Loss, grief, and death are a commonplace experience related to perceived or anticipated losses of life, relationships, valued material objects, physiologic integrity, valued ideals, terminal illness, and other personal crises. The nurse interacts with dying clients and their families or caregivers in a variety of settings, and must recognize its effects on the dying process—legal, ethical, spiritual, biological, psychologic— and be prepared to provide sensitive, skilled, and supportive care to all those affected.
Loss and Grief
Loss is an actual or potential situation in which something that is valued is changed or no longer available. These are physical and abstract concepts such as loss of body image, a significant other, a sense of well-being, a job, personal possessions, or beliefs. Illness and hospitalization often produce losses.
Death is a loss for both the dying individual for those who survive. Although death is inevitable, it can push individuals to understand themselves better. Individuals experiencing loss often search for the meaning of the event, and it is generally accepted that finding meaning is needed in order for healing to occur. However, there are individuals who become well-adjusted without searching for meaning, and individuals who find meaning yet perceive it as an end point rather than an ongoing process.
Types of Loss
- Actual Loss is a type of loss that can be recognized by others.
- Perceived Loss is experienced by an individual but cannot be verified by others. Psychologic losses are often perceived losses because they are not directly verifiable.
- Anticipatory Loss, which can be both actual loss or perceived loss, is experienced before the loss actually occurs.
- Loss may be situational, e.g., losing one’s job, the death of a child, functional loss, or developmental (events occurring in normal development) such as subfertility in old age, the departure of one’s children, or retirement.
Sources of Loss
- Aspect of Self: body image (scarring), physical capabilities, and mental capabilities. Commonly vulnerable in old age.
- External Objects: inanimate objects that have importance to the individual, such as losing money or the burning down of a family’s house, and loss of animate objects such as pets that provide love and companionship
- Familiar Environment: separation from an environment and individuals who provide security can cause a sense of loss. Examples include 6-year-olds first leaving the home environment to attend school, or immigrants leaving their country to settle down in another (culture shock).
- Loved Ones: illness, divorce, separation, or death of loved ones are among the most powerful sources of loss. Changes in personality of the loved one may also make friends and family feel they have lost that individual.
Grief, Bereavement, and Mourning
Grief is the total response to the emotional experience related to loss. This manifests in thoughts, feelings, and behavior associated with overwhelming distress or sorrow. Bereavement is the subjective response experienced by the surviving loved ones. Mourning is the behavioral process through which grief is eventually resolved or altered; it is often influenced by culture, spiritual beliefs, and custom.
Bereavement may have potentially devastating effects on health. Symptoms that accompany grief include anxiety, depression, weight loss, difficulties in swallowing, vomiting, fatigue, headaches, dizziness, fainting, blurred vision, skin rashes, excessive sweating, menstrual disturbances, palpitations, chest pain, and dyspnea. It is important to work through one’s grief as the bereaved may experience alterations in libido, concentration, and patterns of eating, sleeping, activity, and communication.
While potentially threatening, a positive resolution of the grieving process can enrich the individual with new insights, values, challenges, openness, and sensitivity. For some, the pain of loss, though diminished, recurs for the rest of their lives.
Grief Responses
A normal grief reaction may be abbreviated or anticipatory.
- Abbreviated Grief: genuinely felt, but brief reaction.
- Anticipatory Grief: experienced in advance of the event.
- Disenfranchised Grief: an individual is unable to acknowledge the loss to others, such as in socially unacceptable losses that cannot be spoken about, such as suicide, abortion, or giving a child up for adoption.
- Complicated Grief: unhealthy grief; maladaptive and out-of-proportion or inconsistent with cultural, religious, or age-appropriate norms. This can become recognized as a disorder—persistent complex bereavement disorder— if the preoccupation lasts for more than 12 months and leads to reduced ability to function normally.
- Unresolved or Chronic Grief is extended in length and severity.
- Inhibited Grief is difficult to express, or denied by the individual. Often, the normal symptoms of grief are suppressed and other effects, including physiologic, are experienced instead.
- Delayed Grief occurs when feelings are purposely or subconsciously suppressed until a much later time.
- Exaggerated Grief may be experienced as overwhelming and unmanageable feelings of grief, where the individual may engage in risky or self-destructive behaviors as a way to cope with their emotional pain.
