Nursing is a unique
profession in that care is provided at the beginning of a life, at the end of a
life, as well as at various points in between. Some of the greatest challenges
the nurse faces relates to the provision of care for clients with a very poor
prognosis or who are in the process of dying. Not only do nurses have to care
for patients who are dying, but they also have to work with those who are
affected by death, those who have lost someone close to them and those who are
experiencing the grieving process. Therefore, it is important for nurses to have
a sound understanding of issues relating to death and dying in order to be able
to provide appropriate end-of-life care. It should be remembered that hospice
care involves providing care at the end of life, while palliative care promotes
comfort and eases suffering.
Clients experience loss in
many aspects of their lives. Grief is the inner emotional response to loss and
is exhibited through thoughts, feelings, and behaviors. Bereavement includes
both grief and mourning (the outward display of loss) as the individual deals
with the death of a significant individual in their life.
Palliative or end‑of‑life
care is an important aspect of nursing care and attempts to meet the client’s
physical, spiritual, emotional, and psychosocial needs. End‑of‑life issues
include decision‑making in a highly stressful time during which the nurse must
consider the desires of the client and the family. Decisions are shared with
other health care personnel for a smooth transition during this time of stress,
grief, and bereavement.
with all aspects of care there is a legal dimension to care relating to end-of-life
issues. These are specific to this stage of the care spectrum and the most
important ones for the nurse to have knowledge of include the following:
Advance directives: Legal documents that
direct end‑of‑life issues. These enable the client to spell out decisions
about end-of-life care preferences ahead of time.
Living will: Directive documents
for medical treatment as per the client’s wishes. This is a particular form of
an advanced directive usually limited to life sustaining procedures. This enables
the client to give legal instructions regarding preferences for specific
medical care when they are unable to make decisions for themselves.
Health care proxy (also known as durable
power of attorney for health care): A document that appoints someone to make
medical decisions when the client is no longer able to do so on his own behalf.
Types of Loss
dealing with clients the nurse has to understand that clients may have
experienced some form of loss that may help to explain their behavior(s) or
outlook. It is important to note that there are a variety of types of loss that
can be described in the following way:
Necessary loss: A loss related to a
change that is part of the cycle of life that is anticipated but still can be
intensely felt. This type of loss can be replaced by something different or
Actual loss: Any loss of a valued
person, item, or status, such as loss of a job that can be recognized by others.
Perceived loss: Any loss defined by
the client that is not obvious or verifiable to others
Maturational or developmental loss: Any loss normally
expected due to the developmental processing of life. These losses are
associated with normal life transitions and help to develop coping skills
(e.g., child leaving home for college).
Situational loss: Any unanticipated
loss caused by an external event (e.g., family loses home during tornado).
Anticipatory loss: Experienced before
the loss happens (e.g., anticipated loss of income and social connections
Theories of Grief
process of grief has been recognized historically and takes different forms in
various cultures. In our culture one of the best known and most widely used
models is the Kübler-Ross Model, and it is used in medical and care situations,
but has also been widely applied more generally throughout society to help
provide an explanation for the grieving process. It is a recognizable process
and provides perspective on the process that the grieving person is going
model outlines five stages of the grieving process:
Denial: The client has difficulty
believing a terminal diagnosis or loss.
Anger: The client lashes out at
other people or things.
Bargaining: The client negotiates for
more time or a cure.
Depression: The client is overwhelmingly
saddened by the inability to change the situation.
Acceptance: The client acknowledges what
is happening and plans for the future by moving forward.
Note: The stages might not
be experienced in sequential order, and the length of each stage varies from
person to person.
Factors Influencing Loss,
Grief, and Coping Ability
of us are individuals and although we may proceed through the stages of the Kübler-Ross
model, we all experience grief and loss individually. There are a number of
factors that have been identified that have influenced the loss, grief and
coping ability(s) of individuals and these are:
current stage of development.
Gender – men and
women may experience and express grief differently.
relationships and social support networks.
significance of the loss.
religious beliefs and practices.
Manifestations of Grief
can usually recognize when someone is experiencing the grief process in a way
that is “standardized” within our society and we can develop ways in which we
can work with a person who is in this somewhat standardized process in that:
This grief is
Emotions can be
negative, such as anger, resentment, withdrawal, hopelessness, and guilt
but should change to acceptance with time.
should be evident by 6 months after the loss.
complaints can include chest pain, palpitations, headaches, nausea,
changes in sleep patterns, and fatigue.
a grief reaction that occurs before an impending loss is viewed as something
that is normal and understood. It is a way of maintaining the person’s ability
to cope because:
implies the “letting go” of an object or person before the loss, as in a
the opportunity to start the grieving process before the actual loss.
