The Grieving Patient
Learning Objectives
Glossary
Absent grief– In an effort to avoid aspects of the loss and avoid relinquishing the lost object, no grief is experienced.
Anticipatory grief – Grief response before and in preparation for a significant actual or potential loss.
Bereavement– State of having suffered a loss.
Delayed grief– The absence of grief behavior when it would be normally expected.
Disenfranchised grief– Loss that cannot be acknowledged or publicly shared.
Distorted grief– Abnormal extension or overelaboration of grief behavior.
Dysfunctional or complicated grief – Grief reaction that does not follow the usual pattern and may include delayed and/or distorted grief.
Grief – Subjective, emotional response to a loss.
Loss – Situation, real or potential, in which a valued object is rendered inaccessible or is altered in such a way that it no longer has the valued qualities.
Mourning – The process by which grief is resolved.
Prolonged grief– Continued grief behavior lasting much longer than would be expected.
Experiencing loss is a normal part of life. Friends moving away, loss of a job, loss of functional abilities or physical health, or the death of a loved one are something we all experience.
Grief is the normal human response that usually follows these experiences. As things change in our lives, we must adapt. This process of adaptation is called grieving. The purpose of grief is to begin to face the loss, work through the emotions, and eventually let go or adapt with renewed energy to focus on new relationships and goals. Because all individuals respond to loss differently, the process of adapting varies widely and can take days, months, or years depending on many variables. Grief does not decline in a linear, predictable fashion over time. Rather, it can fluctuate over time and be affected by many factors. Variables that can influence the sense of loss include:
Culture also influences the way an individual responds to loss. Most cultures have specific rituals and traditions that provide support and reassurance during the grieving process. Grief caused by a death can be influenced by the cause of death. Unexpected deaths, deaths viewed as preventable, and the death of a child all create additional distress. Death resulting from a cause with a social stigma, such as suicide or AIDS, can be particularly difficult. With suicide, death is unexpected, violent, and possibly preventable. Survivors may experience intense anger, guilt, and self-blame. Those who lose a loved one from AIDS may have had time to prepare for the death, but many complicated feelings may still need to be resolved before grieving can be accomplished. Society's reactions to deaths caused by problems such as these may affect the type of support the mourners receive.
There is no one comprehensive theory that explains normal grief. Research has shown that grief occurs in a sequence of phases or stages with predictable symptoms that change over time, and that these stages do not necessarily progress in an orderly, set fashion.
Acute grief symptoms were first described in Lindemann's classic study of 1944 after the Coconut Grove Night Club fire in Boston. Symptoms include sighing, sobbing, hyperventilating, and a sense of unreality or shock as the first reactions to facing a major loss. Elisabeth Kübler-Ross (1969) and Theresa Rando (1993) both describe stages through which individuals advance in their progression toward resolution (Table 9-2 Adapting to Loss). These stages give us guides for expected behaviors, but each individual goes through the process in his or her own way and time.
During the initial period of shock, the mourner may experience denial or avoidance as a protective mechanism from the overwhelming stress to block out the pain. As denial and shock fade, the mourner begins to face the sadness of the loss. In addition to depression, there may be periods of anger and guilt. Anger can be directed at the lost person for leaving or the person responsible for the situation (if applicable), or it can be displaced onto others. Guilt feelings, possibly evidenced by self-reproach for real or imagined acts of negligence or omissions, can be especially painful. All of these behaviors force the individual to confront the pain over and over again. However, not all reactions cause the individual to feel discomfort. Some can provide comfort, such as a sense of being watched over by the lost person. Maciejewski, Zhang, Block, & Prigerson's (2007) research has validated the model of stages of grief and noted that depression peaked at six months post loss.
