ALL INDIA INSTITUTE OF MEDICAL SCIENCE

BHOPAL

SEMINAR
ON
Coping with loss, death and grief

SUBMITTED TO SUBMITTED BY
Mrs. – Mrs. Geeta Bhardwaj Ms Himani Dhauni
Assistant Professor M.Sc. Nursing 1st year
AIIMS Bhopal
NAME OF THE COURSE – M.Sc. Nursing 1st year
SEMINAR OF SUBJECT – Advance nursing practice.
SEMINAR TOPIC - Coping with loss ,death and grief.
UNIT- 2
GROUP- M.Sc. Nursing.
NUMBER OF STUDENTS- 30
NAME OF THE GUIDE – Mrs. Geeta Bhardwaj
STUDENT NAME- Himani Dhauni.
TEACHING LEARNING METHOD – Lecture cum discussion
AV AIDS- PPT
PREVIOUS KNOWLEDGE OF THE STUDENTS-
Students already have some previous knowledge about this topic of Coping with
loss ,death and grief.
 OBJECTIVES-
GENERAL OBJECTIVES-
 At the end of the seminar the student will have in depth knowledge and proper understanding of this
topic.

SPECIFIC OBJECTIVES-
At the end of the seminar student will be able to
 Explain the loss ,death and grief including its types.
 Describe the sign of death.
 Explain the factors that affect coping from loss, grief and death.
 Describe all the theories related to coping of loss, death and grief.
 Identify all the legal and ethical dimension of the dying patient.
 Describe the role of nurse when caring for patient coping with loss, death
and grief.
 Update their knowledge about existing recent advance related to the topic.
 INTRODUCTION –
 Loss is a part of life cycle. All people experience in the form of changes , growth and
transition . Our loss begin at birth (having to leaving the warmth and security of the womb)
and end with the estimate loss (the death of self ).
 Loss, grief and death are universal phenomenon.
 A wide variety of losses may occur including loss of a body part or function ,loss of one
ability to care for oneself etc.
 So, to cope up with all these loss , death and grief people needs support to move ahead.

LOSS

DEFINATION –
 The fact or process of losing something or someone.
- oxford dictionary
 Loss is defined as the experience of parting with an object ,person, belief or relationship
that one values .These object can be animate or inanimate , a relationship or situation ,even
a change or a failure.

TYPES OF LOSS-

TYPES OF LOSS

PERCIEVED NECESSARY
LOSS LOSS

MATURATIONAL ACTUAL
LOSS LOSS

SITUATIONAL
LOSS

 NECESSARY LOSS- These losses are something natural and often positive. These
are an integral part of each person life.
 Eg- growing up process .We start to leave school and went college to make new
bonds. These losses are replaced by something different and better .

 ACTUAL LOSS - The loss that can be recognised by others including the person
sustaining the loss .
Eg- person losing a spouse, body part , valued object etc.

 PERCIEVED LOSS - Any loss that is uniquely defined by the grieving person but
intangible to others around that person.
Eg - The loss of prestige , loss of self –confidence.

 MATURATIONAL LOSS- This is the form of necessary loss. Any changes in the
natural developmental process that is normally expected during a life time . It is a part of a
normal life transition .
Eg- moving from stage of adulthood to old geriatric stage of life.

 SITUATIONAL LOSS- It include any sudden unpredictable external event. This type
of loss lead to multiple losses.
Eg- A person in automobile accidents sustain an injury with physical changes that makes it
impossible to return to work and this lead to loss of income.

CATEGORIES OF LOSS-

• Loss of external object - When an object that a person highly values is damaged,
changed, or disappeared, loss occurs. The significance of the lost object to the individual
determines the type and amount of grieving that occur.
• Loss of familiar environment - The loss of familiar environment occurs when a
person moves to another home or a different community, changes school or starts a new
job.
• Loss of aspect of self - Loss of an aspect of self can be physiological or
psychological. A psychological aspect of self that may be lost is ambition, a sense of humor
or enjoyment of life.
• Loss of significant other- The loss of loved ones is a significant loss. Such a loss
can be a result of separation, divorce, running away, moving to a different area, or death.

