- Email: [email protected]
Caregiver grief: Taking care of ourselves and our patients
FROM THE FOOD AND DRUG ADMINISTRATION
Caregiver Grief: Taking Care of Ourselves and Our Patients Suzanne Rich, RN, BA lthough nurses are known for caring about and talking with their patients, most have been trained to not get “too involved.” They are to maintain a professional distance to ensure the integrity of professional judgment. However, the death and dying movement, popularized by Dr Elisabeth KublerRoss in the late 1960s, promotes attempts to humanize death within hospital environments, including critical care and trauma units. As health care professionals, nurses are encouraged to extend themselves beyond professional barriers. They are to become involved with patients and their families as part of caregiving. Although benefits of this extension include a better quality of care for patients and their families, sadly, these benefits are often at the risk of a caregiver’s own well-being. This is particularly true in acute care settings and in settings in which staffing shortages lead to heavy workloads. When a patient dies, nurses feel an acute sense of loss, both professionally and personally. Professionally, when particular treatments or interventions fail and the patient clearly shows signs of dying, nurses may feel responsible, guilty, angry, depressed, or helpless. On a personal level, when nurses are unable to relieve or control a patient’s
A
Suzanne Rich, RN, BA is a Supervisory Nurse Consultant with the Food and Drug Administration’s Center for Devices and Radiological Health, is a hospice volunteer, and is completing a Certificate in Thanatology at Hood College. Please write [email protected] with comments. Reprint requests: Suzanne Rich, RN, BA, Center for Devices and Radiological Health, Office of Surveillance and Biometrics, Division of Postmarket Surveillance, Product Evaluation Branch II, Food and Drug Administration, 1350 Piccard Dr, Rockville, MD 20850. Int J Trauma Nurs 2002;8:24-8. 1075-4210/2002/$35.00 + 0 65/1/121332 doi:10.1067/mtn.2002.121332 24 INTERNATIONAL JOURNAL OF TRAUMA NURSING/Rich
symptoms, such as nausea or pain, they may feel incapable of dealing with a dying patient. The dayto-day demands of providing care for critically ill patients in life-or-death situations often prevent caregivers from processing grief associated with the death of a patient, which can result in frustration, depression, stress, and, eventually, burnout. Repeated losses may accumulate without adequate time to process them, which exhausts an individual’s ability to cope and contributes to what is known as bereavement overload.2 This is particularly true in cases in which a patient has died too soon, too young, too painfully, or is too similar to the caregiver. In such cases, it is likely that one or more caregivers, and sometimes an entire ward, may need to grieve.3 BEREAVEMENT, GRIEF, AND MOURNING After a death, both caregivers and patients’ families face the task of integrating the loss into their personal awareness and their particular set of circumstances. The process of adapting to loss or mourning, (also known as griefwork) requires a genuine effort on the part of the survivor to adapt to an environment without the deceased. The terms bereavement, grief, and mourning are often used interchangeably; however, there is a difference between them. Bereavement is the objective state of having suffered a loss. Grief is a passive experience involving a variety of reactions to the perception of loss. It is a necessary first step in accommodating a loss. Mourning is an active response to loss that involves conscious and unconscious processes. It deals with challenges to our assumptions about the world and ourselves that are created by a loss.4 The process of mourning can be understood as similar to the process of healing. Incomplete adaptation to loss can exist just as incomplete wound healing can exist. In his book, Grief Counseling & Grief Therapy, Dr J. William Worden, a leading researcher and writer in the field of death and dying, has identified 4 tasks of mourning. VOLUME 8, NUMBER 1
TASKS OF MOURNING Although there is no specific order for completion, by definition some tasks need to be completed before working on the next. For example, one must accept that a death has occurred before dealing with its emotional impact. Caregivers involved in critical care and trauma settings are usually involved with patients and their families during the time immediately surrounding the death. Still, it is important to understand all 4 of Worden’s tasks to effectively complete the mourning process. 1. Accept the reality of the loss. When a death occurs, survivors experience a sense of shock and unreality, a belief that it just cannot be. Patients and caregivers alike need objective facts to accept the reality of the actual loss. They may have many unanswered questions. This is particularly true in cases of sudden death, in which there is an increased need to understand the events that led up to the death. 