some of the stages of dying? What do you actually see? And we're talking about the psychological stages. What as a nurse you may see. And this is important for nurses, students, especially if you have a patient that is dying. These are some of the things that you're looking for. These are some of the things that you may see. So during the first three months, the dying person begins to withdraw from the world. What some of the things that they enjoy doing, you may see that they're not there more to themselves. Sleep increases. So normally you see a patient if they sleep six to eight hours, now it's eight to 12 hours. They're doing a lot more of the sleeping. The body becomes difficult for the body to digest food. This is especially important because, and again, living in New Orleans, One of the things that we believe, we believe that if you give a patient food or you give someone food, they're going to feel better. How many times you've been sick and they say, oh, here, drink this chicken noodle soup, you're going to be okay. During this time here, we see that family members try to force their loved ones to eat. This is the worst thing you can do, especially giving them meat. Because the body now, they are unable to digest the food as they normally do. The appetite and the food. intake decreases. So now they're not as hungry as the body is starting to break down. You know, liquids are usually preferred. One to two weeks before that, the body is beginning to lose its ability to maintain itself. The blood pressure. So as a nurse, if you're taking patient's blood pressure, which you should be, you would see that the blood pressure is reduced. There are changes in the pulse. Sometimes the pulse can be a bit tachycardic or maybe sometimes you see brady. It's a lot slower. Changes in the skin color. You may see a yellowish or the patient is pale. Temperature fluctuates. Respiratory rate, it increases or decreases. During sleep, the dying person may experience brief periods of apnea where they are not breathing. Congestion may also, you may hear some congestion in the chest, the rattling sound, or sometimes you may hear a nurse, a seasoned nurse say, oh, that's the death rattle. This is true. Congestion may cause a rattling sound or a nonproductive cough, meaning that they're coughing, but they're not bringing up anything. Days to hours before death, you may see a surge of energy. And again, a lot of family members, this is a time they said, oh, they may start thinking, oh, my, my loved one, they're coming back to normal. They're back to themselves. But again, this is something that you may see. Bring mental clarity and a desire to eat and talk with family members. They may decide, hey, today I'm going to eat. And again, family members are sometimes hopeful that their family, their loved one is not approaching that. but Again, we understand that this is one of the stages of dying. As that approaches, loved ones become dehydrated and have difficulty swallowing. So again, you would see that this patient, we may not want to give them thick foods. You may have to go to puree few foods, not a lot of food, not large spoonfuls. The tissue of the tongue and the soft palate, it sags. gag reflex decline so secretions accumulate in the mouth and the throat so normally if you have a nurse that's working with a patient that have the secretions there is normally a medication that they may give to dry the secretion the drug is called hycosamine the lips become crack again you can always put moisturizer on the lips respiration the breathing may be shallow rock or irregular periods of not breathing for 10 to 30 seconds congestion cause a death rather that can be quite loud you can actually hear change strokes respiration may occur no breathing for 10 to 60 seconds then breathing increase in depth and rate of respiration then it becomes slow and shallow the cycle continues in this pattern so definitely the respiration shape. Now when we look at circulation, it decreases and the person may feel clammy. So before when you touch the skin and it says warm, this person here, the skin may feel a bit clammy, almost cold. The blood pressure decrease, the pulse sometimes is hard to detect, the body becomes cool and muddled. Kidney function is decreased causing decreased urine output. Elimination. The patient tends to retain feces so they become a bit constipated and again once a patient has entered into the city of the urn, most of the time the doctors implement a stool softener or a laxative to help with the patient retaining feces. Decreased urine output and urine is more concentrated so you see that it's dark in color and it may be foul smelling. So splinter muscles relaxes causing bowel and bladder incontinence. As we continue with the stages of dying days to hours before the death, muscle throughout the body it may relax causing the face to droop, vision becomes blurry, eyes may be open or partially open but not seeing, patient may see things not visible to others, cognition may become restless and agitated. and some unexpectedly become energized for a time and others less communicative, quiet and withdrawn. Fatigue is common during this time. And moments before death, the dying person does not respond to touch or sound and cannot be awakened. There are long spaces of breath before breathing ceases and the heart stops beating. Again, so when we talk about grief and loss with any other topic, we implement the nursing process. We implement the clinical judgment model. We go through the entire process where we analyze, we see what's going on, what's going on with the patient. When a patient is dying or has experienced loss, you must carefully assess the patient and significant others for the common physical, emotional, behavioral, and cognitive grief reaction. You want to make sure that you assess the way the patient is coping. How do they cope with what's going on? You also want to look at the nature of the family relation. Remember, we said this plays a role in the way that a person grieves. The social support system also important in the grief process and the nature of loss. So again, With assessment, when we implement the nursing process, we start with our assessment. We are analyzing what's going on with that patient. And remember, before we do anything with our patient, we want to always assess. Next, we're going to look at analysis or diagnosis. As we know, this is also part of the nursing process. We look at the anticipatory grieving. This is one of the diagnoses, how the person is grieving, what's going on with that person. Compromise family coping, we know, let's say how a patient is coping or how the family is coping. Debt and anxiety, fear, impaired comfort, grieving, complicated grieving, risk-prone behavior, these are all nursing diagnoses that can be implemented when we are taking care of a patient. that has been experienced loss or has experienced loss. Here are some more nursing diagnosis, risk for complicated grieving. So let's just look at this one, risk for complicated grieving. As a nurse, if you're going to use this, this would be based on risk factors