Death Study Guide

Key Points
Theorists describe grief as stages, tasks, and processes undertaken by survivors to successfully
complete their bereavement and adapt to life with a loss.
Survivors move back and forth through a series of stages and/or tasks many times, possibly
extending over a long period of time.
Grieving people use their own unique history, context, and resources to make meaning out of
their loss experiences. Listen as patients share the experience in their own way.
Knowledge of the types of grief helps nurses identify appropriate interventions.
A persons development, coping strategies, socioeconomic status, personal relationships,
nature of loss, and cultural and spiritual beliefs influence the way he or she perceives and
responds to grief.
Nursing interventions involve reinforcing patients successful coping mechanisms and
introducing new coping approaches when needed.
Assess the terminally ill patient and family wishes for end-of-life care, including the preferred
place for death, desired level of intervention, and expectations for pain and symptom
management.
Establish a caring presence and use effective communication strategies to encourage patients
to share to the degree they are comfortable.
Palliative care allows patients to make more informed choices, achieve better alleviation of
symptoms, and experience a higher quality of life through an illness or death experience.
Hospice is not a place but rather a philosophy of family-centered, whole-person care at the end
of life.
Practice self-care, ask for and accept help, and reflect on the meaning of nursing experiences of
caring for the dying patient and family.

Nurses have a primary duty to prevent illness and injury and help patients return to health. They also play a vital role
in helping patients and families cope with things that cannot be changed and facilitate a peaceful death.
DIFFERENT TYPES OF LOSS
Throughout a lifetime people grieve the loss of multiple things: body parts or function, self-esteem, friendships,
confidence, or income. Children develop independence from the adults who raise them, begin and leave school,
change friends, begin careers, and form new relationships. The values learned in ones family, religious community,
society, and culture shape what a person regards as loss and how to grieve. Chronic illnesses, disabilities, and
hospitalization produce multiple losses. When entering an institution for care, patients lose access to familiar people
and environments, privacy, and control over body functions and daily routines. A chronic illness or disability adds
financial hardships for most people and often brings about changes in lifestyle and dependence on others.
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As people move forward in life, they learn that change always involves a necessary loss, which is a part of
life. Most necessary losses are are eventually replaced by something different or better. The death of a
loved one, divorce, or loss of independence changes life forever and often significantly disrupts a persons
physical, psychological, and spiritual health. Each person responds to loss differently. The type of loss and
the persons perception of it influence the depth and duration of the grief response.
maturational loss is a form of necessary loss and includes all normally expected life changes across the
life span. Maturational losses associated with normal life transitions help people develop coping skills to
use when they experience unplanned, unwanted, or unexpected loss. Example: A mother feels loss when
her child leaves home for the first day of school. A grade school child does not want to lose her favorite
teacher and classroom. Sudden, unpredictable external event bring about situational loss.
For example, a person in an automobile accident sustains an injury with physical changes that make it
impossible to return to work or school, leading to loss of function, income, life goals, and self-esteem.
An actual loss occurs when a person can no longer feel, hear, see, or know a person or object. Examples
include the loss of a body part, death of a family member, or loss of a job. Lost valued objects include those
that wear out or are misplaced, stolen, or ruined by disaster. A child grieves the loss of a favorite toy
washed away in a flood.

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A perceived loss is uniquely defined by the person experiencing the loss and is less obvious to other
people.
For example, some people perceive rejection by a friend to be a loss, which creates a loss of confidence or
changes their status in a group. How an individual interprets the meaning of the perceived loss affects the
intensity of the grief response. Perceived losses are easy to overlook because they are experienced so
internally and individually, but they are grieved in the same way as an actual loss.
Death is the ultimate loss. Although it is a necessary part of the continuum of life and of being human,
death represents the unknown and generates anxiety, fear, and uncertainty for many people. Death
permanently separates people physically from important persons in their lives and causes fear, sadness, and
regret for the dying person, family members, friends, and caregivers. A persons culture, spirituality,
personal beliefs and values, previous experiences with death, and degree of social support influence the
way he or she approaches death.

GRIEF
NURSE: Recognizing that there are different types of grief can help nurses plan and implement appropriate care.
Helpful coping mechenisms for grieving people include hardiness and resilience, a personal sense of control, and the
ability to make sense of and identify positive possibilities after a loss.

Grief is the emotional response to a loss, manifested in ways unique to an individual and based on personal
experiences, cultural expectations, and spiritual beliefs.
Coping with grief involves a period of mourning, the outward, social expressions of grief and the behavior
associated with loss. Most mourning rituals are culturally influenced, learned behaviors. For example, the
Jewish mourning ritual of Shivah incorporates the helping behaviors of the community toward those
experiencing death, sets expectations for survivor behavior, and sustains the community with tradition and
rituals
Bereavement encompasses both grief and mourning and includes the emotional responses and outward
behaviors of a person experiencing loss.
Normal (uncomplicated) grief is a common,universal reaction characterized by complex emotional,
cognitive, social, physical, behavioral, and spiritual responses to loss and death. Feelings of acceptance,
disbelief, yearning, anger, and depression are displayed in normal bereavement grief. Although manner of
death (violent, unexpected, or traumatic) poses greater risk to survivors, it does not always determine how
an individual will grieve.
A person experiences anticipatory grief, the unconscious process of disengaging or letting go before the
actual loss or death occurs, especially in situations of prolonged or predicted loss. They experience intense
responses to grief (e.g., shock, denial, and tearfulness) before the actual death occurs and often feel relief
when it finally happens. Another way to think about anticipatory grief is that it is a forewarning or cushion
that gives people time to prepare or complete the tasks related to the impending death. This idea may not
apply in every situation. Although forewarning is a buffer for some individuals, it increases stress for
others, creating an emotional roller coaster of highs and lows.
People experience disenfranchised grief, also known as marginal or unsupported grief, when their
relationship to the deceased person is not socially sanctioned, cannot be openly shared, or seems of lesser
significance. The persons loss and grief do not meet the norms of grief acknowledged by his or her culture,
cutting the grieving person off from social support and the sympathy given to persons with legitimate
losses.
Examples include the death an ex-spouse, a gay partner, or a pet or death from a stigmatized illness such as
alcoholism or during the commission of a crime.
Ambiguous loss, a type of disenfranchisedgrief, occurs when the lost person is physically present but not
psychologically available, as in cases of severe dementia or severe brain injury. Other times the person is
gone (e.g., after a kidnapping or as a prisoner of war); but the grieving person maintains an ongoing,
intense psychological attachment, never sure of the reality of the situation. Ambiguous losses are
particularly difficult to process because of the lack of finality and unknown outcomes.
In complicated grief a person has a prolonged or significantly difficult time moving forward after a loss.
He or she experiences a chronic and disruptive yearning for the deceased; has trouble accepting the death

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and trusting others; and/or feels excessively bitter, emotionally numb, or anxious about the future.
Complicated grief occurs more often when a person had a conflicted relationship with the deceased, prior
or multiple losses or stressors, mental health issues, or lack of social support. Loss associated with
homicide, suicide, sudden accidents, or the death of a child has the potential to become complicated.
Specific types of complicated grief include exaggerated, delayed, and masked grief.
Exaggerated Grief. A person with an exaggerated grief response often exhibits self-destructive or
maladaptive behavior, obsessions, or psychiatric disorders. Suicide is a risk for these people.
Delayed Grief. A persons grief response is unusually delayed or postponed, often because the loss is so
overwhelming that the person must avoid the full realization of the loss. A delayed grief response is
frequently triggered by a second loss, sometimes seemingly not as significant as the first loss.
Masked Grief. Sometimes a grieving person behaves in ways that interfere with normal functioning but is
unaware that the disruptive behavior is a result of the loss and ineffective grief resolution.