Factors That Can Increase
an Individual's Risk for Dysfunctional Grieving
is anticipated that a person who is grieving may go through the normal and/or
anticipatory stages of the grieving process and that the factors influencing,
loss, grief, and coping ability will not impact upon them detrimentally.
However, there are certain factors that might interrupt the normal/anticipatory
grieving process and produce in the individual a form of dysfunctional
grieving. The factors that can increase an individual’s risk for this are:
exceptionally dependent upon the deceased
A person dying
unexpectedly at a young age, through violence or in a socially
coping skills or lack of social supports
Lack of hope or
preexisting mental health issues, such as depression or substance use
the grieving process does not follow a normal or anticipated pattern it may
become an existential threat for the person who is grieving. The
characteristics of complicated grief are:
chronic grief is a type of complicated grief.
involves difficult progression through the expected stages of grief.
work of grief is prolonged. The manifestations of grief are more severe,
and they can result in depression or exacerbate a preexisting disorder.
The client can
develop suicidal ideation, intense feelings of guilt, and lowered self‑esteem.
complaints persist for an extended period of time.
grief is a type of grief that is not recognized by society and is a type of
hidden sorrow. It is characterized by the following:
There is an
inability to share the grief, and it remains private.
entails an experienced loss that cannot be publicly shared or is not
socially acceptable, such as suicide and abortion.
have to deal with people who are in the grieving process, either when a client
they are caring for has died or when dealing with the family and friends of a
client in another facility but the nurse has ongoing contact with people who
are in the grieving process.
key nursing intervention in relation to the grieving process is for the nurse
to facilitate mourning. There are a number of strategies that the nurse can put
in place to assist and these include:
Grant time for
the grieving process.
expected grieving behaviors, such as crying, somatic manifestations, and
communication related to the client’s stage of grief. Name the emotion the
client is feeling. For example, the nurse can say, “You sound as though
you are angry. Anger is a normal feeling for someone who has lost a loved
one. Tell me about how you are feeling.”
listening, open‑ended questions, paraphrasing, clarifying, and/or
summarizing, while using therapeutic communication.
Use silence and
personal presence to facilitate mourning.
communication that inhibits the open expression of feelings, such as
offering false reassurance, giving advice, changing the subject, and
taking the focus away from the grieving individual.
grieving individual to accept the reality of the loss.
to “move on” in the face of the loss.
building of new relationships.
continuing support. Encourage the support of family and friends.
Assess for evidence
of ineffective coping, such as a client refusing to leave the home months
after his partner died.
information about mourning and grieving with the client, who might not
realize that feelings, such as anger toward the deceased, are expected.
attendance at bereavement or grief support groups. Provide information
about available community resources.
referrals for individual psychotherapy for clients who have difficulty
Ask the client
whether contacting a spiritual advisor would be acceptable, or encourage
the client to do so.
debriefing provided by professional grief and mental health counselors.
care is a term that is known in society but is often misunderstood. Palliative
care is specialized care for people with serious illness, usually those who are
requiring end-of-life care. This type of care is focused upon providing relief
from the symptoms and stress of that serious illness. The goal is to improve
the quality of life for both the patient and family. Palliative care is
provided by specially training doctors, nurses and other specialists to provide
an extra layer of support. This type of care is appropriate at any age and any
stage of a serious illness and it may be provided along with curative treatments
(GetPalliativeCare.org, 2017). The nurse has an important role to play as a
member of the palliative care team and the following points relating to
palliative care are important to understand:
The nurse serves
as an advocate for the client’s sense of dignity and self‑esteem by
providing palliative care at the end of life.
Goal is to learn
to live fully with an incurable condition.
improves the quality of life of clients and their families facing end‑of‑life
interventions are primarily used when caring for clients who are dying and
family members who are grieving. Assessment of the client’s family is\
very important as well.
interventions focus on the relief of physical manifestations (such as
pain) as well as addressing spiritual, emotional, and psychosocial aspects
of the client’s life.
can be provided by an interprofessional team of physicians, nurses, social
workers, physical therapists, massage therapists, occupational therapists,
music/art therapists, touch/energy therapists, and chaplains.
