Attitudes towards loss, death and grief
If you are indifferent to the suffering of others, you do not deserve the title of a human being.
Saadi
LOSS, DEATH AND GRIEVANCE
The topic of a person's attitude to death is of universal importance. Here the interests of medicine are intertwined with the interests of religion, philosophy, art, psychology, etc. According to Christian views, the human soul is immortal, death exists only within the earthly (sinful) world, and in each specific case the question of life and death is ultimately in the hands of the Creator (God). Of the numerous philosophical explanations of the mystery of death, we will cite the materialistic reasoning of the ancient Greek sage Epicurus (341-270 BC): "The most terrible evil, death, has nothing to do with us, because when we exist, death is not yet present; and when death is present, then we no longer exist."
Death is always preceded by the emergence of a crisis situation. And it is very important for the nurse to be able to explain the psychology of a crisis to the patient and his family.
Some confusion can easily arise with the word "crisis" because we can use the term "crisis" to describe three very different situations:
1. A critical (emergency) situation in which something must be done immediately. For example, when there is a fire in the house or someone has a heart attack, death, or an accident.
2. A situation that requires a change in lifestyle or a decision that will be long-term, such as getting a certain job, getting an education, or finding a life partner.
3. The result of ineffective or unreasonable coping methods used when faced with the above situations. For example, getting a job that does not involve the skills or talents of any person, which can result in great dissatisfaction, boredom, and unhappiness.
What is a crisis?
A crisis occurs when a person encounters obstacles on the way to an important life goal that are currently unattainable using conventional problem-solving methods. When conventional problem-solving methods cannot be used to cope with the daily concerns of life, the balance, or equilibrium, of the personality is disrupted. The person experiences internal tension, anxiety, which ultimately leads to a period of emotional distress.
The literature states that a crisis is self-limiting and usually lasts from four to six weeks. It constitutes a transitional period that is a period of heightened psychological vulnerability and provides an opportunity for personal growth and development. In other words, experiencing and living through a crisis has the potential to improve or worsen a person’s emotional health.
The individual goes through a continuous process of encountering, mastering, and resolving a problem or crisis situation. When someone copes effectively, development occurs; when someone copes ineffectively, development does not occur. The outcome of a crisis is determined by the type of interaction that occurs between the individual and key figures in his or her emotional environment. This is largely the responsibility of the helping professions (care workers), especially nurses. If we are to be effective in promoting health and preventing disease, we need to engage with people in some therapeutic way when they are in crisis. This should ideally happen as soon as the crisis begins. People who enter a hospital or any other health care setting are most likely to be anxious, and some may be in crisis. The nurse is a key person in the emotional environment of the patient. Therefore, the nurse can have a great influence on the psychological well-being of the patient during their hospital stay. So, as a nurse, you need to know how to best promote the well-being of your patients.
TYPES OF CRISIS
There are two types of crises:
Growth crises
Growth crises are normal processes of growth and development. They develop over a long period, such as the transition from childhood to adolescence, which is accompanied by significant characterological changes. These are crises that most people go through if they live long enough.
Experiences that occur during a growth crisis: starting school, getting married, having a child, a new job, reaching certain ages, retirement, and others that are familiar to most of us. Situational crises
Situational crises refer to those events that occur in the environment that can be stressful for the individual and, thus, cause a crisis. These crises are associated with a significant loss of status (position), savings, a loved one.
Most people experience this type of crisis at some point in their lives. However, this happens individually for each person. For example, if you live long enough, you will survive the death of your parents. Some people experience this at age 5 or later, while others may not experience the death of their parents until they are in their 80s.
CRISIS INTERVENTION
Crisis intervention is the introduction of situational care to a person in crisis by a nurse, friend, or family. It is based on one or more planned actions to initiate change in a stressful situation.
The primary goal of care is to return the person to an optimal level of psychological and physiological balance within the constraints imposed by the crisis.
PHASES OF CRISIS
A crisis has the following four phases:
1. Psychological shock. The emotional balance, or equilibrium, of the individual is disrupted. The person is in a state of numbness, feels emptiness, anxiety, and fear. There is a feeling of unreality of what is happening, and suicidal thoughts appear.
It is difficult to concentrate, the person often cries, screams or laughs. It is characterized by visual and auditory hallucinations, a feeling of the presence of the deceased.
2. Denial (despair).
In this phase, the individual is unable to face the reality of the problem or situation that has arisen before him. During this phase, we hear people say things like: "I can't believe this happened", or "It's impossible that this happened", or "This is unreal". This phase is characterized by feelings of anger, guilt, acute sadness, a sense of injustice of what is happening. The person begins to avoid others, memory is impaired. The first 6 weeks are especially difficult. Over time, it is replaced by sadness and a feeling of helplessness.
