HUBERT KAIRUKI MEMORIAL UNIVERSITY

FACULTY OF MEDICINE AND NURSINGDEPARTMENT OF BEHAVIOURAL SCIENCES

TOPIC; BEREAVEMENT AND TERMINAL ILLNESSFACILITATOR; DR.A.J LIWADATE; 2OTH APRIL 2015

PRESENTERS; ALBERT K. KALYOI

ROSEGRASIA MABUBU JOYCE N. CHRISTOPHER

PAULINA D. MUGISHAGWE

OUTLINE

• INTRODUCTION• DEFINITION OF TERMS• OBJECTIVES• MAIN PRESENTATION• CONCLUSIONS• SUMMARY• RECOMMENDATIONS• REFERENCES

INTRODUCTION

• As life expectancy decreases more people are faced with the prospect of chronic ill health. Fear of death from a known disease process is an understandable but very stressful experience. One of the most difficult of the doctor’s dilemmas is whether or not to tell a patient that he has a terminal illness. It is part of the doctor’s task to give patients “bad news” about their health, but they find this very difficult.

Introduction cont…

• Death is not a pleasant topic of conversation because of our response to death is avoidance. When death must be talked about, it is usually done in academic terms.

DEFINITION OF TERMS

• Terminal illness; is an infection or disease that can not be cured and result death of the patient eg; cancer or heart disease

• Bereavement; is the period of mourning and grief following

the death of a beloved person, or loss of a person by divorce, of a pet, of a job or status or of loved material possessions.

• Death; is defined as the termination of all vital functions of

the body including the heartbeat, brain activity and breathing

• Denial; is simply refusing to acknowledge that an event has occurred.

• Greif; is a deep sadness usually caused by someone’s death or keen mental suffering or distress over affliction or loss.

OBJECTIVES

At the end of this presentation all students are expected to be able to understand the following;Disclosing terminal illness.Response to disclosure of terminal illness.The forms of fighting behaviour.Caring and supporting a dying patient.

Stages of bereavement.Counselling the bereaved.Importance of counselling the bereaved.

MAIN PRESENTATION

DISCLOSING TERMINAL ILLNESS.• Disclosure implies certainty that death will

occur, but no assurance as to when it will occur. Disclosing terminal illness to patients has two major characteristics;

i. The patient is told that he/she is certain to die but not when. Expectations of death has two dimensions; certainty and time of demise and the first is more readily determined in advance.

ii. The doctors typically do not give details of illness, particularly mode of them. This is a problem of communication; example a doctor finds it hard to explain the illness to a working class patient, while lack of familiarity with technical terms as well as more general deference to the doctor, inhibits the patient’s impulse to question him/her.

The combination of the two characteristics of disclosure often results in short, blunt announcement of terminal illness to the patient. This is often softened in various ways;

a) One is to add religious flavour like “you’ve had a full life now and God will be calling you soon”. This manner is appropriate for older patients.

b) Another is to muffle the language to the patient. The patient questions “ is it cancer, doc?” the doctor responds, “we call it…..” and then gives the technical name that the patient can understand vaguely.

• In some forms, the blunt announcement sharpens the blow of disclosure by forcing a direct confrontation of the truth with little or no preamble.

RESPONSE TO DISCLOSURE.

• There are five stages that many dying patients pass through after they become aware of their prognosis to the actual death.

Stage 1; DENIAL AND NUMBNESS.• This is usually the immediate reaction to bad news.

Typical denial strategies are juggling time, testing for denial, comparing oneself to other patients, blocking communication, becoming intensely active, emphasizing the future orientation and forcing reciprocal isolation.

Stage 2; ANGER.• In this stage there’s a feeling of rage, anger,

envy and resentment. The frequently asked question is “why me?” the anger is projected to all people at any time. Some even project it to their family members, doctors, spouses or even God.

Stage 3; BARGAINING.• The patient tends to look for a way out of the truth and

tries to buy additional time. The most common is that of reaffirming ones faith and getting back into “good” terms with God.

Stage 4; DEPRESSION.• Here, the patient realises that nothing can be done to

change his or her fortunes. All the feelings of anger, denial, rage soon become transformed to depression and the patient realises that they will lose everything and not much can be done to change this.

Stage 5; ACCEPTNCE.• Patients may demonstrate acceptance of

impending death by actively preparing for death, passively preparing for death or fighting against it.

• Active preparation may take a form of becoming philosophical about dying, death and one’s previous life; patients review and discuss how full their life has been with family, nurses, social workers and chaplain.

• Passive preparation for death among patients who accept illness, also has some characteristic forms. One is to take the news in a chalant manner and the other in a non chalant manner.

• Fighting illness; some patients accept illness by deciding to fight it. Unlike denial behaviour, fighting indicates initial acceptance of one’s impending death together with a positive desire to somehow change it.

