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1. Loss
   1. an actual or potential situation in which something that is valued is changed, no longer available, or gone
   2. types of loss
      1. actual loss
         1. a loss that can be identified by others
            1. e.g., loss of the ability to move legs due to paralysis
      2. perceived loss
         1. a loss that is perceived by one person but cannot be verified by another
            1. e.g., loss of financial independence when a woman leaves employment to care for her child at home
      3. anticipatory loss
         1. a loss that is experienced before the loss really occurs
            1. e.g., anticipation of the loss of a foot due to gangrene toes
   3. categories of loss
      1. loss of external objects
         1. e.g., loss of a home in a fire
      2. loss of a known environment
         1. e.g., a 6-year-old boy losing spending most of his day in his home environment when he begins attending kindergarten
      3. loss of significant others
         1. e.g., a wife losing her husband
      4. loss of an aspect of self
         1. e.g., a paraplegic man losing the function of his legs
      5. loss of life
2. Grief
   1. grief
      1. the totality of the subjective response and behavioral process experienced related to a loss
         1. bereavement is the subjective response experienced related to a loss
         2. mourning is the behavioral process experienced related to a loss
            1. mourning is often influenced by culture, religious experience, and custom
               1. e.g., a widow wears black at a funeral, Irish have wakes after a funeral
   2. types of grief reactions
      1. conventional
         1. abbreviated
            1. a grief reaction that is brief, but genuinely felt
         2. anticipatory
            1. a grief reaction that is experienced in advance of a loss
      2. dysfunctional
         1. unresolved
            1. a grief reaction that is extended in length and severity
         2. inhibited
            1. a grief reaction in which many of the normal symptoms of grief are suppressed
   3. stages of grief reactions
      1. Engel (1964)
         1. shock and disbelief
            1. the survivor either refuses to accept the loss or demonstrates intellectual acceptance of the loss but denies the emotional impact
         2. developing awareness
            1. the survivor becomes consciously aware of the reality and meaning of the loss
         3. restitution
            1. the survivor performs the work of mourning, which is accomplished by observing rituals dictated by religion and/or culture
         4. resolving the loss
            1. the survivor focuses energy on thoughts of the deceased
         5. idealization
            1. the survivor represses all negative feelings toward the decreased and, then, through identification, incorporates certain characteristics of the deceased into his or her own personality
         6. outcome
            1. the survivor diminishes psychological dependence on the deceased and becomes interested in developing new relationships
      2. Kubler-Ross (1969)
         1. denial
            1. the individual refuses to believe that the loss is happening
               1. serves as a buffer in helping the client mobilize defenses to cope with the situation
         2. anger
            1. the individual resists the loss
               1. anger, behaviorally described as "acting out", is often directed at family and health care providers
         3. bargaining
            1. the individual attempts to postpone the reality of the loss
               1. serves as a plea for an extension of life or the chance to "make everything right"
         4. depression
            1. the individual realizes the full impact of the loss
               1. serves as the preparation for the impending loss by working through the struggle of separation
         5. acceptance
            1. the individual comes to term with the loss
               1. serves as a form of detachment exemplified by a void of emotion or interest in worldly activities
   4. signs of grief
      1. repeated somatic distress
      2. tightness in the chest
      3. choking or shortness of breath
      4. sighing
      5. empty feeling in the abdomen
      6. loss of muscular control
      7. uncontrolled trembling
      8. loss of appetite
      9. sleep disturbance
      10. intense subjective distress
   5. common interventions for grieving clients
      1. plan time to be available for the client
      2. listen to the client’s grieving process
         1. utilize therapeutic communication skills
         2. utilize attentive listening skills
      3. respect racial, cultural, religious, and personal values of the client and significant others in their expressions of grief
      4. assure the client that intense feelings and reactions are normal initially
      5. provide information about the grieving process and what to expect
      6. encourage the client to express grief with significant others
      7. acknowledge significant others in their own grief and desire to help the client
      8. encourage the development of new relationships
      9. encourage the client to explore available resources
