This document discusses concepts related to loss, death, and grief. It defines loss and grief, describing grief as the physical, psychological, and spiritual response to loss. It outlines different types of grief like normal, anticipatory, complicated, delayed, and chronic grief. Factors that can influence grief like development, relationships, and culture are also discussed. The document then describes the common stages of grief: denial, anger, bargaining, depression, and acceptance. It provides details on clinical manifestations and symptoms experienced at the end of life and discusses nursing implications for caring for terminally ill patients and their families.

1. Concept of loss,
death & grief
- MS. KHYATI CHAUDHARI

2. LOSS
The fact or process of losing something or someone.
-oxford dictionary
DEFINITION-
Loss can be defined as the undesired change or removal of a valued object ,person or
situation.
Unrecoverable and usually unanticipated and non- recurring removal of, or decrease in,
an asset or resource.

3. GRIEF
GRIEF IS THE PHYSICAL ,PSYCHOLOGICAL AND SPIRITUAL RESPONSES TO
LOSS.

4. TYPES OF GRIEF
1. Normal grief
• e.g.; crying, sorrow ,anger
2. Anticipatory grief
• process of disengaging or letting go that occurs before an actual loss of death has
occurred
3. Complicated grief
• difficulty in progressing through normal process of grieving
4. Delayed grief
• Delayed grief is when reactions and emotions in response to a death are postponed
until a later time.

5. 5. Chronic grief
• This type of grief can be experienced in many ways: through feelings of hopelessness,
a sense of disbelief that the loss is real, avoidance of any situation that may remind
someone of the loss, or loss of meaning and value in a belief system.
• At times, people with chronic grief can experience intrusive thoughts.
• If left untreated, chronic grief can develop into severe clinical depression, suicidal or
self-harming thoughts, and even substance abuse.
6. Disenfranchised
• Person experiences grief when a loss is experienced and cannot be openly
acknowledged, socially sanctioned or publicly shared E.g. .loss of partner from AIDS

6. Factors influencing loss & grief
•Human development
•Psychological perspectives of loss and grief
•Socioeconomic status
•Personal relationships
•Nature of loss
•Amount of support for bereaved
•Culture and ethnicity
•Spiritual beliefs

7. Stages of grief

9. Stages of grief
1. Denial and Isolation
-The first reaction to learning of terminal illness or death of a cherished loved one is to
deny the reality of the situation.
-It is a normal reaction to rationalize overwhelming emotions.
-It is a defense mechanism that buffers the immediate shock.
-We block out the words and hide from the facts. This is a temporary response that
carries us through the first wave of pain.

10. 2. Anger
-As the masking effects of denial and isolation begin to wear, reality and its pain re-
emerge. We are not ready.
-The intense emotion is deflected from our vulnerable core, redirected and expressed
instead as anger.
-The anger may be aimed at inanimate objects, complete strangers, friends or family.
-Anger may be directed at our dying or deceased loved one. Rationally, we know the
person is not to be blamed.

11. 3. Bargaining
-The normal reaction to feelings of helplessness and vulnerability is often a need to
regain control.
-If only we had sought medical attention sooner.
-If only we got a second opinion from another doctor.
-If only we had tried to be a better person toward them.
-Secretly, we may make a deal with God or our higher power in an attempt to postpone
the inevitable. This is a weaker line of defense to protect us from the painful reality.

12. 4. Depression
-Two types of depression are associated with mourning.
-The first one is a reaction to practical implications relating to the loss. Sadness and
regret predominate this type of depression.
-This phase may be eased by simple clarification and reassurance. We may need a bit of
helpful cooperation and a few kind words.
-The second type of depression is more subtle and, in a sense, perhaps more private. It is
our quiet preparation to separate and to bid our loved one farewell.

13. 5. Acceptance
Reaching this stage of mourning is a gift not afforded to everyone.
Death may be sudden and unexpected or we may never see beyond our anger or denial.
It is not necessarily a mark of bravery to resist the inevitable and to deny ourselves the
opportunity to make our peace.
This phase is marked by withdrawal and calm. This is not a period of happiness and
must be distinguished from depression.

15. Common symptoms of loss & grief
Shock and disbelief
Sadness
Guilt
Anger
Fear
Physical symptoms

16. Major task of the grief process
(1) Acceptance of the loss,
(2) Acknowledgment of the intensity of the pain,
(3) Adaptation to life after the loss and
(4) Cultivation of new relationships and activities

17. Death & dying
Coping with death, one's own or a loved one's, is considered the ultimate challenge.
The idea of death is threatening and anxiety provoking to many people.
Kubler-Ross stated, 'The key to the question of death unlocks the door of life. For those
who seek to understand it, death is a highly creative force.“
Common fears of dying people are fear of the unknown, pain, suffering, loneliness, loss
of the body, and loss of personal control.

18. Pattern of living
The first is referred to as peaks and valleys or periods of hope and periods of depression.
The second pattern is one described as distinct but descending plateaus.
The third pattern is a clear downward slope with many physiologic parameters indicating
that death is imminent.
The last pattern is a downward slant that reveals a crisis event, such as a severe cerebral
hemorrhage with almost no hope of recovery.

19. Clinical manifestations
AT THE END OF LIFE

20. 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

21. 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)

22. COLD AND CLAMMY SKIN CYANOSIS

23. 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 GI function
• bowel movement may occur before imminent death or at the time of death

24. 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

25. Psychological 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 - A feeling of
impending doom is a sensation or
impression that something tragic is about to
occur.
• Grief

26. Nursing implications

27. Nursing care involves providing comfort, maintaining safety ,addressing physical and
emotional needs ,and teaching coping strategies to terminally ill patients and their
families .
More than ever ,the nurse must explain what is happening to the patient and the family
and be a confident who listens to them talk about dying.
Hospice care , attention to family and individual psychosocial issues ,and symptom and
pain management are all part of the nurse's responsibilities.

28. The nurse must also be concerned with ethical considerations and quality-of-life issues
that affect dying people.
Of utmost importance to the patient is assistance with the transition from living to dying,
maintaining and sustaining relationships, finishing well with the family and
accomplishing what needs to be said and done.
In the hospital, in long-term care facilities, and in home settings, the nurse explores
choices and end-of-life decisions with the patient and family.

29. Referrals to home care and hospice services, as well as specific referrals appropriate for
the management of the situation, are initiated.
The nurse is also an advocate for the dying person and works to uphold that person's
rights. The use of living wills and advance directives allows the patient to exercise the
right to have a "good death” or to die with dignity.

30. The nurse assesses spiritual strength by inquiring about the person's sense of spiritual
well-being, hope, and peace.
The nurse assesses current and past participation in religious or spiritual practices and
notes the patient's response to questions about spiritual needs.
Another simple assessment technique is to inquire about the patient's and family's desire
for spiritual support.
For nurses to provide spiritual care, they must be open to be present and supportive
when patients experience doubt, fear, suffering, despair, or other difficult psychological
states of being.

31. Interventions that foster spiritual growth or reconciliation include being fully present;
listening actively; conveying a sense of caring, respect, and acceptance; using
therapeutic communication techniques to encourage expression; suggesting the use of
prayer, meditation, or imagery; and facilitating contact with spiritual leaders or
performance of spiritual rituals.
Nurses can alleviate distress and suffering and enhance wellness by meeting their
patients' spiritual needs.