Chapter 10

Grief and Loss

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 Introduction

 Loss is the experience of separation from

something of personal importance.
 Loss is anything that is perceived as such by
the individual.
 Loss leads to feelings of GRIEF
• Anticipatory Grief

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 Introduction (cont’d)

 Examples of loss include

• A significant other (person or pet)
• Illness or debilitating conditions
• Developmental/maturational changes
• Decrease in self-esteem
• Personal possessions

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 Theoretical Perspectives

 Stages of grief
• Elisabeth Kübler-Ross
‒ Stage I: Denial
‒ Stage II: Anger
‒ Stage III: Bargaining
‒ Stage IV: Depression
‒ Stage V: Acceptance

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Dimensions of Grieving

 Cognitive responses
o Questioning, trying to make sense of loss
o Attempting to keep lost one present
 Emotional responses (anger, sadness, anxiety)
 Spiritual responses
 Behavioral responses
 Physiological responses

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Cultural Issues and Greving

We must ask what practices are common

Educate yourself as needed

Recognize some practices may seem

different to you, but still support

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 Length of the Grief Process

 Acute grief
• Usually lasts about 6 to 8 weeks; longer in older adults
 The grief process
• Is very individual
• May last for many years

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 Length of the Grief Process (cont’d)

 The grief response is more difficult if:

• The bereaved person was strongly dependent.
• The relationship was an ambivalent one.
• The individual has experienced a number of recent losses.
• The loss is that of a young person.
• The bereaved person’s health is unstable.
• The bereaved person perceives some responsibility for
the loss.

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 Length of the Grief Process (cont’d)

 The grief response may be facilitated if

• The individual has the support of significant others.
• The individual has the opportunity to prepare for
the loss.

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 Length of the Grief Process (cont’d)

 Resolution of the grief process

• Thought to have occurred when a bereaved individual is
able to remember comfortably and realistically both the
pleasures and disappointments of that which is lost

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 Length of the Grief Process (cont’d)

2. Which statement would indicate to the

nurse that a widow is nearing the end of the
grief process?
a) “My husband left me so quickly. I’m furious
that he is not here for me!”
b) “My husband was often grumpy, but I know he
loved me unconditionally.”
c) “I feel so guilty that I was out with my
girlfriend when he had his heart attack.”
d) “My husband was the best husband in the
world.”
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 Anticipatory Grieving

 The experiencing of the feelings and emotions

associated with the normal grief response before
the loss actually occurs
 Difficulty arises when family members complete
the process of anticipatory grief and detachment
from the dying person occurs prematurely.
 Anticipatory grieving may be positive for some
people and less functional for others.

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 Maladaptive Responses to Loss

 Delayed or inhibited grief

• The absence of grief when it ordinarily would be
expected
• Potentially pathological because the person is not dealing
with the reality of the loss
• Remains fixed in the denial stage of the grief process
• Grief may be triggered much later in response to a
subsequent loss.

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 Maladaptive Responses to Loss (cont’d)

 Distorted (exaggerated) grief

• All of the symptoms associated with normal grieving
are exaggerated.
• The individual becomes incapable of managing activities
of daily living.
• The individual remains fixed in the anger stage of the
grief process.
• Depressed mood disorder is a type of distorted
grief response.

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 Maladaptive Responses to Loss (cont’d)

 Chronic or prolonged grieving

• A prolonged grief process may be considered
maladaptive when certain behaviors are exhibited.
‒ Behaviors aimed at keeping the lost loved one alive
‒ Behaviors that prevent the bereaved from adaptively performing
activities of daily living

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 Disenfranchised Grief
 Grief over loss that is not or cannot be openly acknowledged,
mourned publicly, or supported socially:
• A relationship that has no legitimacy
• The loss itself is not recognized.
• The griever is not recognized.
• The loss involves social stigma.

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 Normal Versus Maladaptive Grieving

 One crucial difference between normal and

maladaptive grieving
• The loss of self-esteem does not occur in uncomplicated
bereavement.
‒ The loss of self-esteem ultimately precipitates depression.

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 Normal Versus Maladaptive Grieving (cont’d)

3. Which would the nurse identify as a

maladaptive grieving response?
a) An individual thought she saw her dead
husband when she was out shopping.
b) A client is experiencing marked feelings of
worthlessness and low self-esteem.
c) A woman has not cried since the death of
her husband.
d) A year after his death, a wife maintains all of
her husband’s belongings.
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 Application of the Nursing Process (cont’d)
• Elderly adults
‒ A time in life of the convergence of many losses
‒ May lead to “bereavement overload”
‒ Bereavement overload may result in depression

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 Application of the Nursing Process (cont’d)

4. Elderly individuals often experience a

convergence of losses, the timing of which makes it
impossible for the aging individual to complete the
grief process in response to one loss before
another occurs. What term is used to describe
this situation?
a) Prolonged grieving
b) Distorted grief response
c) Bereavement overload
d) Delayed grief response
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 Outcome

 The client
• Acknowledges awareness of the loss
• Is able to express feelings about the loss
• Verbalizes stages of the grief process and behaviors
associated with each
• Expresses personal satisfaction and support from
spiritual practices

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 Planning/Implementation

 Nursing interventions for the bereaved individual

• Provide assistance through the grief process in a
healthful manner toward resolution.
• Encourage the individual to express feelings about the
loss and how the loss will affect his or her life.

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 Planning/Implementation (cont’d)

 Nursing interventions for the bereaved individual

(cont’d)
• Encourage the individual to participate in usual religious
practices from which he or she derives support.
• Assist the client to identify positive aspects about his or
her life, past relationships, and prospects for the future.
• Seek additional supports via referrals (spiritual leaders,
support groups)

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