Chapter 4 Loss, Grief, Death, and Dying * Objectives Define and explore the meaning of loss and ways to cope with loss. Describe and discuss theories about the grieving process. Explore definitions of death and the meaning of a good death. Examine components of advanced directives. Compare and contrast end of life care options. Loss and Grief (1 of 6)LossFeelings associated with a loss can emerge after:An incident or eventChanges in social role, responsibility, or personal expectationPhilosophical viewLoss helps a person gain a better perspective and understanding of life and eventually rediscover joy Loss and Grief (2 of 2)Wilson identified two categories of loss:CircumstantialUnexpected incidents or events that negatively affect daily lifeDevelopmentalAnticipated events or milestones that occur as a function of personal growth and maturation Loss and Grief (3 of 6)Viktor FranklConcluded that although humans often cannot control life events, they can control their response to those eventsDeveloped logotherapyBased on the belief that the ability to attach meaning to life is key to motivation and life preservation Loss and Grief (4 of 6)Grief“Keen mental suffering or distress over affliction or loss; sharp sorrow; painful regret”Personal, intimate, and intenseAffects an individual emotionally, socially, mentally, and spirituallyDiffers from mourning, which is an outward expression of grief Loss and Grief (5 of 6)Typical reactions to griefSadnessGuiltConfusionLonelinessDisbeliefDenialAngerHappiness Loss and Grief (6 of 6)Typical reactions to grief (continued)FearAcceptanceShockHatredAnxietyEmptinessReliefHelplessness Theories on Managing Grief (1 of 8)Sigmund FreudProposed that an individual should confront their grief by identifying and talking about issues that make it difficult for them to accept their lossesEncouraged patients to “move on” with their lives so that their “broken” hearts and spirits could heal Theories on Managing Grief (2 of 8)Attachment theoryDeveloped by John BowlbyThe level and nature of personal attachments to nurturing figures changes over timeWe mourn persons with whom we have the closest attachmentsEven close relationships have a degree of ambivalence Theories on Managing Grief (3 of 8)Michael Bradley and CaffertyFound those who had a partnership that included high levels of quarreling and tension tended to display more “disordered mourning” after the death of a partnerThose with a healthier relationship tended to display “uncomplicated grief” Theories on Managing Grief (4 of 8)Stage process modelElisabeth Kübler-Ross outlined five stages of grief that help dying people come to terms with their own impending death:DenialAngerBargainingDepressionAcceptance Theories on Managing Grief (5 of 8)Phase process modelsDual Process ModelResolving grief is dynamic and oscillates between two orientationsGrief process shifts between coping with loss and reorienting to daily lifeAvoidance and .

1. Chapter 4
Loss, Grief, Death, and Dying
*
Objectives
Define and explore the meaning of loss and ways to cope with
loss.
Describe and discuss theories about the grieving process.
Explore definitions of death and the meaning of a good death.
Examine components of advanced directives.
Compare and contrast end of life care options.
Loss and Grief (1 of 6)LossFeelings associated with a loss can
emerge after:An incident or eventChanges in social role,
responsibility, or personal expectationPhilosophical viewLoss
helps a person gain a better perspective and understanding of
life and eventually rediscover joy
Loss and Grief (2 of 2)Wilson identified two categories of
loss:CircumstantialUnexpected incidents or events that
negatively affect daily lifeDevelopmentalAnticipated events or

2. milestones that occur as a function of personal growth and
maturation
Loss and Grief (3 of 6)Viktor FranklConcluded that although
humans often cannot control life events, they can control their
response to those eventsDeveloped logotherapyBased on the
belief that the ability to attach meaning to life is key to
motivation and life preservation
Loss and Grief (4 of 6)Grief“Keen mental suffering or distress
over affliction or loss; sharp sorrow; painful regret”Personal,
intimate, and intenseAffects an individual emotionally, socially,
mentally, and spirituallyDiffers from mourning, which is an
outward expression of grief
Loss and Grief (5 of 6)Typical reactions to
griefSadnessGuiltConfusionLonelinessDisbeliefDenialAngerHa
ppiness
Loss and Grief (6 of 6)Typical reactions to grief
(continued)FearAcceptanceShockHatredAnxietyEmptinessRelief
Helplessness
Theories on Managing Grief (1 of 8)Sigmund FreudProposed
that an individual should confront their grief by identifying and
talking about issues that make it difficult for them to accept