UNDERSTANDING EMOTIONS ASSOCIATED WITH GRIEF

AND LOSS
Understanding these emotions can help you manage them effectively and continue to
provide high-quality care.
 Sorrow- When a patient passes away, it’s common to feel a profound sense of sorrow or
sadness. It’s a natural response to loss, particularly if you’ve developed a strong rapport
with the patient over the course of their care.
 Anger - This could stem from frustration over the perceived unfairness of the situation or
resentment towards the disease that caused the death. Managing this anger effectively is
crucial in maintaining professionalism and providing comfort to the deceased patient’s
loved ones.
 Guilt - Guilt is also common, especially if you wonder whether there was more you could
have done to prevent the patient’s death. Remember, as a nurse, you are tasked with
providing the best possible care within your means and knowledge, not guaranteeing
outcomes
 Helplessness - Lastly, you could also wrestle with feelings of helplessness, particularly if
the death was sudden or unexpected. Accepting the limits of medical intervention can be
difficult, but it’s part of the reality of nursing.
IMPACT ON PROFESSIONAL PRACTICE
Compassion fatigue or secondary stress disorder
Compassion fatigue describes the physical, emotional, and psychological impact of
helping others, typically associated with caring too much.
Secondary stress, on the other hand, is an intense, unpleasant, and ongoing psychological
response due to helping or intending to help those traumatized or extremely distressed.
SELF-CARE STRATEGIES FOR NURSES
Nurses often face emotionally draining situations at work, which can take a toll on their
mental health.

Physical Activities
Engage in Hobbies
Mindfulness Techniques

Healthy Eating and Sleeping Habits

Workplace Support
The value of team support in your nursing career cannot be overstated.
1. Emotional Support
Your fellow nurses can be a significant source of relief during such times.

2. Professional Guidance
Hospital administrators also play an essential role in providing support.

DEATH-
 The Uniform definition of death act (1981) provides a legal definition of death as
follows –
1- Irreversible cessation of all function of circulatory and respiratory function .
 2- Irreversible cessation of all function of the entire brain, including the brain stem is
dead .
Death is the cessation or permanent termination of all the biological functions that
sustain a living organism.

 SIGNS OF APPROACHING DEATH

Death usually occurs gradually over hours or days.

PHYSICAL EVENTS
1. Cardiac Dysfunctions
 Failing cardiac functions is one of the first signs that a client’s condition is
worsening.
 At first, heart rate increases in a futile attempt to deliver oxygen to cells. The apical
pulse rate may reach 100 or more per minute. Cardiac output per minute increases.
 Decrease and blood pressure to fall.

2. Peripheral Circulation Changes

 Reduced cardiac output compromises peripheral circulation and impairs cellular
metabolism and produces less heat.
 Skin becomes pale, nail beds and lips may appear blue, client may feel cold.

3. Pulmonary Function Impairment

 Failure of heart pumping function causes fluid to collect in pulmonary circulation.
 Breath sounds become moist and client cannot exhale carbon dioxide adequately
compounding state of hypoxia.

4. Central Nervous System

 With hypoxia, brain is less sensitive to accumulating levels of carbon dioxide, thus
client may experience periods of apnea.
 Pain perception is decreased, client may stare blankly through partially opened
eyes. Senses become impaired.
 Hearing tends to be remain intact.

5. Renal Impairment
 Low cardiac output decreases the urine volume and waste products accumulate.

6. Gastrointestinal Disturbance
 Peristalsis decreases, causes intestinal contents to accumulate. This stimulates
vomiting center inducing nausea and vomiting.

7. Musculoskeletal Changes
 Reflexes become hypoactive.
 The client loses control over sphincters leading to incontinence. Jaw and facial
muscles relax. Tongue may fallback.

PSYCHOLOGICAL EVENTS
 If they have reached the stage of acceptance, some terminally-ill clients look
forward to dying because it will end their suffering.
 Some seen to forestall dying when they feel their loved ones are not prepared.
 This is waiting for permission phenomenon.
NEAR DEATH EXPERIENCE –
In this, a person almost dies but is resuscitated, have been reported for sometime.
People who experience near death experience report similar events such as:
 Floating above their bodies.
 Moving rapidly toward a bright life.
 Seeing familiar people who have already died.
 Feeling warm and peaceful.
 Being told that it is not time yet for them to die.
 Regretting having to return to their resuscitated body.

PERCEPTION OF DEATH AS PER DEVELOPMENTAL STAGES AND

NURSING IMPLICATION
 PATIENT BILL OF RIGHTS
A document designed to guarantee ethical care of clients in terms of their decision making
about treatment choices and other aspects of their care.

THE DYING PATIENT BILL OF RIGHTS-

 I have the right to be treated as a living human being until I die.
 I have the right to maintain a sense of hopefulness however changing its focus may be.
 I have the right to be cared for by those who can maintain a sense of hopefulness however
changing that may be.
 I have the right to express my feelings and emotions about my approaching death in my
own way.
 I have the right to expect continuing medical and nursing attention even though 'cure' goals
must be changed to 'comfort' goals.
 I have the right to be free from pain.
 I have the right to have my questions answered honestly.
 I have the right not to be deceived.
 I have the right to die in peace and dignity.
 I have the right to participate in decisions concerning my care.
 I have the right to have help from and for my family in accepting my
 I have the right to retain my individuality and not be judged for my decisions which may be
contrary to the beliefs of others.
 I have the right to discuss and enlarge my religious and/or spiritual experience whatever
these may mean to others.
 I have the right to expect that the sanctity of the human body will be respected after death.
 I have the right to be cared for by caring, sensitive, knowledgeable people who will
attempt to understand my needs and will be able to gain some satisfaction in helping me
face my death.

