Case Studies
Please Note:All case studies are intended to be generic so that substitutions can be made, according to your own clinical roles. Feel free to adjust the case studies so they are relevant to your participant’s clinical needs.
Module 7
Case Study #1
Mrs. S:Death of a Son
Mrs. S. is a 48-year-old woman who recently immigrated to St. Petersburg, Florida from West Africa.She is a mother of four and a grandmother of six.She has no friends in Florida, as she has only been in the United States for a year.She is of the Muslim faith and attends religious services sporadically at a mosque in Tampa, Florida.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 America, 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 Minnesota 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 fiancée of his tiredness because he was worried about finances, as he had no benefits or health insurance and a salary of about 9 dollars an hour.He had hoped to go back to school to obtain a degree.
Mrs. S. was very close to Micha, who, as an infant, and child, slept with her.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 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 God 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 hospice, 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:
- What additional information should be assessed by hospice about this family?
- What are the risk factors for complicated grief in this case?
- What bereavement services might be provided?What disciplines should be involved?
- What kind of grief might the fiancée be experiencing?What interventions would be appropriate?
Module 7
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 twice a day, at lunch and again at dinnertime, to assist her with her meals and share private time together.He could no longer drive and took a cab 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 twice-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 shuffleboard with his homeowners 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.
Discussion Questions:
- Describe John’s grief reactions.
- Describe John’s grief process in relation to his progression through the stages and tasks of grief.
- Was John experiencing normal or complicated grief?Why?
- What interventions might have facilitated John’s grief?
Module 7
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 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 clinical nurse specialist, 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 Heather’s death.
Discussion Questions:
- How is grief from this sudden death likely to differ from death resulting from chronic illness?
- What communication strategies would be helpful for the clinical nurse specialist to use with Heather’s parents on their arrival to the ER?While she is in surgery?At the time of her death?
- What kind of grief would the fiancée likely experience?What types of interventions
would be helpful?How might his grief differ from Heather’s parents and siblings?
- How should the grief of Heather’s students be assessed and managed?
Module 7
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,and 10).He is very involved in his church, coaches his oldest son’s soccer team, and volunteers two nights/month at a local homeless shelter.
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 local hospital 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 Sam’s bone marrow.Sam was re-inducted with chemotherapy.Following the second round, there were still blasts in the bone marrow.Unfortunately, Sam had inherent drug resistance to the chemotherapy.Other options of treatment were reviewed with Sam, but his condition was deteriorating quickly.Sam did not have an advance directive.
Sam’s two older sons had requested to see their dad, as they had no contact with 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, Sam’s 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:
- You have called Sam’s wife to come to the hospital immediately.Once she arrives, you and the physician tell her about Sam’s death.How would you respond to the wife’s grief?
- How would you make sure the children’s grief was identified?What interventions in your community would be of assistance to the children?
- 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 staff’s grief?
Module 7
Case Study #5
Self-Inventory:It’s Your Turn
As nurses, 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 fillout the necessary paperwork, make necessary phone calls, say good-bye to families, and move on to the next patient.Whether we are hospice nurses, oncology nurses, medical/surgical nurses, advanced practice nurses or educators, 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.
- How long have you been a nurse?
- How many patients have you seen die in the last year?
- How many patients did you care for but were not there when they died?
- Describe your most memorable patient who died?
Was it a “good” death?If so, what made it a good death?
Was it a “bad” death?If so, what made it a bad death?
What steps were put in place to make this a “good” or “bad” death?
What improvements could have been made?
What institutional systems supported the “good” death?What systems supported the “bad” death?
- Does your institution offer bereavement support for staff?
If not, who would you need to contact to get this service offered to you and other staff members at your institution?
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.
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ELNEC-Core CurriculumModule 7:Loss, Grief & BereavementPage M7-1
© COH & AACN, 2007Case Studies
Revised:June 2016