1. Marie-Annette Brown, PhD, RN, FAAN

2. Slide 2 Grief: Therapeutic Interventions TNEEL-NE Foundations for Grief Interventions How Can I Help? by Ram Dass and Paul Gorman: –“Caring for another, we sometimes glimpse an essential quality of our being … We’re reminded of who we are and what we have to offer one another.” (Dass & Gorman, 1985)

3. Slide 3 Grief: Therapeutic Interventions TNEEL-NE Preparation for Intervening Working with loss, grief and dying triggers the nurse’s own personal experience with loss: –Anxieties –Fears –Uncertainties –Doubts –Depression This is similar to what happened to my grandfather. PROCESSING (what I learned from that experience … ) Ok, NOW I’m ready to set aside my fear and help my patient.

4. Slide 4 Grief: Therapeutic Interventions TNEEL-NE Building the Foundation for Sensitive Care Identify –What specific parts of death, dying, grief, and loss that are difficult personally. –Ways that we react to suffering. –Which of our attitudes, beliefs, fears, and concerns limit our ability to give compassionate support. Developing strategies for growth –Counseling –Reading –Workshops

5. Slide 5 Grief: Therapeutic Interventions TNEEL-NE Fear of “Saying the Wrong Thing” Here is no perfect response that will “take away” the griever’s pain. Practice talking about death and grief: –Builds courage –Helps nurse identify their own most comfortable approach

6. Slide 6 Grief: Therapeutic Interventions TNEEL-NE Principles & Strategies for Intervening The Tasks of Grievers as an Intervention Guide –Purpose of grief interventions is to assist patients and families with the mourning

7. Slide 7 Grief: Therapeutic Interventions TNEEL-NE Wolfelt’s Six Basic Needs of Grievers 6. Receive ongoing support from others 5. Search for meaning 4. Develop a new self-identity 3. Remember the person who died 2. Embrace the pain of the loss 1. Acknowledge the reality of the death

8. Slide 8 Grief: Therapeutic Interventions TNEEL-NE Reconciliation Emotions change: Pain evolves away from sharp, stinging. Feelings of loss do not completely disappear, but soften over time. Replaces terms of resolution, recovery, re-establishment, reorganization. –These suggest return to normalcy. Describes the process as the individual works to integrate a new reality without loved one’s physical presence while moving forward in life.

9. Slide 9 Grief: Therapeutic Interventions TNEEL-NE Example Poem for Reconciliation Poem: Life in Memory of Grandpa Wilkie by Jamie Wilkie, age 10. Poetry Reading Which lines in the poem reflect the meaning of this death to the child? What does this poem convey about evolving roles between grandfather and grandchild?

10. Slide 10 Grief: Therapeutic Interventions TNEEL-NE Intervening with Dying Child Play is a means for children to communicate Play helps: –Discharge emotions and anxiety –A positive distraction when intense emotions are aroused Gerald P. Koocher’s 3 sessions –Telling of the story of the loss –Confronting the reality of the loss –Looking forward to the future

11. Slide 11 Grief: Therapeutic Interventions TNEEL-NE Guidelines for Helpers Therese Rando’s “dos & don’ts” –Appropriate for nurses in a variety of settings from the ICU to a hospice. –Key nursing interventions (Rando, 1984) DOs Don’ts

12. Slide 12 Grief: Therapeutic Interventions TNEEL-NE Therapeutic Strategies Strategies from Therese Rando: –Make contact and assess. –Maintain a therapeutic and realistic perspective. –Encourage verbalization of feelings and recollection of the deceased. –Help the griever identify and resolve secondary losses and unfinished business. –Support the griever in coping with the grief process. –Help the griever to accommodate to the loss. –Work with the griever to reinvest in a new life. (Rando, 1984)

13. Slide 13 Grief: Therapeutic Interventions TNEEL-NE Key Nursing Interventions Anticipatory guidance –Sharing knowledge of what is “normal” during the grief process Being present A Nurse’s Response Woman expressing about nurse’s response to her at the time of her mother’s death in the hospital.

