Grief

Life and Loss

There are things that we don’t want to happen, but have to accept…

Things we don’t want to know,

but have to learn…

And people we can’t live without,

but have to let go
~ unknown author ~
Personal Exploration
1. Describe the most painful loss you experienced.
2. Were you able to share your concerns about your
loss?
3. What is your greatest fear concerning loss?
4. How do you respond to others who are experiencing
loss?
5. What is a good helping relationship?
6. What is your greatest asset that you bring into a
helping relationship? Adapted Husar Bereavement Care
Loss, Mourning, Grief Bereavement
• Loss is when you are deprived of someone or
something of value
• Mourning is the outward, social expression of loss
• Grief is the emotional response to loss—or potential
loss
• Bereavement includes grief and mourning
Adapted ELNEC, 2005
Different Kinds of Losses
• Loss of Relationship- death, divorce, • Loss of Trust- loss of trust in a parent, a
pet breakup, illness, adoption, loss of trust in God, loss of trust in a
miscarriage relationship
• Loss of Plans, hopes and Dreams for
• Loss of Significant Person- death,
the Future- adoption, miscarriage,
divorce, illness, relocation, military abortion, stillbirth, infertility,
duty, missing person relationship, job career
• Loss of Safety- vulnerable feelings • Loss of Innocence- early sexual
after rape, robbery, betrayal, experiences, advertising and media
unanticipated events, crises, influences children to grow up too
traumatic events or disasters soon
• Loss of Role- occupation, job,
relationship e.g. parent, child, friend
Loss
• Losses may be actual or perceived.
• Actual loss is easily identified.
• A woman who has a mastectomy
• Perceived loss is less obvious.
• Loss of confidence
• A women who hopes to give birth to a female child delivers a male child instead
• Perceived losses are easily overlooked or misunderstood, yet the process of grief
involved is the same as an actual loss.
Loss
• Maturational Loss
• Loss resulting from normal life transitions
• Loss of childhood dreams, the loss felt in adolescents when a romance fails,
loss felt when leaving family home for college or marriage and establishing a
home of one’s own
• As an individual ages, they experience menopause and loss of hair, teeth,
hearing, sight, and “youth.”
Loss
• Situational Loss
• A loss occurring suddenly in response to a specific external event
• Sudden death of a loved one, or the unemployed person who suffers low self-
esteem
• Personal Loss
• Any loss that requires adaptation through the grieving process
• Loss occurring when something or someone can no longer be seen, felt,
heard, known, or experienced; individuals respond to loss differently
How do we Approach Loss and Grief?
• It is important to approach loss and grief not from an
intellectual but from an emotional perspective
• Cannot resonate with broken hearts and broken dreams from
an intellectual perspective
• “If you approach grief from a conceptual, intellectual
perspective, you leave the griever with much understanding -
but very little recovery.” ~James, J, & Friedman, R, 2009
• “Grief is about a broken heart not a broken brain.” ~ James, J,
& Friedman, R, 2009
 Reality of Grief
• Grief is a natural and normal response to a loss
• The loss may have already occurred or may be
anticipated
• Responses are emotional, cognitive, physical, social
and spiritual
• Intense feelings and emotions are normal
 Myths About Grief
• Myth 1: We only grieve deaths. • Myth 5: We slowly and predictably recover from
Reality: We grieve all losses. grief.
Reality: Grief is an uneven process, a roller
• Myth 2: Only family members grieve. coaster with no timeline.
Reality: All who are attached grieve.
• Myth 6: Grieving means letting go of the person
• Myth 3: Grief is an emotional reaction. who died.
Reality: Grief is manifested in many Reality: We never fully detach from those who
ways.  have died.

