grief and loss psych chap12 linda l. franco rn, msn ne-bc - tie everything together 1

Grief and LossPsych Chap12

Linda L. Franco RN, MSN NE-BC

- Tie everything together

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Definitions of Grief, pg 216Definitions of Grief, pg 216

• Grief - subjective emotions and affect that are a normal response to loss

• Grieving/bereavement- process of experiencing grief

• Anticipatory grief - facing imminent loss• Mourning - outward sign of grief

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• Perinatal loss is death of a fetus or infant from the time of conception through the end • of the newborn period 28 days after birth. Intrauterine fetal death (IUFD) after 20

weeks• gestation is often referred to as stillbirth or fetal demise.• Common causes of perinatal loss – the incidence of fetal death after 20 weeks in the • United States is 6.8 per 1000 total births, accounting for 50% of all perinatal deaths • (Magann, Chauhan, Bofill, 2002). Over 80% of stillbirths occur before term, with more • than 50% occurring before 28 weeks’ gestation (Cunningham, 2001). Factors associated • with perinatal loss can be fetal factors, maternal factors or placental /other (cord

accidents, • twins from assisted fertility technology, amniocentesis, genetic testing, etc) factors.

May• be unknown or related to preeclampsia, eclampsia, abruptio placentae, placenta

previa, • diabetes, congenital anomalies, renal disease, cord accidents, fetal growth restriction,• and alloimmunization.

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• Grief and loss are essential in life; relinquishing and moving on happen as we grow and develop

Grief and loss are uncomfortable

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Types of Losses, pg 216

• Can be planned, expected, or sudden: – Physiologic (loss of limb)

– Safety (domestic violence, posttraumatic stress disorder, breach of confidentiality)

– Security/sense of belonging (relationship loss [death, divorce])

– Self-esteem (ability to work, children leaving home)

– Self-actualization (loss of personal goals, such as not going to college, never becoming an artist or a dancer)

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Theories of the Grieving Processall pretty similar...

• Kuber Ross’s 5 stages of grieving• Bowlby’s 4 phases of grieving• John Harvey’s 3 phases of grieving• Rodebaugh’s 4 stages of grieving• Similarities among theorists • Not all clients follow predictable steps or

make steady progress6

Kubler-Ross’s 5 stages of grieving

1) Denial (shock and disbelief)- may ask for 2nd opinion

2) Anger (toward God, relatives, healthcare providers)

3) Bargaining (trying to get more time, prolonging the inevitable loss)- bargain w/ God

4) Depression (awareness of the loss becomes acute)- weeping and withdraw, changing H levels may compound the stage.

5) Acceptance (person comes to terms with impending death or loss)- can take months to yrs

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• Denial – Even when the initial healthcare provider suspects fetal demise, • the couple is hoping a second opinion may be different.

• Anger – results from feelings of loss, loneliness, and perhaps guilt. The • mother may attempt to identify a specific event that caused the death • and may blame herself.

• Bargaining – More common when the death is anticipated. It is marked • by the couple making mental trade-offs in exchange for the fetus being • healthy.

• Depression – Evidenced by preoccupation, weeping, and withdrawal. • Changing hormonal levels in the first 24 to 48 hours after birth may • compound the depression and associated grief.

• Acceptance – Occurs when resolution occurs. This stage is highly • individualized and may take months to years to complete.

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Bowlby’s 4 phases of grieving

1) Numbness and denial of the loss2) Emotional yearning for lost loved one

and protesting permanence of loss3) Cognitive disorganization and emotional

despair4) Reorganizing and reintegrating sense of

self

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John Harvey’s 3 phases of grieving

1) Shock, outcry, and denial2) Intrusion of thoughts, distractions, and

obsessive reviewing of loss3) Confiding in others to emote and

cognitively restructure

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Rodebaugh’s 4 stages of grieving

1) Reeling2) Feelings3) Dealing4) Healing

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Tasks of the Grieving Process

• Undoing psychosocial bonds to loved one and eventually creating new ties

• Adding new roles, skills, and behaviors• Pursuing a healthy lifestyle• Integrating the loss into life