that the patient may have demonstrated before. So again, what this is, what these nursing diagnoses is, is what you made. assess from the patient and implement it as part of your care. Hopelessness, pain, acute or chronic, risk for loneliness, spiritual distress, readiness for enhanced spiritual well-being, or interrupted family process. Again, we are looking at nursing diagnosis as it relates to what's going on with the patient. So now we're going to talk about planning. So planning outcomes. What you're going to do. So at this point, you haven't even touched the patient. You're planning. You analyze. You found, let's say the patient is depressed or the patient is in pain. Your nursing diagnosis is to, patient is at risk for pain. And now we come to planning. So your planning is going to include, what am I going to do for this patient? And when you're doing it, you want to make sure that you focus on the care. I have here focus on the care of the dying patient. You also want to focus on the care of the loved one. You're focusing on the patient, whoever the patient is, whether it's a dying patient or whether it's the person that is experiencing the grief or loss. Your goal is always to provide comfort. Again, if we use the example that the patient is in pain, sometimes towards the end. Pain is inevitable, meaning that, let's see, the disease process calls for pain. As a nurse, you want to provide comfort. You want to make sure that you're administering the pain medication as needed. You're providing comfort. Preserving family with emotional, social, and spiritual support. You, again, your goal, you want to make sure that you're emotionally there for the patient, spiritual support as needed. Therapeutic communication. Guys, this is not the time for you to say, I told you so. This is a time for you to basically, as we discuss what is therapeutic communication, you want to allow that patient to express how they're feeling. Allow the patient and family to express how they're feeling. Therapeutic communication goes a long way, especially if someone is going towards the end of what's going on, or even someone that's experienced loss. You want to make sure that your communication is therapeutic and effective. Implementation. Now, this is the part of the nursing process where you have analyzed, you have your nursing diagnosis. This is what you plan on doing. Now you're implementing it. And when you're implementing it, you want to make sure that you're developing a trusting relationship. If you tell the patient, hey, I'm going to be back within a certain amount of time. time, please just make sure that you do. If not, you come back and say, hey, I'll be back with five minutes. Again, a trusting relationship, active listening, pay attention to what the patient is saying, empathy, open communication. Communication, again, very important. You want to make sure that you clarify, make sure that you understand. How do you clarify something? Hey, did you, is this what you were saying? And you just want to make sure that you. understand what's going on. And if you don't understand, again, clarify. Address most urgent physical or psychological needs while respecting the patient's expectation and priorities. Again, these are some of the characteristics that you're going to do when you're implementing care to your patient. Implementation, we look at it from a health promotion. When we're talking about implementation, some of the things that you're doing, you're providing palliative care in an acute or restorative setting. We're going to talk more about what is palliative care. You're providing hospice care. We're also going to discuss what is hospice care, using therapeutic communication, providing psychosocial care, managing symptoms, promoting dignity and self-esteem. This is very high on my list, not because a patient is let's say is towards the end you and the patient wants to wear a particular coat no you can't wear that you say no you can't wear that you're dying no no no no no you cannot do that promote dignity and self-esteem at all times ensuring spiritual comfort and hope promoting spiritual comfort and hope protecting against abandonment and isolation again guys as nurses someone is um towards the end abandonment isolation even if you stay and hold the patient hand just so the patient does not pass by themselves. Support the grieving family, assisting with the end-of-life decision making, and facilitating mourning. This is all part of health promotion as a nurse especially towards the end end of life for a patient. Next we have evaluation. What are you doing when you evaluate? You're validate questions of achievement of the patient goals and expectation. Did you meet the patient's goal? Did you meet your goal? What is the most important thing I can do for you at this time? Again, a patient that's towards end of life, hey, what is the most important thing I can do? And they may say, hey, can you just call my daughter, ask her to come, just whatever it is. As a nurse, this is what you're doing. All your needs being addressed in a time, man. Always, whether the patient is at end of life or not, you always want to make sure that the patient needs are being met in a timely manner. Now, let's talk about what is palliative care. So, we have palliative care and we have hospice care and we're going to discuss both. Palliative care is aggressively planned comfort care. It addresses end-of-life concerns. that includes supporting families, caregivers, promoting continuity of care, ensuring respect for the person, addressing emotional and spiritual concerns, and managing symptoms, for example, pain, dyspnea, depression, and ensuring informed decision making. Note that a patient does not have to be actively dying to receive palliative care. It is provided, it is care that's provided over a long period of time for those who have slowly progressive disease. Menoducts, so the patient has been diagnosed. Let's say a patient has been diagnosed with cancer. The disease is slow and progressive, we can implement palliative care. The doctors did not say that the patient is going to pass within a certain amount of time, within six months. With palliative care, it doesn't matter. A patient does not have to be actively dying. They just need to have a disease that is progressive and it continues to get progressively worse. Now, what is hospice care? When we talk about hospice care, hospice care focuses on the holistic care of a patient who is dying or debilitated and not expected to improve. So what's the difference between the two? With hospice care, the doctor says that the patient has a debilitating disease process and is expected to live within or expected to expire within a six-month period. Whereas palliative care, they still have a disease, but a time limit has not been set on it. So for a patient to be eligible for hospice insurance benefit a provider must certify that the patient is likely to die within six months. When we talk about implementing hospice care, it is based on two key premises. One, the quality of life is as important as the length of life. So meaning that