Grieving & death

• Loss

  • Loss of significant others
  • Loss of familiar environment
  • Loss of external objects
  • Loss of aspects of self
  • Loss of life
• Type of Loss

  • Actual: death of person or pet, property
  • Perceived: youth, energy, health, lifestyle
  • Physical: body part, physical & cognitive function
  • Psychological: social status, breaking of relationship, emotion, self-esteem
• Grief


  • A series of internal emotional & behavioral response to loss and its accompanying changes
  • A normal and natural response
  • Should be acknowledged and allowed to happen because it promotes healing
• Mourning


  Outward expression of loss and grief (eg. ceremonies, funerals)
• Bereavement


  • Period of sadness after losing a loved one through death
  • Grief and mourning occur during bereavement
• Grieving


  • A mechanism (with intellectual & emotional response) to cope with the loss gradually and accept it as part of reality
  • Essential for good mental & physical health
  • Bereavement and mourning are both part of the grieving process
• Dying


  • A life course process where death will come at the end
  • Time can be long or short
  • Features include: have a chronic illness, in the late stage of a disease, gradual loss of activity, gradual loss of social function, need someone to take care of, gradual loss of body functions
• Death


  Irreversible complete cessation of all physiological functions: no circulatory function (no heartbeat), no respiratory function (no breathing), loss of all reflexes (e.g. gag reflex, blinking reflex), loss of pupil reaction to light, completely unresponsive to external stimuli, cessation of brain function
• Brain Death


  • Irreversible coma
  • Persistent vegetative state
  • Recovery may occur but very rare
• Brainstem Death


  • Irreversible coma + Irreversible loss of brain stem reflex responses + Irreversible loss of respiratory center function OR demonstration of intracranial blood flow cessation
  • In HK, Brainstem Death = Death
  • Life support withdrawal
  • Organ donation
  • A difficult concept for family and relatives to understand
• Physiological changes of dying patient

  • Musculoskeletal system
  • Respiratory system
  • Circulatory system
  • Digestive and urinary systems
  • Nervous system
  • Sensory system
• Musculoskeletal system changes

  • Loss of muscle strength → decreased mobility and increased stiffness
  • Weak and fatigue
  • Difficult to stand up or maintain a comfortable posture
• Nursing Interventions for musculoskeletal changes

  1. Assist patient out of bed periodically

  2. Regular change of position

  3. Support patient's position with pillows

  4. Elevate client's legs

  5. Prevent pressure ulcers and wound care
• Respiratory system changes

  • Dyspnea
  • Respiratory muscle weakness → rapid, irregular breathing and eventually slow down
  • Increase lung secretions → noisy breathing sounds
  • Weak to cough
• Nursing Interventions for respiratory changes

  1. Oxygen therapy

  2. Fowler's position, if no contraindications

  3. Perform suctioning when necessary
• Circulatory system changes


  • Gradual loss of circulatory functions
  • Reduced body temperature & decreased BP
  • Cyanosis, cool extremities, mottling, pallor
• Nursing Interventions for circulatory changes

  1. Regular turning

  2. Protect bony areas with pads

  3. Gentle massage to promote circulation and relieve edema

  4. Keep warm

  5. Administer medications as prescribed
• Digestive and urinary system changes


  • Swallowing difficulty
  • Decreased peristalsis → constipation, nausea, poor appetite
  • Reduced gag reflex → aspiration
  • Incontinence
• Nursing Interventions for digestive and urinary changes

  1. Provide soft diet/ fluid diet; small frequent meals

  2. Provide patient's favorable food and high fiber food

  3. Give medications as prescribed

  4. Incontinence care
• Nervous system changes

  • Confused, hallucination, self- talking
  • Lethargy
  • Coma
  • Loss of sensory functions
  • Severe pain
• Nursing Interventions for nervous system changes

  1. Respect the patient: address patient's name and inform patient during nursing procedures

  2. Administer medications as prescribed

  3. Give support and clarification when necessary
• Sensory system changes

  • Dry mouth, decreased sensation of taste and smell
  • Poor vision, reduced ability to speak
  • Decreased sensation of touch , but feel pressure of touch
  • Last sense lost: hearing
• Nursing Interventions for sensory changes

