Assessing for grief
FORUM
Week 14 Discussion 1: Assessing for Grief
Week 14: Grief and Bereavement
Week 14 Discussion 1: Assessing for Grief
Completion requirements
To do: Make forum posts: 1
Value: 100 points
Due: Create your initial post by Day 4, and reply to at least two of your peers by Day 7.
Grading Category: Discussions
Note: In this type of discussion, you will not see the responses of your classmates until after you have posted your own response to the following question.
For this discussion, watch the videos and complete the readings. Select one of the videos to focus on for the discussion.
Initial Post
- Identify the symptoms of grief in the individual(s) in the video that you watched, taking culture into consideration.
- Assess if the individual(s) in the video that you watched has a psychiatric illness or if their symptoms are within an adaptive range for grieving for that group/culture.
- Support and substantiate your information with evidence.
Replies
Reply to at least two of your peers. In your reply posts, debate with at least two peers regarding their decisions. Provide other evidence that suggests their conclusions may be correct or incorrect.
Please refer to the Grading Rubric for details on how this activity will be graded.
The described expectations meet the passing level of 80%. You are directed to review the Discussion Grading Rubric for criteria which exceed expectations.
FORUM
Week 14 Discussion 1: Assessing for Grief
Week 14: Grief and Bereavement
Week 14 Discussion 1: Assessing for Grief
Completion requirements
To do: Make forum posts: 1
Value: 100 points
Due: Create your initial post by Day 4, and reply to at least two of your peers by Day 7.
Grading Category: Discussions
Note: In this type of discussion, you will not see the responses of your classmates until after you have posted your own response to the following question.
For this discussion, watch the videos and complete the readings. Select one of the videos to focus on for the discussion.
Initial Post
- Identify the symptoms of grief in the individual(s) in the video that you watched, taking culture into consideration.
- Assess if the individual(s) in the video that you watched has a psychiatric illness or if their symptoms are within an adaptive range for grieving for that group/culture.
- Support and substantiate your information with evidence.
Replies
Reply to at least two of your peers. In your reply posts, debate with at least two peers regarding their decisions. Provide other evidence that suggests their conclusions may be correct or incorrect.
Please refer to the Grading Rubric for details on how this activity will be graded.
The described expectations meet the passing level of 80%. You are directed to review the Discussion Grading Rubric for criteria which exceed expectations.
This is the first video transcript
. End of Life
OK, this is Professor Monique with Regis College to talk about grief and bereavement. The learning objectives for today is to describe behaviors and mental illness health issues resulting from grief and bereavement across the lifespan, so child to end of life. Evaluate the patient information to develop differentials, implement a plan of care, and then adapt a plan to meet the life span and needs of the patient/client family.
So I want to start off with a few things. These are going to be definitions in the first part, and then we’re going to go and jump into the stages of death and dying. So as we talk today, I want to just make sure we understand the differences between grief, mourning, and bereavement. So those are important for you to diagnose your patients with either the primary diagnosis of bereavement, persistent bereavement, or if you’re leaning or deciding it’s just bereavement or major depressive disorder.
So to start with, grief is a normal reaction to a loss. Mourning is the expression of grief and the process by which the individuals adjust to the loss. And then bereavement itself is the period of time during which grief and mourning occur. So know those three definitions as you are reading through the chapter.
So let’s talk about the stages of death and denial. So the first stage is shock and denial. So that’s when a patient is told that they’re dying and their prognosis. They initially will react with shock, and they may follow it by denial or refusal to believe the diagnosis or deny that there’s anything wrong. You can see them as dazed at first. They might even go doctor to doctor until they find a physician that supports their position and whether that’s adaptive or maladaptive. You may come across that.
So anger is the second stage. This is when the person becomes very angry at their being ill. They may ask themselves, quote, “why me, ” end quote. Or they might be angry at God maybe at their fate or maybe even a family or friend member. That might come up as well. This patient is very difficult to treat, and the providers who have difficulty understanding that anger could react negatively. And so the patient then responds to the provider, but it’s not a personal reaction to that provider. So keep that in mind. A lot of empathy will be required during this stage. Anger often represents the patient’s desire to control a situation where they have no control.