if it's one month, two months, six months, the quality of life is also important. Those who are terminally ill should be allowed to face death with dignity and while surrounded by comfort of their home and family. And this is what hospice care implements. What is hospice care? What is the purpose of hospice care? The purpose of admitting a patient to hospice care, the family that provides the family with some respite for a period of time, it's to help stabilize the patient who requires symptom management. We're not going to change the fact that our patient may have cancer, but we may stabilize it in the sense of giving out pain management, treating the symptoms as it comes up. Care for patients who are in the end stage of a disease, example cancer, and need a level of expert care that family members cannot provide at home. So you can have hospice care in-home and you can also have hospice care in a facility. Care for patients and the family. It is a multidisciplinary team of care. It usually consists of an aide, a case manager, which is the nurse that goes out. You may also have a social worker. You may also have someone from whatever religion the patient is and also a doctor that's in place. So again, it's a multidisciplinary team of care. have 24-hour nurse support available so the nurse may not be there with the patient 24 hours but if let's say the patient is at home with a family member there is a number with the hospice company that a nurse will come out so normally what end up happening with a patient in hospice they're not going to be sending the patient to the emergency room they will most likely have the nurse come out the doctor call and say what's going on after the patient die the idea is follow-up bereavement care for the family and again Once the patient pass away, the hospice care facility may have someone come out and talk to the loved one in reference to their loss. Now we're going to talk about care after that. It's very important that as a nurse, you always document documentation, documentation, documentation. If it was not documented, then it wasn't done. or if it's not documented it was not done if a patient is organs and tissue is being donated you will know the facility will let you know what their protocol is if there's an autopsy to be done that will also you would also know what your facility protocol is and post-mortem care also you have to know what post-mortem care what's important when we talk about post-mortem care is making sure that you understand a person's culture is cultures that you cannot do certain things and then there are certain cultures that you can do something so it's important that you understand a patient's culture with post-mortem care you want to make sure that you identify the patient use and double identifies we want to make sure that we have the correct body guides you want to adhere to the appropriate infection control procedures meaning making sure that you continue to wear your gloves, implement your universal precautions or if there were any type of precaution in place you want to continue with that. Treat with respect. Check for any cultural or religious practices, ministers requests etc. Allow for religious or cultural customs or rituals to be part of the post-modern care. Follow the hospital's policy for um care remove as a nurse you will remove any lines meaning if the patient had a pick line if they had a foley catheter you would want to remove that if there is no autopsy unless otherwise ordered remove the patient's clothes and other personal affects and secure and document the content so for example you want to make sure if the patient is wearing a watch you want to to make sure that you have all their personal belongings secured and documented. With post-mortem care, you want to make sure that you close the patient's eyes. There are times when a patient may expire with their eyes open. Make sure that you slightly bring the eyelids down, leave dentures in, or if they're not in, please put them in the patient's mouth. Close the amount. Place patient in supine position with wrist crossed, palms down, or abdomen or on their abdomen. This I would actually say know the patient's culture because in some cultures you cannot cross the patient's arm. Have the patient's arms at the sides of the patient or with a pillow beneath the head. Wash the soil or any bloody area so if you notice that the patient made a bowel movement some patients right before they pass away they may have a bowel movement, pass urine. make sure that you wash the area allow the patient to look as if they were asleep if being viewed place a clean gown comb the patient here cover the cover the patient with a clean sheet up to the neck just make sure guys that the patient just look at peace just put yourself in the family's position would you want to see your patient or your family member looking as if they've been in a battle right before they pass away. No, so again, please use consideration. Place waterproof pads under the perineal area, clean the patient's environment, remove equipment, any soiled linens and supplies. Offer for the loved ones to view the patient. But before you allow the loved ones to view the patient, make sure you as a nurse, you describe how the patient looks and how they may feel. For example, you may want to let them know how, let's say the patient's mouth is open or something happened, you want to just explain. When you go into the room, you're explaining to the family. When you go into the room, the body may feel a little cold. Again, you're just describing how the patient looks. and how the skin may feel. Have family sign freedom of home release and sign for personal items. Obtain the shirt or the post-mortem pack or the morgue stretcher. Again, you would know your facility protocol as it comes to that. Loosely tie the cross wrist and label shawl tag again. When we talk about crossing the wrist, you have to know the patient's culture because not everyone allows you to cross your wrist. The goal here is making sure that the shirt is tagged and attach one to the toe, one to the wrist, and the outside of the shirt, making sure that the patient is identified. Place the body onto the morgue stretcher with blue pad under the perineal area. Wrap the body with the shirt and tie around the neck, around the hip, and around the ankles. Cover the shirted body with a sheet and transfer to morgue with funeral home release and death certificate. For this part here, again, you want to know what your facility protocol is. Grief and Loss presented by myself, Sharon Celestine. If you have any questions, you can reach me at sceles.educ.edu. Thank you. I have added some videos to assist in your visual learning, how to recognize a dying patient, what are some of the signs. Some of you guys are visual learners. So I've included videos to help you recognize again, dying patient, what are the five signs? Also, what does the death rattle sound like? I want you to hear that breathing, when there is that congestion. Also the different types of breathing and death indignity, how to perform post-mortem care. Thank you.

