Grief and Bereavement Flashcards
Marge is a 75-year-old with end stage pancreatic cancer, whose condition has deteriorated
significantly over the past few days. She has become more withdrawn, and states that she does
not want to see anyone in her very large family, except her husband. Her family is very upset by
their lack of access to her in her final days. During your visit, Marge begins to cry, and states,
“They just don’t understand. They just have to say good-bye to me. I have to say good-bye to all
of them.” Of the following, which intervention would be most appropriate in helping Marge and
her family deal with their anticipatory grief?
a. Help Marge to prioritize her visitors.
b. Review old picture albums so Marge can say goodbye.
c. Collaborate with the IDT for patient and family support.
d. Ask family to visit Marge when she is sleeping
. c - Collaborating with the IDT to provide optimal support for the patient and family is the best approach, since there is no simple answer for such complex situations. It is common for patients who are in the dying process to withdraw from others, and this is often very difficult for their loved ones. Providing both patient and family support to allow them to express their feelings, as well as explore alternatives will validate the complex feelings of all parties, and support them in their anticipatory grief
Frank is a 70-year-old retired police officer who has a diagnosis of end-stage prostate cancer. He
is a patient in the hospice house that you work in. He has been increasingly withdrawn over the
past several days. When giving him his night medications, he tells you “This is hopeless. I wish I
had my gun under my pillow. Then I could just get this over with.” Of the following, what would
be the most appropriate initial response?
a. Provide a supportive presence.
b. Admit Frank to a psychiatric facility.
c. Increase Frank’s anti-depressant medication.
d. Give Frank a sedative
. a - Providing a supportive, accepting and non-judgmental presence which permits Frank to openly discuss his feelings of hopelessness would be the best initial response. Taking time to sit with a patient, and allow the expression of difficult feelings is one of the most valuable interventions that can be provided. Additionally, patients who express a desire to harm themselves must have a timely and thorough psychosocial evaluation by an IDT member with this expertise, with appropriate interventions and safety precautions initiated
. Erica is a 52-year-old with end-stage liver disease, who has a history of alcoholism and drug
abuse. She lives alone, and has no caregiver. She has two daughters, both in their twenties, who
live locally, but from whom she has been estranged for many years. During your visit, she begins
to cry, and relates how guilty she feels for all the years that “I chose drugs and alcohol over my
children”. What would be the most appropriate response?
a. Arrange a family meeting with her daughters.
b. Arrange to have a priest visit for confession.
c. Encourage her to journal about her feelings.
d. Call her daughters and let them know she is ill.
c - Journaling is a good starting point to help Erica begin to deal with her feelings of guilt. Depending upon her situation and the daughters’ feelings, a family meeting may be a possibility in the future. Each situation is certainly different, but often, illness may prove to be a bridge of relational healing which all parties can benefit from. This would allow Erica to spend her final days more peacefully, and provide an opportunity for her daughters to repair their relationship with their mother. Collaboration with other members of the IDT is a key component for optimal patient and family support.
Beverly’s husband, Don, was one of your patients. During report this morning, you learn that Don died
during the night. When you call Beverly, she begins to cry and states that she does not know how she
is ever going to manage without him.
330. Of the following, which is the most appropriate response?
a. “You’ll be just fine.”
b. “Your feelings are understandable.”
c. “You should ask your doctor for an anti-depressant.”
d. “Don wouldn’t want you to feel that way.
b - “Your feelings are understandable” is a supportive statement that validates Beverly’s feelings, and does not communicate judgment. Grief is a very individual process, and survivors need to have indivi. dualized support, which includes collaboration with appropriate members of the IDT for optimal outcomes.
A week after Don’s death, you stop in to visit with Beverly, to offer support. She states she is
doing better, is grateful to hospice, and would like to sign-up to be a hospice volunteer as soon
as possible. Of the following, which is the most appropriate response?
a. “That’s a great idea. I’ll ask the volunteer coordinator to call you.”
b. “Family members are not permitted to be hospice volunteers.”
c. “Maybe you should discuss it with your hospice bereavement counselor first.”
d. “I don’t think we need any volunteers at this time.”
c - Volunteers are the backbone of hospice, and are valuable members of any hospice organization. However, most hospices recommend that survivors wait for a specified period after the death of a loved one prior to becoming volunteers, since they are especially vulnerable during the early period of grieving. Discussing it with her bereavement counselor will support her desire to help the organization, but will ensure that Beverly’s welfare is the priority. Each hospice organization is different, and may have individual policies regarding this situation. That which is in the best interest of the survivor’s welfare is the ultimate priority
Jim and Tina’s infant son, Jonathon, was born with a congenital heart defect, and died 9 hours
after birth. Of the following, which would most likely NOT be helpful for them?
