There is nothing more heartbreaking than losing someone who has been a constant companion for us. Often, they are wrenched away from us by horrible maladies that taint the happy memories built throughout the years. As nurses, we must have the understanding of theses stages after a loss or an announcement of a terrible disease. We do not only handle matters of the health of our patients but also of their emotions. Following Elisabeth Kubler-Ross’ Stages of Grief, let us be an advocate for our patients as they go through these heart-breaking changes in their lives.
Client: “You must be wrong. This cannot be happening to me.”
(Yes, I am sure that I heard the physician’s announcement clearly. But I am healthy; I feel healthy! I do not feel any pain at all. I do not have any sickness; this is all a set-up! I am too young to die, I still have plans for my future, and I still have many goals to achieve! I am sure that the physician had it wrong, I would look for a more competent doctor who would tell me otherwise.)
Every human who experiences death and dying is always subjected to grief. Typically, the initial reaction to an announcement of chronic disease or impending death is denial. Patients who were informed that they have a poor prognosis might refuse any additional treatment because they believe that they are well and healthy. It would be hard to deal with this kind of patient especially because they might not want to listen to their caregivers’ advice regarding treatment. For the folks of a dying patient, exclamations of disbelief might ensue.
Nurse: “Yes, I understand where your feelings are coming from. What you are feeling is a normal part of grieving.”
The nurse must constantly be by the patient’s side to attend to his needs. The patient might become argumentative at this stage, but this is only a normal response to grief. We should understand and lend an ear to the patient so he would know that he can trust us with his feelings and we are acting as an advocate for them during this critical stage in their life.
Client: “I hate my life! I don’t want to talk to anyone! Don’t come near me!”
(Just because I am sick does not mean I cannot do the things I used to do anymore. Do not patronize me, and I know how to handle myself, I do not need your help! You were never here for me, and I feel so afraid that this disease might take me away sooner. I would never show that I am sick, I do not want to be seen as a weakling!)
Angry patients often feel afraid and inadequate, and they exhibit these feelings through anger. The more they are ignored or discounted, the angrier they become. Physical aggression may also be involved in this stage, and this suggests that the patient is already out of control. The patient might become demanding and critical of the care given to him or her, and often would argue with the caregivers just to impose his or her own opinion.
Folks who experience anger during because of an announcement of impending death would also compromise the care given to a dying patient. He or she might restrict caregivers from entering the room and may resort to aggressive physical behavior when contradicted.
Nurse: “It is alright to vent out your feelings, I am here to listen to you. Please tone down your voice, we have other patients in the unit and we would not tolerate the shouting anymore.”
The nurse must never feel that the anger is directed towards them. As caregivers, they must gain control of their feelings and maintain self-awareness. You should maintain eye contact and set limits using a firm manner. You should also maintain a normal tone of voice and show that you are actively listening to them even though when they are angry. However, you must watch out for possible signs of physical aggression. Never place the patient between you and the door so you can easily access the door if the patient becomes physically violent. Lastly, remain calm in dealing with an angry patient.
Client: “I would give everything I own if I become healthy and free of this sickness. I promise to do good once my mother is freed from her sickness.”
(I know I cannot do anything to stop this disease from taking me (or my loved one) away. If only God would grant my wish to remove this disease, and I promise I would not return to my vices. I would also pray and be religious. If only this disease would be healed; I promise I would change my ways.)
A patient who is finally settling down or trying to accept his fate is now on a bargaining stage. He or she would give anything just to reduce the cruelty of the disease or to achieve a good prognosis. The patient is finally calming down, and the anger is slipping away. He or she may start to take in the caregivers’ advice and listen to the physicians because they believe that if they do well, they would be rewarded with the relief from their sickness.
Nurse: “I know you are going through a rough patch right now, and we are here to help and assist you all throughout.”
The nurse must be able to recognize the feelings of the patient. He or she must be aware of the stage that the patient is already in, and in bargaining, the patient is now more open to accepting their advice. The nurse must take this opportunity to advise the patient on where he can participate in his care or what he can do to alleviate his discomfort.
Client: “I would rather stay in my room than go out. I do not feel like doing anything all day.”
(Nothing can be done for me anymore. I cannot be cured of this disease; I might as well lie here and fade away. I would still die soon; all hope is lost for me. )
A depressed client lacks motivation, energy, and hope. He or she already believes that he cannot be cured of the sickness, and no intervention could help him anymore. The patient is slowly inching his way towards acceptance. He is more adherent to the treatments but lacks the motivation. This stage now precedes acceptance.
Nurse: “I am here to listen to your thoughts. You can voice them out anytime.”
The nurse must be aware of the symptoms of major depression. They must watch out for signs of impending suicide because most depressed clients, when left to themselves, are too depressed that they finally resort to suicide. Monitor the patient’s activities but do not put a pattern on your rounds. Check on them in unexpected moments. Provide the client with activities that would bring out positive thoughts and avoid triggers of any depressive feelings.
Client: “I am fully aware that I would have this disease for a long time. I would just let God handle my fate, and I would spend more of my time with my loved ones from now on.”
(I fully accept that I would die of this disease. Instead of feeling sorry for myself, I choose to spend my remaining time with my loved ones. I have to leave happy moments for them to cherish after I am gone.)
This is the last stage of Kubler-Ross’ grieving stages. The patient has already embraced the fact that he could be taken away by the disease. More time for the family would be spent and reconciliation for past mistakes would also be possible at this stage. The patient will endeavor to leave with a light heart if he has truly accepted the prognosis.
Nurse: “I am proud that you have overcome any negative feelings. It is good to see you using your time for your family and friends.”
As the nurse, you should guide the patient every step of the way. Now that the patient has reached the final stage of acceptance, you can plan out any interventions that would promote his comfort together with the patient himself. The patient is now readily cooperative and would heed any advice from the caregivers. You must also let the patient know that all his efforts are appreciated and still let them feel special despite the prognosis or the condition of the patient.
Leaving the persons, you love or being left by the person you love is a painful experience that every human should undergo. The way a person handles a critical situation would predict how well he could survive and we nurses have an important role at this moment. We are tasked to care for our patients from the womb until the tomb, and that is exactly what we will do.