The ability to tolerate intense emotions, increasing periods of stability, taking on new roles and relationships, having the energy to invest oneself in new endeavors and ability to bring meaning to one's life (Niemeyer, 1997) are signs that the individual is recovering. Remembering both the positives and negatives of the lost person or object can also indicate successful completion of grieving. However, brief periods of intense feelings may still occur at significant times, such as anniversaries and holidays. Because each individual is unique, the extent of a grief reaction may vary. People may grieve as deeply over the loss of a pet or a longed-for goal as over the death of a family member. Disenfranchised grief can prevent outward expression of grief. This may be seen after an abortion or when the depth of relationship of deceased person is not known publicly. In addition, the length of time to resolution is individual, not necessarily fitting the 1-year tradition. How long grief should go on is less related to the calendar and more to the depth of the loss and the individual's reaction. Also, grief may be delayed because of extreme situations, such as multiple losses, and the mourner must deal with many responsibilities before taking time to experience the loss. Grief can take a more complicated or maladaptive form that interferes with the adaptation to the loss. Examples of these include absent, delayed and distorted grief. These forms of complicated grief often require professional intervention (Ott, 2003). These complicated forms of grief may be related to the circumstances that do not allow the person to complete the grieving process for some reason. With a long illness, anticipatory (or preventative) grief may prepare the person for the future loss (Rando, 2000).
Related Clinical Concerns
The physical stress of grief can place the mourner at risk for health problems (Stroehe & Schut, 2001). Lack of sleep, poor eating, and changes in routine can predispose the individual to illness. Loss of a spouse in elderly people is associated with higher morbidity and mortality rates. Two months after a death, bereaved elderly persons report more illness, greater use of medications, and poor health ratings. Major depressive disorder associated with complicated grief can contribute to higher mortality rate, poor wound healing and immune system dysfunction (Duffy, 2005).
Children
Often adults try to protect children by not including them in the crisis or expressions of grief for other family members. However, they need to be included in the process, based on their level of development, so that they do not feel abandoned and left to face their fear and loss alone. Children generally display grief differently from adults, and it is important not to misinterpret their behaviors to mean that they are not grieving or that they are unaware of what is happening. Children often use symbolic or nonverbal language to communicate their awareness of loss and may even feel ashamed of their loss because they feel differently from their peers. Because they may also need more time to really assimilate what has happened, grief reactions may be delayed (Table 9-3 Children’s Understanding of Death).
Children's initial reaction to death is often shock and sadness but can quickly return to seemingly inappropriate laughter or activity. But their suffering may continue under a different guise (Brown-Saltzman, 2006).
As they struggle with dependency issues, the adolescent may feel vulnerable to express feelings of grief. They may appear to deny or avoid the dying patient, act out their frustration in such ways as school truancy, substance abuse. This may be very distressing to other family members who may view the teen as uncaring.
Elderly people face multiple changes, often including the loss of a spouse, friends, job, financial status, health, and mobility. In spite of the extent of these losses, most elderly persons seem able to adapt, probably because of their past experience. However, the death of a spouse or partner still remains one of the major losses in life. This loss requires multiple life changes that become more difficult with increasing age. Grief can be masked by symptoms of dementia, depression, suicidal ideation, and substance abuse. Brown-Saltzman (2006) notes that the older adults may suffer disenfranchised grief as they experience multiple losses which others may consider normal for this age.
Possible Nurses' Reactions
Thoughts, Beliefs, and Perceptions
Relationships and Interactions
Sedatives and tranquilizers are often used in the early stages of grief to reduce the impact of the intense emotions and promote rest and sleep. However, these medications suppress the intense emotions and interfere with the purpose of the grief process. Antidepressants may be useful, along with psychotherapy, when depressive symptoms are prolonged.
Spiritual
As people face loss and grief, they may be more likely to reach out for spiritual support. They may question their beliefs, talk about an afterlife, and face past wrongdoing. Allow the patient to express feelings and, as needed, seek out clergy available within the agency or ask the patient's or family's own clergy to assist. Churches and temples may also offer special support programs. If the patient requests, provide information on important religious rituals such as the Sacrament of the Sick and prayer, and provide religious articles such as Bibles, prayer books, medals, rosaries, candles, and special clothing. Clergy may also provide important support for staff members who may be struggling with helping patient or family with spiritual issues.
Grieving
GRIEVING evidenced by denial, anger, depression, sorrow related to significant personal loss (actual or potential) including change in relationship, unexpected outcome, illness, death.
Patient Outcomes
Interventions
Grieving
GRIEVING, DYSFUNCTIONAL evidenced by inhibition, suppression, absence, prolongation, or distorted grief reactions related to significant loss, multiple losses, unresolved guilt, lack of support system, difficulty expressing feelings.
Patient Outcomes
Interventions
Patient & Family Education
Who to Call for Help
Community-Based Care