LEGAL AND ETHICAL DIMENSION OF DYING PATIENT –

 The ethical issues relating to death and dying are especially sensitive.
 The one point of agreement that people have when discussing these sensitive issues is that
the dying patient must be treated with dignity.
 ADVANCE DIRECTIVES-
 Advance directives are legal documents that state the patient's wishes when the patient
becomes unable to speak for themselves.
 Advanced directives are created ahead of any medical incapacitation in order to ensure that
the patient has the ability to make their own decisions when they are unable to do so.

 TYPE OF ADVANCE DIRECTIVES-

1-Living Will
2-Durable Power of Attorney .

1-Durable power of attorney-

 Allow you to choose who will make decisions on your behalf if you become incapacitated.
 A durable power of attorney is a legal device that permits one individual, known as a
"principle", to give to another person called the "attorney-in-fact", the authority to act on his
or her behalf" (Morrison, 2010)

 The attorney-in-fact that is appointed is giving the responsibility to take care of banking,
legal and real estate decision making for a specified amount of time that may be for a
lifetime if needed. (Morrison, 2010)

 Issues with a durable power of attorney is the appointed "attorney-in-fact is limited by their
own knowledge of legal matter and finances, therefore leaving room for possible errors.
(Morrison, 2010).

2-Living will-
A living will is a legal document that discloses a persons individual needs and requests
when unable to make competent decisions on their own.
Living will should be validated by two witnesses that are not related to the patient.
(Morrison, 2010)
 Decisions that a living will can address are:
 Life-support treatments such as mechanical ventilation, cardiopulmonary resuscitation
(CPR) and life sustaining medications.
 Nutrition and hydration-feeding tubes & artificial nutrition

 Guardianship or decision maker appointment

 Dialysis and organ donation (Advanced directives, 2014)
Provides specific instructions for how your representative should make decisions.

DO NOT RESUSCITATE-
 do-not-resuscitate order means that no attempts are to be made to resuscitate.
 A do-not-resuscitate (DNR) order is a medical order that instructs health care
professionals not to perform cardiopulmonary resuscitation (CPR) if a patient’s breathing
stops or their heart stops beating. The order is only written with the permission of the patient
 (or the patient’s health care power of attorney, if activated.) Ideally, a DNR order is set up
before a critical condition occurs.

COMFORT MEASURE ONLY-

 Treatments used to ease pain and distress when life-prolonging options are not available,
very hard to tolerate and/or cause more harm than good.

TERMINAL WEANING-
 A clinical intervention for withdrawing mechanical ventilatory support when such support
is an unacceptable outcome for a patient.

EUTHANASIA-
It literally means “good dying”.
ACTIVE EUTHENSIA- It is when death is brought by an act.
For example, taking a high dose of drugs.
To end a person's life by use of drugs, either by oneself or by the aid of physician.

PASSIVE EUTHENSIA-When death is brought by an Omission.

For example, when someone lets the person die, this can be done by withdrawing or
withholding treatment.
Withdrawing treatment: For example, switching off a machine that keeps the person alive.
Withholding treatment: For example, not carrying out a surgery that will extend life of the
patient for a short time.
 ROLE OF NURSE –
 Nursing care involves providing comfort ,maintaining safety, addressing physical and
emotional needs, and teaching coping strategies to terminally ill patients and their
families.
 More than ever, the nurse must explain what is happening to the patient and the family
and be a confident who listens to them talk about dying.
 Hospice care, attention to family and individual psychosocial issues, and symptom and
pain management are all part of the nurse's responsibilities.
 The nurse must also be concerned with ethical considerations and quality-of-life issues
which affect dying people.
 In the hospital, in long-term care facilities and in home settings, n the hospital, in long-
term care facilities and in home settings, the end-of-life decision family.
 The nurse is also an advocate for the dying person and works to uphold that person's
rights.
 Of utmost importance to the patient is assistance with the transition from living to dying,
maintaining and sustaining relationships, finishing well with the family, and
accomplishing what needs to be said and done.

GRIEF

 Grief is a “ normal but bewildering cluster of ordinary human emotions arising in response
to a significant loss , intensified and complicated by the relationship to the person or the
object lost”
Mitchell and Anderson,( 1983)
Three major concepts associated with grieving are loss, grief, and mourning.

