Support for the survivor

SUPPORT FOR THE SURVIVOR There are two parties to suffering that death inflicts, and, in the apportionment ofthis suffering, the survivor takes the brunt. -ARNOLD TOYNBEE ELAINE WHELAN As nurses, we have come a long way in acknowledging our feelings about death. Today we are better able to open the emotional doors with the dying person, as the preceding article by Kennedy demonstrates. But many of us still have to sort out our feelings about loss in order to support that person's fami ly after his death. My concern for our responsibility toward the grieving survivor was provoked dramatically years ago by nurses' responses to a woman whose husband had just died. He was 39, she was 37. Most of the staff reacted with avoidance to her sorrowful outburst. Some nurses attempted to direct her from grieving by firmly suggesting that she think of her responsibilities to her children. Although the motivation of those advising this cognitive response was undoubtedly genuine concern for this widow, their advice was not in the least helpful. Surely she had the right to mourn, a right to wail and be disruptive, a need to grieve in her own way. I had no well-thought-out basis from which to pose logical arguments regarding therapeutic versus nontherapeutic interventions with the grieving woman, but I did feel that something was wrong with the stairs response. The husband had died in the evening; his wife was dead by morning, of a massive stroke. That day I vowed to learn more about helping the bereaved.

I was teaching nursing students then, as I am now. We were a progressive faculty, among the avantgarde in addressing death and dying according to the work of Ktlbler-Ross, and presenting loneliness as Simon and Garfunkel did in "Old Friends." Yet we seemed to skirt the emotions expresed by grieving survivors. As always, we wanted to be supportive, but knew not how. In order to help our students and ourselves as a faculty to sort out our feelings about loss and the everyday living that must continue for the survivor, we studied the literature on grief, which is the natural aftermath of death. Grief and Mourning

Grief is the pain of loss; mourning, the process the survivor goes through to diminish that pain. Grief, the emotion; mourning, a step-by-step process. In mourning, or grief work, the survivor repeatedly experiences memories shared with the dead person until the potency of the loss is, in its entirety, neutralized (1 ). Mourning is an essential process that helps diminish the pain one feels as a consequence of loss(2). To face the loss wholly is too overwhelming, so, quite unconsciously, the shared experiences are divided into small parts, to be faced a few at a time. Grief work cannot be rushed. It takes time, at least a year and a half, longer for some people. The phases of grief work include protest, disorganization, and reorganization. Denial, weeping, and appeals for help characterize the proElaine Whelan, RN,C, MSN, is an associate professor at the School of Nursing, Bergen test phase. Disorganization is manifested by restlessness, unusual beCommunity Collcge, Mahwah, NJ.

havior, and withdrawal. Reorganization, or the acceptance phase of mourning, involves reconsidering thoughts about oneself and others, and gradually acquiring a new sense of identity. Emotional counterparts for these cognitive phases of grief work were proposed by Hauser and Feinberg. These include vacillation, disintegration, and integration. This add ed dimension to a description of grief work allows for the inclusion of such feelings states as separation anxiety, hostility, guilt, depression, loneliness, helplessness, readiness, openness, and the spirit of reconciliation(3). As with any type of work, energy is needed to complete the task. In mourning, anxiety is viewed as the source of the energy required to resolve grief. Used effectively, anxiety resolves grief. If anxiety is not used effectively, as in prolonged denial of the loss, the end result will be failure to resolve the loss, or delayed mourning(4). Recognizing Maladaptive or Delayed Mourning Among the factors that seem to delay mourning are repeated losses in the survivor's past or unresolved losses, an intense but ambivalent relationship with the deceased person, guilt, anger, increased dependence, and lack of interests. Signs that can alert caregivers to a survivor's risk of maladaptive mourning include: • severe separation anxiety • ambivalence with guilt • overactivity with an apparent sense of loss • manifestations of the symptoms that characterized the deceased person's last illness

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• a recognized medical disease • conspicuous change in behavior toward friends and relatives • misdirected hostility • schizophrenic-like behaviors • agitated depression • a change in social interaction that is detrimental to the survivor's social and economic existence(4).

