Competency 6: Loss, Grief, & Death Developed by: Dede Carr, BS, LDA Karen Neu, MSN, CNE, CNP 1 Competency 6: Death & Dying ! Define the stages & processes of death & dying & influences those stages have on clients & families ! List the emotional stages of grief that occur in death & dying ! List the needs of the dying client & their family ! List the different types of death & how they may affect the client & the family’s ability to move through the stages of death 2 Lifetime Losses & Grieving Everyone experiences loss, grieving, & death at some time during his/her life. People may suffer loss of: ! Valued relationships through moving from one city or state to another, separation, divorce, or the death of a family member (parent, grandparent, sibling, spouse) or friend ! Changing life roles as they watch grown children leave home or retire from lifelong work, ! Employment or ability to drive a vehicle safely ! Valued material objects through theft, natural disasters ! Pets (Berman et al., p. 1081) 3 Loss in Health Care Settings ! Healthcare workers interact with dying clients & their families or caregivers in a variety of settings from a death of an unborn child, to the adolescent victim of an automobile collision, to the elderly client who dies from a chronic illness ! There are many influences on the dying process: legal, ethical, religious, spiritual, biological, personal ! It is important that the healthcare worker provides sensitive, skilled, & supportive care to all those affected (Berman et al., p. 1081) 4 Loss in Health Care Settings ! Healthcare workers encounter clients who may be experiencing grief to declining health, loss of a body part, terminal illness, or impending death of self or significant other, loss of function, loss of independence, ! In home healthcare or community, healthcare worker may work with clients grieving losses related to personal crisis (divorce, separation) or disaster (tornadoes, floods, fire) ! It is important to understand the significance of loss & develop an ability to assist clients as they work through the grieving process (Berman et al., p. 1081) 5 Loss Loss: The actual or potential situation in which something that is valued is changed & no longer available ! People can experience the loss of body image, a significant other, a sense of well-being, a job, personal possessions, or beliefs ! Illness & hospitalization often produce losses (Berman et al., p. 1081) 6 Death Death is a fundamental loss for the dying person & for those who survive ! Death can be viewed as the dying person’s final opportunity to experience life in ways that bring significance & fulfillment ! People experiencing loss search for the meaning of the event, & it is generally accepted that finding the meaning is needed in order for healing to occur ! However, persons can be well adjusted without searching for meaning, & even those who find meaning may not see it as an end point but rather an ongoing process (Berman et al., p. 1081) 7 Types of Losses 1. Actual Loss: Loss that can be recognized by others 2. Perceived Loss: Loss experience by one person, but cannot be verified by another ! Example: A woman who leaves her employment to care for her children at home may perceive a loss of independence & freedom Both actual & perceived losses can be anticipatory loss Anticipatory Loss: Loss that is experienced before the loss actually occurs ! Example: A woman whose husband is dying may experience the actual loss in anticipation of his death (Berman et al., p. 1082) 8 Types of Losses Loss can be viewed as situational or developmental. Developmental Losses: Losses that occur during the process of normal development, such as grown children leaving home, retirement from a career, death of aged parents (these generally can be anticipated & prepared for) ! Many sources of loss: Loss of an aspect of self: a body part, a physiologic function (no longer able to bear a child) or a psychological attribute; loss of an object external to oneself; separation from an accustomed environment; loss of a loved or valued person (Berman et al., p. 1081) 9 Loss & Death ! Situational Losses: loss of one’s job, death of a child, or loss of functional ability because of acute illness or injury Types of Death: ! Unexpected death leaves families feeling shocked & bereaved; Examples might be death due to a heart attack ! Traumatic death can lead to complicated grief: Examples: suicide or homicide ! Anticipated death from a chronic or prolonged illness: families may be physically & emotionally exhausted from caring for the family member prior to death (Berman et al.) 10 Grief, Bereavement, Mourning Grief: “The total response to the emotional experience to loss” “Grief is manifested in thoughts, feelings, & behaviors associated with