In addition, you are going to be able to apply the nursing process when caring for a patient and your significant other who is experiencing grief, loss, and or debt. In addition, you will also be able to formulate and individualize plan of care for a dying patient. When we say that, we are going to, you as a student will have to come up with a format, what's going on, a plan of care to give care to a patient that's dying.

You're also going to discuss the nurse's role when performing postpartum care. So to get into this discussion, we're going to first define what exactly is loss. What do we consider loss? Loss can be defined as the undesired change or the removal of a valuable object, person, or situation. So here I have some photos just so you understand again.

When we talk about loss, we're not just talking about someone. It could be the loss of your home, it could be the loss of a loved one, loss of work, loss of something that's dear to you, loss of even your mobility as we get older, losing something, and again, the loss of someone. There are different categories of loss, actual versus perceived loss. When we talk about actual loss it includes the death of a loved one even a relationship that deterioration destruction and anything natural disaster the loss can be identified by others and not just by the person that's experiencing so everyone around you could see that okay this has happened this is loss and then when we talk about perceived loss it is internal it's what you as a person is experiencing as loss. It is identified only by the person that is experiencing it.

Next, we have physical loss versus psychological loss. Physical loss includes injury, removal of an organ, function, a limb. An example of this is a limb that's been amputated or lost of mobility.

This is a physical loss. Psychological loss challenge your brief belief system, trust in someone. Do I trust this person? I had a close friend, but she did something to me and now I no longer have this person as a friend. She betrayed my trust.

This is a loss. It is a psychological loss. Note that some losses can be mixed after removal.

For example, after removal of a prostate gland, a man may feel physical or psychological loss of sexuality. So this is a combination of both. As we continue with the different categories of loss, we have external versus internal loss.

External loss are the actual loss of an object that are important to the person because of the cost or the sentimental value. For example, we have home, jewelry, and photos. These losses can be brought on by theft, destruction, and disasters such as flood and fire.

Some of you guys were present during Hurricane Katrina or even Hurricane Ida. These were all external examples of external loss. Internal loss is another term for perceived or psychological loss. Again, it is what the person feels or that person perceived as a loss. Lost of aspect of self, this includes physical loss such as a body organ, limb, and body function or any type of disfigurement.

Psychological and perceived loss in this category includes the aspect of one's personality, development. mental change related to aging process, loss of hope, dreams, and loss of faith. Again, this is what the person feels. Environmental loss.

This loss involves changes in familiar even if the change is perceived or positive or even negative. For example, moving to a new country, moving into a new home, starting a new job, and going to college. These are all types of environmental laws. These laws can be perceived or it can be actual, meaning that you can actually see what's going on, it's actual, it's actual going on, or it's perceived, what you feel.

Lost of a significant relationship. This includes loss of a spouse, sibling, family member, friend through death, divorce, and separation. Yes, even through divorce, you have actually lost a partner. Now we're going to discuss what is grief.

Grief is the physical, psychological, and spiritual response to a loss. We previously discussed the different types of losing. Now, this is how you react to the loss.

So you may have a process where you decide to mourn. And when we talk about mourning, it consists of the action associated with grief. For example, some people may cry if they lose someone. There are some cultures where they may wear a certain color during the time of their um after they have experienced a loss of a loved one they may wear black clothing then we have what is called the bereavement period and this is the period of mourning and it adjusts an adjustment after a loss there is no set period on how long a person should mourn or the bereavement period remember that mourning and bereavement it is subjective it is the response that the person who is survived by the lost what they are experiencing so again there's no set time you cannot tell someone oh you should only mourn for one month it's how that person it's how that person respond to the loss that they have experienced everyone expressed grief differently no two people ever grieve in the same manner because many factors play a role in the grieving process there are certain factors or consideration that a person may experience or based on the relationship that they have had with that person that determines how they grieve. So now we're going to discuss some of the different types of grief or bring awareness that there are different types of grief.

So when we talk about uncomplicated, grief is just what it says uncomplicated. There's nothing attached. a person. let's say you lose something, there's nothing complicated about it. Then we have something like dysfunctional grief.

When we talk about dysfunctional grief, again, just as it's stated, dysfunctional grief, meaning that the relationship that you may have had with the person has been dysfunctional. Not because the person passes that it's going to change the fact. It's still considered dysfunctional. Let's say there was some abuse going on and that person passed away.

the person, the survivor, they may have some type of dysfunctional grief. Chronic grief. When we talk about chronic grief, last week a parent died, this week another parent died, and then maybe another week someone else died. It's just continuous, chronic, something that's going on and on. Mass grief, as we know, there are times when you're not dealing with the Delayed grief, let's say the person was ill.

