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Course: Oncology Nursing

Topic: Nursing Management of Grief and Bereavement

The Nurses International Community

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Module Goals

Learners will be able to:

Describe the stages and expressions of grief.
Identify the grieving process around cancer diagnosis, trajectory and prognosis.
Describe the importance of self-reflection in grief and bereavement management
Identify resources and support networks to face the diagnosis, trajectory, and prognosis of cancer.
Summarize the understanding on self-reflection on one's own mortality, myths, beliefs and attitudes facing the death.

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What is Grief?

Ignatavicius et.al, 2020

Grief is both an emotional feeling and the perception of loss.
People who are dying from cancer suffer an anticipated death and loss of the ability to engage with others.
Mourning consists of an outward expression of

loss and the act of grieving can last a long time.

Patients and families grieve and is largely

based on cultural beliefs, values and practices.

Some people openly express grief while others are reserved.
Nursing interventions should provide emotional support while allowing patients and families to express concerns and fears.

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Stages of Grief

American Cancer Society, 2019

Denial and isolation-fear, shock, numbness.
Anger, which can last days to weeks.
Bargaining.
Depression.
Acceptance.
Changes in behavior which may be different depending on whether the person is a child or adult.

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Possible Behaviors in Grieving People

Socially withdrawing.
Difficulty thinking, concentrating, restlessness, anxiety, tired, weak.
Loss of appetite, loses weight, appears sad, feelings of depression, trouble sleeping.
Dreams of deceased, preoccupied with death, searches for reasons for loss.
Dwells on mistakes, feels guilty, alone.
Expresses anger or envy of others with their loved ones.

American Cancer Society, 2019

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What would the nurse do?

A terminally ill patient is being cared for by the nurse and the patient’s family. The nursing implications for the patient and the family include which of the following? (Select All That Apply)

Assist the patient and family in understanding grief and acceptance of impending death
Provide a referral for spiritual assistance depending on the patients beliefs
Tell the patient and family not to worry because everything will be okay
Provide active listening so the patient and families needs can be identified

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Grieving Process & Cancer

The grieving process is individualized.
Phases of grieve may consist of a series of ups and downs like a roller coaster.
Dealing with a loss may become stagnant of as is there is no progress in relief or resolution.
Some people may feel better and then become suddenly sad.
There is no set time frame for grief since it’s dependent on the individual.
Factors affecting the grieving process may include the relationship, the circumstances surrounding the death, and one’s own life experiences.

American Cancer Society, 2019

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Length of Grief

It is not uncommon for the grief to last a year or longer
The person that is grieving must resolve emotional and life changes that are associated with the loved ones death.
Even though the pain loses intensity it is not unusual for someone to be emotionally focused on the relationship with the deceased for years.
With time the person can strengthen other relationships with those that are living.
Difficult relationships may cause unique/complicated grieving.
Unexpected forms of grief can result from prolonged illnesses.

American Cancer Society, 2019

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Suggestions for Coping with Loss

Cancer.net, 2018

Think of strategies used to deal with difficult situations in the past.
Allow yourself to feel the pain of impending loss or loss.
Be patient and try to understand that grief is normal.
Talk with others about the sadness and explain that you just need someone to listen, not solve the problem.
Find creative outlets such as journaling
Forgive yourself.

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What would the Nurse do?

A terminally ill patient expresses fear of not being allowed in heaven upon death. How should the nurse respond?

“You shouldn’t worry about that. I am sure God understands.”
“What do you usually do when you are fearful?”
“I will call a pastor to speak with you.”
“Please explain what is making you feel that way.”

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Bereavement Management

Bereavement is the period of mourning after death. It is a normal reaction to loss.
Provide appropriate emotional support for patients and the family.
Involve patient and family in health care decisions.
Be with the patient and family, listen with empathy and provide emotional support.
Do not minimize a patient’s or family’s reaction to impending loss.
Provide as much comfort to the patient as possible until death.

Ignatavicius et al., 2020

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Nursing Interventions in Bereavement

Lippincott Advisor, 2020

Establish a trusting therapeutic relationship.
Encourage the patient to verbalize feelings.
Provide empathetic nonverbal communication.
Provide active listening and emotional support.
Encourage patient and family to identify strengths and effective coping strategies.
Consult pastoral care as appropriate.

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Volunteer Opportunities for Cancer Care

American Cancer Society has short-term volunteer opportunities.
Long-term volunteer opportunities.
Opportunities lasting a few minutes a day to an hour or more a week.
Administrative and clerical volunteer opportunities.
Relay for life.
Road to recovery.

American Cancer Society, 2019

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Support Networks

Help patients and families feel better and know they are not alone.
Provide an opportunity to talk and work through feelings.
Help deal with practical problems such as issues that arise with work or school.
Assist in coping with treatment and side effects of treatment.
Call your local hospital and ask about resources.
Do an online search for organizations that offer cancer support services.

National Cancer Institute, 2019

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What would the Nurse do?

A nurse is caring for patient with a terminal lung cancer who is receiving hospice care. The patient inquires about identification of support services. What suggestions might the nurse provide?