3. Recognition.
This phase occurs when the individual can no longer deny the real problems that have arisen before him. The person admits to himself and others: "Yes, this happened".
4. Adaptation (adaptation).
Adaptation and depression. During this period, insomnia, headaches, appetite disturbances and other diseases of various organs and systems provoked by stress (after threshold arousal) often appear. At this stage, the individual recognizes the problem or situation, he begins to actively cope with it or adapt to it in order to reduce the increase in stress and anxiety. Here the help of a nurse is needed.
Let's consider an example of a crisis situation.
It was a cold winter day, the streets were covered with ice. Mr. Baker stopped at a red light. A few seconds later, a red Mercedes hit the back of his car. A middle-aged man slowly got out of the Mercedes. He had a surprised look. Blood was gushing from a deep cut on his forehead.
"What happened?" he asked.
"You crashed into my car," Mr. Baker replied. "You'd better sit down and I'll call an ambulance."
"No need," the man said, "I'm fine. Call the police."
"You're not fine, especially with that dangerous cut on your forehead," Mr. Baker replied.
"A dangerous cut? What kind of dangerous cut?" the man asked, putting his hand to his forehead.
Then he noticed blood on his arm and on his clothes.
"I must have hurt myself," he said.
"I'll call an ambulance," Mr. Baker repeated.
"Yes, I feel a little dizzy, I'd better sit down," the man replied.
Let's consider the phases of a crisis.
1. Psychological shock
- slowly got out of the Mercedes,
- strange (surprised) look on his face,
- "what happened?"
2. Denial
- "I'm fine",
- "A dangerous cut?"
- "What kind of dangerous cut?"
3. Recognition
- notices blood on the arm and clothes,
- "I must have cut myself",
- "Yes, I feel a little dizzy"
4. Adaptation
- "I'd better sit down".
(adaptation)
Crisis management measures
There are two main differences between the process of caring for a patient and crisis management.
1. We only collect information about what happened and what led to the crisis. While we are caring for a patient, we collect as much information about the individual as possible.
2. Our goal in dealing with a crisis is short-term and aimed mainly at solving the immediate problems of the individual, while the process of caring for a patient is related to both short-term and long-term long-term consequences for the patient.
The nature of the particular crisis will greatly influence the action that will need to be taken to help the person experiencing it. However, there are certain guidelines that must be followed when you are trying to help the person experiencing it. We will now focus on them:
1) Help the person gain an intellectual understanding of the crisis situation.
Some people do not see the connection between what they are feeling and the situation. Help the individual express their feelings. Examine (critically evaluate) their coping mechanisms. Help the person consider alternative ways of coping with stress. Expand their social range. If there is a loss in the person's life, it would be effective to find people who would fill this void.
2) Listen carefully. Try to understand what the person is experiencing and convey this understanding to them.
3) Teach. Help the person understand what they are feeling and give them new tasks that can help them overcome the difficulties. Sometimes it is helpful for the person to understand that they are going through a crisis and that many of their feelings and experiences are normal for anyone going through a crisis. As a helper, you may have some information about the situation that is causing the crisis. This can be helpful for the person. For example, people who have experienced the loss of relatives have a tendency to be physically tired and require much more rest and sleep than usual.
4) Show the way to healthy behavior. Get the person interested in leading a healthy lifestyle. Since there are no standards for healthy behavior, you may make some judgments about what is healthy and what is not. There is a possibility of error. However, the possibility of positive effects is worth the risk of making a mistake. You can encourage the patient to lead a healthy lifestyle by reinforcing this with positive examples.
5) Beware of a hopeless situation. Beware of accepting decisions that would probably help a person overcome a crisis, but which would prevent them from developing or create problems in the future. For example, in order to overcome the pain of separation from a loved one, a person may decide to never be close to anyone again. This may prevent future anxiety, but it would accelerate other problems - loneliness and lack of meaning in life.
6) Avoid labels. Discourage people from labeling themselves sick. Labels of illness, such as neurosis, depression or schizophrenia, can encourage a person to reject any attempts and efforts to overcome a crisis. The reason may be that the sick person needs to be taken care of. Most crises, in order to be resolved constructively, require the activity of the person experiencing the crisis.
7) Make decisions. If the person is overwhelmed or confused, there may be a brief need to make decisions for them. For example, after a fire or car accident, the person may be too overwhelmed to function normally, so it may be necessary to make decisions for them.
8) Maintain a routine. If possible, help the person stay in their normal routine. This can help them get through the crisis and come out of shock more quickly. For example, eating three meals a day or getting dressed every morning.
