Case Study #3 topic: Grief and Loss (see Videbeck chapter 10 as a resource)
The following scenario has questions interspersed throughout the material for ease of reading and review.
Maria Thomas lost her 36-year-old son to death two years ago. This is her experience of going through the grieving process.
Maria’s son David was recently married for his first time and was very happy. This was a great source of comfort to Maria. She also gained a grandson from the union. David became ill with bronchitis which quickly progressed to pneumonia. Although he received medical care, he kept getting weaker over the next few days after finishing antibiotic treatment. He went to the emergency department because he was having trouble breathing. The ED physician diagnosed him with COVID-19 and admitted him to the intensive care unit. The nursing staff and doctor provided excellent, kind care to David. At times Maria believed David was improving. Since Maria had been inoculated for COVID, the staff allowed her to put on personal protective equipment (PPE) and stay at David’s bedside. His wife was outside the room but could see him. She had not had her COVID shots. After 10 days of intense treatment David passed away with his mother at his side. Maria was devastated. Over the next couple of days she told her family, “I can’t believe that he’s gone, it seems so unreal to me.”
1. Which stage of Elisabeth Kübler-Ross’ stage of grieving is Maria experiencing?
2. Define this stage of grief.
Maria became inconsolable, crying all throughout the day. She had been prone to depression and anxiety before her son’s death, but it seemed worse now. She didn’t understand why she couldn’t just “get over it” and feel better.
3. Which stage of Elisabeth Kübler-Ross’ stage of grieving is Maria experiencing?
4. Define this stage of grief.
Maria still had David’s voice on her cell phone messages. She also had photos and a movie of him laughing. She played these over and over so that she could hear his voice again. Sometimes she thought she saw him or evidence that he was still near. She thought he would rustle a curtain or a piece of paper showing that his spirit lingered, giving her more time with him. She was glad to know that he wasn’t really gone. She believed he was helping her get through the loss.
5. Which stage of Elisabeth Kübler-Ross’ stage of grieving is Maria experiencing?
6. Define this stage of grief.
https://youtu.be/REVvDfFw3mA
A few days after David died, Maria’s other son confessed what David had confided in him. David had received the COVID immunization about a month prior to his death. Maria was livid. “Why did he do that? I think that’s what caused his death!” Maria said that David’s doctor kept telling him to get it because he was severely overweight and felt that getting COVID itself would be bad for David. “I wish David wouldn’t have done it! He knows the side effects of those shots! Why didn’t he ask me first – I would have warned him! And why didn’t you tell me sooner?”
7. Which stage of Elisabeth Kübler-Ross’ stage of grieving is Maria experiencing?
8. Define this stage of grief.
David’s funeral seemed to provide some closure for his wife and son, although they missed him terribly. Maria went to visit them often to provide comfort. But often they ended up trying to comfort her instead. Maria continued to cry most of each day. She said, “I don’t understand why this happened, he was so young and had just begun his life with his wife and son.” She would often call family members and cry. She would say, “I still can’t believe it’s real. He’s not really gone. I can’t accept it.” This went on for months after David’s death.
9. Which important stage of Elisabeth Kübler-Ross’ stage of grieving has Maria not yet experienced?
10. Define this stage of grief.
In an effort to ease her depression, Maria’s medical health provider changed her medication. He prescribed fluoxetine.
11. Which medication class is fluoxetine and what are the effects and nursing interventions and education for this medication?
After taking fluoxetine for two weeks, Maria’s suicidality increased. She had a history of suicide ideation but felt worse than ever.
12. Why do you think this occurred?
13. How long does fluoxetine take to become fully therapeutic?
Maria’s doctor advised her to keep taking the medication to see if she would feel more relief later when it reached its full therapeutic level.
After taking fluoxetine for two months, Maria felt increased depression, sadness, and despondency. She had difficulty functioning. She had difficulty sleeping until after midnight and then would sleep 14 hours at a time. She said, “I’m just so tired.”
Maria’s provider tried other medications over the next several months, duloxetine for two months and then bupropion.
14. Which drug classes are each of these medications in?
15. Describe their use, side effects, and nursing interventions/education (for each).
Maria felt little difference in her mood with either of these medications, except for a slight increase in energy. She continued to have severe depression 18 months after David passed away.