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Cultural Considerations

• All cultures grieve • Rituals and habits surrounding death vary

among cultures– Expression of sadness expressed– Time mourning should last –Many rituals have roots in religion

• Nurses should be sensitive to cultural differences

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African Americans African Americans

Typically view the body in church Hymns, poetry, eulogies Public prayerWearing black clothing Decreasing social activities

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Muslim AmericansMuslim AmericansMuslims do not permit cremationFollow 5 steps of burial procedure

Haitian AmericansPractice vodun or calling on spiritsto make peace

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Chinese AmericansChinese Americans

Strict norms for announcing death,preparing the body, arranging the funeraland burialBurning incense and reading scriptureassist the spirit of the deceased on his orher journey

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Japanese AmericansJapanese Americans

Buddhists view death as a life passageBathing and purification rites areperformedFriends and family visit, bringing gifts ormoneyPrayers are saidIncense is burned

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Filipino AmericansFilipino AmericansOften Catholic

Wear armbands or black clothing

Place wreaths on casket

Black banner on the deceased’s home

Prayers and blessings for the soul of the

deceased

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Vietnamese AmericansVietnamese Americans

Predominately BuddhistDeceased bathed and dressed in black Rice and money sent with the deceased View the body before burial at home

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Hispanic AmericansHispanic Americans

Predominately CatholicPray for the soul during a rosaryMourning may involve wearing blackand decreasing social activitiesA wake in the home may be held

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Native AmericansNative Americans

Variety of practices depending on religious

beliefs and practices of different tribes

Death seen as a state of unconditional love

Believe deceased is going on a journey

Celebrations may include a ghost meal

Mourners encouraged to be happy for the

person

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Orthodox Jewish AmericansOrthodox Jewish Americans

Leaving a dying person alone is a signof disrespectBurial must occur within 24 hours unlessdelayed by the SabbathBody should be untouched until ritescan be performed by family, rabbi, orJewish undertaker

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Disenfranchised Grief

• Grief over a loss that is not or cannot be openly acknowledged, mourned publicly, or supported socially:

A relationship has no legitimacy – lovers, same-sex relationships

The loss itself is not recognized - prenatal death, abortion, pet, job

The griever is not recognized - older adults, children, nurses

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Complicated Grieving

• Response that lies outside the norm of grieving in terms of extended periods of grieving: responses that seem out of proportion or responses that are void of emotion

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Vulnerable to complicated grieving

– Low self-esteem

– Low trust in others

– A previous psychiatric disorder

– Previous suicide threats or attempts

– Absent or unhelpful family members

– An ambivalent, dependent, or insecure attachment to the deceased person

Story…-14:00

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Increased risk for complicated grieving, b/c they are such a lrg part of their life

– Death of a spouse or child– Death of a parent (particularly in early

childhood or adolescence)– Sudden, unexpected, and untimely death– Multiple deaths– Death by suicide or murder

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Complicated Grieving• Physical reactions can include:– Impaired immune system (due to the stress)– Increased adrenocortical activity– Increased levels of serum prolactin and growth hormone – Psychosomatic disorders– Increased mortality from heart disease (can become at

risk themselves)• Emotional responses can include:– Depression– Anxiety or panic disorders– Delayed or inhibited grief– Chronic grief

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Potential Nursing Diagnoses

• Grieving• Anticipatory grieving• Dysfunctional grieving

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Nurse’s Role

• Recognition of signs of grief• Support client • Therapeutic communication • Promote the expression and release of emotional

and physical pain • Encourage effective use of grieving behaviors –

Praying, staying with body, rituals, memorial service

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Communication and interpersonal skills to assist grieving:

– Use simple, nonjudgmental statements – Refer to a loved one by name – Appropriate use of touch – Respect client’s process of grieving and personal

beliefs– Be honest, dependable, consistent, and worthy

of client’s trust– Offer a welcoming smile and eye contact

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Perinatal Loss

• A child that loses a parent is an orphan,

• A man who loses his wife is a widower, a woman who loses her husband is a widow,

• However, there is no name for a parent that loses a child, for there is no word to describe such pain.

