Loss, Grief and Bereavement

“…restoring the fit between the world that is and the world that should be…”
from Parkes, CM. Bereavement. Mortality: Virtual Themed Issue 2003.

KEYPOINTS

• Loss is a common human experience. How people experience loss varies tremendously.
• Grief is a natural response to loss and there are no right or wrong ways for expressing grief
• Grief can be experienced psychologically, behaviorally, socially and/or physically
• Grief can be experienced in losses that are not always associated with death
• Grief involves people finding ways to adapt and cope with change, explore meaning in their loss, and find ways to have a continued bond with the deceased
• Emotions, expressions, and understandings of grief are specific to the person, and their relationship to their social, cultural and spiritual world
• Rituals, customs and mourning practices have enormous spiritual, social, and personal significance for the dying and the survivors
• Secondary stressors and life circumstances are risk factors that impact processing and adjustment to loss and death
• Distress and positive emotions are possible at the same time
• Stressful and difficult caregiving situations can impact grief and bereavement

CONSIDERATIONS

Supporting people through their losses, grief and bereavement involves attending to a wide range of possible experiences and contributing factors.

Language of Loss

Grief

• Personal feelings, emotions and reactions to loss

Bereavement

• The state of having experienced a death and the process of integrating the death into one’s life

Mourning

• The private and public rituals, customs, practices and processes to loss

Anticipated grief

• Grief or distressing experiences that may occur when a patient or family/caregiver is expecting a future change, loss or death

Difficult grief

• May be influenced when there are multiple and/or concurrent losses and deaths – survival issues take priority
• May occur when the loss or death is not recognized, valued or accepted in the family and/or community of the bereaved
• May occur when specific social and cultural responses to grief are either intensified or suppressed
• Sudden or unexpected death of patient or other person

Secondary losses

• Other past, present, or future losses and experiences that have happened or may happen as a result of illness and death (e.g., loss of income, faith, support, identity and roles, social connections, personal relationships intimacy, home and other material resources)

Language of Grief

Grief can involve a combination of feelings, emotions, reactions and behaviours. Sometimes, these may seem to conflict with one another. This is a natural and normal part of processing, adjusting, and making meaning to the loss or anticipated losses. They are culturally and socially influenced.
Some examples include:

Physical

• Symptoms of shock
• Tightness in chest
• Shortness of breath
• Weakness, restlessness, lack of energy
• Disruption to sleeping and eating patterns
• Emptiness

Emotional

• Numb, empty
• Anger
• Sadness, crying or wailing,
• Helplessness, hopelessness, fear
• Guilt, relief
• Despair, feeling lost
• Calm
• Overwhelmed
• Abandoned
• Free
• Anxious
• Frustration, powerlessness
• Conflicting emotions

Cognitive

• Confusion, poor concentration
• Self-blame
• Disbelief
• Forgetfulness, problems with short term memory
• Pre-occupation with thoughts of the deceased
• Acceptance
• Lost sense of purpose
• Shift in perspectives

Behavioural

• Isolation, embarrassment, social withdrawal
• Need for information or understanding from different sources
• Pre-occupation with other tasks and responsibilities
• Verbal expression of anger, silence, dissociation

Spiritual

• Blame
• Exploring hope and purpose
• Wanting to die or join the deceased
• Loss or strengthening of beliefs
• Exploring continuing relationship with the deceased

Factors Impacting Grief and Bereavement

Personal

• Coping skills
• Circumstances of the illness and death
• Involvement in the care of the deceased
• Illness beliefs
• Unresolved/concurrent losses
• Addiction or mental health issues

Interpersonal

• Relationship with person who died
• Family dynamics
• Gender, social and cultural expectations
• Roles and responsibilities within family and community systems
• Availability of cultural and/or language support
• Competing and/or current stressors (e.g., other caregiving responsibilities, own illness, etc.)

Socio-economic

• Access to immediate and on-going social support
• Access to financial resources, stable living arrangements, employment

Cultural and spiritual

• Access and availability of spiritual and cultural support systems
• Access to traditional healing practices
• Ability to conduct/participate in rituals, customs and mourning practices
• Loss of meaning or faith

STRATEGIES

Grief and loss is experienced not only after the death of a loved one (bereavement) but can occur throughout the illness continuum. The following questions may be helpful during conversations with patients and family/caregivers to better understand and support their grief, loss, and bereavement experiences:

• “What stresses or changes are you experiencing at this time (e.g., illness changes, difficulties coping, other life stresses)?"
• “How are you feeling physically? What are you noticing?”
• “What kinds of thoughts and feelings have you been experiencing recently?”
• “How are you coping with your thoughts and feelings? Is there anything about your thoughts and feelings that you are concerned or worried about? What do you find helpful?”
• “Who do you share your thoughts and feelings with? How do you share your thoughts and feelings with …? How do you support each other?
• “Tell me about how you are managing with all of your other responsibilities, aside from caregiving for your loved one (e.g., family, employment, community responsibilities)?"
• “Tell me about any important decisions that you are making, or are finding challenging to make?”
• “What are your family, spiritual, and/or cultural traditions that are important for the health care team to know?”
• “How are you finding ways to take care of your self (physically, emotionally, spiritually) during this time?”
• “How can we support you? What would be most helpful during this time”
• "What other types of support might you find helpful (e.g., spiritual support, community organizations, mental health professional, volunteer, etc.)?"

SOURCES/REFERENCES

1. Bruera E, De Lima L, Wenk R, Farr W, editors. Palliative care in the developing world: principles and practice. 1st ed. Houston (TX): International Association for Hospice and Palliative Care; 2004.
2. Cairns M, Thompson M, Wainwright W. Transitions in dying and bereavement: a psychosocial guide for hospice and palliative Care. Victoria (BC): Victoria Hospice Society; 2003.
3. Doka K, Davidson J, editors. Living with grief: who we are, how we grieve. Hospice Foundation of America; 1998.
4. Downing GM, Wainwright W, editors. Medical care of the dying. 4th ed. Victoria (BC): Victoria Hospice Society; 2006.
5. Kumar S. Grieving mindfully. California: New Harbour; 2005.
6. Librach L, Gifford-Jones W. Ian Anderson continuing education program in end-of-life care. Module 13: grief and bereavement. [Online]. Available from: URL:http://www.cme.utoronto.ca/ENDOFLIFE/Modules/GRIEF%20AND%20BEREAVEMENT%20MODULE.pdf
7. Oliviere D, Monroe B, editors. Death, dying, and social differences. New York: Oxford University Press; 2004.
8. Parkes, CM. Bereavement. Mortality: Virtual Themed Issue 2003. [Online]: Available from: URL:http://www.tandf.co.uk/journals/archive/bereave.pdf
9. Parkes C, Laungani P, Young B, editors. Death and bereavement across cultures. London: Routledge; 1997.
10. Stroebe M, Schut H. The dual process model of coping with bereavement: rationale and description. Death Stud 1999;23(3):197-224. http://www.ncbi.nlm.nih.gov/pubmed/10848151
11. Klass D, Silverman P, Nickman S, editors. Continuing bonds: new understanding of grief. Washington: Taylor and Francis; 1996.

Back to top of page Next page Previous page