1. In The Name of God

2. Cognition vs Emotion

3. How to tell the bad news

4. Setting up Arrange for privacy Involve significant others Sit down and appear un-hurried Make an emotional connection Make arrangements to avoid interruptions - eg. Hand off your pager if possible

5. Perceptions Use open ended questions to assess the patient and their families perception of the medical situation. Careful not to talk down or above What is your understanding of your … What have you been told so far?

6. Invitation Explore if the patient wants all the facts or (as you know in some cultures) they may say my daughter or son will take care of everything. How would you like me to give the information about test results?

7. Knowledge A brief warning shot may help Warning that bad news is coming may help lessen the shock. Unfortunately I have some bad news to share then say it clear and concisely. Avoid medical jargon: - say “spread” instead of metastasis

8. The Patient’s Emotions Expect anything: - silence - disbelief - crying - denial - anger - shock

9. Your Emotions Sit and listen, connect with your eyes, hold their hand - whatever is natural I wish the news were different Can empathy be learned?

10. Strategy and Summary Make sure “the emotion part” has cleared enough for this step When ready in “broad strokes” talk about the various treatment options Remind them that many specialists will likely be involved in their care Leave them with some kind of realistic hope. Let them know you will support them through this process.

11. Grief The pain, discomfort, mental and physical feeling that most people feel following the death of a loved one. People suffer grief at the loss of anything. It doesn’t just have to be death.

12. Grieving Process

13. Denial

14. In this stage we refuse to believe what has happened. We try in our mind to tell ourselves that life is as it was before our loss. We can even make believe to an extent by re enacting rituals that we used to go through with our loved one.

15. We set an extra plate at the table. We expect them to be there when we get home. We flash back to memories and conversations. These are all part of this stage.

16. Anger

17. Anger We get angry. The anger can manifest itself in many ways. We blame others for our loss. We become easily agitated having emotional outbursts. We can even become angry at ourselves.

18. Care must be taken here not to turn the anger inwards. Release of this anger is essential!

19. Bargaining

20. Bargaining can be with ourselves or if you are religious with your god. Often we will offer something to try to take away the reality of what really happened. We may try to make a deal, to have our loved one back as they were before the tragic event occurred. It is only human to want things back as they were before.

21. Depression

22. Depression Depression is a very likely outcome for all people that grieve for a loss. This is the most difficult of the stages to deal with. There can be a feeling of listness and tiredness. Outbursts of tears may occur.

23. You may feel like there is no purpose to your life anymore. You may feel like you are being punished. Pleasure and joy may be difficult to express. There may even be thoughts of suicide. If you at any time in this stage, feel like doing yourself harm, professional counseling should be sought.

24. Acceptance

25. This is the final stage of grief. It happens when you know that you have to go on. You can accept your loss and now be able to regain your energy and goals for the future. It may take some time to get to this stage..but you will get there!

26. Coping with Crisis

27. Physical Reactions

28. Numbness Unfeeling Pain Tired Can’t Sleep Tightness in Throat Disinterest in Eating

29. Emotional Reactions

30. Stabbing Pain Sudden Anger Sense of Unfairness Feeling of Relief Anger Guilt Hostility Anxiety Gladness Fear

31. Mourning Process

32. Resolution One starts living a regular life.

33. Anticipatory Grief The mourning process that occurs prior to death in cases of terminal illnesses.

34. 11. Four Basic Needs of the Bereaved

35. Companionship

36. Ventilation of Feelings

37. TIME

38. Time Alone

39. 12.What are some appropriate things to say to the bereaved? "IT'S OKAY TO CRY," "I JUST WANTED YOU TO KNOW I AM THINKING ABOUT YOU."

40. 13.What should you avoid saying to the bereaved? "CHEER UP,“ " TIME WILL HEAL ALL WOUNDS," "HE/SHE IS BETTER OFF," "IT WAS GOD'S WILL," "CALL ME IF YOU NEED ME."