2. Experience the pain associated with grief and express feelings. The pain associated with grief is physical and emotional. Emotionally, it is shown through crying and anger and through the experience of a profound sense of loss and powerlessness. It is important to experience the pain at the time of the loss to move on and feel relief. Suppression of grief provides momentary relief and permanent pain. Experiencing the pain means venting feelings, including those of anger, even if the anger is directed toward the person that died (eg, a teenager who died while drinking and driving). Sudden deaths often provoke strong guilt responses and self-recrimination in survivors (eg, “If only I hadn’t let her go to the party alone”). Along with guilt, survivors experience a sense of helplessness and a need to blame. The reality of sudden death assaults our sense of power and our need for order. Survivors may want to vent their anger, particularly toward caregivers involved with the death of their loved one. Threats of litigation and violence toward medical personnel are efforts to combat the helplessness and rage that survivors experience. A desire for retribution may be a defense against the pain and reality of the death.5 3. Adjust to the environment without the deceased. Survivors face the task of readjusting to an altered world without losing memories of the loved one. In addition to dealing with the pain associated with the loss, adjustment involves many practical issues, including financial and legal concerns. Much support is needed from family, friends, and coworkers, and from pro-
fessionals, such as lawyers, financial advisors, and counselors. 4. Reinvest in life and living. This is the most difficult of the 4 tasks and takes the longest time. It involves emotionally relocating the deceased and moving on with life. Withdrawing emotional energy from the deceased and moving to other relationships or interests is often intrepreted as asking a survivor to forget; however, survivors do not have to deny the past to make a future. The objective is to look at things in a new way, focus on new goals, and reinvest energy spent on grieving into living. The period of grieving will last as long as there are “firsts” (the first Christmas, birthday, or anniversary) after the death of a loved one. The first year is usually the hardest because there are fewer and fewer firsts as time goes on.3
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INTERNATIONAL JOURNAL OF TRAUMA NURSING/Rich 25
FACTORS THAT INFLUENCE ADJUSTMENT TO LOSS Three major factors influence adjustment to loss. 1. Sudden versus expected death. Sudden death is almost always harder to deal with. With an expected death, the survivors can begin anticipatory grief or mourning and this sometimes helps lessen grief after death. In the case of a motor vehicle crash, cardiac arrest, drug overdose, or other trauma, there is not time for anticipatory grief or mourning for survivors or caregivers. 2. Mode of death. If the death was sudden, such as a situation involving a homicide, suicide, or accidental death, survivors have an acute sense of unreality about the loss. It is not unusual for survivors to feel numb and walk around in a daze.4 This reaction may also happen with expected death. 3. Relationship to the deceased. The death of a child is often cited as the most difficult for both families and caregivers. For bereaved parents, the loss of a child can be one of life’s most devastating losses.4 Caregivers typically find it stressful to deal with the reality of death among the young because the loss is seen as untimely, unfair, and unacceptable.6 USEFUL INTERVENTIONS FOLLOWING SUDDEN DEATH As caregivers, nurses can provide a patient’s family with an opportunity to begin their process of grieving. Nurses can answer questions, allow the family to express their grief, and facilitate the
Table 1. Selected professional and caregiver resources* American Association of Suicidology American Hospice Foundation Association for Death Education and Counseling Hospice Foundation of America Last Acts National Center for Post-Traumatic Stress Disorder Project on Death in America Suicide Information and Education Trauma
www.cyberpsych.org www.americanhospice.org www.adec.org www.hospicefoundation.org www.lastacts.org www.dartmouth.edu/dms/pts/dindex.html www.soros.org/death.html www.siec.ca www.ozemail.com.av/dwillsb/trauma.htm
*Adapted from Kastenbaum.2
process of saying “goodbye” by initiating appropriate interventions while the patient is still in the hospital. As difficult as it may be for nurses as caregivers to inform a family of the death of their loved one, it is even more difficult for the family to hear and accept it. The goal is to provide a supportive, private atmosphere (as circumstances can allow) in which family members can begin to express their grief and actualize their loss. A room that is set apart from the active treatment area can provide a calm, reassuring atmosphere for patients’ families who are in crisis. The manner in which a family is treated at the time of crisis often remains indelibly imprinted in the minds of survivors for years to come. Offer help assertively and calmly. Asking a family if they would like help can produce a vague, noncommittal response. Instead, nurses can request an intervention by a designated spiritual or mental health care provider (eg, chaplain, grief counselor, or therapist). A nurse can initiate dialogue with the family to let the family know that he or she is there to work with them as they experience this loss. In the first moments after a death, it is important to provide survivors with sympathetic strength and understanding. This can be accomplished by maintaining direct eye contact, firmly holding the bereaved person’s hand(s) or shoulders, speaking slowly and clearly, answering questions briefly in a calm and controlled manner, and providing firm physical support as needed.7 Provide the family with the choice to see the body. The nurse should make sure the body is displayed as appropriately as possible. If the body is mutilated (eg, in a motor vehicle crash), the family should be informed of this fact before viewing the body. The family should be able to see the body or a part of the body that can help bring home the reality of the loss.4 Use clear, concise, and factual language. Careful discussions can assist the family in coming 26