      10. encourage the client to explore support groups for individuals who have experienced a similar loss
      11. assess client well-being
      12. suggest that the client resume normal activities on a schedule that promotes physical and psychologic health
3. Dying and death
   1. stages of dying and death
      1. Kubler-Ross (1969)
         1. denial
            1. the individual refuses to believe the reality of his/her eventual death
         2. anger
            1. the individual resists his/her eventual death
         3. bargaining
            1. the individual attempts to postpone the reality of his/her eventual death
         4. depression
            1. the individual realizes the full impact of his/her eventual death
         5. acceptance
            1. the individual comes to term with the reality of his/her eventual death
   2. signs of impending death
      1. loss of muscle tone, e.g.:
         1. relaxation of facial muscles
         2. difficulty speaking
         3. difficulty swallowing
         4. gradual loss of the gag reflex
         5. decreased activity of the gastrointestinal tract
         6. possible urinary and rectal incontinence
         7. diminished body movement
      2. slowing of circulation, e.g.:
         1. diminished sensation
         2. mottling and cyanosis of extremities
         3. cold skin
      3. changes in vital signs, e.g.:
         1. decelerated and weaker pulse
         2. decreased blood pressure
         3. rapid, shallow, irregular, or abnormally slow respirations
         4. Cheyne-Stokes respirations
         5. death rattle
      4. sensory impairment, e.g.:
         1. blurred vision
         2. impaired senses of taste and smell
   3. definitions of death
      1. heart-lung death
         1. the irreversible cessation of spontaneous respiration and circulation
         2. emerged from the historical idea that the flow of body fluids was essential for life
         3. manifestations of heart-lung death:
            1. no spontaneous respirations
            2. no spontaneous heart beat
      2. whole brain death
         1. the irreversible cessation of all functions of the entire brain, including the brain stem
         2. emerged in the 1960s from the belief that neocortical functioning is the key to the definition of a human being
         3. manifestations of whole brain death:
            1. unreceptive and unresponsive to external stimuli
            2. no muscular movement
            3. no spontaneous respirations
            4. no relfexes
            5. flat electroencephalogram (EEG) for 24 hours
            6. no circulation to or within the brain evidenced by Doppler ultrasound for 24 hours
            7. positive apnea test
               1. apnea when off the respirator for four minutes with a PaCO₂ of at least 60 mm Hg
      3. higher brain death
         1. the irreversible loss of all "higher" brain functions, of cognitive function
         2. emerged in the 1970s from the belief that the brain is more important than the spinal cord and that the critical functions are the individual’s personality, conscious life, uniqueness, capacity for remembering, judging, reasoning, acting, enjoying, and worrying
   4. changes in the body after death
      1. rigor mortis
         1. stiffening of the body
         2. occurs about 2 - 4 hours after death
      2. algor mortis
         1. gradual decrease of body temperature after death
         2. body temperature falls about 1° C (1.8° F) per hour until it reaches room temperature
      3. livor mortis
         1. discoloration of the skin due to breakdown of red blood cells and release of their hemoglobin
         2. appears in the lowermost, or dependent, areas of the body
4. Factors influencing loss, grief, death, and dying
   1. developmental state
      1. e.g., a 4-year girl, who would typically believe that death is reversible, may assume that her dead grandfather will "wake-up" and come back to life
   2. significance of the loss
      1. e.g., a woman may view menopause not as a loss, but as providing more sexual spontaneity due to freedom from unplanned pregnancies
   3. culture
      1. e.g., in Western society, the prevalent attitude seems to be to view loss and death as dreaded enemies to be fought and postponed
   4. spiritual beliefs
      1. e.g., in the Jewish religion, family and friends sit Shiva with the survivors and the survivors unwrap the deceased’s headstone one year after burial (Jarhzeit)
   5. sex-role
      1. e.g., men are socialized to "be strong" and show very little emotion during grief
   6. socioeconomic status
      1. e.g., a wife, whose husband has an adequate pension plan or insurance, will have more options for coping with widowhood
   7. cause of death
      1. e.g., a gay man’s mother and father may view their son’s death as a the result of acquired immunodeficiency syndrome (AIDS) as punishment for his homosexuality
5. Common interventions for dying clients
   1. develop a trusting nurse-client relationship with client and significant others
   2. explain the client’s condition and treatment to both the client and significant others
   3. if desired, teach client’s significant others how to assist in his/her care
   4. meet physiologic needs of dying clients