  1. Provide oral care / eye care/ nose care if necessary

  2. Be patient while providing nursing care
• Psychological changes for dying patient

  • Denial
  • Anger
  • Bargaining
  • Depression
  • Acceptance
• Denial


  • Deny the reality of death and repress what is discussed → treatment refusal
  • Temporary defensive
  • Last for few months, or even until death
• Nursing interventions for denial

  1. Provide appropriate and accurate information

  2. Accept emotional stages of patient and provide support

  3. Allow mood swings and give time to move through shock

  4. Encourage sharing of feeling
• Anger


  • Express rage and hostility and adopts a "why me?" attitude towards the loss
  • Daily nursing routines disrupted
  • Feel powerless / helpless/ unfair to own disease
  • Express anger in attitude to family, healthcare providers
• Nursing interventions for anger

  1. Accept the patient with empathy and silence

  2. Allow the patient to express feeling, and even complaints

  3. Avoid criticism, negative feedback and false reassurance

  4. Clear explanations of all procedures and treatments
• Bargaining


  • Tries to barter for more time
  • Promises as attempts to postpone or reverse the loss
  • Secret bargain from God for more living time or pain-free
  • Engage in some religious rituals hoping to extend life
  • More friendly and kind, hoping to 'cancel off' the disease
  • Put personal affairs in order, make wills, fulfill last wishes
• Nursing interventions for bargaining

  1. Listen attentively without judgment or pointing out reality

  2. Help to meet wishes as much as possible, and move to the later stages of dying

  3. Provide comfort and pain management

  4. Encourage talking about their beliefs and wills, can refer spiritual counsellor
• Depression


  • Realize the full impact of loss
  • Goes through a period of grief before death. The grief is characterized by crying and not speaking much
  • Either talk freely about the loss or withdraw from others
  • Worry about the family after death
  • S/S of depression: crying, loss of appetite, self-isolation, suicidal thoughts
• Nursing interventions for depression

  1. Accept and allow to express sadness

  2. Beware of suicidal thinking

  3. Accompany patient and provide emotional support
• Acceptance


  • Not all patients can reach this stage
  • Patients accepts the reality of death and prepared to die, feels transquil
  • Happens after expressing emotional feelings
  • Detach from relationships & seek solitude, peace and contentment
  • Resume activities with hopefulness for the future
• Nursing interventions for acceptance

  1. Give quiet time & provide support

  2. Allow patient to express own needs

  3. Discuss option of plan for complete wishes

  4. Show support & reassurance to family members

  5. Respect cultural, religious & social customs

  6. Reinforce feelings and sense of worth, specifically care to pediatric patients
• The 5 stages of dying and death varies from person to person, not move through each stage sequentially, varies in length (few hours to months), stages can be repeated and reverse, and family members also go through the same process
• Factors affecting response to dying and death

  • Age & experience
  • Gender
  • Family
  • Social support
  • Religion / Culture
  • Cause of death
• Nursing process for grieving

  • Assessment
  • Diagnosis
  • Planning
  • Implementation
  • Evaluation
• Assessment


  • Physical needs (pain, anxiety, fatigue)
  • Self-care behavior (perception and knowledge on the terminal illness)
  • Spiritual needs (supporting system, coping strategies, resources)
  • Psychosocial needs (emotion, depression)
  • Extent of physical distress in families (ability to run normal daily routines)
  • Level of guilty
  • Note for somatic symptoms (feelings of grief not expressed)
  • Concern about unfinished business
  • Priorities and preparation needs before death
• Nursing diagnoses for dying patient

  • Anxiety
  • Fear
  • Situational self-esteem
  • Self-care deficit
  • Risk for constipation
  • Risk for impaired skin integrity
• Planning


  • Identify expected outcomes with patient and families
  • Involve both patient and family: Encourage taking active role in planning of care, Take patient's preference into considerations
  • Facilitates acceptance of death by patient and family
  • Provides interventions to meet holistic needs