This document discusses terminal illness and the stages of grief. It begins by defining terminal illness as a disease that cannot be cured and is expected to result in death within a short period of time. It then discusses various types of loss, including actual versus perceived loss, physical versus psychological loss, and external versus internal loss. The document also covers the stages of grief as proposed by Kübler-Ross, including denial, anger, bargaining, depression, and acceptance. It provides descriptions of each stage and the nurse's responsibilities for supporting patients experiencing grief.

1. CHAPTER 14 - CARE OF TERMINALLY ILL PATIENT
Ms.Lincy Thomas
Tutor
St.James’ College of Nursing,
Chalakudy

2. “LOSS,GRIEF AND STAGES OF GRIEF”
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3. TERMINAL ILLNESS
• “Terminal illness is a medical term used to describe a disease that
cannot be cured or adequately treated and ie, reasonably expected to
result in the death of the patient within a short period of time”
• It indicates that eventually ends the life of the sufferer.

4. Loss
‘Loss is the removal or absence of an important object or subject from an
individual’s life’
‘Loss is an actual or potential situation in which something ie, valued is changed,
no longer available or gone’.
‘Loss is an absence of something valued from an individual’s life’.
‘It may be an absence of an object, person, body part, emotion, idea or function
that was valued’.
‘Death is a fundamental loss, both for dying person and for those who survive’.

5. Forms of loss
• Personal loss
• Group loss
• Multiple loss

6. Types of Loss
• Actual loss is identified and verified by others
• Perceived Loss cannot be verified by others
• Maturational Loss occurs in normal development
• Situational Loss occurs without expectations
• Ultimate Loss (Death) both for dying person and for those who
survive

7. Actual versus perceived loss/Anticipatory loss
• Actual loss includes the death of a loved one (or relationship), theft,
deterioration, destruction, and natural disaster. Actual loss can be identified by
others, not just by the person experiencing it (e.g., hair loss during
chemotherapy).
• Anticipatory loss is experienced before the loss actually occurs(e.g: a woman
whose husband is dying may experience actual loss in anticipation of his
death)
• Perceived loss is internal; it is identified only by the person experiencing it
(e.g: a woman diagnosed with an STD may perceive herself as having lost her
purity.
e.g: a women who leaves her employment to care for her children at home
may perceive a loss of independence and freedom)

8. Physical versus psychological loss
• Physical loss includes (1) injuries (e.g., when a limb is amputated); (2)
removal of an organ (e.g., hysterectomy); and (3) loss of function
(e.g., loss of mobility).
• Psychological losses challenge our belief system. They are commonly
seen in the areas of sexuality, control, fairness, meaning, and trust.
Some losses may be mixed. Ex: after removal of a prostate gland, a
man may feel both the physical and psychological loss of sexuality.

9. External versus internal loss
• External losses are actual losses of objects that are important to the person
because of their cost or sentimental value (e.g., jewellery, pets, a home). These
losses can be brought about by theft, destruction, or disasters such as floods and
fire.
• Internal loss is another term for perceived or psychological loss.

10. • Loss of aspects of self
This includes physical losses such as body organs, limbs, body functions,
and/or body disfigurement. Psychological and perceived losses in this category
include aspects of one’s personality, developmental change (as in the aging
process), loss of hopes and dreams, and loss of faith.
• Environmental loss
This involves a change in the familiar environment, even if the change is
perceived as positive. Examples include moving to a new home, getting a new
job, and going to college. These losses can be perceived or actual.
• Loss of significant relationships
This includes, but is not limited to, actual loss of spouses, siblings, family
members, or significant others through death, divorce, or separation (e.g.,
military deployment)

11. GRIEF
• Grief is the natural response to loss. It is the emotional suffering you feel
when something or someone you love is taken away.
• The intensity of the grief depends on the meaning the person attaches to the
loss. Although each person may express grief differently, some aspects of
grief are shared by almost everyone.
DEFINITION OF GRIEF
Grief is defined as “the multifaceted physical, emotional and behavioural
responses of an individual to the death of a significant other or any loss”

12. • Mourning
Outward social expression of grief and the behaviors that are
influenced by cultural mores and customs
(ex: crying, wearing black clothing.)
• Bereavement
The response pattern, psychologic and physiologic,
displayed by an individual following the loss of a significant
object/subject.

