ABC of palliative care: Bereavement

doi:10.1136/bmj.316.7129.456

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Frances Sheldon

Bereavement is a universal human experience and potentially dangerous to health. It is associated with a high mortality, and up to a third of bereaved people develop a depressive illness. Help targeted at those most at risk has been shown to be effective and to make the most efficient use of scarce resources. When a death is anticipated, preparation for bereavement can be made, and this can also improve outcome.

The process of grief

Grief has been described in terms of stages or tasks, but all writers emphasise that it is not a neat and ordered process but rather overlapping phases of a mixture of emotions and responses.

The deathbed of Madame Bovary” by Albert-Auguste Fourie (b 1854)

A sense of shock, disbelief, and denial may occur even when death is expected, but these are likely to last longer and be more intense with an unexpected death.

Stages of grief

Initial shock

Common emotions and experiences–Numbness, disbelief, relief

Task–Accept the reality of the loss

Pangs of grief

Common emotions and experiences–Sadness, anger, guilt, feelings of vulnerability and anxiety, regret, insomnia, social withdrawal, transient auditory and visual hallucinations of the dead person, restlessness, searching behaviour

Task–Experience the pain of grief

Despair

Common emotions and experiences–Loss of meaning and direction in life

Task–Adjust to an environment in which the deceased is missing

Adjustment

Common emotions and experiences–Develop new relationships or interests

Task–Emotionally relocate the deceased to an important but not central place in bereaved person's life and move on

During the acute distress that usually follows, bereaved people often experience physical symptoms, which may be due to anxiety or may mimic the symptoms of the deceased. For some, there may be questioning of previously deeply held beliefs, while others find great support from their faith, the rituals associated with it, and the social contact with others of a …