Grief Process and the Stages

¶ … grief process and the stages of grief. The nursing process for grieving or dying patients is difficult for the nurse to deal with, but the professional nurse plays a vital role in the grief process for dying patients and their families.

One of the most famous experts on the grief process, Elizabeth Kubler Ross, named five overlapping stages in the grief process as Denial, Anger, Bargaining, Depression, and Acceptance. Other writers believe the process occurs in psychological stages. Two grief experts note, "There is an initial sense of numbness after the loss, followed by highly distressing yearning and 'searching' for the deceased person, with subsequent disorganization and despair, and finally psychological reorganization" (Tedeschi & Calhoun, 2004, p. 20).

Understanding the stages of this grieving process can help nurses work with terminally ill patients and their families, and can help them understand just what these patients and families are experiencing, which can help them with the healthcare and well being of the terminal patient.

The first stage of the process is denial. The patient may not accept the diagnosis, ask for another opinion, or put off getting treatment. The next stage is anger. The patient may question "why me?" And show anger at the diagnosis and the outcome. The third stage is bargaining, where the patient "bargains" with God or someone else to "fix" the problem. Then comes depression, where the patient realizes the diagnosis is true and they become depressed over their own mortality. The final stage is acceptance, where the patient finally accepts their fate and acknowledges they are going to die. The nurse must be aware of these stages, so she can assess where the patient is in the grief process, and how she or he can help the patient cope with treatment and healthcare while they are coping with the grieving process. The family members can be going through the same stages, too.

Steps in the grief process include bereavement, mourning, anticipatory grief and dysfunctional grief. Bereavement includes the devastation that comes from losing a loved one, especially one of significance. Bereavement includes physical, emotional, behavioral and cognitive reactions, and it can occur while the patient is dying and after death, and in some cases it can continue for quite some time. Mourning is the act of grieving as society dictates (going to the funeral, wearing black, etc.), and it occurs after the death. Anticipatory grief occurs even before the patient dies, as the death is anticipated and anguished over, and dysfunctional grief is when the grief or the grieving period becomes so prolonged and exceptional that it takes over a person's life and does not allow them to function normally, and it can occur at just about any stage in the grief process.

It is important to note that not all people process grief in the same way, and the nurse must know this. The two writers continue, "If clinicians assume that severe distress is inevitable and absolutely universal (although it is indeed very common), they may inadvertently allow this assumption to guide their clinical responses in ways that are not helpful to the client" (Tedeschi & Calhoun, 2004, p. 26). Two other writers note, "Nurses must be aware that there is no one right way for a patient to respond to dying. Nurses must adapt their care based on patients' current responses and needs and not expect them to always progress through defined stages" (Craven & Hirnle, 2009, p. 1327). Thus, nurses need to be attentive to their dying patients and their moods, and need to take the time to get to know these patients so they can help them through their grieving and make the process a little less painful.

The nurse plays a critical role in the grieving process, because she is often the representative between the family and the dying patient, and she should be able to act as a facilitator between the two, especially if the family has been estranged. She can also learn to recognize the symptoms of grief in patients and families, such as loss of appetite, loss of sleep, depression, lack of interest, loss of sex drive, and other symptoms, to help treat the depression and anxiety with some form of physical or medical treatment, if necessary. If left untreated, grief can turn into dysfunctional grief and literally ruin a person's life, so the nurse plays a key role in helping the patient and family members manage their grief.