Download How Culture and Spirituality Influence Grief and Bereavement

How Culture and Spirituality
Influence Grief and
Bereavement
Associated with
Loss & End of Life Care.
Jeny Covill
Chaplain
North Valley Hospital
January 29, 2015
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Objectives:
1. Define the meaning of culture.
2. Identify the impact of culture on
palliative care for patients.
3. Discuss grief and loss issues as they relate to
end of life nursing care.
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What is Culture, is it Relevant
and How Do We Recognize it?
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Culture & Cultural Identity
“Culture itself is neither good nor bad. One's cultural
identity is intrinsically neutral – it helps define who one
is as part of a people, tribe, tongue or nation. Simply put,
culture is the normal or acceptable thinking or behavior
for a group of people.”
Richard Twiss, One Church Many Tribes
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Cultural Identity Can Include:
Race & Ethnicity
Religion & Spirituality
Relationships
Geography
Age
Health or Illness
Gender
Family System
Economic System
Language & Communication
Politics
Profession
Social Clubs
Art & Entertainment
Hobbies & Interests
Causes
Abilities & Disabilities
Military Service
Experiences
Other ...
Jeny Covill, Chaplain, North Valley Hospital, Whitefish, MT. January 2015
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Benefits & Characteristics
of Culture and Cultural Identity
Provide a sense of belonging, connection, tradition,
safety and security.
Provide a foundation for lifestyle and goal planning.
Always changing and evolving.
Guarded, honored and respected.
Evoke a sense of pride and loyalty.
Connect past, present, and future generations.
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Possible Cultural Identifiers
Language
Behavior
Attitudes
Beliefs
Symbols
Rules / Boundaries
Rituals
Communication
Appearance
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Culture influences a person's response to illness,
death, loss, grief and bereavement. A person's
culture is reflected though:
Treatment Plans
Short and Long Term Goals
Coping Skills
Acceptance
Communication
Views on Disclosure
Support Systems
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Cultural Diversity
“Instead of asking others to give up the ideas and traits
that make them unique, we must come to value those
ideas and traits, to see that those who are different from
us have something to offer us.”
Sosene Le'au, Called To Honor Him
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Importance of Rituals
“How families celebrate holidays, participate in seasonal
activities, or interact at mealtime may seem unimportant.
But according to many mental health authorities, rituals
play a vital role in establishing and perpetuating a healthy
lifestyle for families.”
Marian Behan Hammer, “Rituals: Family Ties That Bind”
Vibrant Native Life, Autumn 2002
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Change & New Rituals
Rituals, like culture, evolve with time and
experiences. As we age, our health and family
structures change. We need new rituals to
keep a sense of meaning and belonging in our lives.
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Respecting Culture and
Cultural Identity
While Creating New Rituals
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Peru
2004
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Cultural Assessments
You can find an established cultural assessment tool or
create your own. Refer to Palliative Care Team Recommendations.
Many things make up ones culture and cultural identity.
Culture is both unique and shared.
Use observations and assessments as a guide for asking
questions, not as a list of answers.
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Chaplain Report
Name
–
Gender
–
Age
–
Race / Ethnicity
–
Marital Status
–
Geographical Location
–
Residence
–
Diagnosis
–
Code Status
–
Religious Affiliation
–
Comfort Care or Hospice?
Family Connection / Identity
M, F
Teens, Middle Age, Elderly,
Community / Traditions / Rituals
Family System / Support
Local, Another County or State
Home, Assisted Living, SNF,
Chronic, Acute, Terminal
DNR, FULL
Spirituality / Community / Traditions
This serves as a guide as I meet and visit with patients.
It is also incorporated into Spiritual Care Assessments.