overwhelming distress or sorrow” (Berman et al., p. 1082) Bereavement: “The subjective response experienced by the surviving loved ones after the death of a person with whom they have shared a significant relationship” (Berman et al., 1082) Bereavement: “A common depressed reaction to the death of a loved one” (Kochrow & Christensen, p. 190) 11 Grief, Bereavement, Mourning Mourning: “The behavioral process through which grief is eventually resolved or altered; it is often influenced by culture, spiritual beliefs, & custom” (Berman et al., p. 1082) Mourning: “(reaction activated by a person to assist in overcoming a personal loss) refers to culturally defined patterns for expressions of grief; mourning patterns include funerals, wakes, memorials, black dress, & defined time of social withdrawal” (Kochrow & Christensen, p. 190) 12 Grief, Bereavement, Mourning ! Grief & mourning are experienced by the person who faces the death of a loved one AND by the person who suffers other kinds of losses (includes healthcare workers) ! Grieving is important for one’s physical & mental health ! Grieving permits individuals to cope with the loss gradually & accept it as part of reality ! Grief is a social process & is best shared & carried out with the assistance of others (Berman et al., p. 1082) 13 Grief, Bereavement, Mourning ! Healthcare workers who work with the terminally ill & bereaved often develop a heightened empathy & identification with their patients ! This occurs because the loss experience is so universal that everyone has experienced its impact ! Previous losses can prepare people for the ultimate loss of death ! Grief is a normal & universal response to loss ! There are many examples of increased illness or an abnormal condition (both physical & mental) after significant losses in the survivors, especially caregivers ! Research indicates that there are increases in breakups in marriages & other significant relationships after the loss of a child or when one partner suffers a loss of a body part or function (Kochrow & Christensen, p. 190) 14 Grief, Bereavement, Mourning ! Grief involves thoughts, feelings, & behaviors & has a useful function when allowed to operate normally ! The goal of the grieving process is to resolve the hurt & to reestablish one’s life ! Grief comes & goes with a person’s life experiences & many years later an event reminds the person of the loss & the feelings return ! Such events might include encounters with smells, places, foods, dates, holidays, clothing, music, & other people ! Grief is not an episode; it is a process, sometimes one that goes on forever (e.g. parents grieving for a child) (Kochrow & Christensen, p. 190) 15 Grief, Bereavement, Mourning Grieving persons try a variety of strategies to cope Tasks of Grief that facilitate healthy adjustment to loss ! Accepting the reality of the loss ! Experiencing the pain of grief ! Adjusting to an environment that no longer includes the lost person, lost object, or the lost aspect of self ! Reinvesting emotional energy into new relationships The successful completion of these tasks leads to the passage from grief to closure These tasks do not necessarily occur in a specific order or sequence; people may work all tasks of grief at the same time or only one or two may be priorities Healthcare workers can assist patients & their families in working through these tasks (Kochrow & Christensen, p. 190) 16 Grief, Bereavement, Mourning Working through one’s grief is important because bereavement may have devastating effects on health Symptoms that may accompany grief are: ! Anxiety, * Excessive sweating ! Depression * Menstrual disturbances ! Swallowing difficulties * Palpitations ! Vomiting * Chest pain ! Fatigue * Changes in libido ! Headaches * Alterations in communication ! Dizziness * Difficulty in concentration ! Fainting * Disturbances in eating patterns ! Blurred vision * Alterations in sleeping patterns ! Skin rashes * Changes in activity ! Shortness of breath (Berman et al., p. 1082) 17 Types of Grief 18 Grief, Bereavement, Mourning ! It’s important to differentiate the expression of grief as a normal healthy response to loss (needs support & public acknowledgement) from grief as a response of greater distress & personal disruption (requires intensive intervention/assistance) There are different types of grief: 1. Normal grief 2. Complicated grief 3. Anticipatory grief 4. Disenfranchised grief 19 Grief, Bereavement, Mourning Although bereavement can threaten health, a positive resolution of the grieving process can enrich the individual with new insights, values, challenges, openness, & sensitivity (Berman et al., p. 1082) ! There is no right or wrong way to grieve; theories of grief are only tools that can be used to anticipate the