16. What is Maria most likely experiencing?
17. What should her provider recommend next?
18. What are risk factors for the above type of grieving?
After some grief therapy and continuing her medications two years after David’s death, Maria admits that she is beginning to finally feel some relief. She finds comfort in the fact that David’s wife has remarried and expecting another child. Her new husband also has a daughter nearly the same age as David’s son. Maria has chosen to feel hopeful as she watches this new family grow. She is supportive and loving as their grandmother.
The following criteria will be used in the scoring rubric. To access the complete rubric, scroll to the bottom of the assignment page.
Identification of the Main Issues/Problems: To achieve full points for this criterion, the main issues and problems must be identified, labeled, and thoroughly described.
Analysis of Issues: To achieve full points for this criterion, all problems/questions presented in the case must be analyzed thoroughly and insightfully.
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References: To achieve full points for this criterion, the reference list must include at least 3 references, including textbooks, professional journals, and noncommercial (e.g., .gov, .edu, .org) websites. Note that the publication date of references should be within the last 5 years unless seminal publication. Also, in-text citations must be present, and there must be no errors in APA in citations or references.
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Grief is a complex and deeply personal experience that varies greatly across individuals. Elisabeth Kübler-Ross's widely recognized five-stage model of grief—denial, anger, bargaining, depression, and acceptance—provides a useful framework for understanding the evolving stages of bereavement. This paper critically analyzes the case of Maria Thomas, who lost her 36-year-old son David two years ago, examining her journey through these stages. Supported by psychological theories and empirical research, the analysis addresses the impact of grief on mental health, pharmacological interventions for depression, and best practices for managing prolonged grief.
Maria’s grief experience, compounded by her history of depression and anxiety, highlights the interplay between personal, psychological, and pharmacological factors in the healing process. This paper will provide a comprehensive examination of each question posed in the scenario, integrating theoretical insights, statistical evidence, and practical nursing considerations.
When Maria initially expressed disbelief about David’s death, stating, "I can’t believe that he’s gone, it seems so unreal to me," she exhibited signs of the denial stage of grief. According to Kübler-Ross (1969), denial serves as a defense mechanism, protecting individuals from the overwhelming pain of loss. This stage is characterized by shock and numbness as the grieving individual struggles to accept reality.
Theoretical Insight: Denial provides temporary emotional respite, enabling individuals to begin processing the loss in manageable increments. Worden’s Task-Based Model of Grief (2009) similarly emphasizes the need to accept the reality of the loss as a foundational task in mourning.
Statistical Evidence: A meta-analysis by Maciejewski et al. (2007) revealed that denial is often the shortest stage of grief, lasting an average of one month post-loss. However, for individuals with pre-existing mental health conditions, this stage can persist longer.
Maria's inconsolable crying, feelings of hopelessness, and inability to "get over" her son’s death indicate that she was experiencing the depression stage of grief. Depression in this context is distinct from clinical depression and represents a natural response to profound loss.
Theoretical Insight: Freud’s (1917) concept of "mourning and melancholia" differentiates between adaptive grief and pathological depression. Maria’s prolonged depressive symptoms suggest a blurring of these boundaries, requiring clinical intervention.
Empirical Evidence: According to Prigerson et al. (2009), about 10% of bereaved individuals develop prolonged grief disorder (PGD), characterized by persistent yearning, sadness, and functional impairment lasting more than six months.
Intervention: Cognitive Behavioral Therapy (CBT) has been shown to effectively reduce depressive symptoms associated with grief (Boelen et al., 2015).
Maria’s repetitive listening to David’s voice recordings and perceiving signs of his lingering spirit are indicative of the bargaining stage. During this stage, individuals often seek ways to reverse or delay the loss, sometimes manifesting as magical thinking.
Theoretical Insight: Kübler-Ross (1969) posits that bargaining is an attempt to regain control in the face of overwhelming helplessness. Bowlby’s Attachment Theory (1980) also underscores the importance of maintaining emotional bonds with the deceased during mourning.
Clinical Observation: Although bargaining is typically short-lived, its persistence may indicate difficulty progressing toward acceptance.
Maria’s anger upon learning that David had received a COVID-19 vaccination reflects the anger stage of grief. She directed her frustration at both David’s decision and his doctor’s recommendation.