Hospice care, as
a comprehensive care delivery system, can be performed in a variety of
settings and is implemented when a client is not expected to live longer
than 6 months. Further medical care aimed toward a cure is stopped, and
the focus becomes enhancing quality of life and supporting the client
toward a peaceful and dignified death.
work directly with the client to maximize their use of palliative care options
client’s sources of strength and hope.
desires and expectations of the client and family for end‑of‑life care.
important part of the nurse’s role in palliative care is in identifying
discomfort and anticipating factors that may cause discomfort:
Approaching Death in the Palliative Care Client
are one of the few professionals to continue to work with, and care for,
clients as death approaches. When delivering care the nurse must be able to
recognize changes that the client is going through as end-of-life approaches.
The nurse should therefore be aware of these changes:
diminished, but client is able to feel the pressure of touch
collecting in large airways
of bowel and/or bladder
(cyanosis) occurring with poor circulation
no longer reactive to light
slow and weak and blood pressure dropping
death approaches for the client the nurse should:
continuity of care and communication by limiting assigned staff changes.
client and family to set priorities for end‑of‑life care.
provision of care does not cease in the end-of-life phase. The nurse has a
professional responsibility to ensure that care and comfort is continually
provided. The range of strategies that the nurse should employ to ensure
adequate care for the client and these include:
priority to controlling findings.
medications (such as morphine) that manage pain, air hunger, and anxiety.
ongoing assessment to determine the effectiveness of treatment and the
need for modifications of the treatment plan, such as lower or higher
doses of medications.
adverse effects of medications.
the client to maintain airway patency and comfort.
the integrity of skin and mucous membranes.
caring touch (holding the client’s hand).
an environment that promotes dignity and self‑esteem.
products of elimination as soon as possible to maintain a clean and odor‑free
careful grooming for hair, nails, and skin.
family members to bring in comforting possessions to make the client feel
appropriate, encourage the use of relaxation techniques, such as guided
imagery and music.
decision‑making in food selection, activities, and health care to give the
client as much control as possible.
the client to perform ADLs, as they are able and willing to do so.
from the nurse providing physical care as the client approaches death, there
are various resources that can be used to assist the client:
an interprofessional approach.
care and foster support to the client and family.
volunteers when appropriate to provide nonmedical care.
therapeutic communication to develop and maintain and facilitate
communication between the client, family, and the provider.
the understanding of information regarding disease progression and
communication between the client, the family, and the provider.
the client to participate in religious practices that bring comfort and
strength, if appropriate.
the client in clarifying personal values in order to facilitate effective
the client to use coping mechanisms that have worked in the past.
sensitive to comments made in the presence of clients who are unconscious
because hearing is the last sensation lost.
Prevention of Abandonment
client who is nearly end-of-life will have many fears and apprehensions that
the nurse will need to deal with. There are a range of interventions that the
nurse may use to prevent or minimize feelings of abandonment and isolation in
the client. These include:
Prevent the fear
of dying alone.
presence known by answering call lights in a timely manner and making
Keep the client
informed of procedure and assessment times.
members to stay overnight.
the client is most comfortable, such as in a room close to the nurses’
Support for the Grieving
the client has died there is a range of grief reactions within the family
and/or friends that the nurse may need to address. There are a number of
interventions that the nurse can use with those experiencing grief and these
family members plan visits to promote the client’s rest.
Ensure that the
family receives appropriate information as the treatment plan changes.
so family members have the opportunity to communicate and express feelings
among themselves without including the client.
members’ desire to provide physical care while maintaining awareness of
possible caregiver fatigue. Provide instruction as necessary.
family about physical changes to expect as the client moves closer to
to express feelings.
Care for the Caregiver
is important for caregivers to take care of themselves. However, caregivers often feel guilt when
they take time away from their loved one.
It can be difficult for them to ask for help from another person or
family member. Read the following
National Cancer Institute publication, Caring for the Caregiver, at https://www.cancer.gov/publications/patient-education/caring-for-the-caregiver.pdf . Using this publication and material
in this CNE course complete
the following activity.
a 2 page, front and back brochure that highlights how important it is for
caregivers to take care of themselves so they can better take of their loved
one. Include coping with grief, learning
how to ask for help, and accepting help from others. Also focus on stress-relief and
health-maintaining strategies as you suggest ways to balance one’s needs.
of the client continues after the client has died. The nurse has an ongoing
responsibility to act professionally and continue to be actively involved with
the client and family/friends. Issues relating to postmortem care are:
are responsible for following federal and state laws regarding requests
for organ or tissue donation, obtaining permission for autopsy, ensuring
the certification and appropriate documentation of the death, and
providing postmortem (after‑death) care.
postmortem care is completed, the client’s family becomes the nurse’s
Care of the Body
nurse continues to work with the client after death occurs. The nurse has a
unique role in relation to caring for the body of a client:
care with respect and compassion while attending to the desires of the
client and family per their cultural, religious, and social practices.
