1. C C E E N N L L E E End-of-Life Nursing Education Consortium International Curriculum Grief, Loss, Bereavement. Essentials of communication Grief, Loss, Bereavement. Essentials of communication

2. E E N N E E C C L L International Curriculum Grief, Loss and Bereavement Patient, family and healthcare providers all experience losses Each person grieves in their own way An interdisciplinary care approach is vital Patient, family and healthcare providers all experience losses Each person grieves in their own way An interdisciplinary care approach is vital 2

3. E E N N E E C C L L International Curriculum Healthcare Provider’s Role Assess the grief Assist the patient with grief Support survivors Assess the grief Assist the patient with grief Support survivors 3

4. E E N N E E C C L L International Curriculum The Grief Process Begins before the death Not orderly or predictable Includes a series of stages or tasks No one “gets over it” Grief work leads to living with the loss Chan et al., 2004 4

5. E E N N E E C C L L International Curriculum Loss A loss may be a person, thing, relationship, or situation. Grief is an emotional response to loss Mourning is the outward, social expression of loss Strongly influenced by culture Corless, 2010 A loss may be a person, thing, relationship, or situation. Grief is an emotional response to loss Mourning is the outward, social expression of loss Strongly influenced by culture Corless, 2010 5

6. E E N N E E C C L L International Curriculum Bereavement The reaction of the survivor to the death of a family member or close friend. Be aware of cultural characteristics. D’Avanzo, 2008 The reaction of the survivor to the death of a family member or close friend. Be aware of cultural characteristics. D’Avanzo, 2008 6

7. E E N N E E C C L L International Curriculum 7

8. E E N N E E C C L L Types of Grief Grief before loss Actual or fear of potential losses Experienced by patient, family, professionals Children have unique needs Glass et al., 2010 Grief before loss Actual or fear of potential losses Experienced by patient, family, professionals Children have unique needs Glass et al., 2010 Anticipatory Grief 8

9. E E N N E E C C L L International Curriculum Normal Grief (Uncomplicated) Normal feelings, behaviors and reactions to loss Physical, emotional, cognitive and behavioral reactions Normal feelings, behaviors and reactions to loss Physical, emotional, cognitive and behavioral reactions 9

10. E E N N E E C C L L International Curriculum Complicated Grief Chronic grief Delayed grief Exaggerated grief Masked grief Chronic grief Delayed grief Exaggerated grief Masked grief 10

11. E E N N E E C C L L International Curriculum Complicated Grief – Risk Factors Sudden or traumatic death Suicide, homicide Death of a child Multiple losses 11

12. E E N N E E C C L L International Curriculum Disenfranchised Grief When loss cannot be openly acknowledged or socially sanctioned At risk- AIDS partners, ex-spouse, step-parent/child, terminated pregnancy When loss cannot be openly acknowledged or socially sanctioned At risk- AIDS partners, ex-spouse, step-parent/child, terminated pregnancy 12

13. E E N N E E C C L L International Curriculum Children’s Grief Based on developmental stages Can be normal or complicated Symptoms unique to children Based on developmental stages Can be normal or complicated Symptoms unique to children 13

14. E E N N E E C C L L International Curriculum Stages and Tasks of Grief Stage 1 Notification and shock Stage 2 Experience the loss Stage 3 Reintegration Corless, 2010 Stage 1 Notification and shock Stage 2 Experience the loss Stage 3 Reintegration Corless, 2010 14

15. E E N N E E C C L L International Curriculum Factors Influencing the Grief Process Survivor personality Coping skills, patterns History of substance abuse Relationship to deceased Spiritual beliefs Type of death Survivor ethnicity and culture Survivor personality Coping skills, patterns History of substance abuse Relationship to deceased Spiritual beliefs Type of death Survivor ethnicity and culture 15

16. E E N N E E C C L L International Curriculum Grief Assessment Begins at time of admission or diagnosis Ongoing to detect complicated grief Corless, 2010 Begins at time of admission or diagnosis Ongoing to detect complicated grief Corless, 2010 16