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Rich
to terms with the reality of the patient’s death. The word “dead” or “died” should be used. Platitudes, such as “it’s going to be all right,” should be avoided because their intent is the direct opposite of what survivors are experiencing. Vague terms promote a survivor’s denial of the death as reality. Make referrals for follow-up care. Followup care can be arranged through institutional, community, or religious resources. It helps to become familiar with these resources, including those that offer specialized support for specific types of sudden death. For example, The Compassionate Friends is an international support group for bereaved parents and siblings. Mothers Against Drunk Driving (MADD) works with families in alcohol-related deaths. Table 1 lists professional and caregiver resources available on the Internet. MANIFESTATIONS OF EARLY GRIEF There are predictable manifestations of early grief for survivors. On learning of the death, caregivers and survivors may experience feelings of sadness, guilt, and anger, some of which may be targeted toward the patient or other caregivers. Survivors may feel shock, numbness, and a sense of helplessness as the reality begins to sink into the consciousness. These feelings may be accompanied by a sense of disbelief, vulnerability, and an increased realization of one’s own mortality. Survivors of traumatic death are left with questions about the order of the universe and a sense of chaos that results from loss of control. They often feel victimized and have an intense need to feel they have regained command of their lives and environment.8 Traumatic death circumstances. Certain deaths are associated with difficulties in grieving. These include suddenness and lack of anticipation; violence, mutilation, and destruction; preventability and/or randomness; multiple deaths; and the VOLUME 8, NUMBER 1
survivor’s personal encounter with death in which there is a significant threat to his or her own survival or a massive shocking confrontation with the death and mutilation of others.9 Learning of a sudden death leaves survivors and caregivers with no time to prepare for the loss. The mere act of confronting death overpowers the ability to adapt to the situation. The emotional and physiologic shock reinforces a sense of personal vulnerability and interferes with the ability to fully grasp what has occurred and begin grieving. Violence, mutilation, and destruction revive a basic death anxiety and fear of extinction, leaving survivors to deal with those stresses in addition to their mourning. The perception of a death being preventable often prolongs the duration and intensity of grief and mourning. A death perceived to be unfair or unjust bewilders the mind and calls for explanation, thus intensifying emotional responses. Random events are offensive because they are unpredictable and, therefore, uncontrollable. It is common to see survivors and victims assume blame for the event. It is easier to assume responsibility than to perceive that the event is truly unpredictable and thus, out of our control. Multiple deaths, in addition to the issues mentioned earlier, confront the survivor with the concurrent stressors of mourning for each deceased individual. This, in turn, may delay or interrupt grieving for the other victims. Survivors of experiences in which there was a threat to individual survival or the shocking confrontation of death and mutilation of others often experience posttraumatic reactions, such as posttraumatic stress disorder. In these situations, posttraumatic stress reactions occur because of the overwhelming threat to personal survival and sudden helplessness in not being able to prevent the deaths of others.
incident.10 Critical incident debriefing is a process whereby caregivers have an opportunity to express individual thoughts and feelings within a peer group. The group members understand the common experience and discuss it in a safe environment, instead of taking it home. Debriefing sessions are led by peer counselors (members of the caregiver team) not directly involved in the trauma situation. The counselors facilitate confidential discussion and provide information and resources for follow-up.3
Debriefing Process Seven steps are involved in the debriefing process. 1. Introduction. The group is oriented to the specific situation being addressed and ground rules are laid, including the requirement of confidentiality. 2. Fact phase. Group participants are asked to characterize the facts about what happened, focusing specifically on the events. 3. Thought phase. Group participants describe the thoughts going through their minds immediately before, during, and after the incident. 4. Reaction phase. Group participants are invited to share their emotions about what happened. 5. Symptom phase. The team counselor discusses physical and emotional signs and symptoms of stress. 6. Teaching phase. The team counselor provides information about responses that signal a need for further follow-up. Individuals may self-identify their need for counseling. 7. Re-entry phase. Constructive suggestions for dealing with the situation are summarized, questions are answered, and closure is accomplished.
