Transcript 05 Grief, Loss, Bereavement Essentials of communication

E LNE C
End-of-Life Nursing Education Consortium
International Curriculum
Grief, Loss,
Bereavement.
Essentials of
communication
Grief, Loss and Bereavement
• Patient, family and healthcare
providers all experience losses
• Each person grieves in their own
way
• An interdisciplinary care approach
is vital
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Healthcare Provider’s Role
• Assess the grief
• Assist the patient with grief
• Support survivors
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The Grief Process
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Begins before the death
Not orderly or predictable
Includes a series of stages or tasks
No one “gets over it”
Grief work leads to living with the
loss
Chan et al., 2004
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Loss
• A loss may be a person, thing,
relationship, or situation.
• Grief is an emotional response to
loss
• Mourning is the outward, social
expression of loss
• Strongly influenced by culture
Corless, 2010
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Bereavement
• The reaction of the survivor to the
death of a family member or close
friend.
• Be aware of cultural characteristics.
D’Avanzo, 2008
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Types of Grief
Anticipatory Grief
• Grief before loss
• Actual or fear of potential losses
• Experienced by patient, family,
professionals
• Children have unique needs
Glass et al., 2010
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Normal Grief (Uncomplicated)
• Normal feelings, behaviors and
reactions to loss
• Physical, emotional, cognitive
and behavioral reactions
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Complicated Grief
• Chronic grief
• Delayed grief
• Exaggerated
grief
• Masked grief
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Complicated Grief – Risk
Factors
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Sudden or traumatic death
Suicide, homicide
Death of a child
Multiple losses
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Disenfranchised Grief
• When loss cannot be openly
acknowledged or socially
sanctioned
• At risk- AIDS partners, ex-spouse,
step-parent/child, terminated
pregnancy
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Children’s Grief
• Based on developmental stages
• Can be normal or complicated
• Symptoms unique to children
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Stages and Tasks of Grief
Stage 1 Notification and shock
Stage 2 Experience the loss
Stage 3 Reintegration
Corless, 2010
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Factors Influencing the Grief
Process
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Survivor personality
Coping skills, patterns
History of substance abuse
Relationship to deceased
Spiritual beliefs
Type of death
Survivor ethnicity and culture
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Grief Assessment
• Begins at time of admission or
diagnosis
• Ongoing to detect complicated grief
Corless, 2010
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Assessment
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Type of grief
Grief reactions
Influencing factors
General health of
caregiver/survivor
Glass et al., 2010
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Bereavement Interventions
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Plan of care
Attitude
Cultural practices
What to say
Anticipatory grief
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Bereavement Interventions
for Children and Parents
• Recognize developmental stage
• Refer to support groups
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Anticipatory Grief
Interventions for Patient and
Family
• Preventive approaches to minimize
sense of loss
– Encourage life review
– Educate patient/family on dying
process
– Provide presence/active listening
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Grief Interventions
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Identify and express feelings – their story
Special attention to disenfranchised grief
Public funerals, rites, rituals, traditions
Private reflection
Spiritual care
Recognize developmental stage in
children
• Refer to support group
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Completion of the Grieving
Process
• No one can predict
completion
• Grief work is never
completely finished
• Healing occurs
when the pain is
less
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Answering the Unanswerable Questions
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Cumulative Loss
The End of the Day
E
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Oncology Curriculum
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Stages of Adaptation
• Health professionals new to working with
the dying need to emotionally & spiritually
adapt
• Stages of adaptation
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Intellectualization
Emotional survival
Depression
Emotional arrival
Deep compassion
The “doer”
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Harper, 1994
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Factors Influencing the Healthcare
Provider ’s Adaptation
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Professional education
Personal death history
Life changes
Support system
Vachon & Huggard, 2010
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Systems of Support
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Balance
Assessing support systems
Spiritual support
Education in end-of-life care
Self care strategies
Vachon & Huggard, 2010
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Conclusion
• Care does not end with the death of
a patient
• Loss, grief and bereavement need
to be assessed with ongoing
intervention
• Healthcare providers must
recognize and respond to their own
grief
• Provide interdisciplinary care
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Caring for the Body and Soul
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Communication
• Terminal illness is a family
experience
• Imparting information so
individuals may make informed
decisions
• Requires interdisciplinary
collaboration
Kimberlin et al., 2004
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Barriers to Communication
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Fear of mortality
Lack of experience
Avoidance of emotion
Insensitivity
Sense of guilt
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Barriers to Communication
(cont.)