Theoretical Insight: Anger in grief often arises from feelings of injustice or helplessness. Parkes and Weiss (1983) highlight that anger can be redirected toward caregivers, the deceased, or even oneself.
Empirical Evidence: Studies during the COVID-19 pandemic indicate that anger and blame were common emotional responses among bereaved families who questioned medical treatments (Stroebe & Schut, 2021).
Maria's inability to accept David's death was evident in her continued disbelief and emotional distress. Acceptance, as defined by Kübler-Ross (1969), involves acknowledging the reality of the loss and finding a way to move forward.
Theoretical Insight: Worden (2009) describes acceptance as the culmination of successful mourning, where the bereaved can reinvest in life.
Clinical Implication: Prolonged inability to reach this stage suggests the need for professional grief therapy and pharmacological support.
Fluoxetine, a selective serotonin reuptake inhibitor (SSRI), was prescribed to Maria to alleviate her depressive symptoms.
Mechanism of Action: Fluoxetine increases serotonin levels in the brain, improving mood and emotional regulation.
Side Effects: Common side effects include nausea, insomnia, and increased anxiety initially (Stahl, 2013).
Nursing Interventions: Nurses should monitor patients for suicidal ideation, particularly during the first few weeks of treatment (APA Guidelines, 2019).
Initial Suicidality: Maria's increased suicidal ideation after starting fluoxetine aligns with evidence that SSRIs can temporarily heighten suicidal thoughts in some patients (Hammad et al., 2006).
Duloxetine: A serotonin-norepinephrine reuptake inhibitor (SNRI) used for both depression and chronic pain. Common side effects include nausea and dizziness.
Bupropion: A norepinephrine-dopamine reuptake inhibitor (NDRI) that is energizing and less likely to cause weight gain. Side effects may include insomnia and anxiety (Stahl, 2013).
Nursing Considerations: Regular monitoring and patient education on side effects are essential for both medications.
Maria's persistent grief symptoms after 18 months suggest she may be experiencing Prolonged Grief Disorder (PGD), recently included in the DSM-5-TR.
Risk Factors:
Therapeutic Approaches: Complicated grief therapy (CGT), a structured form of CBT, has been shown to significantly improve symptoms of PGD (Shear et al., 2016).
Pharmacological Support: SSRIs remain a first-line treatment, but adjunctive therapies such as low-dose antipsychotics may be considered for severe cases.
Maria Thomas' journey through grief underscores the multifaceted nature of bereavement and the critical role of psychological support and pharmacological interventions. The Kübler-Ross model provides a valuable framework for understanding her evolving emotional states, while clinical insights highlight the importance of tailored therapeutic approaches. Effective management of prolonged grief requires a holistic approach that addresses both emotional and biological factors, ultimately guiding individuals toward healing and acceptance.
Maria Thomas’s experience of losing her 36-year-old son, David, to COVID-19 provides a poignant case study for examining the stages of grief as outlined by Elisabeth Kübler-Ross and the challenges of prolonged grief disorder (PGD). This paper will critically analyze Maria’s grieving process, identify the stages of grief she experiences, and evaluate the effectiveness of pharmacological and therapeutic interventions in addressing her prolonged grief. The analysis will be supported by relevant theories, statistical evidence, and credible literature.
Maria’s initial reaction to David’s death—expressing disbelief and stating, “I can’t believe that he’s gone, it seems so unreal to me”—aligns with the denial stage of Kübler-Ross’s five-stage model of grief (Kübler-Ross, 1969). Denial is a defense mechanism that helps individuals cope with the immediate shock of loss by creating a buffer between the reality of death and the emotional pain it causes. Maria’s inability to accept David’s death reflects her struggle to process the enormity of her loss.
Denial is characterized by a refusal to accept the reality of the loss, often accompanied by feelings of numbness and disbelief. This stage serves as a temporary escape from the overwhelming emotions associated with grief, allowing the individual to gradually come to terms with the loss (Worden, 2018). In Maria’s case, her disbelief is a natural response to the sudden and unexpected nature of David’s death, compounded by the traumatic circumstances of his hospitalization and the rapid progression of his illness.
Maria’s inconsolable crying and worsening depression indicate that she has entered the depression stage of grief. This stage is marked by intense sadness, hopelessness, and a sense of emptiness as the reality of the loss sets in. Maria’s preexisting history of depression and anxiety likely exacerbates her emotional distress, making it difficult for her to “get over” her grief.