 Mourning- Mourning is the process by which grief is resolved; it is the societal

expression of post bereavement behavior and practices.
Mourning is the outward, social expression of loss. Individuals outwardly express loss
based on their cultural norms, customs, and practices, including rituals and traditions. Some
cultures may be very emotional and verbal in their expression of loss, such as wailing or
crying loudly. Other cultures are stoic and show very little reaction to loss. Culture also
dictates how long one mourns and how the mourners “should” act. The expression of loss is
also affected by an individual’s personality and previous life experiences.
 Bereavement-Bereavement literally means the state of being deprived of someone by death
and refers to being in the state of mourning.

TYPES OF GRIEF –

 NORMAL GRIEF- Also known as uncomplicated grief . This is a common and

universal reaction characterized by complex emotional ,cognitive ,social ,physical
behavioral and spiritual response to loss and death.
Eg – the reaction of sadness ,crying etc after the death of loved ones.
 Normal grief reactions to a loss can include the following:
 Physical symptoms such as hollowness in the stomach, tightness in the chest, weakness,
heart palpitations, sensitivity to noise, breathlessness, tension, lack of energy, and dry
mouth
 Emotional symptoms such as numbness, sadness, fear, anger, shame, loneliness, relief,
emancipation, yearning, anxiety, guilt, self-reproach, helplessness, and abandonment
 Cognitive symptoms such as a state of depersonalization, confusion, inability to
concentrate, dreams of the deceased, idealization of the deceased, or a sense of presence of
the deceased
 Behavioral signs such as impaired work performance, crying, withdrawal, overactivity,
changed relationships, or avoidance of reminders of the deceased.

 COMPLICATED GRIEF – A grief in which the person experience the prolonged and
significant difficult time moving forward after a loss.
Eg- A women who lost her child a year ago but still she has that believe that her child is
alive.
 Chronic Grief: Normal grief reactions that do not subside and continue over very long
periods of time.
 Delayed Grief: Normal grief reactions that are suppressed or postponed by the survivor
consciously or unconsciously to avoid the pain of the loss.
 Exaggerated Grief: An intense reaction to grief that may include nightmares, delinquent
behaviors, phobias, and thoughts of suicide.
 Masked Grief: Grief that occurs when the survivor is not aware of behaviors that interfere
with normal functioning as a result of the loss. For example, an individual cancels lunch
with friends so they can go to the cemetery daily to visit their loved one’s grave.

 DISENFRANCHISED GRIEF- A grief is also known as hidden grief. A type of

grief that is not usually openly acknowledge ,socially accepted or publicly mourned .
 Those affected by this type of grief do not feel the freedom to openly acknowledge their
grief.
Eg- Death of your former spouse, grief on the elective abortion .

 ANTICIPATORY GRIEF – A type of grief person experiences before the occurrence

of the actual loss or expected loss.
Eg- The process of grieving starts while you are caring for severly ill member of your family.
Here people experience intense response to grief before the occurrence of actual
loss or death of a person . Sometimes anticipatory grief starts at the time of a terminal
diagnosis and can proceed until the person dies. Both patients and their family members
can feel anticipatory loss. The patient often anticipates the loss of independence, function,
or comfort, which can cause significant pain and anxiety if not given the proper support.

SYMPTOMS OF GRIEF-
 Physical Effects of Grief on the Body
 Digestive problems
 Weight changes
 Physical pain
 Suppressed immune system and risk of illness.
 Difficulty sleeping
 Extreme fatigue
 Dehydration
 Memory loss and brain fog
 Broken heart syndrome

 Common Emotional Symptoms of Grief

 Sadness brought on by the realization of the magnitude of the loss
 Depression symptoms
 Shock, denial, or disbelief
 Anhedonia
 Increased anxiety symptoms
 Hopelessness
 Helplessness
 Anger
 Survivor's Guilt
 Low self-esteem

