Chapter 12 Grief and Loss

Grief refers to the subjective emotions and affect that are a normal response to loss. Grieving, also known as bereavement, is the process of experiencing grief. Anticipatory grief is facing an imminent loss. Mourning is the outward sign of grief.

Experiences of grief and loss are essential and normal in the course of life; letting go, relinquishing, and moving on happen as we grow and develop.

Grief and loss are uncomfortable.

Types of Losses Losses may be planned, expected, or sudden. Loss of a loved one is probably the most devastating type of loss, but there are many other types of losses: Physiologic (loss of limb, ability to breathe) Safety (domestic violence, posttraumatic stress disorder, breach of confidentiality)

Types of Losses (contd) Security/sense of belonging (relationship loss [death, divorce]) Self-esteem (ability to work, children leaving home) Self-actualization (loss of personal goals, such as not going to college, never becoming an artist or dancer)

The Grieving Process

Nurses must recognize the signs of grieving to understand and support the client through the grieving process. The therapeutic relationship and therapeutic communication skills are paramount when assisting grieving clients. Using these skills, nurses may promote the expression and release of emotional as well as physical pain during grieving.

Theories of the Grieving Process Kubler-Rosss stages of grieving:

Denial (shock and disbelief) Anger (toward God, relatives, health care providers) Bargaining (trying to get more time, prolonging the inevitable loss) Depression (awareness of the loss becomes acute) Acceptance (person comes to terms with impending death or loss)

Theories of the Grieving Process (contd)

Bowlbys phases of grieving: Numbness and denial of the loss Emotional yearning for lost loved one and protesting permanence of loss Cognitive disorganization and emotional despair Reorganizing and reintegrating sense of self

Theories of the Grieving Process (contd)

John Harveys phases of grieving: Shock, outcry, and denial Intrusion of thoughts, distractions, and obsessive reviewing of loss Confiding in others to emote and cognitively restructure

Theories of the Grieving Process (contd)

Rodebaughs stages of grieving:

Reeling Feelings Dealing Healing There are many similarities among theorists about grief. Not all clients follow predictable steps or make steady progress.

Tasks of the Grieving Process Undoing psychosocial bonds to loved one and eventually creating new ties Adding new roles, skills, and behaviors Pursuing a healthy lifestyle Integrating the loss into life

Dimensions of Grieving Cognitive responses to grief

Questioning and trying to make sense of the loss Attempting to keep the lost one present

Emotional responses to grief Spiritual responses to grief Behavioral responses to grief Physiologic responses to grief

Cultural Considerations All cultures grieve for lost loved ones, but the rituals and habits surrounding death vary among cultures, for instance, how shock and sadness are expressed, how long mourning should last, and so forth. Many cultural bereavement rituals have their roots in a major religion. Nurses should be sensitive to cultural differences and ask how the mourners can be assisted.

African Americans Typically view the body in church before burial Hymns, poetry, eulogies common Mourning may be expressed by public prayer, wearing black clothing, and decreasing social activities for a few weeks to several years

Muslim Americans Muslims do not permit cremation Important to follow the five steps of the burial procedure

Haitian Americans May practice vodun or calling on spirits to make peace

Chinese Americans Strict norms for announcing death, preparing the body, arranging the funeral and burial, mourning Burning incense and reading scripture assist the spirit of the deceased on his or her journey

Japanese Americans Japanese Americans who are Buddhists view death as a life passage Bathing and purification rites are performed Friends and family visit, bringing gifts or money Prayers are said Incense is burned

Filipino Americans Often Catholic Wear armbands or black clothing Place wreaths on casket Drape a black banner on the deceaseds home Ask for prayers and blessings for the soul of the deceased

Vietnamese Americans Predominately Buddhist Deceased is bathed and dressed in black clothes Rice and money may be sent with the deceased on the journey to the afterlife Viewing the body before burial occurs at home

Hispanic Americans Predominately Catholic Pray for the soul during a novena and rosary Mourning may involve wearing black and decreasing social activities A wake in the home may be held

Native Americans
Variety of practices depending on religious beliefs and practices of different tribes Death may be seen as a state of unconditional love Many believe the deceased is going on another journey Celebrations may include a ghost meal Mourners may be encouraged to be happy for the person