Grieving Spouses' Reflections To expand my understanding of survivors, I conducted a pilot study with 11 survivors who had, and some who had not, participated in a hospice program. Their mean age was 63 years; the range, 55 to 75. The mean length of marriage was 39.5 years. The study population was small, but including three individuals who were interviewed to pretest the study questionnaire, I spoke at length and repeatedly with 14 survivors at various times during the first six months after their loss of a spouse. All the deceased had died of cancer. The emotions and thoughts expressed by the bereaved husbands and wives included all that have been mentioned above. Most of their feelings could be grouped in the categories of loneliness, sadness, anger, helplessness or a sense of being overwhelmed by the loss, and the need for support. LONELINESS "Only people who have lost a spouse can know how desperately lonely you feel," a woman said. Another widow: "I don't know which is worse, having him sick or being alone." A woman who had lost two husbands, both to cancer, said "When you hurt most in your life, the only person who can take away the hurt is the one you love. But when he dies, there's no one who can take away the hurt. It's a cycle that keeps repeating itself." NUMBNESS Several individuals mentioned a feeling of numbness, or a lack of reality, at the time of their spouses' deaths and for a month or two afterward. BEING OVERWHELMED The mother of four teen-agers said, "After 30 years of marriage, the most difficult part is becoming assertive."

11 Geriatric Nursing January/February 1985

She felt overwhelmed by the added anyone else to care for." responsibilities once shared with A widow stated that "the availher husband, and expressed anxiety ability and the expertise of nurses because she had no time to her- helped me and my husband feel safe while I was caring for him at self. home." SADNESS "There's not a day that goes by that I don't cry over how Providing information was a she suffered," an elderly man said, form of assistance mentioned reo in addition to expressing loneliness peatedly. "The nurse explained and depression. medications, what they do, reacANGER A woman of 75 felt anger tions to watch for, and suggested a toward physicians for "suggesting written schedule to follow." additional biopsies when they knew Another helpful measure cited he was terminal." At six months of was the suggesting of al~ive bereavement, one individual found medications when those being givthe continuing onslaught of exorbi- en were "doing more harm than tant bills to be "among the most good." distressful things to deal with at A man said, "A nurse told my this time." A middle-aged man sons and me that my wife probably voiced anger toward physicians could still hear even though she'd who, he said, made "callous and lapsed into a coma and could not curt responses." respond. That was extremely valuUNREALITY During her first few able to me. I appreciated it very months of bereavement, a 65-year- much." old woman "felt" the presence of Special consideration for the limher dead husband. "It's as if he ited time left to the dying person were here, watching out for me." and spouse was appreciated. "I Six months after his death, she said used to spend half an hour or rnore she no longer experienced that of my visiting time getting choco"feeling of presence." late milkshakes from the Coffee SUPPORT All participants ex- shop. A nurse who saw me COrning pressed the need for support from up with a milkshake one evening family and friends. Those who had arranged to have them in the Unit been in a hospice program said the refrigerator so I wouldn't have to support they received, which en- wait in the coffee shop. When the abled them to spend more time end is near, every moment is prewith their dying spouse, made ad- cious. I felt comforted by this justment to the loss easier. nurse. She gave me more time to be One man drew great comfort and with my wife." support from his eight-year-old . ~n older man, whose poor night dachshund, who "seems to under- vision meant that he could drive to stand my sadness." the hospital only in daylight, expressed gratitude to the nurses How Nurses Helped who obtained permission for him to The interview questionnaire visit during nonscheduled visitng asked whether the participant hours. thought nurses assisted him or her, Bereavement follow-up Visits and if so, how. wer~ described as emotionally sup"Being there, and knowing what portive. to do," being kind, considerate.and . Sensitivity to the nee~s of the dyattentive to the dying patient, and mg person was perceived as the making the dying spouse comfort- nur.S&'& .~Y respwlslbility by able were responses made in vari- their- grtevlllg spouses. They appreous ways by all participants. Physi- ciated the nurse's interest in their cal care meant a gre.at deaLA be- own welfare but saw the nUrse's reaved husband said, "Toward the principal role in terms of direct end, she perspired a lot from the care for the dying person. temperatures, and the nurses Only a few negative comments changed her sheets so often-they were made about nurses. One wommade it seem as if they didn't have an vividly described an epiSode

wherein a nurse "unfairly and insensitively reprimanded my husband for removing his head dressing, when, in fact, the doctors had removed it and not come back to replace it." This widow reported the incident with considerable residual anger at the insensitivity of the nurse for "yelling at my husband ." Although none of us likes to think that our words to any patient are inappropriate, we need to be especially sensitive to the impact of words and actions on the terminally ill and the family. Guide to Nursing Therapy

