process for the patient with cancer and all those related in the system of care may begin at the time of a prognosis of Helping Patients, Families, terminal illness, but more often even Caregivers, and Physicians, before that point, at the onset of any life- in the Grieving Process limiting or life-altering condition. Every change in status will alter the ensuing Christine A. Bruce, MCAT, MDiv, LMFT grief trajectory to some degree. In the medical arena, the team that has focused its efforts on healing often drops out when a patient becomes ter- minally ill. Patients and family mem- bers may experience this “dropping out” as abandonment at the moment of their greatest need by the experts to whom they have entrusted their hope. They Physical experiences of the body and those that are emotional, cognitive, and are left to traverse the landscape of spiritual are inextricably related. The author, a hospice bereavement coordinator approaching death on their own, with all and counselor, discusses how medical professionals can become personally its emotional intensity, often without prepared to assist in the often intense and intimate passage of life into death knowing what to expect or how to inter- and later through both didactic and personal preparation. She also describes the pret what is happening to the patient major models of grief processes and illustrates the power a caring professional physically. How can medical profes- can have during the dying process and in the aftermath of a patient’s death by sionals become personally prepared to relating personal case scenarios. assist in this often intense and very inti- J Am Osteopath Assoc. 2007;107(suppl 7):ES33-ES40 mate passage of life into death and in its aftermath? The best preparation is both didactic and personal. hen addressing pain, it is impor- not only by the patient, but also by all Knowledge About Grief Wtant to recognize an inextricable those involved in the patient’s care. Specifics of the grief process are being relationship between physical experi- Grief can be defined as the neu- widely investigated today as health pro- ences of the body and those that are ropsychobiological response to any kind fessionals attempt to delineate “normal” emotional, cognitive, and spiritual. of significant loss, with elements both grief from that which is “complicated or Feeling pain is paradoxical: both unde- typical and unique to each individual prolonged,” qualifying for intervention as niably real and exclusively subjective in or situation. The grief response is gen- a clinical condition. Complete under- measurability. Whether specific phys- erally associated with degrees of suf- standing of this profound experience will ical contributors to a given experience of fering, at times intense or even unbear- better prepare all care providers to offer pain can be judged to be neuropathic, able, and of widely variable duration. the most effective intervention(s) under nociceptive, or visceral in origin, all psy- Grief is a systemic event, whether the given circumstances. Such knowledge chogenic components of pain—psy- system is an individual or a larger group may also assist those working through chological, social, spiritual, and emo- of individuals thrown out of equilibrium this very natural, necessary feature of tional—will be added to the physiologic through changes brought on by loss. human life to progress to a more positive register and mediated through the cen- Mourning is the shared expression outcome. tral nervous system. The effect will be of a grief experience, important in Modern psychology, from Sigmund reverberating, greatly influencing the gaining a new equilibrium following Freud forward, has offered models of ability of patient, family, and the care- any manner of deficit, including the grief process—both descriptive and giving team to cope with the patient’s ill- decreased function or role, loss of task-oriented—that serve to define ness and gain the comfort and hope that assumed health, and diminished dreams “appropriate, healthy, normal” sorrow is so necessary to maintaining quality of the future. Grief and mourning and provide guidance through what is of life. The pain of grief is no exception, together constitute the grief process, rep- often called “the journey of grief.”1 and can be a powerful factor in the total resenting movement from life through The anguish of loss is a universal pain experience that must be managed death and back into life again. A grief phenomenon, whereas mourning prac- Correspondence to Christine A. Bruce, MCAT, This continuing medical education publication is supported MDiv, LMFT, 1023 Kipling Rd, Rydal, PA 19046- 3339. by an unrestricted educational grant from Purdue Pharma LP. E-mail: [email protected]. Bruce • Helping With the Grieving Process JAOA • Supplement 7 • Vol 107 • No 12 • December 2007 • ES33 tices vary across cultures; mourners bring you let me know and I’ll have the or complicated, it is not an intrinsically their