Nurses must help manage crises in many different situations. At work, we may deal with crises from patients, relatives of patients, and staff of institutions. At home and in our personal lives, we may deal with our own crises or those of family, relatives, friends, and neighbors. By recognizing crises and crisis phases and understanding how to overcome them, we can be effective in better developing skills for people to overcome the development of a crisis more quickly, which are no less important than skills to overcome the illness itself.
The feeling of loss is a deep and intense suffering caused by the loss of a loved one. Rafael describes the emotional reaction to loss as a combination of heartache, sadness, anger, helplessness, guilt, and despair.
Stages of emotional reaction:
1. Shock. A person is in a state of numbness, feels emptiness, anxiety, and fear. There is a feeling of unreality of what is happening, thoughts of suicide appear. It is difficult to concentrate, a person often cries, screams, or laughs.
2. Despair (denial). Feelings of anger, guilt, intense longing, and a sense of injustice of what is happening. The person begins to avoid others, his memory is impaired. The first five weeks are especially difficult. Despair lasts more than six months and can occur over the next several years. Over time, it changes to sadness and a feeling of helplessness.
3. Recognition.
4. Adaptation. Apathy and depression. During this period, insomnia, headache, appetite disorders and other diseases of various organs and systems provoked by stress (threshold arousal) often appear.
Pathological reactions to loss
The reaction to loss is considered pathological if it is accompanied by an excessive emotional outburst, too long or completely absent. Anger is an emotional reaction that reproduces the rejection of what is happening.
With a pathological reaction to loss, a person can talk for hours about the deceased and the circumstances of his death.
The goal of intervention in crisis situations
To restore psychological balance, help the patient gain control over himself and the situation.
Principles:
- intervention should be timely, active and decisive;
- create an atmosphere of spiritual closeness, fight against alienation;
- seek support from family and society;
- remember that the most difficult experiences occur in the first days after the death of a loved one;
- do not increase the patient's suffering;
- do not delay treatment, plan a course of psychotherapy for six weeks (one conversation per week).
10 tips for those experiencing grief:
1. Give vent to emotions, do not hold back feelings, do not be shy to cry.
2. Talk about your grief with friends. Do not hide what happened. Ask for advice, but do not burden your friends with complaints.
3. Focus on the present. Try not to think about the misfortune that happened. Look to the future with hope.
4. Don't try to solve all the difficulties at once.
5. If you know what you are doing, act quickly and decisively. Act according to the developed plan.
6. Don't be alone, try to do something else. Any activity - sports, theater, clubs - will benefit you.
7. Don't blame others. Restrain anger and hostility, especially directed at family members.
8. Do physical exercises every day: walking, swimming, gymnastics.
9. Stick to the daily routine. The usual way of life (regular meals, housework) brings a sense of security. Don't stay up late and try not to think about your grief before going to bed.
10. If you need help, consult a doctor, you will also be helped in church.
Notification of the accident:
- a doctor or police officer should notify relatives in person, not by telephone;
- the conversation with relatives should be held in a separate room;
- if it is necessary to notify by telephone, this should
be done by an experienced person;
- relatives should be given a detailed and clear explanation of the causes and circumstances of the patient's death, and the post-mortem examination should not be withheld from them.
Recommendations for the person reporting the accident.
1. Give relatives the opportunity to:
1.1. Realize what happened.
1.2. React.
1.3. Express emotions freely.
1.4. Be silent.
1.5. Ask questions.
1.6. See the deceased.
2. Avoid:
2.1. Haste.
2.2. Harshness.
2.3. Lies.
2.4. Banality.
2.5. Answer all questions.
2.6. Do not hide the cause of death.
Help
• Reactions can be very diverse - from stunned silence and unwillingness to believe what happened, to strong anger and feelings of guilt.
• Give the opportunity to cry.
• As a sign of comfort, take the relative's hand or put your hand on their shoulder.
• Offer a cup of tea or water.
• Ask how the person is feeling.
Dying patient
Treating a dying patient is a difficult test for every medical worker, because it is difficult to understand one's own powerlessness. During this period of life, he becomes the closest person to the patient, helping them to live without losing their human dignity, satisfying their physical, emotional and spiritual needs, and experiencing their last joys.
The main components of care include:
• emotional, social and spiritual support;
• symptomatic treatment;
• psychotherapy.
A nurse caring for a dying patient should be able to answer the following questions from the patient:
• What is the essence of the disease?
• What can be done to improve the general condition?
• Will I suffer?
• How long will I live?
• Will I be able to stay at home or will I die in the hospital?
