Loss, Grief and Death

Elmer A. F. Conde
 Definition of Terms
• Loss- the absence of an object, person’s
body part or function, or emotion that
was formerly present.

• Grief – a form of sorrow that follows the

perception or anticipation, loss of one or
more valued or significant objects
 Definition of Terms
• Bereavement – the state of grieving
during which a person goes through
grief reaction. It is the experience of
having lost something or someone by
death.
 Definition of Terms
• Mourning – is the period of acceptance
of loss and grief which the person learns
to deal with the loss. This includes
wakes, funeral rituals, memorial
services, wearing of black/white dress,
and defined time of social withdrawal or
isolation.
 Types of Loss:
Loss of external object
• Possession that is worn – out, misplaced,
stolen, or ruined by disaster or calamity

Loss of life
• How one person views death (relief vs
loneliness)
 Types of Loss:
Loss of a known environment
• Temporary or permanent relocation
• Separation from a known or comfortable
environment
• Hospitalization

• Loss of an aspect of life

• Loss of a body part, physiologic function,
psychological function, emotions, self-
concept, self confidence, power, love
 Types of Loss:
Loss of significant others
• Loss of a parent, spouse, children,
siblings, colleagues, friends, neighbors,
entertainment figures, well known
people and actors.
 Types of Loss:
• Actual • Situational
– Recognized by others – i.e., Loss of job,
death of child
• Perceived
• Developmental
– Experienced by one
– i.e., Departure of
person but cannot be children from home
verified by others
• Anticipatory
– Experienced before
loss occurs
– Can be actual or
perceived
Theories Affecting
Grief
 Engel (1954) Phases of
Grief
I. Shock and Disbelief
• Person refuses to accept the loss
• Stunned and numb responses (“Not
me?”, “No”)

II. Developing awareness

• Presence of physical and emotional
responses (anger, feeling empty, crying,
“Why me?”)
 Engel (1954) Phases of
Grief
III. Restitution
• Involves rituals surrounding loss and
death
• Religious, social, cultural expressions of
mourning such as funeral service.

IV. Resolving the loss

• Dealing with the void/emptiness left by
the loss
 Engel (1954) Phases of
Grief
V. Idealization
• Exaggeration of the good qualities of the
person or object lost
• Followed by the acceptance of the loss
and need to focus on the loss is
lessened

VI. Outcome
• Dealing with the loss a common life
occurrence
 Bowlby (1980) Phases
of Grieving Process
• Phase I: experiencing numbness and
denying the loss

• Phase II: emotionally yearning for the

lost loved one and protesting the
permanence of death
 Bowlby (1980) Phases
of Grieving Process
• Phase III: experiencing cognitive
disorientation and emotional despair
with difficulty functioning in the
everyday world.

• Phase IV: reorganizing and reintegrating

the sense of self to pull life back
together.
 Rodebaugh, Schwindt &
Valentine (1999) Process of
Grief
I. Reeling
• Person feels shock, disbelief and denial

II. Feelings
• Person experiences anguish, guilt,
profound sadness, anger, lack of
concentration, sleep disturbances,
appetite changes
 Rodebaugh, Schwindt &
Valentine (1999) Process of
Grief
III. Dealing
• Person begins to adapt to the loss by
engaging in support groups, grief
therapy, reading and spiritual guidance.

IV. Healing
• Integrates loss a part of life, anguish is
lessen.
• Does not imply that the person has
forgotten or accepted the loss.
 Phases of Death and Dying
(Kobler Ross, 1969)
1. Denial & Isolation
• Client denies he will die
• may repress that is discussed or isolate
self from reality
• Nursing Implications
– Support emotional needs without
supporting denial
 Phases of Death and Dying
(Kobler Ross, 1969)
• Nursing Implications
– Offer to remain with clients, without
discussing reasons for behavior or
need to cope with it until they bring it
up
– Offer regressive care such as food,
drinks and safety
 Phases of Death and Dying
(Kobler Ross, 1969)
2. Anger
• Express anger and retaliates to family
members, staff, physician or supreme
being
• Becomes demanding and accusing
• Maybe precipitated by guilt which will
lead to anxiety and low self-esteem.
Phases of Death and Dying
(Kobler Ross, 1969)
• May feel resentful and jealous to
those who still have lost object or
loved one.
• Nursing implications:
– Provide anticipatory guidance
about feelings and their intensity
experienced as a part of grief.
– Do not take anger personally.
– Meet needs that cause angry
response.
 Phases of Death and Dying
(Kobler Ross, 1969)
3. Bargaining
• Client is willing to do anything to avoid loss
or change the prognosis.
• Bargaining is commonly addressed to the
Supreme Being in an attempt to postpone
death
• A positive way to maintain hope
• Nursing implications:
– Nurses must provide information regarding the
need for decision making.
 Phases of Death and Dying
(Kobler Ross, 1969)
• A positive way to maintain hope
• Nursing implications:
– Nurses must provide information
regarding the need for decision making.
 Phases of Death and Dying
(Kobler Ross, 1969)
4. Depression
• Time for introspection
• Quite and non-communicative,
• May lose interest in appearance and
may become suicidal
• May cope by doing unhealthy behaviors
such as drinking, smoking, drug use
 Phases of Death and Dying
(Kobler Ross, 1969)
• Client struggles with painful realities of
life and preparing for death
• Nursing implications:
– Provide support and empathy
– Support crying by offering touch that
communicates caring
– Assess risk of harm to self and refer
accordingly.
 Phases of Death and Dying
(Kobler Ross, 1969)
• Acceptance
• Individuals accept the terms of loss
and death and begins to plan for it.
• Reminiscence is common and good
outweighs that bad.
• Life begins to stabilize and peaceful
acceptance that death is imminent.
Phases of Death and Dying
(Kobler Ross, 1969)
Nursing implications:
– Offer opportunities to share feelings
verbally in writing or art or by tape
recording.
– Allow and encourage review as often
as clients want to talk.
– Show acceptance of liability of feelings
– Assist in discussing future plans.
 Nursing Considerations:

