This article focuses on the types and stages of grief along with the two types of comfort care. You can follow along with our Fundamentals of Nursing flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.
What is grief?
Grief is the natural reaction to loss. It is a powerful, sometimes overwhelming emotion that can leave people unable to carry on with their normal lives. When someone is grieving, they cannot control the process. They will experience what are known as the stages of grief. People experiencing grief may suffer its effects from months to years. In many instances, it can be beneficial to seek outside professional help when trying to recover or adjust from the cause of one’s grief.
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Grief is not linear
Despite our understanding of grief as a series of stages that occur in a particular order, a grieving patient will typically not transition from one stage to the next in a neat, linear fashion. It is normal for a patient to move randomly from one stage of grief to another, perhaps even skipping over a stage.
After coming to the acceptance stage, a person may still feel some of the other emotions associated with their grief and revisit those other stages. This, too, is normal.
Note that for the purposes of nursing education and testing, we talk about grief as a linear progression, moving from one stage to the next.
The five stages of grief
The five stages of grief are: Denial, Anger, Bargaining, Depression, and Acceptance. These are sometimes referred to by the acronym, DABDA.
Swiss psychiatrist Elisabeth Kübler-Ross first introduced her five-stage grief model in her book “On Death and Dying” in 1969. Her model was based on her work with terminally ill patients.
Today, it is widely accepted that while these are the five most recognized stages of grief, grief may still manifest itself in people in other ways.
Denial
Denial is the first stage of grief. It is the immediate feeling of shock, disbelief or numbness when we are confronted with terrible news. For instance, if we or a loved one were diagnosed with cancer, our initial response might be to think that this situation is not really happening. Or that if we go about our lives as usual, the situation won't be that serious, and everything will work out just fine, when in reality, it might not.
Anger
The second stage of grief is anger. People experiencing this stage might feel abandoned and try to blame others (their healthcare provider, a family member, a higher power) for what they perceive is a terrible injustice. They might ask, “Why is this happening to me?” If it’s a loved one who has been diagnosed with a terminal disease, they might say, “But I love him. This isn't fair.”
Bargaining
The third stage of grief is bargaining. Bargaining is when we negotiate with ourselves or a higher power to try to effect an unrealistic outcome. We make “deals” that are really only false hopes.
If someone is affected by a disease, their bargaining might sound like this: "If I can just make it to my daughter's wedding, then I can die in peace, then I will feel okay leaving this earth." Or they might try to negotiate a change in their life: "I'll give up all of my vices if I can live a little bit longer."
The bargaining stage includes “what if” scenarios, which are rooted in guilt. "What if I had left the house five minutes sooner, then that accident would never have happened." Or "If only I had made him see the doctor months ago, the cancer could have been detected sooner and he could have been saved." Despite having no direct responsibility for a situation, someone in the bargaining stage of grief might take the blame anyway.
Depression
The fourth stage of grief is depression. Depression is probably the emotion most immediately associated with grief. This is when reality sets in, leading to a deep sadness or post-denial feelings of emptiness. Often this leads to a person's desire to withdraw from their day-to-day life.
People dealing with depression might live in a fog or feel numb. They might not want to get out of bed or deal with other people. Sometimes the feeling of hopelessness can lead to suicidal thoughts; a depressed person might ask, "What is the point of carrying on?"
Acceptance
The fifth and final stage of grief is acceptance. Acceptance is when we acknowledge the new reality (for example, the death, or impending death, of a loved one), and that life must go on. We have come to terms with the situation.
It is possible to be at peace with things as they are, but that does not mean we are okay with them. It just means that a way has been found to integrate the grief into our life, and to continue functioning.
Types of grief
The difference between stages and types of grief is that the types of grief are the way we react to grief. As people go through the stages of grief, the manner in which they respond to their grief differs.
The four types of grief are anticipatory, normal, complicated, and disenfranchised. Some researchers and clinicians have outlined additional types of grief, in addition to the ones discussed below.
Anticipatory grief
Anticipatory grief is the response to an impending loss. That is, a loss that is yet to come, but where the grief has already begun (the loss is "anticipated").
For example, consider a family or individual responding to a diagnosis of a terminal illness (in a family member, or themselves). In such instances, the person diagnosed with the terminal disease is still alive — we can see them, talk to them, interact with them — but the grieving process has begun because we know, ultimately, we will lose this person to their illness.
