PsychologyCase 3: Nurses on a palliative care unit at an NHS hospital would like to know more about grief and bereavement in order to feel more able to support the patients and the families of the patients on the unit. It is your job to advise the nurses on the stages of dying and subsequent bereavement, and possible factors that might help ease the processes of dying and bereavement. By Genieva Barfield
Introduction
When approached with this case, your first instinct should be to look at all the given facts, determine what palliative care is being provided, the age of the individual, the stage of the illness and what treatments can be provided. One must keep in mind that prior to determing what care is needed and forming any conclusions, you will be required to obtain all facts which will include speaking to everyone concerned, reviewing all medical and personal charts that arrived with the patient. Once all facts have been reviewed, you can begin a working process . Keep in mind, the overall goal is to relieve suffering for everyone, provide the best quality of life and/or improve quality of life which in itself can be a challenge for all involved. Once all facts have been determined, next try to determine what would be the best course of action to take that works best for the team and the families. To determine this, the following factors must be considered, individual factors of the patients and their families, to include religion, age, gender and family relationship. No two people experience death the same way, nor do they deal with depression the same way. Also keep in mind age, gender, and various religious groups view death differently and have their own ideas on how death should be dealt with. All factors including the five stages of death and dying by Kubler-Ross (1969) and the ‘ Grieving Process’ by Bowlby(1980). This knowledge gives the nursing staff a better understanding of the various processes, and can help them prepare their patients for future situations. The aim of this paper is to better prepare nurses to ease the process of dying and bereavement for patients and their families.
Patient/ Family
Palliative care units treat many different kinds of patients all suffering from serious and chronic illnesses. Some of the different types of illnesses treat are Congestive Heart Failure (CHF), different types of cancers, Chronic Obstructive Pulmonary Disease (COPD), HIV/AIDS, and ALS to name a few (NHS). Each disease/illness on these units cannot be treated the same but all the patients have one thing in common they are in pain and dying. When treating patients on these units, different factors must be taken into account such as how old the patient? Is the patient male or female? Does the patient have a religious preference? These above examples are just a few factors that must be considered. The age of a patient may have an effect on how that individual copes with his/her illness. A child is not likely to be on the same unit as an adult; although, an adult can be anyone over the age of 18. A 21 year old individualwho is on assigned to a palliative care unit cannot be treated the same as someone that is 58 years old as both patients will require different types of needs to be met. Also a male patient needs is different than a female patient even when both are the same age and suffering from the same illness. Palliative care units are also responsible for helping the family members deal with the patient’s illness. The family and the patient together work with the palliative care unit. The palliative care team works with and supports the patients and their family helping to control the patients symptoms, helping the patient and their family understand their treatment and the various options available to them and lastly, the realization and coming to terms with what is happening (NHS Online web site) to them.
Studies/Theories
There have been several theories that help to understand what a person goes through when they know they are dying and when someone they care for dies. ‘ The 5 stages of death and dying’ by Kubler-Ross (1969) and the ‘ Grieving Process’ by Bowlby(1980) will be describe and used in helping those and their families on the palliative care unit. As no two people grieve the same, different approaches should be used in order to provide the best possible care to patients and their families. The ‘ five stages of Death and Dying’ are: Stage 1: Denial, Stage 2: Anger, Stage 3: Bargaining, Stage 4: Depression, and Stage 5: Acceptance. Elisabeth Kubler-Ross established her 5 stages of death and dying stated that people do not go through the 5 steps in a progressive order; people also spend different amounts of time at the different stages. The first stage is denial; a person is in a state of shock and denial, life makes little sense and people can express a feeling of numbness. Denial helps a person to pace their feelings of grief, it allows a person to deal with their feelings and issues in their own time. It has been said that it is nature’s way of letting in only as much as the person can handle. The second stage is anger; this stage is where a person begins to accept the loss that has occurred but you are coping by blaming yourself, someone else, and even a higher power. A person can even be angry at the person who they are grieving for. Misplaced rage and anger can help a person who is grieving hard. It is important for the caretaker not to take things personally as going through this stage is hard on both the caretaker and the one who has lost someone. The third stage is bargaining; according to Kübler-Ross during the bargaining stage a person may try to find ways to change the situation through bargaining. For example, if you are religious you may bargain with God to bring your loved one back, or if you are grieving over a divorce or breakup, you may bargain saying that you will change if your spouse or significant other returns to you or gives you another chance. Depression is the fourth stage. Kübler-Ross stated that this was the stage when a person finally accepts what has happened, and a person’s mental/emotional state is the hardest hit/ effected. Depression symptoms can include sadness, crying, affecting a person’s sleep, and relationships are affected. Acceptance is the final stage of Kübler-Ross model. During this stage a person accepts what has happened and is able to move on. A person may have to go through the above stages more than once to reach this stage. Some go through the stages swiftly while other will linger at each stage (Weiten and Lloyd 2006). The 5 stages of death and dying by Kubler-Ross have been criticized for her use of the word stages when people do not always go through the order she has suggested. (Kastenbaum, 1999). The ‘ Grieving Process’ has four stages which include: Stage 1: Numbness, Stage 2: Yearning, Stage 3: Disorganization and despair, and Stage 4: Reorganization. The first Stage is numbness; the loss of a loved one is unexpected, even if it is expected. It is unfathomable to accept what happened. When the shock begins to fade, intense fear of reality begins to creep in. A person yearns/longs for the way things used to be. People can appear normal on the outside, only because they are not grieving on the outside. The second stage is yearning and searching, the future we envisioned is gone, and along with our expectations for the life we planned. We continue to identify with the person we have lost. The void created by the loss has a person confused and unsure what to do. The third stage is disorganization and despair, the double D; life is not the same; everything has changed. A person can feel angry; life to them is not unfair and they fear nothing will ever be good again. They ask ” why” and ” what if.” It has been called the bleeding stage of grief. The fourth and final stage is reorganization; you begin to adapt and rebuild your inner world. Step by step you begin to trust again. Your faith in life’s ability to renew and repair itself is restored. The current NHS ‘ nice’ guidelines key recommendations state: People affected by cancer should be involved in developing cancer services. There should be good communication and people affected by cancer should be involved in decision making. Information should be free of charge. People affected by cancer should be offered a range of physical, emotional, spiritual and social support. There should be services to help people living with the after-effects of cancer manage these for themselves. People with advanced cancer should have access to a range of services to improve their quality of life. There should be support for people dying from cancer. The needs of family and other careers of people with cancer should be met. There should be a trained workforce to provide services. Factors that help ease the process of dying and bereavement. Several tasks can be used to help family and friends work though their grief. These six tasks include the ability to develop the ability to experience, express, and adjust to painful grief-related changes, finding effective ways to cope with painful changes, establishing a continuing relationship with the person who has passed, staying healthy and keep functioning, do not remove yourself from others, re-establish relationships and understan that others may have difficulty empathizing with the grief they experience developing a healthy image of oneself and the world. (Grief, Bereavement, and Coping with Loss. 2011)
Conclusion
In conclusion every patient cannot be treated the same as no two individuals or their families go through the process of dying the same. The disease alone cannot be treated in the case of palliative care, as the disease is only a part of what the patient is dealing with. Discussing the stages of death and dying by Kubler-Ross as well as the grieving process by Bowley can and should both be shared with the patient and their families so the patient and family members know what to expect in the future. The NHS NICE guideline key recommendations should be followed, as they can help the patient to feel as if they still have some control. Also the family of the patient is also suffering so helping them deal with what is to come will help them with their grief.
