1. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 7Loss, Grief, and End- of-Life Care

2. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins “In this sad world of ours, sorrow comes to all…It comes with bittersweet agony…[Perfect] relief is not possible, except with time. You cannot now realize that you will ever feel better…And yet this is a mistake. You are sure to be happy again. To know this, which is certainly true, will make you feel less miserable now.” Abraham Lincoln

3. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Learning Objectives After studying this chapter, you should be able to Discuss the concepts of loss, grief, mourning, bereavement, and end-of-life care Describe at least three types of losses that an individual with a psychiatric disorder or medical illness can experience Explain the grief process Differentiate normal, unresolved or dysfunctional, and disenfranchised grief

4. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Learning Objectives (cont.) Define advance care planning Compare and contrast the focus of palliative and hospice care Demonstrate an understanding of the importance of cultural competence when providing palliative or hospice care Recognize at least three barriers to receiving palliative and hospice care Construct a list of common responses associated with suffering at the end of life Articulate the needs of dying persons and their survivors State the rationale for “The Dying Person’s Bill of Rights” Compare the perceptions of death by children during the various growth stages

5. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Concept of Loss Change in status of a significant object Any change in an individual’s situation that reduces the probability of achieving implicit or explicit goals An actual or potential situation in which a valued object, person, or other aspect is inaccessible or changed so that it is no longer perceived as valuable A condition whereby an individual experiences deprivation of, or complete lack of, something that was previously present

6. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Loss Sudden Gradual Predictable Unexpected Actual Perceived Anticipatory Temporary Permanent

7. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Grief Theory Grief process Unresolved, or dysfunctional, grief

8. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Elizabeth Kubler-Ross (1969) Stages of the Grieving Process Denial Anger Bargaining Depression Acceptance Progression through these stages does not necessarily occur in any specific order.

9. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Practical Tips for Experiencing Grief Allowing oneself to experience feelings of pain, anger, etc. Sharing personal feelings with others Talking out loud to one’s loved one to release feelings Maintaining or resuming a daily schedule or routine to avoid feeling overwhelmed Avoiding the use of alcoholic beverages to avoid feeling more depressed Sleeping, eating, and exercising regularly Delaying the making of any major decisions immediately following the loss Asking for help to deal with a loss to avoid unresolved or dysfunctional grief

10. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins End-of-Life Care Advance care planning Ethnic considerations and cultural sensitivity Palliative care and hospice care – Manifestations of suffering – Pain – The act of dying

11. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Advance Care Planning Living will Health care directive Durable health care power of attorney Health care proxy Dying declaration exception to hearsay

12. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Spiritual Needs The nurse should be able to naturally respond to spiritual needs. Listening Acknowledging the client’s spirituality Additionally, the nurse can do the following: Suggest that the client talk to the hospital chaplain Suggest that the client talk to the client’s own clergy Suggest that the client talk to members of his or her congregation Suggest that the client talk to other clients with similar religious beliefs Provide quiet time for private meditation or prayer

13. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment of Spiritual Needs in Culturally Diverse Clients Environment Behavior Verbalization Interpersonal relationships

14. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Children and Death Preschool children Children between the ages of 5 and 6 years Children from 6 to 9 years of age Children aged 10 Adolescents

15. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Key Terms Advance care planning Advance directive Anticipatory grief Bereavement Disenfranchised grief Durable health care power of the attorney Dying declaration exception to hearsay Dying Person’s Bill of Rights Dysfunctional grief End-of-life care

16. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Key Terms (cont.) Grief Grief process Health care directive Health care proxy Hospice care Living will Loss Mourning Palliative care Patient self- determination act Suffering Unresolved grief

17. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Reflection A new neighbor tells you that his wife of 30 years was killed in an automobile accident three months ago and he is having difficulty adjusting to living alone. Reflect on the chapter-opening quote by Abraham Lincoln. ? How would you interpret the meaning of this quote? What significance does it have in relation to the neighbor’s disclosure about the loss of his wife?