3. their lossesEncouraged patients to “move on” with their lives so
that their “broken” hearts and spirits could heal
Theories on Managing Grief (2 of 8)Attachment
theoryDeveloped by John BowlbyThe level and nature of
personal attachments to nurturing figures changes over timeWe
mourn persons with whom we have the closest attachmentsEven
close relationships have a degree of ambivalence
Theories on Managing Grief (3 of 8)Michael Bradley and
CaffertyFound those who had a partnership that included high
levels of quarreling and tension tended to display more
“disordered mourning” after the death of a partnerThose with a
healthier relationship tended to display “uncomplicated grief”
Theories on Managing Grief (4 of 8)Stage process
modelElisabeth Kübler-Ross outlined five stages of grief that
help dying people come to terms with their own impending
death:DenialAngerBargainingDepressionAcceptance
Theories on Managing Grief (5 of 8)Phase process modelsDual
Process ModelResolving grief is dynamic and oscillates
between two orientationsGrief process shifts between coping
with loss and reorienting to daily lifeAvoidance and denial are
embraced as potentially helpful

4. Theories on Managing Grief (6 of 8)Worden’s Task-Based
ModelIdentifies four tasks to be completed:Accept the reality of
the lossWork through the pain of griefAdjust to an environment
in which the deceased is missingFind an enduring connection to
the deceased while embarking on a new life
Theories on Managing Grief (7 of 8)Edwin ShneidmanPurported
that the grieving process has many interlaced emotional
“themes” that can appear, disappear, and reappear againBeehive
theoryDepicts the bereaved individual going back and forth
between acceptance and denial
Theories on Managing Grief (8 of 8)
Coping with Loss and Grief (1 of 11)Complicated
grief“Persistent complex bereavement disorder”Inability to
manage griefSymptoms include intense sorrow, yearning, and
emotional pain during the majority of days for more than 12
months
Coping with Loss and Grief (2 of 11)Risk factors for
complicated grief:Witnessing a violent deathLosing someone
with whom they maintained a high level of
dependenceExperiencing high levels of anxietyExhibiting an
insecure attachment style

5. Coping with Loss and Grief (3 of 11)Individuals also face a
higher risk of complicated grief if they have:Low levels of
social supportLimited religious or spiritual supportLow
socioeconomic statusPhysical disability or illness
Coping with Loss and Grief (4 of 11)Theory of complicated
mourningDeveloped by Dr. Therese RandoThree
phases:AvoidanceConfrontationAccommodation
Coping with Loss and Grief (5 of 11)Six steps or “Rs” of
mourning occur within the three phases of complicated
mourning:RecognitionReactionRecollection and re-
experiencingRelinquishingReadjustmentReinvesting
Coping with Loss and Grief (6 of 11)Supporting a person who
has sustained a lossTalking about a personal loss is difficult for
many peopleMay Sarton and Susan Sherman developed a
collection of response strategies that did and did not help
Coping with Loss and Grief (7 of 11)
Coping with Loss and Grief (8 of 11)RitualsOften utilized for
coping with loss and grief and to assist moving through the