The third stage is bargaining also known as the negotiation stage. This is a stage where patients may attempt to negotiate with physicians, friends, maybe their religion for a cure or a promise to fulfill any pledge for a cure, such as charity or going to church again or whatever it is that they have made this bargain with.
So they could even do this to a doctor. They may go to a doctor and consider them a good doctor if they can make them better. So there’s also that type of thought process. It is the understanding that the doctor doesn’t have that ability that should be communicated in a very empathetic way. The patient should encourage to participate in their treatment, continue to be honest with their health care provider.
Depression is the fourth stage, and the signs of depression is that acronym SIGECAPS, which we all know by now. So you also want to really highlight that with isolation, psychomotor slowness, sleep disturbance, hopelessness, and possible suicidal ideation can show up in the stage.
So depression can be about the effects of their illness, such as a job loss or the economic hardship, helplessness and hopelessness, as well as isolating from friends or family. They can also anticipate the loss, that it’s going to happen in their life, what will eventually occur because of the disease and a terminal illness. But you shouldn’t accept that it’s a normal response. You can treat those with antidepressants as well as therapy. So the emphasis on the depression on the fourth stage of life is about dignity of life.
Acceptance, that’s when the patient can be euphoric. They can also just be a natural response. They may say that they accept that this is inevitable. Their mood, again, can be neutral to euphoric. They could have strong religious beliefs and conviction of life after death. That often provides them comfort as well. So those are the terms and the five stages of death and dying.
So lifestyle considerations— so the child, adolescent, adulthood, late age adult, and of course, the famous Erik Eriksons. So as we talk about that one, the children, their attitudes towards death, that’s going to be and reactions are going to be age specific. None welcome death without ambivalence, and they all can temper their acceptance with healthy doses of denial and avoidance, but just know that the dying child is aware that they want to discuss death, and they may have sophisticated views about death and dying. So in general, that’s just children, but I want to focus really about the age groups.
So if you think about that preschool-age child, the preoperational stage of cognitive development, they view death as a temporary absence. The grieving children, again, they could have that indifference, anger. They might have misbehavior rather than being sad so that’s a classic sign of also depression and children’s irritability. Behaviors could be erratic and labial. Strong feelings of anger and fear can come up about abandonment. Abandonment death may show up in the behavior of grieving children as that fear.
Mourning in children— again, you’re going to revisit those terms— that’s when they may need to be addressed again and again as they go through the rite of passages. And what I mean by that, as they begin to grow and they graduate, they may have— or get their license to drive a car, these things can come up.
So behavior in children— I’m going to go back a little— behavior in children under two years old can show loss of speech. Also, that loss of speech can be stressful for the parent as well or their caregiver. When the child is less than five years, they may act by response with controlling their eating. Their sleeping may be erratic, and then they may lose bowel and bladder function. So two and five year olds will respond more with physical responses than with words.
When a child becomes school age, you could see the hypochondria. Maybe they might be withdrawn or phobic during that age. That’s how they mourn. Adolescents can mourn— and this will be hard because we all know adolescence is an age where there’s already mood swings, but you’re going to see erratic mood swings, maybe some somatic behavior. It is to note that boys are delinquent, or girls may turn to more of a sexual pattern for comfort and reassurance.
The rates of depressive episodes in bereaved children and adolescents are just as high as those in adults. With older adults, you’re going to see them more somatic. So you’re going to see that a lot. They’re going to focus a lot on their bowels and bladder. Just it seems like they do anyway as we get older, but that’s what you’ll see more.
So Erik Erikson’s eight stages of development, all I can say is know them and be able to apply them, whether it’s at the Regis curriculum as well as you said for ANCC boards. You could see a scenario come up where you have to pick the age or the stage that they’re in. So I just chose one. It doesn’t mean anything.