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Definitions

• Perinatal loss: Death of a fetus or infant from the time of conception through the end of the newborn period of 28 days after delivery.

• IUFD: intrauterine fetal death after 20 weeks often referred to as stillborn or fetal demise.

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Common Causes of Perinatal Loss

• Fetal Factors• Maternal factors• Placental factors• Unknown

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The Bereaved Family’s Bill of Rights

• You have the right to expect your grief to be acknowledged in a professional and compassionate manner.

• You have the right to be an educated consumer, to have all the requirements and options explained to you.

• You have the right to ask all the questions and receive honest answers.

• You have the right to express your needs, emotional, religious, and spiritual, and have the funeral director listen and facilitate your requests accordingly.

• You have the right to plan a meaningful funeral ritual, tailored to your beliefs, customs, and traditions.

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Rights of the Infant

• To be recognized as a person who was born and has died.

• To be named.• To be seen, touched, and held by the family.• To have the end of life acknowledged.• To be put to rest with dignity.

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Nurses are a Powerful Influence!!!

We encounter families experiencing loss in many settings:Inpatient - antepartum, L & D, postpartum,

nursery, NICU, emergency rooms,med/surg recovery care

Outpatient – clinics, offices, infertility, OB/GYN, family practice,

pediatrician

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Death of Dreams

It does not matter how long the pregnancy lasted, it is still a loss of the personhood of that child.

6 weeks, 6 months, 6 days – it was a child, it was a hope, it was a dream not fulfilled

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Confirmation of Death

• Many times mom notices a decrease or stoppage of fetal movement.

• No heart tones• No cardiac activity on US• Will have drop of estriol levels in the blood

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Responding to Grieving Families

• Remember the 3 H’s Hug Hush Hang around

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What you can say:

• “I’m sad for you”• “How are you doing with all of this”?• “This is hard for you”• “What can I do for you”?• “I’m sorry”

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What Not to say

• “You’re young, you can have more children”

• “You have an angel in heaven”• “This happened for the best”• “Better for you now, before you knew the

baby”• “ There was something wrong with the baby

anyway”• Calling the baby a “fetus” or “it”

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How you Can Help

• Listen• Touch• Cry with the family• Attend the funeral/memorial service• Remember them on their baby’s due date,

birthday, and death day etc• Never forget

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Remembrances You Can Give the Family

• Baby ring• Planter/flowers in a baby vase• Original poem• Tree or rose bush as a living memorial• Donation to a memorial fund• Photographs keepsakes

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Preparing the Family for the Birth

• Hospital room away from other laboring moms• Label patients door• Keep couple together• Same nurse• Encourage to express their feelings• Encourage the parents to see, touch, and name their

baby• Spiritual support• Cultural support

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Preparing for the Birth

• Timing of the induction/delivery• Method of delivery• Medications for induction• Comfort measures• Immediate care of newborn and mom

following delivery

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Nursing Care of the Baby

The baby is washed and dressedIt is wrapped and made to look like a sleeping infantDefects are minimized if possibleParents will usually ask for the baby several times

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Discharge Care of the Family

Remembrance box or packagePicturesEarly dischargeLactation suppressionCommunity referrals/resourcesFuneral arrangements or body disposal

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Difficult Times for Parents

• Anniversaries/holidays• Due date• Death date• Growth and development milestones

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Suggestions for Bereaved Parents

• Name the baby• Find out the sex of the baby if possible• See the products of conception to make baby more

real• Don’t get rushed out of the hospital• See and hold your baby as many times as you want• Have your baby baptized or blessed according to

your religious beliefs• Have a memorial service

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Suggestions for Remembrance

• Do a baby book• Have pictures taken• Save some mementoes such as footprints,

hair, ID bracelets, clothing• Wear a remembrance of your baby• Plant a tree or plant• Buy a Christmas ornament with your baby’s

name

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Suggestions for Memorial Service

• Draw a picture of your child’s face and write poetry for the service

• Write a letter to your baby or God.• Have your baby shown in a cradle at the

funeral home or in your home• If you have cremation, have it done after

visitation and funeral

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