Although there is much being said within the health field and still more is being written about death and dying in professional and lay literature, many older individuals experience problems facing this stage of life. Health care professionals appear to concentrate more on individual clients rather than family and friends when death occurs. The survivors are more often expected to regroup on their own, especially when they are not immediate relatives, but perhaps a friend, the neighbor next door or the lady in the bridge club. As more older adults begin to live in close group/community settings, more attention must be given to the effects of death and dying among cohorts.
Much of the research that has been done with older adults examines the bereavement process after the loss of a spouse. Maddison and Walker attempted to identify widows at high risk for physical and psychological crises after the death of a spouse.1·2 Glick and colleagues documented the early emotional and physical outcomes of bereavement in widows.3 These responses included sadness, crying, confusion, loss of appetite, body aches and pains, lethargy, fear of losing control and anger. Gerber and others evaluated the psychological and social reactions of the aged who had lost spouses.4 From Gerber's study of eighty-one subjects it was evident that the effects of bereavement (reports of illness and increased use of psychotropic drugs) in the elderly sometimes were not manifested until six months after the bereavement. The literature indicates that the death of a spouse causes a significant bereavement reaction in the elderly necessitating resolution of that crisis. This requires support, appropriate resources and a period of adjustment. Might it also be true that the loss of cohorts who live in close proximity, creates a significant bereavement in some older adults, who could use supportive primary preventive intervention to avoid major crisis?
Helping survivors cope with death and dying was an issue addressed by primary care nurses in a community setting with older adults (55 years and older). These older adults were encouraged to participate in a support group facilitated by a psychiatric nurse educator and a family nurse practitioner. Individuals who were extended invitations to join this group were members of a community of seniors who lived and interacted within a half mile radius of each other. There were two housing complexes for older adults within this small area, a 30-unit complex and a 120-unit complex, as well as the local senior citizen center to which 650 seniors of the town belong.
In less than two years of occupancy, residents of the two units experienced six deaths. In addition, a number of older citizens who lived within the community, but outside this complex, had died also. Because of the close physical proximity of the seniors in this community, it became obvious that the deaths of friends and neighbors had an impact on the survivors, apparently regardless of the degree of closeness in reference to familial or friendship ties. This impact especially focused concern on two issues. First, for older adults, the deaths of cohorts are a constant reminder of their own mortality. Secondly, there is an expression of helplessness in assisting themselves and others to cope with the grieving process.
The nurse practitioner observed that the incidence of vague complaints and symptoms (ie, depression, aches and pains, fatigue, etc.) increased around the time of a death in the community. Although many of these seniors had encountered a number of deaths of friends and family members previously, it was still difficult for them to talk about the death or dying of their peers. This was clear to the nurse practitioner as she noted whispered comments, such as, "Perhaps you should go see about Peg. She has been feeling low lately, especially since Cindy died" (Peg's neighbor); or "It's too bad about Bob, poor fellow" (conversation ends). So with information gained from observations, increased generalized complaints with no identifiable biophysical source, and support from other community professionals (ie, social worker, housing director and senior center coordinator) a pilot experience with a death and dying support group for survivors was started.
The nurse practitioner identified fourteen individuals whom she had seen on individual visits for various complaints. Twelve of the individuals interviewed had indicated that a friend or neighbor had died within the last year. Two male clients of the nurse practitioner were invited into the group to attempt to maintain a heterogenous group mixture. An invitational letter was mailed to each individual requesting that he/she attend. The letter gave some indication about the function and role of the group. A letter was written rather than a phone call or other method, because each individual would have an opportunity to refer to the letter at various intervals while making a decision and not have to rely totally on memory.
The facilitators began to anticipate some problems once the need and a possible membership for the support group had been identified. One problem concerned naming the group. In our search for a non- threatening name, we realized we were already behaving contrary to one of our goals, that is, to make the subject of death and grieving an open one, one that was safe to discuss. Therefore, rather that using a euphemism, we labeled the group exactly what it was, "A death and dying support group," and hoped some individuals would join.