I chose integrity versus despair. So this is the old age conflict between integrity and despair. So this is that sense of satisfaction a person may feel when they look back at their life. Was it productive, or was it of little purpose or meaning? So that’s where you’re going to say, oh, OK, that’s stage eight. That’s the integrity versus despair. So if you look at table 34-16, it’s page 1073. Again, that’s chapter 34-16. And it’s page 1073. It goes through those eight stages of development. And I’m sure by now everyone’s tired of hearing them, but just know them and be able to apply them to a case scenario.
So bereavement, grief, and mourning so the reactions— I’ll spend a few minutes before I go and jump into palliative and hospice care. So just know on the bereavement reactions, there’s normal bereavement reaction. The longest lasting symptom is loneliness, and that can last from years throughout their life, and you’ll see that with a death of a spouse. Anticipate most persons or people, they can get their equilibrium back in their life within a few months. They may even pursue a new relationship from six months to a year. But there is no prescribed interval of bereavement. It’s going to be very individualized.
So how do you determine bereavement from grief and depression? We’re going to go through that in a moment. So I just wanted to point out that it is very individualized, but at the same time, you can see the evidence shows around a few months, they feel their life’s equal that that being their spouse.
Within six months to a year, they may be open to a relationship. But again, that’s not going to happen with every patient. That’s very individualized. So grief therapy, I just wanted to point that out that that’s very specialized, and you may want to have some referrals for that unless you get certified or have a lot of experience with it.
So persistent complex bereavement disorder was formally known as complicated grief disorder. So the DSM-5, if you guys look at your book, it’s on page 851. It talks about— oh, sorry, 850 to 851. It talks about differentiating depressive symptoms from bereavement and major depressive disorder and then persistent complex bereavement disorder.
So in summary, if you look specifically on page 851, to meet this persistent complex bereavement disorder, there is a timeline. So look at that timeline. Adults is 12 months, and for a child, it’s six months after bereavement, which bereavement is up to two months. So know those timeline markers, and you can start diagnosing. So let’s take a closer look.
OK, so bereavement’s on the left side, major depressive disorder in the middle, and then persistent complex bereavement formally known as complicated grief disorder is on the right. So to know these differences, start with the overall understanding. So with bereavement, this type of patient will meet the syndrome of major depressive disorder, but the difference is they don’t usually feel guilty or have worthlessness. They rarely are suicidal, and they don’t have the psychomotor slowness.
Now, major depressive disorder, remember the acronym SIGECAPS, more than two weeks— there’s a timeline— where a persistent complex bereavement formerly known as complicated grief disorder, the grief is very disabling, it’s prolonged, and they last more days than not, for more than 12 months in adults and then more than six months in children.
So there’s your timeline. With bereavement, the onset, again, is within the first two months, and it usually subsides within two months. Major depressive can have a single episode or reoccurring. With the symptoms of major depressive disorder, the thoughts and reminders of the deceased is what brings on the dysphoria where in persistent complex bereavement, it’s unshakeable grief. It doesn’t follow a general pattern of improvement over time.
And one of the ways I can express that as a patient I worked with— I worked with them in the rehabilitation center, residential treatment center for substance use, and had a patient whose daughter had been passed away for two years. She was probably about 18 or so when she passed away. The mother came to the facility for treatment.
She had a picture of her daughter on the nightstand. She wore a picture of her daughter on a necklace around her neck. And then she had a folder where she had a picture of her daughter inside the folder where she could look at the picture pretty much every hour on the hour. And she couldn’t go beyond every few sentences without talking about her daughter.
And so she never really get out of this unshakeable grief, and it cost her to the point that she was isolating. She was not having a life of fulfillment, and she was not making it to work very well. She was missing shifts, and she was on her final write-up. Her husband was separated from her, and her other daughter had stopped talking to her. She’d gone off to college, and she never really communicated with her. She was just always stuck with the grief she couldn’t get past.
So that would be an applicable persistent complex bereavement diagnosis. She was distressed functional impairment. Her job was in jeopardy, her relationship with her husband when she was separated, and she had not been able to really connect with her daughter that was in college.
