1. Loss and Grief RN Certificate in Palliative Care

2. Introduction Loss, grief, and bereavement are universal experiences that occur across the life span Nurses should use the interdisciplinary approach to support those working through these feelings and the grief process

3. Definitions

4. Theoretical Foundations Kubler-Ross (1969) 5 Stages (Denial, anger, bargaining, depression, acceptance) Listening and humanizing care Hope Lindeman and Freud Lindeman- normal/abnormal responses, clinical guidelines Freud-bereavement theory, psychological consequences, adaptation to loss

5. Second Generation Grief Models Worden-tasks of grief: (accept, work and adjust) Model of coping with grief: oscillation between loss and restoration Transformation theories: personal growth, individualized pathway

6. Grief Assessment Family Replace patient’s lost capacities Role changes Relationship changes Moving forward without patient Finding new equilibrium in self/family Family Sense of future Function Self Image Social role Relationships Material matters

7. Manifestations of Grief Uncomplicated normal grief Physical Psychological/emotional Spiritual Sociocultural Cognitive

8. Grief vs. Depression Grief focus is on the loss fluctuating ability to feel pleasure variable physical symptoms closeness of others is usually reassuring fluctuating emotions relatively stable self-esteem some specific guilt/regret thoughts of wanting to be with deceased, but not actual wish to die extrasensory experiences Depression focus is on the self inability to feel pleasure chronic physical complaints persistent isolation fixed emotions loss of self-esteem generalized sense of guilt suicide ideation to end pain hallucinations and/or psychosis

9. Complicated Grief Chronic grief Delayed grief Exaggerated grief Masked grief Disenfranchised grief Risk factors for complicated grief

10. Brief Complicated Grief Assessment How much are you having trouble accepting the death of ______________? Not at all0 Somewhat1 A lot--------------------------------------------2 How much does your grief still interfere with your life? Not at all0 Somewhat 1 A lot......................................................2 How much are you having images or thoughts of _____________ when s/he died or other thoughts about the death that really bother you? Not at all0 Somewhat1 A lot......................................................2 Are there things you used to do when ______ was alive that you don’t feel comfortable doing anymore, that you avoid? Like going somewhere you went with him/her, or doing things you used to enjoy together? Or avoiding looking at pictures or talking about _________? How much are you avoiding these things? Not at all0 Somewhat1 A lot......................................................2 How much are you feeling cut off or distant from other people since _________ died, even people you used to be close to like family or friends? Not at all0 Somewhat1 A lot.......................................................2 (Shear, Simon, Wall, Zisook, Neimeyer, Duan, et. al., 2011)

11. Use the IDT Active listening Questionnaires Early referrals Encourage experiencing the loss Acknowledge the “work” of grief Support systems HPNA patient and family teaching sheets Interventions

12. Explanation of death Correct language Rituals HPNA teaching sheets for age specific interventions Intervention for Grieving Children

13. Ten Areas (Parkes & Weiss,1983) 1.Functioning has returned to a level equal to or better than before bereavement 2.Outstanding problems are being resolved 3.Acceptance of the loss has occurred 4.Socialization is as effective as before the death 5.The future is viewed positively and realistically 6.General health is at pre-bereavement level 7.Anxiety or depression levels are appropriate 8.Guilt or anger levels are appropriate 9.Self-esteem levels are appropriate 10.Coping with future loss is feasible Accommodation to Grief

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