Death and Bereavement: Somebody

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Death and Bereavement Somebodys Gotta Talk
About it

• Indiana University School of Social Work Alumni
  Conference

2
Why Do I Think Its Important for Social Workers
to Know These Basics?

• I had patients die before and was lost
• Were all going to encounter it in some way
  regardless of setting
• Now that I work in hospice I think EVERYONE
  should know this stuff!

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Why Are We So Hesitant to Discuss Death?

• Cultural taboo
• Forces us to face our own mortality
• Fear of offending, scaring or angering our
  clients and families
• What the heck are we supposed to say?
• Lack of expertise

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The Needs of the Dying

• David Kessler
• The best way to treat a dying patient is to
  remember that he or she is still a living
  patient
• Focus on cure often ignores the spiritual,
  physical, emotional and cognitive aspects of
  dealing with a terminal illness/injury

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The need to be treated as a living human being

• The Needs of the Dying

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The need to maintain a sense of hopefulness,
however changing its focus may be

• The Needs of the Dying

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The need to express feelings emotions about
death in ones own way

• The Needs of the Dying

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The Needs of the Dying

• The need to participate in decisions concerning
  ones care
• The need to have all questions answered honestly
  fully
• The need for continuing medical care

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The Needs of the Dying

• The need to be free of physical pain
• The need to be cared for by compassionate,
  sensitive knowledgeable people

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The need to express feelings emotions about
pain in ones own way

• The Needs of the Dying

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The Needs of the Dying

• The need to seek spirituality
• The need to die in peace dignity
• The need not to die alone
• The need to know that the sanctity of the body
  will be respected after death

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Spiritual Realm

• Is there an afterlife? If so, what is it?
• Deathbed visitations, hallucinations, hauntings,
  angels
• Near death experiences

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Symptoms of Dying

• Increased sleeping
• Decreased eating
• Memory loss
• Decreased urine
• Difficulty with or changes in breathing

• Death rattle
• Agitation or restlessness
• Involuntary sounds or movements
• Skin color changes

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Suffering

• Can it be alleviated?
• Is it valuable to the patient in some way?
• Emotional, spiritual, mental or physical
• Unfinished business
• Suffering, if it is accepted together, borne
  together, is joy. Mother Teresa

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Legacy Projects

• Tailored to the patient
• Patient directed
• Often the role of the social worker
• Can help with symptom control for some
• Wide variety in size, scope, focus

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Professional Interventions The Power of Presence

• Concrete Interventions
• Assessments
• Clinical Interventions
• Presence

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Death Ideation vs Suicidal Ideation

• Both can occur
• Both require attention
• Are not the same and should not be handled as such

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What is Normal Grief?Physical Symptoms

• Hyperactivity or under active
• Chest pain
• Headaches
• Stomach pains/nausea
• Change in appetite
• Weight changes
• Fatigue

• Sleeping problems
• Restlessness
• Crying
• Sighing
• Shortness of breath
• Tightness in the throat
• Changes in coordination

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What is Normal Grief?Emotional Symptoms

• Numbness
• Sadness
• Anger
• Fear
• Relief
• Irritability
• Guilt

• Longing
• Anxiety
• Meaningless
• Apathy
• Vulnerability
• Abandonment
• Loneliness

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What is Normal Grief?Social Symptoms

• Being overly sensitive
• Becoming more dependent on others
• Becoming withdrawn
• Avoiding others
• Lack of initiative
• Lack of interest

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What is Normal Grief?Behavioral Symptoms

• Forgetfulness
• Searching for the deceased
• Slowed thinking process
• Disturbing dreams
• Sensing the deceased presence
• Wandering aimlessly
• Avoiding talking about it in fear of making
  others uncomfortable
• Needing to retell the story of the loved ones
  death

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Grief Theory

• Freud pathological, get over it
• Kubler-Ross five traditional stages
• Bowlby and Parkes four phases attachment
  theory
• Worden four tasks not stages
• Wolfet companioning the bereaved
• Neimeyer narrative and constructivist
• Maciejewski et al recent Yale Bereavement Study

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Primal Response

• Grief served an evolutionary purpose
• Fight or flight
• Reactions trigger by reptilian parts of brain as
  with other traumatic experiences

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Complicated Bereavement

• When grief gets in the way of ones ability to
  accomplish required tasks of daily life
• When symptoms of grief are severe and persistent
• When one is unable to cope with the loss after an
  extended period of time.