Theories of Grief and Mourning

NURSE: Knowledge of grief theories and normal responses to loss and bereavement will help you better understand
these complex experiences and how to help a grieving person.
Grief theorists describe the physical, psychological, and social reactions to loss. Remember that people who vary
from expected norms of grief or theoretical descriptions are not abnormal. The variety of theories supports the
complexity and individuality of grief responses. Although most grief theories describe how people cope with death,
they also help to understand responses to other significant losses.

Stages of death
Kbler-Ross describes five stages of dying in her classic behavioral theory: denial, anger, bargaining,
depression, and acceptance. The stages of dying are not linear. Patients will move back and forth through
the stages.

1.

A person in the denial stage cannot accept the fact of the loss, which often provides psychological
protection from a loss that the person cannot yet bear.
When experiencing the anger stage of adjustment to loss, a person expresses resistance and sometimes feels
intense anger at God, other people, or the situation.
Bargaining cushions and postpones awareness of the loss by trying to prevent it from happening. Grieving
or dying people make promises to self, God, or loved ones that they will live or believe differently if they
can be spared death.
When a person realizes the full impact of the loss, depression occurs. Some individuals feel
overwhelmingly sad, hopeless, and lonely.
In acceptance the person incorporates the loss into life; develops the capacity to have a breadth of
emotions, even positive ones; and finds ways to move forward.

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Bowlbys Attachment Theory

1. Numbing, the shortest stage of mourning, may last from a few hours to a week or more. The grieving
person describes this stage as feeling stunned or unreal. Numbing protects the person from the full
impact of the loss.
2. Emotional outbursts of tearful sobbing and acute distress characterize the second bereavement stage,
yearning and searching (separation anxiety). Common physical symptoms in this stage include
tightness in the chest and throat, shortness of breath, a feeling of lethargy, insomnia, and loss of
appetite. A person also experiences an inner, intense yearning for the lost person or object. This stage
lasts for months or considerably longer.
3. During the stage of disorganization and despair, a person endlessly examines how and why the loss
occurred or expresses anger at anyone who seems responsible for the loss. The grieving person retells
the loss story again and again and gradually realizes that the loss is permanent.
4. With reorganization, which usually takes a year or more, the person begins to accept change, assume
unfamiliar roles, acquire new skills, and build new relationships. Persons who are reorganizing begin
to separate themselves from their lost relationship without feeling that they are lessening its
importance.

 Wordens Grief Tasks Model

He describes how individuals actively engage in behaviors by responding to outside interventions to help
themselves. Working through the grief tasks typically requires a minimum of a full year, although the time
varies from person to person.
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4.

Task I: Accept the reality of the loss. Even when a death is expected, survivors register some is belief
and surprise that it has really happened. Task I involves the process of accepting that the person or
object is gone and will not return.
Task II: Experience the pain of grief. Even though people respond to loss differently, it is impossible to
experience a significant loss without some emotional pain. People react with sadness, loneliness,
despair, or regret and work through painful feelings using the coping mechanisms most familiar and
comfortable to them.
Task III: Adjust to a world in which the deceased is missing. A person does not realize the full impact
of a loss for at least 3 months. Family members or friends pay less attention to the bereaved person at
about the same time, just as the finality of the loss becomes real. People completing this task begin to
take on roles formerly filled by the deceased, including some jobs they do not want.
Task IV: Emotionally relocate the deceased and move on with life. The deceased person is not forgotten
but rather takes a different and less prominent place in the survivors emotional life. People often fear
that in making new attachments they will forget their loved one or seem disloyal, making this a
potentially difficult task to complete. Realizing that it is possible to love other people without
betraying the deceased, the person moves forward.

Randos R Process Model

Describes grief as a series of processes instead of stages or tasks. However, her processes are similar to the
stages and tasks already described. Randos processes include recognizing the loss, reacting to the pain of
separation, reminiscing, relinquishing old attachments, and readjusting to life after loss. Reminiscence is an
important activity in grief and mourning. A person recollects and re-experiences the deceased and the
relationship by mentally or verbally anecdotally reliving and remembering the person and past experiences.
Dual Process model
The dual process model describes the everyday life experiences of grief as moving back and forth between lossoriented and restoration-oriented activities. Loss-oriented behaviors include grief work, dwelling on the loss,
breaking connections with the deceased person, and resisting activities to move past the grief. Restorationoriented activities such as attending to life changes, finding new roles or relationships, coping with finances,
and participating in distractions provide balance to the loss-oriented state. The extent to which an individual
engages in loss or restoration-oriented processes depends on factors such as personality, coping styles, or
cultural practices.
Post Modern Grief Thoery
More recent grief theories take into consideration that human beings construct their own experiences and truths
differently and make their own meanings when confronted with loss and death. Differences in social and
historical context, family structure, and cognitive capacities shape an individuals truths and grief experiences.
No ones grief follows a predetermined path.
Factors influencing Loss and Grief
1. Human development- Patient age and stage of development affect the grief response.
-For example, toddlers cannot understand loss or death but often feel anxiety over the loss of objects and
separation from parents.
-School-age children understand the concepts of permanence and irreversibility but do not always
understand the causes of a loss. Some have intense periods of emotional expression.
-Young adults undergo many necessary developmental losses related to their evolving future. They leave
home, begin school or a work life, or form significant relationships. Illness or death disrupts the young
adults future and establishment of an autonomous sense of self.
-Midlife adults also experience major life transitions such as caring for aging parents, dealing with changes
in marital status, and adapting to new family roles.

-For older adults the aging process leads to necessary and developmental losses. Some older adults
experience age discrimination, especially when they become dependent or are near death; but they show
resilience after a loss as a result of their prior experiences and developed coping skills
NURSE: Relieving depression and maintaining physical function are therapeutic goals for grieving older adults
2.

Personal Relationships
When loss involves another person, the quality and meaning of the lost relationship influence the grief
response. Grief resolution is hampered by regret and a sense of unfinished business, especially when people
are closely related but did not have a good relationship at the time of death. Social support and the ability to
accept help from others are critical variables in recovery from loss and grief. When patients do not receive
supportive understanding and compassion from others, grief becomes complicated or prolonged.

3.

Nature of the loss

Exploring the meaning a loss has for your patient helps you better understand the effect of the loss on the
patients behavior, health, and well-being. Highly visible losses generally stimulate a helping response from
others.
-For example, the loss of ones home from a tornado often brings community and governmental support. A
more private loss such as a miscarriage brings less support from others. When the death is sudden and
unexpected, the survivors do not have time to let go. In chronic illness survivors have memories of
prolonged suffering, pain, and loss of function. Death by violence or suicide or multiple losses by their very
nature complicate the grieving process in unique ways.

4.

Coping Strategies
Life experiences shape the coping strategies that a person uses to deal with the stress of loss. Emotional
disclosure (i.e., venting, talking about ones feelings, or expressing anger or other negative feelings) is one
way to cope with loss. Negative themes that are present when people talk about grief sometimes predict
more distressful reactions. However, some individuals cope better in situations of loss when they instead
focus on positive emotions and optimistic feelings. Emotional disclosure is often accomplished by having
people write about their feelings in letters to lost loved ones or personal journals.

5.

Socioeconomic Status
Socioeconomic status influences a persons ability to access support and resources for coping with loss and
physical responses to stress. When people lack financial, educational, or occupational resources, the
burdens of loss multiply.
-For example, a patient with limited finances is not able to replace a car demolished in an accident and pay
for the associated medical expenses.

6.

