Death and Dying: Loss, Grief & Bereavement

Case Studies June 2016

Think about each of these case studies and how you might manage each
situation These case studies will discussed during the lecture and your active
participation in the discussions is required

Case Study #1
Mrs. S: Death of a Son

Mrs. S. is a 58-year-old woman who recently immigrated to Malaysia from West Africa. She is a
mother of four and a grandmother of six. She has no friends in Malaysia as she has only been
here for a year. She is of the Muslim faith and attends religious services sporadically at a large
mosque in the city. Her religious beliefs are strongly internalized.

Her husband died of a genetic heart disorder at the time of the birth of her son, Micha, some 22
years ago. She supported herself and her children by carrying on the family business of food
brokerage. Her youngest son, Justin, had begged her to come to Malaysia after she had sent him
there to expand the family business. One year later, she followed at the request of her second
son, Paulo, whose wife had left him with three young children. She came to help the family and
care for the children in a comfortable home where Micha also lived. She has two other children,
a married daughter with one child who lives in Australia and a son who lives in West Africa.

Her son, Micha, worked as a deliveryman for a grocery market. He began complaining of
fatigue and wanted to quit this job but felt that he had to have another job first. He was engaged
to be married to a young Christian woman who also urged him to continue with this job until he
found another one. He never told his fiance of his tiredness because he was worried about
finances, as he had no benefits or health insurance and a salary of about RM500 per month. He
had hoped to go back to school to obtain a degree.

Mrs. S. was very close to Micha, who as a child had been by her side constantly. He had always
been her favorite child. She felt that he was "her husband, her father, and her brother" who had
all died. She said he replaced the grief she felt for all the men she had lost. He was always very
attentive to her needs. He would listen to her concerns, take her out, and buy her things. He
never said no to any of her requests. Recently, she felt that she had not paid enough attention to
him. She had been focusing her attention on her grandchildren and Paulo, who was going
through so much turmoil with his wife's "desertion."

Although she had told Micha to quit his job and to go to the doctor, she had not insisted. At the
time, she felt that he was an adult and she respected his independence and choice not to see a
physician. Micha rushed out from his bedroom screaming in pain early one morning, collapsed

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and died of a heart attack from a genetic heart condition. This was a traumatic shock to all of the
family, but one that Mrs. S. now feels extremely guilty about.

Eight months after Micha's death, Mrs. S. states she cannot forgive herself and wishes Allah
would take her so she can be with her son and husband. She states she would not commit suicide
as it is against her religion, and if she did commit suicide, she would not be able to see her son
again. She longs to see him even if only in her dreams.
Mrs. S. is only sleeping soundly for about two hours a night. She wanders the house at night
hoping to feel and see Micha just one last time. Her appetite has decreased considerably. She
has lost interest in her personal care and only dresses in the late afternoon right before her son,
Paulo, comes home from work.

She chooses not to leave the home and no longer goes out to the backyard to watch the
grandchildren play. She no longer goes to the mosque but prefers to stay in her room. She
refuses to allow anyone to go in or touch Micha's things in his room. She has asked the youngest
boy grandchild to sleep with her at night so she does not become "frightened" or "lonely" during
the night.

She has developed pain in her left side, headaches and stomach pains but refuses medical
intervention. She states that doctors are too expensive here and she does not want to burden her
son who now works two jobs to support the family. A concerned co-worker of Paulo's suggests
he contact the local health clinic as maybe they can help his grieving mother.

Source:
Lo, K. (2000). Mrs. S. Largo, FL: The Hospice Institute of the Florida Suncoast. Reprinted with permission.

Discussion Questions:

1. What additional information would be needed about this family?

2. What are the risk factors for complicated grief in this case?

3. What treatment would you recommend for this patient and for her family?

4. What services might be needed and what is available in Sabah? What disciplines should be
involved?

5. What kind of grief might the fiance be experiencing? What interventions would be
appropriate?

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 Case Study #2
John and Rose: A Loss of a True Love

Rose resided in a long-term care nursing facility for almost two years. She and her husband John
had been married for 52 years and had a very close relationship. They had no children. John
would visit Rose three times a day, at breakfast, lunch and again at dinnertime to assist her with
her meals and share private time together. He could no longer drive and took a taxi to the
nursing facility. He knew many of the residents and would frequently be seen telling them a joke
or pushing them in their wheelchairs. Rose was confused at times and always seemed very
peaceful and relaxed when John came to visit.

