Transcript Clinical Review

Clinical Review for the
Generalist Hospice and
Palliative Nurse
Grief and Bereavement: The Grief of
a Terminal Diagnosis and the
Subsequent Bereavement of Family
After a Patient’s Death
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Objectives
1. Define loss, mourning, grief, and
bereavement
2. Discuss manifestations of grief
3. Differentiate between grief and clinical
depression
4. Discuss assessment and interventions for
grief and bereavement
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National Consensus Project
for Quality Palliative Care
National Consensus Project for Quality
Palliative Care - Guideline 3.2.
 A grief and bereavement program is
available to patients and families, based on
the assessed need for services.
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Grief
 An emotional response to loss (inner
experience)
 Caused by a variety of losses
 Exists at numerous levels
 Different for each individual
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Loss
 Not having something/someone
that you used to have
 May occur before death
 Most losses trigger grief and mourning
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Mourning
 Outward social expression of loss
 Influenced by culture, rituals, outcomes,
practices
 Signify respect for deceased
 Promotes expression of feelings by the
bereaved
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Bereavement
 Process by which individual deals with their
grief
 Not all forms of bereavement are healthy
 An individual experience
 Includes grief and mourning
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No Single Theory of Grief
 Culture
 Religion
 Diversity issues
 Commonality
 stages of grief and series of tasks
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Stages and Task of Grief
Stage 1 – Notification and shock
 Task – recognize the loss
Stage 2 – Experience the loss
 Task – working through the pain of the loss
Stage 3 – Reintegration
 Task – reorganize / restructure
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Physical Manifestations
of Grief
 Shortness of breath and tachycardia
 Insomnia
 Muscular tension and headaches
 Tiredness
 Loss of appetite
 Restlessness
 Vulnerable to illness
 Sexual dysfunction
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Psychological Manifestations
of Grief
 Behavioral
 work performance, crying, withdrawal
 Emotional
 Sadness, anger, guilt, relief
 Cognitive
 Disbelief, inability to concentrate,
preoccupied with thoughts or image of the
deceased
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Influencing the Grief Process
 Coping Skills
 Relationship to deceased
 Religious / spiritual / ethnicity / cultural
 Type of death
 Support systems
 Previous dealing with loss
 Preparation of the death
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Stages of Coping:
Shock and Denial
 Shock: To go on as nothing happened
 Denial: “This isn’t happening to me.”
 Unresponsive or unable to take in information
or process or go on as nothing is about to
change
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Shock and Denial
Interventions
 Allow time to process information
 Detrimental responses
 Open ended questions
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Stages of Coping: Anger
 Question
 “Why
is this happening to me?”
 Generalized rage at the world
 Isolated and furious
 Feel betrayed
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Anger Interventions
 Permit to express anger
 Don’t take personally
 Anger may turn to rage
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Stages of Coping: Bargaining
 “I promise I will be/do/feel…if you make
this situation better.”
 Try to fix things
 Attempt to strike bargains
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Bargaining Interventions
 Communicate that if healthcare provider
could, s/he would make it better
 Patient/Family didn’t fail to ‘do something’
 Review positive
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Stages of Coping: Depression
 “I don’t care anymore.”
 Absorbed in intense pain
 Overwhelmed by helplessness and sadness
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Depression Interventions
 History and Physical
 Suicide Assessment
 Goals that bring joy or pleasure
Focus on quality of life issues – priorities
 Demonstrate interest and concern
 Pharmacological and non-pharmacological
interventions

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Clinical Depression
 Despair or despondency
 Loss of interest
 Duration of symptoms for at least 2 weeks
 Cause of depression may be elusive
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Stages of Coping: Acceptance
 “I’m ready for whatever comes.”
