Understanding grief and bereavement

The purpose of this review is to outline the theories of grief, explain the terms anticipatory and complicated grief, discuss the role of spirituality at the end of life, and consider factors that contribute to ‘a good death’.

THEORIES OF GRIEF

Freud¹ proposed the original ‘grief work’ theory, which involved the breaking of ties with the deceased, readjusting to new life circumstances, and building new relationships. Kübler-Ross² proposed the ‘stage theory’ where grief proceeded along a series of predictable stages including shock and denial, anger, resentment and guilt, depression, and finally acceptance. Stroebe and Schut³ proposed a ‘dual-process model’ with grief being a process of oscillation between two modes, a ‘loss orientation’ mode when the griever engages in emotion-focused coping, and a ‘restoration orientation’ mode when the griever engages in problem-focused coping. Bonanno et al⁴ suggested chronic grief was associated with pre-loss dependency and resilience with pre-loss acceptance of death, whereas Neimeyer and Sands⁵ suggested that the construction of meaning was the main issue in grief. Hall⁶ has proposed that loss provides the possibility of life-enhancing ‘post-traumatic’ growth as the individual integrates the lessons of loss and resilience.

ANTICIPATORY GRIEF

Aldrich⁷ defined anticipatory grief as grief that occurs prior to a loss, as distinguished from grief occurring at or after a loss. Olsen⁸ found that carers of patients with cancer had a heightened awareness of mortality and inability to plan for the future, and called this ‘indefinite loss’. However, Nielsen et al⁹ conducted a systematic review of anticipatory grief studies and could not demonstrate a positive association between anticipatory grief and bereavement, and questioned the concept that anticipatory grief was an alleviator of carer grief during bereavement.

COMPLICATED GRIEF

Shear et al¹⁰ outlined four key features of complicated grief: 1) a sense of disbelief regarding the death; 2) anger and bitterness over the death; 3) recurrent pangs of painful emotions with intense yearning and longing for the deceased; and 4) preoccupation with thoughts of the deceased that often include distressing and intrusive thoughts related to the death. Kelly et al¹¹ in an assessment of carers of patients with cancer at the time of referral to palliative care and 4 months post-bereavement found the main predictors of complicated grief were: 1) the carer’s psychological symptom score at the time of referral; 2) the number of adverse life events; 3) the carer’s coping strategies; 4) past bereavement and separation experiences; 5) the carer’s relationship with the patient; and 6) the severity of the patient’s illness at the time of referral.

SPIRITUALITY AND ‘A GOOD DEATH’

Patients with cancer approaching death embark on an inner journey involving a search for meaning, and their quality of life is closely related to their spiritual wellbeing. Murray et al¹² showed that patients with cancer and their carers expressed needs for love, meaning, purpose, and transcendence, and had significant spiritual needs. Grant et al,¹³ in a study of patients with cancer nearing the end of life, found their spiritual needs centred on a loss of roles and self-identity, and a fear of dying. Becker et al,¹⁴ however, in a systematic literature review into the role of spirituality in the grieving process and how it may be influenced by characteristics such as age, gender, culture, and religion, concluded that it was not possible to give a definite answer one way or the other due to deficiencies in the methodology of the studies. Holdsworth¹⁵ investigated the end-of-life experience of bereaved carers and described six factors contributing to a ‘good death’: 1) social engagement and connection to identity; 2) carer’s characteristics and actions; 3) carer’s confidence and ability to care; 4) preparation and awareness of death; 5) presentation of the patient at death; and 6) support for grieving carers after death.

IMPLICATIONS FOR GPs

GPs play an important role in end-of-life care and in the support of loved ones during bereavement. Hopefully this review provides useful information and helpful insights into a major life event affecting everyone at some stage in their lives.