There are three forms of fighting behaviour.Intensive living.Going to marginal doctors.Participating in an experiment.• This mode can be readily transformed into

active preparation for death if it increases the patient’s fullness of life before death.

• Many of the standard arguments given by doctors for and against disclosure anticipate a single, permanent impact on the patient. The patient is expected to ‘be brave’, ‘go make peace’, ‘commit suicide’, ‘loose all hope’ or to ‘plan for the future’ and such.

• A doctor decides whether to tell the patient therefore should

consider not a single impact as a desiderata, but how, in what directon and with what consequences the patient’s response is likely to go, and what types of staff are available and how they will handle the patient at each stage.

CARING AND SUPPORTING A DYING PATIENT.The major task of the physician in caring for a dying patient is to provide compassionate concern and continuing support. The appropriate care given to dying patients include the following;o Visiting the patient regularly.o Maintaining eye contact.o Touching appropriately.o Listening to what the patient has to say.o Be willing to answer all questions in a respectful manner.

BEREAVEMENT.

• Bereavement is about trying to accept what happened, learning to adjust to life without that person and finding a place to keep their memory alive while you try to get along as best as you can.

• It can be a confusing time involving a lot of very powerful emotions, which grow, fade and shift as we move across the different stages of bereavement.

• Not everyone experiences the same stages of bereavement at the same time or in the same order. However, most people generally go through the following four stages at some point.

STAGES OF BEREAVEMENT.

ACCEPTANCEGRIEF AND PAINADJUSTINGMOVING ON ACCEPTANCE;• Acceptance is an essential part of bereavement process.

Without acceptance, you may find it hard to really grieve for your loved one.

GRIEF AND PAIN;• Grief is the agony you feel inside when you

realise that you have lost somebody. Grief is complex. It comes in a million different forms, some people cry for days, some people get angry and lash out, other people withdraw from the world and grieve in their own way

ADJUSTING;• Once you have accepted your loss and spent time

understanding and releasing your emotions, you may eventually find yourself adjusting to a new kind of life. The realisation that you need to proceed with everyday life without your loved one maybe hard but with time however; your feet will hit solid ground again and you will start to adjust to life without them.

MOVING ON;• One day you will probably get to a point where

life begins to take you on a new route. Eventually you will begin to move on, this is not a bad thing and it doesn’t mean that you are heartless it simply means you have found a new way to channel your emotions into a new thing.

COUNSELLING THE BEREAVED.Experiences of impending death vary from person to person, so does the experience of losing a relative or friend. Much depends on the relationship. However, a sudden, unexpected death is often harder to get over than one to whom there was time to grieve before the occurance of death; this is known as ‘anticipatory’ or ‘pre-bereavement’ mourning.• The first step in working with the family of a dead patient

is to develop an alliance with them that can allow them to talk about their lives and stress by offering some understanding.

• Also the physician should try to assess to what degree the family members want direction or help.

• Help the bereaved accept the change in role, social situation and self image in becoming the widower/widow, fatherless, childless and disabled.

• Help the bereaved gain a positive but realistic memory of the deceased through repeated discussion.

IMPORTANCE OF COUNSELLING.

• Encourages the bereaved person to think about new relationships, activities and self-help groups.

• Help the bereaved identify the effects of the loss and address the loss and gauge about the future.

• It brings hope and balance.• It fosters personal growth.• During bevearing with others you can share, reflect and

learn as well as support.• It helps the bereaved address the secrecy and social stigma.• It helps the bereaved understand the loss in day to day

living.

CONCLUSIONS.

• Benefits and liabilities of unawareness as opposed to disclosure and the possibilities for acceptance or denial, depends on the nature of the individual case.

• We must see the bereaved people we serve and counsel as our teachers. We need to allow them to teach us with what they experience, rather than constructing some set of goals and experiences that we expect them to meet and achieve.

SUMMARY.

• Death and bereavement is inevitable to each and every human being but the way we deal with it varies from person to person. Thus the counsellor should listen well to bereaved persons and provide as much compassion as possible.

• Also we have discussed disclosure of terminal illness

and why the doctors fail to disclose terminal illness to the patients. The response process after disclosure that is denial, anger, bargaining and acceptance.

RECCOMENDATIONS.

• Counselling in death and bereavement is of great importance to both medical practitioners’ and the bereaved, creation says that we will also die. Thus the knowledge on how to handle the loss will help understand death and overcome states of denial.

• It is also recommended to the doctor and other medical personnel to disclose the terminal illness to the patient after knowing how best it has to be done, and how to guide the patient through the response process.

REFERENCES.

• Lecture notes on behavioural sciences by A.C.P.Sims & W.I.Hume

• Comprehensive textbook of psychiatry volume 2.

• Shorter oxford textbook of psychiatry 5th edition.

QUESTIONS……..???