2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

Encountering Grief in Patient Care
Overview: Grief is essentially unavoidable and is a normal
reaction to loss. Grief may be experienced by patients and
their loved ones as well as by physicians and members of the
health care team in response to the consequences of illness or
death. Grief is typified by certain indicators that may significantly
effect one’s emotional and physical well-being. Although
these indicators tend to follow a general pattern, there
is variability among individuals. Complicated grief may require
EMILY DICKINSON wrote, “I measure every grief I
meet with analytic eyes—I wonder if it weighs like
mine—or has an easier size.” 1 For most humans, grief
is unavoidable. Physicians encounter grief in their patients
and their patient’s loved ones but may also experience grief
on a personal level in response to caring for a patient. In the
practice of medicine, grief is often associated with death but
may also be experienced in response to loss from the ravages
of illness. It is valuable for physicians to explore the process
of grief, not only to enhance patient care but also to optimize
their own well-being. Grief has the potential to connect us to
our humanity.
The Meaning of Grief
A common definition of grief is a “deep and poignant
distress caused by or as if by bereavement,” where bereavement
refers to “suffering the death of a loved one.” 2 However,
the meaning of grief, may also connote a broader
application. In the Education in Palliative and End-of-Life
Care (EPEC) Project oncology core module regarding loss,
grief, and bereavement, grief is defined as the “experience of
a loss” and bereavement as the “state of living with a loss.” 3
Although grief is most often associated with a loss from
death, it is important to recognize that loss is present
throughout the course of illness. There may be a multitude
of losses that effect nearly every aspect of life for the patient
and their loved ones. 3
Some of these losses may be easily recognizable, such as
the loss of one’s usual physical appearance and bodily
functions. With illness, the usual roles of the patient and his
or her loved ones often change. The former caregiver may
now become the patient, thus threatening the equilibrium of
former relationships. The alterations in these social interactions
between the patient and members of his or her
community may lead to a sense of loss for the familiarity of
prior responsibilities. In addition, the financial costs of
illness, including expenses and lost wages, may induce a
tangible loss of relative monetary stability. A study of 988
patients with various terminal illnesses (51.8% with cancer)
found that nearly 35% had moderate to high care needs (e.g.,
required assistance with transportation, personal and nursing
care, and homemaking). 4 These patients reported a
greater economic burden than those with low care needs.
There are also the subtle losses that may develop on an
emotional or philosophical level, such as the loss of expectations
for the future, the loss of fulfillment of dreams, and the
loss of a common human perspective that death is somehow
far away. When death becomes imminent or occurs, it tends
to shake the foundation of how we view life.
By Teresa Gilewski, MD
psychiatric intervention. Caring for the seriously ill or dying
patient may be particularly challenging from an emotional
level and may increase the risk of burnout. Recognition of
these emotions is a critical aspect of providing compassionate
care on a sustainable level. Various strategies may be beneficial
in coping with grief, and the exploration of grief may
provide greater insight into the humanistic basis of medicine.
Physicians are privy to some of these losses in their
interactions with patients and their loved ones. However,
physicians may also experience their own grief in response
to caring for patients with such losses. Physicians themselves
may feel a sense of loss or distress regarding ineffective
treatments, an inability to adequately respond to the
patient’s suffering, or the death of a patient.
Stages and Types of Grief
Grief consists of multiple reactions, including behavioral,
psychologic/emotional, social, spiritual, and physical changes
(Table 1). 3,5 Various characteristics of the mourning process—proposed
by Sigmund Freud, Eric Lindemann, Colin
Parkes, and John Bowlby—have been essential to an understanding
of grief and bereavement. 6 Elisabeth Kübler-Ross,
MD, popularized five stages of grief in her classic book “On
Death and Dying,” published in 1969. 7 When faced with
death because of an incurable illness, she observed that
patients commonly experienced denial, anger, bargaining,
depression, and acceptance. However, these stages may be
of various durations and intensities. Individuals may not
experience all of these stages, nor may they occur in the
same order. Since then, further evaluation has provided
greater insight into the patterns of grief—either normal and
uncomplicated or complicated.
The Yale Bereavement Study queried 233 bereaved individuals
whose family member or loved one died of natural
causes. 8 Over a period of 24 months, five grief indicators
were rated: disbelief, yearning, anger, depression, and acceptance.
Yearning was the most often reported negative
indicator with a peak value at 4 months post-loss. Disbelief
peaked at 1 month post-loss, anger peaked at 5 months
post-loss, and depression at 6 months post-loss. Interestingly,
acceptance was the most commonly reported factor
and continued to increase during the duration of the study.
This trajectory is most consistent with an uncomplicated
or normal grief reaction. However, significant expression
of negative emotions after 6 months may indicate a more
complex grief reaction that requires additional assessment.
Complicated grief comprises a unique entity that signifies
a greater level of dysfunction and portends a greater risk of
morbidity. Characteristic features may occur in anticipation
From the Memorial Sloan-Kettering Cancer Center, New York, NY.
Author’s disclosure of potential conflicts of interest are found at the end of this article.
Address reprint requests Teresa Gilewski, MD, Memorial Sloan-Kettering Cancer Center,
300 East 66 th St., New York, NY; email: gilewskt@mskcc.org.
© 2012 by American Society of Clinical Oncology.
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