A loss may occur suddenly (eg, death of a child due to an auto accident) or gradually (eg, loss of a leg due to the progression of peripheral vascular disease). It may be predictable or occur unexpectedly. Loss has been referred to as actual (the loss has occurred or is occurring), perceived (the loss is recognized only by the client and usually involves an ideal or fantasy), anticipatory (the client is aware that a loss will occur), temporary, or permanent. For example, a 65-year-old married woman with the history of end-stage renal disease is told by her physician that she has approximately 12 months to live. She may experience several losses that affect not only her, but also her husband and family members, as her illness gradually progresses. The losses may include a predictable decline in her physical condition, a perceived alteration in her relationship with her husband and family, and a permanent role change within the family unit as she anticipates the progression of her illness and actual loss of life. Whether the loss is traumatic or temperate to the client and her family depends on their past experience with loss; the value the family members place on the loss of their mother/wife; and the cultural, psychosocial, economic, and family supports that are available to each of them. Box 7-1 describes losses identified by student nurses during their clinical experiences.

Grief theory proposes that grief occurs as a process. The grief process is all-consuming, having a physical, social, spiritual, and psychological impact on an individual that may impair daily functioning. Feelings vary in intensity, tasks do not necessarily follow a particular pattern, and the time spent in the grieving process varies considerably, from weeks to years (Schultz & Videbeck, 2002).

Several authors have described grief as a process that includes various stages, characteristic feelings, experiences, and tasks. Staudacher (2000) states there are three major stages of grief: shock, disorganization, and reorganization. Westberg (2004) describes ten stages of grief work, beginning with the stage of shock and progressing through the stages of expressing emotion, depression and loneliness, physical symptoms of distress, panic, guilt feelings, anger and resentment, resistance, hope, and concluding with the stage of affirming reality. Kübler-Ross (1969) identifies five stages of the grieving process: denial, anger, bargaining, depression, and acceptance; however, progression through these stages does not necessarily occur in any specific order. Her basic premise has evolved as a result of her work with dying persons. The creation of hospices, palliative care, and programs on pain management has been attributed to the work of Kübler-Ross. The care of the dying is in the forefront of medicine and the voices of the dying are increasingly recognized (Munoz, 2004). Box 7-2 discusses Kübler-Ross’s five stages of the grief process.

Unresolved or dysfunctional grief could occur if the individual is unable to work through the grief process after a reasonable time. The cause of dysfunctional grief is usually an actual or perceived loss of someone or something of great value to a person. Clinical features or characteristics include expressions of distress or denial of the loss; changes in eating and sleeping habits; mood disturbances, such as anger, hostility,
or crying; and alterations in activity levels, including libido (sex drive). The person experiencing dysfunctional grief idealizes the lost person or object, relives past experiences, loses the ability to concentrate, and is unable to work purposefully because of developmental regression. The grieving person may exhibit symptoms of anxiety (Chapter 19), depression (Chapter 21), or psychosis (Chapter 22). Kishiyama (2004) lists practical tips for clients’ experiencing grief. Paraphrased, they include:

Advance care planning is a thoughtful, facilitated discussion that encompasses a lifetime of values, beliefs, and goals for the client and family. Advance care planning often involves completion of an AD. The two most common forms of advance directives are the living will or the health care directive and the durable health care power of attorney or health care proxy (Allen, 2002; Norlander, 2001).

The living will is a document filled out by the client with specific instructions addressing issues of cardiopulmonary resuscitation (CPR); life support systems such as the use of a ventilator or intubation; tube feedings or artificial nutrition and hydration; and emergency measures such as surgery, blood transfusion, or antibiotics to treat end-stage diseases. Living wills give some guidance, but a document called Five Wishes enables all caretakers to know and understand the desires of a dying client. Each wish gives a specific desire regarding end-of-life care (Box 7-3).

A durable health care power of attorney permits an individual to name a health care decision-maker or surrogate to make medical decisions in the event that the individual is unable to make these decisions or give informed consent. If a health care power of attorney or surrogate has not been named, the law allows a health care proxy to be appointed to act on behalf of the client (eg, an individual has a stroke and is unable to communicate his wishes). Examples of health care proxies include spouses, guardians, or parents.

A unique form of advance directive, the dying declaration exception to hearsay allows statements referred to as “death bed declarations” to be honored by the medical and nursing staff. For example, a client, who is aware that death is imminent and has not completed a living will, may inform the nursing staff that he wants all medication, including intravenous (IV) therapy, to be discontinued. Such a request can be honored if documented (Scanlon, 2003).

Our health care system is based on a scientific, biomedical model of disease. Many other cultures have a
more spiritual or nature-based view (Norlander, 2001

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