Introduction to Medical-Surgical Nursing, 6th ed.
24
Lesson Plans for
Loss, Death, and End-of-Life Care
CHAPTER LESSON PLANS & OBJECTIVES
Lesson 24.1:
2. Describe responses of patients and their families to terminal illness and death.
4. Assist in the development of a care plan for the terminally ill.
Lesson 24.2:
6. Explore the needs of the nurse who works with terminally ill patients.
7. Identify issues related to caring for the dying patient, including advance directives,
do not resuscitate decisions, brain death, organ donations, and pronouncement of death.
CHAPTER TEACHING FOCUS
• In this chapter, the student will be introduced to topics related to loss, death, and end–of–life care. The
student will have the opportunity to become acquainted with the concept of loss; grief and the grieving
process; fears associated with terminal illness and death; and the needs of a terminally ill patient’s
significant others.
• The clinical signs of impending death, physical changes after death, assessment of the terminally ill or
dying patient, and potentially contentious issues, such as organ donation and cardiopulmonary
resuscitation, are also included in the chapter.
CONCEPTS
The following conceptual themes and specific concepts match those presented in Giddens, J. R. (2013).
Concepts for nursing practice. St. Louis: Elsevier. The specific exemplars chosen and listed below for
each concept have been tailored specifically to correspond to the Linton textbook.
THEME: Health Care Delivery
• Concept: Palliative Care
• Exemplar: Nursing Care of Terminally Ill and Dying Patients, p. 375
2 Chapter 24 Loss, Death, and End-of-Life Care _________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
CHAPTER PRETEST
Have the students answer these questions prior to covering this chapter to understand where they stand
in relation to the content.
1) A cancer patient whose hair falls out will most likely experience which type of loss?
a) Developmental change
b) Loss of possessions
c) Change in self-image
d) Loss of significant other
2) Grieving that occurs before death is known as __________.
a) dysfunctional grief
b) anticipatory grieving
c) maladaptive grieving
d) functional grieving
3) Which of the following best describes a school-age child’s belief about death?
a) Death is seen as a future event.
b) Death is reversible.
c) Death anxiety may be experienced.
d) Death is related to violence.
4) According to Kübler-Ross, which of the following is one of the five stages of grieving?
a) Anger
b) Shock and disbelief
c) Avoidance
d) Accommodation
5) The state of awareness in which the patient and family realize the patient is ill but lack awareness
related to impending death is __________.
a) denial
b) mutual pretense
c) open awareness
d) closed awareness
6) When a patient is dying, the vital signs show which changes?
a) Respirations stay stable.
b) Blood pressure decreases.
c) Circulation increases.
d) Blood pressure increases.
7) Cheyne-Stokes breathing is __________.
a) rapid, shallow respirations
b) absence of respirations
c) irregular respirations with periods of apnea
d) very slow respirations
8) When preparing the body for family viewing after death, the nurse should __________.
a) raise the head of the bed to 30 degrees
b) remove the clothing and cover the body with a sheet
c) leave the body just as it is
d) cleanse the body if soiled
9) A document that states the patient’s wishes regarding medical care is a(n) __________.
a) will
b) advance directive
c) power of attorney for health care
d) do not resuscitate (DNR) order
10) What is the definition of a chemical code?
a) Complete and total heroic measures
b) The use of CPR only
c) The use of medications but not CPR
d) No interference in the dying process
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Introduction to Medical-Surgical Nursing, 6th ed.
Chapter Pretest Answers
CHAPTER BACKGROUND ASSESSMENT
Discuss these questions with your students prior to covering this chapter to understand where they stand
in relation to the content.
Question: Define the term loss. What are specific examples of three types of loss?
Question: What are three clinical signs associated with impending death?
4 Chapter 24 Loss, Death, and End-of-Life Care _________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 24.1
Textbook Objectives Covered
2. Describe responses of patients and their families to terminal illness and death.
4. Assist in the development of a care plan for the terminally ill.
Lesson Preparation Checklist
• Prepare lecture from TEACH lecture slides available on Evolve.