14. Slide 14 Grief: Therapeutic Interventions TNEEL-NE Therapeutic Activities and Resources for Grievers Serve as tools for “grief work”: –Rituals –Letters of Condolence –Poetry –Music –Reading Material –Media –Internet –Counseling and support groups

15. Slide 15 Grief: Therapeutic Interventions TNEEL-NE Rituals Part of all cultures Address all aspects of human life (i.e. birth, marriage, death) –Funerals The therapeutic value of ritual Teenager whose younger sister died 5 year prior discussing a “ritual” activity at the sister’s funeral and how it offered her the opportunity to express things that were left unsaid.

16. Slide 16 Grief: Therapeutic Interventions TNEEL-NE Therapeutic Properties of Rituals Power of acting-out. Legitimization of emotional and physical ventilation. The delimitation of grief. The opportunity to interact extensively with memory of the deceased. Assistance in mourning and confronting unresolved grief Learning gained through doing and experiencing. Provides focus for managing confusion, disorganization and loss of control. Promote social interaction. Structure “celebrations” of anniversaries and holidays. (Rando, 1984)

17. Slide 17 Grief: Therapeutic Interventions TNEEL-NE Letters of Condolence from Healthcare Provider Comment on their courage or other positive characteristics required to deal with dying persons and/or grief. Describe special anecdotes and memories that occurred during your caregiving. Allow your humanity, kindness, gentleness and sensitivity to come through. Acknowledge their support and love toward the deceased. Express your appreciation of their cooperation, etc. (Zunin & Zunin, 1991)

18. Slide 18 Grief: Therapeutic Interventions TNEEL-NE Seven Components of Condolence Letters (Zunin and Zunin, 1991) Acknowledge the loss. Close with thoughtful word or phrase. Offer assistance (if appropriate) Note special qualities of the bereaved. Recount a memory about the deceased. Note special qualities of the deceased. Express your sympathy.

19. Slide 19 Grief: Therapeutic Interventions TNEEL-NE Letters of Condolence: Sample A nurse wrote this letter to the widow of a patient: Dear Mrs. Jackson, I just learned that the inevitable happened last night. Even though it was clear that the end was imminent, the loss remains just as painful. As one of the nurses caring for your husband during this period and seeing you almost daily, I have had the greatest respect and appreciation for your compassion through this very difficult time. My heart goes out to you. He was blessed to have had you so near. With respect and affection, (Zunin & Zunin, 1991)

20. Slide 20 Grief: Therapeutic Interventions TNEEL-NE Poetry i.Poem: “Tip Toeing” by David Mook ii.Poem: “If One More Day” by Deanna Edwards iii.Poem: “Life in Memory of Grandpa Wilkie” by Jamie Wilkie Article: “Poetry” by Yvonne Williams

21. Slide 21 Grief: Therapeutic Interventions TNEEL-NE Grieving Person’s Bill of Rights You have the right to: –Experience your own unique grief –Talk about your grief –Feel a multitude of emotions –Be tolerant of your physical and emotional limitations –Experience grief attacks –To make use of ritual –Embrace your spirituality –Search for meaning –Treasure your memories –Move toward your grief and heal (Wolfert, 1994)

22. Slide 22 Grief: Therapeutic Interventions TNEEL-NE Music Song: On the Wings of a Dream by John Denver Yesterday I had a dream about dying About laying to rest and then flying How the moment at hand Is the only thing we really own And I lay in my bed and I wonder After all has been said and is done for Why is it thus we are here And so soon we are gone copyright Cherry Lane Music Company, New York. Lyrics reproduced with permission

23. Slide 23 Grief: Therapeutic Interventions TNEEL-NE Books Healing Your Grieving Heart: 100 Practical Ideas by Alan D. Wofelt, Ph.D. (Wofelt, 1998)

24. Slide 24 Grief: Therapeutic Interventions TNEEL-NE Media Magazines, newsletters, TV, film and radio

25. Slide 25 Grief: Therapeutic Interventions TNEEL-NE Internet Information about grief process Therapeutic activities –Chat rooms –On-line support groups Limitations/cautions –Variable quality of information –Increased risk of problems associated with unsupervised groups –Vulnerability of the bereaved

26. Slide 26 Grief: Therapeutic Interventions TNEEL-NE Individual Counseling & Support Groups Valuable to encourage “grief work”: –Provides structure to discuss issues over time. –Opportunity for conversations after social network stops asking. –Helps those with unresponsive social network.