Orthodox Jewish Americans Leaving a dying person alone is a sign of disrespect Burial must occur within 24 hours unless delayed by the Sabbath Body should be untouched until rites can be performed by family, rabbi, or Jewish undertaker

Nurses Role
The nurse must encourage clients to discover and use effective and meaningful grieving behaviors: Praying Staying with the body Performing rituals Attending memorials and public services

Disenfranchised Grief or Complicated Grieving

Disenfranchised grief is grief over a loss that is not or cannot be openly acknowledged, mourned publicly, or supported socially:
A relationship has no legitimacy The loss itself is not recognized The griever is not recognized

Complicated grieving is a response that lies outside the norm of grieving in terms of extended periods of grieving: responses that seem out of proportion or responses that are void of emotion

Disenfranchised Grief People who are vulnerable to disenfranchised grieving:

Relationships that may be viewed as having no legitimacy: lovers, friends, neighbors, foster parents, colleagues, caregivers, same-sex relationships, cohabitation without marriage, and extramarital affairs Losses that may not be recognized: prenatal death, abortion, relinquishing a child for adoption, death of a pet, or other losses not involving death such as job loss, separation, divorce, and children leaving home Grievers who may not be recognized: older adults, children, nurses

Complicated Grieving People who are vulnerable to complicated grieving include those with:
Low self-esteem Low trust in others A previous psychiatric disorder Previous suicide threats or attempts Absent or unhelpful family members An ambivalent, dependent, or insecure attachment to the deceased person

Complicated Grieving (contd) Experiences increasing the risk for complicated grieving include:
Death of a spouse or child Death of a parent (particularly in early childhood or adolescence) Sudden, unexpected, and untimely death Multiple deaths Death by suicide or murder

Complicated Grieving as a Unique and Varied Experience Physical reactions can include:
Impaired immune system Increased adrenocortical activity Increased levels of serum prolactin and growth hormone Psychosomatic disorders Increased mortality from heart disease

Emotional responses can include:

Depression Anxiety or panic disorders Delayed or inhibited grief Chronic grief

Application of the Nursing Process

Assessment Does the client have adequate perception regarding the loss?
What does the client think and feel about the loss? How is the loss going to affect the clients life? What information does the nurse need to clarify or share with the client?

Does the client have adequate support? Does the client have adequate coping behaviors?

Application of the Nursing Process (contd)

Data Analysis and Planning Possible nursing diagnoses: Grieving Anticipatory Grieving Dysfunctional Grieving

Application of the Nursing Process (contd)

Outcome Identification Grieving The client will: Identify the effects of his or her loss Seek adequate support Apply effective coping strategies while expressing and assimilating all dimensions of human response to loss in his or her life

Application of the Nursing Process (contd) Outcome Identification (contd)

Anticipatory Grieving The client will: Identify the meaning of the expected loss in his or her life Seek adequate support while expressing grief Develop a plan for coping with the loss as it becomes a reality

Application of the Nursing Process (contd)

Outcome Identification (contd) Dysfunctional Grieving The client will:

Identify the meaning of his or her loss Recognize the negative effects of the loss on his or her life Seek or accept professional assistance to promote the grieving process

Application of the Nursing Process (contd)

Intervention
Regarding perception of the loss
Explore perception and meaning of the loss

Regarding adequate support

Help the client reach out and accept what others want to give

Regarding adequate coping behaviors

Shift from an unconscious defense mechanism to conscious coping Compare and contrast past coping Encourage the client to care for self

Application of the Nursing Process (contd) Essential communication and interpersonal skills to assist grieving:
Use simple, nonjudgmental statements Refer to a loved one or object of loss by name (if acceptable in the clients culture) Appropriate use of touch indicates caring Respect the clients unique process of grieving Respect the clients personal beliefs Be honest, dependable, consistent, and worthy of the clients trust Offer a welcoming smile and eye contact

Application of the Nursing Process (contd)

Evaluation Evaluation of progress is based on the goals established for the client. Make an evaluation of the clients status based on the theoretical tasks and phases of grieving.

Self-Awareness Issues Examining ones own experiences with grief and loss Taking a self-awareness inventory and reflecting on the results may be helpful.