• Fear of not knowing
• Disagreement with decisions
• Lack of understanding culture or
goals
• Personal grief issues
• Ethical concerns
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Myths of Communication
• Communication is deliberate
• Words mean the same to
sender/receiver
• Verbal communication is primary
• Communication is one way
• Can’t give too much information
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Patient/Family Expectations
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Be honest
Elicit values and goals
Team communication
Take time to listen
Coyne & Drew, 2010; Quill, 2000
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Verbal and Non-Verbal
Communication
• Includes body language, eye
contact, gestures, tone of voice
• 80% of communication is
nonverbal
Dahlin, 2010
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Communication
• Ask how much patient/family want to
know
• Initiate family meetings
• Illness can strengthen or weaken
relationships
• Base communication with children
on developmental age
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Cultural Differences in
Communication Related to:
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Sexual orientation
Religion
Age
Ethnicity
Gender
Tribes
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Energy & Involvement
Listening Steps
Helping Others/
Active
Empathizing
Analyzing & Evaluating
Information
Retaining
Information
Understanding
Hearing
Ray, 1992
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Attentive Listening
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Encourage them to talk
Be silent
Share your feelings
Avoid misunderstandings
Buckman, 2001
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Attentive Listening
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Don’t change the subject
Take your time in giving advice
Encourage reminiscing
Create legacies
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Presence
Requires:
• Acknowledging vulnerability
• Intuition
• Empathy
• Being in the moment
• Serenity and silence
Dahlin, 2010; Stanley, 2002
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Guidelines for Encouraging
Conversation
• Setting the right atmosphere
• Does the patient/family want to
talk?
• Attentive listening
Dahlin, 2010; Duhamel & Dupris, 2003
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Factors Influencing
Communication
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Family system changes
Financial uncertainties
Physical limitations
Cultural Issues
Friedrichsen et al., 2001;
Rabow et al., 2004
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Healthcare Professionals Influence
Communication Outcomes
• Be aware of behaviors and
communication style
• Lack of personal experience with
death and dying
• Fear of not knowing the answer
• Lack of understanding patient’s and
family’s end-of-life goals
• Language barriers
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Family Meetings
• Patient may attend
• Family members
• Appropriate clinicians (best if
includes primary care along with
palliative care)
• Goal to enhance communication
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Breaking Bad News… Breaking a Heart
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Communication Strategies to
Facilitate End-of-Life
Decisions
• Initiate end-of-life discussions
• Use words such as “death” and
“dying” or “very sick”
• Maintain hope
• Clarify benefits and burdens
• Be honest
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Team Communication
• Intra-team communication is vital,
especially between RN and MD
• Should occur frequently
• Document
• Expect conflicts
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Resolving Conflict
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Try to take a step back
Identify your own emotions
Define the conflict
Obtain agreement on the conflict
Talk about it
Patient’s best interest should
always be foremost
Dahlin, 2010
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Summary
• Communication is complex
• The ultimate objective is the patient’s
best interest
• Patient’s and their families must be
involved in communication
• Primary healthcare provider to
promote communication among team
members, patients and family
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Collaboration
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Give the answers to the
following questions please:
1. What are the definitions of Grief,
Loss and Bereavement.
2. Describe and evaluate different
models of grief.
3. List the Steps of Listening
E L N E C International Curriculum