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Kubler-Ross stages

or the five stages of grief, is the series of emotional stages that someone experiences when faced with impending death or other extreme, awful fate. The five stages are denial, anger, bargaining, depression and acceptance

goals of the grief process.

both before and after the death include resolving emotions, reflecting on the dying person, expressing feelings of loss and sadness, and valuing what has been shared.


term used for issues related to death and dying, as well as services provided to address these issues (end of life care)

Physical Signs and symptoms of impending death.

metabolism is reduced
body gradually slows down
respirations cease first
followed by stop of heart beat

Define normal grief pattern

1. Shock and Disbelief = first confrontation!
2. Developing Awareness (Yearning, Protest, Anguish, Despair; Confrontation)
3. Restitution (Reorganization)
4. Resolution (Reorganization & Restoration; Accommodation)
5. Idealization (Restoration; Accommodation)

Define an atypical grief pattern

Delayed grief response (Absent Grief) -- stuck in denial; go on after a major loss as if nothing has happened.

Describe the stage of denial

I cannot believe this is happening to me

Describe the stage of anger

common and normal response to grief. Nurses often target, angry with the dying loved one who is leaving them.

Describe the stage of bargaining

1. Usually begins when anger is somewhat dissipated.
2. "I'll do anything if....."

Describe the stage of depression

1. Occurs with realization that death is inevitable.
2. Person may refuse visitors, be silent, refuse to see friends, cry, or stare into space.
3. Patient seems to be preparing for time when he/she will no longer see or hear others.
4. "Yes---me."

Describe the stage of acceptance

1. Person goes about saying & doing all the unfinished business of his/her life.
2. Stage of feeling at peace with oneself, with one's imminent death, and with the universe; a quiet sense of expectation.
3. Person content with 1 or 2 close friends & family--fear of death is removed.
4. "I am ready now."

Cheyne-Stokes respiration -

a pattern of breathing characterized by alternating periods of apnea and deep rapid breathing, seen when person nears death

What body function ceases first/second as person approaches death?

1st respirations cease, then heart stops beating within a few minutes

Goal of EOL care - state four.

1. provide comfort and supportive care during the dying process
2. improve the quality of the patient's remaining life
3. help ensure a dignified death
4. provide emotional support to the family

Sensory changes of approaching death.

*blurred vision
*sinking and glazing eyes
* blink reflex absent
*eyelids remain half-open

Where does the sense of touch decrease first?

in the lower extremities because of circulation alterations

death rattle

a rattling or gurgling sound produced by air passing through mucus in the lungs and air passages of a dying person

adaptive grief

A healthy response. Grief that assists the person in accepting the reality of death. It may be associated with grieving before a death actually occurs or when the realty that death is inevitable is known.

anticipatory grief

The unconscious process of disengaging or "letting go" before the actual loss or death occurs.

prolonged grief disorder

Prolonged and intense mourning, can include symptoms of such as recurrent distressing emotions, intrusive thoughts related to the loss of a loved one, self-neglect and denail of death longer than 6 months

For the past 5 years, Tom has repeatedly asked his mother to donate his deceased father's belongings to charity, but his mother has refused. She sits in the bedroom closet, crying and talking to her long-dead husband. What type of grief is Tom's mother experiencing?

prolonged grief disorder

palliative care

any form of care or treatment that focuses on reducing the severity of disease symptoms, rather than trying to delay or reverse the progression of the disease itself or provide a cure.

Goal of palliattive care

1. prevent and relieve suffering
2. improve quality of life for pt. with serious life-limiting illness

Who initiates palliative care?

person receiving diagnosis of life-limiting illness

Where do patients receive pallative care?

acute care facilities


when all vital organs and body systems cease to function; irreversible cessation of cardiovascular, respiratory, and brain function

death brain

occurs when cerebral cortex stops functioning, irreversible loss of all brain functions, including the brainstem.

function of brainstem

Controls basic functions like breathing, heart rate, etc., clinical diagnosis

Circulation changes due to approaching death.

decreased, noticable on the skin; extremities are pale, mottled,cyanotic, skin is cool to touch, firsts in feet and legs, then progressining to hands and arms, fianlly to torso

Loss of muscle tone due to approaching death.

facial muscles lose tone, causing the jaw to sag, difficulty in speaking, swallowing difficut, gag reflex eventually lost


the period of time following the death of a loved one during which grief is experienced and mourning occurs


refers to the reaction to loss and adapting to change

Gastrointestinal manifestations at end of life.

gastrointestinal motility diminishes, leading to constipation, gas accumulation, distension, and nausea

Kidney function manifestations at end of life.

ability of kidneys to produce urine and the urinary system to excrete urine decreases, loss of sphincter control can lead to fecal an urinary incontinance

Psychosocial manifestations at end of life.

response to questions may be sluggish because of fatigue, weakness, and confusion

Characteristics of spiritual distress at terminal diagnosis.

anger toward God or higher being
change in behavior and mood
desire for spiritual assistance
displaced anger toward religious representatives
display of "gallows humor"

gallows humor

humor in the face of pain or death

Psychosocial care for an appraoching death.

anxiety most common distress symptom. Hel wtih relaxation strategies as music & imagery, can help hopelessmess by allowing patient make descixions, pt afraid of pain (assure pain control)

delayed grief response (absent grief)

stuck in denial; go on after a major loss as if nothing has happened.