Culture and ethnicity

Culture and family or religious affiliation influences interpretations of loss and the ability to establish
acceptable expressions of grief, which affects the ability to provide stability and structure in the midst of
chaos and loss. Grief theories commonly used to understand loss and death have cultural limitations.
Cultural differences influence processes such as obtaining informed consent or making life-support
decisions. Research has shown that ethnicity is strongly related to attitudes toward life-sustaining
treatments during terminal illness and the use of hospice services.
-For example: North Americans may better understand work, tasks, and time expectations for grief
compared to other cultural groups not as defined by work achievements or with a different sense of time.
Some cultural groups experience grief as a timeless, communal expression or state of being. Many people
in Western European and American cultures hold back their public displays of emotion. In other cultures
behaviors such as public wailing and physical demonstrations of grief, including survivor body mutilation,
show respect for the dead. Core American cultural values of individualism and self-determination stand in
contrast with communal, family, or tribal ways of life. Americans value and expect honesty and truth telling
in end-of-life situations, but some cultures have strict taboos surrounding what should be discussed
regarding the diagnosis and prognosis in serious illness.

7.

Spiritual and Religious Beliefs

A contrasting set of practices (i.e., transformative strategies) acknowledge life limits and help dying people
find meaning in suffering so they are able to transcend (go beyond) their personal existence. Transformative
practices are associated with healing and spiritual or religious beliefs. Spiritual resources include faith in a
higher power, communities of support, friends, a sense of hope and meaning in life, and religious practices.
Spirituality affects the patients and family members ability to cope with loss. Positive correlations show
that spiritual well-being, peacefulness, comfort,and serenity are all important aspects of a peaceful death.
Findings in the literature verify that religious beliefs provide a sense of structure in end-of-life situations
and are linked to more positive attitudes toward death. Spirituality and hope play a vital role in a patients
adjustment to loss and death.
Hope, a multidimensional concept considered to be a componentof spirituality, energizes and provides
comfort to individuals experiencing personal challenges. Hopefulness gives a person the ability to see life
as enduring or having meaning or purpose. As a future-shaping, motivating force, hope helps patients
maintain anticipation of a continued good, an improvement in their circumstances, or a lessening of
something unpleasant. With hope a patient moves from feelings of weakness and vulnerability to living as
fully as possible. Spiritual distress often arises from a patients inability to feel hopeful or foresee any
favorable outcomes.
Critical thinking
To provide appropriate and responsive care for the grieving patient and family, use critical thinking skills to
synthesize scientific knowledge from nursing and non-nursing disciplines, professional standards, evidence-based
practice, patient assessments, previous caregiving experiences, and self-knowledge. To understand a patients
subjective experiences of loss, form assessment questions based on your theoretical
and professional knowledge of grief and loss but then listen carefully to the patients perceptions. A culturally
competent nurse also uses culture-specific understanding of grief to explore the meaning of loss with a patient.
Some patients ignore, lash out, plead with, or withdraw from other people as part of a normal response to loss.
Instead of taking things personally, a critically thinking nurse integrates theory, prior experience, appreciation of
subjective experiences, and self-knowledge to respond to the patients emotions with patience and understanding. In
designing plans of care, use professional standards, including the Nursing Code of Ethics (see Chapter 22), the dying
persons bill of rights (Box 36-2), the American Nurses Association Scope and Standards of Hospice and Palliative
Nursing Practice (2007), and clinical standards such as the American Society of Pain Management Nurses
guidelines for pain assessment in the nonverbal patient.
NURSE: Because of the importance of symptom management and priority of comfort in end-of-life care, prioritize
your initial assessment to encourage patients to identify any distressing symptoms.
Assessment
o A trusting, helping relationship with grieving patients and family members is essential to the assessment
process. A caring nurse encourages a patient to tell his or her story, which then becomes a primary source of
assessment data.
o Be aware that attitudes about self-disclosure; sharing emotions; or talking about illness, fears, and death are
shaped by an individuals personality, coping style, and culture.
o Explore with patients their unique responses to grief or their preferences for end-of-life care, which may
include advance directives. Patient perceptions and expectations influence how you prioritize your nursing
diagnoses. To assess patient perceptions, you ask, What is the most important thing I can do for you right
now? You usually gather information from patients first, but with advanced illness and as death
approaches, patients often rely on family members to communicate for them.
o Assess patients and family members understanding of treatment options to implement a mutually
developed care plan. Assessment of grief responses extends throughout the course of an illness into the
bereavement period following a death. Because most deaths are now negotiated among patients, family
members, and the health care team, discuss end-of-life care preferences early in the assessment phase of the
nursing process.
o If you feel uncomfortable in assessing a patients wishes for end-of-life care by yourself, ask a health care
provider experienced in discussing these issues to help you.
o Communicate what you have learned about patient preferences during any RN hand-off, at health care team
conferences, in written care plans, and through ongoing consultation.

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Keep an open mind, listen carefully, and observe the patients verbal and nonverbal responses. Facial
expressions, voice tones, and avoided topics often disclose more than words.
Anticipate common grief responses, but allow patients to describe their experiences in their own words.
Open-ended questions such as What do you understand about your diagnosis? or You seem sad today.
Can you tell me more? may open the door to a patient-centered discussion.
The use of pauses, gentle questioning, and silence honors the patients privacy and readiness to talk. Talk to
patients and family members in a private, quiet setting.
Many times a patient wants to have family members present so everyone hears the same thing and has an
opportunity to add to the conversation. However, some people want their concerns and questions addressed
privately. Ask patients and family members about their preferences.
As you gather assessment data, summarize and validate your impressions with the patient or family
member. Information from the medical record and other members of the health care team, physicians,
social workers, and spiritual care providers contributes to your assessment data.

The meaning of loss to a pt often leads to other important areas of assessment. Ask open ended questions (Box 363) to assess the nature of the loss, cultural and spiritual beliefs, life goals, family grief patterns, self-care, and
sources of hope.
-For example, when your patient exhibits signs of a normal grief reaction, but you learn that the loss occurred 2
years ago, the patients response most likely indicates a complicated, chronic grief experience. Focus your
assessment on how a patient is reacting to loss or grief and not on how you believe that patient should be reacting.
Grief reactions
o Analyze assessment data and identify possible related causes for the signs and symptoms that you observe.
-For example, after a significant loss a person has a sad affect, withdrawn behaviors, headaches, upset stomach,
and decreased ability to concentrate. You associate these symptoms with several potential causes, including
anxiety, gastrointestinal disturbances, medication side effects, or impaired memory.
o Careful analysis of the symptoms in context leads you to an accurate nursing diagnosis. Ask: How are the
symptoms related to one another when they occur? When did they begin? Were they present before the
loss? To what does the person attribute them?
o Loss takes place in a social context; thus family assessment is a vital part of your data gathering. Family
members also experience a variety of physical and psychological symptoms.
o Assess the familys response to loss and recognize that sometimes they are dealing with their grief at a
different pace.
Diagnosis
In addition to numerous diagnoses related to physical symptoms at the end of life, additional nursing diagnoses
relevant for patients experiencing grief, loss, or death include:
Compromised family coping
Death anxiety
Fear
Impaired comfort
Ineffective denial
Grieving
Complicated grieving
Risk for complicated grieving
Hopelessness
Pain (Acute or Chronic)
Risk for loneliness
Spiritual distress
Readiness for enhanced spiritual well-being
o

You cannot make accurate nursing diagnoses on the basis of just one or two defining characteristics.
- For example, a dying patient who cries often, has angry outbursts, and reports nightmares gives evidence
of several possible nursing diagnoses: pain (acute or chronic), ineffective coping, grieving, or spiritual
distress.

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Examine the available data, validate assumptions with the patient, and look for other validating behaviors
and symptoms before making a diagnosis.
Clarification of the related factors ensures that you select appropriate interventions.
-For example, a nursing diagnosis of complicated grieving related to the permanent loss of mobility
requires different interventions than a diagnosis of complicated grieving related to infertility after an
ectopic pregnancy.
When identifying nursing diagnoses related to a patients grief or loss, you sometimes identify other related
diagnoses.
Some patients experiencing grief or impending death have nursing diagnoses such as disturbed body image
or impaired physical mobility. A patient entering the phase of active dying often has diagnoses related to
physical changes, including impaired urinary elimination, bowel incontinence, acute pain, nausea,
disturbed sensory perception, and ineffective breathing pattern.

