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Chapter 4
Loss, Grief, Death, and Dying

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Objectives

Define and explore the meaning of loss and ways to cope with loss.

Describe and discuss theories about the grieving process.

Explore definitions of death and the meaning of a good death.

Examine components of advanced directives.

Compare and contrast end of life care options.

Loss and Grief (1 of 6)

  • Loss
  • Feelings associated with a loss can emerge after:
  • An incident or event
  • Changes in social role, responsibility, or personal expectation
  • Philosophical view
  • Loss helps a person gain a better perspective and understanding of life and eventually rediscover joy

Loss and Grief (2 of 2)

  • Wilson identified two categories of loss:
  • Circumstantial
  • Unexpected incidents or events that negatively affect daily life
  • Developmental
  • Anticipated events or milestones that occur as a function of personal growth and maturation

Loss and Grief (3 of 6)

  • Viktor Frankl
  • Concluded that although humans often cannot control life events, they can control their response to those events
  • Developed logotherapy
  • Based on the belief that the ability to attach meaning to life is key to motivation and life preservation

Loss and Grief (4 of 6)

  • Grief
  • “Keen mental suffering or distress over affliction or loss; sharp sorrow; painful regret”
  • Personal, intimate, and intense
  • Affects an individual emotionally, socially, mentally, and spiritually
  • Differs from mourning, which is an outward expression of grief

Loss and Grief (5 of 6)

  • Typical reactions to grief
  • Sadness
  • Guilt
  • Confusion
  • Loneliness
  • Disbelief
  • Denial
  • Anger
  • Happiness

Loss and Grief (6 of 6)

  • Typical reactions to grief (continued)
  • Fear
  • Acceptance
  • Shock
  • Hatred
  • Anxiety
  • Emptiness
  • Relief
  • Helplessness

Theories on Managing Grief (1 of 8)

  • Sigmund Freud
  • Proposed that an individual should confront their grief by identifying and talking about issues that make it difficult for them to accept their losses
  • Encouraged patients to “move on” with their lives so that their “broken” hearts and spirits could heal

Theories on Managing Grief (2 of 8)

  • Attachment theory
  • Developed by John Bowlby
  • The level and nature of personal attachments to nurturing figures changes over time
  • We mourn persons with whom we have the closest attachments
  • Even close relationships have a degree of ambivalence

Theories on Managing Grief (3 of 8)

  • Michael Bradley and Cafferty
  • Found those who had a partnership that included high levels of quarreling and tension tended to display more “disordered mourning” after the death of a partner
  • Those with a healthier relationship tended to display “uncomplicated grief”

Theories on Managing Grief (4 of 8)

  • Stage process model
  • Elisabeth Kübler-Ross outlined five stages of grief that help dying people come to terms with their own impending death:
  • Denial
  • Anger
  • Bargaining
  • Depression
  • Acceptance

Theories on Managing Grief (5 of 8)

  • Phase process models
  • Dual Process Model
  • Resolving grief is dynamic and oscillates between two orientations
  • Grief process shifts between coping with loss and reorienting to daily life
  • Avoidance and denial are embraced as potentially helpful

Theories on Managing Grief (6 of 8)

  • Worden’s Task-Based Model
  • Identifies four tasks to be completed:
  • Accept the reality of the loss
  • Work through the pain of grief
  • Adjust to an environment in which the deceased is missing
  • Find an enduring connection to the deceased while embarking on a new life

Theories on Managing Grief (7 of 8)

  • Edwin Shneidman
  • Purported that the grieving process has many interlaced emotional “themes” that can appear, disappear, and reappear again
  • Beehive theory
  • Depicts the bereaved individual going back and forth between acceptance and denial

Theories on Managing Grief (8 of 8)

Coping with Loss and Grief (1 of 11)

  • Complicated grief
  • “Persistent complex bereavement disorder”
  • Inability to manage grief
  • Symptoms include intense sorrow, yearning, and emotional pain during the majority of days for more than 12 months

Coping with Loss and Grief (2 of 11)

  • Risk factors for complicated grief:
  • Witnessing a violent death
  • Losing someone with whom they maintained a high level of dependence
  • Experiencing high levels of anxiety
  • Exhibiting an insecure attachment style

Coping with Loss and Grief (3 of 11)

  • Individuals also face a higher risk of complicated grief if they have:
  • Low levels of social support
  • Limited religious or spiritual support
  • Low socioeconomic status
  • Physical disability or illness

Coping with Loss and Grief (4 of 11)

  • Theory of complicated mourning
  • Developed by Dr. Therese Rando
  • Three phases:
  • Avoidance
  • Confrontation
  • Accommodation

Coping with Loss and Grief (5 of 11)

  • Six steps or “Rs” of mourning occur within the three phases of complicated mourning:
  • Recognition
  • Reaction
  • Recollection and re-experiencing
  • Relinquishing
  • Readjustment
  • Reinvesting

Coping with Loss and Grief (6 of 11)

  • Supporting a person who has sustained a loss
  • Talking about a personal loss is difficult for many people
  • May Sarton and Susan Sherman developed a collection of response strategies that did and did not help

Coping with Loss and Grief (7 of 11)

