Health care providers will encounter grieving individuals throughout their personal and professional lives.[1] The progression from the final stages of cancer to the death of a loved one is experienced in different ways by different individuals. In fact, one may find that the cancer experience, although it is difficult and trying, has led to significant personal growth. Coping with death is usually not an easy process and cannot be dealt with in a cookbook fashion. The way in which a person will grieve depends on the personality of the grieving individual and his or her relationship with the person who died. The cancer experience, the manner of disease progression, one’s cultural and religious beliefs, coping skills and psychiatric history, the availability of support systems, and one’s socioeconomic status also affect how a person will cope with grief.

Distinguishing between the following terms is important: grief, mourning, and bereavement. These terms are sometimes used interchangeably, yet often with different intentions.[2]

Grief: The normal process of reacting both internally and externally to the perception of loss.[3] Grief reactions may be seen in response to physical or tangible losses (e.g., a death) or in response to symbolic or psychosocial losses (e.g., divorce, losing a job). Each type of loss implies experience of some type of deprivation. As a family goes through a cancer illness many losses are experienced and each prompts its own grief reaction. Grief reactions can be psychological, emotional, physical, or social. Psychological/emotional reactions can include anger, guilt, anxiety, sadness, and despair. Physical reactions can include sleep difficulties, appetite changes, somatic complaints, or illness. Social reactions can include feelings about taking care of others in the family, the desire to see or not to see family or friends, or the desire to return to work. As with bereavement, grief processes are dependent on the nature of the relationship with the person lost, the situation surrounding the loss, and one’s attachment to the person. One author [4] noted 5 characteristics of grief:

1. Somatic distress.
2. Preoccupation with the image of the deceased.
3. Guilt.
4. Hostile reactions.
5. A loss of the usual patterns of conduct.

Mourning: The process by which people adapt to a loss. Different cultural customs, rituals, or rules for dealing with loss that are followed and influenced by one’s society are also a part of mourning.

Bereavement: The period after a loss during which grief is experienced and mourning occurs. The length of time spent in a period of bereavement is dependent upon the intensity of the attachment to the deceased, and how much time was involved in anticipation of the loss.

Grief work includes 3 tasks for a mourner.[5] These tasks include freedom from ties to the deceased, readjustment to the environment from which the deceased is missing, and formation of new relationships. To emancipate from the deceased, a person must modify the emotional energy invested in the lost person. This does not mean that the deceased was not loved or is forgotten, but that the mourner is able to turn to others for emotional satisfaction. In readjustment, the mourner’s roles, identity, and skills may have to be modified in order to live in the world without the deceased. In modifying emotional energy, the energy that was once invested in the deceased is invested in other people or activities.

Since these tasks usually require significant effort, it is not uncommon for grievers to experience overwhelming fatigue. The grief experienced is not just for the person who died, but also for the unfulfilled wishes, plans, and fantasies that were held for the person or the relationship. Death often awakens emotions of past losses or separations. One author [6] describes 3 phases of mourning:

1. The urge to recover the lost person.
2. Disorganization and despair.
3. Reorganization.

These phases grew out of the attachment theory of human behavior, which postulates people’s need to attach to others in order to improve survival and reduce risk of harm.

References

1. Casarett D, Kutner JS, Abrahm J, et al.: Life after death: a practical approach to grief and bereavement. Ann Intern Med 134 (3): 208-15, 2001.  [PUBMED Abstract]
   
   
2. Rando TA: Grief, Dying and Death: Clinical Interventions for Caregivers. Champaign: Research Press Company, 1984. 
   
   
3. Corr CA, Nabe CM, Corr DM: Death and Dying, Life and Living. 2nd ed. Pacific Grove, Calif: Brooks/Cole Publishing Company, 1997. 
   
   
4. DeSpelder LA, Strickland AL: The Last Dance: Encountering Death and Dying. 2nd ed. Palo Alto, Calif: Mayfield Publishing Company, 1987. 
   
   
5. Lindemann E: Symptomatology and management of acute grief. 1944. Am J Psychiatry 151 (6 Suppl): 155-60, 1994.  [PUBMED Abstract]
   
   
6. Bowlby J: Processes of mourning. Int J Psychoanal 42: 317-40, 1961. 
   
   

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