PROBLEMS OF LOSS AND DEPRESSION PROCESS OF GRIEF AND MOURNING AND THERAPEUTIC ROLE OF NURSE INTRODUCTION Loss, grieving, and death are experienced by everyone at some time during their life. People may suffer the loss of valued relationship through life changes, letting go, relinquishing, and moving on are unavoidable passages as a person moves through stages of growth and development. People frequently say goodbye to places, people, dreams and familiar objects. To support and care for the grieving client, the nurse must understand these phases as well as cultural responses to loss. DEFINITION OF THE TERMS: y Loss: A person, thing or relationship that is killed, wounded, taken or lost. y Grief: Deep and poignant distress caused by suffering from a loss. y Bereavement: The state or fact of being deprived of something or having something taken away, especially by force. y Mourning: To feel or express grief or sorrow or to show customary signs of grief for a death. LOSS: Throughout our lives from birth to death, we form attachments and suffer losses. Experience of loss is essential in human life. Letting go, relinquishing, and moving on are unavoidable passages as the person moves through the stages of growth and development. Loss allows a person to change, develop and fulfill innate human potential. It may be planned, expected or sudden. Although it can be difficult, loss sometimes is beneficial. Other times, it is devastating and debilitating. TYPES OF LOSSES: A helpful way to examine different types of losses is to use Maslows hierarchy of human needs. y Physiologic loss: Examples include amputation of limb, loss of adequate air exchange, or decrease in pancreatic functioning etc. y Safety loss: Loss of safe environment is evident in domestic or public violence. A person may perceive a breach of confidentiality in a professional relationship as a loss of psychological safety secondary to broken trust of self and health care provider. y Loss of security and a sense of belonging: The loss of a loved one affects the need to love and be loved. Loss accompanies changes in relationships, such as birth, marriage, divorce, illness and death; as the meaning of a relationship changes, a person may lose role within the family and group. y Loss of self esteem: Any change in how a person is valued at work or in a relationship can threaten his or her self esteem needs. A change in self perception can challenge sense of self worth. A loss of role function and the self-perception and worth tied to that role may accompany the death of a loved one. y Loss related to self actualization: An external or internal crisis that blocks or inhibits striving towards fulfillment may threaten personal goals and individual potentials. A change in goals or

direction will precipitate an inevitable period of grief. E.g.: having to give up plans to attend graduate school or losing the hope of marriage and family. GRIEF OR GRIEVING PROCESS Grief is a multi-faceted response to loss. It includes the emotion numbness, disbelief, separation, anxiety, despair, sadness, and loneliness that accompany the loss of someone or something loved. Although conventionally focused on the emotional response to loss, it also has physical, cognitive, behavioral, social, and philosophical dimensions. Common to human experience is the death of a loved one, whether it be a friend, family, or other companion. While the terms are often used interchangeably, bereavement often refers to the state of loss, and grief to the reaction to loss. TYPES OF GRIEF 1. Normal grief: It is said to occur when a persons emotional and behavioral responses to a loss are expected ones, according to the individuals experience, culture, social status, and relationship to that which has been lost. Often the normal grief response to a loss can prove positive helping one to mature and develop as a person. Expected changes:Physical appetite sleeping pattern energy level sexual function blood pressure digestive process general health Functional ADL Economic status Productivity at work or school Interpersonal relationship family roles social status social skills Intrapersonal mood stress level concentration thoughts of dying, death, life, living. focus on health sense of self identity Spiritual beliefs the search for understanding the search for purpose and meaning the need to ask the' big question'

2. Anticipatory grief: It occurs before a death, usually at the time of diagnosis. A patient may anticipate loss of good health, independence, and life itself. Family members, friends and caregivers may grieve for the patients losses as well as their own. This grief provides time to acknowledge that the patient is dying, to prepare for the death, to adapt to changes, to tend to matters left unsettled and to resolve conflicts. When families are prepared and support services are used before the death, healthy adaptation during bereavement is more likely to occur. There are risk in this type as family members may withdraw emotionally from the client too soon, leaving the client with no emotional support as death approaches. Sometimes if the person nearing death survives, family members may have difficulty reconnecting and may even be resentful that the person has lived past life expectancy.