Depression in the context of grief involves profound sadness, withdrawal from social interactions, and difficulty finding meaning or joy in life. It is a natural response to the recognition of the permanence of the loss (Stroebe et al., 2017). Maria’s inability to function normally and her persistent crying are indicative of this stage, as she grapples with the emotional weight of David’s absence.
Maria’s behavior of replaying David’s voice messages, looking at photos, and believing that his spirit is still present suggests that she is in the bargaining stage of grief. Bargaining often involves attempts to regain control or make sense of the loss by seeking connections to the deceased or attributing symbolic meaning to everyday occurrences.
Bargaining is characterized by a desire to negotiate with a higher power or reality to reverse or mitigate the loss. It may involve “if only” statements or magical thinking, such as believing that the deceased is still present in some form (Neimeyer et al., 2014). Maria’s belief that David’s spirit lingers and her reliance on his recorded voice and images reflect her attempt to maintain a connection with him and delay the full acceptance of his death.
Maria’s anger toward David’s decision to receive the COVID-19 vaccine and her frustration with her other son for not informing her sooner indicate that she is experiencing the anger stage of grief. Anger is a common emotional response to loss, often directed at oneself, others, or even the deceased.
Anger in grief arises from feelings of helplessness, injustice, or frustration over the loss. It may be directed at medical professionals, family members, or even the deceased for perceived mistakes or oversights (Bonanno & Malgaroli, 2020). Maria’s lashing out at David’s doctor and her son reflects her struggle to assign blame and make sense of a seemingly senseless tragedy.
Maria has not yet reached the acceptance stage of grief. Acceptance involves coming to terms with the reality of the loss and finding a way to move forward without the deceased. Maria’s persistent disbelief and inability to function normally suggest that she has not yet achieved this stage.
Acceptance does not mean forgetting or no longer feeling sadness about the loss; rather, it signifies a recognition of the new reality and the ability to integrate the loss into one’s life (Holland & Neimeyer, 2010). Maria’s prolonged grief and difficulty functioning indicate that she is still struggling to reach this stage.
Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) commonly used to treat depression and anxiety. It works by increasing serotonin levels in the brain, which can improve mood and reduce symptoms of depression.
Effects: Fluoxetine may take 4-6 weeks to reach full therapeutic effect. Common side effects include nausea, insomnia, and sexual dysfunction (Stahl, 2017).
Nursing Interventions: Monitor for suicidal ideation, especially in the initial weeks of treatment. Educate the patient about the delayed onset of therapeutic effects and the importance of adherence.
Patient Education: Advise Maria to report any worsening symptoms or side effects and to avoid abrupt discontinuation of the medication.
Maria’s increased suicidality may be due to the initial activation effects of fluoxetine, which can exacerbate anxiety and agitation before improving mood. This is particularly concerning given her history of suicidal ideation.
Fluoxetine typically takes 4-6 weeks to achieve full therapeutic effect. Maria’s provider advised her to continue the medication to allow time for its benefits to manifest.
Duloxetine: A serotonin-norepinephrine reuptake inhibitor (SNRI) used for depression and anxiety. Side effects include nausea, dry mouth, and fatigue. Nursing interventions include monitoring for liver function and blood pressure.
Bupropion: An atypical antidepressant that inhibits dopamine and norepinephrine reuptake. It is used for depression and smoking cessation. Side effects include insomnia and weight loss. Nursing interventions include monitoring for seizure risk and providing education on avoiding alcohol.
Maria is likely experiencing prolonged grief disorder (PGD), a condition characterized by persistent and severe grief symptoms lasting beyond 12 months. Risk factors for PGD include a history of mental health issues, traumatic loss, and lack of social support (Prigerson et al., 2021).
Maria’s provider should recommend grief therapy, such as cognitive-behavioral therapy (CBT) or complicated grief therapy (CGT), which has been shown to be effective for PGD (Shear et al., 2016).
Maria’s journey through grief highlights the complexity of the grieving process and the challenges of prolonged grief disorder. Her experience underscores the importance of tailored interventions, including pharmacological treatment and grief therapy, to support individuals navigating profound loss. By understanding the stages of grief and the factors that contribute to prolonged grief, healthcare providers can offer more effective and compassionate care to those like Maria.
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