Planning
Nurses provide holistic, physical, emotional, social, and spiritual care to patients experiencing grief, death, or loss.
The use of critical thinking ensures a well-designed care plan that supports a patients self-esteem and autonomy
by including him or her in the planning process. A care plan for the dying patient focuses on comfort; preserving
dignity and quality of life; and providing family members with emotional, social, and spiritual support.
Goal and outcomes: Consider a patients own resources such as physical energy and activity tolerance,
family support, and coping style.
-Example: nursing diagnosis of powerlessness related to experimental cancer therapy with a goal of Patient
will be able to describe the expected course of disease is realistic for a patient who frequently asks for
clarification about the treatment plan and participates in educational discussions. In contrast, an expected
outcome of Patient will identify a minimum of three effective coping skills is appropriate for a patient with
the same nursing diagnosis who is experiencing depression from feeling powerless about having experimental
cancer treatment. Some nursing care goals for patients facing loss or death include accommodating grief,
accepting the reality of a loss, or maintaining meaningful relationships.
o

Priorities:
1. What the pt wants prioritized; comfort being first.
o Encourage patients and family members to share their priorities for care at the end of life.
o Give priority to a patients most urgent physical or psychological needs while also considering his or her
expectations and priorities.
Ex: If a terminally ill patients goals include pain control and promoting self-esteem, pain control takes
priority when the patient experiences acute physical discomfort. When comfort needs have been met, then
you address other issues important to the patient and family.
2.

Autonomy/independence
When it is realistic for the patient to remain independent, strategies that foster his or her sense of autonomy
and ability to function independently take priority.
A patients condition at the end of life often changes quickly; therefore maintain an ongoing assessment to
revise the plan of care according to patient needs and preferences.

3. When a patient has multiple nursing diagnoses, it is not possible to address them all simultaneously.
-Example: In conjunction with her recent medical diagnosis, she experiences associated health problems
identified in the nursing diagnoses chronic pain, imbalanced nutrition: less than body requirements, fatigue,
and hopelessness. The chronic pain experienced by the patient is often the first focus. Until the patients pain is
under control, it will not be possible for her to feel more energized, eat well, or regain her sense of hopefulness.
Teamwork: A team of nurses, physicians, social workers, spiritual care providers, nutritionists, pharmacists, physical
and occupational therapists, patients, and family members works together to provide palliative care, grief care, and
care at the end of life. Massage or music/art therapists who provide alternative therapies are sometimes part of the
team. Team members communicate with one another on a regular basis to ensure coordination and effectiveness of
care.

Implementation
o Health promotion in serious chronic illness or death focuses on facilitating successful coping and
optimizing physical, emotional, and spiritual health. People often find personal growth and spiritual
insights they have not previously experienced and need family and nurse support as they strive to maintain
a degree of normalcy; live with loss; make health care decisions; prepare for death; and adjust to
disappointments, frustration, and anxieties along the way.
o

Palliative care
Palliative care focuses on the prevention, relief, reduction, or soothing of symptoms of disease or
disorders throughout the entire course of an illness, including care of the dying and bereavement
follow-up for the family.
The primary goal of palliative care is to help patients and families achieve the best possible quality of
life. Although it is especially important in advanced or chronic illness, it is appropriate for patients of
any age, with any diagnosis, at any time, or in any setting and not just for the end of life.
Making this distinction is important because some patients, family members, or health care
professionals refuse helpful palliative care interventions, believing that palliative care is only for the
dying.

Hospice
Hospice care is a philosophy and a model for the care of terminally ill patients and their families.
Hospice is not a place but rather a patient- and family-centered approach to care.
It gives priority to managing a patients pain and other symptoms; comfort; quality of life; and
attention to physical, psychological, social, and spiritual needs and resources.
Patients accepted into a hospice program usually have less than 6 to 12 months to live.
Hospice services are available in home, hospital, extended care, or nursing home settings. Hospice
team members offer 24-hour accessibility and coordinate care between the home and inpatient setting.
A patient receiving home hospice care may enter the hospital for stabilization of symptoms or for
caregiver respite.
It is important that the hospice team knows the patients preference. When family issues complicate the
options, hospice caregivers try to support the patients wishes but also consider what is best for
everyone. Patient care goals are mutually set, and all participants fully understand the patients care
preferences and try to honor them.
Hospice services provide bereavement visits made by the staff after the death of the patient to help the
family move through the grieving process.
Home hospice services eligibility: A patient must have a family caregiver to provide care when the
patient is no longer able to function alone. Provided with home health aide who assist with hygienic
needs and a nurse to coordinate and manage symptom relief.
Nurses providing hospice care use therapeutic communication, offer psychosocial care and expert
symptom management, promote patient dignity and self-esteem, maintain a comfortable and
peaceful environment, provide spiritual comfort and hope, protect against abandonment or
isolation, offer family support, assist with ethical decision making, and facilitate mourning.
1.

Therapeutic communication
Establish a caring, trusting relationship with a patient and family by using an open hearted, nonassuming communication style.
Open-ended questions invite patients to expand on their thoughts and tell their stories.
Use active listening, learn to be comfortable with silence, and use prompts (e.g., go on, tell me
more) to encourage continued conversation.
Empathize with the patients grief; offer your caring, transformative presence and use intentional,
meaningful touch.
Remain supportive by letting patients and family members know that feelings such as anger are
normal by saying, You are understandably upset right now. I just want you to know Im here to
talk with you if you want.

Invite patients to reveal the emotions and concerns of greatest importance to them and
acknowledge their feelings and concerns in a nonjudgmental manner.
Express a willingness to be available at any time.
If you are reassuring and respectful of a patients privacy, a therapeutic relationship likely
develops.
Avoid communication barriers such as denying a patients grief, providing false reassurance, or
avoiding discussion of sensitive issues.
Above all, remember that a patients emotions are not something you can fix. Instead view
emotional expression as a necessary part of the patients adjustment to significant life changes and
development of effective coping skills.
Help family members access other professional resources.
For example, call on a spiritual care provider to help patients and family members discuss difficult
issues related to personal meanings, faith beliefs, and values.

2. Provide Psychosocial Care.

Patients at the end of life experience a range of psychological symptoms, including anxiety, depression,
altered body image, denial, powerlessness, uncertainty, and isolation.
Worry or fear is common in many patients and often heightens their perception of discomfort and suffering.
Providing information helps patients understand their condition, the course of their disease, and the benefits
and burdens of treatment options.
Suffering, a complex social and psychological response to illness, loss, and death, goes beyond
psychological diagnoses. Nurses validate and support those who suffer.
3. Manage Symptoms
Managing the multiple symptoms commonly experienced by chronically ill or dying patients remains a
primary goal of palliative care nursing.
Maintain an ongoing assessment by reassessing pain and medication side effects, using pain management
expertise, and advocating for change if the patient does not obtain relief from the prescribed regimen.
It is essential for you to learn how to assess patients who are debilitated or dying because they often lose
their ability to communicate or self-advocate.
During the dying process, patients renal and liver function decline, decreasing metabolism and rate of drug
clearance and leading to a need for decreased medication dosages to avoid toxicities.
Also be aware that advancing disease pathology, anxiety, or delirium sometimes requires the use of higher
doses or different drug therapies.
Remain alert to the potential side effects of opioid administration: constipation, nausea, sedation,
respiratory depression, or myoclonus.
Family members are often concern about addiction. Not only is the incidence of true addiction very low,
but a patients need for pain relief at the end of life takes priority.
4. Dignity and Self-Esteem
Nurses promote patients self-esteem and dignity by respecting them as a whole.
Giving importance to the things that a patient cares about validates the person, at the same time
strengthening communication among the patient, family members, and the nurse.
Spending time with patients as they share their life stories helps you know him or her better and facilitates
the development of individualized interventions.
Show respect for older patients by calling them by surnames and titles and obtaining their permission to
include others in private conversations.
Attending to the patients physical appearance promotes dignity and self-esteem.
Cleanliness, absence of body odors, and attractive clothing give patients a sense of worth.
Allow patients to make decisions such as how and when to administer personal hygiene, diet preferences,
and timing of nursing interventions.
Keep the patient and family members informed about daily activities, tests, or therapies; their purposes; and
anticipated effects.