3. Complicated grief: When a person has difficulty progressing through the normal phases of grieving it becomes complicated. This can threaten a persons relationship with others. It includes the following types. y Chronic grief: Active acute mourning that is characterized by normal grief reaction that do not subsides and continue over very long period of time. It is highlighted by bitterness and idealization of the dead. It is more likely to occur when the relationship between the bereaved and the deceased had been extremely close, ambivalent or dependent and when social supports are lacking and friends and relatives are not available to share the sorrow over the extended period of time needed for most mourners. y Delayed grief: characterized by normal grief reactions that are suppressed or postponed and the survivor consciously or unconsciously avoids the pain of the loss. Active grieving is held back only to resurface later usually in response to a trivial loss or upset. For e.g.: a wife may only bereave a few weeks after the death of her spouse, only to become hysterical and sad a year later when she attends a family gathering. This extreme sadness is a delayed response to death of her husband. y Exaggerated grief: Persons become overwhelmed by the grief, and they cannot function. This may be reflected in the form of severe phobias or self destructive behavior such as alcoholism, substance abuse or suicide. y Masked grief: survivors are not aware that behaviors that interfere with normal functioning are a result of their loss. For e.g.: a person who has lost a pet may develop alterations in sleeping or eating patterns. 4. Disenfranchised grief: Persons experience grief when a loss is experienced and cannot be openly acknowledged, socially sanctioned, or publically shared (ELNEC, 2000). An e.g.: includes the loss of partner from HIV OR AIDS, children experiencing the death of a step-parent, or the mother whose child dies in utero or at birth. GRIEF THEORIES AND MODELS Early Grief Theories Freud the father of psychoanalysis was the first to publish a bereavement theory. Lindeman a psychiatrist, studied acute grief reactions experienced by individuals bereaved by natural causes, disaster, and war. Based on his observations, Lindeman differentiated normal from abnormal reactions to loss. Bowlby was the first bereavement theorist to base his conclusions on empirical evidence. Bowlby, a psychoanalyst and the father of attachment theory, empirically studied how the intensity of the grief could be influenced by the type of attachment that one had to the deceased Second-Generation Grief Models Parkes, a student and colleague of Bowlby, conducted bereavement research in Europe and the United States. He conceptualized grief as a series of shifting pictures that presented for a time and then faded out while the next phase faded in, only to peak and give way to the next wave. The

work of Worden extended bereavement theory by emphasizing the role that counselors and therapists play in offering care and comfort to grieving clients. Based on research with children and adults, Worden presented a unique conceptualization of "the mourning process Continuing Bonds Theory Hospice nurses often hear bereaved family members describe a continued but changed relationship with the deceased, which was not addressed by early psychoanalytical theories of grief. Findings from a study by nurse-researchers, Hogan and DeSantis, based on data from 186 adolescents bereaved of a sibling, established that instead of emancipating, bereaved adolescents actively maintained an ongoing attachment to their dead siblings. Silverman and colleagues published a study showing that parentally bereaved children and adolescents maintained a continuing connection to the deceased parent. Findings from this study revealed that the bereaved children and adolescents made an effort to reach out for a connection to their dead parent and maintained their attachment through transitional objects. The Dual Process Model Psychologists Stroebe and Schut introduced the "Dual Process Model of Coping with Bereavement" to address the limitations of earlier models that presented grief as a series of stages, phases, or tasks. For hospice nurses, the Dual Process Model provides an explanation of why the bereft either avoid the reality of the loss or dwell in suffering. Transformation Theories of Grief A subsequent study of bereavement resulted in the generation of the Experiential Theory of Bereavement. The theory has two components; the first describes how survivors witness the illness course of a loved one. The second component defines the bereavement process from the time of loss, through suffering, emerging from the intensity of grief, and, finally, experiencing personal growth. The Grief to Personal Growth Theory was subsequently tested empirically using structural equation modeling. The pathway ended when the bereft had more good than bad days and had reached a point where they could let go of some of the intensity of their grief and begin to experience personal growth. For decades, grief counselors and healthcare providers have encouraged the bereft to sever ties with the deceased to achieve healing. Today, it is understood that relationships with the deceased can be continued in new ways and that grief can spur personal growth. KUBLER ROSSS STAGES OF GRIEVING (1969) Stage Denial Behavioral responses Refuses to believe that loss is happening. Is unready to deal with practical problems, such as prosthesis after loss of Nursing implications Verbally support client but do not reinforce denial. Examine your own behavior to ensure that you do not share in clients denial.

