Nurses regularly encounter clients who are experiencing loss. Loss is any situation in which a valued object is changed or is no longer accessible to the individual. Loss can be actual (e.g., loss of a spouse), perceived (e.g., only experienced by the person but not tangible to others), anticipated (e.g., loss of a spouse vs. dealing with terminal illness), tangible (real), intangible (e.g., loss of income vs. loss of extremity), maturational (e.g., losses related to growth and development), situational (e.g., in response to an external event beyond one’s control), physical (e.g., personal injury), psychological (e.g., feeling of inadequateness), or collective (e.g., experienced by many through a societal event).

The categories of loss are the loss of external objects, the loss of familiar environment, the loss of aspects of self, and the loss of significant other. Grief is a normal, natural, necessary, and adaptive series of responses that occur following a loss. Grief is labeled as uncomplicated, dysfunctional, or anticipatory

Several theories have been developed to explain grief. Kubler-Ross described five stages of grieving: denial, anger, bargaining, depression, and acceptance. Lindmann described grief work as a process in which the griever adjusts to an environment without the deceased and establishes new relationships. Engle describes three stages leading to acceptance of the loss: shock and disbelief, developing awareness, and restitution and resolution. Worden outlined four tasks for the griever: accepting the loss, experiencing emotional pain, adjusting to an environment without the deceased, reinvesting into another relationship.

Bereavement is the period of time after a loss in which people may neglect their own health or are unable to function. Mourning is the period of time when grief is expressed.

Anticipatory grief is the occurrence of grief work before an expected loss. Dysfunctional grief means to not progress through the stages of grief or to not demonstrate the usual behaviors of grief, despite feeling the emotions of grief. Experiencing dysfunctional grief is more common when the loss is sudden, when the loss is caused by a socially unspeakable event (such as suicide), or when the relationship with the deceased was difficult. Disenfranchised grief, grief experienced in situations where grief is discouraged and social supports are absent, may contribute to dysfunctional grief.

The factors affecting grief are the person’s developmental level, religious and cultural beliefs, relationship to the loss object, and the cause of the death. Beliefs about the after-life and faith can assist grief work. The relationship with the deceased can have a large affect on grieving because the mourner may have unfinished business with the person who dies. Generally, the closer the mourner is to the deceased, the more intense the grief experienced. Unexpected death leaves mourners with the feeling that they did not get to say good-bye. Traumatic death often results in complicated grief, due to the imagery the bereaved experiences. Suicide may leave survivors with guilt, anger, and shame, further complicating the grieving process.

The role of the nurse in caring for the grieving person is supportive. Assessment begins with a discussion of the personal meaning of the loss. Nursing diagnoses related to grieving are Dysfunctional Grieving and Anticipatory Grieving. Outcomes that are important for the person experiencing grief include verbalizing feelings, sharing grief, accepting loss, and renewing activities and relationships. Interventions include reassurance, counseling, and support. Evaluation of care for the grieving may be difficult since resolution occurs over an undetermined time.

Nurses are heavily involved in end-of-life (EOL) care. Ethical issues arise for clients who are terminally ill, particularly physician-assisted suicide in the United States. When assessing the dying client, it is important to discover the client and family’s knowledge, the availability of social support, physical symptoms, emotional status, presence of advanced directives, concern about unfinished business, and the client’s priorities and preparation needs. Nursing diagnoses appropriate for the dying client may include Powerlessness, Helplessness, High Risk for Spiritual Distress, and Altered Family Processes.

Interventions include being with the client, attending to physical needs, providing palliative care (comfort; providing symptom management), referral to hospice care, meeting psychosocial needs, promoting spiritual comfort, teaching the client and family, and providing support for the family. Hospice care should include a “Do Not Resuscitate” prescription to avoid attempts to rescue the terminal client. Psychosocial challenges for the dying client include anxiety, decreased independence, and decreased social interaction.

Nursing care of the dying incorporates care of the body after death. The nurse should (1) take care when removing tape from the body to avoid skin breakdown that results from algor mortis (lack of skin elasticity from the decrease in the body temperature); (2) elevate the head to prevent bluish purple discoloration of the face brought on by liver mortis, which results from red blood cell destruction; (3) close the eyelids, insert dentures, close the mouth, and position the body in a natural position; (4) remove tubes; (5) place identification tags on the body’s toe and wrist; and (6) place the body in a plastic or fabric shroud and tag the shroud. An autopsy (postmortem examination to determine the cause of death) is mandated when an unusual death has occurred. When the deceased has given permission for organ donation and the circumstance allows, body organs may be recovered for transplantation, with family permission.