Care of

terminally ill

patient

Prepared by :

Christian Raveina

MTIN, Changa.

Concept of loss, grief,

grieving process

– Loss can be defined as, “ an

experience in which an

individual relinquishes(give

away) a connection to a

valued object “

Loss may includes :

– Death of loved person

– Loss of favored status

or position

– Separation or divorce

– Financial losses

– The break up of

romantic affair

– Retirement

– Separation from a

friend

– Absence from the

home for the time

– Loss of cherished

– Loss can give rise to the symptoms of acute grief

– Walsh & Mc Goldrick (1991) stated that loss

requires movement through a process of

mourning(the expression of sorrow for someone's

death) in order to get what is needed from

experience or relationship to continue or with

one’s life.

Definition

– Grief is the painful psychologic & physiologic

response to loss

– It affects the physical, cognitive, behavioral,

emotional, social & spiritual aspects of the

life

Symptoms of grief : Physical

symptoms

– Weakness

– Anorexia

– Feeling of

choking

– Shortness of

breath

–Tightness of

chest

–Dry mouth & GI

disturbances

– Insomnia

Symptoms of grief : Cognitive

symptoms

–Difficulty in concentration

–People may experience

hallucination

Symptoms of grief : behavioral &

relating symptoms

– Disruption in

pattern of conduct

(mannerism of

behavior)

– Disorganized

behavior

– Ranging from an inability to perform even basic activities of daily living

– Restlessness

Symptoms of grief : Affective

(relating to mood, feeling, attitude)

symptoms

– Sadness

–Guilt

–Anger

–Major depression

Types

of grief

1. Anticipating grief ( pre

mourning )

– It is defined as grief associated with anticipation

of predicted death or loss

– Adaptive process that can help resolve

relationships & prepare solutions to some extent

for the loss

2. Acute grief

–Usually referred to simply as grief ,is the

typical painful experience after a loss

–Person might initially respond to death

of loved one without shock or disbelief

– Many factors other than culture & religion

influence the length & intensity of grief

– These are the nature of relationship, manner

of death, survivor’s involvement in care, length

of illness & the presence or absence of hope

– Acute grief does not have clear ending

3. Dysfunctional grief

– Described in multiple ways.

– Types are :

– Absent or inhibited grief

– Distorted grief

– Converted grief

– Chronic grief

Absent or Inhibited grief

– Characterized by no expression of grief following

significant loss

– Suppressed grief may manifest as chronic physical

illness such as :

– Ulcerative colitis

– Peptic ulcer

– Major depression

Distorted grief

– Characterized by distortion(twisting), usually

exaggeration, of one or more component of

grief especially guilt or anger

– Lead to depression or legal difficulties

following angry or violent outbursts

Converted(change) grief

– It is similar to conversion disorder in which

deep thinking may be over dramatization to

the extent that the survivor exhibits

symptoms or characteristics of deceased

(recently dead)

Chronic grief

– It is unending grief

– Its symptoms may intensify over time

– It occurs in response to a loss (ex: death)

4. Chronic sorrow

– Characteristics of other form of grief but differs in

several key aspects

– Chronic sorrow is a response to ongoing loss such

as chronic illness

– Ex: sorrow of parents having a child with drug

addiction

Stages of grief

process by

kubler Ross

Stage 1: Denial

– One of the first reactions is Denial, wherein

the survivor imagines a false, preferable

reality.

Stage 2 : Anger

– When the individual recognizes that denial

cannot continue, it becomes frustrated, especially

at proximate individuals.

– Certain psychological responses of a person

undergoing this phase would be: "Why me? It's

not fair!"; "How can this happen to me?"; '"Who

is to blame?"; "Why would God let this happen?".

Stage 3: bargaining

– The third stage involves the hope that the individual can

avoid a cause of grief.

– Usually, the negotiation for an extended life is made

with a higher power in exchange for a reformed lifestyle.

– Other times, they will use anything valuable against

another human agency to extend or prolong the life.

People facing less serious trauma can bargain or seek

compromise.