Provide privacy during nursing care procedures and be sensitive to when the patient and family need time
alone together.
5. Maintain a Comfortable and Peaceful Environment.
A comfortable, clean, pleasant environment helps patients relax, promotes good sleep patterns, and
minimizes symptom severity.
Keep a patient comfortable through frequent repositioning, making sure that bed linens are dry and
controlling extraneous environmental noise and offensive odors.
Pictures, cherished objects, and cards or letters from family members and friends create a familiar and
comforting environment for the patient dying in an institutional setting.
Research supports the use of soft massage and brief hand massages for reducing stress
Use patient-preferred music in the background, provide guided-imagery exercises, and dim the lights to
provide a soothing environment for the patient and family.
Patient-preferred forms of complementary therapies offer noninvasive methods to increase comfort and
well-being at the end of life.
6. Promote Spiritual Comfort and Hope.
Help patients make connections to their spiritual practice or cultural community.
Draw on the resources of spiritual care providers in an institutional setting or collaborate with the patients
own spiritual or religious leaders and communities.
Making an audiotape or videotape for the family, writing letters, or keeping a journal assures patients that
something of their essence will survive past their death.
Nursing strategies that promote hope are often quite simple: be present and provide holistic care that
affirms a patients life and maintains dignity.
Patients perceive the love of family and friends, faith, goal setting, positive relationships with professional
caregivers, humor, and uplifting memories as hope promoting.
Circumstances that hinder the preservation of hope include abandonment or isolation, uncontrolled
symptoms, or being devalued as a person.
Listen for shifts in patients hopes and find ways to help them meet their desired goals.
7. Protect Against Abandonment and Isolation.
Many patients with terminal illness fear dying alone.
Nurses in institutional settings need to answer call lights promptly and check on patients often to reassure
them that someone is close at hand.
If family members plan to stay with the patient at all times or if you have assessed high privacy needs for
the patient and family, a private room is best. On the other hand, many patients appreciate being able to
stay involved and interact with others, which is possible when sharing a room.
Some family members who have a difficult time accepting a patients impending death cope by making
fewer visits.
When family members do visit, inform them of the patients status and share meaningful insights or
encounters that you have had with the patient.
Find simple and appropriate care activities for the family to perform such as offering food, cooling the
patients face, combing hair, or filling out a menu.
Suggest that a family member stay through the night if possible.
Record contact information for them so you can reach them at any time.
8. Support the Grieving Family.
In palliative care patients and family members constitute the unit of care.
In these extremely intimate and emotionally challenging times, offer holistic, family-centered support,
compassion, and education that incorporates the uniqueness of each patient.
Family members caring for people with serious life-limiting illness need attention and support early and
consistently throughout the experience of illness and death.
Educate family members in all settings about the symptoms that the patient will likely experience and the
implications for care.

-For example, patients in the last days of life often develop anorexia or feel nauseated by food. Illness,
decreased activity, treatments, and fatigue decrease a patients caloric needs and appetite. Family members,
distressed with the decline, often believe that they need to encourage the patient to eat. Forcing food or
fluids stresses the patients compromised gastrointestinal and cardiovascular systems, potentially creating
increased discomfort. Help families shift their focus to other helping activities during this time.
Family members who have limited prior experience with death do not know what to expect. They may need
personal time with the nurse to share their concerns, ask about treatment options, validate perceived
changes in the patients status, or explore the possible meaning of patient behaviors.
Whenever possible, communicate news of a patients declining condition or impending death when family
members are together so they can support each other.
Reduce family member anxiety, stress, or fear by describing what to expect as death approaches.
Do not try to predict the time of death; instead use your assessments to help family members anticipate
what is happening. Share your observations and through your role modeling.
Encourage a sense of patience, compassion, and comfort throughout the dying process.
After death assist the family with decision making such as notification of a funeral home, transportation of
family members, and collection of the patients belongings.
Nurses are a primary source of family support. Remember that, because of differing responses to grief,
some family members prefer to be alone at the time of a death, whereas others want to be surrounded by a
support community.
When uncertain about what a family member prefers for support, pose simple questions and offer
suggestions for assistance.
In the home setting fatigued family caregivers benefit from respite care. During respite care, a patient
temporarily receives care from others so family members are able to get away to rest and relax.
9. Assist with End-of-Life Decision Making
Patients and family members often face complex treatment decisions at the end of life.
Decisions the family often need to make include: Which medical interventions would the patient want to
use? Should life-extending treatments be stopped if there appears to be little chance of recovery? Should
artificial nutrition and hydration be provided when a patient is near death and no longer able to eat?
They need time and careful explanations by nurses and other health care providers to make decisions.
Suggest to patients that they clearly communicate their wishes for end-of-life care so family members are
able to act as faithful surrogates when the patient can no longer speak for himself or herself.
Advance directives often decrease the stress of family members when end-of- life decisions must be made.
Some patients and family members rely on the nurse and other members of the health care team to initiate
discussions regarding end-of-life care.
Nurses often provide options that family members do not know are available and are advocates for patients
and family members making decisions at the end of life.
10. Facilitate Mourning.
Nurses who work with grieving family members often provide bereavement care after the patients death.
Helpful strategies for assisting grieving persons include the following:
Help the survivor accept that the loss is real. Discuss how the loss or illness occurred or was discovered,
when, under what circumstances, who told him or her about it, and other factual topics to reinforce the
reality of the event and put it in perspective.
Support efforts to adjust to the loss. Use a problem-solving approach. Have survivors make a list of their
concerns or needs, help them prioritize, and lead them step-by-step through a discussion of how to proceed.
Encourage survivors to ask for help.
Encourage establishment of new relationships. Reassure people that new relationships do not mean that

they are
replacing the person who has died. Encourage involvement in nonthreatening group social activities (e.g.,
volunteer activities or church events).
Allow time to grieve. Anniversary reactions (i.e., renewed grief around the time of the loss in
subsequent years) are common. A return to sadness or the pain of grief is often worrisome. Openly
acknowledge the loss, provide reassurance that the reaction is normal, and encourage the survivor to
reminisce.

 Interpret normal behavior. Being distractible, having difficulty sleeping or eating, and thinking that they
have heard the deceaseds voice are common behaviors following loss. These symptoms do not mean that
an individual has an emotional problem or is becoming ill. Reinforce that these behaviors are normal and
will resolve over time.
Provide continuing support. Survivors need the support of a nurse with whom they have bonded for a time
following a loss, especially in home care or hospice nursing. The nurse has become an important actor in
the drama of the deceaseds life and death and has helped them through some very intimate and memorable
times. Attachment for awhile after the death is appropriate and healing for both the survivor and the nurse.
Be alert for signs of ineffective potentially harmful coping mechanisms such as alcohol and substance
abuse or excessive use of over-the-counter analgesics or sleep aids.
Care After Death

