2. مدیریت سوگ در بازماندگان بیماران مرگ مغزی و اهدائ عضو
مدیریت سوگ در بازماندگان بیماران مرگ مغزی و اهدائ عضو
دکتر مهدی شیرزادیفر روانپزشک
رتبه دوم بورد تخصصی کشور استادیار دانشگاه

3. قران کریم و مرگ
كُلُّ نَفْسٍ ذَآئِقَةُ الْمَوْتِ ... ؛ هر جاندارى (به ناچار) چشنده مرگ است ،

4. اگر بشود چيزي‌ را با ضدش‌ معرفي‌ كرد بايد گفت‌ كه: مرگ‌ پايان‌ زندگي‌ دنيوي‌ است. چنانكه‌ علي(ع) مي‌فرمايند: "اَلموت‌ غايته"و "بالموت‌ تختم‌ الدنيا

5. آن یکی می گفت خوش بودی جهان گر نبودی پای مرگ اندر میان
آن یکی می گفت خوش بودی جهان       گر نبودی پای مرگ اندر میان                
   آن دگر گفت: ار نبودی مرگ هیچ              کَه نیرزیدی جهان پیچ پیچ                                                      (

6. مرگ با تولد اغاز میگردد در حالی که زندگی یک حس درونی بین دو تنفس است
یک تعریف جالب
مرگ با تولد اغاز میگردد در حالی که زندگی یک حس درونی بین دو تنفس است

7. Thanatology Thanatology= study of death
Roark, 2004
Thanatology
Thanatology= study of death
The description of study of the phenomena of death, and of psychological mechanisms for coping with death

9. DEFINITIONS OF THE KEY COMPONENTS
Universality. Universality refers to the understanding that all living things must eventually die.

10. Causality. Unlike the other three components, there is no consensus as to the definition of Causality. However, collectively, the various approaches suggest that Causality involves an abstract and realistic understanding of the external and internal events that might possibly cause an individual's death. "Abstract" refers to the fact that the causes specified are not restricted to particular individuals or events but are classes of causes which are applicable to living things in general. "Realistic" refers to the fact that the causes specified are generally accepted by mature adults as valid causes of death.

11. Nonfunctionality. Nonfunctionality refers to the understanding that once a living thing dies all of the typical life-defining capabilities of the living physical body (e.g., walking, eating, hearing, seeing, thinking, and learning) cease. Here again, specifying the person's physical body distinguishes this aspect of the concept of death from the issue of whether some noncorporeal aspect of a person, such as the spirit, is capable of any life-like functions (e.g., loving, helping) after death.

12. Irreversibility. Irreversibility refers to the understanding that once the physical body dies it cannot be made alive again. In offering this definition the question of whether there is some sort of noncorporeal continuation after death of the body (e.g., concepts such as reincarnation and resurrection) is left open. It has also been useful to distinguish the irreversibility of death of the physical body from the question of whether any kind of life functions continue after death. This latter aspect is the component Nonfunctionality.

13. Loss and Grief Terminology
Bereavement: period of sorrow following the death of a significant other
Loss: real or perceived deprivation of something deemed meaningful (death or non-death related)
Grief: an emotion generated by an experience of loss characterized by sorrow and/or distress, and the personal and interpersonal experience of loss.
Coping: Time limited reaction in which an event is endured or momentarily managed with coping skills
Loss Adaptation: Process of adjusting to loss/grief (active process of modification, revision, reorganization, and assimilation over time
Deprived – state of being denied or without
Grief again – arises from death and non-death related losses

15. Ambiguous Loss (AL) Two types
Physically absent / psychologically present (e.g. kidnapping, people missing from natural disaster, divorce situations, baby put up for adoption, etc.)
Physically present / psychologically absent:person is emotionally and cognitively missing (Alzheimer’s, traumatic brain injury, addictions)
The uncertainty characteristics of (AL) can bring about long term dysfunctional coping often contributing to complications in the grieving process

16. What Is Grief?
“Grief is the emotion people feel when they experience a loss. There are many different types of loss, and not all of them are related to death. For example, a person can also grieve over the breakup of an intimate relationship or after a parent moves away from home.”
The Nemours Foundation.

17. What are the Five Stages of Grief and Do They Always Occur in the Same Order?

18. Kubler-Ross Stages of Grief
Denial
Anger
Bargaining
Depression
Acceptance
Roark, 2004

19. Stage 1: Denial Refusing to believe a probable death will occur.
You can help others face it by being available for them to talk instead of forcing them to talk about it.

21. Stage 3: Bargaining
They dying person may start to negotiate with God i.e. “I’ll live a healthier life,” “I’ll be a nicer person,” “I was angry so let me ask nicely to please let me live.”
They may negotiate with the doctor by saying, “How can I get more time so I can live in my dream home, and so on.
There is a deep sense of yearning at this stage to be well again.