Stage 4: Depression

– "I'm so sad, why bother with anything?"; "I'm going to

die soon so what's the point?"; "I miss my loved one,

why go on?“

– During the fourth stage, the individual becomes

saddened by the certainty of death.

– In this state, the individual may become silent, refuse

visitors and spend much of the time mournful

Stage 5: Acceptance

– "It's going to be okay."; "I can't fight it, I may as

well prepare for it.

– People dying may precede the survivors in this

state, which typically comes with a calm,

retrospective view for the individual, and a stable

condition of emotions.

Stages of grief process

by

john bowlby & parkes

Stage 1 : Shock and

numbness– This is the phase where there is a sense the loss is not

real and seems impossible to accept.

– There is physical distress during this phase, which can

result in somatic symptoms.

– If person do not progress through this phase person will

struggle to accept and understand our emotions and

communicate them. Person will emotionally shut-down

and not progress through the phases of grief.

Stage 2: Yearning and

searching

– In this phase person acutely aware of the void

left in life from the loss. The future imagined is

no longer a possibility.

– Person search for the comfort he/she used to

have from the person he has lost and try to fill

the void of their absence.

– continue identifying with the person who has

died, looking for constant reminders of them and

ways to be close to them.

– If person cannot progress through this phase

person will spend his life trying to fill the void of

the loss and remain obsessed with the person we

have lost.

Stage 3: Despair and

disorganization

– In this stage, have accepted that everything

has changed and will not go back to the way

it was or the way we imaged.

– There is a hopelessness and despair that

comes with this, as well as anger and

questioning.

– Life feels as though it will never improve or make

sense again without the presence of the person

who died. withdrawal from others.

– if person do not progress through this phase he

will continue to be consumed by anger,

depression, and that our attitude toward life will

remain negative and hopeless.

Stage 4 :Re-organization and

recovery

– In this phase faith in life starts to be restored. Person

establish new goals and patterns of day-to-day life.

– Slowly person start to rebuild and come to realize that

his life can still be positive, even after the loss.

– In this phase grief does not go away nor is it fully

resolved, but the loss gradually diminish and shifts to a

hidden section of the brain, where it continues to

influence but is not at the forefront of the mind.

Stages of grief

by

George Engel

– Stage 1: shock & disbelief

– Stage 2: developing awareness

– Stage 3: Restitution – Restoration

– Stage 4: resolution of loss - Purposeful

– Stage 5: Recovery

Grieving

process

Phases of grieving process

1. Initial phase realization :

– Central issues : Intention of the self protective

response of denial of a painful reality

– Affective component : shock, disbelief & feeling of

emotional numbness, anger & dissatisfaction toward

anyone who encourages acceptance of loss, acute

emotional pain as the changing to the middle phase

– Activities : mobilization of psychological

resources aimed at achieving reunion,

recovery or restoration of the person,

relationship or object

– Resolution : Realization that the loss is

inevitable or has occurred and is irreversible

2. Middle phase-emotional pain :

– Central issues : conflicts & acknowledgement of the loss,

tolerating the emotional pain & biopsychosocial symptoms of

grieving, acceptance of support from other

– Affective component : Emotional pain is acute & unceasing,

guilt feelings focused on perceived negligence what should or

could have been done to prevent the loss, anger toward the

lost person for abandoning oneself, fear of going insane or

losing control, inappropriateness of anger or panic reactions

– Activities : aimless & apathy show personality

disorganization, reacting out to others for

reassurance, tears shed, mind & emotionally

painful past memories recalled, deep thinking

with lost object

– Resolution : Pervasive intensity of the emotional

component decreased but not yet resolved

3. Concluding phase : mourning & resolution :

– Central issues : withdrawing & letting go of the

emotional investment in the lost of object,

working through the loss & building a life

without the lost object

– Affective component : episodes of sadness &

tearfulness, feelings experienced with

increasingly less emotional pain

– Activities : gradual process of remembering,

thinking about & talking about the loss,

resumption of daily living activities, gradual

reconnection with social life

– Resolution : Reconstruction of life style, finding

new meanings & purpose for life

Thank you…