1. Elsevier items and derived items © 2005 by Mosby, Inc. CHAPTER 20 Loss and Grief

2. Elsevier items and derived items © 2005 by Mosby, Inc.Loss b External loss- outside of individual ; objects, possessions, loved ones, support b Internal loss-involve part of oneself b Imagined/perceived b Temporary b Permanent b Sudden b Gradual

3. Elsevier items and derived items © 2005 by Mosby, Inc. Loss b Maturational- give up something to gain a higher level of development

4. Elsevier items and derived items © 2005 by Mosby, Inc. Can be actual, potential, imagined, temporary or permanent, maturational or situational, expected or unexpected Significance determined by person experiencing it Reactions to loss are based on level of development, past experiences, and current support system. (Cont’d…) LossLoss

5. Elsevier items and derived items © 2005 by Mosby, Inc. (…Cont’d) Children’s understanding of and reaction to loss change as they mature.   Infants feel the loss of their caregivers, but show little emotional reaction as long as their basic needs are met.   Toddlers are concerned with themselves and do not understand the meaning of loss.   Preschoolers cannot understand a permanent loss such as death. They believe that their thoughts can control events, which can lead to believe that the child was responsible for the loss. (Cont’d…) Loss across the Lifespan

6. Elsevier items and derived items © 2005 by Mosby, Inc. (…Cont’d)   School-aged children have some idea about cause and effect. They still associate bad thoughts or misdeeds with loss At age 6 or 7, they apply a broad definition to loss, especially death. By age 9 or 10, most children have an adult concept of loss and death.   Adolescents react to loss with adult thinking and childlike emotions. Thus, they are the age group least likely to accept the situation. (Cont’d…) LossLoss

7. Elsevier items and derived items © 2005 by Mosby, Inc. (…Cont’d) Adults facing loss are able to perceive events more abstractly than younger individuals.   Know the difference between temporary and permanent losses   Usually able to accept losses and grow from the experience   As they continue to encounter and cope with various losses, most develop sense of self-confidence and understanding about life and death LossLoss

8. Elsevier items and derived items © 2005 by Mosby, Inc. Nature of Grief and Mourning b Grief – set of emotional reactions that accompany loss b Mourning – PROCESS of working through or resolving one’s grief b Bereavement – the behavioral state of thoughts, feelings, and activities that follow loss b Can be intense and painful b Short or long periods of time b Individualized b NO right of wrong way to grieve

9. Elsevier items and derived items © 2005 by Mosby, Inc. Denial   Feeling of shock   Attempt to reject the loss   Refusal to give up cherished object or person   Refusal, sometimes, to acknowledge that a loss has occurred   Emotional buffer affords time to mobilize resources for work ahead (Cont’d…) Stages of the Grieving Process

10. Elsevier items and derived items © 2005 by Mosby, Inc. (…Cont’d) Yearning   Realization that the loss can no longer be denied   Griever becomes overwhelmed   Crying, self-blame, anger are common   May become suicidal (Cont’d…) Stages of the Grieving Process

11. Elsevier items and derived items © 2005 by Mosby, Inc. (…Cont’d) Depression and identification   The work of mourning begins as the full impact of the loss is realized.   Feelings of guilt and remorse are frequent as attempts are made to cope with the void left by the loss.   Withdrawal from social interactions, unhealthy behaviors, or experiencing overwhelming loneliness are not uncommon.   As time passes, most people become willing to share memories and rely on the emotional support of others. (Cont’d…) Stages of the Grieving Process

12. Elsevier items and derived items © 2005 by Mosby, Inc. (…Cont’d) Acceptance and recovery   Grieving individuals begin to focus energies toward the living.   Begin to reinvest their feelings in others and nurture remaining relationships.   Eventually, new self-awareness and inner strength evolve from the grieving process. Stages of the Grieving Process

13. Elsevier items and derived items © 2005 by Mosby, Inc. Stages b Dynamic b Not usually step by step b Backsliding/regression b Length of time varies b Active mourning may last 5 yrs or longer

14. Elsevier items and derived items © 2005 by Mosby, Inc. Healthy grieving occurs when griever is allowed time to mourn and to regress and work through the stages of grief as needed. Healthy grieving can last as long as 5 years. Anticipatory grief   Process of grieving before the actual loss occurs   Prompted by awareness of an impending loss Of a body part Of a life (i.e., terminal illness) GriefGrief

15. Elsevier items and derived items © 2005 by Mosby, Inc. Can result from mental health problems   Renders people unable to shift attention from their loss to realities of every day   They become so preoccupied with the loss that they are unable to function effectively. Two types   Bereavement-related depression-   Complicated grief (Cont’d…) Unresolved Grief