Impeded grief reaction -

suddenly stop grieving. May have been told, "Stop feeling sorry for yourself--get on with your life!"

masked grief

survivor is unaware that behaviors that interfere with normal functioning are a result of the loss.

NANDA for grieving

"Dysfunctional Grieving"

conflicted grief

when there are unresolved, ambivalent feelings toward the deceased.

exaggerated grief

survivor resorts to self-destructive behaviors, such as suicide.

chronic or pathologic grief

normal patterns that persist for very long periods of time.

Other ways manifestation of delayed or impeded grief expressed.

• Developing imagined illnesses
• Becoming a "work-a-holic"
• Using "retail therapy"--(person who shops & spends money, often getting into serious financial problems, just to avoid the work of mourning.)
• Becoming a chemical abuser to help forget their grief
• Becoming a crusader for a certain cause—might be good in itself, but not to avoid grief.

Communicating with the patient who is dying "The Do's"

1. Explore feelings.
2. Answer questions with questions.
3. Listen, Listen, Listen!
4. Be therapeutic -- Offer self!
5. Touch
6. Open-ended questions

Communicating with the patient who is dying "The Do nots"

1. Patronize/use clichés
2. Force conversation
3. Violate privacy
4. Avoid the subject

Name cliches not to use with a dying patient.

*I know exactly how you're feeling.
*I can imagine how you are feeling.
*I understand how you are feeling.
*I'm always here for you, call me if you need anything.
*You should be over it by now. It's time you moved on.
*You had so many years together. You are so lucky.
*At least you have your children.
*You're young, you'll meet someone else.
*At least her suffering is over. She is in a better place now.
*He lived a really long and full life.
*How old was he?

Helpful comments to use with family members of deceased patient.

*I am sorry that you are going through this painful process.
*It must be hard to accept that this has happened.
*It's OK to grieve and be really angry with God and anyone else.
*I can bring dinner over either Tuesday or Friday. Which will be better for you?
*Grieving takes time. Don't feel pushed to hurry through it.
*I did not know __________, will you tell me about him? What was your relationship like?
*It's not your fault. You did everything you could do.
*What's the most scary part about facing the future alone without __________?
*You will never forget __________, will you?
*It's not easy for you, is it? What about your relationship will you miss the most?
*He meant a lot to you.

What occurs during first confrontation?

1. Shock and Disbelief = first confrontation!
a. Marked by DENIAL (Avoidance).
b. May last from minutes to days or months, & take a physical as well as emotional toll.
1) Griever may have insomnia, nightmares, exhaustion, diaphoresis, nausea, & anorexia, as well as an emotional distress.
2) Immune system is temporarily impaired when stress occurs -- watch for signs of developing a serious illness!
c. Main function of denial -- Emotional survival!

Process of developing awareness of impeding death.

2. Developing Awareness (Yearning, Protest, Anguish, Despair; Confrontation)
a. Reality of the loss permeates consciousness.
b. Intense sadness & longing.
1) Anger-- at patient, family member, doctor, nurse!
2) Guilt --"Why didn't I do more?"
3) Depression, despair -- after rage is exhausted. "I
felt like World War 3 had happened, & I was the only one who experienced it."


3. Restitution (Reorganization)
a. "THE WORK OF MOURNING " or doing grief work.
b. Time to share grief.
c. Time of RITUALISM (funeral, wake, memorial service) --provides some closure.
d. Bereavement -- includes grief & mourning--the inner feelings & outward reactions of the survivor.

Resolution of deceased loved one.

4. Resolution (Reorganization & Restoration; Accommodation)
a. Does not proceed smoothly or in orderly fashion.
b. Preoccupation with the loss.
c. "Somaticism" -- May take on the physical symptoms or
characteristics of the lost loved one.
d. Dreaming &/or communication with lost loved one in
some personal way.
e. Negative feelings suppressed
f. Feelings of guilt easily surface.

idealization of deceased loved one

5. Idealization (Restoration; Accommodation)
a. Start of getting back to normal.
b. Still keeps certain aspects of lost person or object within
his/her personality.
c. Renewed interest in life

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