copying with loss death and greaving

1. Coping with loss, Death, and
grieving
PRESENTATION BY: ASHUTOSH TIWARI
MSC NURSING (PRE.)

2. WHAT IS LOSS?
• “Loss can be defined as the undesired change Or removal
of a valued object, person Or situation “

3. TYPES OF LOSS
• Necessary loss: Necessary loss are something natural And
positive.
Eg. Start and leave School, Change frinds.
• Actual loss:
Eg. Loss of limb, Role at work.

4. • Perceived Loss: any loss that is uniquely
defined by grieving Client.
• Eg. Loss of confidence and prestige.
• Maturational loss: Any changes in the
developing process that is normally
Expected during life time
• Loss of external objects.
• Loss of Life.
• Loss of known environment.

5. GRIEF
• Grief is the physical, psychological and spiritual and emotional
responses to loss.
• Grief is a “set of cognitive, emotional and social difficulties that
follow the death of loved one.
• Mourning is the psychological process through which the
individual passes on to successful adaptation to the loss of a
valued object.

6. Types of grief
1. Anticipatory grief. (feeling of grief occurring before an loss)
2. Normal or common grief. (normal response to any loss)
3. Complicated grief. (experiencing symptoms of grief for years after a loss)
4. Disenfranchised grief. (when your grieving doesn’t fit in with your larger
society’s attitude about dealing with death and loss)

7. CLINICAL MANIFESTATIONS OF GRIEF
Shock and disbelief.
Sadness.
Guilt.
Anger.
Fear.
Disorganized behavior.
Physical symptoms.
Anorexia, GI issues.

8. STAGES OF GRIEVING: KUBLER ROSS(1975)
1. Denial.
2. Anger.
3. Bargaining.
4. Depression
5. Acceptance.

9. DEATH AND DYING
Death
in 1981, the president’s commission for the study of ethical problems in
medicine, behavioural and biomedical research defined death as an individual
has sustained either irreversible cessation of circulatory and respiratory
functions or irreversible cessation of all functions of the entire brain, including
brain stem.

10. STANDARDS OF DEATH DETERMINATIC
• A person is dead when, according to ordinary standards of medical practice,
there is irreversible cessation of the person’s spontaneous respiratory and
circulatory functions. (Patient is pulseless, apnoeic and unresponsive to verbal
stimuli for a period of at least 2 – 5 minutes).
• If artificial means of support that a person’s spontaneous respiratory and
circulatory functions have ceased, the person is dead when according to
ordinary standards of medical practice, there is irreversible cessation of all
spontaneous brain function.

11. DYING PERSON’S BILL OF RIGHTS
• From American Journal of nursing, 75(1)99
• I have the right to be to be treated as a living human being until i die.
• I have the right to maintain a sense of hopefulness, however changing its
focus may be.
• I have the right to be cared for by those who can maintain a sense of
hopefulness, however changing this may be.
• I have the right to express my feelings and emotions and my approaching
death in my own way.

12. • I have the right to participate in decisions
concerning my care.
• I have the right to expect continuing medical
and nursing attention.
• I have the right not to die alone.
• I have the right to be free from pain.
• I have the right to have my questions
answered honestly.
• I have the right not to be deceived.
• I have the right to have help from and for my
family in accepting my death.
• I have the right to die in peace and dignity.

13. • I have the right to retain my individuality and not be judged by my
decisions, which may be contrary to the beliefs of others.
• I have the right to discuss and enlarge my religious or spiritual
experiences, regardless of what they mean to others.
• I have the right to expect that the sanctity of the human body will be
respected after death.
• I have the right to be cared for by caring, sensitive, knowledgeable
people who will attempt to understand my needs and will be able to
gain some satisfaction in helping face my death.

14. • I have the right to retain my individuality and not be
judged by my decisions, which may be contrary to the
beliefs of others.
• I have the right to discuss and enlarge my religious or
spiritual experiences, regardless of what they mean to
others.
I have the right to expect that the sanctity of the human
body will be respected after death.
• I have the right to be cared for by caring, sensitive,
knowledgeable people who will attempt to understand
my needs and will be able to gain some satisfaction in
helping face my death.

15. CLINICAL MANIFESTATIONS AT THE END OF LIFE
• SENSORY SYSTEM
• Hearing- usually last sense to disappear
• Touch-decreased sensation
• - decreased perception of touch and pain
• Taste decreased with disease progress.
• Smell decreased with disease progress.
• Sight –blurring of vision
• -blink reflex absent
• -eyelids remain half open

16. • INTEGUMENTARY SYSTEM-Cold clammy
skin
• -cyanoses on nose, nail beds
• RESPIRATORY SYSTEM-Increased
respiratory rate
• -cheyne stroke respiration (alternating
periods of apnea, deep and rapid
breathing)
• -irregular breathing gradually slowing
down to terminal gasps (guppy breathing)
• -noisy wet sounding (death rattle)

17. • URINARY SYSTEM-Gradual decrease in urinary
output
• -urinary incontinence or unable to urinate
• GASTROINTESTINAL SYSTEM-Accumulation of
gas
• -distension and nausea
• -loss of sphincter control
• -possible cessation of Gl function
• -bowel movement may occur before imminent
death or at the time of death

18. • MUSCULOSKELETAL SYSTEM-Gradual loss of
ability to move
• -loss of gag reflex
• -sagging of jaw results in loss of facial muscle
tone, dysphagia, difficulty in speaking
• CADIOVASCULAR SYSTEM-Increased heart
rate: later slowing
• -irregular rhythms
• -decreased blood pressure
• -weakening of pulse

19. PSYCHOSOCIAL MANIFESTATIONS
A variety of feelings and emotions affect the dying patients at the end of life care. They are
• Altered decision making
• Fear of loneliness
• fear of pain
• Helplessness
• Restlessness
• Anxiety
• Impending doom
Grief

20. ASPECTS OF END OF LIFE CARE.
• Palliative care
• Preparation at the end of life care
• Advanced directives
• Understanding CPR and DNR
• Hospice care

21. PALLIATIVE CARE
• The palliative care means taking care of the whole person-body, mind and
spirit, heart and soul.
• The goal of palliative care not to give cure to the disease condition but to
reduce the pain and side effects and to improve the quality of life.