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Additional Considerations
Cultural assessments can also include:
Hometown or Birthplace
Hobbies or Social Clubs
Relatives, Children, or Caregivers
Daily Routines
Use of Music, Sound Machines, Aromatherapy, Massage
Entertainment – TV, Reading, Games, Mobile Devices
Pets & Pet Therapy
Food Preferences, Allergies, Prohibitions & Comfort Food
Employment, Retirement, Military Service
Level of Privacy & Modesty
Views on Healing
Beliefs Regarding Diagnosis, Treatments and Interventions:
Pain, Loss, Grief, Organ Donation, Blood Transfusions, Feeding Tubes, Death
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Self Assessment of Culture
“Great difficulty arises when one culture sees itself as
superior to others. Instead, we must understand that all
the various members of human society need each other,
that there is no superior or inferior culture.”
Sosene Le'au, Called To Honor Him
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Eye
Exercises
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Self Assessment Outcome
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Local At Risk Populations
Racial & Ethnic Minorities
- American Indian, Russian, Hispanic, Filipino, African American, Jewish
Military
– Active Duty and Veterans
Homeless
- Resident, Transient, Runaways
Prisoners
- Inmates and Convicts on Parole, Probation and who have completed time.
Seniors
Minors
Addicts
Mental Health Issues
Disabled
Deaf
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Culture & Spirituality
Often culture and spirituality are so
intertwined, separating one from the
other could unravel the whole. They
are separate, yet the same. Many
cultures do not distinguish between
them. Which came first? Which
changes first? Which supports the
other? Spirituality is a component
of culture and cultural identity. Yet,
culture is an expression of Spirituality.
This image appears on the cover of the Dec. 17, 2013, issue of Advanced
Functional Materials. Credit: Frank Moutos and Farshid Guilak
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How Do We Define Spirituality?
Definitions include being centered on religion,
being centered on personal awareness and growth,
either, or, all and both … and everything in between.
There is no RIGHT or WRONG way. Everyone has their own definition.
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Jeny's Definition
“Spirituality is the sum
of one's attitudes, customs and beliefs
pertaining to their spirit-self and
it's relationship with the soul, the body,
the greater, governing, creative Spirit
and all creation.”
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Spiritual Care Screening Tool
Patient
Support System
Family / Friend Support
System
0 1 2 3 4
0 1 2 3 4
Spiritual Coping System
0 1 2 3 4
0 1 2 3 4
Patient
Family / Friend
Despair VS Hope
0 1 2 3 4
0 1 2 3 4
Dread VS Courage
0 1 2 3 4
0 1 2 3 4
Helplessness VS
Empowerment
0 1 2 3 4
0 1 2 3 4
Curse VS Blessing
0 1 2 3 4
0 1 2 3 4
Meaninglessness VS
Fullness of Life
0 1 2 3 4
0 1 2 3 4
Swindell Hodges, Chaplain Resident / Heart Care Service Line, The Methodist Hospital Houston, TX.
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Spiritual Care Assessment – 7X7 Model
WHOLISTIC DIMENSIONS
Medical Dimension:
Psychological Dimension:
Psychosocial Dimension:
Family Systems Dimension:
Ethnic & Cultural Dimension:
Societal Issues Dimension:
SPIRITUAL DIMENSION
Beliefs & Meaning:
Vocation & Consequences:
Experience & Emotion:
Courage & Growth:
Ritual & Practice:
Life in Community:
Authority & Guidance:
From Assessing Spiritual Needs
by George Fitchett, pp. 42-50.
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Simple Spiritual Assessment
A simple assessment tool for nursing care. Any 'no' answer could
lead to a referral for a spiritual care visit or consult.
1. Does the patient have a sense of meaning and purpose in their life?
2. Does the patient have a sense of love and belonging?
3. Does the patient have a healthy freedom from guilt and shame?
Rev. Pam Roberts
Director of Education
Centered Life: Education, Counseling & Spiritual Care
Colorado Springs, CO
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Spiritual Impacts
of Injury, Illness and Trauma
Three Levels of Spirituality
1. Spirituality of Light
2. Spirituality of Cloudiness
3. Spirituality of Darkness
“Developing an Adequate “Pneumatraumatology”:
Understanding the Spiritual Impacts of Traumatic Injury”
Duane R Bidwell, M.Div., L.S.T.D.