Over the course of a few months, Rose's condition began to deteriorate. She declined food and
fluids and died peacefully with John present. John had a memorial service for Rose, but few
friends came. John had stopped visiting his friends when Rose was admitted to the nursing
facility and he became so busy with his daily visits. John cried continuously for three days after
the memorial service. When he talked about Rose, he spoke of her as if she were still alive. On
most days, he could not decide what to eat or what he was supposed to be doing.

Two months after the death of Rose, John was only crying sporadically. His appetite was not
good and he had lost some weight. He spent a good deal of his time at home looking at pictures
of himself and Rose when they were younger. Once a week, he would visit the nursing facility
where Rose died and converse with the other residents and nursing facility staff. Five days a
week he would go to the cemetery to visit Rose's grave. The neighbors were concerned about
John. When they offered to take him out to eat, he became angry, tearful and declined their
invitation.

Six months after the memorial service, John began going to the store and church, but he had very
little interest in these activities. He had always enjoyed walking around the nursing facility
grounds, but he no longer enjoyed walking. He would visit the cemetery once a week. He
would forget where he put things in the house. He allowed neighbors to visit and spent most of
the time reminiscing about his life with Rose, her illness and her death. He had difficulty
sleeping and would spend many nights wandering around the house.

Ten months after Rose died, John began feeling more energetic. He would still cry when
something profound reminded him of Rose, but he did not cry very often. He began eating
regular meals and going out to dinner with the neighbors twice a week. He also started playing
lawn bowls with a loacl club and contacted a few friends he hadn't seen in years. One year after
Rose died, John visited the nursing facility to plant a tree in Rose's name in the nursing facility
courtyard. He also visited her grave that day. That afternoon, he played shuffleboard and went
to dinner with a friend he hadn't seen in two years.

Source:
Lo, K. (2000). John and Rose. Largo, FL: The Hospice Institute of the Florida Suncoast. Reprinted with
permission.

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Discussion Questions:

1. Describe John's grief reactions.

2. Describe John's grief process in relation to his progression through the stages and tasks of
grief.

3. Was John experiencing normal or complicated grief? Why?

4. What interventions might have facilitated John's grief?

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 Case Study #3
Heather: A Sudden Death

Heather was 24-years old. She was just beginning her second year as a 7th grade math teacher
and was engaged to be married to her high school sweetheart in two months. Heather was
driving to school when she was hit by a truck that ran a red light. She sustained multiple
fractures, head injury, and extensive internal injuries. Her parents and older brother were
informed on arrival at the E.R. that her chances for survival were extremely low. She was taken
to the operating room but after 3 hours of surgery with uncontrollable bleeding and several
resuscitation attempts, she died in the O.R. A nurse, who is on the rapid response team at the
hospital, was called to be with the family when they arrived at the hospital. She stayed with them
after they received the news of Heathers death. The nurse had known Heather from school and
also knew some of the family members.

Discussion Questions:

1. How is grief from this sudden death likely to differ from death resulting from chronic illness?

2. What communication strategies might be helpful for the nurse to use with Heathers parents
on their arrival to the ER? While she is in surgery? At the time of her death?

3. What kind of grief would the fiance likely experience? What types of interventions
might be helpful? How might his grief differ from Heathers parents and siblings?

4. How best would the grief of Heathers students be assessed and managed?

5. What impact might this situation have on the nurse? What supports might she need after this
event?

6. How might the other staff involved in this event be affected? What supports might be
required?

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 Case Study #4
Sam: The Death of a Father

Sam is 36 years-old and has worked for a governmental agency since he graduated from college
12 years ago. Sam is married and has 4 sons (ages 2, 5, 8 & 10). He is very involved in his
church, coaches his oldest sons soccer team, and volunteers at local community events and
functions. He lives in a kampong 3 hours drive from the nearest city.

