CARE OF DYING CLIENT

Loss and Grief

- Loss: the actual or potential situation in which something that is valued is changed, no
longer available or gone

: can be viewed as situational or developmental.

* Types of loss:

1. Actual loss – can be recognized by others.

2. Perceived loss – experienced by one person but cannot be verified by others.

3. Anticipatory loss – experienced before the loss actually occurs.

* Sources of loss:

1. The loss of an aspect of one self – a body part, a physiologic function or

psychologic attribute.

2. The loss of an object external to oneself.

3. Separation from an accustomed environment

4. Loss of loved or valued person

I. GRIEF

- It is the total response to the emotional experience related to loss.

- It is manifested in variety of ways that are unique to an individual and based on personal
experiences, cultural expectations, and spiritual beliefs (Farber [Link]., 1999)

* Bereavement: includes grief and mourning – the inner feelings and outward reactions of the survivor
(ELNEC, 2000); it is the subjective response experienced by the surviving loved ones after the death of a
person with whom they have shared a significant relationship.

* Mourning: behavioral process through which grief is eventually resolved or altered.

Types of Grief Responses:

1. Abbreviated grief - brief but genuinely felt.

2. Anticipatory grief - is experienced in advance of the event.

3. Disenfranchised grief - occurs when a person is unable to acknowledge the loss of a

person; characterized by extended time of denial, depression, severe physiologic symptoms or
suicidal thoughts.
 - Also known as marginal or unsupported grief

4. Pathologic or Dysfunctional grief - unhealthy grief which may be unresolved or

inhibited.

5. Unresolved grief -is extended in length and severity.

6. Inhibited grief - many of the normal symptoms of grief are suppressed and other effects,
including somatic, are experienced instead.

*Factors influencing the loss and grief response: age, significance of the loss, culture, spiritual beliefs,
gender, socioeconomic status, support systems, and cause of the loss or death.

*Manifestation of grief that would be considered normal: verbalization of the loss, crying, sleep
disturbance, loss of appetite and difficulty concentrating.

*Some symptoms that accompany grief: anxiety, depression, weight loss, fatigue, dyspnea, palpitations,
mental disturbances, difficulty in swallowing, blurred vision, vomiting, fainting and dizziness.

II. STAGES OF GRIEF

a. Engel's theory (1964)

Engel's Stages of Grieving theory describes these steps in this proper sequential order: Shock and
disbelief; developing awareness, restitution, resolving the loss, idealization and outcome.
Stages Behavioral Responses
Refuses to accept loss.
Has stunned feelings.
Shock and disbelief Accepts the situation intellectually, but denies it
emotionally.
Reality of loss begins to penetrate consciousness.
Developing Awareness
Anger may be directed at agency, nurses, or others.

Restitution Conducts rituals of mourning

Attempts to deal with painful void
Still unable to accept new love object to replace lost
Resolving the loss person/object.
May accept more dependent relationship with
support person
Thinks over and talks about memories of the lost
object.
Produces image of lost object that is almost devoid
of undesirable features.
Represses all negative and hostile feelings toward
lost object.
Idealization May feel guilty and remorseful about past
inconsiderate or unkind acts to lost person.
 Unconsciously internalizes admired qualities of lost
object.
Reminders of lost object evoke fewer feelings of
sadness.
Reinvests feelings in others.
Behavior influenced by several factors (importance
of lost object as source of support, degree of
dependence on relationship, degree of ambivalence
Outcome towards lost object, number and nature of other
relationship, and number and nature of previous
grief experiences which tend to be cumulative.)

b. Kubler-Ross’s Stages of Grief

The framework for Kubler-Ross's theory (1969) is behavior oriented and includes 5 stages:

 Denial - individual acts as though nothing has happened and may refuse to believe or
understand that a loss has occurred.

 Anger - the individual resists the loss and may strike out at everyone and everything.