Anger

leg. May assume artificial cheerfulness to prolong denial. Client or family may direct anger at nurse or staff about matters that normally would not bother them.

Bargaining Seeks to bargain to avoid loss. May express feelings of guilt or fear of punishment for past sins, real or imagined. Depression Grieves over what has happened and what cannot be. May talk freely or may withdraw. Acceptance Comes to terms with loss. May have decreased interest in surroundings and support people. May wish to begin making plans (e.g., will, prosthesis etc)

Help clients understand that anger is normal response to feelings of loss and powerlessness. Avoid retaliation or withdrawal; do not take anger personally. Deal with needs underlying any angry reaction. Provide structure and continuity to promote feelings of security. Allow clients as much control over their life. Listen attentively, and encourage clients to talk to relieve guilt and irrational fear. If appropriate, offer spiritual support. Allow clients to express sadness. Communicate nonverbally by sitting quietly without expected conversation. Help family and friends understand clients decreased need to socialize. Encourage client to participate as much as possible in the treatment program.

ENGELS STAGES OF GRIEVING (1964) Stage Shock and disbelief Developing awareness Restitution Resolving the loss Behavioral response Refuses to accept loss. Has stunned feelings. Accepts the situation intellectually, but denies it emotionally. Reality of loss begins to penetrate consciousness. Anger may be directed at agency, nurses or others. Conducts rituals of mourning( e.g., funeral, wake etc) Attempts to deal with painful void. Still unable to accept new love object to replace lost person or object. May accept more dependent relationship with support person.

Idealization

Outcome

Thinks over and talks about memories of lost object. Produces image of the lost object that is almost devoid of undesirable features. Represses all negative and hostile feelings towards lost object. May feel guilty and remorseful about past inconsiderate or unkind acts to lost person. Unconsciously internalizes admired qualities of lost object. Reminders of lost object evoke fewer feelings of sadness. Reinvests feelings in others. Behavior influenced by several factors: importance of lost object as a degree of support, degree of dependence on relationship, degree of ambivalence toward lost object, number and nature of other relationships, and number and nature of previous grief experiences.

BOWLBYS PHASES OF MOURNING (1980) y Numbing: it may last from a few hours to a week or more and may be interrupted by periods of extremely intense emotion. The grieving person may describe the phase as felling stunned or unreal. It may serve to protect the body from the onslaught or consequences of loss. y Yearning and searching: it arouses emotional outbursts of tearful sobbing and acute distress in most persons. The phase is painful, but must be endured. The hopeless yet intense desire to restore the bond with the lost person compels the bereaved to search for and recover him/her. As hopes for the lost ones return diminish, sadness and loneliness become constant. y Disorganization and despair: the bereaved person begins to understand the losss permanence. They recognize that patterns of thinking feeling, and acting attached to life with the deceased must change. Night is a time of acute loneliness during this phase. y Reorganization: The bereaved person begins to re-establish a sense of personal identity, direction and purpose for living. He or she regains independence and confidence. The person still misses the deceased but thinking of him no longer evokes painful feelings.

