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Page 1: Death, Dying & Grief by Prof. Unn Hidle Updated Spring 2009.

Death, Dying & GriefDeath, Dying & Grief

byby

Prof. Unn HidleProf. Unn Hidle Updated Spring 2009 Updated Spring 2009

Page 2: Death, Dying & Grief by Prof. Unn Hidle Updated Spring 2009.

Suggested VideosSuggested Videos

““Dealing with Death and Dying”Dealing with Death and Dying”

““The Dying Child”The Dying Child”

Page 3: Death, Dying & Grief by Prof. Unn Hidle Updated Spring 2009.

DefinitionsDefinitions LossLoss

– The absence of a person or possessionThe absence of a person or possession GriefGrief

– The emotional response to lossThe emotional response to loss MourningMourning

– The outward, social expression of lossThe outward, social expression of loss BereavementBereavement

– Grief and mourning combinedGrief and mourning combined

****ALL STRONGLY influenced by individuality and ALL STRONGLY influenced by individuality and culture!culture!

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Page 5: Death, Dying & Grief by Prof. Unn Hidle Updated Spring 2009.

Why do we grieve?Why do we grieve?

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LOSSLOSS Different types of lossDifferent types of loss::

– Death of a parent, grandparent, sibling, partner, Death of a parent, grandparent, sibling, partner, childchild

– Death of a close friendDeath of a close friend– Loss or break-up of a relationshipLoss or break-up of a relationship– Loss of friendshipLoss of friendship– Serious illness in self or other Serious illness in self or other – Loss of sentimental valuesLoss of sentimental values

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Page 8: Death, Dying & Grief by Prof. Unn Hidle Updated Spring 2009.

The Grief ProcessThe Grief Process Each person grieves in their own wayEach person grieves in their own way Grief work leads to living with lossGrief work leads to living with loss Certain factors may influence the grieving process:Certain factors may influence the grieving process:

– Personality, coping, relationship to the deceased, type Personality, coping, relationship to the deceased, type of death, spiritual beliefs, religionof death, spiritual beliefs, religion

Grief assessment:Grief assessment:– Begins at time of diagnosis or admissionBegins at time of diagnosis or admission– Ongoing to detect complicated griefOngoing to detect complicated grief– No one can predict completionNo one can predict completion

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Pablo Perea Emotions

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Types of GriefTypes of Grief

Anticipatory GriefAnticipatory Grief ““Uncomplicated”/”Normal” griefUncomplicated”/”Normal” grief Complicated GriefComplicated Grief Disenfranchised GriefDisenfranchised Grief Childrens’ GriefChildrens’ Grief

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Anticipatory GriefAnticipatory Grief

Grief before the Grief before the actual lossactual loss

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““Uncomplicated/Normal” GriefUncomplicated/Normal” Grief

““Normal” feelings, behaviors and Normal” feelings, behaviors and reactions to lossreactions to loss

Follow the stages of the grieving Follow the stages of the grieving processprocess

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Complicated GriefComplicated Grief Chronic griefChronic grief

– Ongoing cycleOngoing cycle

Delayed griefDelayed grief Exaggerated griefExaggerated grief Masked griefMasked grief

Risk factors:Risk factors:– Sudden or traumatic Sudden or traumatic

deathdeath– Suicide, homicideSuicide, homicide– Death of a childDeath of a child– Multiple lossMultiple loss

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Disenfranchised GriefDisenfranchised Grief

When loss cannot be openly When loss cannot be openly acknowledged or socially acknowledged or socially sanctionedsanctioned

Examples may include death from Examples may include death from AIDS, abortion, drugs, suicide, ex-AIDS, abortion, drugs, suicide, ex-spouse, etc.spouse, etc.

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Childrens’ GriefChildrens’ Grief

ALWAYS complicatedALWAYS complicated Symptoms unique to childrenSymptoms unique to children Based on developmental stagesBased on developmental stages

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Should death be discussed Should death be discussed with dying children?with dying children?

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Special Needs of ChildrenSpecial Needs of Children ““Experts” agree that it is best for dying children to Experts” agree that it is best for dying children to

discuss deathdiscuss death Children of most ages understand that death exist Children of most ages understand that death exist

through:through:– Direct informationDirect information– Reasoning about health status and experiencesReasoning about health status and experiences

Children express their knowledge:Children express their knowledge:– Directly: WordsDirectly: Words– Indirectly: stories, gestures, drawingsIndirectly: stories, gestures, drawings– SilenceSilence

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Special Needs of ChildrenSpecial Needs of Children

Parents also benefit from discussing death Parents also benefit from discussing death with their dying child:with their dying child:– Less regrets after the child is goneLess regrets after the child is gone– Decreased guiltDecreased guilt– Better communicationBetter communication– Closeness / bondingCloseness / bonding– Honesty Honesty

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What to expect when grievingWhat to expect when grieving

Emotional SymptomsEmotional SymptomsStages of GriefStages of Grief::– DenialDenial

This isn’t happening to me!This isn’t happening to me!– AngerAnger

Why is this happening to Why is this happening to me?me?