6. mourning processCan be personal, faith-based, or socialCan be
undertaken as an individual or groupParticipating in a ritual
can:Strengthen feelings of social connectednessOffer
psychological supportProvide meaning to the loss
Coping with Loss and Grief (9 of 11)BurnoutCaused by
excessive and prolonged stress caused by the work
environmentCommon signs:Emotional exhaustionFeeling
detached from patients and their careLack of personal
accomplishmentIncreases risk for making mistakes
Coping with Loss and Grief (10 of 11)Compassion fatigueAlso
known as secondary or vicarious traumaAffects individuals
affected by trauma experienced by someone elseSigns
include:Lack of self-careLow levels of compassionLoss of
boundaries with a patient/client
Coping with Loss and Grief (11 of 11)Combat burnout and
compassion fatigue by:Maintaining physical healthEngaging in
an increased variety of clinical rolesPursuing hobbiesRelying on
meditation techniquesMaintaining realistic expectations about
workLimiting work to 40 hours a weekEngaging in rituals
Death and Dying (1 of 5)DeathDetermining when death occurs
can be complicatedClinical death occurs when:The heart stops
circulating blood through the bodyThe lungs are unable to
oxygenate the bloodPossible to resuscitate a clinically dead
individual

7. Death and Dying (2 of 5)Brain deathGenerally follows a
devastating brain injuryOccurs when coma, apnea, and lack of
brainstem reflexes occurLife support is considered futile except
to preserve organs for donation to a living being
Death and Dying (3 of 5)Persistent vegetative state
(PVS)Occurs when brain activity in the cortex ceases, but
primal functions regulated in the brain stem continueNo
possible return to normal functioning
Death and Dying (4 of 5)Natural deathDying at an old age when
the body stops functioning on its ownPremature deathDying at a
young ageCompression of morbidityReducing personal and
systemic burden caused by illness to the shortest time possible
Death and Dying (5 of 5)Perspectives on deathImportant not to
assume that anyone is, or is not, prepared to dieConversations
about death and dying are shaped by our own experiences and
perspectivesFear of death typically peaks in young
adulthoodCan create anxiety
Seeking a Good Death (1 of 6)Good deathMeans something
different for everyoneMost hope for pain-free death without
distress and sufferingWe also want our end of life to be:Aligned
with our own and our families’ wishesReasonably consistent

8. with clinical, cultural, and ethical standards
Seeking a Good Death (2 of 6)SuicideTaking one’s own
lifeIllegal in most states and viewed as morally reprehensible in
most culturesHigh rates of suicide in men age 75+Older men are
unlikely to seek therapeutic counseling services/mental health
servicesLimited number of programs developed specifically for
older adults to address suicide
Seeking a Good Death (3 of 6)EuthanasiaAn act of killing
another beingPassive euthanasiaStanding by and not taking
action to prevent deathActive euthanasiaTaking direct action to
shorten lifeIllegal except for lethal injection used in capital
punishment
Seeking a Good Death (4 of 6)Physician-assisted suicideTaking
one’s own life under the guidance of a physicianCurrently legal
in some countries in Western Europe and in a few U.S. states
and the District of ColumbiaCritics argue that individuals may
not receive adequate counseling or may not fully understand the
outcome
Seeking a Good Death (5 of 6)Advanced directivesLiving
willInstructs healthcare providers how you want to be treated if
you become seriously ill or are terminally ill or cannot
communicate their wishesHealth care power of attorney
(HCPOA)Appoints a designated individual to speak for you in
making health care decisions if you cannot speak for yourself

9. Seeking a Good Death (6 of 6)Do not resuscitate (DNR)
orderProhibits life-saving treatments in the event that your heart
stopsCannot be revoked by anyoneOrgan and tissue
donationOne person can potentially save 8 lives and provide
help to 50 additional people
End of Life Care Options (1 of 4)HospiceFor individuals
diagnosed with a terminal illness or injuryOffers compassionate
care that includes palliative careCan only be received after an
individual has been certified by two physicians as having 6
months or less time to live
End of Life Care Options (2 of 4)Hospice utilizes an
interdisciplinary team to offer support to the recipient and
familyProvides comfort and care in the recipient’s preferred
surroundings without pain and invasive medical treatmentMay
include services such as pastoral care, homemaker/companion
services, and recreational and rehabilitation therapy
End of Life Care Options (3 of 4)
End of Life Care Options (4 of 4)Working with dying
patientsOften referred to as a callingKey points:Offer words of
kindness and supportRefrain from judging anyone or expressing
discontentTreat everyone with respect and dignityListen and

10. watchReflect on the situation to learn more about yourself
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