Coping with Loss and Grief (8 of 11)

  • Rituals
  • Often utilized for coping with loss and grief and to assist moving through the mourning process
  • Can be personal, faith-based, or social
  • Can be undertaken as an individual or group
  • Participating in a ritual can:
  • Strengthen feelings of social connectedness
  • Offer psychological support
  • Provide meaning to the loss

Coping with Loss and Grief (9 of 11)

  • Burnout
  • Caused by excessive and prolonged stress caused by the work environment
  • Common signs:
  • Emotional exhaustion
  • Feeling detached from patients and their care
  • Lack of personal accomplishment
  • Increases risk for making mistakes

Coping with Loss and Grief (10 of 11)

  • Compassion fatigue
  • Also known as secondary or vicarious trauma
  • Affects individuals affected by trauma experienced by someone else
  • Signs include:
  • Lack of self-care
  • Low levels of compassion
  • Loss of boundaries with a patient/client

Coping with Loss and Grief (11 of 11)

  • Combat burnout and compassion fatigue by:
  • Maintaining physical health
  • Engaging in an increased variety of clinical roles
  • Pursuing hobbies
  • Relying on meditation techniques
  • Maintaining realistic expectations about work
  • Limiting work to 40 hours a week
  • Engaging in rituals

Death and Dying (1 of 5)

  • Death
  • Determining when death occurs can be complicated
  • Clinical death occurs when:
  • The heart stops circulating blood through the body
  • The lungs are unable to oxygenate the blood
  • Possible to resuscitate a clinically dead individual

Death and Dying (2 of 5)

  • Brain death
  • Generally follows a devastating brain injury
  • Occurs when coma, apnea, and lack of brainstem reflexes occur
  • Life support is considered futile except to preserve organs for donation to a living being

Death and Dying (3 of 5)

  • Persistent vegetative state (PVS)
  • Occurs when brain activity in the cortex ceases, but primal functions regulated in the brain stem continue
  • No possible return to normal functioning

Death and Dying (4 of 5)

  • Natural death
  • Dying at an old age when the body stops functioning on its own
  • Premature death
  • Dying at a young age
  • Compression of morbidity
  • Reducing personal and systemic burden caused by illness to the shortest time possible

Death and Dying (5 of 5)

  • Perspectives on death
  • Important not to assume that anyone is, or is not, prepared to die
  • Conversations about death and dying are shaped by our own experiences and perspectives
  • Fear of death typically peaks in young adulthood
  • Can create anxiety

Seeking a Good Death (1 of 6)

  • Good death
  • Means something different for everyone
  • Most hope for pain-free death without distress and suffering
  • We also want our end of life to be:
  • Aligned with our own and our families’ wishes
  • Reasonably consistent with clinical, cultural, and ethical standards

Seeking a Good Death (2 of 6)

  • Suicide
  • Taking one’s own life
  • Illegal in most states and viewed as morally reprehensible in most cultures
  • High rates of suicide in men age 75+
  • Older men are unlikely to seek therapeutic counseling services/mental health services
  • Limited number of programs developed specifically for older adults to address suicide

Seeking a Good Death (3 of 6)

  • Euthanasia
  • An act of killing another being
  • Passive euthanasia
  • Standing by and not taking action to prevent death
  • Active euthanasia
  • Taking direct action to shorten life
  • Illegal except for lethal injection used in capital punishment

Seeking a Good Death (4 of 6)

  • Physician-assisted suicide
  • Taking one’s own life under the guidance of a physician
  • Currently legal in some countries in Western Europe and in a few U.S. states and the District of Columbia
  • Critics argue that individuals may not receive adequate counseling or may not fully understand the outcome

Seeking a Good Death (5 of 6)

  • Advanced directives
  • Living will
  • Instructs healthcare providers how you want to be treated if you become seriously ill or are terminally ill or cannot communicate their wishes
  • Health care power of attorney (HCPOA)
  • Appoints a designated individual to speak for you in making health care decisions if you cannot speak for yourself

Seeking a Good Death (6 of 6)

  • Do not resuscitate (DNR) order
  • Prohibits life-saving treatments in the event that your heart stops
  • Cannot be revoked by anyone
  • Organ and tissue donation
  • One person can potentially save 8 lives and provide help to 50 additional people

End of Life Care Options (1 of 4)

  • Hospice
  • For individuals diagnosed with a terminal illness or injury
  • Offers compassionate care that includes palliative care
  • Can only be received after an individual has been certified by two physicians as having 6 months or less time to live

End of Life Care Options (2 of 4)

  • Hospice utilizes an interdisciplinary team to offer support to the recipient and family
  • Provides comfort and care in the recipient’s preferred surroundings without pain and invasive medical treatment
  • May include services such as pastoral care, homemaker/companion services, and recreational and rehabilitation therapy

End of Life Care Options (3 of 4)

End of Life Care Options (4 of 4)

  • Working with dying patients
  • Often referred to as a calling
  • Key points:
  • Offer words of kindness and support
  • Refrain from judging anyone or expressing discontent
  • Treat everyone with respect and dignity
  • Listen and watch
  • Reflect on the situation to learn more about yourself

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