WORDENS FOUR TASK OF MOURNING (1982) y Task 1: To accept the reality of loss. Even when a death has been expected, there is always some period of disbelief and surprise that the event has really happened. This task involves the processes required to accept that the person or object is gone and will not return.

y Task 2: To work through the pain of grief. Even though people respond to loss differently, it is impossible to experience a loss and work through grief without emotional pain. Individuals who deny or shut off the pain prolong their grief. y Task 3: To adjust to environment in which the deceased is missing. A person does not realize the full impact of loss for at least 3 months. At this point many friends and associates stop calling and the person is left to ponder the full impact of loneliness. People completing this task must take on roles formerly filled by the deceased, including some tasks that they never fully appreciated. y Task 4: To emotionally relocate the deceased and move on with life. The goal of this task is not to forget the deceased or to give up the relationship with the deceased but to have the deceased take a new, less prominent place in a persons emotional life. A person completes t his stage after realizing that it is possible to love other people without loving the deceased person less.

SANDERS PHASES OF BEREAVEMENT (1998) Phase Shock Description Survivors are left with the feelings of confusion, unreality and disbelief that the loss has occurred. They are often unable to process the normal thought sequences. Phase may last from a few minutes to many days Behavioral response Disbelief Confusion Restlessness Feelings of unreality Regression and helplessness State of alarm Physical symptoms: dryness of mouth and throat, sighing, weeping, loss of muscular control, uncontrolled trembling, sleep disturbance and loss of appetite. Psychological symptoms: preoccupation with thought s of deceased and psychologic distancing. Separation anxiety Conflicts Acting out emotional expectations Prolonged stress Physical symptoms crying and sleep disturbance Psychological symptoms: anger, guilt, frustration, shame, oversensitivity, disbelief and denial, dreaming, sense of presence of the deceased and fear of death. Physical symptoms: weakness, fatigue, need

Awareness of loss

Friends and family resume normal activities. The bereaved experience the full significance of their loss.

Conservation/ During this phase, survivors feel a

withdrawal

Healing: the turning point

need to be alone to conserve and replenish both physical and emotional energy. The social support available to the bereaved has decreased, and they may experience despair and helplessness. The bereaved move from distress about living without their loved ones to learning to live more independently.

for more sleep, and a weakened immune system. Psychologic symptoms: withdrawal, obssesional review, grief work, and ultimately a renewal of hope.

Renewal

Assuming control Identity restructuring Relinquishing roles, such as spouse, child, or parent. Physical symptoms: increased energy, sleep restoration, immune system restoration and physical healing. Psychologic symptoms: forgiving, forgetting, searching for meaning and hope Survivors move onto a new self Functional stability awareness, an acceptance of Revitalization responsibility for self, and learning to Assumption of responsibility for self care live without the loved one. needs Psychologic symptoms: loneliness, anniversary reactions, and a reaching out to others.

THEORETICAL MODELS FOR UNDERSTANDING GRIEF Loss restoration model (Stroebe and Schut ,1999) Loss oriented coping includes concentrated thinking about life before the loss or with the person and circumstances and events surrounding the death or loss. Restoration oriented coping includes doing new things, distracting oneself from grief, avoiding or denying grief, assuming new roles and transcendence. The changes can result in new perspectiveness in self-actualization. Oscillation and mental and physical health are necessary for optimal adjustment overtime. Overtime, repeated exposure and confrontation may lead to the reaction response weakening and the individual no longer thinks about the specific aspects of loss. This model has the potential to be applicable to different culture, as well as gender differences, and emphasize coping with bereavement rather than outcome.

LOSS ORIENTED Grief work Intrusion of grief Breaking bonds/ ties/relocation Denial /avoidance of restoration changes

RESTORATION ORIENTED Attending to life changes Doing new things Distraction from grief Denial /avoidance of grief New roles, identities, relationships

Loss response model (Jett, 2004) When loss occurs within the system, the impact is experienced as acute grief. The systems equilibrium is in chaos, and is seen as a functional disruption i.e. the system cant perform its usual activities; either the person or the members are in a state of disequilibrium. The family or individual then searches for meaning why this happen to them. The family then may become active in informing others. It may involve engaging emotions that may have been previously withheld or subdued. The expression of emotion can release energy that can be seen to recognize the family structure. Someone else steps up to perform the role of dead person e.g. elder son in the fathers role. Finally if the system is to survive it must redefine itself by reframing its memories i.e. families accept the portraits and reunions are still possible, just different from how they were before loss.