Check the client’s religion and make attempts to comply.
that the provider certifies death by pronouncing the time and documenting
therapies used, and actions taken prior to the death.
are a number of issues that the nurse should be aware of in relation to viewing
of the body that include:
the family whether they would like to visit with the body, honoring any
where the client’s personal belongings should go: with the body or to a
to the same procedures when the client is an infant, with the following
the infant’s body in a clean blanket.
the infant in the nurse’s arms or in an infant carrier based on facility
mementos of the infant (identification bracelets, footprints, the cord
clamp, a lock of hair, photos).
Preparing the Body for
family may wish to view the both and the nurse can assist in the process by:
all tubes (unless organs are to be donated or this is a medical examiner’s
all personal belongings to be given to the family.
and aligning the body supine with a pillow under the head, arms with palms
of hand down outside the sheet and blanket, dentures in place, and eyes
of fresh linens with absorbent pads on bed and a gown.
the client’s hair. Replace any hairpieces.
excess supplies, equipment, and soiled linens from the room.
the lights and minimize noise to provide a calm environment.
the viewing of the body is complete the nurse will need to:
identification tags according to facility policy.
aware of visitor and staff sensibilities during transport.
will be policies and procedures in place at a local and state level that relate
to organ and tissue donation and are respectful of the wishes of the client.
The nurse will need to:
that specifically trained personnel must make requests for tissue and
support and education to family members as decisions are being made. Use
private areas for any family discussions concerning donation.
sensitive to cultural and religious influences.
ventilation and cardiovascular support for vital organ retrieval.
upon the circumstances surrounding the death of the client and autopsy may need
to be performed. In relation to this:
provider typically approaches the family about performing an autopsy.
nurse’s role is to answer the family members’ questions and support their
can be conducted to advance scientific knowledge regarding disease
processes, which can lead to the development of new therapies.
law can require an autopsy to be performed if the death is due to
homicide, suicide, or accidental death, or if death occurs within 24 hr of
facilities require that all tubes remain in place for an autopsy.
and completion of forms following federal and state laws typically
includes the following:
pronounced the death and at what time.
of and preparation for organ donation.
of any tubes or lines left in or on the body.
of personal articles.
was notified, and any decisions made.
of identification tags.
the body left the facility and the destination.
The Care of Nurses Who
Caring long‑term for
clients can create personal attachments for nurses and all client deaths have
the potential to impact those who have cared for the client. Nurses need to be
aware of their own vulnerabilities in relation to this aspect of their job and
nurses can use coping strategies:
to the client’s funeral.
in writing to the family.
debriefing sessions with colleagues.
stress management techniques.
with a professional counselor.
Palliative Care Case Study
Case Study #1 This CNE activity is not graded and will not
impact the score you receive for correctly answered items.
nurse is caring for a 68-year old client who is terminally ill.
signs and symptoms would they expect to see that would indicate that the client
is nearly the end of his life?
do you consider to be the five (5) most important things that the nurse can do
to provide for the physical care needs of the client at this time?
five (5) approaches or resources that can be used to assist with the
psychosocial care of this client.
measures would you put in place to prevent this patient from feeling abandoned
American Association of Colleges of Nursing (AACN) (2016) CARES: Competencies
And Recommendations for Educating Undergraduate Nursing Students Preparing
Nurses to Care for the Seriously Ill and their Families. Retrieved 24 November
2017 from http://www.aacnnursing.org/Portals/42/ELNEC/PDF/New-Palliative-Care-Competencies.pdf
A., Snyder, S. & Frandsen, G. (2016). Kozier
& Erb’s Fundamentals of nursing: concepts,
Process, and Practice (10th Ed.). Hoboken, NJ: Pearson.
NursingREVIEW MODULE EDITION 9.0 2017 Assessment Technologies Institute, LLC.
Retrieved 24 November 2017 from GetPalliativeCare.org.
D., Perry, S.E., Cashion, K., & Rhodes Alden, K. (2016). Maternity and women’s health care (11th Ed.). St. Louis, MO:
National Cancer Institute.
(2014) Caring for the Caregiver.
Retrieved from https://www.cancer.gov/publications/patient-education/caring-for-the-caregiver.pPN
Mental Health Nursing REVIEW MODULE EDITION 10.0 2017 Assessment Technologies
P.A., Perry, A. G., Stockert, P. A. & Hall, A.M. (2017). Fundamentals of nursing (9th Ed.). St. Louis, MO: Elsevier.