NEEDS OF CAREGIVERS Although caregivers experience death in their own ways, an opportunity to grieve these losses should be provided in the workplace. Caregivers may exhibit simultaneous or sequential feelings of fear, anger, guilt, and frustration. Caregivers may not only suffer the frustration of having been powerless at the time of the death, but they may also find themselves equally powerless to deal with the intense emotional response. In a 1999 study at Brussels University Hospital, survey comments indicate that health care providers consider other emergency department staff members to be their primary support and prefer to have a debriefing with their colleagues after a critical
Weekly rounds to discuss the circumstances surrounding a patient’s death may be helpful. Staff members involved in the patient’s care discuss what they learned from the patient, the course of treatment surrounding the death, ways in which treatment may have been improved, and feelings or symptoms they may be experiencing.6 In the rounds, involved caregivers can do specific acts, such as sign and send a sympathy card to the patient’s family a month after the death. The individuality of each person’s grief response is acknowledged and discussed. Caregivers may or may not experience well-known symptoms of grief such as a decreased ability to concentrate, absent-minded behavior, sleep and appetite disturbances, and a lack of energy. Care-
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givers may also experience physical manifestations of grief, such as those seen in patients: shortness of breath, palpitations, dry mouth, muscle weakness, and suppression of the immune system in cases of prolonged stress.4 CONCLUSION Not everyone grieves in the same way. Thus it is important to recognize, validate, and support individual differences in mourning. Some people may express their grief primarily by talking through their feelings (intuitive grieving). Other people may express their grief primarily through activity or problem solving (instrumental grieving). Instrumental grievers are often uncomfortable sharing their feelings with others and often avoid discussing them in a group setting.11 By understanding grief as a predictable, yet individual response to the loss of a patient or a loved one, caregivers can take care of themselves while providing quality care for those whom they serve. I acknowledge the editorial guidance and assistance of Dr Dana Cable and Dr Terry Martin, professors of Psychology and Thanatology, Hood College, Frederick, Md.
REFERENCES 1. Vachon ML. Staff stress in care of the terminally ill. Qual Rev Bull 1979;5:13-7. 2. Kastenbaum R. Death, society, and human experience. 7th ed. Boston: Allyn & Bacon; 2001. 3. Parkes CM. The caregiver’s griefs. J Palliat Care 1986;2:5-7. 4. Cable D, Martin T. Principles of counseling the bereaved. Frederick (MD): Hood College; 2001. 5. Rynearson EK. Bereavement after homicide: a descriptive study. Am J Psychiatry 1984;141:1452-4. 6. Vachon ML. Occupational stress in the care of the critically ill, the dying, and the bereaved. Washington: Hemisphere; 1987. 7. Pine V. Psychological aspects of disaster death. In: Doka K, editor. Living with grief after sudden loss. Washington: Hospice Foundation of America; 1996:103-16. 8. Weeks O. Using funeral rituals to help survivors. In: Doka K, editor. Living with grief after sudden loss. Washington: Hospice Foundation of America; 1996:127-38. 9. Rando T. Complications in mourning traumatic death. In: Doka K, editor. Living with grief after sudden loss. Washington: Hospice Foundation of America; 1996:139-60. 10. Flam R. Helping the bereaved at the emergency department: a study at the Brussels University Hospital. Int J Trauma Nurs 1999;5:95-8. 11. Martin T, Doka K. Men don’t cry…women do: transcending gender stereotypes of grief. Philadelphia: Buchanan; 2000.
Glutaraldehyde—Occupational Hazards in Hospitals The National Institute of Occupational Safety and Health (NIOSH) of the Centers for Disease Control and Prevention (CDC) has developed a brochure to make health care providers aware of the adverse health effects of glutaraldehyde, common methods of exposure, and methods used to reduce occupational exposure. Glutaraldehyde has been used widely in hospitals to disinfect heat-sensitive instruments, to fix histologic specimens, and to process x-rays. It is provided under the trade names of Cidex, Hospex, Metricide, Ominicide, Sonacide, Sporicidin, and Wavicide. To obtain a copy of the brochure, readers may write to NIOSH—Publications Dissemination, 4676 Columbia Pkwy, Cincinnati, OH 45226-1998; call 1-800-35NIOSH (1-800-356-4674); fax (512) 533-8573; or e-mail [email protected]. The report can be read online at http://www.cdc.gov/niosh/2001-115.html.