These are the most difficult questions. In order to discuss them with the patient, honesty, tact and experience are required.
Diseases for which radical treatment is not possible include: malignant neoplasms in the terminal stage, HIV infection in the AIDS stage, late stages of heart, kidney, respiratory and liver failure, severe neuropsychiatric diseases.
Helping patients and their relatives
A nurse must:
- be able to listen;
- understand non-verbal fashion;
- provide emotional support;
- communicate with the patient openly, trustingly, treat the patient with compassion;
- answer questions honestly, do not give hopes that do not come true;
- give the opportunity to ask;
- understand the needs of the patient;
- try to meet the patient's needs;
- anticipate difficulties and be ready to solve them.
The patient wants to feel protected. He is waiting to be reassured, told that he will not suffer. It is important for the patient to know that everything possible is being done, he should not feel isolated, he should not feel that something is being hidden from him. The worst thing for the patient is the refusal of a medical worker to help. The most common problems in dying patients:
- depressed mood;
- anxiety;
- pain;
- anorexia (lack of appetite);
- nausea, vomiting;
- constipation.
E. Kubler-Ross identifies four stages of dying:
- denial;
- anger;
- depression;
- acceptance.
The stages may vary, there may be no individual stages, but the scheme as a whole allows you to understand what the dying person is going through and to plan the consultation correctly.
The main principles of consultation are as follows:
- always be ready to provide help;
- show patience;
- give the opportunity to speak out;
- say a few comforting words, explain to the patient that his feelings are completely normal;
- treat his anger calmly;
- avoid inappropriate optimism;
- advise family members to be together.
For people facing imminent death, spiritual life is of particular importance. Believers come to terms with imminent death more easily. Many non-believers, faced with death, search for the meaning of the life they have lived.
Those around them should understand how confused the sick person is and should be ready to lend him a helping hand. The priest plays a huge role here. Helping a patient to rely on his spiritual strength means helping him to rise above his illness.
The cessation of life occurs gradually, even with seemingly instantaneous death. Therefore, death is a process, and in this process several stages can be distinguished: preagony, agony, clinical and biological death.
Preagony is characterized by different duration (hours, days). During this period, shortness of breath, a decrease in blood pressure to 60 mm Hg. and below, tachycardia are observed. A person experiences a clouding of consciousness. If a patient develops a terminal condition, it is imperative to inform relatives about this.
Agony (from the Greek agonia - struggle) is initially observed some increase in blood pressure, increase in heart rate, sometimes even restoration of consciousness (short-lived, up to several minutes). Then, after this, it would seem, improvement, there is a sharp drop in blood pressure (up to 10-20 mm Hg), heart rate slows down to 20-40 per minute, breathing becomes uneven, superficial, with rare short and deep breathing movements and, finally, it stops altogether, consciousness is lost. There is spontaneous urination and defecation. The pupils dilate, the corneal reflex disappears. General tonic convulsions are observed, body temperature decreases. The duration of the agonal period in patients dying from chronic diseases is several hours. This stage is characterized by the cessation of all body functions and at the same time the extreme tension of protective devices, which are already losing their expediency.
Clinical death is a state when all visible signs of life have disappeared (breathing and heart function have stopped), but metabolism, albeit at a minimal level, still continues. At this stage, life can be restored.
Signs of clinical death are:
- lack of reaction of the pupils to light;
- lack of breathing;
- lack of pulse on the carotid artery;
- lack of consciousness.
Clinical death lasts 5-6 minutes.
That is why resuscitation measures are carried out in the stage of clinical death in order to return a person to life.
Biological death is characterized by irreversible changes in the body.
It is better not to leave loved ones alone with a dying or deceased person. A nurse should be ready to provide them with psychological support, to sit them down, to give them water. Dying is the disintegration of the integrity of the body. The body ceases to be a self-regulating system. First, those elements that unite the body into a single whole are destroyed. This is, first of all, the nervous system. The most sensitive to hypoxia is the cerebral cortex. First, brain cell activation occurs, which causes motor excitement, increased breathing and pulse, increased blood pressure, and then inhibition occurs.
Biological death is accompanied by:
• cardiac arrest;
• respiratory arrest;
• muscle relaxation;
• cooling of the body to ambient temperature.
Corpse blue spots appear on the lower parts of the body. The doctor records the fact of death and writes the day and time in the inpatient patient's chart.
After the doctor has registered the fact of death, it is necessary to:
1) put a screen near the deceased's bed or take the bed to another room;
2) take away the pillow;
3) remove the clothes from the deceased;
4) lay the deceased on his back, close his eyes, tie up the lower jaw, straighten his limbs;
5) cover the deceased with a sheet.