Stages of Grief
There are two commonly cited theories. The most well-known and common is by Kübler-Ross (1969). Whether an individual can integrate the loss and how this is accomplished are related to that individual’s development, personality, and emotional preparedness. In addition, individuals responding to the very same loss cannot be expected to follow the same pattern or schedule in resolving their grief, even while they support each other.
| Stage | Behavioral Responses | Nursing Implications |
|---|---|---|
| Denial | Refuses to believe that loss is happening. Is unready to deal with practical problems, such as prosthesis after the loss of a leg. May assume artificial cheerfulness to prolong denial. | Verbally support client but do not reinforce denial. Examine your own behavior to ensure that you do not share in client’s denial. |
| Anger | Client or family may direct anger at nurse or staff about matters that normally would not bother them. | Help client understand that anger is a normal response to feelings of loss and powerlessness. Avoid withdrawal or retaliation; do not take anger personally. Deal with needs underlying any angry reaction. Provide structure and continuity to promote feelings of security. Allow clients as much control as possible over their lives. |
| Bargaining | Seeks to bargain to avoid loss (e.g., “let me just live until [a certain time] and then I will be ready to die”). | Listen attentively, and encourage client to talk to relieve guilt and irrational fear. If appropriate, offer spiritual support. |
| Depression | Grieves over what has happened and what cannot be. May talk freely (e.g., reviewing past losses such as money or job), or may withdraw. | Allow client to express sadness. Communicate nonverbally by sitting quietly without expecting conversation. Convey caring by touch. |
| Acceptance | Comes to terms with loss. May have decreased interest in surroundings and support people. May wish to begin making plans (e.g., will, prosthesis, altered living arrangements). | Help family and friends understand client’s decreased need to socialize. Encourage client to participate as much as possible in the treatment program. |
Manifestations of Grief
The nurse assesses the grieving client or family member following a loss to determine the phase or stage of grieving. Physiologically, the body responds to a current or anticipated loss with a stress reaction. The nurse can assess the clinical signs of this response.
Manifestations of grief considered normal include verbalization of the loss, crying, sleep disturbance, loss of appetite, and difficulty concentrating. Complicated grieving may be characterized by extended time of denial, depression, severe physiologic symptoms, or suicidal thoughts.
Factors Influencing the Loss and Grief Responses
- Age affects an individual’s understanding of an reaction to loss. With familiarity, individuals usually increase their understanding and acceptance of life, loss, and death.
- Significance of the Loss depends on the perception of the individual experiencing the loss.
- Culture influences an individual’s reaction to loss, especially in the expression of grief.
- Spiritual Beliefs and practices related to loss and death can be very powerful for advancing through the stages of grief.
- Gender roles can place stereotypes on grief responses, with men expected to “be strong” and show little emotion, whereas it is acceptable for females to show grief by crying.
- Socioeconomic Status; economic hardship can cause further stress and difficulty in coping.
- Support Systems in place greatly benefit the grieving client.
- Cause of Loss or Death: views on the cause of a loss or death may significantly influence the response. “Clean” deaths such as those resulting from cardiovascular disorders can engender compassion, whereas others may be viewed as repulsive and less fortunate. The preventability of the loss may also alter the views on the loss.
Nursing Management
- Assessment encompasses three major components: nursing history, assessment of personal coping resources, and physical assessment. History of and previous losses is assessed, and the nature and significance of the loss to the client must be explored.
- Greater detail is required for current or recent loss. Physical ailments may be caused by loss emotional responses.
- Determine general health status; other personal stressors; cultural and spiritual traditions; and support networks. These are necessary for formulating a plan of care.
- Diagnosing: nursing diagnoses of Grief and Potential for Complicated Grief may be appropriate for problems related to death, loss, and bereavement.
- Planning: the overall goals for clients grieving the loss of body function or a body part are to adjust to the changed ability and to redirect both physical and emotional energy into rehabilitation. The goals for clients grieving the loss of a loved one or thing are to remember them without feeling intense pain and to redirect emotional energy into one’s own life and adjust to the actual or impending loss.
- Implementing: besides providing physical comfort, maintaining privacy and dignity, and promoting independence, the skills most relevant to situations of loss and grief are those of effective communication— attentive listening, silence, open and closed questioning, paraphrasing, clarifying and reflecting feelings, and summarizing. Communication must also be related to the client’s stage of grief.
- Evaluating: the long-term nature of grief makes evaluation of nursing care difficult. Criteria for evaluation must be based on goals set by the client and family. If outcomes are not achieved, the nurse needs to explore why the plan was unsuccessful. The nurse should reassess the client and consider if grieving behaviors appear dysfunctional, are related to other nursing diagnoses, or are being affected by additional stressors.
Dying and Death
The concept of death develops throughout life. Young children do not understand the concept of death, older children begin to understand death as the final and inevitable end of life, adolescents fear death but are not preoccupied, adults accept their mortality and encounter death of parents and peers which bring about the peak of death anxiety, and older adults fear prolonged illness; sometimes valuing death as more valuable than living with a poor quality of life.