a. communication patterns: use of

therapeutic communication
b. proxemics and kinethetics
c. risk factors: death of a child, spouse,
parent; sudden, untimely death; multiple
deaths, deaths by suicide, murder or
manslaughter
 Nursing Considerations:

d. cultural variability
e. susceptibility factors: low self-esteem,
mistrust, co-morbid disorders, previous
suicidal threats and attempts,
absent/unhelpful family
 Question 1
A client’s family tells the nurse that their culture
does not permit a dead person to be left alone
before burial. Hospital policy states that after
6:00 PM when mortuaries are closed, bodies are
to be stored in the hospital morgue refrigerator
until the next day. How would the nurse best
manage this situation?

3. Gently explain the policy to the family and then

implement it.
4. Inquire of the nursing supervisor how an
exception to the policy could be made.
5. Call the client’s primary care provider for advice.
6. Move the deceased to an empty room and assign
an aide to stay with the body.
 Rationales 1
• When possible, modifications of policy that
demonstrate respect for individual
differences should be explored.
• Correct. When possible, modifications of
policy that demonstrate respect for
individual differences should be explored.
• The primary care provider is in no position
to modify the implementation of hospital
policy.
• Utilizing an empty room and a staff
member for a deceased client is an
inappropriate use of resources.
 Question 2
The shift changed while the nursing staff was
waiting for the adult children of a deceased
client to arrive. The oncoming nurse has never
met the family. Which of the following
greetings is most appropriate?

3. “I’m very sorry for your loss.”

4. “I’ll take you in to view the body.”
5. “I didn’t know your father but I am sure he was
a wonderful person.”
6. “How long will you want to stay with your
father?”
 Rationales 2
• Correct. This statement acknowledges
the family’s grief simply.
• Avoid statements that may be
interpreted as overly impersonal.
• Avoid statements that may be
interpreted as false support.
• Avoid statements that may be
interpreted as harsh.
 Question 3
An 82-year-old man has been told by his
primary care provider that it is no longer safe
for him to drive a car. Which statement by the
client would indicate beginning positive
adaptation to this loss?

3. “I told the doctor I would stop driving, but I am

not going to yet.”
4. “I always knew this day would come, but I
hoped it wouldn’t be now.”
5. “What does he know? I’m a better driver than
he will ever be.”
6. “Well, at least I have friends and family who
can take me places.”
 Rationales 3
• This option does not demonstrate movement
toward a goal of adaptation nor problem
solving.
• This option does not demonstrate movement
toward a goal of adaptation nor problem
solving.
• This option does not demonstrate movement
toward a goal of adaptation nor problem
solving.
• Correct. Adaptive responses indicate the
client can put the loss into perspective and
begin to develop strategies for coping with the
loss.
 Question 4
When asked to sign the permission form for
surgical removal of a large but noncancerous
lesion on her face, the client begins to cry.
Which of the following is the most appropriate
response?

3. “Tell me what it means to you to have this

surgery.”
4. “You must be very glad to be having this
lesion removed.”
5. “I cry when I am happy or relieved
sometimes, too.”
6. “Isn’t it wonderful that the lesion is not
cancer?
 Rationales 4
• Correct. The nurse needs to assess
and explore the meaning of the
client’s crying.
• Option 2 leaps to assumptions about
the meaning of the tears and ignores
the possibility of the client’s distress.
• Option 3 suggests that the client has
the same feelings as the nurse, which
may not be correct.
• Option 4 leaps to assumptions about
the meaning of the tears and ignores
the possibility of the client’s distress.
 Question 5
A nursing care plan includes the desired
outcome of “quality of life” for a client with a
chronic degenerative illness who is likely to
live for many more years. Which of the
following is one example that would indicate
the outcome has been met?

3. The client demonstrates having adequate

financial resources to pay for health care for
many more years.
4. The client spends the majority of his or her
time in spiritual reflection.
5. The client has no signs or symptoms of
preventative complications of the illness.
6. The client verbalizes satisfaction with current
relationships with other persons.
 Rationales 5
• Although being able to pay for care may
appear to contribute to good quality of life,
only the client’s expression of satisfaction can
provide the data the nurse requires to
evaluate the goal.
• Although apparent spiritual peace may appear
to contribute to good quality of life, only the
client’s expression of satisfaction can provide
the data the nurse requires to evaluate the
goal.
• Although the absence of physiological
complications may appear to contribute to
good quality of life, only the client’s
expression of satisfaction can provide the data
the nurse requires to evaluate the goal.
• Correct: Quality of life is determined by the
client and expressed in terms of his or her
Thank
You!!!