Federal and state laws require institutions to develop policies and procedures for certain events that occur
after death: requesting organ or tissue donation, performing an autopsy, certifying and documenting the
occurrence of a death, and providing safe and appropriate postmortem care.
A specially trained professional (e.g., transplant coordinator or social worker) makes requests for organ
and tissue donation at the time of every death.
Nurses provide support and reinforce and clarify explanations given to them during the request process.
Even though a patient who is brain dead is legally declared dead, he or she remains on life support to
provide the vital organs with blood and oxygen before transplant.
The appearance of a live-looking body confuses the family, and they need help to understand that the life
support is only preserving the vital organs. Non-vital tissues such as corneas, skin, long bones, and middle
ear bones are taken at the time of death without artificially maintaining vital functions.
If the deceased has not left behind instructions concerning organ and tissue donation, the family gives or
denies consent at the time of death.
Be aware that the laws governing who to approach for organ donation may not be acceptable in other
cultures.
Family members give consent for an autopsy (i.e., the surgical dissection of a body after death) to
determine the exact cause and circumstances of death or discover the pathway of a disease.
A coroner or medical examiner determines the need to perform an autopsy.
Law sometimes requires that an autopsy be performed when death is the result of foul play; homicide;
suicide; or accidental causes such as motor vehicle crashes, falls, the ingestion of drugs, or deaths within 24
hours of hospital admission. Unattended deaths or those that occur in the workplace or during incarceration
also usually require an autopsy.
Usually the physician or other designated health care provider asks for autopsy permission while the nurse
answers questions and supports the familys choices.
Inform family members that an autopsy does not deform the body and that all organs are replaced in the
body
Respect and honor family wishes and final decisions.

Documentation
Documentation of a death provides a legal record of the event.
Physicians or coroners sign some medical forms such as a request for autopsy, but the registered nurse
gathers and records much of the remaining information surrounding a death.
Nurses also usually witness or delegate the signing of forms (e.g., release of body or personal
belongings forms).
Nursing documentation becomes relevant in risk management or legal investigations into a death,
underscoring the importance of accurate, legal reporting.
Documentation also validates success in meeting patient goals or provides justification for changes in
treatment or expected outcomes.
o

Proper documentation requires:

1. Time and date of death and all actions taken to respond to the impending death
2. Name of health care provider certifying the death

3.

Persons notified of the death (e.g., health care providers, family members, organ request team,
morgue, funeral home, spiritual care providers) and person who comes to declare time of death
4. Name of person making request for organ or tissue donation
5. Special preparations of the body (e.g., desired or required religious/cultural rituals)
6. Medical tubes, devices, or lines left in or on the body
7. Personal articles left on and secured to the body
8. Personal items given to the family with description, date, time, to whom given
9. Location of body identification tags
10. Time of body transfer and destination
11. Any other relevant information or family requests that help clarify special circumstances.
o
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Give only factual information in a nonjudgmental, objective manner and avoid sharing your opinions.
State law and agency policy govern the sharing of the written medical record information, which usually
involves a written request. Follow legal guidelines for documentation and sharing of medical records.
When a patient dies in an institutional or home care setting, nurses provide or delegate postmortem care,
the care of a body after death.
A human body deserves the same respect and dignity as a living person and needs to be prepared in a
manner consistent with the patients cultural and religious beliefs.
Death produces physical changes in the body quite quickly; thus you need to perform postmortem care as
soon as possible to prevent discoloration, tissue damage, or deformities.

Care of the Body After Death

There are culturally specific rituals and mourning practices that loved ones use to achieve a sense of acceptance and
inner peace and participate in socially accepted expressions of grief. Ones culture greatly influences what behaviors
and rituals are expected at the time of death. Institutional guidelines and end-of-life care procedures for patients
from all cultures provide standards based on compassion, maintaining privacy and dignity, and respect for patients
and family members cultural beliefs and practices. Expert end-of-life care allows time for patients and their families
to make private and public preparations and complete unfinished communication. Understanding the uniqueness of
cultural expectations at the end of life helps a nurse know what questions to ask. The cultural or religious practices
described below are not necessarily exclusive to the culture named but are offered to give you an idea of some
culturally specific concerns you may encounter in end-of-life care.
Implications for Practice
African American: Care of the body after death depends on the African Americans country of origin and degree
of American acculturation. The presence of large extended family groups, including the church family, is common at
time of death. The mourning period is relatively short, with a memorial service and a public viewing of the body or a
wake before burial. Organ donation and autopsy are allowable.
Chinese: Death is regarded as a negative life event, and there is no concept of an afterlife. The dead are treated
with the same respect as the living and may be buried with food and other artifacts. Members of an extended family
usually stay with the deceased for up to 8 hours after death. The oldest son or daughter bathes the body under
direction from an older relative or a temple priest. They often believe the body should remain intact; thus organ
donation and autopsy are uncommon.
Hispanic or Latino: Honoring family values and roles is essential in providing care and making decisions at the
end of life. People in Hispanic and Mexican-American cultures often use special objects such as amulets or rosary
beads, alternative healing practices (folk medicine), and prayer. Grief is expressed openly. Religious and spiritual
rituals (predominantly Catholic) are essential at the end of life. Death is often believed to be the will of God.
Native American: Native Americans encompass diverse tribal groups with differing practices, traditions, and
ceremonies. Traditional Navajos do not touch the body after death. Care of the body in the large Navajo tribe
includes cleansing the body, painting the deceaseds face, dressing in clothing, and attaching an eagle feather to
symbolize a return home. Mourners also have a ritual cleansing of their bodies. The dead are buried on the
deceaseds homeland.

 Islamic: The deceaseds body is ritualistically washed, wrapped, cried over, prayed for, and buried as soon as
possible after death. The eyes and mouth are closed, and the face of the deceased is turned toward Mecca. Muslims
of the same gender prepare the body for burial. Bodies are buried, not cremated. Autopsies interfere with a quick
burial; make autopsy requests with sensitivity and only if necessary. The proximity of loved ones after death is
important since it is believed that the soul stays with the body until it is buried. Organ donation is permissible by
some Quran interpretations.
Buddhist: Buddhists believe in an afterlife in which humans manifest in different forms. Death is preferred at
home, and a persons state at the time of death is important. Individuals usually minimize emotional expressions and
maintain a peaceful, compassionate atmosphere. Male family members prepare the body. Buddhists recommend not
touching the body after death to give the deceased a smoother transition to the afterlife. People often say prayers
while touching and standing at the head of the deceased. The body is not left alone after death. Family and friends
pay respects after death and before cremation of the body.
Hindu: The body is placed on the floor with the head facing north. Persons of the same gender handle the body
after death. There are no general prohibitions against autopsy. Bodies are cremated after death to purify by fire.
Jewish: If the family practices Orthodox Judaism, determine if members from the Jewish Burial Society are
coming to the facility before preparing the body. A family member often stays with the body until burial. Usually the
burial occurs within 24 hours but not on the Sabbath. Some but not all types of Judaism avoid cremation, autopsy,
and embalming.
Evaluation
o
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The success of the evaluation process depends partially on the bond that you have
formed with the patient.
Refer back to the goals and expected outcomes established during the planning phase to
determine the effectiveness of nursing interventions.
A patients responses and perceptions of the effectiveness of the interventions determine
if the existing plan of care is effective or if different strategies are necessary.
Evaluate verbal and nonverbal communication and behaviors for cues related to
expressions of hope. Continue to evaluate the patients progress, the effectiveness of the
interventions, and patient and family interactions.

The following questions help you validate achievement of patient goals and expectations:
What is the most important thing I can do for you at this time?
Are your needs being addressed in a timely manner?
Are you getting the care for which you hoped?
Would you like me to help you in a different way?
Do you have a specific request that I have not met?