28
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VOLUME 8, NUMBER 1
Caregiver Grief: Taking Care of Ourselves and Our Patients Suzanne Rich, RN, BA lthough nurses are known for caring about and talking with their patients, most have been trained to not get “too involved.” They are to maintain a professional distance to ensure the integrity of professional judgment. However, the death and dying movement, popularized by Dr Elisabeth KublerRoss in the late 1960s, promotes attempts to humanize death within hospital environments, including critical care and trauma units. As health care professionals, nurses are encouraged to extend themselves beyond professional barriers. They are to become involved with patients and their families as part of caregiving. Although benefits of this extension include a better quality of care for patients and their families, sadly, these benefits are often at the risk of a caregiver’s own well-being. This is particularly true in acute care settings and in settings in which staffing shortages lead to heavy workloads. When a patient dies, nurses feel an acute sense of loss, both professionally and personally. Professionally, when particular treatments or interventions fail and the patient clearly shows signs of dying, nurses may feel responsible, guilty, angry, depressed, or helpless. On a personal level, when nurses are unable to relieve or control a patient’s
A
Suzanne Rich, RN, BA is a Supervisory Nurse Consultant with the Food and Drug Administration’s Center for Devices and Radiological Health, is a hospice volunteer, and is completing a Certificate in Thanatology at Hood College. Please write [email protected] with comments. Reprint requests: Suzanne Rich, RN, BA, Center for Devices and Radiological Health, Office of Surveillance and Biometrics, Division of Postmarket Surveillance, Product Evaluation Branch II, Food and Drug Administration, 1350 Piccard Dr, Rockville, MD 20850. Int J Trauma Nurs 2002;8:24-8. 1075-4210/2002/$35.00 + 0 65/1/121332 doi:10.1067/mtn.2002.121332 24 INTERNATIONAL JOURNAL OF TRAUMA NURSING/Rich
symptoms, such as nausea or pain, they may feel incapable of dealing with a dying patient. The dayto-day demands of providing care for critically ill patients in life-or-death situations often prevent caregivers from processing grief associated with the death of a patient, which can result in frustration, depression, stress, and, eventually, burnout. Repeated losses may accumulate without adequate time to process them, which exhausts an individual’s ability to cope and contributes to what is known as bereavement overload.2 This is particularly true in cases in which a patient has died too soon, too young, too painfully, or is too similar to the caregiver. In such cases, it is likely that one or more caregivers, and sometimes an entire ward, may need to grieve.3 BEREAVEMENT, GRIEF, AND MOURNING After a death, both caregivers and patients’ families face the task of integrating the loss into their personal awareness and their particular set of circumstances. The process of adapting to loss or mourning, (also known as griefwork) requires a genuine effort on the part of the survivor to adapt to an environment without the deceased. The terms bereavement, grief, and mourning are often used interchangeably; however, there is a difference between them. Bereavement is the objective state of having suffered a loss. Grief is a passive experience involving a variety of reactions to the perception of loss. It is a necessary first step in accommodating a loss. Mourning is an active response to loss that involves conscious and unconscious processes. It deals with challenges to our assumptions about the world and ourselves that are created by a loss.4 The process of mourning can be understood as similar to the process of healing. Incomplete adaptation to loss can exist just as incomplete wound healing can exist. In his book, Grief Counseling & Grief Therapy, Dr J. William Worden, a leading researcher and writer in the field of death and dying, has identified 4 tasks of mourning. VOLUME 8, NUMBER 1
TASKS OF MOURNING Although there is no specific order for completion, by definition some tasks need to be completed before working on the next. For example, one must accept that a death has occurred before dealing with its emotional impact. Caregivers involved in critical care and trauma settings are usually involved with patients and their families during the time immediately surrounding the death. Still, it is important to understand all 4 of Worden’s tasks to effectively complete the mourning process. 1. Accept the reality of the loss. When a death occurs, survivors experience a sense of shock and unreality, a belief that it just cannot be. Patients and caregivers alike need objective facts to accept the reality of the actual loss. They may have many unanswered questions. This is particularly true in cases of sudden death, in which there is an increased need to understand the events that led up to the death. 