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

Unless otherwise stated, the content of this page is licensed under Creative Commons Attribution-ShareAlike 3.0 License

Subscription expired — please renew

Pro account upgrade has expired for this site and the site is now locked. If you are the master administrator for this site, please renew your subscription or delete your outstanding sites or stored files, so that your account fits in the free plan.