Care of terminally ill

patient
•Concept of loss,
• Grief,
•Grieving process
 LOSS
• – Loss can be defined as, “ an experience in which an
individual relinquishes(give away) a connection to a
valued object “
• Loss may includes : – Death of loved person – Loss of
favored status or position – Separation or divorce –
Financial losses – The break up of romantic affair –
Retirement – Separation from a friend – Absence from
the home for the time – Loss of cherished
• Loss can give rise to the symptoms of acute
grief – Walsh & Mc Goldrick (1991) stated that
loss requires movement through a process of
mourning(the expression of sorrow for
someone's death) in order to get what is
needed from experience or relationship to
continue or with one’s life.
 Grief

• Grief is the painful psychologic & physiologic

response to loss – It affects the physical,
cognitive, behavioral, emotional, social &
spiritual aspects of the life
• Symptoms of grief :
Physical symptoms –
• Weakness –
• Anorexia –
• Feeling of choking –
• Shortness of breath –
• Tightness of chest –
• Dry mouth & GI disturbances –Insomnia
 Cognitive symptoms –
• Difficulty in concentration –People may
experience hallucination.
• behavioral & relating symptoms – Disruption
in pattern of conduct (mannerism of behavior)
– Disorganized behavior – Ranging from an
inability to perform even basic activities of
daily living – Restlessness
• Affective (relating to mood, feeling, attitude)
symptoms –Sadness –Guilt –Anger –Major
depression
• Types of grief
1. Anticipating grief ( pre mourning ) – It is defined
as grief associated with anticipation of predicted
death or loss – Adaptive process that can help
resolve relationships & prepare solutions to some
extent for the loss
2. Acute grief –Usually referred to simply as grief ,is
the typical painful experience after a loss –Person
might initially respond to death of loved one
without shock or disbelief
• Many factors other than culture & religion
influence the length & intensity of grief –
These are the nature of relationship, manner
of death, survivor’s involvement in care,
length of illness & the presence or absence of
hope – Acute grief does not have clear ending.
3. Dysfunctional grief –
Described in multiple ways. –
Types are : – Absent or inhibited grief –
Distorted grief – Converted grief – Chronic
grief
Absent or Inhibited grief – Characterized by
no expression of grief following significant loss
– Suppressed grief may manifest as chronic
physical illness such as : – Ulcerative colitis –
Peptic ulcer – Major depression
• Distorted grief – Characterized by distortion(twisting),
usually exaggeration, of one or more component of
grief especially guilt or anger – Lead to depression or
legal difficulties following angry or violent outbursts
Converted(change) grief – It is similar to conversion
disorder in which deep thinking may be over
dramatization to the extent that the survivor exhibits
symptoms or characteristics of deceased (recently
dead)
• Chronic grief – It is unending grief – Its
symptoms may intensify over time – It occurs
in response to a loss (ex: death)
4. Chronic sorrow – Characteristics of other
form of grief but differs in several key aspects
– Chronic sorrow is a response to ongoing loss
such as chronic illness – Ex: sorrow of parents
having a child with drug addiction
Stages of grief process
• Stage 1: Denial – One of the first reactions is Denial,
wherein the survivor imagines a false, preferable reality.