reframin g memorie s

impact

reorganis ing structure

functiona l disruptio n

engaging emotions

informin g others

TASKS OF GRIEVING PROCESS (Rando 1984) o Undoing psychosocial bonds to the loved one and eventually creating new ties. o Adding new roles, skills, and behaviors and revising old ones into a new identity and sense of self. o Pursuing a healthy life style that includes people and activities. o Integrating the loss into life, this does not mean ending the grieving but accommodating the reality of the loss. FACTORS INFLUENCING LOSS AND GRIEF Human development: Persons of different ages and stages of development will display different and unique symptoms of grief. For e.g.: y Toddlers are unable to understand loss or death, but they feel great anxiety over loss of objects and separation from parents. y School age children experience grief over the loss of a body part or function. y Middle age adults usually began to reexamine life and are sensitive to their own physical changes. y Malkinson and BarTur (1999) older adults often express anticipatory grief because of aging and the possible loss of self care abilities. They are at increased risk of negative outcomes related to grief. Lund (1989) found that older adults are often resilient in responding to grief despite it being a highly stressful process. Psychosocial perspective of loss and grief: The valuing of individuals is a unique, learned response of a specific culture and society. Age, gender, status, race, spirituality, religious beliefs, intellect, achievement, self expression and cultural opportunities are the basis for an individual to define and qualify the definition of life and death. An individuals expression of grief evolves as the person matures. Personal experiences shape the coping mechanism that the individual use to cope with

stressors. When older coping mechanisms are unsuccessful newer ones are attempted. Professional assistance is often required to help the client and family understand and deal realistically with losses. Socioeconomic status: It influences a persons ability to obtain options and use support mechanism when coping with loss. Generally a person feels greater burden with loss when there is a lack of financial, educational or occupational resources. For e.g. a client with limited financial resources may not be able to buy necessary medications to a newly diagnosed disease. Personal relationships: When loss involves a loved one, the quality and meaning of a relationship are critical in understanding a persons grief experience. It has been said that to lose your parents is to lose your past; to lose the spouse is to lose your present and to lose a child is to lose your future. When a relationship between two individuals has been very close and well connected, it can be very difficult for the one left behind to cope. When clients do not receive supporting understanding and compassion from others, they become unable to handle grief and look to the future. Nature of loss: The ability to resolve grief depends on the meaning of loss and the situation surrounding the loss. The visibility of loss influences the support a person receives. For e.g. loss of ones house in floods brings support from the community whereas a private loss of an important possession may bring less support. The suddenness of a loss can often cause slower resolution from grief. For e.g.: a sudden unexpected death in family is more difficult to accept compared to a one following a long term chronic illness. Culture and ethnicity: Interpretation of loss and the expression of grief arise from cultural background and family practices. Culture affects how client and their support systems or families respond to loss. For e.g. in the western hemisphere the grieving process is usually personal and people show restrained emotions, whereas in eastern nations like India, China etc wailing and physical demonstration of grief is seen. Nurses must be able to support and guide clients and families in a culturally informed and acceptable manner. Research has shown that ethnicity is strongly related to attitudes towards life sustaining treatment during terminal illness. Spiritual beliefs: Individuals spirituality significantly influences their ability to cope with loss. Loss can sometimes cause internal conflicts about spiritual values and the meaning of life. Clients who have a strong interconnectedness with a higher power are often very resilient and able to face death with relatively minimum discomfort. DIMENSIONS AND SYMPTOMS OF GRIEVING CLIENT o Cognitive Responses To Grief: The pain that accompanies grieving results from a disturbance in the persons beliefs. The loss disrupts, if not shatters, basic assumptions about lifes meaning and purpose. Questioning and trying to make sense of loss: the grieving person needs to make sense of the loss. The loss challenges old assumptions about life. For e.g. when a loved one dies prematurely, the grieving person often questions the belief that life is fair. The nurse might hear questions like why did such a young person have to die? Questioning may help the person