Texas Christian University
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3-Step Approach Through the Cloudiness
Step 1: Help patients share about their views of their faith and how that
faith is challenged by their circumstances. Offer reflective listening and
gentle questioning.
Step 2: Help patients share about the pain they are experiencing. Not only
physical pain, but also pain of seeing their faith in a new way and letting go
of old beliefs that don't fit anymore. Utilizing community is effective in
this step, whether its family members, clinical staff, palliative care team, or
support groups.
Step 3: Help patients look to the future, integrating their illness, injury,
trauma or painful experience with a new courage and freedom to practice
life and faith differently. Help patients by asking “What will be different?”
Help patients “story themselves” into the future.
“Developing an Adequate “Pneumatraumatology”: Understanding the Spiritual Impacts of Traumatic Injury” Duane R. Bidwell, M.Div.,
L.S.T.D. The 3-Step Approach is Bidwell's reflections on Walter Brueggermann's model and writings found in “Hope Within History”
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Spiritual Care Interventions
Be present.
Be a compassionate listener.
Provide validation and encouragement.
Serve as an advocate and / or liaison.
Provide resources.
Provide prayer, meditation, blessings and readings from
sacred texts.
Facilitate / assist with rituals.
Facilitate talking circles for sharing memories.
Make referrals.
Provide support for family and friends.
Coordinate care with patient's pastor, priest or faith group.
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Cultural and Spiritual Considerations of
Communication &
Decision Making
Things to consider:
Ability to participate and understand terminology
Ability to comprehend what is happening
Is English their primary language? Availability of non-family interpreters
Conversation style – Direct or Indirect
Views on privacy, personal space, touch and eye contact
Relationship with nurses, doctors, and other team members
Views on healthcare in general
Views on acceptance, claiming, and identifying illness.
Views on autonomy and family structure values
Have supportive, connective routines, rituals or beliefs been affected?
If so, has it affected the patient's ability to be 'present'?
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Roles: Who Else Is Involved
Ask, Ask, Ask
Who is involved in care and what are their roles?
Who are considered family?
Who are the caregivers?
Who make decisions?
Who are included in discussions?
Who are the peacemakers? Who need care themselves?
Who provide spiritual support or strength?
Are there complicated relationships and roles?
Is anyone missing?
Are roles changing and evolving with the patient's
health, culture and spirituality changes?
Is full disclosure to all involved acceptable?
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Language to Avoid
Avoid using any kind of cliché.
Avoid minimalizing.
Avoid confusing or unknown terminology.
Avoid phrases that have more than one meaning.
Avoid statements that add or remove value.
Be a good learner. Let patients and family members be the experts
on how they feel and view their situations. Ask questions.
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Loss, Grief and Bereavement
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Change Leads to Loss
Various types of loss include:
Material Loss – loss of a tangible object or familiar surroundings
Relationship – loss of emotional or physical presence
Intrapsychic – loss of emotionally important image of oneself
Functional – loss of muscular or neurological functions of the body
Role – loss of a specific social role or position in a group or network
Systemic – loss when a whole system has to shift
Additional variables include:
avoidable, unavoidable, temporary, permanent, anticipated,
unanticipated, leaving, being left …
Kenneth R. Mitchell and Hebert Anderson 1983
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All losses lead to Grief.
Grief is a normal, emotional
response to the loss of something
or someone important.
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Grief – A Tangled Ball of Emotions
H. Norman Wright
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Clinical Implications of Grief
1. Grief is experienced psychologically, behaviorally, socially,
physically and spiritually.
2. Grief is constantly changing with time.
3. Grief is natural and expectable.
4. Grief is a reaction to all types of loss.
5. Grief is dependent upon the individual's unique perceptions of loss.
“Clinical Incident Stress Management: Grief Following Trauma” (Rando 1993).