Short-term outcomes indicating effectiveness of grief interventions include talking about

the loss without feeling overwhelmed, improved energy level, normalized sleep and
dietary patterns, reorganization of life patterns, improved ability to make decisions, and
finding it easier to be around other people.
Long-term achievements include the return of a sense of humor and normal life patterns,
renewed or new personal relationships, and decrease of inner pain.
Nurses experience grief and loss too. Many times, even before a nurse has a chance to
recover from an emotionally draining situation, he or she encounters another difficult
human story. Nurses in acute care settings often witness prolonged, concentrated
suffering on a daily basis, leading to feelings of frustration, anger, guilt, sadness, or
anxiety.
Frequent, intense, or prolonged exposure to grief and loss places nurses at risk for
developing compassion fatigue. Compassion fatigue, described as physical, emotional,
and spiritual exhaustion resulting from seeing patients suffer, leads to a decreased
capacity to show compassion or empathize with suffering people.
Nurses develop self-care strategies to maintain balance. Self-reflection, an element of
critical thinking, serves as a useful tool when you feel overwhelmed.

o
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-For example, ask yourself if your sadness is related to caring for a patient or to an
unresolved, disruptive experience in your personal life. Talking with friends, a spiritual
care provider, or a close colleague helps you recognize your own grief and reflect on the
meaning of caring for dying patients.
Creative strategies help you cope with the loss of a patient to whom you have become
attached. You sometimes gain closure by attending a mortuary viewing or a funeral or
writing a sympathy letter to the family.

Quiz

1. A nurse encounters a family that experienced the death of their adult child last
year. The parents are talking about the upcoming anniversary of their childs death.
The nurse spends time with them discussing their childs life and death. The nurses
action best demonstrates which nursing principle?
a. Pain management technique
b. Facilitating normal mourning
c. Grief evaluation
d. Palliative care
2. A cancer patient asks the nurse what the criteria are for hospice care. What
should the nurse answer?
a. Having a terminal illness, such as cancer
b. Needing assistance with pain management
c. Expected to live less than 6 to 12 more months
d. Completion of an advance directive
3. A terminally ill patient is experiencing constipation secondary to pain medication.
What is the best way for the nurse to improve the patients constipation problem?
a. Massage the patients abdomen.
b. Contact the provider to discontinue pain medication.
c. Administer enemas twice daily for 7 days.
d. Use a stimulant laxative and increase fluid intake.

4. A severely depressed patient cannot state any positive attributes to his or her
life. The nurse patiently sits with this patient and assists the patient to identify
several activities the patient is actually looking forward to in life. The nurse is
helping the patient to demonstrate which spiritual concept?
a. Time management
b. Hope
c. Charity
d. Faith
5. In preparation for the eventual death of a female hospice patient of the Muslim
faith, the nurse organizes a meeting of all hospice caregivers. A plan of care to be
followed when this patient dies is prepared. This plan of care would include
a. Male health care workers care for the body after death has occurred.
b. Body preparation for autopsy.
c. Body preparation for cremation.
d. Female health care workers care for the body after death has occurred.
6. Family members gather in the emergency department after learning that a family
member was involved in a motor vehicle accident. After learning of the family
members unexpected death, the surviving family members begin to cry and
scream in despair. The nurse recognizes this as the Bowlby Attachment Theory
stage of
a. Numbing.
b. Disorganization and despair.
c. Bargaining.
d. Yearning and searching.
7. After the anticipated demise of a chronically ill patient, the unit nurse is found
crying in the staff lounge. The best response to her crying colleague would be
a. It is normal to feel this way. Give yourself some time to mourn.
b. Your other patients still need you, so hurry back to them.
c. Youre being a bad role model to the units nursing students.
d. Why dont you take a sedative to cope?
8. A family is grieving after learning of a family members accidental death. The
transplant coordinator requests to talk with the family about possible organ and
tissue donation. The nurse recognizes that
a. All religions allow for organ donation.
b. Life support must be removed before organ and tissue retrieval occurs.
c. The best time for organ and tissue donation is immediately after the autopsy.
d. The transplant coordinator is working in accordance with federal law.

9. An Orthodox Jewish Rabbi has been pronounced dead. The nursing assistant
respectfully asks family members to leave the room and go home as postmortem
care is provided. Which of the following statements from the supervising nurse
reflects correct knowledge of Jewish culture?
a. I wish they would go home because we have work to do here.
b. Family members stay with the body until burial the next day.
c. I should have called a male colleague to handle the body.
d. I thought they would quietly leave after praying and touching the Rabbis head.
10. The palliative teams primary obligation to a patient in severe pain includes
which of the following?
a. Supporting the patients nurse in her grief
b. Providing postmortem care for the patient
c. Teaching the patient the stages of grief
d. Enhancing the patients quality of life

11. A man is hospitalized after surgery that amputated both lower extremities owing
to injuries sustained during military service. The nurse should recognize his need to
grieve for what type of loss?
a. Maturational loss
b. Situational loss
c. Perceived loss
d. Uncomplicated loss
12. I know it seems strange, but I feel guilty being pregnant after the death of my
son last year, said a woman during her routine obstetrical examination. The nurse
spends extra time with this woman, helping her to better bond with her unborn
child. This demonstrates which nursing technique?
a. Facilitating mourning
b. Providing curative therapy
c. Promoting spirituality
d. Eradicating grief
13. The nurse has had three patients die during the past 2 days. Which approach is
most appropriate to manage the nurses sadness?
a. Telling the next patients why the nurse is sad
b. Talking with a colleague or writing in a journal
c. Exercising vigorously rather than sleeping
d. Avoiding friends until the nurse feels better
14. A woman is called into her supervisors office regarding her deteriorating work
performance since the loss of her husband 2 years ago. The woman begins sobbing

and saying that she is falling apart at home as well. The woman is escorted to the
nurses office, where the nurse recognizes the womans symptoms as which of the
following?
a. Normal grief
b. Complicated grief
c. Disenfranchised grief
d. Perceived grief
15. The father has recently begun to attend his childrens school functions since the
death of his wife. This would best be described as which task in the Worden Grief
Tasks Model?
a. Task I
b. Task II
c. Task III
d. Task IV
16. The mother of a recently murdered child keeps the childs room intact. Family
members are encouraging her to redecorate and move forward in life. The visiting
nurse recognizes this behavior as ____ grief.
a. Normal
b. Endoflife
c. Abnormal
d. Complicated
17. Validation of a dying persons life would be demonstrated by which nursing
action?
a. Taking pictures of visitors
b. Calling the organ donation coordinator
c. Listening to family stories about the person
d. Providing quiet visiting time
18. A couple is informed that their fetus condition is incompatible with life after
birth. Nurses can best help the couple with their endoflife decision making by
offering them which of the following?
a. An advance directive to complete
b. Brief discussion and funeral guidance
c. Time and careful explanations
d. Instructions on how to proceed
19. A correctional facility nurse is called to the scene of a deceased inmate. The
correction officer wants to quickly move the body to the funeral home because he is
not comfortable with death. The inmates body will need to be transported where?

a. Coroners office for an autopsy

b. Police department for an investigation
c. Directly to the inmates family
d. Warden for inspection
20. A dying patient with liver and renal failure requires pain medication. The nurse
anticipates that the medication dose will be
a. Given at appropriate milligrams per kilogram medication levels.
b. A decreased dose from milligrams per kilogram levels.
c. An increased dose from milligrams per kilogram levels.
d. Given at midrange for dosing at recommended levels.
21. A patient cancels a scheduled appointment because she will be attending a
Shiva for a family member. Recognizing the importance of this cultural ritual, the
nurses best comment would be which of the following?
a. Congratulations, whats the babys name?
b. Im so sorry for your loss.
c. Missionary church outreach is so important.
d. Can I buy a ticket to this fundraiser?
22. During a followup visit, a woman is describing new onset of marital discord with
her terminally ill spouse. Using the KblerRoss behavioral theory, the nurse
recognizes that the spouse is in which stage of dying?
a. Denial
b. Bargaining
c. Anger
d. Depression
23. Enuresis is reported in a previously toilet trained toddler. While gathering a
health history from the grandparent, the nurse asks about which factor as the most
likely cause?
a. Lack of outside playtime
b. Having too many toys
c. Dietary changes
d. Recent parental death
24. Mrs. Harrisons father died a week ago. Mr. Harrison is experiencing headaches
and fatigue, and keeps shouting at his wife to turn down the television, although he
has not done so in the past. Mrs. Harrison is having trouble sleeping, has no
appetite, and says she feels like she is choking all the time. How should the nurse
interpret these assessment findings as the basis for a followup assessment?
a. Mrs. Harrison is grieving and Mr. Harrison is angry.
b. Mrs. Harrison is ill and Mr. Harrison is grieving.
c. Both Mr. and Mrs. Harrison likely are in denial.

d. Both Mr. and Mr. Harrison likely are grieving.