13. TYPES OF GRIEF
• Normal Grief reaction- Abbreviated & Anticipatory
• Unhealthy Grief reaction- Pathologic & Dysfunctional(Unresolved &
Inhibited)
Abbreviated Grief
is brief but genuinely felt. The lost object may not have been sufficiently
important to the grieving person or may have been replaced immediately by
another, equally esteemed object.
Anticipatory Grief
is experienced in advance or before of the event

14. • Pathologic (Unresolved )
is extended in length and severity. The same signs are expressed as
with normal grief, but bereaved may also have difficulty expressing the
grief, may deny the loss or may grieve beyond the expected time.
• Dysfunctional (Inhibited)
many of the normal symptoms of grief are suppressed and other
effects, including somatic are experienced instead.

15. • Dysenfranchised Grief
occurs when a person is unable to acknowledge the loss to
other persons.
eg: socially unacceptable loss such as suicide, abortion or giving a
child up for adoption, a man whose wife has had a miscarriage,
a mistress whose lover dies, or a bereaved partner in a
homosexual relationship not recognized by the families
• Exaggerated Grief
An intense reaction to the loss that can include thoughts of suicide,
phobias or nightmares.

16. Factors Affecting Grief
• Significance of the loss
The meaning the person has attached to the person or object lost will be
different for each person. The more attachment to the relationship or object,
the more difficult is the grieving.
• Support System
The amount of support for the bereaved: People with more emotional and
psychosocial support typically have less complicated grief.
• Circumstances of the loss
If the circumstances of the loss leave the bereaved feeling guilty or
responsible, his or her healing process may be impeded. (this may occur in
losses other than death such as loss of a job)

17. • Previous Loss
If the person has sustained more than one loss in a short period of time, the
grieving process can become more complicated.
• Spiritual/Cultural Beliefs and Practices
Can help or hinder the grieving process. One person might believe the
deceased is in a place of contentment and happiness, where all suffering is
over. Another may believe that the deceased person will be reborn into
another form. Yet another may believe that death is final and there is no
afterlife.
• Age of a person grieving

18. • Gender
Men are frequently expected to be strong and show very little emotion
during grief.
• Expectations of death / cause of loss or death
Injuries or deaths occuring during respected activities in the line of
duty are considered honourable
Those occurring during illicit activities are considered socially
unacceptable loss.

19. PHYSICAL SYMPTOMS OF GRIEF
We often think of grief as a strictly emotional process, but grief
often involves physical problems, including:
• Fatigue
• Nausea
• Lowered immunity
• Weight loss or weight gain
• Aches and pains
• Insomnia

20. EMOTIONAL SYMPTOMS OF GRIEF
• Shock and disbelief.
Right after a loss, it can be hard to accept what happened. You may feel numb, have trouble
believing that the loss really happened, or even deny the truth. If someone you love has died,
you may keep expecting them to show up, even though you know they’re gone.
• Sadness.
Profound sadness is probably the most universally experienced symptom of grief. You may
have feelings of emptiness, despair, or deep loneliness. You may also cry a lot or feel
emotionally unstable.
• Guilt.
You may regret or feel guilty about things you did or didn’t say or do. You may also feel guilty
about certain feelings (e.g. feeling relieved when the person died after a long, difficult illness).
After a death, you may even feel guilty for not doing something to prevent the death, even if
there was nothing more you could have done.

21. • Anger.
Even if the loss was nobody’s fault, you may feel angry and resentful. If you
lost a loved one, you may be angry with yourself, God, the doctors, or even
the person who died for abandoning you. You may feel the need to blame
someone for the injustice that was done to you.
• Fear.
A significant loss can trigger a host of worries and fears. You may feel
anxious, helpless, or insecure. You may even have panic attacks. The death
of a loved one can trigger fears about your own mortality, of facing life
without that person, or the responsibilities you now face alone.

22. STAGES OF GRIEF

23. “Stages of grief is the series of emotional stages or responses that
someone experiences when faced with an impending death or other
extremes of loss”( Griever is expected to move through these stages)
It was introduced by DR.ELIZABETH KUBLER- ROSS in 1969 and these
stages also known as Kubler Ross Model

24. • Elisabeth Kübler-Ross was a Swiss-American psychiatrist, a pioneer in
near-death studies, and author of the internationally best-selling
book, On Death and Dying, where she first discussed her theory of
the five stages of grief.