FACTOR INFLUENCING GRIEF-

Multiple factors influence the way a person perceive and responds to loss. There are
following factor which effect the grief –
1- Human development – patient age and stages of development affect the grief response.
E.g.- toddlers cannot understand loss or death.
2-Personal relationship- when loss involves another person, the quality and meaning of the
lost relationship influence the grief response.
E.g.- when a relationship between two people was very rewarding and well connected, the
survivor often finds it difficult to move forward after death.
3- Nature of loss- Exploring the nature of the loss will help you understand the effect of the
loss on the patient’s behaviour, health and well being.
Eg- was the loss temporary or permanent ? the sudden death of doesn’t give survivors the
time to say good bye while death due to long term illness survivors has prolonged memories.
4- Coping strategies – The coping strategies of person also effect the process of grief.
Eg- The effective coping skills of person will help that person to cope in life when he will
encounter with any loss ahead.
5-Socioeconomic- Socio-economic status also effect the persons grief process directly and
indirectly.
Eg- A person with limited resources will go through a deep dark phase in case of car
demolishment but the person with same incident of higher status will not go through the
same way as they have sufficient enough to buy a new car or to repair it easily .
6-Culture and religious belief- A cultural belief and religious belief have great impact on
the process of grief .
 People have different faith according to their religion and culture , so they have different
way of dealing with loss .
Eg – People follows particular rituals to deal with the loss .As they perform different
kind of ceremonies to deal with the loss of loved ones death

Cognitive reactions Behavioral reactions

• Inability to concentrate • Impulsivity
• Forgetfulness • Indecisive
• Impaired judgment • Social withdrawal
• Decreased problem-solving ability • Distancing

FACTOR INFLUENCING GRIEF-

Multiple factors influence the way a person perceive and responds to loss. There are
following factor which effect the grief –
1- Human development – patient age and stages of development affect the grief response.
Eg- toddlers cannot understand loss or death .
2- Personal relationship- when loss involves another person, the quality and meaning of the
lost relationship influence the grief response.
Eg- when a relationship between two people was very rewarding and well connected , the
survivor often finds it difficult to move forward after death.
3- Nature of the loss- Exploring the nature of the loss will help you understand the effect of the
loss on the patients behaviour, health and well being.
Eg- was the loss temporary or permanent ?

4- Coping strategies – The coping strategies of person also effect the process of grief.
Eg- The effective coping skills of person will help that person to cope in life when he will
encountered with any loss ahead.
5- Socioeconomic status- Socio-economic status also effect the persons grief process directly
and indirectly.
Eg- A person with limited resources will go through a deep dark phase in case of car
demolishment but the person with same incident of higher status will not go through the same
way as they have sufficient enough to buy a new car or to repair it easily .
6-Culture and religious believes- A cultural belief and religious belief have great impact on the
process of grief .
People have different faith according to their religion and culture , so they have different way
of dealing with loss .
Eg – People follows particular rituals to deal with the loss .As they perform different kind
of ceremonies to deal with the loss of loved ones death.

THEORIES OF GRIEF-
1. KUBLER ROSS THEORY –
Dr. Elizabeth Kubler-Ross introduced the most commonly taught model for understanding the
psychological reaction to imminent death in her 1969 book, On Death and Dying.
The book explored the experience of dying through interviews with terminally ill patients
and outlined the five stages of dying:
1- Denial
2- Anger
3- Bargaining
4-Depression
5- Acceptance.

Kubler-Ross's Five Stages of Dying-

1- Denial -
 It is a common defense mechanism used to protect oneself from the hardship of
considering an upsetting reality.
 Kubler-Ross noted that patients would often reject the reality of the new information after
the initial shock of receiving a terminal diagnosis.
 Kubler-Ross noted that patients would often reject the reality of the new information after
the initial shock of receiving a terminal diagnosis.

2- Anger –
 Anger is commonly experienced and expressed by patients as they concede the reality of a
terminal illness.
 It may be directed at blaming medical providers for inadequately preventing the illness,
family members for contributing to risks or not being sufficiently supportive, or spiritual
providers .
 The anger may also be generalized and undirected, manifesting as a shorter temper or a
loss of patience.

3- Bargaining-
 A person attempts to negotiate or make compromises.
 Try to make agreements with ourselves, or a deal with a higher power.

4- Depression-
 Depression is a feeling of sadness and hopelessness that often results with the loss .
 patients experience it with unsurprising symptoms such as sadness, fatigue, and
anhedonia.
5- Acceptance-
 patients experience it with unsurprising symptoms such as sadness, fatigue, and anhedonia
 Patients may focus on enjoying the time they have left and reflecting on their memories.
 They may begin to prepare for death practically by planning their funeral or helping
to provide financially or emotionally for their loved ones.