They passed away, you wasn't expecting it. It may be, you may not feel it right away, but eventually you do. Disenfranchised grief, again, disenfranchised, you're disconnected. Anticipatory grief, meaning that the person was ill over a period of time, you knew that this was coming.

So again, there are different types of grief that we all or our patient may experience. There are different factors that affect grief. The type of relationship you have with the person can affect grief.

So let's go over this now. The significance of loss. This means that the person has attached to the person or object loss will be different from each person. For example, you can have a mother with two children and both of those children may experience a different type of grief, although it's the same parent. Because the relationship that they had with this particular person may be a little bit different.

The greater the attachment, the more difficult the grief will be. There are some times where kids are more attached to one parent than the other. So again, this is a factor that may affect the way that they grieve. Support system. People with strong emotional and psychosocial support system typically have less complicated grief.

Unresolved conflicts. Sometimes we see this a lot, especially if the parents, you may have some type of dysfunction going on within the family dynamics. It may cause prolonged or dysfunctional grief can occur with unresolved conflicts.

You didn't resolve the conflict, so it's there. A conflict left unresolved may prolong grief. circumstances of grief the manner or circumstances of the death can lead to bereaved feeling guilty responsible or unprepared sometimes let's just say I think I was looking at a movie recently and the parent bought the son a motorbike he went out on the motorbike and he had an accident and he died again based on those circumstances she may feel guilty she may feel a certain type of way because she was the one that actually bought her son the motorcycle.

A violent death, murder, suicide, or accident, it can result in a prolonged, complicated grief. Previous or multiple loses. A person who has sustained several loss in a short period of time may experience complicated or dysfunctional grief.

Spiritual, cultural beliefs and practices. With that, what we see is spiritual and religious belief can help or hinder the grieving. process.

For example, some believe that the deceased is in a place of happiness where others may believe that the deceased is reborn, yet another may believe that that is final and there is no life after. So it all depends on the person's spiritual or cultural beliefs that can also affect the grieving process. The timelessness of the debt. The debt of a child or young person is almost universal, more difficult to accept.

than the death of an older person meaning that most cultures they believe that the children should be burying the parents and not the parents burying the children so again this also plays a factor in the way that a patient or a person is affected by grief now let's go into talking about the different stages of grief and so according to Elizabeth Kubler-Ross there are five stages of grieving. It's denial. anger, bargaining, depression, and acceptance. When we talk about denial, during this stage here, denial may entail refuting the reality of the loss or any associated feeling.

This stage may involve being numb, disbelief in response to the news of a loss. It may serve as an emotional buffer to prevent someone from feeling or from feeling overwhelmed. So you would see that they would have things like, may say things like, not me, this cannot be happening. They're in denial.

Anger, during this stage an individual may direct their anger towards the person who died, the doctors, family members, or religious entities. As nurses working in the hospital, you may see this a lot. You may hear the family member saying, it's the doctor's fault. It's this.

This replaces the numbness of shock and denial. It is important to address the anger. The description, they may say again, why me?

Why is this happening to me? Bargaining. Bargaining, it involves thoughts such as, I will do anything if you take away the pain. This stage may come at a point within the grieving process.

It is frequently accompanied by guilt. usually takes form of bargaining with God or higher power. And again, you would see the patient may say, if only I can live until my daughter's wedding, I'll give up, you know, I'll give an example of something. God, please, you know, please allow me to live. Please allow me to see my 50th birthday.

Please allow me. This is in the bargaining stage. Next, depression. At this point, a person may experience feelings of emptiness and intense sadness. They may also withdraw from daily activities that they once enjoyed.

While this stage is difficult, it is a necessary step towards healing. Acceptance. This is the final stage of the grieving process.

Acceptance does not mean that people feel okay about the loss. Rather, it means that they realize the loss is their new reality. they understand that while life will not continue as it did before, it will go on.

Please understand that individuals may not experience every stage or go through the stages in linear order. In addition, individuals may experience two or more stages at the same time. So again, although we call it the five stages of grieving, it does not occur one after the other and it does not con...

continue at one at a time. It could be you experiencing two at a time or it could be in different steps. What are some of the stages of dying?

What do you actually see? And we're talking about the psychological stages. What as a nurse you may see. And this is important for nurses, students, especially if you have a patient that is dying.

These are some of the things that you're looking for. These are some of the things that you may see. So during the first three months, the dying person begins to withdraw from the world.

What some of the things that they enjoy doing, you may see that they're not there more to themselves. Sleep increases. So normally you see a patient if they sleep six to eight hours, now it's eight to 12 hours.

They're doing a lot more of the sleeping. The body becomes difficult for the body to digest food. This is especially important because, and again, living in New Orleans, One of the things that we believe, we believe that if you give a patient food or you give someone food, they're going to feel better. How many times you've been sick and they say, oh, here, drink this chicken noodle soup, you're going to be okay. During this time here, we see that family members try to force their loved ones to eat.

This is the worst thing you can do, especially giving them meat. Because the body now, they are unable to digest the food as they normally do. The appetite and the food. intake decreases.