      1. provide personal hygiene measures, e.g.:
         1. mouth care
         2. clean, dry, wrinkle-free linen
         3. frequent changes of gown if diaphoretic
      2. relieve respiratory difficulties, e.g.:
         1. Fowler’s position
         2. pharyngeal suctioning
         3. oxygen as needed
      3. assist with movement, nutrition, hydration, and elimination, e.g.:
         1. frequent changes of position
         2. antiemetics to stimulate appetite
         3. encourage fluids
         4. skin care if incontinent
      4. provide measures related to sensory changes, e.g.:
         1. touch
         2. speak clearly and do not whisper (hearing is the last to go)
         3. brightly lit room
      5. relieve pain, e.g.:
         1. provide pharmacologic, nonpharmocologic, and/or cognitive-behavioral pain management
   5. meet spiritual needs of dying clients
      1. if comfortable, a nurse can directly provide spiritual care for the dying client
         1. e.g., pray with the client, read scripture with the client, meditate with the client
      2. if uncomfortable, a nurse should arrange access to individual(s) who can provide spiritual care for the dying client
         1. e.g., priest, minister, rabbi
   6. meet pyschologic needs of dying clients
      1. prevent loss of control and dependency
         1. encourage the client to make as many decisions as possible about his/her care
      2. prevent social isolation, e.g.:
         1. help the client maintain involvement in established, significant relationships
         2. provide meaningful environmental stimulation
         3. encourage significant others to stay in communication through caring, silence, touch, and telling the client of their love
      3. life review and framing memories, e.g.:
         1. encourage the client and significant others to talk about past accomplishments, pleasures, and hardships
         2. ask the client to give significant others meaningful information to pass on to future generations
         3. have significant others share with the client what he/she means to them and their future aspirations
      4. guided imagery, e.g.:
         1. self-chosen or instructor-suggested images of the hospital room as a safe, comfortable place to die
         2. death as a state of eternal peace
         3. heaven as a garden of flowers eternally in bloom
      5. final wishes and saying good-bye, e.g.:
         1. preferences for the funeral
         2. burial arrangements
         3. wish to offer body to science or organs for transplantation
   7. meet needs of the significant others of dying clients
      1. listening to significant others’ concerns, e.g.:
         1. utilize therapeutic communication skills
         2. utilize attentive listening skills
      2. remind significant others to care for themselves, e.g.:
         1. get rest
         2. eat nutritiously
      3. prepare significant others for the reality of death, e.g.:
         1. explain the signs of impending death
         2. explain changes in the body after death
         3. explain the grieving process
   8. provide postmortem care
      1. care of the client’s body
         1. remove or cut all tubes and lines according to health care agency policy
         2. close the client’s eyes
         3. replace dentures or other dental appliances, if worn
         4. straighten the client and lower the bed to a flat position
         5. place a pillow under the client’s head
         6. wash the client if needed, honoring any religious or cultural rituals
         7. comb and arrange the client’s hair
         8. place pads under the client’s hips and around the perineum to absorb feces and urine
         9. clean up the client’s room or unit
         10. prepare the client for transfer to either a morgue or funeral home
             1. wrap the client in a shroud
             2. attach identification tags per agency policy
      2. care of the client’s significant others
         1. listening to significant others’ grieving process
            1. utilize therapeutic communication skills
            2. utilize active listening skills
         2. if desired, allow significant others to see the body in private and perform any religious or cultural custom they wish
         3. provide a private place for significant others to begin the grieving process
         4. if requested, notify the hospital chaplain or appropriate community religious leader
      3. care of other clients
         1. listening to other clients’ grieving processes who were aware of the death of the client
      4. care of other nurses
         1. listening to other nurses’ grieving processes who were involved in the client’s care
   9. hospice care
      1. focuses on support of the dying client and family with the goal of facilitating a peaceful and dignified death
      2. based on holistic concepts that emphasize care to improve the quality of remaining life rather than cure
      3. four key features of hospice:
         1. interdisciplinary team
         2. inclusion of family as defined by the client
         3. pain management and symptom control, or palliation (lessening)
         4. individuality and dignity 

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