16. Elsevier items and derived items © 2005 by Mosby, Inc. (…Cont’d) Bereavement-related depression   Griever feels loss so intensely that feelings of despair and worthlessness overwhelm everything else   Griever feels there is nothing to look forward to   Life becomes a burden and every day is filled with remorse   Griever experiences changes in eating, sleeping, and activity level   Griever often becomes socially isolated This type of grief commonly leads to suicide but responds well to treatment if caught early. (Cont’d…) Unresolved Grief

17. Elsevier items and derived items © 2005 by Mosby, Inc. (…Cont’d) Complicated grief   Persistent yearning for deceased; can occur without depression   Symptoms appear to be those of normal grieving but are associated with impaired psychological functioning and disturbances of mood, sleep, and self-esteem   Griever may idealize and search for lost person or object or relive past experiences   Social isolation not uncommon Treatment depends on presence of depressive symptoms (Cont’d…) Unresolved Grief

18. Elsevier items and derived items © 2005 by Mosby, Inc. (…Cont’d) Therapeutic interventions   Listening   Providing emotional support   Referral to appropriate resources When grievers are encouraged to verbalize feelings, real healing begins Nurses and direct caregivers are often the first to identify signs and symptoms Unresolved Grief

19. Elsevier items and derived items © 2005 by Mosby, Inc. Dying b Last stage of growth and development b Sudden or gradual

20. Elsevier items and derived items © 2005 by Mosby, Inc. Resistance   Individual fights issue through denial, avoidance, anger, and bargaining Working or review   Consciousness broadens as life is reviewed   Unfinished business is dealt with Acceptance   Individual is comfortable with and acknowledges death   Can discuss death with peace and calm   More time is spent focusing energy inward, away from reality. Stages of Dying

21. Elsevier items and derived items © 2005 by Mosby, Inc. Age Differences and Dying b 8 yrs = sense of doom and danger associated with dying b 12yrs = aware that death is irreversible, do not relate it to their own death b Adolescents/young adults-do not relate to death unless forced b As people grow older they face their own mortality

22. Elsevier items and derived items © 2005 by Mosby, Inc. The Dying Child b Children are observant and have intuition b Know the seriousness of their illness b Focus is on activities of daily living b Aware of family reaction b Open discussions IllnessIllness OutcomeOutcome feelingsfeelings

23. Elsevier items and derived items © 2005 by Mosby, Inc. b Siblings of the dying child need extra attention during this time JealousyJealousy AngerAnger guiltguilt

24. Elsevier items and derived items © 2005 by Mosby, Inc. (…Cont’d) Terminal illness: A condition in which the outcome is death Diagnosis of a terminal illness is among the most difficult challenges an individual can face. Diagnosis of a fatal illness or condition is received with disbelief and shock and is a true crisis.   A time of great uncertainty   Crisis intervention can be effective. DeathDeath

25. Elsevier items and derived items © 2005 by Mosby, Inc. b Denial and hope allow the client and family to adjust to the reality of the situation b Continue activities until no longer able b Received in variety of ways Young- may refuse to acceptYoung- may refuse to accept Wake up call / motivatorWake up call / motivator

26. Elsevier items and derived items © 2005 by Mosby, Inc. Cultural factors b Native Americans- death is final loss b E. Indian Hindus-passage from one existence to another b Dictates funeral process Chinese wear white to mournChinese wear white to mourn North Americans wear black to mournNorth Americans wear black to mourn

27. Elsevier items and derived items © 2005 by Mosby, Inc. Stages of Dying b Psychological stages b Kubler-Ross DenialDenial AngerAnger BargainingBargaining DepressionDepression acceptanceacceptance

28. Elsevier items and derived items © 2005 by Mosby, Inc. b Now 3 Stages b Resistance- fights issue through denial, avoidance, anger, bargaining b Working- deals with unfinished business b Acceptance-comfortable and acknowledges death, discusses death with peace and calm

29. Elsevier items and derived items © 2005 by Mosby, Inc. Hospice b Philosophy of car for people with terminal illness or conditions and loved ones b Goal is to make the remainder of an individual’s life as meaningful and comfortable as humanly possible

30. Elsevier items and derived items © 2005 by Mosby, Inc. “Good death”: One in which the dying and the living participate fully and completely   Dying persons control personal destiny.   Clients decide when to stop aggressive treatments, refuse a surgical procedure, or end a painful treatment.   Peace, serenity, and acceptance replace denial, fighting, and anger.   Clients value and cherish each day but look forward to the day when suffering will end.   They are not afraid of death. A Good Death

31. Elsevier items and derived items © 2005 by Mosby, Inc. Hierarchy of Dying Needs

32. Elsevier items and derived items © 2005 by Mosby, Inc.

33. http://www.spokesmanreview.com/blogs/video/ play.asp?file=092306_mother_sr_hi.mov Peter http://www.healthyplace.com/COMMUNI TIES/depression/related/loss_grief.asp

34. Elsevier items and derived items © 2005 by Mosby, Inc. Loss Grief and Mental Health b Those with mental illness can experience significant impairments when faced with stresses of loss and grief b Table – 19-1 symptoms of dying