So now they're not as hungry as the body is starting to break down. You know, liquids are usually preferred. One to two weeks before that, the body is beginning to lose its ability to maintain itself.

The blood pressure. So as a nurse, if you're taking patient's blood pressure, which you should be, you would see that the blood pressure is reduced. There are changes in the pulse.

Sometimes the pulse can be a bit tachycardic or maybe sometimes you see brady. It's a lot slower. Changes in the skin color. You may see a yellowish or the patient is pale.

Temperature fluctuates. Respiratory rate, it increases or decreases. During sleep, the dying person may experience brief periods of apnea where they are not breathing.

Congestion may also, you may hear some congestion in the chest, the rattling sound, or sometimes you may hear a nurse, a seasoned nurse say, oh, that's the death rattle. This is true. Congestion may cause a rattling sound or a nonproductive cough, meaning that they're coughing, but they're not bringing up anything.

Days to hours before death, you may see a surge of energy. And again, a lot of family members, this is a time they said, oh, they may start thinking, oh, my, my loved one, they're coming back to normal. They're back to themselves. But again, this is something that you may see. Bring mental clarity and a desire to eat and talk with family members.

They may decide, hey, today I'm going to eat. And again, family members are sometimes hopeful that their family, their loved one is not approaching that. but Again, we understand that this is one of the stages of dying.

As that approaches, loved ones become dehydrated and have difficulty swallowing. So again, you would see that this patient, we may not want to give them thick foods. You may have to go to puree few foods, not a lot of food, not large spoonfuls. The tissue of the tongue and the soft palate, it sags. gag reflex decline so secretions accumulate in the mouth and the throat so normally if you have a nurse that's working with a patient that have the secretions there is normally a medication that they may give to dry the secretion the drug is called hycosamine the lips become crack again you can always put moisturizer on the lips respiration the breathing may be shallow rock or irregular periods of not breathing for 10 to 30 seconds congestion cause a death rather that can be quite loud you can actually hear change strokes respiration may occur no breathing for 10 to 60 seconds then breathing increase in depth and rate of respiration then it becomes slow and shallow the cycle continues in this pattern so definitely the respiration shape.

Now when we look at circulation, it decreases and the person may feel clammy. So before when you touch the skin and it says warm, this person here, the skin may feel a bit clammy, almost cold. The blood pressure decrease, the pulse sometimes is hard to detect, the body becomes cool and muddled.

Kidney function is decreased causing decreased urine output. Elimination. The patient tends to retain feces so they become a bit constipated and again once a patient has entered into the city of the urn, most of the time the doctors implement a stool softener or a laxative to help with the patient retaining feces. Decreased urine output and urine is more concentrated so you see that it's dark in color and it may be foul smelling. So splinter muscles relaxes causing bowel and bladder incontinence.

As we continue with the stages of dying days to hours before the death, muscle throughout the body it may relax causing the face to droop, vision becomes blurry, eyes may be open or partially open but not seeing, patient may see things not visible to others, cognition may become restless and agitated. and some unexpectedly become energized for a time and others less communicative, quiet and withdrawn. Fatigue is common during this time.

And moments before death, the dying person does not respond to touch or sound and cannot be awakened. There are long spaces of breath before breathing ceases and the heart stops beating. Again, so when we talk about grief and loss with any other topic, we implement the nursing process. We implement the clinical judgment model.

We go through the entire process where we analyze, we see what's going on, what's going on with the patient. When a patient is dying or has experienced loss, you must carefully assess the patient and significant others for the common physical, emotional, behavioral, and cognitive grief reaction. You want to make sure that you assess the way the patient is coping. How do they cope with what's going on?

You also want to look at the nature of the family relation. Remember, we said this plays a role in the way that a person grieves. The social support system also important in the grief process and the nature of loss.

So again, With assessment, when we implement the nursing process, we start with our assessment. We are analyzing what's going on with that patient. And remember, before we do anything with our patient, we want to always assess. Next, we're going to look at analysis or diagnosis.

As we know, this is also part of the nursing process. We look at the anticipatory grieving. This is one of the diagnoses, how the person is grieving, what's going on with that person. Compromise family coping, we know, let's say how a patient is coping or how the family is coping.

Debt and anxiety, fear, impaired comfort, grieving, complicated grieving, risk-prone behavior, these are all nursing diagnoses that can be implemented when we are taking care of a patient. that has been experienced loss or has experienced loss. Here are some more nursing diagnosis, risk for complicated grieving.

So let's just look at this one, risk for complicated grieving. As a nurse, if you're going to use this, this would be based on risk factors that the patient may have demonstrated before. So again, what this is, what these nursing diagnoses is, is what you made.

assess from the patient and implement it as part of your care. Hopelessness, pain, acute or chronic, risk for loneliness, spiritual distress, readiness for enhanced spiritual well-being, or interrupted family process. Again, we are looking at nursing diagnosis as it relates to what's going on with the patient.

So now we're going to talk about planning. So planning outcomes. What you're going to do. So at this point, you haven't even touched the patient.

