Grief and Loss Psych Chap12

- Tie everything together Grief and LossPsych Chap12 Linda L. Franco RN, MSN NE-BC

Definitions 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

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.

2:40 Grief and loss are uncomfortable • Grief and loss are essential in life; relinquishing and moving on happen as we grow and develop

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)

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 progress

Kubler-Ross’s 5 stages of grieving • Denial (shock and disbelief)- may ask for 2nd opinion • Anger (toward God, relatives, healthcare providers) • Bargaining (trying to get more time, prolonging the inevitable loss)- bargain w/ God • Depression (awareness of the loss becomes acute)- weeping and withdraw, changing H levels may compound the stage. • Acceptance (person comes to terms with impending death or loss)- can take months to yrs

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.

Bowlby’s 4 phases of grieving • Numbness and denial of the loss • Emotional yearning for lost loved one and protesting permanence of loss • Cognitive disorganization and emotional despair • Reorganizing and reintegrating sense of self

John Harvey’s 3 phases of grieving • Shock, outcry, and denial • Intrusion of thoughts, distractions, and obsessive reviewing of loss • Confiding in others to emote and cognitively restructure

Rodebaugh’s 4 stages of grieving • Reeling • Feelings • Dealing • Healing

6:35 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

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

African Americans Typically view the body in church Hymns, poetry, eulogies Public prayer Wearing black clothing Decreasing social activities

Muslim Americans Muslims do not permit cremation Follow 5 steps of burial procedure Haitian Americans Practice vodun or calling on spirits to make peace

Chinese Americans Strict norms for announcing death, preparing the body, arranging the funeral and burial Burning incense and reading scripture assist the spirit of the deceased on his or her journey

Japanese Americans Buddhists view death as a life passage Bathing and purification rites are performed Friends and family visit, bringing gifts or money Prayers are said Incense is burned

Filipino Americans Often 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

Vietnamese Americans Predominately Buddhist Deceased bathed and dressed in black Rice and money sent with the deceased View the body before burial at home

Hispanic Americans Predominately Catholic Pray for the soul during a rosary Mourning may involve wearing black and decreasing social activities A wake in the home may be held

Native 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

Orthodox Jewish Americans Leaving a dying person alone is a sign of disrespect Burial must occur within 24 hours unless delayed by the Sabbath Body should be untouched until rites can be performed by family, rabbi, or Jewish undertaker

8:50 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

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

Story…-14:00 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

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

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

Potential Nursing Diagnoses • Grieving • Anticipatory grieving • Dysfunctional grieving

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

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

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.

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.

Common Causes of Perinatal Loss • Fetal Factors • Maternal factors • Placental factors • Unknown

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.

19:15 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.

20:40 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

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

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

Responding to Grieving Families • Remember the 3 H’s Hug Hush Hang around

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”

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”

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

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

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

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

Nursing Care of the Baby The baby is washed and dressed It is wrapped and made to look like a sleeping infant Defects are minimized if possible Parents will usually ask for the baby several times

27:08 Discharge Care of the Family Remembrance box or package Pictures Early discharge Lactation suppression Community referrals/resources Funeral arrangements or body disposal

Difficult Times for Parents • Anniversaries/holidays • Due date • Death date • Growth and development milestones

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

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

Grief and Loss Psych Chap12