Providing Quality Bereavement Care

1. Providing Quality Bereavement Care Objectives: • Define bereavement terms • Identify myths associated with grief • Identify five theories related to grief • Describe normal grief reactions • Discuss typical grief stages • Identify specific types of losses • Discuss effective listening skills- including phone support

2. Providing Quality Bereavement Care Objectives: • Describe techniques to assist the bereaved • Discuss the use of bereavement support groups • List complicated grief factors • Discuss interventions for complicated grief • Differentiate between depression and grief • Describe interventions for depression • Describe suicide assessment and intervention techniques

3. Personal Exploration • Describe the very first loss you experienced. • Were you able to share your concerns about your loss? • What is your greatest fear concerning loss? • How do you respond to others who are experiencing loss? • What is a good helping relationship? • What is your greatest asset that you bring into a helping relationship?

4. Definitions • Bereavement-objective event of loss • Grief-physical, emotional and social response to loss • Secondary Loss- losses that are consequences of the initial loss • Mourning- outward acknowledgement of the loss • Grief Work-process of confronting the reality of the death

5. Common Myths about Grief • All bereaved grieve in the same way • It takes a year to “get over” a significant loss • It’s better to not think or talk about the pain • The intensity and length of your grief reflects how much you loved the deceased

6. When you are sorrowful, look again in your heart, and you shall see that in truth you are weeping for that which has been your delight. -Kahill Gibran, The Prophet

7. Grief Theorists John Bowlby • Human beings are “hard wired” to attach, to love, and therefore to grieve • The stronger OR more ambivalent the attachment, the stronger the grief reaction

8. Grief Theorists William Worden- Four Tasks of Mourning • Accept the reality of the loss • Work through the pain of grief • Adjust to an environment in which the deceased is missing • Emotionally relocate the deceased and move on with life

9. Therese Rando Avoidance Confrontation Reestablishment Judy Tatelbaum Shock Suffering/ Disorganization Aftershock/ Reorganization Grief Theorists

10. Grief Theorists Monica McGoldrick -Family Grief Response • Developmental differences • Family reorganization • Reassignment of roles

11. Contemporary Thoughts on Grief • No “endpoint” to mourning • Dwelling on what has been “lost” is not productive • The relationship does not “end” but instead reincorporated in new ways • Remembering is comforting and life-enhancing

12. “If life is a journey, then dealing with the death of a loved one is one of those steep rocky mountain roads that you don’t know if you have the strength to climb up and over. The only way is one step at a time, moment by moment, and eventually you are on top of the mountain with an easier path to follow.” - Patricia Rose Upczak

13. The Physical and Cognitive Experience of Grief • Confusion, Dizziness, Irritability • Anxiety, Shortness of Breath • Tightening of the Chest and Throat • Sleep and Eating Disturbances

14. The Physical and Cognitive Experience of Grief • Depression, Paranoia • Memory gaps • Auditory and visual hallucinations • Frightening Dreams • Inactivity/ Hyperactivity • Searching Behavior

15. Stage One: Shock and Disbelief • “When Dr. Redding told me my mother was dead I remember thinking he must be speaking about someone else’s mother.” • “I remember almost nothing in the week following the death of my son. That week seems like a blur.”

16. Stage One: Shock and Disbelief • Adaptive response • Able to cope with final arrangements • Funerals/memorials assist transition to reality • Feelings of disbelief return during the grief process

17. Stage Two: Suffering and Disorganization When the reality of the loss sinks in, the bereaved may…… • Feel profound sadness, loneliness • Feel despair over lost dreams • Loose confidence in themselves • Be forced to establish identity as single person

18. Stage Two: Suffering and Disorganization When the reality of the loss sinks in, the bereaved may…… • Have to take on roles and tasks of deceased spouse • Express difficulty being with others • Cope with changing relationships with others • Feel embarrassed about emotional outbursts • Re-experience prior losses

19. Additional Stage Two Emotions • Guilt • “I could have done more to prevent her suffering” • “I didn’t get to see him before he died.” • “I was supposed to die first, not him.” • “I shouldn’t feel relieved, but I do.” • “I didn’t tell her I loved her before she died.” • Anger • “How dare you die and leave me with all this.” • “I blame the doctor. He missed finding the lump.” • “If God loved me, he wouldn’t have taken her from me.”

20. Additional Stage Two Emotions • Jealousy • “Why didn’t it happen to someone else?” • “I can’t stand to see them so happy together.” • Idealization of the deceased • “My father never once got angry in his whole life.” • “My wife was perfect in every way.”

21. Stage Three: Aftershock and Reorganization As the bereaved “reconstruct their life without their loved one” they may…... • Define what is meaningful to them • Report confidence in acquiring new skills • Rekindling of old relationships- start new ones • Take on new hobbies and interests

22. Stage Three: Aftershock and Reorganization As the bereaved “reconstruct their life without their loved one” they may…... • Enjoy reminiscing about life with their loved one • Accept the reality and finality of death • Return to stable eating and sleeping patterns • Experience release and relief from their loved one • Adjust to new role changes

23. Specific Types of Losses • Loss of a Spouse • Men are more “instrumental” grievers • Women are more “expressive” grievers • Length of relationship does not predict grief response • Adult Loss of a Parent • Most common form of bereavement • Adult child left feeling “orphaned” • “Cushion” of mortality gone

