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Out of Hours
Ian J Hamilton
British Journal of General Practice 2016; 66 (651): 523. DOI: https://doi.org/10.3399/bjgp16X687325
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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 circ*mstances, 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.
- © British Journal of General Practice 2016
REFERENCES
- 1.↵
- Strachey J
- Freud S
(1957) in The standard edition of the complete psychological works of Sigmund Freud, Mourning and melancholia, ed Strachey J (Hogarth Press, Institute of Psycho-Analysis, London), 14, pp 152–170.
OpenUrl
- 2.↵
- Kübler-Ross E
(1969) On death and dying (Macmillan, New York, NY).
- 3.↵
- Stroebe M,
- Schut H
(1999) The dual process model of coping with bereavement: rationale and description. Death Stud 23(3):197–224.
OpenUrlCrossRefPubMed
- 4.↵
- Bonanno GA,
- Wortman CB,
- Lehman DR,
- et al.
(2002) Resilience to loss and chronic grief: a prospective study from preloss to 18-months postloss. J Pers Soc Psychol 83(5):1150–1164.
OpenUrlCrossRefPubMed
- 5.↵
- Neimeyer R,
- Harris D,
- Winokuer H,
- et al.
- Neimeyer R,
- Sands D
(2011) in Grief and bereavement in contemporary society: bridging research and practice, Meaning reconstruction in bereavement: from principles to practice, eds Neimeyer R, Harris D, Winokuer H, et al. (Routledge, New York), pp 9–22.
- 6.↵
- Hall C
(2011) Beyond Kübler-Ross: recent developments in our understanding of grief and bereavement. InPsych 33(6), https://www.psychology.org.au/publications/inpsych/2011/december/hall/ (accessed 8 Sep 2016).
- 7.↵
- Schoenberg B,
- Carr AC,
- Peretz D,
- et al.
- Aldrich CK
(1974) in Anticipatory grief, Some dynamics of anticipatory grief, eds Schoenberg B, Carr AC, Peretz D, et al. (Columbia University Press, New York).
- 8.↵
- Olsen RE
(2014) Indefinite loss: the experiences of carers of a spouse with cancer. Eur J Cancer Care (Engl) 23(4):553–561.
OpenUrlCrossRefPubMed
- 9.↵
- Nielsen MK,
- Neergaard MA,
- Jensen AB,
- et al.
(2016) Do we need to change our understanding of anticipatory grief in caregivers? A systematic review of caregiver studies during end-of-life caregiving and bereavement. Clin Psychol Rev 44:75–93.
OpenUrl
- 10.↵
- Shear K,
- Frank E,
- Houck PR,
- Reynolds CF 3rd.
(2005) Treatment of complicated grief: a randomised controlled trial. JAMA 293(21):2601–2608.
OpenUrlCrossRefPubMed
- 11.↵
- Kelly B,
- Edwards P,
- Synott R,
- et al.
(1999) Predictors of bereavement outcome for family carers of cancer patients. Psychooncology 8(3):237–249.
OpenUrlCrossRefPubMed
- 12.↵
- Murray SA,
- Kendall M,
- Boyd K,
- et al.
(2004) Exploring the spiritual needs of people dying of lung cancer or heart failure: a prospective qualitative interview study of patients and their carers. Palliat Med 18(1):39–45.
OpenUrlCrossRefPubMed
- 13.↵
- Grant E,
- Murray SA,
- Kendal M,
- et al.
(2004) Spiritual issues and needs: perspectives from patients with advanced cancer and non-malignant disease. A qualitative study. Palliat Support Care 2(4):371–378.
OpenUrlPubMed
- 14.↵
- Becker G,
- Xander CJ,
- Blum HE,
- et al.
(2007) Do religious or spiritual beliefs influence bereavement? Palliat Med 21(3):207–217.
OpenUrlCrossRefPubMed
- 15.↵
- Holdsworth LM
(2015) Bereaved carers’ accounts of the end of life and the role of care providers in a ‘good death’. A qualitative study. Palliat Med 29(9):834–841.
OpenUrlCrossRefPubMed
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British Journal of General Practice
Vol. 66, Issue 651
October 2016
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