Another concern was our belief that individuals in this age group are not particularly accustomed to sharing their feelings in a group situation. Further, they correctly labeled themselves as "well" and any hint at therapy might not be acceptable to them. We also had difficulty finding information geared toward facilitating groups with well elders. Much of the how-to literature discusses groups that involve institutionalized seniors who often are identified as sick. Literature on facilitating a reality orientation group, a music therapy group, a remotivation therapy group or reminiscing groups was not particularly helpful when working with a group of healthy, ambulatory independent seniors living in their own community. However, our overall premise that these individuals had something to gain by sharing their efforts to cope with loss and by lending support to one another overcame these concerns.
The nurse practitioner was already offering health services to the seniors of the community based on a crisis nursing model. The program emphasis under this model for older adults is health maintenance and health promotion. The client is encouraged to be an active participant in his/her own care. So a support group seemed congruent with the health/nursing model already being used.
The original goals identified by the facilitators were:
1 provide a non-threatening atmosphere where the topic of death and dying could be discussed openly
2 look at the process of grief and grieving (stages one is apt to go through when experiencing any loss), and
3 explore helpful and not so helpful coping behaviors (look at ways one adjusts, accepts or behaves when facing death of those around him or her).
The group was scheduled to meet for one hour weekly for five weeks. Of the 14 individuals invited to attend, five accepted. The age range was 59-80 years of age. Those who refused gave a number of reasons for doing so: "The time of day is not good," "I don't want to talk about that," "Why should I? Do you think I am going to die soon?"
The participants were concerned during the first session about "why are we here." Although the group members insisted they did not wish to talk about their losses, they did so throughout the sessions. The facilitators gave permission for this, but did not push, nor did they need to. This was a very warm group, with much sharing, and strongly directed by the members themselves. As each member related a loss episode, the facilitators were allowed to process for the group and to do some teaching around universal grief expression, focusing on its normalcy.
One man who originally had objected strongly to discussing his losses spontaneously told a poignant story about his best friend who was attempting to cope with the loss of a grandchild. This member looked to the group for help in dealing with his friend. It was not unusual for members to seek ways of assisting their grieving friends. A frequent theme was "What can I say? What can I do? I feel so helpless." This gave the facilitators the opportunity to talk about listening and giving support as the survivor works through this healthy, adaptive process.
One woman was quiet throughout the sessions. She had one contribution to make at one session, and that was to ask the group's permission to read a poem. It was a beautiful, but very sad poem about death. The group readily understood that she was telling us that she was indeed a member and sharing her feelings in a way that was comfortable and acceptable for her.
There were other examples of sharing that were not necessarily overt expression of feelings. One elderly woman insisted at the first couple of meetings that one should not discuss feelings openly, but rather bury them. Her frequent advice to others was, "Just don't think about it and it will go away." In the first session, a member had passed out "warm fuzzies" to the other members, including our denier. During a later session she announced that her "warm fuzzy" had accompanied her to a particularly stressful dental appointment. "I held it all the while." In her own way she was connected to the group and gaining some support from it.
Group members realized gains in the form of acceptance of the fact that the feelings they experienced as individuals were normal feelings experienced by others when faced with similar situations. One group member phrased it this way, "I am glad to discover that I am not strange or crazy. Others feel the same way I do. " Another member identified friendship ties as being a benefit of participating in this group. Still other members thought they had learned new ways of coping with anxiety in response to various losses.
Evaluations and Implications
We identified three major problems in conducting this group. First, this population considered themselves "well," so members were not always motivated to attend. A second problem was the brevity of the group program. This population clearly needed a longer period of time to function as a group and to be productive. Finally, we learned to steer the group away from long term psychodynamic issues since they were not only threatening to the members, but could not be dealt with over such a short period of time. A counseling-teaching format was more acceptable and productive.
There are no doubts in the minds of the authors that this is a useful forum for older adults to share feelings about coping with loss. Most older individuals are losing friends through death or their friends are experiencing loss and they want to learn how to cope. This is especially visible in a senior center or a senior living community. This group not only allows for the sharing of feelings and mutual problem-solving, but it is also a forum for teaching about normal, healthy grief. Nurses are in strategic positions within the community to provide continuous and quality supportive care for this age group in coping with death and dying.
There is a need for more research into support/therapy groups that would be most helpful for this population of well elders. With an increased emphasis on preventive mental health and the increase in senior centers and other community living arrangements for older adults, this would seem a worthwhile area of study.
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