tance gained through contact during the dying person's illness, may enable the nurse to foresee that expert counseling might be needed during the mourning period . If so, an appropriate referral can then be offered. Help Over Time Nurses who have sustained contact with survivorshospice team members, community health nurses, day-care and senior citizen center staff, for examplecan, through continuing education, become reasonably secure in offering help during the full grieving process. An experienced older nurse has found that clients are often helped to recognize that change (resolution) will come and how that change will feel if the nurse says something like this:

ly bereavement, denial may include hallucinations, either visual or auditory, in which the deceased person is "seen" or "heard." This phenomenon is significant to the survivor, a natural part of gradually letting go of the beloved. Mourning cannot be rushed. There will be times of vacillation and perhaps even regression to a former plateau before true resolution takes place . Helping people through grief includes sensitive tolerance of the temporary need for denial as anesthesia against pain and shock. Reality needs to be introduced a little at a time, in tune with the tempo of the grieving survivor(6). Delayed mourning is an indication to refer the client for psychological therapy. The therapist's goal is to facilitate the grief work that has not been successful to date. Interpersonal skills are used to help the survivor consciously experience the full reaction to separation . As the person moves through the phases of grief, the therapist acts as an enabler, encourager, interpreter, and support system. Through this therapeutic alliance, the grieving person learns to trust that he and the counselor can work through the grief together. At the point of resolution-acceptance of the loss-the survivor recognizes his own resources and believes in his ability to depend on himself. Shakespeare's advice to Macbeth captures the deepest need of the grieving person and suggests the therapy:

As nurses, all of us need an understanding of the grief process and its importance in the resolution of loss. We need, also, to confront our own feelings about loss, and our be- The empty spot in your heart will havior and defenses in response to always be there because no one will ever take his place. But gradually loss. Because some nurses have not the hurt will lessen and all the worked through grief for them- good memories grow stronger. And selves, they are not able to cope some morning you'll wake up and with the entire grief process in a realize that you feel more alive way that would be supportive to a and /ike yourself again . The regret bereaved survivor. These nurses won't be gone, but life will have recan, however, recognize a survi- gained balance and you'll be vor's need for immediate, or first thankful for what was good and feel ready to say yes to what lies aid, assistance. Other nurses, because they work ahead(5). in institutions, lose touch with the Besides understanding our own grief-stricken husband, wife, lover, or friend when the dead person's feelings about loss, we need to acbody is removed from the institu- cept the survivor's feelings about tion. But they, too, can provide im- the changes he or she is undergoing as mourning continues. A genuine mediate help. . First Aid to the Bereaved Reas- acceptance helps the grieving persurance to the bereaved person that son endure the painful period after intense emotions are normal and the initial numbness wears off, supthe nurse's calm acceptance of an- ports the bereaved's self-concept, Give sorrow words; the grief that ger, hostility, or profound sorrow and prevents isolation. Thus accep- does not speak whispers the o'erfraught heart and bids it break. are the first forms of assistance. tance promotes resolution. Explaining the process of gr ievThis usually entails providing a private room where the first shock of ing, the progressive steps and the loss can be cried out, talked out, or long time involved is helpful, espe- References I. Adler, C . S., and others. W.. Are but a Mocially when the survivor exhibits even shouted out. ment's Sunlight! Understanding Death. New York, Wash ington Sq . Press, '76, p. 171. Comfort measures are part of the anxiety about intense emotions. 2. Ibid .. p. 172. first aid-reassuring touch, a cup Reassurance that it is natural to 3. Hauser. M. J .• and Feinberg . D. R. An operof tea, tissues inconspicuously sup- find these feelings upsetting will ofational approach to the delayed grief and mourning process. LPsychtatr.Nurs. 14:30. plied, and simply being present if ten allay fears. Ju ly 1976. -' Denial is a natural defense mechthe survivor wants companionship 4. Ibid .. p. 33. (or leaving the survivor alone if anism, but it needs to be dealt with 5. Personal commun icat ion. Doris Schwartz, Aug. 21. 1981. very sensitively. Denial takes many that's the preference) . 6. Haber. Jud ith , and others. Compr..hensive Knowledge of the bereaved per- forms. Initially it may be a kind of Psychiatric Nursing. New York, McGrawHill Book Co.. 1978, pp. 462-464. son's state of mind, and acquain- numbness or unreality. During ear-

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