accept the reality of why someone died. It may result in realizing that loss and death are realities that everyone must face one day. Attempting to keep the lost one present: Belief in an afterlife and the idea that the lost one has become a personal guide are cognitive responses that serve to keep the lost one present. o Emotional responses to grief: Anger, sadness, and anxiety are the predominant emotional responses to loss. The grieving person may direct anger and resentment towards the deceased and his health practices, family members or health care providers. Guilt over things not done or said in the lost relationship is another painful emotion. Feelings of hatred and revenge are common when death has resulted from extreme circumstances such as suicide, murder, or war. Research study: A study to assess the short-term grief responses after elective abortion, Williams (2001) noted that some women experience feelings of loss of control, death anxiety, and dependency as well as feelings of despair and anger. o Spiritual responses to grief: The deeply embedded personal values that give meaning and purpose to life and the belief systems that sustain them are the central components of spirituality and the spiritual response to grief. During loss, it is within the spiritual dimension of human existence that a person may be lost comforted, challenged or devastated. The grieving person may become disillusioned and angry with God. The anguish of abandonment, loss of hope or loss of meaning can cause deep spiritual suffering. Ministering to the spiritual needs of those grieving is an essential part of nursing care. Nurses can promote a sense of wellbeing by providing opportunities for clients to share their sufferings and assists in the psychological and spiritual transformation that can evolve through grieving. o Behavioral responses to grief: By recognizing behaviors common to grieving, the nurse can provide supportive guidance for the clients journey of emotionally and cognitively rough terrain. The symptoms include: Functioning automatically. Tearful sobbing ; uncontrollable crying Great restlessness; searching behaviors Irritability and hostility Seeking and avoiding places and activities with the lost one Keeping valuables of lost one while wanting to discard them Possibly abusing drugs or alcohol Possible suicidal or homicidal gestures or attempts Seeking activity and personal reflection during phase of reorganization. o Physiologic responses: those grieving may complain of : headaches, insomnia, impaired appetite, weight loss, lack of energy, palpitations, indigestion. Changes in immune and endocrine glands. PROMOTING ADAPTIVE COPING WITH GRIEF AND LOSS (Clements and Henry 2002) Goals for healing: y Do set goals for yourself. Start with small, short term ones. y Do accept that what you are feeling is real and may be painful.

y y y y y

Do remember that the pain of loss may manifest itself in many different ways. Do cry if and when you feel like it. Dont allow yourself to become reclusive and avoid the people who care about you. Dont allow guilt or fear to set you back. Do experience your thoughts and feelings 1 day at a time.

Responses to grieving y Dont try to rush through your grief. y Dont be too hard on yourself by thinking you should be feeling better or over it in a month or two. y Dont allow others to define the loss for you. y Do allow yourself to backslide. Just because you felt better yesterday doesnt mean you will feel the same today. y Do know it is OK to feel angry, betrayed, fearful, tired, confused or ill. These symptoms can be normal grief responses. y Dont be surprised if you find yourself repeating the story of loss over and over again y Do eat nutritiously, exercise, and get adequate rest , although you may not feel like it. Interventions for healthy grieving y Do contact a grief counselor or health care provider if you feel you need help. y Do join a support group, which can provide an opportunity for you to speak with others who can relate to what you are going through. y Do accept the help of family and friends. y Dont allow others to talk you into making any major decisions. Effectiveness Short term achievements y You can talk about the loss without feeling overwhelmed or crying. y Your energy level is improved, and you feel like participating in work, school, or social activities. y Your sleep and dietary pattern comes to normal. y Your life feels more organized. y Decision making is easier. Long term achievements y y y y Your inner pain begins to disappear. Your sense of humor returns. Your sleep and dietary pattern returns to normal. Your personal relationships are renewed.