 Bargaining- the individual postpones awareness of the reality of the loss and may deal in a
subtle or overt way as through the loss can be prevented.

 Depression - the person finally realizes the impact and significance of the loss the individual
may feel overwhelming lonely and withdrawal from interpersonal interaction.

 Acceptance - the individual accepts the loss and begins to look to the future.

Stages Behavioral Responses Nursing Implications

Refuses to believe that loss is Verbally support client but do not
happening. reinforce denial.

Is unready to deal with practical Examine your own behavior to

Denial
problems. ensure that you do not share in
client’s denial.

May assume artificial

cheerfulness to prolong denial.

Client of family may direct anger Help client understand that anger
at nurse or staff about matters is normal response to feelings of
that normally would not bother loss and powerlessness.
them.
Avoid withdrawal or retaliations;
do not take anger personally.

Deal with needs underlying any

 Anger angry reaction.

Provide structure and continuity

to promote feelings of security.

Allow clients as much control as

possible over their lives.

Seeks to bargain to avoid loss. Listen attentively and encourage

May express feelings of guilt, client to talk to relieve guilt and
fear of punishment for past, sins, irrational fear.
Bargaining real, or imagined.
If appropriate offer spiritual
support.

Grieves over what has happened Allow client to express sadness.

and what cannot be.

May talk freely. Communicate nonverbally by

Depression sitting quietly without expecting
conversation.

Convey caring by touch.

Comes to terms with loss. Help family and friends

understand client’s decreased
need to socialize.

Acceptance May have decreased interest in Encourage client to participate as

surroundings and support people. much as possible in the treatment
program.

May wish to begin making plans.

III. GRIEF PROCESS

- grief and the grieving process are characterized with suffering, despair, sleep
impairments, pain, distress, anger, detachment, guilt, and even personal growth.
The Grief Process
Kubler-Ross's Five Stages of Bowlby's Four Phases of Worden's Four Tasks of
Dying Mourning Mourning
- Denial - Numbing - Accepting the reality of a
- Anger - Yearning and searching loss
- Bargaining - Disorganization and - Working through the pain
- Depression despair of a grief
- Acceptance - Reorganization - Adjusting to the
environment without the
deceased
- Emotionally relocating
the deceased and moving
on life.

*Bowlby’s Phases of Mourning:

- Bowlby’s attachment theory (1980) is the foundation for his theory in mourning.
- Attachment is described as an instinctive behavior that the leads in the development of affectional
bonds between children and their primary caregiver.
> Numbing: may last from a few hours to a week or more and maybe interrupted by period of
extremely intense emotion; it is the briefest phase of mourning; the grieving person describes this
stage as feeling “stunned or unreal”
> Yearning and searching: arouses emotional outbursts of tearful sobbing and acute distress in
most person; separation anxiety.
> Disorganization and despair: and individual may endlessly examine how and why the loss
occurred.
> Reorganization: may require as much as a year or more, the person beings to accept
unaccustomed roles, acquire new skills, and build new relationships.

*Worden’s Four Tasks of Mourning (1982)

- implies that persons who mourn can be actively involved by helping themselves and be assisted
by outside intervention; task-based grief theory.

> Task I: Accepting the reality of the loss. This involves the process of accepting the that the
person or object is gone and will not return.

>Task II: Experience the pain of grief. People react with sadness, loneliness, despair, or regret
and work through painful feelings using the coping mechanisms most familiar and comfortable to
them.

>Task III: Adjust to the world in which the deceased is missing. A person does not realize the full
impact of loss for at least 3 months thus, people completing this task begin to take on roles
formerly filled by the deceases, including some jobs they do not want.

> Task IV: Emotionally relocate the deceased and move on with life. The deceased person is not
forgotten but rather takes a different and less prominent place in the survivor’s emotional life.
References:

 Fundamentals of Nursing Practice (8th Edition) (Author: Kozier, [Link])

 Fundamentals of Nursing (2003) (Author: Potter and Perry)