Normal grief
Normal grief, also referred to as “uncomplicated grief,” is experienced following a loss (as opposed to anticipatory grief). Over time, usually 6 months to 1 year, the grief the patient is experiencing will dissipate, and they will go about their regular lives. Normal grief resolves independently and does not impair a person’s ability to function.
Complicated grief
Complicated grief is called that (and not "abnormal") because grief is complicated, yet is a natural part of human existence.
This type of grief can be devastating, intense, and persist for a long time — it is prolonged sorrow that lasts longer than a year and interferes with an individual's daily functioning. Often, people experiencing complicated grief can't work. Sometimes the grief is so intense, they cannot get out of bed.
An example of complicated grief is when someone experiences a loss and, subsequently, won't touch any of their lost loved one's items. If it is their partner, they might keep that person's side of the bed and room exactly as it was when they were alive. They might blame themselves for their loss, even when they had nothing to do with the cause.
Disenfranchised grief
Disenfranchised grief is the experience of a loss that is not publicly acknowledged. The grieving person keeps the loss to themselves, because they don't feel comfortable sharing their feelings, or, occasionally, because it's taboo to admit something about their loss.
Examples of disenfranchised grief include miscarriage. Please note: If you find this topic hard to deal with or are triggered by it, you should skip to the next section.
Not all miscarriages will cause disenfranchised grief. Meris shares her personal experience with miscarriage in the above video. "Speaking from personal experience, having had eight miscarriages, I can report that the first three led to disenfranchised grief. I did not share my loss with anybody. I did not tell anyone. I just kept it to myself and suffered in silence — the hallmark of disenfranchised grief is suffering in silence. The times I chose to share what had happened and talk to my friends and family about what I was going through meant, I was not experiencing disenfranchised grief."
An example of disenfranchised grief that might relate to a taboo is mourning the death of an extramarital lover. In this case, the grieving person doesn't want to acknowledge what others might regard as sinful behavior, or behavior that breaks societal norms. Here, too, they suffer in silence.
Types of comfort care
The two types of comfort care are palliative care and hospice care. The major difference is that palliative care may be provided to complement interventions aimed at curing a disease, while hospice care is not focused on curing a disease.
Palliative care
Palliative care is the management and treatment of the symptoms of a disease or illness (e.g., pain, shortness of breath) with a dual focus on improving a patient's quality of life and decreasing their suffering. As mentioned above, palliative care may be provided along with interventions aimed at curing a disease.
Palliative care can be extended to patients who are terminally ill or not. For example, a friend of Meris's had bone cancer when she was a child. She underwent curative treatment that included chemotherapy and radiation. In addition, she received palliative treatment — she saw a pain management specialist who helped her manage her symptoms and her pain.
Hospice care
Hospice care is directed at symptom management for a life-limiting or terminal illness. As mentioned above, this type of care is not focused on curing a disease.
Hospice care includes emotional support and bereavement services for families. And it can be provided at home or in a facility. As Meris shared in the video, when her father was dying of pancreatic cancer, he was on hospice care, but it was in his own home. He didn't go to the hospital or some other facility. That's because this is a philosophy of care aimed at decreasing the patient's symptoms and managing their pain as they are exiting this earth. Making them comfortable in their ordinary, daily setting is often a key part of hospice care.
Typically, hospice care is for people who have a diagnosis of a terminal illness with less than six months to live. For patients who live longer than six months, hospice care continues based on their physician's best estimate of how long the patient will need to receive this type of care.
Note that if a patient is on Medicare, they require their provider's prognosis in order to receive ongoing hospice care. For patients on private insurance, their access to hospice care will depend on the timing and progression of that individual's disease.
Hospice care does not require DNR status, which might sound counterintuitive, but isn’t. That’s because this care philosophy’s focus is on palliative, non-curative care.
And if the patient's prognosis improves, they may be discharged from hospice care.
Again, the major takeaways regarding the types of comfort care are that palliative care is focused on treating symptoms and managing pain, and is aimed at people who are terminally ill or who have a chronic, lifelong condition. Hospice care is typically for those with six months or less to live, and this type of care is not aimed at curative treatment — rather, it focuses on managing pain as a person is actively dying.
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