a. General hospice bereavement group
b. Mementoes, such as Jonathon’s handprints and footprints
c. Time to hold Jonathon during and after his death
d. Support group with other parents whose children have die
a - A general hospice bereavement group would most likely not be helpful, since grief associated with the death of a child is such a unique experience. Of course, each individual’s bereavement experience is unique, but those with similar issues often find it more helpful to attend groups in which the members identify with each other’s situations.
x
x
After a patient’s death, which member of the IDT typically coordinates bereavement support
transitioning for the patient’s family?
a. The patient’s nurse
b. The hospice volunteer
c. The hospice counselor
d. The hospice director
. c - The hospice counselor is typically the member of the IDT who coordinates bereavement support transitioning for the patient’s family. Other members of the IDT may also participate in this support as appropriate
Which of the following would NOT be an appropriate closure activity for the hospice nurse to
participate in for a surviving family member?
a. Attending a movie together
b. Sending a card
c. Making a closure visit
d. Attending the memorial service
. a - Attending a movie with a surviving family member would not be an appropriate closure activity, as this blurs professional boundaries. All other options are common methods for closure. Typically, a closure visit, as a minimum, from the patient’s nurse is important to the family, since the nurse has usually been increasingly involved in the patient’s care over the period of declining patient status until death. Closure activities not only benefit families, but are also critical for hospice staff to perform as a means of self-care, since they deal with such a high volume of death and loss.
What is not a factor that influences family functioning in grief?
a. Family System boundaries (rigid/open)
b. multigenerational legacy of losses
c. medical professionals in the family.
d. patterns of interaction (enmeshed/estranged)
e. sudden vs. linger death
C.
Other factors:
• Role “replacement”
• Blame, shame, guilt re. loss
• Sociopolitical, historical context of
death
• Communication
• Level of family, social economic
resources
Kuber Ross work falls into what pre-modern grief theory?
A. Grief Work Theory
B. Stages Theory
C. Task Theory
D. Phase Theory
B. Stages Theory
Dual Process Model of Grief, bereaved focus oscillates between:
A. Yearning/searching and re-organization
B. Continuing to have what we have lost
C. Loss Oriented and Restoration Oriented
C Loss Oriented and Restoration Oriented
( A. phase theory)
(B. Task theory)
Common criticism of Stage Theories
A. confused with acting theories
B. not evidence based
C. Rigid, judgmental, labelling &
pathologizing
c.
Which of these are Loss oriented focus of bereaved according to dual process model?
A. Intrusion of grief
B. Letting-go—continuing –
relocating bonds;
C. Denial/avoidance of
grief
D. Denial/Avoidance of restoration changes
E. All but D
E.
Which of these are restoration focused for bereaved according to dual process theory?
A. tending to life changes
B. Doing new things
C.Grief work
D. Distraction from grief
E. New roles/identities
/relationships
F. All but C.
F
Which post modern grief theory is focused on Maintaining a connection with the person who has died
Continuing Bonds (Klass, Silverman, & Nickman, 1996)
Which post modern grief theory provides a framework for understanding complicated grief
Dual Process model
5 categories of grief (bereaved)
(CADAT)
Complicated (or prolonged)
Ambiguous
Disenfranchised
Anticipatory
Traumatic
Grief category for dying person
Preparatory grief
Medicare Hospice Conditions for Participation Bereavement defines Bereavement Counseling as:
“Emotional, psychosocial, and spiritual support and services provided before and after the death of the patient to assist with issues related to grief, loss, and adjustment”
Who usually provides bereavement counseling before the death on hospice ID teams?
usually the role of the social worker and chaplain. Medicare standards do not state bereavement counselors must be the providers.
