Grief is a typical reaction to the loss of a source of psychological gratification. It is a syndrome with somatic and psychological symptoms that diminish when grief is resolved. Grief processes have been extensively described by Erich Lindemann and George Engle.^*

1. CONCEPTS AND PRINCIPLES RELATED TO GRIEF:
1. Cause of grief: reaction to loss (real or imaginary, actual or pending).
2. Healing process can be interrupted.
3. Grief is universal.
4. Uncomplicated grief is a self-limiting process.
5. Grief responses may vary in degree and kind (e.g., absence of grief, delayed grief, and unresolved grief).
6. People go through stages similar to stages of death described by Elisabeth Kübler-Ross.
7. Many factors influence successful outcome of grieving process:
1. The more dependent the person on the lost relationship, the greater the difficulty in resolving the loss.
2. A child has greater difficulty resolving loss.
3. A person with few meaningful relationships also has greater difficulty.
4. The more losses the person has had in the past, the more affected that person will be, because losses tend to be cumulative.
5. The more sudden the loss, the greater the difficulty in resolving it.
6. The more ambivalence (love-hate feelings, with guilt) there was toward the dead, the more difficult the resolution.
7. Loss of a child is harder to resolve than loss of an older person
2. ASSESSMENT—CHARACTERISTIC STAGES OF GRIEF RESPONSES:
1. Shock and disbelief (initial and recurrent stage):
1. Denial of reality ("No, it can't be.")
2. Stunned, numb feeling.
3. Feelings of loss, helplessness, impotence.
4. Intellectual acceptance.
2. Developing awareness:
1. Anguish about loss.
1. Somatic distress.
2. Feelings of emptiness.
2. Anger and hostility toward person or circumstances held responsible.
3. Guilt feelings—may lead to self-destructive actions.
4. Tears (inwardly, alone; or inability to cry).
3. Restitution:
1. Funeral rituals are an aid to grief resolution by emphasizing the reality of death.
2. Expression and sharing of feelings by gathered family and friends are a source of acknowledgment of grief and support for the bereaved.
4. Resolving the loss:
1. Increased dependency on others as an attempt to deal with painful void.
2. More aware of own bodily sensations—may be identical with symptoms of the deceased.
3. Complete preoccupation with thoughts and memories of the dead person.
5. Idealization:
1. All hostile and negative feelings about the dead are repressed.
2. Mourner may assume qualities and attributes of the dead.
3. Gradual lessening of preoccupation with the dead; reinvesting in others.
3. ANALYSIS: (Table 10.8. Analysis/Nursing Diagnosis: Altered Feeling States Related to Grief) and (Figure 10.3. Grief Versus Depression).
4. NURSING CARE PLAN/IMPLEMENTATION IN GRIEF STAGES:
1. Apply crisis theory and interventions.
2. Demonstrate unconditional respect for cultural, religious, and social mourning customs.
3. Utilize knowledge of the stages of grief to anticipate reactions and facilitate the grief process.
1. Anticipate and permit expression of different manifestations of shock, disbelief, and denial.
1. News of impending death is best communicated to a family group (rather than an individual) in a private setting.
2. Let mourners see the dead or dying, to help them accept reality.
3. Encourage description of circumstances and nature of loss.
2. Accept guilt, anger, and rage as common responses to coping with guilt and helplessness.
1. Be aware of potential suicide by the bereaved.
2. Permit crying; stay with the bereaved.
3. Mobilize social support system; promote hospital policy that allows gathering of friends and family in a private setting.
4. Allow dependency on staff for initial decision making while person is attempting to resolve loss.
5. Respond to somatic complaints.
6. Permit reminiscence.
7. Encourage mourner to relate accounts connected with the lost relationship that reflect positive and negative feelings and remembrances; place loss in perspective.
8. Begin to encourage and reinforce new interests and social relations with others by the end of the idealization stage; loosen bonds of attachment.
9. Identify high-risk persons for maladaptive responses (see I. G.Many factors influence successful outcome of grieving process, Psychosocial Integrity).
10. Health teaching:
1. Explain that emotional response is appropriate and common.
2. Explain and offer hope that emotional pain will diminish with time.
3. Describe normal grief stages.
5. EVALUATION/OUTCOME CRITERIA: outcome may take 1 year or more—can remember comfortably and realistically both pleasurable and disappointing aspects of the lost relationship.
1. Can express feelings of sorrow caused by loss.
2. Can describe ambivalence (love, anger) toward lost person, relationship.
3. Able to review relationship, including pleasures, regrets, etc.
4. Bonds of attachment are loosened and new object relationships are established.

^* Adapted from a classic article by George Engel: Grief and grieving. Am J Nurs 9(64):93–98, 1964.