2. Experience the pain associated with grief and express feelings. The pain associated with grief is physical and emotional. Emotionally, it is shown through crying and anger and through the experience of a profound sense of loss and powerlessness. It is important to experience the pain at the time of the loss to move on and feel relief. Suppression of grief provides momentary relief and permanent pain. Experiencing the pain means venting feelings, including those of anger, even if the anger is directed toward the person that died (eg, a teenager who died while drinking and driving). Sudden deaths often provoke strong guilt responses and self-recrimination in survivors (eg, “If only I hadn’t let her go to the party alone”). Along with guilt, survivors experience a sense of helplessness and a need to blame. The reality of sudden death assaults our sense of power and our need for order. Survivors may want to vent their anger, particularly toward caregivers involved with the death of their loved one. Threats of litigation and violence toward medical personnel are efforts to combat the helplessness and rage that survivors experience. A desire for retribution may be a defense against the pain and reality of the death.5 3. Adjust to the environment without the deceased. Survivors face the task of readjusting to an altered world without losing memories of the loved one. In addition to dealing with the pain associated with the loss, adjustment involves many practical issues, including financial and legal concerns. Much support is needed from family, friends, and coworkers, and from pro-
fessionals, such as lawyers, financial advisors, and counselors. 4. Reinvest in life and living. This is the most difficult of the 4 tasks and takes the longest time. It involves emotionally relocating the deceased and moving on with life. Withdrawing emotional energy from the deceased and moving to other relationships or interests is often intrepreted as asking a survivor to forget; however, survivors do not have to deny the past to make a future. The objective is to look at things in a new way, focus on new goals, and reinvest energy spent on grieving into living. The period of grieving will last as long as there are “firsts” (the first Christmas, birthday, or anniversary) after the death of a loved one. The first year is usually the hardest because there are fewer and fewer firsts as time goes on.3
JANUARY-MARCH 2002
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Rich 25
FACTORS THAT INFLUENCE ADJUSTMENT TO LOSS Three major factors influence adjustment to loss. 1. Sudden versus expected death. Sudden death is almost always harder to deal with. With an expected death, the survivors can begin anticipatory grief or mourning and this sometimes helps lessen grief after death. In the case of a motor vehicle crash, cardiac arrest, drug overdose, or other trauma, there is not time for anticipatory grief or mourning for survivors or caregivers. 2. Mode of death. If the death was sudden, such as a situation involving a homicide, suicide, or accidental death, survivors have an acute sense of unreality about the loss. It is not unusual for survivors to feel numb and walk around in a daze.4 This reaction may also happen with expected death. 3. Relationship to the deceased. The death of a child is often cited as the most difficult for both families and caregivers. For bereaved parents, the loss of a child can be one of life’s most devastating losses.4 Caregivers typically find it stressful to deal with the reality of death among the young because the loss is seen as untimely, unfair, and unacceptable.6 USEFUL INTERVENTIONS FOLLOWING SUDDEN DEATH As caregivers, nurses can provide a patient’s family with an opportunity to begin their process of grieving. Nurses can answer questions, allow the family to express their grief, and facilitate the
Table 1. Selected professional and caregiver resources* American Association of Suicidology American Hospice Foundation Association for Death Education and Counseling Hospice Foundation of America Last Acts National Center for Post-Traumatic Stress Disorder Project on Death in America Suicide Information and Education Trauma
www.cyberpsych.org www.americanhospice.org www.adec.org www.hospicefoundation.org www.lastacts.org www.dartmouth.edu/dms/pts/dindex.html www.soros.org/death.html www.siec.ca www.ozemail.com.av/dwillsb/trauma.htm
*Adapted from Kastenbaum.2
process of saying “goodbye” by initiating appropriate interventions while the patient is still in the hospital. As difficult as it may be for nurses as caregivers to inform a family of the death of their loved one, it is even more difficult for the family to hear and accept it. The goal is to provide a supportive, private atmosphere (as circumstances can allow) in which family members can begin to express their grief and actualize their loss. A room that is set apart from the active treatment area can provide a calm, reassuring atmosphere for patients’ families who are in crisis. The manner in which a family is treated at the time of crisis often remains indelibly imprinted in the minds of survivors for years to come. Offer help assertively and calmly. Asking a family if they would like help can produce a vague, noncommittal response. Instead, nurses can request an intervention by a designated spiritual or mental health care provider (eg, chaplain, grief counselor, or therapist). A nurse can initiate dialogue with the family to let the family know that he or she is there to work with them as they experience this loss. In the first moments after a death, it is important to provide survivors with sympathetic strength and understanding. This can be accomplished by maintaining direct eye contact, firmly holding the bereaved person’s hand(s) or shoulders, speaking slowly and clearly, answering questions briefly in a calm and controlled manner, and providing firm physical support as needed.7 Provide the family with the choice to see the body. The nurse should make sure the body is displayed as appropriately as possible. If the body is mutilated (eg, in a motor vehicle crash), the family should be informed of this fact before viewing the body. The family should be able to see the body or a part of the body that can help bring home the reality of the loss.4 Use clear, concise, and factual language. Careful discussions can assist the family in coming 26