She couldn’t go anywhere without the picture and talking every few sentences, and so she was really struggling with that. Where bereavement— the functional impairment is transient. It’s very mild. Your job is obtainable. Your relationships are still— major depressive that’s going to be persistent and associated with poor work.
So I just started with those three. It’s also on page 850 to 851. With the persistent grief, the complex bereavement, there is a symptom group B and symptom group C. Take a very careful look because you only need one symptom from group B and then six symptoms from group C to meet the persistent complex bereavement, which this is pointed.
I want to jump into palliative care now. So there are psychological symptoms at end of life. There’s psychiatric syndromes, depression, anxiety. Confused states would be more as the patient is maybe dehydrated or has strokes or something like that. And general treatment principles are going to be across the board pretty much applicable to everybody, whether it’s medical or psych.
Now I want to talk about patient family unit as well as the transition to palliative care. So on palliative care, the psychological symptoms at end of life are nearly universal, and that’s going to be the effects of the psychiatric syndrome. So I guess those are one or two. So psychiatric syndrome, the depression, anxiety, and confused states, those are going to increase with frequency as end of life is approaching, but what is different is both the age and the gender distribution. Those follow a unique pattern so I’m going to refer you back to the book.
General treatment principles, it’s going to be the same. You want to improve the quality of life. So the pharmacological treatment, you would maybe consider antidepressants that relieve pain if that’s what they’re in as well as depression and anxiety. So the natural thought is Cymbalta. That’s what I would think so. But it’s about bringing relief to those symptoms. So that I wanted to touch upon. The general treatment principles, again, it’s just about bringing relief to the symptoms.
So patient family unit, you want to open up the patient family dialogue, and what you can observe or what you may work with is that patient that doesn’t want to talk about death in front of family because that makes them uncomfortable or the family doesn’t want to talk about death in front of the patient.
So it’s almost like there’s this awkwardness to that dynamic of the relationship. So you’re going to work— not necessarily work with the whole family— but the patient you can work with how to bring that to the surface without causing anyone anxiety or less anxiety. So opening up patient family dialogue is the key there.
Family-centered grief therapy, initially that that’s going to include the patient that’s got the terminal illness, but it continues after that patient’s death, and that provides that family a setting where you can continue interventions if you work with the patient, and typically, that could be separated by different providers.
But how do you transition to palliative care? Well, that’s not always a clear pattern, but once there’s a diagnosis that’s incurable, then the focus is no longer on the diagnosis or the cure. It’s focused on a positive goal. But what I want to talk about with palliative care, that the thought is to decrease pain and suffering and also provide support and comfort for people with serious illness.
Not all palliative care is for terminally ill patients. It’s just for patients undergoing treatment to cure their illness or prolong their end of life. So you’re working on controlling nausea, fatigue, pain, symptoms like that where I want to talk about hospice in a moment. But before I talk about hospice, let’s talk about communication, processing the bad news with patients and their families.
So as a psychiatric nurse practitioner, I can’t imagine you giving a terminally ill diagnosis. However, the patient would be referred to you. Remind yourself, empathy, active listening, allowing that patient to express their fears, and how to react to those in a more positive way or supportive way. So if a patient is upset with you, it’s not because they’re upset with you. It’s often because they can’t control a situation or they’re in those five stages of grief that we talked about earlier. So caring for the family, that’s going to, again, I don’t know if you really can take on a whole family as much as you would take a patient that has a terminal illness, work with that patient on how to open up family dialogue.
So hospice care, child, adult, end of life— what I wanted to talk about with that one is that hospice care, that’s going to help people who are facing end of life. You want to make them as comfortable as possible. It can be provided in a home or hospital or nursing home setting. Hospice care is about giving people control and dignity and comfort in their final days. It doesn’t prolong or hasten death. It does help ease the fear of pain and loneliness that terminally ill patients and their families face.
Hospice is a family-centered care approach model. So it allows the patient sometimes they live at home, or sometimes they go to a nursing home to complete their final days. So if you’re looking for a timeline, you should, usually it’s less than six months for hospice care. As with child and end of life care, we often don’t necessarily think of child as end of life, but there’s times that there’s cancer diagnosis or there’s accidents, which is most common in children, accidents and cancer.