22. Stage 4: Depression
When reality sets in about their near death, bargaining turns into depression.
Fear of the unknown
Guilt for demanding so much attention and depleting the family income occurs.
Be available to listen instead of cheering them up, or rambling, repetitive talk.
Distraction like talk about sports, etc., is good but don’t ignore the situation.

23. Stage 5: Acceptance
When the dying have enough time and support, they can often move into acceptance.
There is an inner peace about the upcoming death.
The dying person will want someone caring, and accepting by their side.

24. Cultural Backgrounds Affect Beliefs Concerning Death
Roark, 2004
Cultural Backgrounds Affect Beliefs Concerning Death
Organized religious practices
Nurses need to be in tune with patients’ spiritual needs
Becoming familiar with cultural views will help…
Can you name some cultural practices associated with loss, grief, and death?

25. Cultural Backgrounds Affect Beliefs Concerning Death
Roark, 2004
Cultural Backgrounds Affect Beliefs Concerning Death
Beliefs, attitudes, and values that stem from the patient’s cultural background will strongly influence their reaction to loss, grief, and death
Expressions of grief are governed by what is acceptable by the family and within the cultural context
Comfort may be found through spiritual beliefs, and finding comfort in specific rites, rituals, and practices

26. “Grief is a natural reaction to the loss of someone important to you
“Grief is a natural reaction to the loss of someone important to you. Grief is also the name for the healing process that a person goes through after someone close has died. The grieving process takes time, and the healing usually happens gradually.”
ｩ The Nemours Foundation.

27. Behavioral responses that obstruct the expression of grief
Roark, 2004
Behavioral responses that obstruct the expression of grief
Sudden, unexpected death
Lengthy illness resulting in death
Loss of a child
Perception that the death was preventable
Unsteady relationship with deceased
Mental illness of survivor
Lack of social support

28. Grief can make us feel guilty
*Grief can make us feel guilty. *Some people might blame themselves or think they could have done something to stop the death.
ｩ The Nemours Foundation.

29. “Others might think if only they had been better people, than their loved ones might not have died. These things aren't true, of course - but sometimes feelings and ideas like this are just a way of trying to make sense of something that's difficult to understand.”
ｩ The Nemours Foundation.

30. .
*Knowing someone is going to die can give us time to prepare. *If they were suffering, it can mean a sense of relief. *If the person that died was young, we may feel it was unfair.
ｩ The Nemours Foundation.

31. “Losing someone suddenly can be extremely traumatic, though, no matter how old that person is. Maybe someone you know died unexpectedly - as a result of violence or a car accident, for example. It can take a long time to overcome a sudden loss because you may feel caught off guard by the event and the intense feelings that are associated with it.”
ｩ The Nemours Foundation.

32. Coping cont. *Throw selves into activities to take mind off loss.
*Become depressed and withdraw from activities, peers, family.
*Everyone handles grief in different ways. 1
ｩ The Nemours Foundation.

33. “For some people, it may help to talk about the loss with others
“For some people, it may help to talk about the loss with others. Some do this naturally and easily with friends and family, others talk to a professional therapist.”
The Nemours Foundation.
ｩ The Nemours Foundation.

34. Key Technique in Working With Loss, Grief, and Bereaved Clients
Master the Art of Silence
Respectful silence is bearing witness
Silence punctuates moments, prompts reflection, provides support, deepens process, and is healing
We are creating a space for coping, holding, adapting
We do not solve grief
We do not rescue grief

35. The Witness We bear witness Thus as a witness we:
To observe, to listen, to hear, to remember, and to understand at the deepest level the powerful narratives of loss and grief
Listen more than we talk
Employ respectful silence
Fully attend (see what is here)
Exhibit comfort
Allow grief (don’t fix even when clients request rescue)
No judgment
The Witness

36. Roark, 2004
Support the client
you can help to identify coping mechanisms, and encourage effective coping mechanisms
Allow client/family to visit the chapel if desired
Allow family members around
Client may have problems with conflicting feelings that do not align with culture or religious practices-nurse can evaluate coping and guide the client to appropriate interventions

37. Role of religione and traditions
Roark, 2004
Role of religione and traditions
Can be a member of the health care team
Assist with religious practices
Perform rites
Provide prayer, support, and comfort
Assist with mobilizing other support systems that are important to the client
Support family members

38. Key points Time heals all wounds. Think about the good times.
God needed another (angel, plumber, teacher, coach, etc.) in heaven.
It was God’s will / Everything happens for a reason.
Something good will come of this.
She/he led a full life.