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Rich
to terms with the reality of the patient’s death. The word “dead” or “died” should be used. Platitudes, such as “it’s going to be all right,” should be avoided because their intent is the direct opposite of what survivors are experiencing. Vague terms promote a survivor’s denial of the death as reality. Make referrals for follow-up care. Followup care can be arranged through institutional, community, or religious resources. It helps to become familiar with these resources, including those that offer specialized support for specific types of sudden death. For example, The Compassionate Friends is an international support group for bereaved parents and siblings. Mothers Against Drunk Driving (MADD) works with families in alcohol-related deaths. Table 1 lists professional and caregiver resources available on the Internet. MANIFESTATIONS OF EARLY GRIEF There are predictable manifestations of early grief for survivors. On learning of the death, caregivers and survivors may experience feelings of sadness, guilt, and anger, some of which may be targeted toward the patient or other caregivers. Survivors may feel shock, numbness, and a sense of helplessness as the reality begins to sink into the consciousness. These feelings may be accompanied by a sense of disbelief, vulnerability, and an increased realization of one’s own mortality. Survivors of traumatic death are left with questions about the order of the universe and a sense of chaos that results from loss of control. They often feel victimized and have an intense need to feel they have regained command of their lives and environment.8 Traumatic death circumstances. Certain deaths are associated with difficulties in grieving. These include suddenness and lack of anticipation; violence, mutilation, and destruction; preventability and/or randomness; multiple deaths; and the VOLUME 8, NUMBER 1
survivor’s personal encounter with death in which there is a significant threat to his or her own survival or a massive shocking confrontation with the death and mutilation of others.9 Learning of a sudden death leaves survivors and caregivers with no time to prepare for the loss. The mere act of confronting death overpowers the ability to adapt to the situation. The emotional and physiologic shock reinforces a sense of personal vulnerability and interferes with the ability to fully grasp what has occurred and begin grieving. Violence, mutilation, and destruction revive a basic death anxiety and fear of extinction, leaving survivors to deal with those stresses in addition to their mourning. The perception of a death being preventable often prolongs the duration and intensity of grief and mourning. A death perceived to be unfair or unjust bewilders the mind and calls for explanation, thus intensifying emotional responses. Random events are offensive because they are unpredictable and, therefore, uncontrollable. It is common to see survivors and victims assume blame for the event. It is easier to assume responsibility than to perceive that the event is truly unpredictable and thus, out of our control. Multiple deaths, in addition to the issues mentioned earlier, confront the survivor with the concurrent stressors of mourning for each deceased individual. This, in turn, may delay or interrupt grieving for the other victims. Survivors of experiences in which there was a threat to individual survival or the shocking confrontation of death and mutilation of others often experience posttraumatic reactions, such as posttraumatic stress disorder. In these situations, posttraumatic stress reactions occur because of the overwhelming threat to personal survival and sudden helplessness in not being able to prevent the deaths of others.
incident.10 Critical incident debriefing is a process whereby caregivers have an opportunity to express individual thoughts and feelings within a peer group. The group members understand the common experience and discuss it in a safe environment, instead of taking it home. Debriefing sessions are led by peer counselors (members of the caregiver team) not directly involved in the trauma situation. The counselors facilitate confidential discussion and provide information and resources for follow-up.3
Debriefing Process Seven steps are involved in the debriefing process. 1. Introduction. The group is oriented to the specific situation being addressed and ground rules are laid, including the requirement of confidentiality. 2. Fact phase. Group participants are asked to characterize the facts about what happened, focusing specifically on the events. 3. Thought phase. Group participants describe the thoughts going through their minds immediately before, during, and after the incident. 4. Reaction phase. Group participants are invited to share their emotions about what happened. 5. Symptom phase. The team counselor discusses physical and emotional signs and symptoms of stress. 6. Teaching phase. The team counselor provides information about responses that signal a need for further follow-up. Individuals may self-identify their need for counseling. 7. Re-entry phase. Constructive suggestions for dealing with the situation are summarized, questions are answered, and closure is accomplished.
