Chapter 27: Bereavement PDF

**Chapter 27: Bereavement** - **Loss**: Significant person or pet. Illness or debilitating condition - Developmental/maturational changes. Decrease in self-esteem. Personal possessions - **Theoretical perspectives: stages of Grief, table 27-1** - **KNOW Elisabeth Kubl...

**Chapter 27: Bereavement** - **Loss**: Significant person or pet. Illness or debilitating condition - Developmental/maturational changes. Decrease in self-esteem. Personal possessions - **Theoretical perspectives: stages of Grief, table 27-1** - **KNOW Elisabeth Kubler-Ross, pg. 759 Natural/expected grief process** - **Stage I: Denial**: In this stage, individuals have difficulty believing that the loss has occurred. They may say, "No, it can't be true!" or "It's just not possible." This stage may protect individuals from the psychological pain of reality. - **Stage II: Anger:** This is the stage when reality sets in. Feelings associated with this stage include sadness, guilt, shame, helplessness, and hopelessness. Self-blame or blaming of others may lead to feelings of anger toward the self and others. Anxiety levels may be elevated, and individuals may experience confusion and a decreased ability to function independently. They may be preoccupied with an idealized image of what has been lost. Numerous somatic complaints are common. - **Stage III: Bargaining:** At this stage in the grief response, individuals attempt to strike a bargain with God for a second chance or for more time. They acknowledge the loss, or impending loss, but hold out hope for additional alternatives, as evidenced by statements such as, "If only I could..." or "If only I had..." - **Stage IV: Depression:** In this stage, individuals mourn for that which has been or will be lost. This is a very painful stage during which individuals must confront feelings associated with having lost someone or something of value (called reactive depression). - An example might be the individual who is mourning a change in body image. Feelings associated with an impending loss (called preparatory depression) are also confronted. - Examples include regression, withdrawal, and social isolation may be observed behaviors with this stage. - Therapeutic intervention should be available, but not imposed, and with guidelines for implementation based on individual readiness. - **Stage V: Acceptance:** At this time, individuals have worked through the behaviors associated with the other stages and accept or are resigned to the loss. Anxiety decreases, and methods for coping with the loss have been established. Individuals at this stage are less preoccupied with what has been lost and increasingly interested in other aspects of the environment. - If this is an impending death of self, the individual is ready to die. The person may become very quiet and withdrawn, seemingly devoid of feelings. These behaviors are an attempt to facilitate the passage by slowly disengaging from the environment. - **KNOW John Bowlby "Bowling's Night Down"** - **Stage I: Numbness or protest:** This stage is characterized by a feeling of shock and disbelief that the loss has occurred. Reality of the loss is not acknowledged. - **Stage II: Disequilibrium:** During this stage, the individual has a profound urge to recover what has been lost. Behaviors associated with this stage include a preoccupation with the loss, intense weeping and expressions of anger toward the self and others, and feelings of ambivalence \[contradictory ideas/feelings\] and guilt associated with the loss. - **Stage III: Disorganization and despair:** Feelings of despair occur in response to realization that the loss has occurred. Activities of daily living become increasingly disorganized, and behavior is characterized by restlessness and aimlessness. Efforts to regain productive patterns of behavior are ineffective, and the individual experiences fear, helplessness, and hopelessness. Somatic complaints are common. Perceptions of visualizing or being in the presence of that which has been lost may occur. Social isolation is common, and the individual may feel a great deal of loneliness. - **Stage IV: Reorganization:** The individual accepts or becomes resigned to the loss. New goals and patterns of organization are established. The individual begins a reinvestment in new relationships and indicates a readiness to move forward within the environment. Grief subsides and recedes into valued remembrances. - **George Engel** - Stage 1: shock & disbelief,Stage 2: developing awareness - Stage 3: Restitution,Stage 4: Resolution of loss,Stage 5: Recovery - **J. William Worden** - Task 1: Accepting reality of loss,Task 2: Processing pain of grief - Task 3: Adjusting to world without lost entity,Task 4: Finding enduring connections with lost entity - **KNOW Maladaptive \[complicated\] grieving:** - Maladaptive can include **loss of self-esteem** and feelings of worthlessness \[indicative of depression rather than uncomplicated, normal bereavement\] - **One crucial difference between normal and maladaptive grieving is the loss of self-esteem. Loss of self-esteem is more symptomatic of clinical depression.** - **s/s:** episodes of rage, or prolonged, unresolved anger; inability to focus on anything but the loss; intense focus on or avoidance of any reminders of the lost entity; prolonged difficulty accepting the reality of the loss; self-destructive behavior, including alcohol & drug abuse; suicidal thoughts & actions - **Depression associated with bereavement: four s/s were absent in the bereaved population and those were** suicidal thoughts, feeling they were a burden to others, feeling they wold rather be dead, and psychmotor retardation - Suicidal thoughts, Feeling burden to others, BODF \[bereavement overload dysfunctional grieving\] - Psychomotor retardation. Loss of hope. Feelinging like they\'d rather be dead - **KNOW Factors of Grief process**: - The bereaved person was strongly dependent on or perceived the lost entity as an important means of physical and/or emotional support. - The relationship with the lost entity was highly ambivalent. A love-hate relationship may instill feelings of guilt that can interfere with the grief work. - The individual has experienced a number of recent losses. Grief tends to be cumulative, and if previous losses have not been resolved, each succeeding grief response becomes more difficult for that individual to handle. - The loss is that of a young person. Grief over the loss of a child is often more intense than it is over the loss of an elderly person. Traumatic death, in