9 Communication with Loss and Grief

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Introduction

According to the Canadian Mental Health Association (CMHA), grief is both a feeling and a process that people typically go through after a death or other significant loss (2021). Loss in its simplest description means losing something or someone and from this loss feelings of grief emerge. Loss and grief are entities experienced in the health care environment. Health care professionals often prepare patients/clients and their families for this sometimes inevitable experience. A serious injury, chronic illness, an unexpected alteration in body, or death are experiences that can trigger an array of emotional responses categorized as loss and grief. Anticipatory grief is a reaction to an upcoming, impending, or expected loss event. Experiencing grief can be an important part of the process and can help a person sort out emotions in preparation for the loss. In these sensitive moments what is said or not said has a significant impact. Importantly the perception of loss is real and unique to each person. Grief is in the internal emotional processing of the loss an individual experiences.

A compassionate approach is needed and HCAs can provide comfort both in words and in action. It can be challenging to comfort someone who is experiencing grief as it may remind us we are not able to remove or stop the pain. As empathetic practitioners, we often want to make it better and take the pain away. This chapter is designed to provide a thoughtful examination of loss and grief to support therapeutic communication processes.

Assessing What You Already Know

This  activity to designed to explore what you may know about this chapter topic

Alternative Text Option

Emotional Responses to Grief

As mentioned in the introduction to the chapter grief can trigger several emotional reactions. Developing an awareness of these emotional responses strengthens the ability to support patients/clients, and their families. Some examples of emotional reactions are explored further in the next paragraphs.

Sadness is an emotional reaction commonly associated with grief. The profound hopelessness, despair, and loneliness can make the individual feel emotionally unstable. They may cry frequently as an emotional display.

Shock as an emotional reaction sees an individual expressing feelings of disbelief . At this point, the individual may feel numb and are experiencing trouble accepting the loss has occurred or is occurring.

Guilt is an emotional response that often leaves the individual feeling guilty for something they did or didn’t do. Even if the loss is out of their control, they may still feel they could have done anything to help prevent it.

Fear can be an emotional response to grief and individuals may feel anxious, uncertain about the future, and generally express feelings of worry. The fear is generally rooted in moving on to accept life as it now is, not as it was.

Media 9.1. 5 Things About Grief No One Really Tells You [Video]. From Psycho2Go, 2020. CC BY.

Studying and Understanding Grief

Our understanding of grief is a constantly evolving process and over time several grief models have emerged. According to Clewell (2004), Sigmund Freud proposed over 100 years ago a theory of grief which proposed that “mourning comes to a decisive end when the subject severs its emotional attachment to the lost one and reinvests the free energy in a new object.”

A more recent model of grief is known as the adaptive grief model. This model was proposed by Kenneth Doka and Terry Martin in the book Grieving Beyond Gender. Adaptive grief reflects that grief is a complex process and is unique to the individual. It involves accepting that life will never look or feel the same. The theory also recognizes response to grief has many variables such as an individual’s personality and cultural background.

Stages of Grief

Elisabeth Kübler-Ross was a psychiatrist who conducted significant investigative studies relating to near-death grief and from this groundbreaking research key stages of grief were identified in her book On Death and Dying (1993).  The five stages identified include denial, anger, bargaining, depression and acceptance. These stages are a part of the framework that facilitates learning to live with loss and they are also sometimes referred to as the Kübler-Ross Grief Cycle. Initially, this cycle referred to death only and has since been expanded to encompass all types of grief and loss. David Kessler a death and grieving expert identified the sixth stage of grief referred to as finding meaning. Kessler explored this stage in the book titled Finding Meaning, The Sixth Stage of Grief (2019).

Let’s explore the grief stages further outlined by Kübler-Ross. Each stage is listed in order based on the grief cycle however, it is important to consider not every individual goes through all stages, nor do they transition in the order provided in this chapter. Grief and loss are experienced uniquely for everybody.

Denial

Denial is often presented as the first stage of grief lasting weeks or months. Think of a time when you received extremely upsetting news involving a loss. Often the immediate denial reaction triggers feelings of being in a state of shock or numbness with little to no emotional reaction. The temptation to think a mistake or error has been made accompanies the denial phase. The state of shock denial helps with the survival need surrounding the event, it is the creation of an alternate reality as a coping strategy.

Anger

In this stage, the individual begins to transition back to reality. Individuals may begin to blame others or question, why me? Anger can be the most difficult for caregivers to witness. Individuals experiencing the anger stage may lash out at everyone alike because they are angry about their situation. Often, nothing done is done right for them. They have negative things to say about other aspects of their life as well (Lowey, 2015).

Bargaining

In this stage, an individual may experience a sense of false hope. If they make a promise to do better it may fix the situation and take away the grief and loss. The person attempts to create a deal in a hopeless effort to repair the event. It is a stage that is rarely visible to onlookers as it happens internally within the person affected. In this stage, individuals realize that they are past denial and they have been angry about it, with neither of the two causing any change in the outcome (Lowey, S. 2015).