NEEDS OF CAREGIVERS Although caregivers experience death in their own ways, an opportunity to grieve these losses should be provided in the workplace. Caregivers may exhibit simultaneous or sequential feelings of fear, anger, guilt, and frustration. Caregivers may not only suffer the frustration of having been powerless at the time of the death, but they may also find themselves equally powerless to deal with the intense emotional response. In a 1999 study at Brussels University Hospital, survey comments indicate that health care providers consider other emergency department staff members to be their primary support and prefer to have a debriefing with their colleagues after a critical
Weekly rounds to discuss the circumstances surrounding a patient’s death may be helpful. Staff members involved in the patient’s care discuss what they learned from the patient, the course of treatment surrounding the death, ways in which treatment may have been improved, and feelings or symptoms they may be experiencing.6 In the rounds, involved caregivers can do specific acts, such as sign and send a sympathy card to the patient’s family a month after the death. The individuality of each person’s grief response is acknowledged and discussed. Caregivers may or may not experience well-known symptoms of grief such as a decreased ability to concentrate, absent-minded behavior, sleep and appetite disturbances, and a lack of energy. Care-
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givers may also experience physical manifestations of grief, such as those seen in patients: shortness of breath, palpitations, dry mouth, muscle weakness, and suppression of the immune system in cases of prolonged stress.4 CONCLUSION Not everyone grieves in the same way. Thus it is important to recognize, validate, and support individual differences in mourning. Some people may express their grief primarily by talking through their feelings (intuitive grieving). Other people may express their grief primarily through activity or problem solving (instrumental grieving). Instrumental grievers are often uncomfortable sharing their feelings with others and often avoid discussing them in a group setting.11 By understanding grief as a predictable, yet individual response to the loss of a patient or a loved one, caregivers can take care of themselves while providing quality care for those whom they serve. I acknowledge the editorial guidance and assistance of Dr Dana Cable and Dr Terry Martin, professors of Psychology and Thanatology, Hood College, Frederick, Md.
REFERENCES 1. Vachon ML. Staff stress in care of the terminally ill. Qual Rev Bull 1979;5:13-7. 2. Kastenbaum R. Death, society, and human experience. 7th ed. Boston: Allyn & Bacon; 2001. 3. Parkes CM. The caregiver’s griefs. J Palliat Care 1986;2:5-7. 4. Cable D, Martin T. Principles of counseling the bereaved. Frederick (MD): Hood College; 2001. 5. Rynearson EK. Bereavement after homicide: a descriptive study. Am J Psychiatry 1984;141:1452-4. 6. Vachon ML. Occupational stress in the care of the critically ill, the dying, and the bereaved. Washington: Hemisphere; 1987. 7. Pine V. Psychological aspects of disaster death. In: Doka K, editor. Living with grief after sudden loss. Washington: Hospice Foundation of America; 1996:103-16. 8. Weeks O. Using funeral rituals to help survivors. In: Doka K, editor. Living with grief after sudden loss. Washington: Hospice Foundation of America; 1996:127-38. 9. Rando T. Complications in mourning traumatic death. In: Doka K, editor. Living with grief after sudden loss. Washington: Hospice Foundation of America; 1996:139-60. 10. Flam R. Helping the bereaved at the emergency department: a study at the Brussels University Hospital. Int J Trauma Nurs 1999;5:95-8. 11. Martin T, Doka K. Men don’t cry…women do: transcending gender stereotypes of grief. Philadelphia: Buchanan; 2000.
Glutaraldehyde—Occupational Hazards in Hospitals The National Institute of Occupational Safety and Health (NIOSH) of the Centers for Disease Control and Prevention (CDC) has developed a brochure to make health care providers aware of the adverse health effects of glutaraldehyde, common methods of exposure, and methods used to reduce occupational exposure. Glutaraldehyde has been used widely in hospitals to disinfect heat-sensitive instruments, to fix histologic specimens, and to process x-rays. It is provided under the trade names of Cidex, Hospex, Metricide, Ominicide, Sonacide, Sporicidin, and Wavicide. To obtain a copy of the brochure, readers may write to NIOSH—Publications Dissemination, 4676 Columbia Pkwy, Cincinnati, OH 45226-1998; call 1-800-35NIOSH (1-800-356-4674); fax (512) 533-8573; or e-mail [email protected]. The report can be read online at http://www.cdc.gov/niosh/2001-115.html.
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