• Student performance evaluation of all entry-level skills required for student comprehension of
principles underlying loss, death, and end-of–life care, including:
• Grief, the grieving process, and stages of grieving
Materials and Supplies
• computer and PowerPoint
projector
Key Terms
• advance directive (p. 378)
• algor mortis (p. 375)
• mourning (p. 369)
• palliative care (p. 368)
_________________________________________________ Chapter 24 Loss, Death, and End–of-Life Care 5
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 24.1
Student Preparation
Assignments 2 hours
1
READ – Textbook (pp. 368-377)
REVIEW
• Table 24-1: Age-Related Beliefs About Death (p. 371)
ANSWER – Text
ANSWER – Study Guide
• Part IC: 1-12 (pp. 138–139)
2
READ – Textbook (pp. 368-377)
REVIEW
• Table 24-2: Rando’s Phases of Mourning and Related Processes (p. 372)
ANSWER – Text
• Review Questions for the NCLEX Examination: 2-6 (p. 383)
ANSWER – Study Guide
• Part IA: 2-11 (p. 137)
• Part IB: 1-13 (p. 138)
• Part IIIE: 1, 2 (p. 140)
3
READ – Textbook (pp. 368-377)
REVIEW
• Table 24-3: Physical Manifestations of Approaching Death (p. 374)
ANSWER – Study Guide
4
READ – Textbook (pp. 368-377)
ANSWER – Study Guide
• Part IIIE: 5, 6, 8 (p. 141)
6 Chapter 24 Loss, Death, and End-of-Life Care _________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 24.1
Lecture Outline 20 minutes
Slide 1
Chapter 24
Loss, Death, and End-of-Life Care
1
Slide 2
Concept of Loss
• Loss may be defined as a real or potential absence of someone or something that is
valued
• Real losses occur when something actually happens: valued people or possessions
are no longer available
TALKING POINTS:
• Death, like birth, is a natural part of the life cycle.
• What is the palliative care movement?
Slide 3
Types of Losses
• Change in self-image
• Perceived change in body image, such as pregnancy, hair loss, disability, or radical
surgery, can alter a person’s self-concept
• The uncertainties and insecurities in role changes result in perceived loss in terms of
former roles
• Developmental changes
• Changes or milestones may cause insecurities, fears, and feelings of loss
TALKING POINTS:
• Within each individual’s life, ideas about personal worth, usefulness, roles, and beliefs are
created.
Slide 4
Types of Losses (cont.)
• Loss of possessions
• Possession has perceived value to the owner; its value may not be apparent to others
• An object may be irreplaceable because of memories associated with it, or it may be
valuable from a monetary standpoint
• When significant object is lost or left behind, the individual loses a part of his or her
identity
TALKING POINTS:
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 24.1
Slide 5
Types of Losses (cont.)
• Loss of significant others
• Through death, separation, growth of children, change of residence, divorce, or lack
of communication
• Separation from significant others may be related to actual distance, or it may be
emotional
TALKING POINTS:
• The loss of a loved one through death is a permanent loss.
• How is death viewed differently in nonindustrialized societies compared with American
society?
Slide 6
Grief
• Definition
• A normal, natural response to a loss
• Emotional reaction necessary to maintain quality in emotional and physical well-being
TALKING POINTS:
• Grieving during a death loss is a complex and intense emotional experience.
• Is grieving a healthy response to loss?
Slide 7
Adaptive Grief
• A healthy response
Slide 8
Anticipatory Grief
• Usually related to a loss or death
• May be a healthy or an unhealthy response to the grief process
• Patient and family members can experience anticipatory grieving
Slide 9
Reactive Grief
• After an actual loss or a death occurs
8 Chapter 24 Loss, Death, and End-of-Life Care _________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 24.1
Dysfunctional Grieving
• Grief that is delayed or exaggerated
• May relate to a real loss or a perceived loss
TALKING POINTS:
• Unresolved issues may be identified and past experiences reviewed.
• What emotions may be displayed?
Slide 11
The Grieving Process
• Culture, religious beliefs, and age affect a person’s understanding of and reaction to death
or loss
• People who believe in “toughing it out” or “being strong” may not express themselves
when they have experienced a tragic loss
TALKING POINTS:
• People experiencing the inevitability of death, the final loss, need caregivers who are
knowledgeable about personal attitudes that affect the experience.
• What does the Protestant ethic emphasize?
• Children have a different understanding of loss and death than adults.
The Grieving Process (cont.)
• A child who loses a loved one to death may regress or be delayed in emotional
2
Slide 13
Stages of Grieving
• Kübler-Ross
• Denial
• Anger
• Bargaining
• Depression
TALKING POINTS:
• Denial serves to protect the patient, family, or both from the reality of the loss.
• The patient or family members may become angry or outraged with situations.
• In the bargaining stage, the person wishes for more time to avoid the loss.
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 24.1
Slide 14
Stages of Grieving (cont.)
• Martocchio
• Shock and disbelief
• Yearning and protest
Slide 15
Stages of Grieving (cont.)
• Rando
• Avoidance
• Confrontation
• Accommodation
Slide 16
Common Signs and Symptoms of Grief
• Physical symptoms
• Tightness in the chest, shortness of breath, suffocation, generalized weakness,
intense tightening in the abdomen, and emptiness or churning in the stomach
• Symptoms may fluctuate throughout the grief process
TALKING POINTS:
• What causes the physical symptoms?
• You should be aware that the stress reaction is a very real experience.
Common Signs and Symptoms of Grief (cont.)
• Awareness of terminal illness
Slide 18
Common Signs and Symptoms of Grief (cont.)
