A normal grief response affects all aspects of a person’s being, including physical, cognitive, emotional, behavioral, and spiritual. Some or all of these responses may occur simultaneously. (See Characteristics of grief responses, page 235.)

Physically, bereaved persons are at risk for new illness or worsening of existing illness during the first year after experiencing a loss. Cognitively, no matter how much the death is expected, when it occurs, family members experience shock and disbelief. This will be more pronounced when someone dies suddenly. People may report seeing the deceased person.

Emotional acceptance takes time. When the death is acknowledged cognitively, the bereaved person opens his emotions to the pain. The awareness
of loss may occur in incremental amounts as the person can endure it. The bereaved person may imagine what he might have done to prevent the death. Guilt may be intense if the bereaved person was indirectly involved in the death of the family member. The sadness may be broken at times but returns quickly with reminders of the deceased person, such as sorting the person’s clothes or hearing the person’s favorite song.

Behaviorally, daily functioning returns gradually after the initial shock of the death. The bereaved person must take care of the funeral or burial and adjust to the role changes brought about by the death of a family member. Behaviors that are destructive to self or others or involve substance abuse are maladaptive but not unusual.

Spiritual beliefs about death and life after death differ and will affect the way each person grieves. A family’s religion and culture may prescribe certain acts and behaviors after a death, but individual family members may or may not hold those beliefs.

Some people have abnormal — also known as complicated — grief responses. These can stem from various internal and external factors, including the circumstances of the death and the person’s relationship with the deceased. The bereaved person may have had an ambivalent relationship with the deceased before death. The survivor may have unexpressed hostility toward the deceased. In this case, the survivor is likely to feel anger and guilt, which inhibit grief.

Another type of ambivalent relationship is a highly narcissistic one in which the deceased is seen as an extension of the surviving family member. A person grieving a death in a highly dependent relationship has lost the source of that dependency and will experience a change in self-image.

Feelings of helplessness may overwhelm the person’s ability to experience and work through intense feelings of grief.

Many circumstantial factors may lead to complicated grief. Among them are uncertain losses, such as a soldier missing in action. The bereaved are never sure that the person is really dead. Multiple losses, such as those that occur in disasters, airplane crashes, earthquakes, hurricanes, and fires leave bereaved family members with bereavement overload after losing several family members, their home, and their life as they once knew it. Those with complicated grief after one loss will have trouble resolving later losses.

Survivors of someone who has committed suicide may be less likely to discuss their loved one’s death from fear of the social stigma. This creates a conspiracy of silence that deprives the survivors of the social support that’s normally a part of bereavement. The survivor who discovered the body of the deceased may be left with terrible memories.

Another circumstance that reduces support for the bereaved is a socially negated loss, such as abortion. The decision to abort is usually made in isolation, and the woman’s family isn’t involved. Social isolation itself can complicate grieving. People move around the country, and many live without
close proximity to extended family. When a family member dies, the survivor may have no one who even knew the deceased.

Recognizing complicated grief is difficult because normal grief responses are very intense. In complicated grief, the survivor’s grief intensifies to the point of overwhelm, and the person may resort to maladaptive behaviors. The difference between normal grief and complicated grief isn’t the presence of a symptom but its intensity and duration. (See Characteristics of complicated grief reactions.)

Bereaved individuals with complicated grief reactions should be referred for counseling. Resources for referrals of complicated grief should be readily available in agencies and facilities where families may suffer the loss of a family member.

Even when death is expected, survivors must come to terms with the reality that death has occurred. The opposite of accepting the reality is denial of the loss or of the meaning of the loss. (See Accepting the reality of death, page 238.)

You can help surviving family members begin to accept reality. Although no one should be forced to view a body, seeing the deceased’s body after death may be important in helping close family members acknowledge the death and begin to form tolerable memories of the death of their loved one.

If the death resulted from trauma, the emergency department team shouldn’t completely remove all evidence of physical intervention, so survivors can see the efforts made to save their loved one’s life. However, evidence that survivors might find horrifying should be removed so the family can see their loved one without the shock of seeing blood and other signs of suffering.

After a sudden death, it’s helpful if two people with authority are present to break the news. If possible, they should stay to share the subsequent reactions of the survivors. The sensitivity (or lack of it) of professionals in telling the family members the bad news will be remembered long after the event and may be relived repeatedly as the survivor grieves the loss.

Active listening will help grieving people express their emotions and begin to work through the pain of grief. The grieving person will repeat the story of the loss over and over. Repetition is an effort to absorb the reality of the loss, to believe in what has happened. Ask the bereaved person what happened or later in the process ask what the funeral was like. Letting the person repeat the story, using the name of the deceased and the word death instead of a euphemism, helps them accept the reality of the loss.

Anger isn’t uncommon after a loss and may be directed toward helping professionals. Don’t take it personally. Acknowledging the survivor’s anger will be perceived as support. Defensive statements or reasoning will be perceived as confrontation and may increase the bereaved person’s anger. Acting out in an aggressive manner is unacceptable, however, and needs immediate intervention with help from security or police. Survivors who become violent toward others or themselves early after the death should be referred for immediate intervention. Drug and alcohol abuse is maladaptive as well.

Nurses can play an important role in helping the bereaved to complete the task of getting through the pain of grief. (See Working through the pain of grief.)

Immediately after a death, your quiet presence can comfort the family survivors. Many nurses, accustomed to always doing something, underestimate the value of presence. Simply stand by and witness the survivors’ emotional expressions without trying to fix them. Grief is painful and necessary. Being there is a form of empathy and is crucial to a supportive relationship during the mourning process.

Tears and sadness on your part are fine, if genuine. Real emotions demonstrate to the bereaved that you valued their loved one and reinforce the reality of the loss. However, avoid expressing emotions that require comfort by the bereaved person or family.

Grieving people often are frightened of their strong feelings and the inability to think and concentrate. They fear they are going crazy and that
they’ll never be free of pain. Normalizing these responses to grief can be helpful when applied appropriately. Tell them that intense feelings and lack of concentration, though very painful, are experienced by many people after a significant loss. This information can reduce their feeling out of control and address their fears about feeling crazy. Be careful, however, that your efforts to normalize their feelings don’t minimize them instead. Also, don’t try to normalize their emotions by saying, “I know how you feel.” Instead, explain that others who are grieving have reported these painful responses.

Some people gain emotional strength and insights from writing. For those who do, suggest writing in a journal or writing a letter. Writing can be an outlet for intense emotions. Reading may help as well. Many books are available that address personal responses to illness and grief. Recommend them to those who are interested. If someone is having difficulty dealing with his grief, help him find support. Many organizations offer help to grieving people. (See Resources for dealing with grief, pages 240 and 241.)

Most authorities discourage the use of medication, particularly antidepressants, for those in bereavement. One reason is the length of time needed for these drugs to take effect. Another is that these drugs may be dangerous for people who might consider suicide. Tranquilizers may be used in complicated grief, particularly for a person already taking psychotropic drugs for mental illness. These drugs aren’t appropriate in normal grief, where the tranquilized person may lose the opportunity to express feelings early after the loss, when family, friends, and supportive professionals are present. Plus, the tranquilizer eventually will wear off, usually after the funeral when extended family and friends have moved back into their own lives. Finally, in a normal grief response, tranquilizers may reinforce latent substance abuse and delay normal grief responses.