1. Aftermath of a Death: Procedures for Staff Sandra Waring, MSN, CNN, CPHQ Richard Russo, MSW, CSW

2. Death is a fearful thing. William Shakespeare Death! thou comest when I had thee least in mind! Unknown While grief is fresh, every attempt to divert only irritates. You must wait till it be digested, and then amusement will dissipate the remains of it. Samuel Johnson

3. Preparation Clearly define the unit policy: “Tell” or “Don’t Tell” other patients Denial Mode: Officially don’t tell anyone Special Mode: Only tell those patients that ask Open Mode: Tell everyone

4. Preparation Examine the rationale of the policy –Benefits to patients and staff –Deterrents to patients and staff –How does the staff feel about the policy?

5. Preparation Have you developed procedures for implementing the policy? Are they written? This is a process – it should be written so everyone knows what is expected of them

6. Preparation Staff Meeting –How do staff members feel about the death of a patient? –What do they think is the impact on other patients? –How will they recognize the patient who is deeply affected by the death of another patient? –What can they do to help the troubled patient?

7. Preparation Actively involve your Social Worker –Ask him/her to talk with staff about: Patient’s fear and anger about the death of another Grief and the grieving process Signs and symptoms of depression Potential reactive patient behavior and how to assist patients

8. Telling Other Patients How do you tell other patients: –Word of Mouth? Who tells the other patients? –Notices? What kind? Where is it posted? What do you tell other patients: Protect Patient Confidentiality –Patients are frightened – reassure them of their safety –Patients may be grieving – support them

9. Acknowledge the Death Patients and staff need rituals to facilitate resolution of grief Rituals provide an invitation for patients and staff to talk about the deceased and their feelings Provide opportunity for patients/staff to talk about their feelings

10. Rituals to Ponder Post staff “condolences” to family an friends Post funeral arrangements Facilitate patient attendance at funeral services Have a “moment of silence” on the patients shift Place a rose on the patient’s chair Celebrate the patient’s life with a collage of pictures

11. Business as Usual? DO NOT assume it’s just another day/week Death is painful and uncomfortable to talk about – it causes fear and anger Some staff may not be able to provide support for patients Staff may need help dealing with their own and other patients feelings

12. Guidelines for Social Workers In-servicing of Staff Preparatory Grief vs. Depression –Preparatory Grief –Experienced by mostly all dying patients –And patients who perceive themselves as dying and/or experiencing a deep sense of loss –Pharmacotherapy for grief is an exception, not the rule

13. Preparatory Grief Freud: “the reaction to the loss of a loved person, or to the loss of some abstraction which has taken the place of one, such as one’s liberty.”

14. Adjustment to Loss Emotional Social Spiritual Physical Cognitive and behavioral changes

15. Loss Experiences Separation from loved ones Lost of simple pleasures of life, a daily walk in the park, having a hot chocolate on a cold day Reflections of past to relive great moments and mourning for lost opportunities Future expectations of experience Self-image Other lost objects

16. Facilitate Grief with Proper Support R  E  L  I  E  V  E  R R eflect. Mirror patient’s emotions. E mpathize. Try to make a personal connection. L ead. Guided questions can help address concerns. I mprovise. Respect emotional boundaries of person and offer support within those boundaries. This includes the emotion of anger.

17. R  E  L  I  E  V  E  R E ducate. Grief comes in waves. Grief is individual and expressed differently. Anger and anxiety are normal. –Identifying, validating and channeling constructive outlets for anger helps decrease conflict. V alidate the E xperience, the normalcy of the feelings being expressed. R ecall. Need for life review, ask about details.

18. Management of Depression Persistent flat affect, negative self-image May require combined psychosocial interventions and pharmacotherapy –However, it is important to ease fears which can precipitate or worsen depression. IE – Talk therapy Freud called it, “The Talking Cure” Working Psychodynamically

19. Fear of Abandonment Stress experienced by family and professional caregivers may lead to forms of actual abandonment Addressing these issues and identifying coping strategies can help minimize alienation and abandonment

20. Fear of the Unknown Fear that death in itself is painful Educate about the dying process and pain management options Use of alternative therapies Massage Art Relaxation Music Guided imagery

21. Fear for Loved Ones Assist patients and families in making plans for the future potential losses

22. Fear of the Afterlife and the Future Take a spiritual history to better understand how this fear may impact the patient Spiritual needs should be assessed and referrals to spiritual caregivers provided, if required

23. Grief vs Depression Grief can be supported and facilitated Depression can be treated Requires support of a skilled interdisciplinary team –Medical –Psychosocial –Dietary

24. Staff and Grief Denial of death and loss is NOT healthy Maintaining status quo builds up unconscious feelings that go unresolved Staff can experience an acute grief reaction similar to what a family member may experience

25. Acute Grief Reaction Numbness or dampened emotions Temporary loss of self-esteem –Generally returns to normal quickly Anger, anxiety Impaired concentration and short-term memory Mood swings Preoccupation with the deceased

26. Acute Grief Reaction Vivid images of the deceased Mild disassociative experiences Urge to search for the deceased Restless sleep Increased physical preoccupations

27. Anger and Displacement An attempt to get rid of the anger by displacing or projecting it onto someone else Often staff is the receiving target of anger from other patients –These patients are in the same predicament as the deceased Encourage patients to vent, express, and verbalize their fears and anger in an appropriate, supportive environment

28. Staff may also experience: Regret Anger Guilt Failure Irritation and frustration Feelings of Inadequacy Sadness

29. How to Cope Recognize and accept feelings about loss Team review of facts concerning the loss –Helps individuals process feelings Verbalize anger, other feelings –Work it out physically through hobbies, exercise Importance of Self-care –Diet –Rest –Maintain friendships and social activities

30. Providing Optimum Care Being aware of, and open to, issues involved in grief processes help staff maintain healthier lives and be more available to their patients Processing complex emotions involved in grieving promotes better connection with ourselves and our patients