You're planning. You analyze. You found, let's say the patient is depressed or the patient is in pain. Your nursing diagnosis is to, patient is at risk for pain. And now we come to planning.

So your planning is going to include, what am I going to do for this patient? And when you're doing it, you want to make sure that you focus on the care. I have here focus on the care of the dying patient. You also want to focus on the care of the loved one. You're focusing on the patient, whoever the patient is, whether it's a dying patient or whether it's the person that is experiencing the grief or loss.

Your goal is always to provide comfort. Again, if we use the example that the patient is in pain, sometimes towards the end. Pain is inevitable, meaning that, let's see, the disease process calls for pain.

As a nurse, you want to provide comfort. You want to make sure that you're administering the pain medication as needed. You're providing comfort.

Preserving family with emotional, social, and spiritual support. You, again, your goal, you want to make sure that you're emotionally there for the patient, spiritual support as needed. Therapeutic communication. Guys, this is not the time for you to say, I told you so. This is a time for you to basically, as we discuss what is therapeutic communication, you want to allow that patient to express how they're feeling.

Allow the patient and family to express how they're feeling. Therapeutic communication goes a long way, especially if someone is going towards the end of what's going on, or even someone that's experienced loss. You want to make sure that your communication is therapeutic and effective.

Implementation. Now, this is the part of the nursing process where you have analyzed, you have your nursing diagnosis. This is what you plan on doing.

Now you're implementing it. And when you're implementing it, you want to make sure that you're developing a trusting relationship. If you tell the patient, hey, I'm going to be back within a certain amount of time. time, please just make sure that you do. If not, you come back and say, hey, I'll be back with five minutes.

Again, a trusting relationship, active listening, pay attention to what the patient is saying, empathy, open communication. Communication, again, very important. You want to make sure that you clarify, make sure that you understand.

How do you clarify something? Hey, did you, is this what you were saying? And you just want to make sure that you.

understand what's going on. And if you don't understand, again, clarify. Address most urgent physical or psychological needs while respecting the patient's expectation and priorities.

Again, these are some of the characteristics that you're going to do when you're implementing care to your patient. Implementation, we look at it from a health promotion. When we're talking about implementation, some of the things that you're doing, you're providing palliative care in an acute or restorative setting.

We're going to talk more about what is palliative care. You're providing hospice care. We're also going to discuss what is hospice care, using therapeutic communication, providing psychosocial care, managing symptoms, promoting dignity and self-esteem. This is very high on my list, not because a patient is let's say is towards the end you and the patient wants to wear a particular coat no you can't wear that you say no you can't wear that you're dying no no no no no you cannot do that promote dignity and self-esteem at all times ensuring spiritual comfort and hope promoting spiritual comfort and hope protecting against abandonment and isolation again guys as nurses someone is um towards the end abandonment isolation even if you stay and hold the patient hand just so the patient does not pass by themselves.

Support the grieving family, assisting with the end-of-life decision making, and facilitating mourning. This is all part of health promotion as a nurse especially towards the end end of life for a patient. Next we have evaluation.

What are you doing when you evaluate? You're validate questions of achievement of the patient goals and expectation. Did you meet the patient's goal? Did you meet your goal?

What is the most important thing I can do for you at this time? Again, a patient that's towards end of life, hey, what is the most important thing I can do? And they may say, hey, can you just call my daughter, ask her to come, just whatever it is.

As a nurse, this is what you're doing. All your needs being addressed in a time, man. Always, whether the patient is at end of life or not, you always want to make sure that the patient needs are being met in a timely manner. Now, let's talk about what is palliative care. So, we have palliative care and we have hospice care and we're going to discuss both.

Palliative care is aggressively planned comfort care. It addresses end-of-life concerns. that includes supporting families, caregivers, promoting continuity of care, ensuring respect for the person, addressing emotional and spiritual concerns, and managing symptoms, for example, pain, dyspnea, depression, and ensuring informed decision making. Note that a patient does not have to be actively dying to receive palliative care. It is provided, it is care that's provided over a long period of time for those who have slowly progressive disease.

Menoducts, so the patient has been diagnosed. Let's say a patient has been diagnosed with cancer. The disease is slow and progressive, we can implement palliative care. The doctors did not say that the patient is going to pass within a certain amount of time, within six months.

With palliative care, it doesn't matter. A patient does not have to be actively dying. They just need to have a disease that is progressive and it continues to get progressively worse.

Now, what is hospice care? When we talk about hospice care, hospice care focuses on the holistic care of a patient who is dying or debilitated and not expected to improve. So what's the difference between the two? With hospice care, the doctor says that the patient has a debilitating disease process and is expected to live within or expected to expire within a six-month period. Whereas palliative care, they still have a disease, but a time limit has not been set on it.

So for a patient to be eligible for hospice insurance benefit a provider must certify that the patient is likely to die within six months. When we talk about implementing hospice care, it is based on two key premises. One, the quality of life is as important as the length of life.

So meaning that if it's one month, two months, six months, the quality of life is also important. Those who are terminally ill should be allowed to face death with dignity and while surrounded by comfort of their home and family. And this is what hospice care implements.