Depression

Depression is the fourth stage and is a natural part of grief where feelings of sadness occur. The ability to function with normal day-to-day routines may be impacted. Some individuals may experience a prolonged period of sadness and will require additional considerations and supports.

Acceptance

The final stage is acceptance. This stage does not mean that the person is happy about the situation, but rather that they have come to accept it and have found a sense of peace with it. The first four stages involved mostly negative emotions which have taken a toll on those involved. In the case of a terminally ill patient, the time has progressed and patients can begin to move past the negative emotions and focus on the time they have left. During this stage, their hope for a cure is replaced by a hope that their final days will be peaceful and their death will be what they want it to be (Lowey, 2015).

Communicating with Individuals Experiencing Grief and Loss

As mentioned at the start of this chapter, it can be overwhelming to communicate with someone who is grieving and experiencing a loss. In the role of an HCA, we will be exposed to many forms of loss and grief. Loss and grief can be intensely emotional. Being aware of communication techniques to support patients/clients and their families during these circumstances are critical for establishing and maintaining a therapeutic relationship.

Behaviour strategies to support the therapeutic communication process can include:

• Acknowledge the situation. Recognizing what the individual is going through at this moment is extremely painful. This provides space for the individual to grieve fully. Making a statement such as “It’s really tough right now for you” demonstrates a recognition of the emotional pain.
• Express authentic concern. Focus on the individual experiencing this loss. Making a statement such as “I’m sorry you’re suffering” demonstrates an empathetic acknowledgment.
• Provide space for the grieved to talk. Asking if the grieved would like to talk or share how they feel about their loss is helpful.
• Recognize common situations that result in difficult communication, such as a patient receiving bad news about their health condition. It’s human nature to want to avoid stressful situations. Supporting someone who is grieving may be a stressful situation.

Ambiguous Loss

This is a type of loss experienced where there is no clear or direct understanding of the loss.  Examples of this kind of loss include infertility, unexpected termination of a pregnancy, a family member in cognitive decline. Ambiguous loss can be either physical or psychological. This differs in comparison to traditional loss largely in the way the individual’s loss is perceived and supported by those around them. With ambiguous loss, it tends not to be legitimized by society therefore, the typical supports provided may not exist. An HCA can demonstrate support when therapeutically communicating with client and family members recognizing loss may not be an obvious event and something that transpires over time.

Beliefs, Culture, Spirituality, and Experiences

In times of grief and loss, individual beliefs can provide support and comfort. The manner in which people mourn is affected by religious practices, beliefs, and cultural traditions. People who are grieving are sometimes described as bereaved. Personal philosophies may affect reactions and responses to grief and loss. For example, in some cultures, people believe a deceased family member’s spirit influences the remaining family members. Individuals gain comfort in the belief that their loved one is watching over them. Generally, beliefs provide a mechanism to help people make sense of the loss experienced.

In most cultures, death is associated with rituals which are designed to honour the individual lost and help the family members cope with their loss. For instance how a body is handled after death matters as does burial or cremation beliefs. Another example is the privatization of grief, in some cultures, grief is expressed quietly while in others grief is expressed loudly and publicly. As HCA’s we should recognize various beliefs and respond with care and without judgement. Remember there is no right or wrong way to grieve.

Some cultural examples to consider surrounding death and dying include:

• African death ritual of turning all pictures to face the wall and covering all mirrors, windows, and reflective surfaces so the dead can’t view themselves.
• Death customs in China see the removal of mirrors and hanging cloth on the doorway of their homes. Not following proper rituals means death and misfortune for the grieving family.
• Some South American practices include drinking a mixture of ashes and bananas to keep the spirit of the deceased alive.
• In Russia, prior to a funeral family members stop clocks and cover mirrors to avoid more death in the family.

The combination of social and cultural influences impacts the grieving cycle. The social influences of grief include: withdrawal from activity typically enjoyed to avoid judgement by others, isolation from society, arising conflict related to grieving differently than others in their social circle leading to unrealistic expectations and unresolved grief.

End-of-Life Care Options and Decisions

End-of-life care is the term used to describe the support and medical care given during the time surrounding death. End-of-life care and planning are critically important to the next decades of health care in Canada. Between 2005 and 2036 in Canada, the number of seniors 65 years and older is projected to increase by up to 25% and the number of deaths by 65%. The majority of patients are currently admitted to hospital and many to intensive care units at the end of life; however, up to 70% of elderly patients say they would prefer a less aggressive treatment plan focusing on providing comfort rather than a technologically supported, institutionalized death (Fowler, 2013). According to Health Canada Services at Canada.ca, these options include palliative care, do not resuscitate (DNR) orders, refusal or withdrawal of treatment, refusal of food and water, sedation to ensure comfort, and medical assistance in dying. Decisions at end of life are uniquely individual and personal.