24. Specific Types of Losses • Adult Loss of a Sibling • Most neglected loss • Loss of connection to past • Guilt about any unresolved issues • Loss of a Child • Anger, guilt, separation, search for meaning • May be the hardest loss • May have negative effects on couple’s relationship • Miscarriage, stillborn and newborn death must be acknowledged

25. Listening Skills • Strong emotion, even months after the loss, is not abnormal • Listening to someone crying is difficult, but important • Calm down someone who is hysterical • Don’t change the subject or distract the griever • Don’t give advice or quiz for details

26. Listening Skills • Empathy is helpful-don’t over-do sympathy • Realistic reassurance is OK • Don’t interrupt- speak when they are done • Be nonjudgmental- what the survivor feels is important (even anger) • Allow silence

27. Listening Skills • Listen for content AND the feelings underneath the content • Look for the main idea of the speaker • Pay attention to non-verbal communication • Relax, be yourself • Secure a quiet place to talk

28. Listening Responses • Nod, smile, intermittent eye contact • Pause • Casual Remark -“I see” “Uh huh” • Echo- repeating back the last few words

29. Listening Responses • Clarify- asking for more information • Paraphrase- summarizing what you heard • Interpret the speaker’s ideas within context

30. Phone Support • Use words and tone of voice that convey concern • Enunciate and speak slowly • Convey understanding even if the response is superficial • Visualize the speaker in a positive way

31. Phone Support • Respect a desire not to engage in conversation • Reinforce that they are not alone • Schedule a visit • Review VITAS bereavement services

32. Reflective Listening Exercise

33. Techniques to Assist the Bereaved • Encourage the survivor to grieve in their own way • Find a quiet, private place to talk • Use the deceased’ name in the past tense • Use the words died, death, dead • Have them describe the death and any memorial events

34. Techniques to Assist the Bereaved • Ask how they’ve been coping since the death • Ask how they coped with prior losses/ crises • Acknowledge their strengths and past accomplishments • Affirm their surviving the current loss

35. Techniques to Assist the Bereaved • Ask them about their relationship with deceased • Help them examine their special qualities/talents • Advise against any drastic changes • Reassure them it’s normal to feel overwhelmed

36. Techniques to Assist the Bereaved • Help them identify feelings, including relief • Warn them that emotional ups and downs are normal • Remind them to take care of themselves physically- eat well, rest, exercise • Suggest they limit alcohol and mind altering medications

37. Techniques to Assist the Bereaved Suggest that the bereaved…. • Be patient with themselves and others • Set realistic expectations-small goals • Take one day at a time • Start slowly with customary chores • Do small things for other people • Set limits and say “no” when appropriate

38. Techniques to Assist the Bereaved You can also… • Validate the survivor for developing new skills, roles • Affirm their right to feel joy and to develop new relationships

39. Specific Aids • Validate the bereaved’ desire to review medical records • Encourage the use of symbols and “transitional objects”-photos, clothing, jewelry

40. Specific Aids • Suggest that the bereaved: • Journal to express their grief • Write a letter to the deceased, to God • Read about grief- library, bookstore, internet • Make a family memory book or box • Do art work to express their grief • Play out “unfinished business” • Role play to increase coping skills

41. Support From Others Don’t tell me that you understand Don’t tell me that you know Don’t tell me that I will survive How I will surely grow Don’t come at me with answers That can only come from me Don’t tell me how my grief will pass That I will soon be free Accept me in my ups and downs I need someone to share Just hold my hand and let me cry And say, “My friend, I care.” -Anonymous

42. Support From Others • Support system important in adjustment to loss • Encourage bereaved to: • Reach out for help-talk with people who listen well and reminisce about the deceased • Reach out for professional help if needed • Take people up on their offers to help-and be specific with requests

43. Support From Others • Educate bereaved that: • Friends may call less- fear of intruding or don’t know what to say • It’s not their role to protect or provide support to others • It’s OK to set limits with someone who gives advice

44. Bereavement Support Group • Benefits of Support Groups • Talk with others who understand • Learn ways to cope • Average time is 3 months after loss • Assess that survivor is appropriate for group experience

45. Bereavement Support Group • Groups should be organized by • similar losses (i.e., death, suicide) • similar ages (i.e., teens, adults) • Suggest the survivor try the group at least twice before dropping out

46. Complicated Grief Reactions • Grief is generally complicated when it is extremely intense and consuming for more than six months • What is Complicated Grief? • High risk factors that lead to maladaptive adjustment, or…. • Normal symptoms with abnormal intensity and duration

47. Complicated Grief Reactions • In Assessment, we look for … • Risk factors • Bio-psycho-social-spiritual factors • Naturally resilient? • Physically healthy? • Positive or negative outlook? • Adequate support system? • Concurrent life stressors? • Strength from spiritual faith? • Normal grievers are generally more in touch with reality

48. Complicated Grief Reactions • Suicidal ideation • Alcohol or prescription and non-prescription drug abuse • Self destructive behaviors • Lack of self care • Radical lifestyle changes • Ongoing numbness • Isolation from self or others

49. Complicated Grief Reactions • Highly anxious and restless • Depression with sleep and eating disturbances • False euphoria • Persistent guilt and/or lowered self esteem • Irritable and angry continually • Paranoia

50. Complicated Grief Reactions • Preoccupation with loved one or with their death • Themes of loss come up in other areas • Inability to speak about the deceased without experiencing intense and fresh grief • Inability to change or move possessions of the deceased