What is hospice care? What is the purpose of hospice care? The purpose of admitting a patient to hospice care, the family that provides the family with some respite for a period of time, it's to help stabilize the patient who requires symptom management. We're not going to change the fact that our patient may have cancer, but we may stabilize it in the sense of giving out pain management, treating the symptoms as it comes up.

Care for patients who are in the end stage of a disease, example cancer, and need a level of expert care that family members cannot provide at home. So you can have hospice care in-home and you can also have hospice care in a facility. Care for patients and the family. It is a multidisciplinary team of care.

It usually consists of an aide, a case manager, which is the nurse that goes out. You may also have a social worker. You may also have someone from whatever religion the patient is and also a doctor that's in place. So again, it's a multidisciplinary team of care.

have 24-hour nurse support available so the nurse may not be there with the patient 24 hours but if let's say the patient is at home with a family member there is a number with the hospice company that a nurse will come out so normally what end up happening with a patient in hospice they're not going to be sending the patient to the emergency room they will most likely have the nurse come out the doctor call and say what's going on after the patient die the idea is follow-up bereavement care for the family and again Once the patient pass away, the hospice care facility may have someone come out and talk to the loved one in reference to their loss. Now we're going to talk about care after that. It's very important that as a nurse, you always document documentation, documentation, documentation.

If it was not documented, then it wasn't done. or if it's not documented it was not done if a patient is organs and tissue is being donated you will know the facility will let you know what their protocol is if there's an autopsy to be done that will also you would also know what your facility protocol is and post-mortem care also you have to know what post-mortem care what's important when we talk about post-mortem care is making sure that you understand a person's culture is cultures that you cannot do certain things and then there are certain cultures that you can do something so it's important that you understand a patient's culture with post-mortem care you want to make sure that you identify the patient use and double identifies we want to make sure that we have the correct body guides you want to adhere to the appropriate infection control procedures meaning making sure that you continue to wear your gloves, implement your universal precautions or if there were any type of precaution in place you want to continue with that. Treat with respect.

Check for any cultural or religious practices, ministers requests etc. Allow for religious or cultural customs or rituals to be part of the post-modern care. Follow the hospital's policy for um care remove as a nurse you will remove any lines meaning if the patient had a pick line if they had a foley catheter you would want to remove that if there is no autopsy unless otherwise ordered remove the patient's clothes and other personal affects and secure and document the content so for example you want to make sure if the patient is wearing a watch you want to to make sure that you have all their personal belongings secured and documented.

With post-mortem care, you want to make sure that you close the patient's eyes. There are times when a patient may expire with their eyes open. Make sure that you slightly bring the eyelids down, leave dentures in, or if they're not in, please put them in the patient's mouth. Close the amount.

Place patient in supine position with wrist crossed, palms down, or abdomen or on their abdomen. This I would actually say know the patient's culture because in some cultures you cannot cross the patient's arm. Have the patient's arms at the sides of the patient or with a pillow beneath the head. Wash the soil or any bloody area so if you notice that the patient made a bowel movement some patients right before they pass away they may have a bowel movement, pass urine.

make sure that you wash the area allow the patient to look as if they were asleep if being viewed place a clean gown comb the patient here cover the cover the patient with a clean sheet up to the neck just make sure guys that the patient just look at peace just put yourself in the family's position would you want to see your patient or your family member looking as if they've been in a battle right before they pass away. No, so again, please use consideration. Place waterproof pads under the perineal area, clean the patient's environment, remove equipment, any soiled linens and supplies. Offer for the loved ones to view the patient.

But before you allow the loved ones to view the patient, make sure you as a nurse, you describe how the patient looks and how they may feel. For example, you may want to let them know how, let's say the patient's mouth is open or something happened, you want to just explain. When you go into the room, you're explaining to the family.

When you go into the room, the body may feel a little cold. Again, you're just describing how the patient looks. and how the skin may feel. Have family sign freedom of home release and sign for personal items. Obtain the shirt or the post-mortem pack or the morgue stretcher.

Again, you would know your facility protocol as it comes to that. Loosely tie the cross wrist and label shawl tag again. When we talk about crossing the wrist, you have to know the patient's culture because not everyone allows you to cross your wrist. The goal here is making sure that the shirt is tagged and attach one to the toe, one to the wrist, and the outside of the shirt, making sure that the patient is identified. Place the body onto the morgue stretcher with blue pad under the perineal area.

Wrap the body with the shirt and tie around the neck, around the hip, and around the ankles. Cover the shirted body with a sheet and transfer to morgue with funeral home release and death certificate. For this part here, again, you want to know what your facility protocol is.

Grief and Loss presented by myself, Sharon Celestine. If you have any questions, you can reach me at sceles.educ.edu. Thank you. I have added some videos to assist in your visual learning, how to recognize a dying patient, what are some of the signs.

Some of you guys are visual learners. So I've included videos to help you recognize again, dying patient, what are the five signs? Also, what does the death rattle sound like? I want you to hear that breathing, when there is that congestion. Also the different types of breathing and death indignity, how to perform post-mortem care.

Thank you.

Transcript for:Understanding Grief and Loss in Nursing

Transcript for:
Understanding Grief and Loss in Nursing