22. PRINCIPLES OF PALLIATIVE CARE
• palliative care respects the goals, likes, and choices of the dying person and his or her loved ones and
helping them to understand the illness and what can be expected from it, and to figure out what is most
important during the time.
• Palliative care looks after the medical, emotional, social and spiritual needs of the dying person with a
focus on making sure he or she is comfortable, not left alone, and able to look back on his or her life
and find peace.
• Palliative care supports the need of family members, helping them with the responsibilities of care
giving and even supporting them as they grieve

23. • Palliative care helps to gain access to needed health care
providers and appropriate care settings involving various
kinds of trained providers in different settings, tailored to
the needs of the patient and his or her family.
• Palliative care builds a way to provide excellent care at
the end of life through education of care providers,
appropriate health policies, and adequate funding from
insures and the government

24. THE PALLIATIVE CARE TEAM
• doctor
• dietitian
• nurses
• Spiritual advisor
• Social worker
• physiotherapist.

25. PALLIATIVE CARE SETTINGS
• HOSPITALS
Despite the economic and human costs associated with death in the
hospital settings, as many as 50% of all deaths occur in the acute
care settings. It is clear that many patients will continue to opt for
hospital care or default will find themselves in hospital settings at
the end of life care.

26. • IN HOME CARE SETTING
Where ever the patient may ultimately die, they are likely to
spend most of their last year of life in their own home being
cared for by close family members. When the patient and the
family's hopes are focussed on allowing the patient to die in his
or her own home, the nurses need to be acutely sensitive to the
shifting needs of the caring family.

27. PREPARATION AT THE END OF LIFE CARE
• GRIEVING LOSSES
• Learning that persons illness has become terminal can bring about intense
feelings of anger, fear grief, regret and other strong emotions.
• Encourage the patients Talking about feelings and concerns with family,
friends and caregivers can help bring comfort.
• Inform It is normal to grieve and mourn the loss of your abilities, the loved
ones you will leave behind, and the days you will not have.

28. ADVANCED DIRECTIVES
• Advance directives are the legal documents that explain the kind of medical
treatment would want and would not want if patient become unable to make
these decisions for yourself.
• Advance directives protect client’s rights and preferences for the medical
treatment and diminish the burden of family members and the other caregivers
making decision for client

29. TYPES OF ADVANCE DIRECTIVE
• LIVING WILL
A type of advance directive in which the individual documents treatment preferences.. A living will can
include
Whether client want the medical team to use cardiopulmonary resuscitation(CPR) and or artificial life
support such as mechanical ventilator, if breathing or heart stops.
Whether client want to receive a feeding tube, if you cannot be fed otherwise?
• Whether client want certain procedures such as dialysis.

30. UNDERSTANDING CPR AND DNR
• A DNR order is a type of advance directive and it is the written physician’s
order instructing health care providers not to attempt CPR and it is often
requested by patient and family. A ‘no code ‘or DNR order allows the person to
die with comfort measures only and without the interference of the technology
Unlike other advance directives that are written and signed by the individual, a
DNR order must be completed and signed by doctor or other health care
provider.

31. PROVIDING COMFORT
• Use foam cushions to make beds and chairs more comfortable and help the
patient to change positions frequently and change the bed linens as necessary.
• Elevate the patient’s head or turn the patient on his or her side to help make
breathing easier.
• Use blankets to help keep the person warm & gently rub the person’s hand,
feet or soak the hands and feet in warm water.

32. CONTROLLING PAIN
• Controlling pain is an important part of dying comfortably and peacefully.
• Administer medications around the clock in a timely manner and on a regular
basis to provide constant relief rather than waiting until the pain is unbearable.
• Concentrated morphine solution can be very effective by delivered by the
sublingual route.
• In case of uncontrolled pain, palliative sedation

33. HOSPICE CARE
• Hospice is not a place but a concept of care that provides compassion,
concern, and support for dying. Hospice and palliative care are frequently used
interchangeably. Hospice exists to provide support and care for person in the
last phases of the incurable diseases so that they might live as fully and as
comfortable as possible.
Criteria for hospice care
1.the patient must desire the services;
2.a physician must certify that the patient has 6 months or less to live

34. COMPARING PALLIATIVE CARE AND HOSPICE CARE
• Although the term palliative care and hospice care are sometimes used
interchangeably, they have slightly different meanings.
• Palliative care starts much earlier in a disease process where as hospice is
traditionally is limited to the projected last six months of life.

35. NURSING MANAGEMENT: END OF LIFE CARE
• TO REDUCE THE PAIN
• TO PREVENT DEHYDRATION
• FOR DYSPNΟΕΑ
• TO PREVENT SKIN BREAKDOWN
• FOR WEAKNESS AND FATIGUE
• FOR ANOREXIA, NAUSEA AND VOMITING
• PSYCHOSOCIAL CARE