Question

What is the difference between actual loss, perceived loss, and anticipatory loss?

What are the stages of grief/dying according to Kubler Ross? Describe each stage.

Define death.

Describe a "good death".

What is the role and limitations of a nurse in providing a good death?

What is the difference between normal and dysfunctional grief?

Answer 1

• Actual Loss is a type of loss that can be regcognized by others as well as by the person sustaining the loss. For example loss of a limb, of a spouse, of a valued object such as money, loss of a job.
• Perceived Loss is a type of loss is felt by the person but is intangible to others. For example Loss of youth, financial independence, a valued environment.
• Anticipatory Loss is a type of loss in which a person displays loss and grief behaviors for a loss that has yet to take place. It is Often seen in families of patients with serious and life-threatening illnesses, and serves to lessen the impact of the actual loss of a family member.

The 5 stages of grief and loss are:
1. Denial and isolation
2. Anger
3. Bargaining
4. Depression
5. Acceptance.

People who are grieving do not necessarily go through the stages in the same order or experience all of them. They are tools to help us frame and identify what we may be feeling.

The Five Stages of Grief

1. Denial

The first reaction to learning about the terminal illness, loss, or death of a cherished loved one is to deny the reality of the situation. “This isn’t happening, this can’t be happening,” people often think. It is a normal reaction to rationalize our overwhelming emotions.

Denial is a common defense mechanism that buffers the immediate shock of the loss, numbing us to our emotions. We block out the words and hide from the facts. We start to believe that life is meaningless, and nothing is of any value any longer. For most people experiencing grief, this stage is a temporary response that carries us through the first wave of pain.

2. Anger

As the masking effects of denial and isolation begin to wear, reality and its pain re-emerge. We are not ready. The intense emotion is deflected from our vulnerable core, redirected and expressed instead as anger. The anger may be aimed at inanimate objects, complete strangers, friends or family. Anger may be directed at our dying or deceased loved one. Rationally, we know the person is not to be blamed. Emotionally, however, we may resent the person for causing us pain or for leaving us. We feel guilty for being angry, and this makes us more angry.

3. Bargaining

The normal reaction to feelings of helplessness and vulnerability is often a need to regain control through a series of “If only” statements, such as: If only we had sought medical attention sooner…If only we got a second opinion from another doctor…If only we had tried to be a better person toward them…This is an attempt to bargain. Secretly, we may make a deal with God or our higher power in an attempt to postpone the inevitable, and the accompanying pain. This is a weaker line of defense to protect us from the painful reality. Guilt often accompanies bargaining. We start to believe there was something we could have done differently to have helped save our loved one.

4. Depression

There are two types of depression that are associated with mourning. The first one is a reaction to practical implications relating to the loss. Sadness and regret predominate this type of depression. We worry about the costs and burial. We worry that, in our grief, we have spent less time with others that depend on us. This phase may be eased by simple clarification and reassurance. We may need a bit of helpful cooperation and a few kind words. The second type of depression is more subtle and, in a sense, perhaps more private. It is our quiet preparation to separate and to bid our loved one farewell.

5. Acceptance

Acceptance is often confused with the notion of being “all right” or “OK” with what has happened. This is not the case. Most people don’t ever feel OK or all right about the loss of a loved one. This stage is about accepting the reality that our loved one is physically gone and recognizing that this new reality is the permanent reality. We will never like this reality or make it OK, but eventually we accept it. We learn to live with it. It is the new norm with which we must learn to live. We must try to live now in a world where our loved one is missing. In resisting this new norm, at first many people want to maintain life as it was before a loved one died. In time, through bits and pieces of acceptance, however, we see that we cannot maintain the past intact. It has been forever changed and we must readjust. We must learn to reorganize roles, re-assign them to others or take them on ourselves. Finding acceptance may be just having more good days than bad ones. As we begin to live again and enjoy our life, we often feel that in doing so, we are betraying our loved one. We can never replace what has been lost, but we can make new connections, new meaningful relationships, new inter-dependencies. Instead of denying our feelings, we listen to our needs; we move, we change, we grow, we evolve. We may start to reach out to others and become involved in their lives. We invest in our friendships and in our relationship with ourselves. We begin to live again, but we cannot do so until we have given grief its time.

Death

Death is defined as the permanent cessation of all vital functions of the body including the heartbeat, brain activity (including the brain stem), and breathing. Death comes in many forms, whether it be expected after a diagnosis of terminal illness or an unexpected accident or medical condition.

Good Death:

A good death is "Free from avoidable distress and suffering for patient, family and caregivers, in general accord with the patient's and family's wishes, and reasonably consistent with clinical, cultural and ethical standards."

Nurses’ roles and responsibilities for care at the end of life are grounded in the fundamentals of excellent
practice and clinical ethics. Respect for patient autonomy is an important dimension of clinical decisionmaking,
including at the end of life. While often rewarding, care of patients and families when a person is
dying is demanding work that requires the nurse to marshal professionalism and compassion while honoring
the nurse’s personal integrity.

Guidance and Support for Patients and Families at the End of Life
Nursing care includes not only disease management but also attention to physical comfort, and the
recognition that patients’ well-being also comprises psychological, interpersonal, and spiritual dimensions.
Nurses should have the knowledge and skills to manage pain and other distressing symptoms for patients
with serious or life-limiting illness, and to work with patients and their families in palliative and end-of-life
care decision-making.
Palliative care refers to aggressive symptom management, supported decision-making, and end-of-life care.
Primary palliative care refers to the knowledge and skills of palliative care that all providers should have,
including basic symptom management, the ability to support decision-making (based on accurate
physiologic data), and the ability to provide support for patients and families. Specialist palliative care refers
to the use of consultant specialists with expert knowledge in palliative care to improve care of patients and
families. This is much the same model as is used to enhance cardiovascular, renal, neurologic, or other
dimensions of patient care.

Roles of nurses in Providing a Good Death

• Making environmental changes to promote dying with dignity.

The nurse should encourage family members to stay with the patient. Beds should be made available for family members and also food and showering facilities. Soothing music would add a nice touch. There should also be quiet places for prayer and meditation and family gathering.

• Being present:

“The ICU is no place to die" So help the patient in moving to private rooms. It would be nice to have a comfortable, quiet, spacious room for those who are dying. Let everyone in and let the rest of the ICU function as it should.

No patient should face death alone.Every patient needs to have someone present with them at the moment of death,to touch them, speak to them, to let them know it’s okay to go. A patient’s primary nurse should be relieved of all other responsibilities and focus on caring for the dying patient and the patient’s family.

• Managing patients’ pain and discomfort:

Minimizing patient suffering by administering adequate comfort measures, ie, intravenousdrugs and withdrawing vasopressors, hemodialysis,IABP [intra-aortic balloon pump], and blood products,depending on the patient’s level of consciousness and whether or not there is an advance directive.

• Knowing and following patients’ wishes for end-of-life care​
• Promoting earlier cessation of treatment or not initiating aggressive treatment at all ( stopping all invasive procedures and the treatments to patient in a futile situation )
• Communicating effectively as a healthcare team :

​Improved communication between physicians and nurses would ultimately facilitate a good death because everyone could work toward the same goal or plan of care. A specialized counselor can help work with families in denial.

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