• Myth 4: Individuals should leave grieving • Myth 7: Grief finally ends.

at home. Reality: Over time most people learn to live with
Reality: We cannot control where we loss.
grieve.
• Myth 8: Grievers are best left alone.
Reality: Grievers need opportunities to share
their memories and grief, and to receive support.
•
Hospice Foundation of America
Grief reactions related to
• Chronologic age
• Developmental stage
• Cognitive level
• Socialization
• Culture
• Past experiences
• Relationships between individual, family members,
caregivers, health professionals

ELNEC, 2005
Cognitive Responses
• Difficulty concentrating
• Forgetfulness
• Loss of skills
• Disorganization
• Memory Problems
• Focused on loss/feeling life is not real
Five Stages of Grief
• Denial: “This can’t be happening to me.”
• Anger: “Why is this happening? Who is to blame?”
• Bargaining: “Make this not happen, and in return I
will ____.”
• Depression: “I’m too sad to do anything.”
• Acceptance: “I’m at peace with what happened.”
The 4 D’s in Dealing with Grief

• Denial
• Drugs
• Diversions
• Distractions

These keep people from going to the scary

places of grief
At the loss of a Loved One
What They
People Don’t
Need
1. Sermonizing
Permission to grieve
2. Bible
Hope quoted to them
3. Told
Comfort/support
what to feel
4. Indifference
Understanding grief cycle
Coping with Grief Means
• Understanding and making sense of a loss
• Identifying & expressing feelings and emotions
• Remembering the person’s life
• Continuing on - reintegration

Adapted: Hill, M. Drawn together. www.DrawnTogether.com

Normal grief
• What’s “normal” but
• Can include:
• disbelief
• anger
• guilt
• sadness
• preoccupation with the death
• Sleep loss or excessive sleep
• Weight loss or gain
Complicated grief
• Long period of time
• Significantly interferes with life activities
• Intense symptoms (ex: suicidal thoughts or acts).
• Factors include:
• Suddenness or circumstances of the death
• Gender of mourner
• Relationship to the deceased
• Previous psychiatric history or substance abuse*
(http://www.cancer.gov/cancertopics/pdq/supportivecare/bereavement)
Grief and Grieving
• Unresolved, Dysfunctional Grief
• Bereavement is a state of great risk physically, as well as
emotionally and socially.
• Unresolved grief
• There have been some disturbances of the normal progress toward
resolution.
• Dysfunctional grieving
• There is a delayed or exaggerated response to a perceived, actual,
or potential loss.
Grief and Grieving
• Unresolved, Dysfunctional Grief
• Dysfunctional grief occurs when an individual
• Gets “stuck” in the grief process and becomes depressed
• Is unable to express feelings
• Cannot find anyone in daily life who acts as the listener he or she needs
• Suffers a loss that stirs up other, unresolved losses
• Lacks the reassurance and support to trust the grief process and fails to believe that he
or she can work through the loss
Grief and Grieving
• Signs, Symptoms, and Behaviors of Dysfunctional Grieving
• Acquisition of symptoms belonging to the last illness of the deceased
• Alteration in relationships with friends and relatives
• Lasting loss of patterns of social interaction
• Actions detrimental to one’s social and economic well-being
• Agitated depression with tension, insomnia, feelings of worthlessness, bitter
self-accusation, obvious needs for punishment, and even suicidal tendencies
Grief and Grieving
• Signs, Symptoms, and Behaviors of Dysfunctional Grieving (continued)
• A feeling that the death occurred yesterday, even though the loss took place
months or years ago
• Unwillingness to move the possessions of the deceased after a reasonable
amount to time
• Inability to discuss the deceased without crying, particularly more that 1 year
after the loss
• Radical changes in lifestyle
• Exclusion of friends, family members, or activities associated with the
deceased
Unresolved Grief
What can it do?
• Repressed, unrecognized or unresolved grief can cause
• personal anguish
• increased anxiety
• multiple physical complaint
• functional impairment
• strained relationship
• marital discord
• disrupted sleep
• impaired childhood
• increased substance abuse– tobacco, alcohol, drugs, tranquilizers
• clinical depression
• increased mortality from heart disease and suicide
Grief and Grieving
• Supportive Care during the Dying and Grieving Process
• Assessment
• To give compassionate nursing care and support to the family and patient during the
grieving and dying process, the nurse should consider the five aspects of human
functioning:
• Physical
• Emotional
• Intellectual
• Sociocultural
• Spiritual
Grief and Grieving
• Supportive Care during the Dying and Grieving Process
• Physical assessment
• Sleeping patterns
• Body image
• Activities of daily living (ADLs); mobility
• General health
• Medications
• Pain
• Basic needs: nutrition, elimination, oxygenation, activity, rest, sleep, and safety
Grief and Grieving
• Supportive Care during the Dying and Grieving Process
• Emotional assessment
• Patient’s and family’s anxiety level, guilt, anger, level of acceptance, and identification
• Major fears: abandonment, loss of control, pain and discomfort, and the unknown
Grief and Grieving
• Supportive Care during the Dying and Grieving Process
• Intellectual assessment
• Evaluation of the patient’s and family’s educational level, their knowledge and abilities,
and expectations they have in regard to how and when death will occur
Grief and Grieving
• Supportive Care during the Dying and Grieving Process
• Social assessment
• Assessment of the patient’s and family’s support systems is valuable.
• Ascertain whether family members desire to assist in the patient’s daily care. Never
assume they do; many do, others do not.
• When families choose to take the patient home for care, be sure that they are well-
prepared before discharge for what they need to know and do.
Grief and Grieving
• Supportive Care during the Dying and Grieving Process
• Spiritual assessment
• Assess the spiritual dimension by gaining insight into the patient’s philosophy of life,
religious resources, and how the rituals of the particular faith group have significance in
dealing with his or her death.
Tasks of Mourning
Task I:
• To accept the reality of the loss
• Death is final
• Reunion is impossible, at least in this life
• Distortions in the form of denial or minimizing the impact of the loss
Task II:
• To experience the pain of grief
• Important to feel physical, emotional and behavioral pain associated
with loss
• Avoidance of feelings prolongs grief
Worden, J.W. (1982)
Tasks of Mourning