• Strauss and Glaser: three states of awareness
• Closed awareness
• The family and the patient recognize that the patient is ill; there is a lack of
TALKING POINTS:
• In general, honesty is the best choice in dealing with death.
• Is open awareness appropriate for everyone?
10 Chapter 24 Loss, Death, and End-of-Life Care _________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 24.1
Fears Associated with Terminal Illness and Death
• Fear of pain
• Physiologically, no indication that death is always painful
TALKING POINTS:
• The patient and family need assurance that medication will be given promptly when it is
needed.
• How is pain control best accomplished?
Fears Associated with Terminal Illness and Death (cont.)
• Fear of loneliness
• Most terminally ill/dying people do not want to be alone
TALKING POINTS:
• What quality nursing responses may be helpful for the terminally ill patient?
Fears Associated with Terminal Illness and Death (cont.)
• Fear of meaninglessness
• During dying process, most people review their lives
3
Slide 22
Clinical Signs of Impending Death
• Loss of muscle tone
• The muscular system weakens gradually
• Body movements slow; facial muscles lose tone, jaw may sag
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 24.1
Slide 23
Clinical Signs of Impending Death (cont.)
• Circulatory and respiratory changes
• The pulse slows and weakens
• Blood pressure drops
• Temperature may be elevated
• Respirations rapid, shallow, and irregular, or very slow
• Breathing may sound wet and noisy
Slide 24
Clinical Signs of Impending Death (cont.)
• Sensory changes
• Include decreasing pain and touch perception, blurred vision, and decreasing sense
of taste and smell
• Blink reflex lost eventually; patient appears to stare
Slide 25
Clinical Signs of Impending Death (cont.)
• Sensory changes
• Body gradually relaxes until all function ends
• Generally, respirations cease first
Clinical Signs of Impending Death (cont.)
• In 1968, Harvard Medical School faculty developed the Harvard Criteria: determines a
permanently nonfunctioning brain
TALKING POINTS:
12 Chapter 24 Loss, Death, and End-of-Life Care _________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 24.1
Clinical Signs of Impending Death (cont.)
• Cerebral death
• Cerebral cortex stops functioning or is irreversibly destroyed
TALKING POINTS:
• What criteria have been recommended by the Quality Standards Subcommittee of the
American Academy of Neurology?
Slide 28
Physical Changes After Death: Decomposition
• Rigor mortis
• Within 2 to 4 hours the body stiffens
• Caused by chemical changes within the body’s cells that prevent muscle relaxation
Physical Changes After Death: Decomposition (cont.)
• Algor mortis
• The body begins to cool
Physical Changes After Death: Decomposition (cont.)
• Livor mortis
• Breakdown of red blood cells causes a discoloration in the skin
TALKING POINTS:
• Decomposition of the body happens faster in warmer temperatures or environments
because of bacterial growth.
• How can decomposition be slowed?
4
Slide 31
Assessment
• Document the specific event that brought patient to the health care facility
• Record medical diagnoses, medication profile, and allergies
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 24.1
Slide 32
Assessment (cont.)
• Functional assessment of activities of daily living elicits information about the patient’s
abilities, food and fluid intake, patterns of sleep and rest, and response to the stress of
terminal illness
Slide 33
Assessment (cont.)
• Neurologic assessment especially important; includes level of consciousness, reflexes,
and pupil responses
• Evaluate vital signs, skin color, and temperature; indicates changes in circulation
• Monitor respiratory status; describe character of respirations and characteristics of breath
sounds
TALKING POINTS:
• It is important to be sensitive and not to impose repeated, unnecessary assessments on
the dying patient.
• What nursing diagnoses may be appropriate for the dying patient?
Assessment (cont.)
• General nursing diagnosis of grieving deals with normal grieving experienced following
a loss
TALKING POINTS:
• What are examples of goals for anticipatory and dysfunctional grief?
Slide 35
Question 1
• All of the following are true about loss EXCEPT _____________.
A. loss may be defined as a real or potential absence of someone or something that is
valued
B. real losses occur when something actually happens so that valued people or
possessions are no longer available
C. potential losses relate to an individual’s perceptions of what might occur if a valued
person or object were lost permanently
D. real losses are a worse experience to the person than potential losses
TALKING POINTS:
and grief are common with both real and potential losses.
Introduction to Medical-Surgical Nursing, 6th ed.
Slide 36
Question 2
• The correct order for Martocchio’s five clusters of grief is ____________.
A. shock and disbelief; disorganization and despair; yearning and protest; identification
in bereavement; and reorganization and restoration
B. anguish, disorganization, and despair; shock and disbelief; yearning and protest;
identification in bereavement; and reorganization and restoration
C. yearning and protest; shock and disbelief; anguish, disorganization, and despair;
identification in bereavement; and reorganization and restoration
D. shock and disbelief; yearning and protest; anguish, disorganization, and despair;
identification in bereavement; and reorganization and restoration