general, increases the likelihood of maladaptive grief, but when a child dies a violent death, studies have found an increased incidence of post-traumatic stress disorder (PTSD) in parents and particularly among mothers. - The state of the person's physical or psychological health is unstable at the time of the loss. - The bereaved person perceives (whether real or imagined) some responsibility for the loss. - The loss is secondary to suicide. - The loss is a traumatic death such as murder. - **Maladaptive Responses, pg. 762** - **KNOW Delayed or inhibited grief** - Potentially pathological d/t avoidance of reality of loss - They remain fixed in the denial stage of the grief process, sometimes for many years - Overreaction to another person's grief process - Recognition is critical d/t px of assimilation & delay in return to satisfying life - Subsequent losses can be compounded - **Delayed grieving most commonly occurs because of ambivalent feelings toward the lost entity, outside pressure to resume normal function, or perceived lack of internal and external resources to cope with a profound loss** - **KNOW Distorted \[exaggerated\] grief response** - "Trapped" in own grief - Typical grief reactions/responses are exaggerated; depressive mood - **Feelings of sadness, helplessness, hopelessness, powerlessness, anger, and guilt, as well as numerous somatic complaints** - Remains fixated on "anger" stage - **KNOW Chronic or prolonged grieving** - Argument of adaptive vs maladaptive. Memorial rituals - A prolonged process may be considered maladaptive when enduring thoughts, emotions, and behaviors prevent the bereaved person from adaptively performing activities of daily living - **Ex: is a widow who refused to participate in family gatherings following the death of her husband, but instead, for many years until her own death, took a sandwich to the cemetery on holidays, sat on the tombstone, and ate her "holiday meal."** - **Concepts of death by developmental age:** - **Birth-2 years old**: Experiences loss and separation - **Age 3-5**: Some understanding of death; belief death is reversible - **Age 6-9:** Begin to understand finality of death - Consideration of own death - Normal reactions include regression and aggressive bx - **Age 10-12:** Understanding death is final & affects everyone. Feelings of anger, guilt, & depression common - Disruption of peer relationships & school performance - **Adolescents:** View death on adult level. Difficulty perceiving own death. May or may not cry; may withdraw - Exhibit acting out bx. Easier to talk to peers than adults - **Cultural considerations:** - Death rituals & expectations. Identify specific rituals & expectations - Encourage individual to describe rituals & mourning practices - Preferences regarding burial practices. Responses to death & grief - Identify values & beliefs about death & grief - Explore individual perceptions about death, dying, & the afterlife - **Nursing dx:** - Risk for complicated grieving r/t loss of a valued entity/ concept; loss of loved one - Risk for spiritual distress r/t complicated grief process - **Outcomes**: - Acknowledge awareness of loss. Express feelings about the loss - Verbalize stages of grief process & behaviors associated with each - Express personal satisfaction & support from spiritual practices - **Interventions**: - Assess stages of grief - Develop trust & show empathy, concern, & unconditional positive regard - Accepting and nonjudgmental - Assist in actualization of loss by asking - "When did it happen?" Or "How did it happen?" - Assist in identification of emotions: Anger, guilt, anxiety/ helplessness & encourage expression of these - Anger, guilt, anxiety, helplessness, and encourage expression of these - Provide continuing support. Contact spiritual leader if requested - **Evaluation**: - Has the patient discussed the recent loss with staff and family members? - Able to verbalize feelings & behaviors associated with each stage of the grieving process and recognize their own position in the process? - Obsession with and idealization of the lost entity subsided? - Anger toward the loss expressed appropriately? - Able to participate in usual religious practices with satisfaction and support? - Seeking out interaction with others in an appropriate manner? - Able to verbalize positive aspects about his or her life, past relationships, and prospects for the future? - **KNOW Hospice care: A program that provides palliative and supportive care to meet the special needs of people who are dying and their families; Pain & symptom management** - **Provides physical, psychological, spiritual, and social care for the person for whom aggressive tx is no longer appropriate** - **Patient and family emotional support; encouraged to discuss the process and eventual outcome of dz process** - **Seven components of hospice care**: Pastoral & spiritual care; Bereavement counseling; 24hr on-call staff. Staff support. Focus of care is on quality of life - **Interdisciplinary treatment team approach:** - Nurses, nursing aids. Physicians, physician assistants, & nurse practitioners - Social workers & counselors. Rehabilitation therapists. Dietitians. Trained volunteers - **Advanced directives:** - Living Will or durable power of attorney for healthcare (health care proxy) - Allows an individual to provide directions about their future medical care and final wishes - Follow clearly stated directives - Unless natural death act has been enacted into law by that state - All patients must be advised of their rights - To refuse tx. To make advance directives available to pts on admission - To keep records of whether a pt has an advance directive or designated health care proxy - Allows patient to be in control of end-of-life decisions - Spares family & loved one's burden of making choices without knowing what was important to the person - **KNOW Reasons advance directives are not honored**: - Advance directives that were formulated long before their implementation may call into question whether clients understood the ramifications of their decisions for future medical problems and interventions at that time. - In general, the language used in standard living will documents is not specific enough to cover all health-care circumstances. Consequently, health-care providers may lack clarity about how to proceed because the advance directive itself lacks clarity. - Because state laws vary, when patients are in a state other than the one where the advance directive was established, it may raise questions about the document's legality.