17. E E N N E E C C L L International Curriculum Assessment Type of grief Grief reactions Influencing factors General health of caregiver/survivor Glass et al., 2010 Type of grief Grief reactions Influencing factors General health of caregiver/survivor Glass et al., 2010 17

18. E E N N E E C C L L International Curriculum Bereavement Interventions Plan of care Attitude Cultural practices What to say Anticipatory grief Plan of care Attitude Cultural practices What to say Anticipatory grief 18

19. E E N N E E C C L L International Curriculum Bereavement Interventions for Children and Parents Recognize developmental stage Refer to support groups Recognize developmental stage Refer to support groups 19

20. E E N N E E C C L L International Curriculum Anticipatory Grief Interventions for Patient and Family Preventive approaches to minimize sense of loss –Encourage life review –Educate patient/family on dying process –Provide presence/active listening 20

21. E E N N E E C C L L International Curriculum Grief Interventions Identify and express feelings – their story Special attention to disenfranchised grief Public funerals, rites, rituals, traditions Private reflection Spiritual care Recognize developmental stage in children Refer to support group 21

22. E E N N E E C C L L International Curriculum Completion of the Grieving Process No one can predict completion Grief work is never completely finished Healing occurs when the pain is less No one can predict completion Grief work is never completely finished Healing occurs when the pain is less 22

23. E E N N E E C C L L International Curriculum Cumulative Loss 23

24. E E N N E E C C L L International Curriculum Stages of Adaptation Health professionals new to working with the dying need to emotionally & spiritually adapt Stages of adaptation –Intellectualization –Emotional survival –Depression –Emotional arrival –Deep compassion –The “doer” Harper, 1994 Health professionals new to working with the dying need to emotionally & spiritually adapt Stages of adaptation –Intellectualization –Emotional survival –Depression –Emotional arrival –Deep compassion –The “doer” Harper, 1994 24

25. E E N N E E C C L L International Curriculum Factors Influencing the Healthcare Provider ’s Adaptation Professional education Personal death history Life changes Support system Vachon & Huggard, 2010 25

26. E E N N E E C C L L International Curriculum Systems of Support Balance Assessing support systems Spiritual support Education in end-of-life care Self care strategies Vachon & Huggard, 2010 Balance Assessing support systems Spiritual support Education in end-of-life care Self care strategies Vachon & Huggard, 2010 26

27. E E N N E E C C L L International Curriculum Conclusion Care does not end with the death of a patient Loss, grief and bereavement need to be assessed with ongoing intervention Healthcare providers must recognize and respond to their own grief Provide interdisciplinary care 27

28. E E N N E E C C L L International Curriculum Caring for the Body and Soul28

29. E E N N E E C C L L International Curriculum Communication Terminal illness is a family experience Imparting information so individuals may make informed decisions Requires interdisciplinary collaboration Kimberlin et al., 2004 Terminal illness is a family experience Imparting information so individuals may make informed decisions Requires interdisciplinary collaboration Kimberlin et al., 2004 29

30. E E N N E E C C L L International Curriculum Barriers to Communication Fear of mortality Lack of experience Avoidance of emotion Insensitivity Sense of guilt 30

31. E E N N E E C C L L International Curriculum Barriers to Communication (cont.) Fear of not knowing Disagreement with decisions Lack of understanding culture or goals Personal grief issues Ethical concerns 31

32. E E N N E E C C L L International Curriculum Myths of Communication Communication is deliberate Words mean the same to sender/receiver Verbal communication is primary Communication is one way Can’t give too much information Communication is deliberate Words mean the same to sender/receiver Verbal communication is primary Communication is one way Can’t give too much information 32

33. E E N N E E C C L L International Curriculum Patient/Family Expectations Be honest Elicit values and goals Team communication Take time to listen Coyne & Drew, 2010; Quill, 2000 33

34. E E N N E E C C L L International Curriculum 34

35. E E N N E E C C L L Verbal and Non-Verbal Communication Includes body language, eye contact, gestures, tone of voice 80% of communication is nonverbal Dahlin, 2010 Includes body language, eye contact, gestures, tone of voice 80% of communication is nonverbal Dahlin, 2010 35

