Fast Fact and Concept #32: Grief and Bereavement (Part I)

Title: Fast Fact and Concept #32: Grief and Bereavement (Part I)

Author(s): James Hallenbeck, MD

Grief is a normal response to loss, any loss: a job, a limb, a life. Clinicians have an important role in facilitating healthy grieving, and observing for signs of complicated grief. Grief experienced by dying patients and loved-ones prior to and in anticipation of death is called anticipatory grief (or mourning); grief of loved-ones following a death is termed bereavement.

Grief is a normal response to loss that involves processes and tasks at emotional, cognitive and behavioral levels. The initial shock of learning of impending or actual loss evolves into a process of creating a new relationship between the grieving person and the person (or object) of loss.
Grief tends to be experienced in waves, triggered predictably by new losses (such as a loss of functional status) or unpredictably, by seemingly trivial events. Over time the intensity of these waves tends to decrease.
Grief does not have a set schedule; individuals progress through the grief process at different speeds. However, no progress, getting stuck in one phase of grief, can be cause for concern.
Anticipatory grief for patients involves reviewing one's life; for families/friends it means looking to a future without the dying person. Byock has suggested that patients and families may wish to say to each other, in some way, "Forgive me, I forgive you, thank you, I love you and good-bye." People from different cultural backgrounds may differ in terms of how and what they want to say or do in preparation for death. Not knowing or acknowledging that a person is dying will likely delay or interfere with normal anticipatory grief. (See Fast Fact #30, Prognostication)
Grief reactions in dying patients may be confused with pain, depression and even imminent death (e.g. social withdrawal may imply pain, depression or anticipatory grief). Note: Neither pain nor depression are normal aspects of the dying experience, they should be carefully evaluated as both are treatable.
Grief tends to be experienced as sadness, whereas depression is associated with lack of self-worth. The question, "Are you sad or are you feeling depressed," may help begin a dialog to help you distinguish between grief and clinical depression.

What can the physician do to facilitate normal grieving:

Be honest-be very honest when discussing prognosis, goals and treatment options; nothing inhibits normal anticipatory grief more than ambiguity from the physician.
Listen-open the door to meaningful discussion, ask, "How are you doing with this recent news".
"Are you scared?", "Tell me what is going through your mind."
Ask for help---you are not the only health professional available to help with grief-contact a nurse, social worker, chaplain or psychologist/psychiatrist if you need assistance.
Assess for and aggressively treat pain and depression.

Watch for Part 2: Bereavement and Complicated Bereavement

Also See:
Fast Fact #43: Is it Grief or Depression

References

Byock I. Dying Well. Riverhead. NY. 1997.

Rando TA, Clinical Dimensions of Anticipatory Mourning, Research Press, Champaign, Il, 2000.

Fast Facts and Concepts was originally developed as an end-of-life teaching tool by Eric Warm, MD, U. Cincinnati, Department of Medicine. See: Warm, E. Improving EOL care--internal medicine curriculum project. J Pall Med 1999; 2: 339-340.

Copyright Notice: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Warm, E. Fast Facts and Concepts #32: Grief and Bereavment (Part 1), January, 2001. End-of-Life Physician Education Resource Center, www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 1/2001

Format: Handouts

Purpose: Instructional Aid, Self-Study Guide

Audience(s)

Training: Fellows, 1st/2nd Year Medical Students, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice

Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery

Non-Physician: Clergy/Chaplains, General Public, Graduate Students, Lawyers, Patients/Families, Nurses, Social Workers

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Grief/bereavement

The Fast Facts series is distributed for educational use only and does not constitute medical advice. For the most current version of Fast Facts visit the EPERC web site at www.eperc.mcw.edu. This mirror version is provided subject to copyright restrictions for educational use within the Inter-Instutional Collaborating Network on End-of-Life Care (IICN).