JOHN BOWLY THEORY ON GRIEF

 John bowly was the first attachment theorist. He described attachment as a "lasting
psychological connectedness between human beings.
 Bowlby’s attachment theory is the foundation for his theory on mourning.
 Before Kübler-Ross's five stages of grief John Bowlby (1907-1990) introduced a
four-stage model of grief known as the "grief process.“
 The four stages of grief introduced by Bowlby and Parkes are -
1. Shock and numbness
 Bereaved individuals experience the initial stages of grief known as shock and
disbelief when they first suffer through trauma.
 In this stage, shared grief reactions include feeling numb, withdrawing emotionally,
and becoming stuck in grief.
 It is the briefest phase of mourning.
2. Yearning and searching
It arouses emotional outburst of sobbing and acute distress in most persons
An individual who suddenly or violently loses someone or something they have a
special attachment to often yearns for that person or thing to return.
 Many people will spend months, even years, yearning and searching.
 In this stage, it's typical for grieving individuals to experience other intense grief
reactions, including preoccupation, anger
 Common physical symptoms are tightness in the chest and throat, shortness of
breath, feeling of weakness and lethargy, insomnia and loss of appetite.
3. Disorganization and despair
  This stage is when changed behaviors become necessary for a suffering individual
to progress through their grief.
 A person suffering through loss must learn to do away with old behavior patterns
and ways of thinking.
 Survivors often experience feelings of disorganization while trying to accept that
their life is no longer the same.
 In this phase, an individual may endlessly examine how and when the loss occurred
4. Reorganization and repair
 The final stage in the grief process involves the restoration of hope and a renewed
sense of purpose in life.
 After coming to terms with loss, bereaved individuals slowly realize that life is
worth living once more.
 Persons experiencing this phase must be encouraged to untie themselves from their
old relationship, while not devaluating it or feeling that in doing so they are
lessening its importance

GRIEF TASK MODEL-

 There are actually four tasks of healthy grief outlined by psychologist William Worden in
his book Grief Counseling and Grief Therapy: A Handbook for the Mental Health
Practitioner in 1991.
 Worden empowers mourners to actively engage with four tasks.
 Worden's four tasks of grieving are:
1. Accept the Reality of the Loss
2- Experience the Pain of Grief
3. Adjust to an Environment With the "Deceased" Missing
4. Find an Enduring Connection with the "Deceased" While Embarking on a New life.
1- Accept the Reality of the Loss-
Acceptance is the surrendering to reality as it is. Therefore, you must acknowledge the
loss and
it didn't happen.
2- Experience the Pain of Grief –
Griever experience the pain of what you have lost. Allow the emotion into your
consciousness and take proper steps to process the feelings. You can process with a
trusted friend, mentor, or family member.
3- Adjust to an Environment With the "Deceased" Missing-
 You have to adjust and adapt to the new normal, which entails reorienting and
restructuring what you do without your loved one in the picture.
4-Find an Enduring Connection with the "Deceased" While Embarking on a New life-
Gradually you create a balance between remembering the person who died and living a
full and meaningful life.

RANDO ‘S “R” PROCESS MODEL-

 Rando contributes a model of the grief process that she observed people to
experience while adjusting to significant loss.
 She called her model the "Six R’s.
 She breaks the process into six parts, within three phases, and these are part of
the process of moving through grief.

Avoidance phase

Confrontation phase

Accommodation phase
 Avoidance
In early grief we struggle to understand what has happened, and accept it as real. We avoid
the reality. In this model we need to recognize what has happened to us.

Recognize the loss-

This is the step of acknowledging and understanding the death, and accepting its reality.
This also includes understanding the cause of the loss, which can be difficult for people
whose partners were killed in accidents, were murdered, or died by suicide.

Confrontation –
In the confrontation phase we process what we are going through.

React to the separation

This step is about feeling all the emotions that are part of grief and loss – anger, pain, sadness,
sorrow, and all the other things we go through – and accepting them.
Reacting to them. Working through them. Sometimes we might have to give yourself
permission to feel all of these things. It's also about accepting the secondary losses – things
like the future we planned, the places we were going to go, the growing old together we had
expected.

Recollect and re – experience the person and the relationships-

When things begin to feel less raw, we can begin to remember the people we lost. It took a
while after Tim died for me to even think about the things we'd done together, the things we'd
loved doing together.

Relinquish attachment to the old life –

This sounds harsh but I don't think it's meant to be. It's not about moving on or forgetting or
leaving behind. It's about working through what has happened, and about accepting how it
has changed our past, our present and our future.

Accommodation phase-
The accommodation phase is about creating a new meaning and a new life, without forgetting
the old.

Readjust and move into the new world-

The readjustment stage talks about accepting who we are now and making a new identity for
ourselves, while we still remember the person we lost.

Reinvest –
The first big decision I made after Tim died was to do a part-time MA. For me this was
reinvesting in myself, and in a future that I hadn't expected or planned for but that I wanted to
try.
Engel’s Stages of Grieving
 Grief is a typical reaction to loss of a valued object.
 There are six stages of grief, and progression through each stage is necessary for
healing.
 The goal of grieving process is for the mourner to accept the loss and let go to the
deceased.