36. E E N N E E C C L L International Curriculum Communication Ask how much patient/family want to know Initiate family meetings Illness can strengthen or weaken relationships Base communication with children on developmental age Ask how much patient/family want to know Initiate family meetings Illness can strengthen or weaken relationships Base communication with children on developmental age 36

37. E E N N E E C C L L International Curriculum Cultural Differences in Communication Related to: Sexual orientation Religion Age Ethnicity Gender Tribes Sexual orientation Religion Age Ethnicity Gender Tribes 37

38. E E N N E E C C L L International Curriculum Listening Steps Ray, 1992 38

39. E E N N E E C C L L International Curriculum Attentive Listening Encourage them to talk Be silent Share your feelings Avoid misunderstandings Buckman, 2001 Encourage them to talk Be silent Share your feelings Avoid misunderstandings Buckman, 2001 39

40. E E N N E E C C L L International Curriculum Attentive Listening Don’t change the subject Take your time in giving advice Encourage reminiscing Create legacies Don’t change the subject Take your time in giving advice Encourage reminiscing Create legacies 40

41. E E N N E E C C L L International Curriculum 41

42. E E N N E E C C L L Presence Requires: Acknowledging vulnerability Intuition Empathy Being in the moment Serenity and silence Dahlin, 2010; Stanley, 2002 42

43. E E N N E E C C L L International Curriculum Guidelines for Encouraging Conversation Setting the right atmosphere Does the patient/family want to talk? Attentive listening Dahlin, 2010; Duhamel & Dupris, 2003 Setting the right atmosphere Does the patient/family want to talk? Attentive listening Dahlin, 2010; Duhamel & Dupris, 2003 43

44. E E N N E E C C L L International Curriculum Factors Influencing Communication Family system changes Financial uncertainties Physical limitations Cultural Issues Friedrichsen et al., 2001; Rabow et al., 2004 Family system changes Financial uncertainties Physical limitations Cultural Issues Friedrichsen et al., 2001; Rabow et al., 2004 44

45. E E N N E E C C L L International Curriculum Healthcare Professionals Influence Communication Outcomes Be aware of behaviors and communication style Lack of personal experience with death and dying Fear of not knowing the answer Lack of understanding patient’s and family’s end-of-life goals Language barriers 45

46. E E N N E E C C L L International Curriculum Family Meetings Patient may attend Family members Appropriate clinicians (best if includes primary care along with palliative care) Goal to enhance communication 46

47. E E N N E E C C L L International Curriculum Breaking Bad News… Breaking a Heart 47

48. E E N N E E C C L L International Curriculum Communication Strategies to Facilitate End-of-Life Decisions Initiate end-of-life discussions Use words such as “death” and “dying” or “very sick” Maintain hope Clarify benefits and burdens Be honest 48

49. E E N N E E C C L L International Curriculum Team Communication Intra-team communication is vital, especially between RN and MD Should occur frequently Document Expect conflicts Intra-team communication is vital, especially between RN and MD Should occur frequently Document Expect conflicts 49

50. E E N N E E C C L L International Curriculum Resolving Conflict Try to take a step back Identify your own emotions Define the conflict Obtain agreement on the conflict Talk about it Patient’s best interest should always be foremost Dahlin, 2010 Try to take a step back Identify your own emotions Define the conflict Obtain agreement on the conflict Talk about it Patient’s best interest should always be foremost Dahlin, 2010 50

51. E E N N E E C C L L International Curriculum Summary Communication is complex The ultimate objective is the patient’s best interest Patient’s and their families must be involved in communication Primary healthcare provider to promote communication among team members, patients and family Communication is complex The ultimate objective is the patient’s best interest Patient’s and their families must be involved in communication Primary healthcare provider to promote communication among team members, patients and family 51

52. E E N N E E C C L L International Curriculum Collaboration 52

53. E E N N E E C C L L International Curriculum Give the answers to the following questions please : 1.What are the definitions of Grief, Loss and Bereavement. 2.Describe and evaluate different models of grief. 3. List the Steps of Listening 1.What are the definitions of Grief, Loss and Bereavement. 2.Describe and evaluate different models of grief. 3. List the Steps of Listening