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Loss, Grief, and End-Of-Life Care in This Sad World of Ours, Sorrow Comes to All

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Loss, Grief, and End-Of-Life Care in This Sad World of Ours, Sorrow Comes to All Chapter6 Loss, Grief, and End-of-Life Care In this sad world of ours, sorrow comes to all... It comes with bittersweet agony... (Perfect) relief is not possible, except with time. You cannot now realize that you will ever feel better... And yet this is a mistake. You are sure to be happy again. To know this, which is certainly true, will make you feel less miserable now. —ABRAHAM LINCOLN Learning Objectives Key Terms After studying this chapter, you should be able to: Advance care planning 1. Discuss the concepts of loss, grief, and end-of-life care. Advance directive 2. Describe at least three types of losses that an individual can experi- Bereavement ence. Durable health care power of attorney 3. Explain the grief process. Dying declaration exception to 4. Differentiate between normal and unresolved or dysfunctional grief. hearsay 5. Define advance care planning. Dying Person’s Bill of Rights 6. Articulate the needs of dying persons and their survivors. Dysfunctional grief 7. State the rationale for The Dying Person’s Bill of Rights. End-of-life care Grief 8. Compare the perceptions of death by children during various growth stages. Grief process Health care directive Health care proxy Hospice care Living will Loss Mourning Palliative care Patient Self-Determination Act Suffering Unresolved grief eople are complex, biopsychosocial beings. When occur. Because we live in a culture marked by dramati- P they become ill, undergo diagnosis for altered cally different responses to the experiences of loss and health states, experience a loss, or progress into the grief, nurses often feel inadequate in planning interven- end stage of life, their responses are the result of the tions to facilitate grief management and the healing complex interaction of biopsychosocial changes that process. 63 64 UNIT II SPECIAL ISSUES RELATED TO PSYCHIATRIC–MENTAL HEALTH NURSING This chapter provides information to familiarize the care as they are experienced by individuals, families, student with the concepts of loss, grief, and end-of-life and/or their significant others. Loss Grief The concept of loss can be defined in several ways. The Grief is a normal, appropriate emotional response to an following definitions have been selected to familiarize external and consciously recognized loss. It is usually the student with the concept of loss: time-limited and subsides gradually. Staudacher (1987, • Change in status of a significant object p. 4) refers to grief as a “stranger who has come to stay in both the heart and mind.” Mourning is a term used to • Any change in an individual’s situation that describe an individual’s outward expression of grief reduces the probability of achieving implicit or regarding the loss of a love object or person. The indi- explicit goals vidual experiences emotional detachment from the object • An actual or potential situation in which a val- ued object, person, or other aspect is inaccessible or changed so that it is no longer perceived as valuable BOX 6.1 • A condition whereby an individual experiences Examples of Losses Identified by deprivation of, or complete lack of, something Student Nurses that was previously present Everyone has experienced some type of major loss at one • Loss of spouse, friend, and companion. The client was time or another. Clients with psychiatric disorders, such a 67-year-old woman admitted to the psychiatric hos- as depression or anxiety, commonly describe the loss of a pital for treatment of depression following the death of spouse, relative, friend, job, pet, home, or personal item. her husband. During a group discussion that focused on losses, the client stated that she had been married for Types of Loss 47 years and had never been alone. She described her deceased husband as her best friend and constant com- A loss may occur suddenly (eg, death of a child due to an panion. The client told the student and group that she auto accident) or gradually (eg, loss of a leg due to the pro- felt better after expressing her feelings about her losses. gression of peripheral vascular disease). It may be pre- • Loss of body image and social role as the result of a dictable or occur unexpectedly. Loss has been referred to as below-the-knee amputation. The client was a 19-year- actual (the loss has occurred or is occurring), perceived (the old girl who was involved in a motorcycle accident. She loss is recognized only by the client and usually involves had shared her feelings with the student nurse about her an ideal or fantasy), anticipatory (the client is aware that a “new” body image and dating after hospitalization. loss will occur), temporary, or permanent. For example, a • Loss of a loved one owing to fetal demise or intrauter- ine death. The student nurse had been assigned to a 65-year-old