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Grief Stages and Models
Elisabeth Kubler-Ross
Model of Grief (1969)
1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance
Engel's Stages of Grief (1964)
1. Shock and disbelief
2. Developing awareness
3. Restitution – Rituals about the loss
4. Resolution – Preoccupied with loss
5. Recovery
Bowlby 4 Phases of Grief (1980)
1. Numbness and denial
2. Emotionally yearning, protesting the loss
3. Cognitive disorganization, emotional despair
4. Reorganizing, reintegrating self
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Characteristics and
Dynamics of Grief
Grief is universal
Grief and grieving is intentional
Grief begins with birth and ends with death
Life is a series of attachments and separations
Grief is a lifelong experience of learning to live with limits
Grief is revisiting old losses with each new loss
Grief includes:
Numbness and shock
Emptiness and loneliness
Rev. Pam Roberts
Fear and anxiety
Director of Education
Guilt and shame
Centered Life: Education, Counseling & Spiritual Care
Colorado Springs, CO
Anger
Sadness and despair
Physical pain and discomfort
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Grief is a Form of Honor
“Grief is not a sign of spiritual or emotional weakness. It
is a sign that we are human beings and that we are but
flesh. It is also the ultimate form of honor, in that our
grief shows how valuable the person that has died was
and is to us. Grief is a type of closure that allows us to
draw a line between what was, what is now, and what is
to come. The more important the person was to us in our
lives, the more impacted we will be by the loss.”
Qaumaniq & Suuqiina, “Warfare by Honor:
The Restoration of Honor … A Protocol Handbook”
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Types of Grief
Anticipated Grief – Grief that comes with anticipating
a perceived or expected future loss.
Normal Grief
Complicated Grief – Chronic, delayed, exaggerated, masked
Disenfranchised Grief – Loss that can not be openly
acknowledged or socially sanctioned.
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Mourning & Bereavement
Mourning is generally the outward
social expression of loss resulting
from death. It is strongly influenced
by culture.
Bereavement is the period of
grief and mourning following a death.
It includes the period of processing
and adjusting to the loss as well as
creating a new way of life.
A person's culture and spirituality are a large factor in how they
experience change, loss, grief, mourning and bereavement.
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End of Life Loss Affects Everyone
Change and loss affect everyone, everywhere, all the time.
Grief associated with loss is ongoing, normal, natural, and expected.
Everyone grieves differently according to their experiences, attachments,
culture and spirituality.
In End of Life and Palliative Care, everyone will experience losses …
patients, family members, friends, caregivers, nurses and other
healthcare professionals.
Patients benefit greatly from an interdisciplinary approach to screening
and assessing loss, grief and bereavement.
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Nurse's Role
in Palliative and End of Life Care
Assess a patient's grief.
Consider their culture and spirituality, including rituals, communication,
decision making, and the roles of their support system.
Assess self.
Consider reflections of personal grief and personal attitudes toward
'opposing poles' regarding cultural, spiritual and emotional
responses to situation, treatment, loss, grief and bereavement.
Assist patient with grief.
Support survivors.
Communicate with interdisciplinary team as needed.
Self-care.
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Rev. Jeny Running Brook Covill is a Chaplain at North Valley
Hospital in Whitefish, MT. She is an ordained minister with
Indigenous Messengers International. She is the founder of
First Nations Monday, an international prayer mobilization
network focused on promoting prayer and consideration for
First Nations people and those serving in Native Ministry.
Formerly she hosted a radio program, Across Turtle Island. She
is a 2010 Nominee for Aboriginal Peoples Choice Music Awards
(APCMA) for Best Aboriginal Music Radio Program & Recipient
of the 2011 Silver Arrow Award for Outstanding Contribution
to Native American Radio.
Jeny is enrolled with the Amonsoquath Tribe of Cherokee and
a member of the Paint Clan. She is married with two children.
She enjoys farming, ranching, single action shooting, beading,
and attending local rodeos and pow-wows.
Jeny serves as a volunteer with the Missing In America Project
(MIAP) and is a member of the Whitefish Ministerial Association.
Contact Information: [email protected] or (406) 863-3585
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