According to Medicare Conditions of Participation what is the best way to ensure loss and grief needs are continually monitored and addressed?
strong lines of communication and collaboration between IDT and bereavement staff
The state of mental and physical pain that is experienced when the loss of a significant object,
person or part of the self is realized. The highly personal and subjective, emotional response to
the event of a loss is which of the following?
a. Bereavement
b. Mourning
c. Grief
d. Loss
c - Grief is the correct answer. Mourning is the process of incorporating the experience of the loss into ongoing lives. the outward acknowledgement and expression of the loss. The social customs and cultural practices that follow a loss. Bereavement is the state of having experienced the death of a significant person/object. Loss is the generic term that signifies the absence of an object, person, position, ability or attribute. It signifies the absence of a possession or future possession. The meaning of the loss is determined primarily by the individual sustaining it
The acknowledgment on the part of both patients and family members of the loss of future
togetherness that includes physical, psychological and social aspects:
a. Letting go.
b. Disenfranchised grief.
c. Bereavement
d. Mourning
. a - Letting go is the acknowledgement of the loss of future togetherness. Disenfranchised grief is the grief experienced in relation to a loss that is not cannot be openly acknowledged, publicly mourned, or socially supported. Bereavement is the state of having experience the death of a significant person/object. Mourning is the process of incorporating the experience of the loss into ongoing lives. the outward acknowledgement and expression of the loss. The social customs and cultural practices that follow a loss.
Normal responses to grief/loss of health within patients and family systems include all of the
following except:
a. Variable states of emotions.
b. Open expression of anger.
c. Extreme weight loss and lethargy.
d. Socially responsive
. c - Normal responses to grief/loss of health include variable emotional states, open expression of anger, preoccupation with the loss, self-limiting time frame, lack of energy and slight weight loss, episodic insomnia, crying evident and provides some relief, socially responsive to others, vivid dreams, adapts without professional intervention. Extreme weight loss and lethargy are signs of a more severe depression related to the grief/loss experience
. Examples of dysfunctional coping responses/styles include which of the following?
a. Humor
b. Guilt
c. Aggression
d. Spiritual rituals
e. All of the above.
f. Both b and c only
. f - Guilt and aggression are both examples of dysfunctional coping responses/styles along with fantasy, minimization, addictive behaviors and psychosis. Functional coping responses/styles include humor, normal grief work, problem-solving and spiritual rituals.
In providing bereavement support and follow up to the wife of a patient you cared for at length,
she tells you that she is distraught over the fact that her pre-school aged grandchildren act as if
their grandfather never existed. She states that “they come over and play and act as if nothing
has changed”. The proper response to help her better understand the actions of her young
grandchildren would be:
a. “Children often forget about the person who died quickly”.
b. “Given their age, they likely do not understand that death is permanent”.
c. “You should sit them down and talk about death and what it means”.
d. “Tell their parents to explain that their grandfather is never coming back”.
b - Pre-school aged children typically view death as temporary or reversible as in cartoons. They are often told that the person “went to heaven”, so they assume that the person will “be back”. Given the situation, it is most likely that these young children do not understand that their grandfather’s death is permanent and therefore is the best response for the nurse to help the wife understand their actions. The options of C and D would likely cause more harm and option A does not provide a realistic rationale for the actions of the children.
Which of the following are the Symptoms that preparatory grief and the normal dying experience are similar?
a. anorexia
b. weight changes
c. constipation
d. suicidal ideation
all but D
What symptoms do preparatory grief and depression have in common?
a. withdrawal from family/friends
b. rumination about the past
c. periods of sadness, crying
d. anxiety
e. feelings of worthlessness, guilt
f. feelings of hopelessness
g. suicidal ideation
a through d only
An intervention used to address preparatory grief (of terminally ill patient)?
None–trick question! Preparatory grief is a normal life cycle event, not pathological
distinguish the following symptoms and label:
G (grief) D (Depression)
1. temporal variation of mood (good/bad days)
2. persistent flat affect
3. disturbed self esteem
4. distressing guilt generalized to all facets of life
5. distressing guilt focused on specific issues
6. feeling of worthlessness and being a burden
7. ability to feel pleasure
8. Social support most effective to resolve
9. Active desire for early death whose symptoms/social needs are reasonably met
- G 2. D 3. D 4. D 5. G 6 D 7. G
- G 9. D
Normal responses to grief/loss of health within patients and family systems include all of the following except:
a. Variable states of emotions.
b. Open expression of anger.
c. Extreme weight loss and lethargy.
d. Socially responsive.
c - Normal responses to grief/loss of health include variable emotional states, open expression of anger, preoccupation with the loss, self-limiting time frame, lack of energy and slight weight loss, episodic insomnia, crying evident and provides some relief, socially responsive to others, vivid dreams, adapts without professional intervention. Extreme weight loss and lethargy are signs of a more severe depression related to the grief/loss experience
The acknowledgment on the part of both patients and family members of the loss of future togetherness that includes physical, psychological and social aspects:
a. Letting go.
b. Disenfranchised grief.
c. Bereavement
d. Mourning
a - Letting go is the acknowledgement of the loss of future togetherness. Disenfranchised grief is the grief experienced in relation to a loss that is not cannot be openly acknowledged, publicly mourned, or socially supported. Bereavement is the state of having experience the death of a significant person/object. Mourning is the process of incorporating the experience of the loss into ongoing lives. the outward acknowledgement and expression of the loss. The social customs and cultural practices that follow a loss.