SHOCK AND DISBELIEF

The initial reaction to a loss is a stunned, numb feeling accompanied by refusal to
acknowledge the reality of the loss in an attempt to protect the self against
overwhelming stress.

DEVELOPING AWARENESS
As the individual begins to ac-knowledge the loss, there may be crying, feelings of
helplessness, frustration, despair and anger that can be directed at self or others,
including God or the deceased person.

RESTITUTION:
Participation in the rituals associated with death, such as a funeral, wake, family
gathering, or religious ceremonies that help the individual accept the reality of the
loss and begin the recovery process.

RESOLUTION OF THE LOSS:

The individual is preoccupied with the loss, the lost person or object is idealized,
the mourner may even imitate the lost person. Eventually, the preoccupation
decreases, usually in a year or per-haps more.

RECOVERY:
The previous preoccupation and obsession ends, and the individual is able to go on
with life in a way that encompasses the loss.
 COPING WITH LOSS, DEATH AND GRIEF
Coping is defined as the thoughts and behaviors mobilized to manage internal and
external stressful situations.

• Maladaptive coping
• Adaptive coping

 Adaptive coping refers to the use of effective and healthy strategies to manage and
overcome stressful or difficult situations. These coping mechanisms help
individuals to adapt to and deal with adversity, trauma, or significant life changes.
 Maladaptive coping refers to the use of ineffective and unhealthy strategies to
manage and deal with stressful or difficult situations.

Brief COPE model-

It was developed by Charles S. Carver in 1997.

Adaptive coping
 Emotional support refers to the provision of empathy, encouragement, and
reassurance from others to help individuals manage stress, emotions, and difficult
situations.
 Positive reframing is the process of intentionally shifting one's perspective to
focus on the positive aspects of a situation, rather than dwelling on the negative.
 Acceptance is a powerful coping strategy that involves acknowledging and
accepting reality as it is, without judgment or resistance.
 Religious beliefs and practices can provide emotional comfort and solace during
difficult times, such as illness, loss, or trauma.
 Positive reframing is the process of intentionally shifting one's perspective to focus on the
positive aspects of a situation, rather than dwelling on the negative.
 Acceptance is a powerful coping strategy that involves acknowledging and accepting
reality as it is, without judgment or resistance.
 Religious beliefs and practices can provide emotional comfort and solace during difficult
times, such as illness, loss, or trauma.

Maladaptive coping
Venting can be seen as a maladaptive coping strategy when it becomes excessive,
unproductive, or harmful.
1. Perpetuating Negative Emotions:
Constantly venting without a solution can keep individuals stuck in their negative
emotions, reinforcing feelings of frustration, anger, or helplessness.
2. Lack of Resolution:
If venting is done without an effort to address the problem, it can prevent any real
problem-solving or change from occurring. This can lead to feeling stuck and helpless.
3. Impact on Relationships:
Overly venting, especially when done frequently or excessively to the same people, can
strain relationships. The constant focus on negative emotions can drain others and
create tension.
4- Behavioural disengagement –
 It is a type of coping mechanism where an individual withdraws or disengages from a
stressful situation or task rather than actively confronting it or trying to solve the
problem. It is often seen as a passive response to stress or challenges, where a person
might give up, procrastinate, or stop making an effort altogether.
5- Self – distraction-
It involve deliberately diverting attention away from a problem or emotional distress,
but in a way that prevent dealing with the issues or leads to unhealthy behaviour.
COPING STRATEGIES TO DEAL WITH THE LOSS AND DEATH -
1.Understand That Not Everyone Will Know How To Help You.
2. Take Responsibility For Your Recovery.
3- Accept That Your Life Will Likely Change.
4. Talk About How You Feel.
5. Develop A Line Graph Of Your Significant Loss Experiences.
6- Focus Your Energy On Self-Care Activities.
7-Find Comfort In Your Spiritual/Religious Practices.
8- Hold Off On Making Major Life Decisions Or Changes.
9- Allow Yourself Any Potential Happiness.
10- Be Patient With Your Grief.
11- Seek Professional Help.
12--Be patient. Each person will go through the grieving process at his or her own pace.
13- Keep up a normal routine.
14- Eat a healthy diet.
15- Write in a journal.
16-Get plenty of rest.
17- Exercise.
18- Participate in enjoyable activities.
19- Do something nice for another person.
20- Practice stress management techniques.
21- Deep breathing.

