Traumatic death requires different set of responses

Hospice can play a role, but beware of differences

As the United States prepared for war in Iraq, a nation caught glimpses of soldiers bidding goodbye to their families, and it collectively prayed for their safe return. But the reality of war is that men and women far too young to die do just that, leaving behind grief-stricken families to pick up what is left of their lives and carry on.

As U.S. troops made their way to Baghdad, news of scattered casualties dominated evening newscasts. Such reports serve as a reminder to hospices, especially those near military installations that have deployed service members to Iraq, of the potential for widespread community grief as a result of military casualties. Even the death of a single soldier represents an opportunity for hospices to reach out and lend their expertise in bereavement care.

Recognizing its community responsibilities, San Diego Hospice, which is located close to a naval base in Coronado and a Marine base at Camp Pendleton, held a teleconference on traumatic grief last April as away of educating organizations and professionals on public tragedy and how participants can support their communities and help those dealing with a traumatic loss, says Melissa DelaCalzada, a spokeswoman for the hospice.

As Birgit Lisanti, RN, executive director of Pennyroyal Hospice in Hopkinsville, KY, watches the war news unfold, she is aware of the need to prepare traumatic grief programs. The small hospice in rural southern Kentucky is located near Fort Campbell, the home of the 101st Airborne Division, whose members were sent to both Afghanistan and Iraq.

"Our big concern is children," says Lisanti, "because there isn’t anything for them to help them deal with grief."

While well-intentioned hospices will address their communities’ needs, they must first accept the principle that bereavement care for hospice families is not the same as that of families who have lost loved ones in a traumatic manner.

In community crisis situations and individual cases of traumatic death, hospices need to address the following points to be effective:

  • the need to partner with community groups in anticipation of catastrophic community events;
  • the need for ongoing training specific to traumatic death, such as post-traumatic stress syndrome;
  • the importance of victims sharing their stories with one another in group sessions.

Experiences of community tragedy, such as school shootings and the events of Sept. 11, 2001, point to the eagerness of community organizations and volunteers to offer their help, but they also highlight the difficulty hospices have in integrating their services with those provided by others, especially organizations most affected by the tragedy.

The experiences of hospices in Washington D.C. and New York in the aftermath of 9/11 has taught hospice leaders to have systems, policies, and partnerships in place prior to any community catastrophe.

Help grieving patients do the necessary work

While there is a need for training outside bereavement care for anticipated deaths, experts say there are themes that can be applied in traumatic death situations. Most hospice programs approach bereavement care by applying a set of goals laid out in a bereavement care plan. These goals may call for bereavement professionals to help grieving patients perform the following tasks:

  • express all their feelings over this loss: anguish, longing, relief, anger, depression, numbness, despair, aching, guilt, confusion, and often unbearable pain;
  • let the nonnegotiable and excruciating reality sink in that they will never again be in the physical presence of their deceased loved one;
  • review their relationship with the deceased from the beginning and see the positive and negative aspects of the person and the relationship;
  • identify and heal their unresolved issues and regrets;
  • explore the changes in their family and other relationships;
  • integrate all the changes into a new sense of themselves and take on healthy new ways of being in the world without the deceased;
  • form a healthy new inner relationship with this person and find new ways of relating to him or her.

Off all the differences between the two types of grief, time is perhaps the most significant. Families being cared for under hospice while they prepare for the death of a loved one from a terminal illness have the opportunity to prepare for the impending death, which helps to soften the blow. While everyone is different, the bereavement process can last one to two years. In traumatic situations, that time period could extend well beyond two years. Hospices must be sure they have the resources for sustained treatment programs.

In traditional hospice situations, those suffering from grief are provided the following services over a one- or two-year period:

  • Group-oriented bereavement counseling. Isolation and guilt are among the emotions the bereaved endure. Group counseling provides the understanding and support from others that may be missing. In addition, the support of those who have gone through the same process can help those grieving the loss of a loved one understand their own emotions.
  • Individual grief counseling. While group counseling is perhaps an efficient way to counsel more than one grieving person, many require individual counseling to deal with the emotions surrounding their grief.
  • Community services. Nonprofit survivors’ support groups exist in many communities. Hospices should be aware of the services available in their area.

Don’t mix traumatic loss patients with others

For the most part, the same services are provided to traumatic grief patients. However, hospices must be aware of the subtle and not-so-subtle differences that come into play. For example, group counseling should not integrate traumatic loss patients with those whose loved ones died during hospice care. Traumatic loss patients often have a more profound story to tell that may cause others in the group to trivialize their own loss.

Additional tips include:

  • Work on coping strategies from the beginning of treatment.
  • In cases of newsworthy events, protect patients from gratuitous coverage and teach them how to cope in those situations, including knowing when to turn the television off.
  • Set up a private ritual on the anniversary of their loved one’s death and the days leading up to the anniversary. Try to surround them with people who support them, and insulate them from other distractions.
  • Be aware of other significant dates that can send them into an emotional spiral.

In many ways, there isn’t a great difference in treating expected grief and traumatic grief. But where there are differences, experts agree, having expertise can prove critical. Keep this in mind: It is easy to believe that the two types of deaths have parallels, but losing someone to cancer or some other disease is like getting punched in the gut; losing someone under traumatic circumstances is like getting punched in the gut and not seeing it coming.