– BargainingBargaining I promise I’ll be a better I promise I’ll be a better

person if …….person if …….– DepressionDepression

I don’t care anymoreI don’t care anymore– AcceptanceAcceptance

I’m ready for what comesI’m ready for what comes– Kubler-Ross, 1969Kubler-Ross, 1969

Physical SymptomsPhysical Symptoms– SleeplessnessSleeplessness– SadnessSadness– Decreased appetiteDecreased appetite– TearfulnessTearfulness– FatigueFatigue– Upset stomachUpset stomach– AnxietyAnxiety– Dreams/nightmaresDreams/nightmares– Lack of concentrationLack of concentration

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Bereavement InterventionsBereavement Interventions

Plan of carePlan of care Anticipatory griefAnticipatory grief Provide presenceProvide presence Emotional supportEmotional support What to sayWhat to say Active listening, “touch”, reassuranceActive listening, “touch”, reassurance Use bereavement servicesUse bereavement services

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Ways to Help Others Cope with LossWays to Help Others Cope with Loss

Ask if they want to talk about their loss Ask if they want to talk about their loss – Remember, you have to be willing to listen!Remember, you have to be willing to listen!

Just sit with them, you don’t have to say Just sit with them, you don’t have to say anything to comfort othersanything to comfort others

Allow them to cry and be sadAllow them to cry and be sad Don’t minimize their feelingsDon’t minimize their feelings Show you care by words and actionsShow you care by words and actions Help with practical needsHelp with practical needs

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Coping SkillsCoping Skills CounselingCounseling Support groupsSupport groups Talking & listeningTalking & listening Understanding the grieving processUnderstanding the grieving process Letting others helpLetting others help Taking care of physiological needs (Maslow)Taking care of physiological needs (Maslow) Acknowledge pain and allow tearsAcknowledge pain and allow tears

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When to Get HelpWhen to Get Help You feel you cannot handle this aloneYou feel you cannot handle this alone You are loosing weightYou are loosing weight Your grades, work &/or social life are Your grades, work &/or social life are

sufferingsuffering You have repeated thoughts of death or You have repeated thoughts of death or

dyingdying You feel you need to talk and you think your You feel you need to talk and you think your

friends are tired of listeningfriends are tired of listening

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Nurses’ Death AnxietyNurses’ Death Anxiety Death anxietyDeath anxiety Cumulative lossCumulative loss Lack of resolutionLack of resolution Personal death awarenessPersonal death awareness Personal defensesPersonal defenses

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Hospice CareHospice Care

Decreased daily physical stress for Decreased daily physical stress for family membersfamily members

Support systemSupport system Peace for the childPeace for the child

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AdvancedAdvanced DirectivesDirectives What is it?What is it?

– Health Care ProxyHealth Care Proxy– Living WillLiving Will

When should it be offered to the patient?When should it be offered to the patient? Part of medical record?Part of medical record? LegalitiesLegalities Informed consent versus assentInformed consent versus assent DNR versus DNIDNR versus DNI

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The Dying ProcessThe Dying Process

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““Into the light….”Into the light….”

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The Dying Patient’s Bill of RightsThe Dying Patient’s Bill of Rights

Be treated as a human beingBe treated as a human being HopeHope Freedom to express feelings and emotionsFreedom to express feelings and emotions Medical and nursing care (as indicated)Medical and nursing care (as indicated) Sensitive careSensitive care Not to die aloneNot to die alone Freedom from painFreedom from pain HonestyHonesty Help for self and family in accepting deathHelp for self and family in accepting death Die in peace and dignityDie in peace and dignity Retain individuality and beliefsRetain individuality and beliefs Expect respect of body after deathExpect respect of body after death

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Care and Comfort MeasuresCare and Comfort Measures

Pain managementPain management Provide comfort Provide comfort Turning and positioningTurning and positioning Hygiene / Oral hygieneHygiene / Oral hygiene Communication Communication Attend to psycho-social needsAttend to psycho-social needs Support: physical, emotional, spiritualSupport: physical, emotional, spiritual

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Page 37: Death, Dying & Grief by Prof. Unn Hidle Updated Spring 2009.

Impending Signs of DeathImpending Signs of Death

““Mental Work”Mental Work”– Separation from family and friendsSeparation from family and friends– Withdrawal from the world and peopleWithdrawal from the world and people– Less communicationLess communication– Separation from bodySeparation from body

Going inside of selfGoing inside of self

– Decreased PO intakeDecreased PO intake– Excessive sleeping > 20 hours/dayExcessive sleeping > 20 hours/day

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Impending Signs of DeathImpending Signs of DeathPhysical SignsPhysical Signs

One to three monthsOne to three months– Withdrawal Withdrawal

One to two weeksOne to two weeks – Disorientation: hallucinations; Disorientation: hallucinations; pickingpicking at clothes at clothes– Body Body slows downslows down: Decreased HR, BP, PO: Decreased HR, BP, PO

Days to hoursDays to hours– Surge of energy!Surge of energy!

MinutesMinutes– ““fish out of water” or “death rattle” breathingfish out of water” or “death rattle” breathing– ““death stool” death stool”

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Postmortal CarePostmortal Care ALLOW family/friends to spend time with ALLOW family/friends to spend time with

the deceased and initiate the grieving the deceased and initiate the grieving processprocess

Postmortal care as per facility proceduresPostmortal care as per facility procedures Provide privacy, support and comfortProvide privacy, support and comfort Honor last wishes/requests from family Honor last wishes/requests from family

members (within reason)members (within reason)

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Can there be a Can there be a goodgood death? death?