Palliative Care

This is specialized care offered to those experiencing a serious illness. This type of care focus is primarily on relieving symptoms and the encompassing stressors caused by the condition. Often the goal is to provide and support quality of life for the patient and their family members. The supports can include, emotional, nutritional, medical interventions such as pain medications, and additional comfort measures.  Palliative care can be provided in a hospital setting, as residential care in a long-term care facility, and daycare/homecare. As an HCA you may work in a palliative care setting and therapeutic communication skills are essential elements of supporting quality of life for clients and their families.

Advance Care Planning (ACP)

This is a formal process supporting adults of varying stages of life identifying and sharing their values and decisions regarding future medical care. An example of this is a document commonly referred to as a living will, included within the living will is usually advance care directives. A directive in this context could outline how medical care will be utilized if the individual does not have the capacity to make a decision during a critical health event. Other examples of advance care planning include a do not resuscitate (DNR) order, substitution decision-maker assigned often to a loved one by the client to make health and other related decisions if they become unable to do so.

Assisted Dying

This is a practice where a person suffering a terminal illness or incurable condition is assisted in concluding their life. In Canada, it is often referred to as MAiD (medical assistance in dying). Clients who make these end-of-life decisions need support and understanding as do their family members. It is often a highly emotional time for all persons involved and therapeutic communication techniques are extremely important to ensure clear, timely communication is conveyed to the client and family surrounding this event.

Check Your Understanding

Summary

In this chapter you have:

• Explored the components of loss and grief within the context of health care.
• Recognized everyone experiences grief and loss in their life.
• Focused on grief and the internal processing of loss.
• Explored how developing an awareness of loss and grief better equips the HCA to approach situations involving these sensitive interactions with care and empathy.

Key Terms

Alternate: Taking the place of the current.

Anticipatory grief: Is a reaction to an upcoming, impending, or expected loss event.

Bargaining: Negotiating, agreement, or contract. (Merriam-Webster, n.d)

Bereaved: Someone who is afflicted by the death of a loved one. (Merriam-Webster, n.d)

Cognitive: Thinking, reasoning, knowing, remembering, and problem-solving abilities.

Compassionate: Showing concern for others.

Despair: Complete loss of hope.

Disbelief: Inability to accept something is real or true.

Grief: Is both a feeling and a process that people typically go through after a death or other significant loss.

Legitimized: Viewed as valid.

Mourn: To feel or show deep sorrow or regret.

Philosophies: A system of thought.

Rituals: Ceremony consisting of several ordered steps.

Shock: State of being severely disturbed. (Merriam-Webster, n.d)

Spirit: The non-physical part of a person their emotions and character; the soul.

Trigger: Something that causes the appearance of something else. (Merriam-Webster, n.d)

References

Canadian Mental Health Association. (2021). Understanding and coping with loss and grief. CMHA Ontario. https://ontario.cmha.ca/documents/understanding-and-coping-with-loss-and-grief/

Clewell, T. (2004, March 1). Mourning beyond melancholia: Freud’s psychoanalysis of loss. Journal of the American Psychoanalytic Association, 52(1): 43-67. https://doi.org/10.1177%2F00030651040520010601

Fowler, R., & Hammer, M. (2013, June 1). End-of-life care in Canada. Clinical and Investigate Medicine, 36(3): E127-32. doi: 10.25011/cim.v36i3.19723

Kübler-Ross, E. (1969, revised 1993). On death and dying. Collier Books/Macmillan Publishing.

Lowey. S. (2015). Nursing care at the end of life: What every clinician should know. Pressbooks by Open SUNY Textbooks. https://openlibrary.ecampusontario.ca/catalogue/item/?id=00e26b2d-3c99-4955-9173-fe6dee00a840

Assessing What You Already Know (Text-based Activity)

Question 1

Recall the recording at the start of this chapter. Based on what you heard and the members involved in this recording, do you think Dr. Oleg has disappointing health news for the client, Kelly?

1. True
2. False

The correct response is True. It can be very challenging to deliver disappointing news.

Question 2

Consider a friend reached out to you today. This friend told you they were in an car accident last week and are presently in the hospital recovering. This friend shared since the accident their ability to walk appears to be compromised. The primary care physician is unsure what deficits will remain for mobility. The friend expressed feelings a sadness and worry about what will come next in their recovery process. If you were to apply a description to what your friend is experiencing which of the following words apply, select all that apply:

1. Confusion
2.  Lack of motivation
3. Loss
4. Grief

The correct response is option three. This is an example of a physical loss where your friend is experiencing the possible alteration of body and ability. This will have a number of considerations for their future.

Question 2

Is grief a normal reaction to a loss?

1.  True
2.  False

The correct response is true, grief can be a normal reaction to any type of loss.

Question 3

Is anger an unusual response to grief?

1. True
2.  False

The correct response is false. Anger is a normal part of grieving. it is not unusual for people to experience a range of emotions as part of the healing process. Return to Activity