• Stage 2 : Anger – When the individual recognizes that

denial cannot continue, it becomes frustrated, especially at
proximate individuals. – Certain psychological responses of
a person undergoing this phase would be: "Why me? It's
not fair!"; "How can this happen to me?"; '"Who is to
blame?"; "Why would God let this happen?"
• Stage 3: Bargaining – The third stage involves the
hope that the individual can avoid a cause of
grief. – Usually, the negotiation for an extended
life is made with a higher power in exchange for a
reformed lifestyle. – Other times, they will use
anything valuable against another human agency
to extend or prolong the life. People facing less
serious trauma can bargain or seek compromise.
• Stage 4: Depression – "I'm so sad, why bother with anything?"; "I'm
going to die soon so what's the point?"; "I miss my loved one, why
go on?“ – During the fourth stage, the individual becomes
saddened by the certainty of death. – In this state, the individual
may become silent, refuse visitors and spend much of the time
mournful
• Stage 5: Acceptance – "It's going to be okay."; "I can't fight it, I may
as well prepare for it. – People dying may precede the survivors in
this state, which typically comes with a calm, retrospective view for
the individual, and a stable condition of emotions.
 Stages of grief
• Stage 1 : Shock and numbness – This is the phase where
there is a sense the loss is not real and seems impossible to
accept. – There is physical distress during this phase, which
can result in somatic symptoms. – If person do not progress
through this phase person will struggle to accept and
understand our emotions and communicate them. Person
will emotionally shut-down and not progress through the
phases of grief.
• Stage 2: Yearning and searching – In this
phase person acutely aware of the void left in
life from the loss. The future imagined is no
longer a possibility. – Person search for the
comfort he/she used to have from the person
he has lost and try to fill the void of their
absence.
• continue identifying with the person who has
died, looking for constant reminders of them
and ways to be close to them. – If person
cannot progress through this phase person
will spend his life trying to fill the void of the
loss and remain obsessed with the person we
have lost.
• Stage 3: Despair and disorganization – In this stage, have accepted
that everything has changed and will not go back to the way it was
or the way we imaged. – There is a hopelessness and despair that
comes with this, as well as anger and questioning.
• Life feels as though it will never improve or make sense again
without the presence of the person who died. withdrawal from
others. – if person do not progress through this phase he will
continue to be consumed by anger, depression, and that our
attitude toward life will remain negative and hopeless.
• Stage 4 :Re-organization and recovery – In this phase
faith in life starts to be restored. Person establish new
goals and patterns of day-to-day life. – Slowly person
start to rebuild and come to realize that his life can still
be positive, even after the loss. – In this phase grief
does not go away nor is it fully resolved, but the loss
gradually diminish and shifts to a hidden section of the
brain, where it continues to influence but is not at the
forefront of the mind.
 Stages of grief

• Stage 1: shock & disbelief

• Stage 2: developing awareness

• Stage 3: Restitution – Restoration –

• Stage 4: resolution of loss - Purposeful

• Stage 5: Recovery
Grieving process
Phases of grieving
process
• 1. Initial phase realization : – Central issues : Intention of
the self protective response of denial of a painful reality –
Affective component : shock, disbelief & feeling of
emotional numbness, anger & dissatisfaction toward
anyone who encourages acceptance of loss, acute
emotional pain as the changing to the middle phase
• Activities : mobilization of psychological resources aimed
at achieving reunion, recovery or restoration of the person,
relationship or object – Resolution : Realization that the
loss is inevitable or has occurred and is irreversible
• 2. Middle phase-emotional pain : – Central issues :
conflicts & acknowledgement of the loss, tolerating the
emotional pain & biopsychosocial symptoms of grieving,
acceptance of support from other – Affective component :
Emotional pain is acute & unceasing, guilt feelings focused
on perceived negligence what should or could have been
done to prevent the loss, anger toward the lost person for
abandoning oneself, fear of going insane or losing control,
inappropriateness of anger or panic reactions.
• Activities : aimless & apathy show personality
disorganization, reacting out to others for
reassurance, tears shed, mind & emotionally
painful past memories recalled, deep thinking
with lost object – Resolution : Pervasive
intensity of the emotional component
decreased but not yet resolved
• 3. Concluding phase : mourning & resolution :
– Central issues : withdrawing & letting go of
the emotional investment in the lost of object,
working through the loss & building a life
without the lost object – Affective component
: episodes of sadness & tearfulness, feelings
experienced with increasingly less emotional
pain.
• Activities : gradual process of remembering,
thinking about & talking about the loss,
resumption of daily living activities, gradual
reconnection with social life – Resolution :
Reconstruction of life style, finding new
meanings & purpose for life
Thank you