1. Loss Physical (loss of something tangible)
Psychosocial: (loss of something symbolic or intangible)
Two general categories of loss exist. Examples of physical loss: stolen car, house burns down, amputation. Examples of psychosocial loss: divorce, retirement, development of chronic illness.

2. Change: always constitutes loss
Developmental change
Normal change and growth
Competency-based loss
Any change necessarily involves loss. At the very least loss of the status quo. Developmental: occurs as we age (eyesight, muscular strength, skin turgor). Normal change and growth: having a baby, moving from dependency on parents). Competency: child leaving home, graduation, attainment of a desired goal).

3. Secondary loss
A loss that coincides with or develops as a consequence of the initial loss.
(examples: loss of income when spouse dies, loss of concept of self as healthy when serious illness occurs)
Each of these secondary losses must be mourned as well as the initial loss.

4. Grief & Mourning
Grief: the process of experiencing the psychological, behavioral, social, and physical reactions to the perception of loss.
Mourning: the work of adapting and changing as a result of the loss

5. Grief
Experienced in four major ways: psychologically, behaviorally, socially, physically
A continuing development
A natural reaction
Expected with all types of loss
Dependent upon the individual’s perception of the loss

6. Mourning Reacting to separation from the deceased
Modification of roles, skills, identity
Learning to live in a healthy way without the deceased

7. Myths & Misconceptions
Grief declines steadily over time
The mourner must put the loss out of mind
Intensity and length of mourning are a testimony to love
Grief involves only the loss of the person
Mourning is complete in a year
Time is a healer

8. Danger: don’t rigidly apply grief theory
Commonalities exist
Idiosyncratic variations occur
It’s not a static state, but rather a process of many changes over time

9. Kubler-Ross’ Stages
Denial
Anger
Bargaining
Depression
Acceptance

10. Why think about death? To give meaning to human existence
To encourage productivity & enjoyment of life
To prepare for ultimate acceptance of death

11. Ways to prepare:
Be close to someone who is facing death with inner peace
Plan financially
Develop solid support
Incorporate religious beliefs into life

12. How can we help??? Denial: support without reinforcing
Stay physically present
Offer regressive care (food, drink, safety)

13. How can we help??? Anger Provide anticipatory guidance
Don’t take it personally
Meet needs that precipitate anger

14. How can we help??? Bargaining Provide information for decision-making
Offer resources and referrals

15. How can we help??? Despair Supportive listening Touch Avoid cliches
Assess risk of harm to self

16. How can we help??? Acceptance Assist in planning
Utilize cultural practices
Allow expression of feelings
Accept changes in feelings
Support groups for patient & families

17. Hospice Care A philosophy of caring for the dying Curing vs. Caring
Criteria for moving to hospice care

18. Helpful hints:
Don’t ask whether I’m ‘over it’. I’ll never be ‘over it’.
Don’t tell me he’s in a better place. He isn’t here.
Don’t say “At least he isn’t suffering”. I wonder why he had to suffer at all.
Don’t tell me you know how I feel unless you have had the same experience.
Don’t tell me ‘God doesn’t make mistakes’; you mean God did this on purpose???
Don’t tell me ‘God doesn’t give more than we can handle’. I don’t feel like I am “handling” it.

19. Please just say: That you are sorry. That you miss him too, if you do.
That you will listen.

20. As we learn to help:
“Birds make great sky circles of their freedom. But how do they learn it? They learn by falling, and by falling they’re given wings.