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Why Assess for Risk

• You may be completely unaware of the losses that
  your patients are experiencing
• Identify if somatic complaints are grief related
• Identify supports that can be put into place
• Implement appropriate medical interventions
• Provide support and education

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What Should a Risk Assessment Explore?

• Loss history divorce, miscarriage, death,
  moving, job loss, etc.
• Available supports emotional, spiritual,
  resources, within the community
• Health history known medical and mental health
  concerns

• Emotional stability level of dependence, anger,
  acceptance
• Considerations for children
• Circumstances surrounding death
• Course of illness

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When to Assess for Risk?

• Time of diagnosis
• When subsequent losses occur
• Changes in prognosis or patients condition
• When death occurs
• After initial impact of death has sunk in
• Frequent updates to assessment is ideal

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When is it More Than Grief?

• Diagnostic standards
• Practical implications
• Overlapping symptoms with depression, anxiety,
  attachment disorders, post traumatic stress
  disorder
• Wishing for death

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How Does Grief Impact Health?

• Grief is stressful!
• Exacerbates existing health concerns
• May trigger previously unidentified medical
  problems
• Can intensify mental health concerns
• Behavioral implications that impact health

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Anticipatory Grief

• But the person isnt dead yet!
• Can serve a very useful, protective purpose
• Can help to identify problems that may be carried
  over to the typical course of bereavement

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What Can We Do to Help the Bereaved?

• Listen to the story even if you think you know
  the story
• Dont try to plan solutions help to identify
  supports and resources instead
• Be with the grieving
• Ask meaningful questions
• Try to be comfortable when discussing the loss
• Be aware of non-verbal communication, word choice
  and tone of voice

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What Can I Say?

• I am so sorry for your loss.
• I wish I had the right words. Please know I
  care.
• I dont know how you feel, but I am here if I can
  help in any way.
• You and your loved ones will be in my thoughts
  and prayers.

• My favorite memory of him is
• I am always just a phone call away.
• We all need help at times like this. I am here
  for you.
• I am usually up early and stay up late.
• Dont talk Just be with them. Hugs can be very
  powerful.

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What Not to Say

• At least she lived a long life. Many people die
  young.
• Hes in a better place.
• She brought this on herself.
• There is a reason for everything.
• You can still have another child.
• It was Gods will.
• Youll get over it.
• Shes better off this way.
• Be strong.

• Arent you over him yet? Hes been dead for a
  while now.
• She was such a good person. God wanted her to be
  with Him.
• You think thats bad? My loved one
• It was her time.
• It was just a miscarriage.
• I know how you feel.
• Tears wont bring him back.
• Youre still young.

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Encourage Self Care

• Be patient with ones self
• Ask for and accept help
• Talk to others
• Recognize that bad days will come
• Rest
• Schedule fun and rest
• Journaling
• Eat regularly
• Schedule time with others

• Exercise
• Keep a routine
• Engage in old or new hobbies
• Welcome new experiences
• Take care of something else a plant or pet for
  example
• Drink plenty of water
• Plan for alone time

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Grief Impacts Professionals, Too!

• Medical professionals are exposed to death and
  suffering more often
• Loss is cumulative
• Impacts personal and professional relationships
• Your own self care is important!

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What Can We Do To Better Support Professionals?

• Reduce stigma associated with professional grief
• Explore systemic changes that understand grief
  and offer supports
• Model appropriate interactions with patients and
  families for others
• Engage in good self care

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Struggling and Need Help?

• Natural sources of support formal and informal
  mentors, coworkers, family members
• External resources community mental health
  providers, funeral homes, hospital or hospice
  providers
• Reach out if you cant find a group that works
  for you help to make one. You cant be the only
  one!

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Grief is like the ocean it comes in waves,
ebbing and flowing. Sometimes the water is calm,
and sometimes it is overwhelming. All we can do
is learn to swim.Vicki Harrison