Understanding Loss and Grief

Loss

• Loss happens when something valued is altered or becomes inaccessible, diminishing its value.
• Actual loss is recognized by others and the individual such as loss of a limb or job.
• Perceived loss is intangible and only experienced by the individual like loss of youth.
• Physical loss includes the loss of a body and psychological loss involves altered self-image.
• Maturational loss is from natural development like a first child feeling loss of status when a sibling is born.
• Situational loss occurs due to unpredictable events such as traumatic injury or a natural disaster.
• Anticipatory loss is when someone displays grief behaviors for a loss that has yet to occur and is common in families with a seriously ill patient.
• Anticipatory loss may reduce the impact of the actual loss on family members.

Grief

• Grief is an internal emotional reaction to loss, caused by separation or death
• Grief can occur from the loss of a body part, job, house, or pet.
• Normal grief expressions include physical (crying, headaches, fatigue), emotional (sadness), social (isolation), and spiritual (questioning meaning) reactions.
• Mourning includes actions and expressions of grief such as funerals.
• Bereavement is the state of grieving due to the death of a loved one.
• Grief reactions are similar to reactions to dying
• These reactions vary among people and the stages overlap.

Grief Stages

• Individuals may skip or repeat stages of grief.
• Grief is a process that varies from person to person.
• Engel (1964) defined six stages of grief:
• Shock and disbelief involving refusal to accept the loss, expressed as "No, not me".
• Developing awareness characterized by anger and crying, expressed as "Why me?".
• Restitution involving rituals such as funerals.
• Resolving the loss involves dealing with the void.
• Idealization is the exaggeration of good qualities.
• Outcome includes dealing with loss as a common occurrence.
• Kübler-Ross (1969) defined five similar stages: denial and isolation, anger, bargaining, depression, and acceptance.

Definitions of Death

• Defining death has become more complex due to technological advancements like cardiopulmonary resuscitation.
• The Uniform Determination of Death Act (1981) defines death as:
• Irreversible cessation of circulatory and respiratory functions, OR
• Irreversible cessation of all brain functions, including the brainstem.
• A determination of death must follow accepted medical standards.
• The Harvard criteria say that the irreversible loss of brain function should be the definitive definition of death.
• Special attention is required when determining death in children younger than 5 years.
• Protocols require two separate clinical examinations to establish death which needs to be certain that error did not occur due to hypothermia or drug intoxication.
• Medical criteria to certify a death:
• Breathing cessation.
• No response to deep painful stimuli.
• Lack of reflexes and spontaneous movement.
• Flat encephalogram (brain waves).
• Heart-lung death is the cessation of the apical pulse, respirations, and blood pressure.
• Cerebral or higher brain death is when the cerebral cortex is irreversibly destroyed.
• An electroencephalogram or cerebral blood flow study can confirm these clinical signs.

Signs of Impending Death

• Clinical signs of approaching death:
• Difficulty talking or swallowing.
• Nausea, flatus, and abdominal distention.
• Urinary or bowel incontinence or constipation.
• Loss of movement, sensation, and reflexes.
• Decreasing body temperature.
• Weak, slow, or irregular pulse.
• Decreasing blood pressure.
• Noisy, irregular, or Cheyne-Stokes respirations.
• Restlessness or agitation.
• Cooling, mottling, and cyanosis of the extremities.
• Decreased consciousness or agitated delirium may happen as death nears.
• Nurses should prepare family members and assess their comfort level during this time.

Responses to Dying and Death

• Attitudes about death vary
• People choose to die at home or in ICUs
• Emotional responses to death and dying have similarities.
• The stages of dying may overlap and vary in duration.
• Kübler-Ross defined five stages people go through:
• Denial demonstrated by the patient denying the reality of death, expressed as "They made a mistake in the diagnosis. Maybe they mixed up my records with someone else's."
• Anger expressed through rage and hostility, expressed as "Why me? I quit smoking and I watched what I ate. Why did this happen to me?"
• Bargaining when the patient tries to buy more time, expressed as "If I can just make it to my son's graduation, I'll be satisfied. Just let me live until then."
• Depression during a grief period before death
• Acceptance when the patient feels tranquil, expressed as "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."
• Patients should be encouraged to involve family when planning for the patient's care.

Palliative Care and Hospice

• Palliative care addresses the whole person like body, mind, and spirit.
• Palliative care aims to give patients with life-threatening illnesses the best quality of life by managing symptoms.
• The American Nurses Association (ANA) and the Hospice and Palliative Nurses Association (HPNA) partnered to develop Call for Action: Nurses Lead and Transform Palliative Care in January 2016.
• Seriously ill patients should receive quality palliative care in all settings, which is achieved by primary palliative care nursing regardless of setting
• Palliative care screening tools can help identify patients who need help
• Hospice care is provided for people with limited life expectancy, often at home.
• Indicators for hospice referral:
• Poor performance status.
• Declining cognitive status.
• Advanced age.
• Poor nutritional intake.
• Pressure injuries.
• Comorbidities.
• Previous hospital admissions for acute decompensation.
• Hospice care focuses on the dying while palliative care is for all stages of illness
• The HPNA promotes excellence in palliative nursing care.

Advanced Care Planning

• Advance care planning (ACP) is planning for future care if a person cannot make their own decisions.
• ACP is recommended for all adults because events needing ACP can occur in healthy people
• Two kinds of written advance directives can help:
• Living will, which provides instructions about health care.
• Durable power of attorney for health care, which appoints an agent to make decisions.
• Aging with Dignity offers a living will titled Five Wishes which specifies a person for making care decisions, types of needed medical treatment, desired comfort, how the person wants to be treated, and what the patient wants loved ones to know.
• The Patient Self-Determination Act of 1990 requires all hospitals to inform patients about advance directives.
• Advance Directive
• It is for anyone 18 and older
• It provides instructions for future treatment
• It appoints a Health Care Representative
• It does not guide Emergency Medical Personnel
• It guides inpatient treatment decisions when made available
• Physician Order for Life-Sustaining Treatment (POLST) Form:
• This is for people with serious illness-at any age
• It provides medical orders for current treatment
• It guides actions by Emergency Medical Personnel when made available
• It guides inpatient treatment decisions when made available
• Patients may request a Comfort Measures Only order for a comfortable, dignified death without life-sustaining measures.
• A Do-Not-Hospitalize order is for patients who elect not to be hospitalized for further aggressive treatment.

Euthanasia

• Euthanasia means "good dying."
• Active euthanasia is taking steps to cause a patient's death.
• Passive euthanasia is withdrawing medical treatment to cause death.
• Assisted suicide involves providing the means for a patient to end their own life.
• Nurses should provide interventions to relieve pain and other symptoms with palliative care practice standards but may not act with the sole intent to end life.”
• Palliative sedation lowers patient consciousness to limit awareness of suffering that is intractable and intolerable

Death Certificate and Autopsy

• U.S. law requires a death certificate including specified information
• Death certificates are sent to local health departments
• The mortician handles filing the death certificate
• A clinician's signature is required on the certificate
• An autopsy is an examination of the body after death
• Consent for autopsy is legally required

Addressing Needs

• Physiologic care includes hygiene, pain control, nutrition, movement, elimination, and respiratory care.
• Personal hygiene includes cleanliness of the skin, hair, mouth, nose, and eyes.
• Psychologic responses to death include fear of the unknown, pain, separation, loss of dignity, loss of control, and unfinished business.
• Kübler-Ross said that a repressed fear regarding what will happen when the person dies overwhelms the patient.