39. List management strategies appropriate for grieving persons
Roark, 2004
List management strategies appropriate for grieving persons
Open ended statements
Patient sets the pace
Accept any grief reaction
Be aware—nurse may be target of anger
Remove barriers
Avoid giving advice
Allow patient to talk
Allow patient to express signs of hope
Support hope by helping focus

40. Assist Family to Grieve
Roark, 2004
Assist Family to Grieve
Explain procedures and equipment
Prepare them about the dying process
Involve family and arrange for visitors
Encourage communication
Provide daily updates
Resources
Do not deliver bad news when only one family member is present

41. Choices of Care Setting
Roark, 2004
Choices of Care Setting
Families have choices of where to care for the dying loved one
Ask the patient and family preferences
Support whatever the choice
Hospital, Home/Hospice

42. *“Although everyone experiences grief when they lose someone, grieving affects people in different ways.”
*Depends on relationship with person.
*Circumstances under which they died.

43. Coping With Grief
“The grieving process is very personal and individual - each person goes through his or her grief differently. Some people reach out for support from others and find comfort in good memories.” 1

44. Do children experience grief?
“Yes, if children are old enough to love, they are old enough to grieve. Many times in our society children are the forgotten grievers. For instance, when a parent dies, whom do we expect to help the child with their grief? The surviving parent. That parent not only has their own grief to deal with but they are learning for the first time how to be a single parent. They, like their child, can use support in their grieving.”
&

45. DSM IV V62.82 Bereavement along w/diagnosis of Major Depressive Disorder
“This category can be used when the focus of clinical attention is a reaction to the death of a loved one.”
Can be linked with a “Major Depressive Episode (e.g., feelings of sadness and associated symptoms such as insomnia, poor appetite, and weight loss).”
Symptoms must still be present 2 months after loss.
Can’t be considered “normal” grief reactions.
DSM IV, p , V62.82
*Very limited information
DSM IV, p , V62.82
*Very limited information

46. Typical Physical Symptoms of Grief
difficulty going to sleep, or waking in the middle of the night
weight loss or gain; over- or under-eating
low energy or fatigue
headaches, chest pain, or racing heart
upset stomach or digestive problems
hair loss

47. Grief or Depression? Grief Depression Experienced in waves
Diminishes in intensity over time
Healthy self-image
Hopelessness
Response to support
Overt expression of anger
Preoccupation with deceased
Depression
Moods and feelings are static
Consistent sense of depletion
Sense of worthlessness and disturbed self-image
Pervasive hopelessness
Unresponsive to support
Anger not as pronounced
Preoccupation with self
* Excerpts from Therese A. Rando (1993). Treatment of Complicated Mourning. Research Press, Champaign, IL.

48. There are many ways people who are grieving can help themselves:
Attending support groups
Therapy with a psychologist or other licensed mental health professional
Journaling
Eating Well
Exercising
Getting enough rest
Antidepressants such as Zoloft, Paxil, Wellbutrin, Lexapro, Celexa, Prozac and can be very effective to those who become clinically depressed

49. (continued) Reading and learning about death-related grief responses
Seeking comforting rituals
Avoiding major changes in residence, jobs, or marital status
Allowing emotions
Seeking solace in the faith community

50. Factors that may hinder the healing process
Avoiding or minimizing emotions
Using alcohol or drugs to self-medicate
Using work to avoid feelings

51. Gender Differences Men Women express their feelings early after loss
reach out for social support
are seen to express more sorrow, depression, and guilt
more willing to talk about the loss of a child
Men
more likely to take on a managerial role
intellectualize their emotions
indicate that they feel more anger, fear, and loss of control
use denial more
more private about grief

52. It's only when we truly know and understand that we have a limited time on earth -- and that we have no way of knowing when our time is up, we will then begin to live each day to the fullest, as if it was the only one we had. ~Dr. Elisabeth Kübler-Ross

53. What to Do Act natural Show genuine care and concern
Make it clear that you are there to listen
Talk openly and directly about the person who died
Keep in mind that evenings, weekends, anniversaries, and holidays can be extra challenging times

54. What to Do
Find a way to help children symbolize and represent the death
Pay attention to the way a child plays; this is one of the main ways that children communicate
Say that you are sorry about the loss
Sit next to a child that wants closeness

55. What NOT to Do
Try to shelter children from the reality of death; it can be a learning experience
Give false or confusing messages (“Grandma is sleeping now.”)
Tell a child to stop crying because others might get upset
Try to cheer the person up or distract from the emotional intensity (“At least he’s no longer in pain.” “She’s in a better place now.”)

56. What NOT to Do
Offer advice or quick solutions (“I know how you feel.” “Time heals all wounds.”)
Pry into personal matters
Ask questions about the circumstances of the death