Sam had been feeling tired for the past couple of months and last week noticed that his gums
bled more than usual after flossing. He also experienced two episodes of epistaxis. He had not
had a physical examination in 5 years, so decided to see his primary physician. Upon
examination of Sam and reviewing lab work and a bone marrow biopsy, it was determined that
Sam had acute myelogenous leukemia (AML). He was immediately sent to the oncology unit at
the closest hospital (3 hours away) and began chemotherapy after a central line was placed.
After the first induction of the chemotherapy regimen, it was found that there were still
numerous blasts in Sams bone marrow. Sam was re-inducted with chemotherapy. Following
the second round, there were still blasts in the bone marrow. Other options of treatment were
reviewed with Sam, but his condition was deteriorating quickly. Sam did not have an advance
directive.

Sams two older sons had requested to see their dad, as they had not seen him since he began his
chemotherapy over a month ago. All four children had experienced colds and coughs while their
dad was in the hospital and their mother felt it would not be appropriate for the children to see
their dad, since they were not well. In addition, Sams wife was concerned that the children
would be upset if they saw their father so ill. Your dad will be home soon and will be as good
as new, she said.

The following night after hearing that his leukemia had not been controlled with the
chemotherapy, Sam began to have spontaneous bleeding from his mouth, nose, eyes, and rectum.
He was diagnosed with disseminated intravascular coagulation (DIC). Unfortunately, Sam died
very quickly, despite aggressive CPR.

Discussion Questions:

1. You have called Sams wife to come to the hospital immediately. Once she arrives, you and
the physician tell her about Sams death. How would you respond to the wifes grief?

2. How would you make sure the childrens grief was identified? What interventions in your
community would be of assistance to the children?

3. Sam had been in and out of the hospital for the past 10 weeks (mostly in). The staff had
become fond of him and his wife. How would you deal with your own grief over this loss?
What interventions might be helpful with the staffs grief?

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 Case Study #5
Elder Autonomy.

Olive, an 86 year old woman, has been placed into a nursing home by her family as they are
unable to care for her at home any longer. Olive has been unwell for some time. She suffers with
pain in her bones and joints, is incontinent in both bladder and bowel, is experiencing problems
in most of her internal organs and her mobility is restricted such that she is mostly bedridden.
She lost her husband 8 years ago and has told her family that she just wishes to be allowed to
pass away peacefully. She is cognitively intact and coherent and able to explain that she does not
want to live any longer with the pain and other problems. Olive has been refusing to eat or drink
and is currently restrained in her bed at the nursing home and is being feed via naso-gastric line.
She had previously signed an advance directive and a Do Not Resuscitate order and has her will
and other paperwork in order.

Questions:
1. Discuss the rights of the patient versus the rights of the family in this case.

2. How can this case be managed? What discussions might need to happen with the family
and the patient?

3. What are the ethical considerations in this case?

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 Case Study #6
Self-Inventory: Its Your Turn

As doctors, nurses and other health care professionals, we many times experience cumulative
loss. We have had the privilege to spend the last days, hours, and minutes with our patients
before they die. Once they die, we fill-out the necessary paperwork, make necessary phone calls,
say good-bye to families and move on to the next patient. Whether we are working in a hospice,
oncology department, medical/surgical department, primary health setting, Klinik Kesihatan or
rural hospital, our time is usually short to complete tasks and then we must move on to the
next event. For many, there is never closure to these cumulative losses. Great care must be
given to provide care for nurses who do this work daily.

Below is a set of questions that will assist you in thinking about some of the losses you have
experienced in your professional career.

Have you experienced the death of a patient? What was this experience like for you?
How did other staff respond?

Have you experienced the death of a family member or close friend? What was this
experience like for you?

Does your institution offer bereavement support for staff?

If not, how could you get support or assistance if you were experiencing difficulty
with this area?
How would you envision this bereavement support?

What do you do to take care of yourself?

How do you spend your time away from your work?
Do you have hobbies, friends, or family?
When did you last take a vacation?
Do you have a mentor? If not, consider choosing someone who is a little further
down the road who can offer you insight into what you encounter daily.

Lastly, write a reflective paragraph of your experience in the palliative care ward and the tutorial/
role play sessions. What effect did these sessions have on you and how is your thinking about
this topic now? What skills do you need to develop to prepare for situations discussed in the case
studies? Any other thoughts/ comments?

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A Short Case Exploring Loss and Grief

Sue and Tom lost their child Jill to leukemia approximately one year ago. Tom suggested that
Sue attend Professional Counselling because she still doesnt seem to be able to cope with
everyday living. For ease of writing the Professional Counsellor is abbreviated to C.