25. • Dr. Elizabeth Kübler-Ross has researched the dying process and has
identified 5 stages of grieving that dying patients and their families
may experience in preparation for death.
• Stages may not appear in order and some patients may be in several
stages at the same time. Some patients die before progressing
through all the stages.

26. STAGES OF GRIEF
1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance
(These stages popularly known by the acronym DABDA)

27. Stage 1: Denial
Denial is an immediate response to news of loss
or impending loss
lt is a conscious or unconscious refusal to accept facts,
information, reality, etc., relating to the situation concerned.
That means ,the individual may refuses to believe that a loss has
occurred.
It's a defense mechanism and perfectly natural.

28. Statements such as
“No, that can’t be so” and “it can’t be happening to me” are common
In this stage , person may often experiences a state of shock & disbelief
and you may feel numb ,disoriented or reports a sense of unreality. This is a
temperory response that carries us through the first wave of pain.
Physiologic response may include muscular weakness, tremors, deep sighs,
flushed /cold/clammy skin, diaphoresis, anorexia and discomfort

29. Nurses responsibility
• Support emotional needs without reinforcing denial (the patient
might become argumentative at this stage but this is only a normal
response)
• The nurse must constantly be by the patient’s side to attend his
needs.
• Offer basic care ,such as food, drink, oxygenation, comfort and safety

30. Stage 2: Anger
Individual resist the loss and may act out to everyone and everything in the
environment. It is an intense emotion that is expressed as anger. They may
become irritable and frustrated.

31. Anger can manifest in different ways. People dealing with emotional upset
can be angry with themselves, and/or with others, especially those close to
them, family, staff, physicians, to god or inanimate objects etc..
In this stage , the individual may be reluctant to share their feelings and
thoughts.
Common statements ,
“why me”, “why is this happening to me”
“I hate my life, I don’t want to talk to anyone, Don’t come near me” etc…

32. Nurses responsibility
• Nurse should also maintain a normal tone of voice and show that you
are actively listening to them even though when they are angry.
• Nurse should remain calm in dealing with an angry patient.
• Provide anticipatory guidance about their feelings.
• Nurse must never feel that the anger is directed towards them
• Do not allow them to take anger personally
• Encourage client and family to express their feelings

33. Stage 3: Bargaining
This stage of grief may be marked by persistent thoughts about what “could
have been done” to prevent the death or loss.
Bargaining is often accompanied by guilt. This is basically our way of
negotiating with the hurt and pain of loss.
Common statements are,
“if only we had sought medical attention sooner…….”
“if only we got a 2nd opinion from another doctor…..”
“I would give everything I own if I become healthy and free of this sickness”

34. Nurses responsibility
• Listen attentively and encourage client to talk to relieve his guilt,
discomfort and irrational fear.
• If appropriate ,offer spiritual support.

35. Stage 4: Depression
At this stage the individual has come
to recognize that a loss has occurred or will occur. The individual may
isolate themselves and spend time in crying and grieving.
Depression and sadness are the most recognizable and perfectly
normal emotional response.

36. During this stage, you will likely to withdraw from normal activities and
feel as you are in a fog of sadness.
You may find it difficult to go on without that person in your life or you
believe that you cannot be cured of the sickness.
Common statements
“I would rather stay in my room rather than go out “
“I do not feel like anything all day” etc..

37. Nurses responsibility
• Allow the client to express sadness
• Communicate non-verbally by sitting quietly without expecting
conversation
• Convey caring by touch
• Nurse must be aware of the symptoms of major depression-watch out
for signs of impending suicide because most depressed clients finally
resort to suicide.
• Provide the client with activities that would bring out positive
thoughts.

38. Stage 5: Acceptance
This is the point or stage where the individual
will come to accept the loss or new reality.
They understand the situation logically and
they have come to terms emotionally with
the situation.
Acceptance doesn’t mean that you are okay with your situation; it simply
meant, you recognize that person is indeed gone, that your situation has
changed and people may wish to begin making new plans
(eg:will,prosthesis,altered living arrangements etc.)

39. Nurses responsibility
• Help family and friends understand client’s decreased need to
socialize.
• Encourage client to participate as much as possible in the treatment
program
• Make interventions to promote his comfort

40. Video on stages of grief
http://www.metacafe.com/watch/5788546/5_stages_of_grief_giraffe/