married woman with the history of end stage young woman, who was in her twenty-eighth week of renal disease is told by her physician that she has approx- pregnancy and delivered a preterm newborn who died imately 12 months to live. She may experience several immediately after birth. The following day, the client losses that affect not only her, but also her husband and expressed a sincere thanks to the student nurse for family members, as her illness gradually progresses. The supporting her during such a difficult time in her life. losses may include a predictable decline in her physical • Loss of physiologic function, social role, and indepen- condition, a perceived alteration in her relationship with dence because of kidney failure. A 49-year-old woman her husband and family, and a permanent role change was admitted to the hospital for improper functioning within the family unit as she anticipates the progression of of a shunt in her left forearm. She was depressed and her illness and actual loss of life. Whether the loss is trau- asked that no visitors be permitted in her private room. matic or temperate to the client and her family depends on She shared feelings of loneliness, helplessness, and hopelessness with the student nurse as she described the their past experience with loss; the value the family mem- impact of kidney failure and frequent dialysis treatment bers place on the loss of their mother/wife; and the cul- on her lifestyle. Once an outgoing, independent person, tural, psychosocial, economic, and family supports that are she was housebound because of her physical condition available to each of them. Box 6-1 describes losses identi- and “resented what her kidneys were doing to her.” fied by student nurses during their clinical experiences. CHAPTER 6 LOSS, GRIEF, AND END-OF-LIFE CARE 65 or person, eventually allowing the individual to find spiritual, and psychological impact on an individual other interests and enjoyments. Some individuals expe- that may impair daily functioning. Feelings vary in rience a process of grief known as bereavement (eg, feel- intensity, tasks do not necessarily follow a particular ings of sadness, insomnia, poor appetite, deprivation, pattern, and the time spent in the grieving process and desolation). The grieving person may seek profes- varies considerably from weeks to years (Schultz & sional help for relief of symptoms if they interfere with Videbeck, 2002). activities of daily living and do not subside within a few Several authors have described grief as a process that months of the loss. includes various stages, characteristic feelings, experi- ences, and tasks. Staudacher (1987) states there are Grief Theory three major stages of grief: shock, disorganization, and reorganization. Westberg (1979) describes ten stages of Grief theory proposes that grief occurs as a process. The grief work, beginning with the stage of shock and pro- grief process is all-consuming, having a physical, social, gressing through the stages of expressing emotion, depression and loneliness, physical symptoms of distress, panic, guilt feelings, anger and resentment, resistance, BOX 6.2 hope, and concluding with the stage of affirming reality. Five Stages of Grief Identified by Kubler-Ross Kubler-Ross (1969) identifies five stages of the grieving process including denial, anger, bargaining, depression, • Denial: During this stage the person displays a disbelief and acceptance; however, progression through these in the prognosis of inevitable death. This stage serves stages does not necessarily occur in any specific order. as a temporary escape from reality. Fewer than 1% of Her basic premise has evolved as a result of her work all dying clients remain in this stage. Typical responses with dying persons. Box 6-2 discusses Kubler-Ross’s five include: “No, it can’t be true,” “It isn’t possible,” and stages of the grief process. “No, not me.” Denial usually subsides when the client realizes that someone will help him or her to express feelings while facing reality. Unresolved or Dysfunctional Grief • Anger: “Why me?” “Why now?” and “it’s not fair!” are Unresolved or dysfunctional grief could occur if the a few of the comments commonly expressed during individual is unable to work through the grief process this stage. The client may appear difficult, demanding, after a reasonable time. The cause of dysfunctional grief and ungrateful during this stage. is usually an actual or perceived loss of someone or • Bargaining: Statements such as “If I promise to take my medication, will I get better?” or “If I get better, I’II something of great value to a person. Clinical features or never miss church again” are examples of attempts at characteristics include expressions of distress or denial bargaining to prolong one’s life. The dying client of the loss; changes in eating and sleeping habits; mood acknowledges his or her fate but is not quite ready to disturbances, such as anger, hostility, or crying; and die at this time.
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