A summary of the session is as follows:

In the first session C concentrated on building rapport with Sue and listening to her story. Sue
felt that it was the first time that anybody had really listened. She felt that her friends and family
didnt want to even mention her daughter as they didnt want to upset her. A lot of useful
information was gathered throughout this session which is summarised below.

Essential Case Information

Her husband Tom feels that she should be more advanced in her recovery because he himself is
coping much better and getting on with life. Sue is dwelling on guilt prone thoughts such as
Why her, she was so young, Im still alive, I didnt tell her I loved her before she died and
What did I do wrong.

Sue and Tom have a son David who is 12 and are currently divided on parenting styles, whereas
before the death they were fairly similar in their approach. Tom feels that David should be able
to do what he wants. He feels that life can be short and therefore doesnt want to be restrictive.
Tom feels that Sue is being over protective whereas Sue feels that she has already lost one child
and doesnt want to lose another. She feels that she couldnt protect Jill and is now doing
everything she can to protect David.

Jill was diagnosed with leukaemia only six months before she passed away. Sue was working
part-time before Jill was diagnosed but gave up work to be with Jill during treatment. Sue has not
returned to work. Before, when Sue was working part-time she was also doing all the housework,
now Sue cant even (her words) get the housework done.

As Sue was very talkative and needed to get a lot of things off her chest in the first session. C
just focused upon building rapport and trust by fully attending to what was said. Therefore at the
beginning of the second session C started the process of establishing goals by asking the client
what she wanted to achieve out of counselling. It was also determined when and how Sue would
know that counselling was no longer required.

C then wanted to normalise some of Sues responses by providing her with some information
about the stages of Grief and Loss. C was careful to highlight that each individual moves through
and expresses the stages differently.

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C then asked Sue if she could identify with any of the stages and what stage she felt she was
currently in. Sue felt she could relate to the first four stages and that currently she was in the
Guilt stage. C then asked Sue what stage she felt Tom was in. Sue felt that Tom was in the
Acceptance Stage or may have moved on to complete recovery.

Again C highlighted to Sue that it is normal for people to move through the stages of grief and
loss at different rates. C then spent some time examining how Sue felt about being in a different
stage to Tom.

C also discussed the length of time (only 6 months) that Sue had known about her impending
loss before the loss actually occurred. Sue felt more relieved by discovering that it can be normal
for someone to become stuck in a stage when they only have a short time to come to terms with a
death before it happens.

At the end of the session Sue left with an affirmation that she had constructed with the assistance
of C to affirm the normality of her current Grief and Loss behaviour. The affirmation Sue
constructed was The feelings I am experiencing are normal for the stage I am in. I will progress
to the next stage when I am ready. As Sue and Toms communication skills are quite good Sue
is also going to discuss the stages of grief with Tom and highlight to him that people progress
through the stages at different rates, in order to ease Toms concerns about Sues progress.

In the following sessions it was apparent that Sue was feeling more comfortable with the stage
she was at and was now accepting her feelings. Consequently, other issues could now be worked
upon to assist her to progress smoothly through the remaining stages of the grief process.

This lead to a discussion about the effects of not having her needs met and how it might
contribute to her uncomfortable feelings at the moment. Issues that were discussed in detail
included the fact that she used to gain recognition within her work environment and from home
entertaining as well as by the praises she used to receive about being able to juggle raising a
family, the housework etc.

The discussion then moved to ways that Sue could actually gain some need gratification now
whilst she is still grieving. C made a point of acknowledging that Sue is not going to be able to
do all the things she used to as of yet. This lead quite nicely into an awareness of the need for
time management training. C highlighted how a loss can upset routines and the loss of a routine
can be a loss in itself. It was explained that time management training may assist Sue in
regaining a routine as people often need to relearn skills they had previously in order to help
them get back on track.

This left future sessions to explore the new parenting issues which the loss has created. Sue
agreed for Tom to join the counselling process at this stage to explore the differences. Once Tom
and Sue acknowledge each others thoughts and feeling about the loss of Jill and how this
impacted on their thoughts and fears regarding David they were in a better position to co-develop
a suitable solution.

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Once this issue was resolved there was no further need for counselling. It is important to note
that Sue has not finished the grieving process but now has more skills and resources to deal with
the final stages without continued counselling support.

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