Final thoughts y If the long term achievements apply to you, then you are successfully navigating the grief process. y Inner healing occurs over time. It will be completed when you find yourself reinvesting in life. y Dont be ashamed or surprised to find yourself saddened during holidays, family gatherings. y As healing progresses, the saddening may decrease, but may never completely go away. y The goal of healthy grief is not to try forget the loss but to put the loss into perspective in your own particular life history and reinvest in your life. CONTINUUM OF EMOTIONAL RESPONSE Adaptive responses Emotional responsiveness Uncomplicated grief reaction Suppression of emotion Maladaptive responses Delayed grief reaction Depression/ Mania

GRIEF, UNRESOLVED GRIEF, AND DEPRESSION Feelings of sadness and depression are an integral part of grief, but grief itself is not considered a disorder. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) considers the depression associated with bereavement a "normal" reaction to loss, provided it is does not linger too long. There is no way to define a "normal" length of bereavement since it varies from person to person and culture to culture. According to the DSM-IV, a diagnosis of Major Depressive Disorder is generally not given unless symptoms have lasted beyond two months. Depression which lingers beyond what is expected could be a sign that the stress of grieving has triggered a Major Depressive Episode. Studies have shown that the extreme stress associated with grief can trigger both medical illnesses, such as heart disease, cancer and the common cold, as well as psychiatric disorders like depression and anxiety. Depressive symptoms associated with bereavement: y Symptoms may meet syndromal criteria for major depressive episode but survivor rarely has morbid feelings of guilt and worthlessness, suicidal ideation or psychomotor retardation. y Considers self bereaved. y Dysphoria often triggered by thoughts or reminders of the deceased. y Onset is within 2months of bereavement. y Duration of depressive symptoms is < 2 months. y Functional impairment is transient and mild. y No family or personal history of major depression.

ROLE OF NURSE 1. Assessment Assess the meaning of loss for the patient. Observe behavior and other symptoms indicative of grief response. Note quality and extent of patients family support. o Experience : Caring for a patient who experienced a physical or emotional loss. Caring for a patient who died. Personal experience with loss or death of a significant others. o Attitudes : Take risk if necessary to develop a close relationship with the client to understand loss. o Standards : Demonstrate ethical principles of health care. Apply individual standards of significance. o Knowledge : Group process Pathophysiology related illness threatening a loss. Cultural perspectiveness Therapeutic communication. Family dynamics 2. Planning Select communication strategies that assist the client/ family in accepting and adapting to loss. Select interventions designed to maintain the patients dignity and self esteem. Provide skills/ knowledge for the family to understand care for the dying patient. o Experience : Previous client responses to planned nursing interventions for pain and symptom management or loss of a significant other. o Attitudes : Be responsible for delivering high quality supportive care. Demonstrate an openness to participate in experiencing loss. o Standards : Provide privacy for the client and family. Apply ethical principles of autonomy in supporting the clients choice regarding treatment. Individualize therapies for the patients for the patient self esteem. Apply appropriate professional standards for end of life care. o Knowledge : Spirituality as a resource for dealing with loss. Role other health professional play in helping clients deal with loss. Services provided by the community agencies. Principles of providing comfort. Principles of grief support.

3. Implementing The skills relevant include attentive listening, silence, open ended questions, paraphrasing clarifying and summarizing. Communication with grieving client must be relevant to their stage. Facilitate the grief work. Teach family members to encourage the clients expression of grief. Provide emotional support. Refer to support groups if needed. 4. Evaluation Evaluate signs and symptoms of clients grief. Evaluate family members ability to provide supportive care. Evaluate terminal clients level of comfort and symptoms relief. Ask if patients family expectations are being met. o Experience : Previous patient response to planned nursing intervention for symptom management or loss. o Attitudes : Persevere in seeking successful comfort measures for terminally ill clients. Standards : Use establish patient outcomes to evaluate patients response to care Knowledge : Characteristics of resolution of grief. Clinical symptom of an improved level of comfort. Principles of palliative care. CONCLUSION Bereavement, loss, grief and mourning are part of our lives although how we experience and act on them will be influenced by the culture in which we live. There are many theories and models of grief and grief counseling. Recent theories do not seek to help the bereaved to complete mourning and move on. Instead they promote the possibility that grief may be never ending without being hopeless as the lost object lives on within the mourner. Nurses have a vital role to play in listening to, supporting and nurturing hope when they encounter grief, whether that grief is because of death, shortening of life expectations or the multitude of other losses, which are part of human existence.

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