GRIEF COUNSELING AND GRIEF THERAPY

 Grief counseling is a form of therapy intended to help you cope with loss.
 Grief counseling can help people of all ages work through sorrow and other emotions that
are part of a normal reaction to losing someone.
 Counseling involves helping people facilitate uncomplicated, or normal grief to a healthy
completion of the tasks of grieving within a reasonable timeframe.
 Grief therapy, on the other hand, utilizes specialized techniques that help people with
abnormal or complicated grief reactions and helps them resolve the conflicts of
separation.
 Grief therapy is most appropriate in situations that fall into three categories:
(1) The complicated grief reaction is manifested as prolonged grief;
(2) The grief reaction manifests itself through some masked somatic or behavioral
symptom;
(3) The reaction is manifested by an exaggerated grief response.

GRIEF THERAPY TECHNIQUE -

1-Cognitive behavioral therapy
2-Acceptance and commitment therapy (ACT)
3-Complicated grief therapy
4- Person-Centred Therapy

1-Cognitive Behavioral Therapy in Grief Counseling

1. Cognitive Restructuring: This involves identifying and challenging negative
thought patterns that contribute to feelings of hopelessness and despair.
2. Behavioral Activation: Encouraging individuals to engage in meaningful activities
to counteract the withdrawal and inactivity that often accompany grief.
3. Exposure Therapy: Gradually confronting and processing painful memories and
emotions related to the loss.
4. Mindfulness and Relaxation Techniques: Teaching individuals to stay present
and manage anxiety and stress associated with grief.
5. Problem-Solving Skills: Helping individuals develop practical solutions to
challenges arising from their loss.
6. Identifying Triggers: Recognizing specific triggers that intensify grief and
developing strategies to manage them.
7. Building Resilience: Equipping individuals with skills to build resilience and adapt
to life after loss.

2-Acceptance and commitment therapy (ACT)

According to ACT, grief is a normal human emotion, and it is essential to
acknowledge and accept these emotions. In ACT, the focus is on accepting things
as they are rather than trying to control them. This means acknowledging the pain
and discomfort associated with grief and allowing yourself to feel these emotions
without judgment.
6 ACT Tools
Tool 1. Values
 Values represent what matters to you most and what you choose to consider as
meaningful.
After a loss, we’re usually tempted to act quickly, fix things, get out of pain.
Without purpose and meaning, these actions are aimless and may cause more harm
than good. So, do what matters the most.
Tool 2. Committed Action
Prioritizing your values and committing to taking action reduces anxiety and allows
you to direct your energy and time toward the things that matter.
Some of these actions will be physical (e.g. exercising and eating healthy food).
Some of it will be emotional (e.g. allowing yourself to cry).
Tool 3. Acceptance
Acceptance means acknowledging difficult emotions, without judging them or
judging yourself for experiencing them.
Tool 4. Being Present
Being present may sound so simple. But more often than not, we are either living in
the past regretting things that happened or in the future worrying about things that
might happen.
This leads to feelings of anxiety and distress.
Tool 5. Cognitive Defusing
Cognitions” is just another name for your thoughts and “defusion” means
separating yourself from these thoughts. Cognitive defusion involves creating
space between yourself and your thoughts and feelings so that you can discern
which thoughts serve your well-being and deserve attention.
Tool 6. “The Observing Self”
Self-as-context, or “the observing self,” is a way of describing your thoughts,
emotions, and experiences as an observer of yourself, rather than the embodiment
of your thoughts and feelings.
3-Person-Centred Therapy
 The Person-Centred Approach to Grief Counselling is a form of therapy that
focuses on providing a supportive and non-judgmental environment for those who
are grieving.
 Person-centered therapy is a type of non-directive therapy that is empathetically
driven toward providing a person with a safe space to talk, self-actualize (realize
full potential), and make positive changes in their life.

ROLE OF NURSE-
 Provide an open accepting environment.
 Encourage ventilation of feelings and listen actively
 Provide various diversional activities
 Provide teaching about common symptoms of grief
 Bring together similar aggrieved persons, to encourage communication, shares
experiences of loss and offer companionship, social and emotional support.
 Facilitate understanding of the mourning process.
 Maintaining autonomy
 Encouraging reality .
  Provide continuing support.
 Assess client's stage in the grief process.
 Provide treatment .
 Shows empathy, concern, and unconditional positive regards.
 Communicating with sensitivity.
 Providing for human comfort and support.
 If this is not possible by the nurse, then offer referrals to support groups Support
groups of individuals going through the same experiences can be very helpful for
the grieving.

CONCLUSION-
Grief is a process. It is not just a single emotion.
Actually, the feeling of not grieving correctly, of being separate from grief, is grief itself. It is
that feeling of separation from ourselves. Go slowly and with great gentleness .Its really
important to deal with all your losses with adaptive coping stragies.
Loss and death brings lots of emotions and stages of grief, its important to cope with this with
help of family ,friends and medical professionals. Every person has different coping
mechanism and All these theories and models of grief explains it very well.
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