Grief and Loss
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Outline
Overview
- Grief – The natural human response of deep sorrow after the loss (death, separation) of someone important, and the attempt to deal with that loss
- Loss – Definition: state or feeling of grief when deprived of someone or something of value
- The expression of mourning has cultural, spiritual, and/or religious influences on how this is expressed
Nursing Points
General
- Grief
- Grief in children depends on where they are developmentally
- May not understand death as permanent until adolescent years
- May regress
- The typical grief response occurs in 3 stages, but there is NO standardized grief response or timeline
- Shock and disbelief
- Numbness
- Labile emotions
- Isolation
- Experiencing the loss
- Anger
- Guilt
- Bargaining
- Depression
- Reintegration
- Reorganization of life
- New relationships
- Shock and disbelief
- Grief in children depends on where they are developmentally
Assessment
- Types of grief
- Normal
- Can take months-years
- Various reactions can occur
- Anticipatory
- Grief that occurs prior to the death because loved ones know it is eventual
- For example, terminal illness
- Disenfranchised
- When a loved one cannot grief openly
- May be due to strained relationship or cultural norms
- Dysfunctional
- A deviation from “normal” grieving
- Unhealthy coping mechanisms
- Lack of resolution
- Complicated
- An ongoing, heightened state of mourning that prevents healing and limits daily functioning
- Think of it like a wound ‘complication’, but emotional
- Extreme focus on their death or their memory
- Problems accepting the loss
- Wish they had died, too
- And many more
- Normal
- Loss can be sudden or anticipated
Therapeutic Management
- Your role in supporting loved ones during grief and loss
- Facilitate grief process, support emotionally
- They may be upset, emotionally labile, crying, etc.
- Assess religious, cultural, spiritual beliefs and influences; make sure to follow customs appropriately
- Establish trust and rapport
- Express empathy
- Involve health care team
- Child life specialists
- Social workers
- Palliative care
- Chaplains or other religious leaders
- Bereavement specialists
- Facilitate grief process, support emotionally
Nursing Concepts
- Mood Affect
- Grief
Patient Education
- There is no right or wrong way to grieve
- Feelings are valid
- Healthy coping mechanisms
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Transcript
In this lesson we’re going to talk about Grief and Loss. These concepts are similar and have a lot of crossover, so we’re going to talk about them together.
So let’s start with definitions – grief is the natural human response of deep sorry, especially after a loss or death. Loss is the state or feeling of grief when deprived of something or someone of value. So grieving is a state of being, a mood, a behavioral response of deep sorrow that could be in response to anything. Loss is specifically grief associated with losing something or someone.
So it’s important to know that grief occurs in stages. There is no standardized timeline or any right or wrong length of time to experience grief, but it IS important that everyone progress, in their own time, through each of the stages. For this lesson we talk about 3 stages: shock and disbelief, experiencing the loss, and reintegration into life. You may also have heard of Denial, Anger, Bargaining, Depression, and Acceptance. Those kind of fit here in this 3 stage process as well. In the first stage they’re just kind of numb, they can’t believe this has happened, and might even be in denial. When they’re actually physically and emotionally experiencing the loss, they may feel the anger, bargaining, or depression during this stage – this is the part that might look different for everyone – not everyone truly experiences a deep depression. Then we have the reintegration phase where they’re trying to reorganize or restructure their life without this person or thing or with their new reality. One big thing to note is that grief can look very different in children because they may not really be able to process what’s happening. They may even experience regression – go back to the defense mechanism lesson to remember what happens in regression.
So in addition to stages, there are also types or ways to classify grief. There is normal grief – that’s someone that progresses through all of the stages and successfully reintegrates into a new normal life. Anticipatory grief is when someone starts to experience these things before the loss has actually happened – we see this a lot with terminal illness. Disenfranchised grief occurs when someone is unable to really grieve openly, usually because of family or social pressures. A good example of this, unfortunately, might be someone’s mistress or someone they weren’t supposed to even have a relationship with – that person can’t grieve openly because no one even knows they were involved. So their grief becomes disenfranchised and it’s difficult for them to progress through the stages in a healthy way. The next one is Dysfunctional – this is exactly what it sounds like – they just aren’t progressing through the stages like they should or they are using unhealthy coping mechanisms or they just kind of never fully get to resolution. We know there’s no such thing as ‘normal’, but essentially dysfunctional grief is someone who just doesn’t progress through “normal” grief. And finally there’s something known as complicated grief. This is more significant than just dysfunctional. It’s like they get stuck in this ongoing, heightened state of mourning, they fixate on their loss, and they literally cannot even function in their daily life. Think of it like a wound complication, but emotional and grief-related. You know that not all wounds heal the same, but ultimately they should all develop granulation tissue and scar up, right? So think of dysfunctional grief as one that maybe needed a bit more help like a wound vac, or maybe they ended up with a way bigger scar than you’d expect. BUT – complicated grief is like a wound that develops an infection and gets deeper or bigger and maybe even ends up resulting in the loss of limb. It’s an extreme complication of the emotional grief process.
So what can we do for these people – well one thing we need to realize is that cultural, religious, and spiritual beliefs can all impact the grief process, so make sure you’re evaluating that and being sensitive to it. Establish trust and rapport and express empathy for their situation. We also want to considering involving a multidisciplinary team like palliative care, the chaplain, and any other departments that can help facilitate the grief process and provide support to those who are grieving. One thing I do want to make clear to here, as a nurse, it is okay for you to cry. It’s okay to cry with them, just make sure that you stay professional and that you don’t lose it so much that you can’t do your job. But, it’s okay to shed a tear, and what that actually does is that it makes them feel like they’re safe with you and it expresses empathy.
Priority nursing concepts for a client experiencing grief and loss would be, obviously, grief – keeping that process in your mind. Mood/affect so we can determine how well they’re progressing. And, safety – you know, grief is something I wouldn’t wish on my worst enemy, it’s hard, especially the first time you experience a significant loss – so keep this in mind and make sure you’re evaluating for risk of self-harm in these clients.
Just to recap – remember that grief IS highly individualized, it should follow the stages but there is no specific timeline and someone’s culture or religion will definitely play a part. We want to assess their grief stage and type to make sure they’re exhibiting healthy responses and behaviors and staying safe. We also want to help facilitate the grief process by being a safe place for them to express their feelings, expressing empathy, and providing any resources they might need.
So those are the basics of grief and loss. If you have any questions or concerns on how to handle this, especially as you start working as a nurse – please contact a mental health professional or talk to someone you trust. We love you guys and we know you’re going to be strong for your clients and their families, which makes such a difference for them during this time. Go out and be your absolute best self today. Happy nursing.
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