A CHILD OR PARENT HAS DIED ...How Can the Nurse Help?

WHAT IS GRIEF?
Grief is a normal human experience that takes place after the death of a loved one. The circumstances surrounding the family and the death will influence whether the grief is complicated or uncomplicated.

Parents and their children experience grief whenever there is a loss of a child -- at any stage of that child's development from conception through to old age.

When parents lose a child, they lose their future. They experience pain like no other. Their grief is unimaginable and unbelievable. After all, children aren't supposed to die. Parents cry out, "How can I survive?"

Intense feelings (such as sadness, guilt and anger - to name a few), physical ailments, and changes in daily behaviour are all part of the natural process of grieving. While these expressions are painful, they are also integral to the emotional pain of the individual experiencing them.

HOW CAN I HELP?
There's a strong possibility in your professional career that you'll be called upon to support a parent who has just lost a child through death -- and to support the surviving siblings, too. You'll need to draw on every skill you possess to help the family deal with this loss.

Can you help? What will you say? What practical things can you do for them? Will you be able to offer the support they'll need? What will you do?

There is a high probability that in your professional career you will have to call on your skills to help a parent deal with the death of their child -- and to help the surviving siblings, too. What will you do?

Nurses, you are key people in handling bereavement. Parents and family members feel comfortable with nurses -- you are the caregivers -- and they will turn to you for help.

BEFORE THE DEATH
Before a death, you can help the parents and family:

Listen.
The best support you can give to a parent in this situation is to listen carefully to what they have to say -- let them express their emotions and talk about their child.

Be honest.
You won't know all the answers. You may not even know what to say to the family. But, it's okay to say "I don't know." And if you say the wrong thing, admit it and start over again.

Be non-judgmental.
Each person manages tragedy and expresses grief in their own unique way. Accept them whether or not you understand. Each culture has its own practices and traditions. Be sensitive to these differences.

Allow parents to parent.
Give parents a time with their child, and the chance to hold them and care for them. Let the parents have privacy to say their good-byes. Siblings and other family members, such as grandparents, may also want to be with the dying child.

Be consistent.
If possible, let one nurse be the contact with the parents and family. Dealing with one person will make communications easier and more consistent for the parents.

Be the advocate.
Parents will be too distraught to think clearly. You can suggest options, choices and alternatives that are available to them. And you can explain the implications of choices and options that they may not understand.

Above all -- be the supportive presence they need.

FACILITATING MOURNING

William J. Worden, PhD., a psychotherapist and researcher in the field of terminal illness and suicide, describes four tasks of mourning which the nurse can facilitate. We use examples to illustrate how to help.

An eight year old boy has just died in your emergency room. He was hit by a car two hours ago. The parents are in the waiting room. What will you do?

Let the parents know, clearly, the child has died. Use the words of death, speaking in realistic terms (past tense). Use gentle repetition to reinforce the message.

Involve the parents in the decisions to be made. Let them be parents: this will be the last decision they'll make regarding their child. The shock of the situation may prevent the parent from asking the appropriate questions. Give them the information they'll need, in simple, clear language.

Allow parents private time with their child -- after death, autopsy or termination of life support systems -- parents may want to see their child or have some physical contact, touching, holding, kissing, saying their goodbyes. They may want to take their child's belongings with them; you can arrange this for them.

You can provide the atmosphere to let them express their feelings. Grief is an individual emotion and will be expressed in different ways. At the same time, it's okay to express your own emotions, and show them you care.

The parents have needs that are often forgotten in these tragic situations. They'll be worn out with grief; they may forget to eat; they may need to be surrounded by other siblings and family members. They may want the support of their clergy. Nurses, your sensitivity to their needs is crucial.

HELP FAMILY MEMBERS IDENTIFY AND EXPRESS THEIR FEELINGS

As a community nurse, you have had a new client added to your assignment. This client is a woman in her mid-thirties who is depressed. you understand that her 13 year old daughter committed suicide six months ago. How will you help her express her feelings?

Bereaved parents can think they're going out of control -- that they're losing their minds with grief. Often, they are distracted -- they may express a lot of anger and can even experience physical pain.

You can help by establishing a relationship with them. As the health-care professional, you can reassure them that their feelings and thoughts are a normal part of grief. Parents may experience things that are not regularly a part of their lives. Siblings may experience fears and concerns that are deeply troubling. Let them know that it's all right to reflect on and accept their grief, and be sensitive to how each of them expresses it individually.

Sympathetic listening will help you understand what it is the parent needs to explore -- the child's life time of experiences; the pain of the loss; the time of death and dying.

Even sitting with them in silence can help them to feel they're not alone.

ASSIST THE FAMILY TO THINK ABOUT LIFE WITHOUT THE CHILD

You are a nurse practitioner in a family practice setting. A mother of a 4 year old has come for her son's pre-school checkup. You inquire about how she is and she bursts into tears. You know her other son died two years ago. What will you do?

Mourning has been described as an emotional roller-coaster. Recognize that the parents will have days when their loss seems unbearable -- but also others when it will be more manageable.

Remembering and talking about the child will reassure family members that the child won't be forgotten. Recognize that parents want to remember -- with special memorials, photo albums and diaries, they'll keep the child's memory alive.

Your support can continue to help a bereaved parent. A telephone call or brief note can help parents feel they're not alone or that everyone has forgotten their loss.

ENCOURAGE THE FAMILY TO BUILD NEW RELATIONSHIPS AND START NEW ACTIVITIES

You are helping a group of parents who are 'saying good-bye' to their child and learning to live with just memories. One of the members wants to know what to do with her life, now that her child has died ... What will you say?

Nurses can encourage parents to recognize that their child is not coming back, and that their lives have changed irrevocably, Here, too, nurses can help parents take a first step towards a new life without their child:

Value present relationships: Help the parent to identify and value existing ties. The parent has lost enough already through the loss of the parent-child relationship. With time and permission to grieve, the parent will be able to return to daily activities. Remember -- above all else -- that grieving takes time.

Help with immediate & long term needs: Each individual will need to evaluate their current life situations while considering such future choices as career change and family planning.

Rebuild self esteem: Parents will need to rebuild an awareness of self. You can help them realize that making changes is important -- as long as it's recognized they need time to make changes. Help them to focus on activities which promote feelings of self-worth. If we listen carefully to the bereaved they will tell us what they need.

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The above examples and plans of action only scratch the surface of how nurses can help parents who experience the death of a child -- yet it is a beginning and will be both a personal and professional challenge.

HOW BEREAVED FAMILIES CAN HELP
There is no time limit on the grieving period. It can take at least 18-24 months just to stabilize after the death of a child. The family may appear to be coping rather well at the time of the death and funeral. In actual fact they are probably in shock, experiencing numbness and a lack of feeling. It is only later that manifestations of grief may appear -- tears, depression, anger and physical symptoms of distress.

Bereaved Families provides a caring support system designed to help families cope with the painful reality of their loss and return to the mainstream of life.

Small group discussions led by trained bereaved facilitators are available for parents, siblings (age 3 through 30) and grandparents. Over a period of three months, small groups of approximately eight meet each week for two-hour sessions. More informal meetings with Bereaved Families are available through family nights, newsletters and individual contact.

Professionals with expertise in the nature and dynamics of grief, supervise all group programs and train the bereaved parents for their sensitive role as group leaders. Where needed, we can provide a professional referral.

Bereaved Families also provides educational programs and workshops for professionals and for the bereaved.