own respective life histories and nurses do something about it.’ pathologic state, but rather, a normal and context to the grief experience. There- needful adjustment response. What are fore, amid the diversity of approaches During the night, my father was given some common, predictable grief reac- to grief, three attitudes remain the basic the task of informing the patient’s husband tions? Every one of us has experienced foundation for healing practice: empathy, that his wife was dying. Although it was not them to some degree in the face of loss. attentiveness, and respect. a part of standard medical protocol at the In the cognitive-emotional realm, there Ⅵ Empathy springs from simultaneous time, it occurred to my father to inquire of her may be disbelief, sadness, anger, guilt, awareness both of oneself and of another husband about her spiritual affiliation. The and self-reproach, panic, anxiety, lone- person. man responded that they were Catholics. liness, listlessness, and apathy, shock, Ⅵ Attentiveness requires a level of per- Acting on instinct, my father called for a yearning, numbness, depersonalization, sonal comfort sufficient under extreme priest and participated in the ritual of extreme and, depending on the circumstances, circumstances to remain “tuned in”— unction with the patient and family. At 5 relief. cognitively, emotionally, and spiritually AM, approximately 12 hours after the young Grievers may become preoccupied “present.” woman’s admission to the emergency room, with their loss, and their thought pro- Ⅵ Respect entails cultural sensitivity and the patient died. A postmortem examination cesses can become confused. There may openness. revealed that she had died of Ayres disease, a be a sense of timelessness. If someone hereditary pulmonary stenosis for which there has died, there is often a sense of pres- Case Scenario was no known intervention six decades ago. ence, or of seeing or hearing the deceased. A significant event in the life of my father, The next day, the patient’s husband Physical sensations might include mus- a physician, illustrates the principles of called the hospital to obtain the name of the cular weakness, fatigue, tightness in the empathy, attentiveness, and respect. That medical student who had stayed up all night. chest and throat, dry mouth, nausea, and event was his first encounter with the The family invited my father to the home for sensitivity to noise. There may be sleep death of a patient. the wake, grateful to him as the “doctor” who and appetite disturbances, social with- As a first-year medical student at Penn- had cared for their family member in her drawal, sighing, searching, and crying, sylvania State University in 1943, he had dying hours, and grateful for his sensitivity restless overactivity, reminiscing, and been designated on a Friday afternoon to work to the family’s emotional and spiritual needs. laughing, treasuring objects that belonged in the emergency room. Around 4:30 PM, a His participation in the end-of-life story of to the deceased, or avoiding such 25-year-old woman, the mother of two young this patient and her family would become a reminders.3 children, was brought in and assigned to him. foundation of healing for them in the after- However it proceeds, the grief pro- She was several hours into the sudden onset math; for my father, it was an unforgettable cess poses a challenge to human systems of respiratory distress of unknown cause. As lesson in the power of a caring professional. at each level—through personal, inter- my father began to take a careful history, he We live in a grief-saturated world. personal, family, and caregiver systems. could see that this woman’s life was ebbing More than 2 million individuals die in Inherent in this process is the demand away. He brought in the resident and called the United States each year. It is difficult for change and substantial potential for for the chief physician; no one knew what to estimate how many others are directly growth—and/or decline. Loss disrupts was happening except that her pericardial affected by these deaths, and it is even equilibrium, and subsequent readjust- sac was filled with fluid, which they aspi- more complex to estimate how many will ments are multifaceted and complex rated to no great effect. The hours passed and have compromised health due to bereave- involving somatic, psychological, social, at 3 AM, despite efforts of the staff, she con- ment. Healthcare institutions may fail to cultural, spiritual, and historical compo- tinued to decline. At that time in medicine, address the needs of the bereaved. nents. Practically speaking, this means there was nothing more that the hospital staff Although the primary responsibility of that besides somatic changes due to ill- could do for this woman. healthcare providers is to the patient, the ness, one must be aware of a patient’s My father stayed with her, though the well-being of the family and others close grief-associated symptoms.