Again, you think about those stages. How does a 10-year-old process death versus a 16-year-old? That’s something to keep in mind. And you want to ensure that the patient, if it’s the child, that you’re there to support them, make them comfortable, listen to them, and help them at the stage that they’re in for milestones, meaning emotionally where do you expect them to be at or where should they be at.
So one thing we often can forget about is that religion and culture plays a huge role in end of life. So we have to think about that patient’s faith, their meaning to their life with religion practices and the impact of coping with end of life if they use religious or cultural practices. So you want to work in harmony with that patient with their religion as well as their culture.
So if there’s a spiritual guide available, and what I mean by spiritual guide, it’s going to be different depending on the religion. So sometimes there’s preachers. Sometimes there’s priests. And different types of culture that has different spiritual guides. So keep that in mind, and you want to respect that and bring that into your practice with that patient on what they would be most comfortable with.
There is another as you think about end of life, and especially with adults and older adults, you can use the psychotherapy, of course, the grief therapy, but you want to use pharmacotherapy such as antidepressants to control pain with depression and anxiety. We know that we can use antidepressants for that to have an offset on pain.
Fatigue can be a— pyschostimulants can be used. Just take that into consideration. If they’re having pain, that’s not— the pain itself will not be as much as I can imagine the psych nurse practitioner managing— pain would be managed by a medical professional or a pain doctor where they would use opiates I would imagine. So look into [inaudible 25:55], a pretty good review about pain and the scope and standard of practice.
The last thing I want to talk about, and it’s very controversial, is the suicide in end of life. So just read the book on that. It’s something that you may come across. There is different rules and laws about that so I’m not going to get into that because we’re from all over the United States and we all have different views so we’re not going to open that can of worms today.
So there is the suicide and end of life. Again, go back to the book on how to deal with suicide. And then as for end of life, you’re thinking about antidepressants, psych stimulants, pain management by a medical doctor, therapy, and always, always remember that the patient is more than just medication and the individual you see in front of you. They often will have religious practices as well as cultural practices that you’ll want to incorporate. So the references I took from was the DSM-5 and then Sadock. Thank you for listening, and this is Monique signing off.
The second video transcript
Minari
Jacob: The car is ready. We’ll assess the situation before we escape.
Monica: Escape, why?
Jacob: If the tornado hits, this house will fly away.
Monica: Stop staring. Go to the car.
Jacob: We need to wait here and watch.
Monica: Watch what?
Jacob: The news is tracking the tornado. Look.
Anne: Mom!
Jacob: See? It’s a “tornado watch,†not a “warning.†We worried for no reason.
[Monica throws pillow at Jacob]
Jacob: Are you crazy?
Monica:Who’s calling who crazy?
[Children making paper airplanes and writing “don’t fight†on the airplanes]
Jacob: For you, for our kids!
Monica: For our kids? Oh, come on!
Jacob: I worked for ten years. Ten years! Staring at chicken butts all day. Working myself to the bone! Living in a tiny home with no money!
Monica: And where did that money go?
Jacob:Don’t start again.
Monica: Start what? How much money went to the kids?
Jacob:I’m the eldest son. I had to take care of my family. I’m done now. They’re doing well!
Monica: Who is doing well? My Monica? Us? Which family are you even talking about?
Jacob: Enough! We said we wanted a new start. This is it.
Monica: If this is the “start†you wanted, maybe there’s no chance for us.
The third video transcript
The Grey
Ottway:There’s not a second goes by when I’m not thinking of you in some way. I want to see your face, feel your hands in mine, feel you against me. But I know that will never be. You left me, and I can’t get you back.
I move like I imagine the damned do, cursed. And I feel like it’s only a matter of time. I don’t know why I’m writing this. I don’t know what can come of it. I know I can’t get you back.
I don’t know why this has happened to us. I feel like it’s me, bad luck, poison, and I’ve stopped doing this world any real good. Once more into the fray, into the last good fight I’ll ever know. Live and die on this day. Live and die on this day.