The state of mental and physical pain that is experienced when the loss of a significant object, person or part of the self is realized. The highly personal and subjective, emotional response to the event of a loss is which of the following?
a. Bereavement
b. Mourning
c. Grief
d. Loss
c - Grief is the correct answer. Mourning is the process of incorporating the experience of the loss into ongoing lives. the outward acknowledgement and expression of the loss. The social customs and cultural practices that follow a loss. Bereavement is the state of having experienced the death of a significant person/object. Loss is the generic term that signifies the absence of an object, person, position, ability or attribute. It signifies the absence of a possession or future possession. The meaning of the loss is determined primarily by the individual sustaining it.
Which of the following is the correct term for the form of severe suffering from any cause (physical, emotional or spiritual) that is so severe that even intensively aggressive interventions are often insufficient to alleviate?
a. Terminal restlessness
b. Terminal sedation
c. Terminal distress
d. Terminal anguish
d - Terminal anguish is the correct term for this form of severe suffering described as a tormented state of mind related to longstanding, unresolved spiritual issues, emotional problems, interpersonal conflicts, and/or suppressed unpleasant memories. Terminal restlessness is a specific form of delirium observed in patients in last hours or days of life. Terminal sedation (palliative sedation) is the monitored use of medications to induce sedation as a means to control refractory and unendurable symptoms near the end of life, potentially caused by terminal anguish. Terminal distress is not a recognized term in hospice/palliative care.
Janet was transferred home with hospice care one week ago and has remained unresponsive. Her NG feedings were discontinued but she continues to be physically stable with no signs of imminent death. Her husband and daughters are her primary caregivers but the daughters are now questioning their decision to abide by her living will by stating “She is so strong, and is fighting to live. We need to do everything for her”; while their father, the patient’s husband remains adamant that they do what Janet would have wanted. At the nursing visit, you witness a very heated dispute between the family members that ends with the daughter’s threatening to call the police and protective services to report their father “killing” their mother; and the father breaking down in tears stating he “was only trying to do what she would have wanted”. What is the best course of action for the nurse to take to address this dispute?
a. Advise everyone to leave the home to “cool off” while you care for the patient.
b. Encourage the father to tell his daughters that the decision has been made and cannot be changed.
c. Instruct the family that their behavior is unacceptable and could result in the patient being discharged from hospice.
d. Notify the interdisciplinary team (IDT) and arrange for a family meeting to discuss the patient’s plan of care and wishes in a more effective manner.
d - The best action would be for the nurse to involve the IDT and arrange a family meeting to allow for a discussion in an open, respectful method of communication and to remind everyone of the patient’s wishes which are to be honored and upheld
Janet is a 68-year-old previously healthy woman who suffered a traumatic subdural hematoma two weeks ago with significant brain damage that has remained unchanged since the incident. She has since remained unresponsive except for opening her eyes occasionally at random. She does not follow commands. She has been receiving nasogastric tube feedings despite having a living will that notes she does not wish to be fed artificially if her condition is irreversible. She requires total care for all activities of daily living. The patient is physically stable however, and needs to be transferred within the next 10-14 days as her insurance will no longer pay for her hospital stay. You are asked by the care manager as the palliative care/hospice nurse to meet with the family and review the plan of care and options for discharge.
345. When meeting with the family what should be the nurse’s first priority to address?
a. Identify which nursing home they want patient to be transferred to and make necessary arrangements.
b. Discuss the patient’s wishes outlined in the living will and adapt the plan of care accordingly.
c. Inform the family that all support will be removed and patient sent home with hospice as her care in the hospital is no longer paid for.
d. Review with the family that you do not believe the patient’s care should be changed as there is still hope for her to recover.
b - The priority for the nurse in this case is to discuss the patient’s wishes listed in the living will. This is necessary despite the underlying implications of needing to modify the care plan for institutional/financial reasons. Hospice and palliative care approaches the patient/family from the perspective that this is their experience. Goals are patient/family goals rather than nurse/physician directed goals. The family may or may not wish a transfer to a nursing home or home with or without hospice, and certainly giving hope for a recovery would be inadvisable given the clinical data.
346. Janet was transferred home with hospice care