Answers and rationales

1. ANS: B
Anniversary reactions can reopen grief processes. A nurse should openly
acknowledge the loss and talk about the common renewal of grief feeling around
the anniversary of the individuals death. This facilitates normal mourning. The
nurse is not attempting to alleviate a physical pain. The actions are of open
communication, not evaluation. Palliative care refers to comfort measures for
symptom relief.
2. ANS: C
The criterion for hospice care is being expected to live less than 6 to 12 more
months. Patients with a terminal illness are not eligible until that point. Palliative
care provides assistance with pain management when a patient is not eligible for
hospice care. An advance directive can be completed by any person, even those
who are healthy.
3. ANS: D
Opioid medication is known to slow gastrointestinal transit time, which places the
patient at high risk for constipation. Stimulant laxatives are indicated for opioidinduced constipation. Added water to the diet will allow water to be pulled into the
GI tract, softening up stool. Massaging the patients abdomen may cause further
discomfort. Discontinuing pain medication is inappropriate for a terminally ill

patient. Enema administration is not the first step in the treatment of opioidinduced constipation.
4. ANS: B
The concept of hope is vital to nursing; it enables a person to anticipate
positive experiences. Being patient and friendly and creating positive
relationships are key concepts in all areas of nursing, but especially with
depressed patients. The nurses actions do not address time management,
charity, or faith.
5. ANS: D
Islamic culture calls for modesty and samesex caregivers whenever possible.
Muslim faith discourages cremation and autopsy to preserve the sanctity of the soul
of the deceased.
6. ANS: D
Yearning and searching characterize the second bereavement phase in the Bowlby
Attachment Theory. Emotional outbursts are common in this phase. During the
numbing phase, the family may feel a sense of unreality. During disorganization and
despair, the reason why the loss occurred is constantly questioned. Bargaining is
part of the KblerRoss stages, not of the Bowlby Attachment Theory.
7. ANS: A
Nurses often witness suffering on a daily basis. Nurses, as humans, also experience
grief and loss when they have been intensely involved in the patients suffering and
death. Offer comfort and understanding to colleagues, and maintain a stable patient
care environment. It is inappropriate to create guilt by telling a grieving nurse to
hurry back to her patients or by indicating that she is a bad role model. Suggesting
that a colleague take sedative during a shift is dangerous for the safety of patients
in her care.
8. ANS: D
It is a federal law to require facilities to develop policies about organ donation. The
transplant coordinator has additional education on providing answers about organ
donation. Not all religions allow for organ donation. A patient may be on life support
during organ removal to preserve organ tissues. Autopsy compromises organ
integrity; removal should occur prior.
9. ANS: B
Jewish culture calls for family members or religious officials to stay with the
decedents body until the time of burial. A male provider is unnecessary. Requesting
or expecting the family to go home is not providing culturally sensitive care.
10.ANS: D
The primary goal of palliative care is to help patients and families achieve the best
quality of life.
Providing support for the patients nurse is not the primary obligation when the
patient is experiencing severe pain. Not all collaborative team members would be

able to provide postmortem care, as is the case for nutritionists, social workers, and
pharmacists. Teaching about stages of grief should not be the focus when severe
pain is present.
11.ANS: B
Loss of a body part from injury is a situational loss. Maturational losses occur as part
of normal life transitions. Perceived loss is not obvious to other people.
Uncomplicated is not a type of loss; it is a description of normal grief.
12.ANS: A
The nurse facilitates mourning in family members who are still surviving. By
acknowledging the pregnant womans emotions, the nurse helps the mother bond
with her fetus and recognize the emotions that still exist for the deceased child. The
nurse is not attempting to help the patient eradicate grief, which would be
unrealistic. Curative therapy and spiritual promotion are not addressed by the
nurses statement.
13.ANS: B
Selfcare strategies for nurses include talking with a close colleague and reflecting
on feelings by writing in a journal. It is inappropriate for a nurse to talk with patients
to resolve the nurses grief. Although exercise is important for selfcare, sleep is also
important. Shutting oneself away from friends is not selfcare; the nurse should
spend time with people who are nurturing.
14. ANS: B
Complicated or dysfunctional grief occurs when an individual has a complicated
grieving process that interferes with common routines of life for excessively long
periods of time. Normal grief is the most common reaction to death; it involves a
complex range of normal coping strategies. Disenfranchised grief involves a
relationship that is not socially sanctioned. Perceived grief is not a type of grief;
perceived loss is a loss that is not obvious to other people.
15. ANS: C
The Worden Grief Tasks Model consists of four tasks. Task III is seen when the
surviving family member begins to adjust to life without the deceased. Task I is
accepting the reality of the loss, Task II is working through the pain of grief, and Task
IV is emotionally relocating the deceased and moving on with life.
16. ANS: A
Family members will grieve differently. One sign of normal grief is keeping the
deceased individuals room intact as a way to keep that person alive in the minds of
survivors. This is happening after the family member is deceased, so it is not endoflife grief. It is not abnormal or complicated grief; the child died recently.
17. ANS: C
Listening to family members stories validates the importance of the dying
individuals life and reinforces the dignity of the persons life. Taking pictures of

visitors does not address the value of a persons life. Calling organ donation and
providing private visiting time are components of the dying process, but they do not
validate a dying persons life.
18. ANS: C
Families can have limited knowledge when asked to make important ethical
decisions. Nurses have the time, patience, and knowledge base to assist the family
to understand their ethical situation and to help them make their own educated
decision. Advance directives are completed by the person who is dying. Funeral
guidance is best provided by a chaplain or a caretaker.
19. ANS: A
Law often requires that an autopsy be performed if death occurred during
incarceration; as the result of foul play, homicide, or suicide; or as an accidental
death, as occurs in car accidents. The nurse must understand the policies that are
applied in cases of foul play death and must ensure that the decedents body is
properly cared for after death, despite the emotional feelings of individuals in close
contact with the decedent.
20. ANS: B
A dying individual will likely have a decline in renal and liver functioning. Because of
reduced organ functioning, a decreased dose would be in order, so the individual
does not develop toxic levels of the medications.
21. ANS: B
The Jewish mourning ritual of Shiva incorporates the communitys helping behaviors
toward those experiencing death, sets expectations for behaviors of the survivor,
and provides the community with sustaining traditions and rituals. An
understanding of the religious and cultural significance of Shiva allows the nurse to
know how to appropriately respond.

22. ANS: C
KblerRoss traditional theory involves five stages of dying. The anger stage of
adjustment to an impending death can involve resistance, anger at God, anger at
people, and anger at the situation. Denial would involve failure to accept a death.
Bargaining is an action to delay acceptance of death by bartering. Depression would
present as withdrawal from others.
23. ANS: D
A childs stage of development and chronological age will influence how he or she
grieves. Toddlers can show grief through changes in their eating patterns, changes
in their sleeping patterns, fussiness or irritability, and changes in their bowel and
bladder habits. It is common for younger children to regress when under increased
stress. Lack of outside playtime, dietary changes, and having too many toys are
unlikely to cause enuresis.

24. ANS: D
Symptoms of normal grief include headache, fatigue, and oversensitivity to noise,
insomnia, appetite disturbance, and choking sensation. Different people manifest
different symptoms. Denial is assessed when the person indicates that he is not
accepting that the loss happened.