Grief is the emotional response to real, perceived, or anticipated loss. Grief can be experienced by patients, families, and survivors. The feelings associated with grief cannot directly be felt by others, but the reactions to the grief and associated behaviors may be assessed by the nurse. These feelings can include anger, frustration, loneliness, sadness, guilt, regret, peace and an array of other feelings.

What are the types of grief expressed by people?

1. Anticipatory grief: Grief before loss associated with diagnosis, acute and chronic illness and terminal illness experienced by patient, family and caregivers.
2. Normal grief (uncomplicated grief): Normal feelings, behaviors and reactions to a loss.
3. Complicated grief: Four types of complicated grief:
1. Chronic grief is characterized by normal grief reactions that do not subside and continue over very long periods of time.
2. Delayed grief is characterized by normal grief reactions that are suppressed or postponed and the survivor consciously or unconsciously avoids the pain of the loss.
3. Exaggerated grief - The survivor resorts to self-destructive behaviors such as suicide.
4. Masked grief - The survivor is not aware that behaviors that interfere with normal functioning are a result of the loss.
4. Disenfranchised grief: The grief encountered when a loss is experienced and cannot be openly acknowledged, socially sanctioned or publicly shared.

Grief is a process. Grief begins before the death for the patient and survivor as they anticipate and experience loss. Grief continues for the survivor with the loss of the patient. The grief process is not always orderly and predictable. Usually the grief process includes a series of stages and/or tasks that the survivor moves through to help resolve grief. No one really "gets over" a loss, but he/she can heal and learn to live with a loss and/or live without the deceased.

What are the stages of grief process?

1. Stage 1: Notification and shock - Recognize the loss.
2. Stage 2: Experiencing the loss emotionally and cognitively - Share in the process of working through the pain of the loss.
3. Reintegration - Reorganize and restructure family systems and relationships and reinvest in other relationships.

The personality of the survivor, their coping skills can effect how the survivor will deal with the grief. History of substance abuse or suicidal tendencies can imply vulnerability of the survivor. A good quality of relationship with family and friends can help as they can offer support and company to the patient. History of mental illness, depression or low self esteem can make it difficult for the patient to cope with grief. Professional help should be sought in such cases. Other factors can be experienced with loss, gender, religion, culture, and support systems.

No one can predict when the grief work will be complete. Grief work is never completely finished as there will always be times when a memory, object, anniversary of the death or feelings of loss occur. Grief can diminish and healing can occur as characterized by: the pain of the loss becomes less, the survivor has adapted to life without the deceased, the survivor has been able to, physically, psychologically and socially, "let go." The survivor, however, will continue to experience memories of the deceased

Who experiences grief?

Grief assessment includes the patient, family members, significant others. Older adults who have spent the end of their lives in a nursing home will have additional grief issues.

When does grief occur?

Grief assessment begins at the time the patient is admitted to a hospital, nursing facility, assisted living facility, time of diagnosis of acute or chronic illness, terminal illness. Grief assessment is on going throughout the course of an illness for the patient, family members and significant others and for the bereavement period after the death for the survivors. Grief should be assessed frequently during the bereavement period to alert the nurse to possible signs/symptoms/reactions of complicated grief.

How to cope with grief?

Patients and families can follow the following guideline while coping with grief.

1. Presence, active listening, touch, or silence.
2. Identify support systems.
3. Use of bereavement specialists, bereavement resources.
4. Normalizing the grief process and individual differences.
5. Actualizing the loss and facilitating living without the deceased.
6. Identifying and expressing feelings.
7. Disenfranchised grief - acknowledge and validate the survivor's relationship with the deceased, feelings, grief reactions and support his/her need for ritual, memorial service/funeral, traditions.
8. Public funerals, memorial services, rites, rituals and traditions; private rituals.
9. Spiritual care.
10. Identifying need for additional assistance and making referrals.