Task III:
• To adjust to an environment in which the deceased is missing or to adjust
to an environment after loss
• Child may need to learn to turn to others beside a parent for help

Task IV:
• To withdraw emotional energy and reinvest it in another relationship
• note written by a teenager to her mother after the death of her dad
“there are many other people to be loved, and it does not mean that I
love Dad any less”
• Not feeling like they are dishonoring, abandoning, forgetting the
deceased
Worden, J.W. (1982)
Shares Information Regarding Loss
What to Say
Words to use Avoid
• died • passed on
• death • long sleep
• pushing up daisies
• kicked the bucket
• went to sleep and died
• went to the hospital
and died
 Grief Support Facilitator
Supports the Grieving Process
• Listen
• Be honest, include, involve
• Respect photos and other mementos
• Minimize change
• Avoid assessment
• Support the observance of anniversaries
• Provide structure as needed
• Listen

Adapted Managing Grief Better: People with Intellectual Disabilities, Sheilla Hollins
 Grief Support Facilitator
Supports the Grieving Process
DO’S DONT’S
• Listen – seek a private place • Be judgmental, criticize or blame
• Mention the person by name – it • Tell them how they should feel
personalizes the loss • Lie or tell half truths
• Be genuine with expression of your • Use euphemisms like “gone away”,
feelings “resting”,“sleep”, etc…
• Encourage them to resume their • Be afraid to tell the individual that
normal activities, especially for you don’t know all the answers
adolescents peer group very • Avoid the individual – change
important subject
• Be prepared to attend to • Minimize the loss
individual’s spontaneous • Attempt to become a substitute for
expressions of feelings deceased
• Set limits, as needed • Pressure the individual to talk
Supportive Actions
Listening Actions
• Listening to someone who is crying is difficult, but important
• Calm down someone who is hysterical
• Don’t change the subject or distract the griever
• Don’t give advice or quiz for details
• Listen for content & the feelings underneath the content
• Pay attention to non-verbal communication
• Relax, be yourself
• Tolerate silence

Husar Bereavement Care

Supportive Actions
Listening Responses
• Nod, smile, intermittent eye contact
• Pause
• Casual Remark -“I see” “Uh huh”
• Echo- repeating back the last few words
• Clarify- asking for more information
• Paraphrase- summarizing what you heard
• Interpret the speaker’s ideas within context
Husar Bereavement Care