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Mortality, Myths, Beliefs and Attitudes Facing Death

Cancer related myths and stigmas are not addressed in many countries.
Myths can have a negative or silencing effect.
Myths and stigmas directly relate individual behaviors and may decrease searching support or cancer reducing behaviors.
There are beliefs that cancer is always fatal.
Belief that cancer is a type of punishment for actions throughout life.
There is a reluctance for surgical treatment of cancer due to the belief that once opened the cancer spreads throughout the body.

Daher, 2012

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Attitudes

Individuals often perceive cancer as an isolating disease and sometimes families try to isolate the patient.
Cancer of the reproductive systems and genital areas are often not discussed in some cultures.
Some perceptions are death, fear, pain and suffering,loss of control of independence, helplessness and isolation.
Middle eastern countries often depend on spirituality and faith when coping with illness.
Negative spirituality increases pain while positive spirituality decreases pain.

Daher, 2012

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Opportunities to Shift Perception for Positive Changes

Dissemination of appropriate and accurate information.
School systems can provide information and increase cancer awareness and prevention strategies.
Provide resources for information and emotional comfort.
Strengthen advocacy in international settings and build accurate perceptions of cancer.
Provide information about tobacco use and poor nutrition and the connection to cancer.
Assist people in their cancer control efforts by decreasing the stigma.

Daher, 2012

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What would the nurse do?

A nurse is educating members of a community about cancer and prevention strategies.

What information can the nurse provide? (Select all that apply)

Provide teaching about avoiding tobacco substances and nutrition
Provide education to increase cancer awareness
Provide resource information for patient and family support options
Be a patient advocate to build accurate perceptions of cancer
Explain to the community that cancer is not preventable and is a result of actions during life

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Red Flags

Overwhelming depression
Inability to talk with others
Self-mutilation without meaning to cause death
Suicidal ideations and developing a plan might be accepted in some cultures or areas
Life circumstances and overwhelming stressor may precede or increase the risk of suicide
Effects of suicide on loved ones can be devastating and cause conflicting emotions

MedicineNet, 2007

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Cultural Considerations

Cultural perspectives can be unique as grief is shaped by one’s society and culture.
Turkish cultural perspectives seek the lesson God might be teaching them through their illness and Ethiopians may not practice preventative health care or seek out care from Westerners.
Christianity believes in heaven and hell, Judaism encourages the reciting of the confessional and Islams belief is 1 God and the prophet Muhammad.
Romani believe in the evil eye and discussions of cancer cause death and Hmong believe Spiritual illness cause cancer and balance can be restored with hot/cold remedies.

Honan et al., 2018; Ignatavicius et al., 2020

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Additional Cultural Considerations

Although cultures are different, personal experiences among cultures are similar.
Different cultures have different mourning ceremonies and grief may be interdependent with unfinished business.
Demonstrate respect regardless of the cultural beliefs.
Ask questions about final arrangements.
What does the family or patient feel happens after death and what roles does each family member play?
A culture may respond the loss or death with grief or celebration.

MedicineNet, 2007

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References:

American Cancer Society. (2019, May 10). Grief and bereavement. Retrieved from: https://www.cancer.org/treatment/end-of-life-care/grief-and-loss/grieving-process.html

American Cancer Society (2019, May 10).Volunteer From Anywhere Opportunities. Retrieved from: https://www.cancer.org/involved/volunteer/acs-can.html

Cancer.net Editorial Board. (2018, March). Coping with Grief. Retrieved from: https://www.cancer.net/coping-with-cancer/managing-emotions/grief-and-loss/coping-with-grief

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References:

Daher, M. (2012). Cultural beliefs and values in cancer patients. Annals of Oncology (Supplement 3): iii66–iii69, 2012, doi:10.1093/annonc/mds091

Furnham, A., (2017, August, 3). Personal Reflections on Coping with Loss. Retrieved from: https://thepsychologist.bps.org.uk/personal-reflections-coping-and-loss

Honan, L., Bautista, C., & Eposito, C., (2018). Focus on Adult Health Medical-Surgical Nursing 2nd ed. Philadelphia, PA. Lippincott, Williams and Wilkins, Wolters Kluwer.

Ignatavicius, D.D., Workman, M. L., Rebar, C. R., & Heimgartner, N.M. (2020). Medical-Surgical Nursing E-Book: Concepts for Interprofessional Collaborative Care. Elsevier Health Sciences

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References:

Lippincott Advisor for Education. (2020, October, 2). Retrieved from: https://advisor-edu.lww.com/lna/document.do?bid=43&did=914418&searchTerm=bereavement%20management&hits=management,bereavement

MedicineNet.(n.d.). Retrieved from https://www.medicinenet.com/script/main/art.asp?articlekey=83860

MedicineNet (2020). Retrieved from: https://www.medicinenet.com/suicide/article.htm

National Cancer Institute (2019). Cancer Support Groups. Retrieved from: https://www.cancer.gov/about-cancer/coping/adjusting-to-cancer/support-groups

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