 At peace with the death
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Acceptance Intervention
 Encourage to focus on what is helping them
to cope
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Worden’s Tasks of Mourning
 Accept the reality of the loss
 Experience the pain of grief
 Adjust to an environment without the
diseased
 Withdraw emotional energy and reinvest in
another relationship
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Rando’s
Process of Bereavement
 Recognize
 React
 Reminisce
 Relinquish
 Readjust
 Reinvest
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Grief Assessment
 Begins at the time of diagnosis or admission
 Patient
 Family members
 Ongoing throughout course of illness for
patient
 Continues past death of family members
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Bereavement Interventions
 Develop plan of care
 goal facilitating grieving process
 Be non-judgmental
 Respect cultural traditions, rituals
 Listen
 Follow-up
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Complicated Grief
 Overwhelming
 Maladaptive
 Usually prolonged
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Indicators for
Complicated Grief
 Death is sudden
 A child dies
 Great suffering at the end of life
 Inadequate support
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Manifestations of
Complicated Grief
 May include normal grief reactions
 Symptoms may be intensified, interfere
with the person’s psychological, social, and
physiological functioning
 Extreme isolation
 Violent behavior
 Suicidal idealization
 Workaholic
 PTSD
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Anticipatory Grief
 Occurs before a death
 Anticipate losses
 Loved ones grieve for patient’s losses and
loss of patient
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Anticipatory Grief
 Preparation and support prior to death
 Provide time to acknowledge
 Patient’s dying
 Prepare for death
 Adapt to changes
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Disenfranchised Grief
 Loss not validate or recognized by society
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Children’s Grief
Children mourn and grieve based on their
development level
Symptoms in younger children
 Frequent sickness
 Accident prone
 Nightmares
 Excessive dependency on remaining parent
 Antisocial behavior / Rebellious behavior
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Children’s Grief
Symptoms in the older child
 Difficulty in concentrating, poor schoolwork
 Antisocial behavior
 Resistance to discipline
 Nightmares, symbolic dreams
 Frequent sickness
 Experimentation with alcohol / drugs
 Compulsive behavior
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Interventions
 Provide active listening, touch, silence,
presence
 Assisting in identifying support systems
 Encourage reminiscing
 Teach relaxation, guided imagery,
journaling
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Bereavement Services
 Hospice Medicare benefit – 13 months from
time of death
 Initial and periodic assessment
 Plan of care
 Bereavement coordinator
 Palliative care
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Bereavement Program:
Assessment
 Begins at admission to hospice or palliative
care service
 Completed at time of death
 Involves significant people in patient’s life
 Divided into normal vs. abnormal grief
 Continues with family after death
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Bereavement Program:
Plan of Care
 Developed from assessment
 Can involve numerous individuals
 Goal oriented
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Suggested
Bereavement Follow-up
 Condolence card and periodic letters
 Holiday letter
 Phone calls
 Bereavement group
 Memorial service
 Individual sessions
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Bereavement Volunteers
 Additional training
 Phone calls
 Assist with memorial services
 Should be limited to normal grief responders
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Suggested Bereavement CQI
 Send out program assessment letter in 13th
month with postage attached
 Collate comments and themes
 Keep team updated
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References
1.
Altilio T, Indelicato RA, Eighmy JB, Nahman EJ. Care of
the patient and family. In: Berry PH, ed. Core Curriculum
for the Generalist Hospice and Palliative Care Nurse. 2nd
ed. Dubuque, IA: Kendall/Hunt; 2005: 147-168.
2. Corless IB. Bereavement. In: Ferrell BR, Coyle N, eds.
Textbook of Palliative Nursing. 2nd ed. New York, NY:
Oxford University Press, 2006: 531-544.
3. Bednash G, Ferrell BR. End-of-life nursing education
consortium (ELNEC). Washington, DC: Association of
Colleges of Nursing; 2009.
4. Kübler-Ross E. On Death and Dying. New York, NY:
Macmillan Press; 1969.
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References
5. Potter ML. Loss, suffering, bereavement and grief. In:
Matzo ML, Sherman DW, eds. Palliative Care Nursing:
Quality Care to the End of Life. New York, NY:
Springer; 2001; 275-321.
6. Worden JW. Bereavement care. In: Berger A, Portenoy R,
Weissman. eds. Principles & Practice of Palliative
Care & Supportive Oncology. 2nd ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2002: 813-818.
7. Rando T. Treatment of Complicated Mourning.
Champaign, IL: Research Press; 1993.
8. Rando T. Clinical Dimensions of Anticipatory Mourning.
Champaign, IL: Research Press; 2000.
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Additional References
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Christ G, Siegal K, Christ A. Adolescent grief. JAMA.
2002;288(10):1269-1278.
Neimeyer R. Traumatic loss and reconstruction of
meaning. Journal of Palliative Medicine. 2002;5(6):93569942.
Payne S, Lloyd-Williams M. Bereavement care. In:
Lloyd-Williams M, ed. Psychological Issues in Palliative
Care. New York, NY: Oxford University Press; 2003.
Rando TA. Grief, Dying and Death: Clinical
Interventions for Caregivers. Champaign, IL: Research
Press; 1984.
Worden JW. Grief Counseling and Grief Therapy: A
Handbook for the Mental Health Practitioner. 2nd ed.
New York, NY: Springer; 1991.
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 Perley MJ, Psychosocial Emotional and Spiritual Issues.
In: Perley MJ, Dahlin C, ed. Core Curriculum for the
Advanced Practice Hospice and Palliative Care Nurse.
Pittsburgh, PA: Hospice and Palliative Nurses Association;
2007: 417-437.
 National Consensus Project for Quality Palliative Care
(2009). Clinical Practice Guidelines for quality palliative
care, 2nd ed. Available at
www.nationalconsensusproject.org. Accessed October 8,
2009.
 Supiano K, Altilio T. Care of the Patient and Family. In:
Berry PH, ed. Core Curriculum for the Generalist Hospice
and Palliative Care Nurse. 3rd ed. Dubuque, IA:
Kendall/Hunt; 2010:156-158.
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