Fundamentals - Practice & Skills, part 8: Grief and Comfort Care
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.
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 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.
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.”
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.
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?"
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 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, 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 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 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 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 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.
Hi. I'm Meris, and in this video, we're going to be talking about the types and stages of grief along with the different types of comfort care. I'm going to be following along with our Fundamentals of Nursing flashcards. These are available on our website, leveluprn.com. If you already have a set, you can follow along with me. I will be starting on card number 65. Let's get started. So first up, we're going to talk about the stages of grief. And now, what I want to mention here before we even start is that your patient will not move from one to the other in a nice, neat, linear fashion. They're going to ping around all over the place, and even after feeling acceptance, they may go back and feel some of these other emotions, and that's okay. That's normal. That's part of grief. But for the purposes of nursing education and test, we're going to talk about it as a linear progression. So the phases, the stages of grief are going to be denial, anger, bargaining, depression, and then, acceptance. So denial is that immediate feeling [you're?] shocked, disbelief that this is happening. For instance, let's say somebody I love was diagnosed with cancer. I'm in denial. I don't think it's happening. I'm like, "Yeah, yeah." I'm just living my life. And I'm thinking about it, right, but it's not that serious. It's going to be fine. That might be something, I would say, in the denial stage. In anger, this is, "Why is this happening to him? I love him. This isn't fair." That's going to be anger. Bargaining, you'll typically see this from the person affected by a disease such as, "If I can just make it to my daughter's wedding, then I can die, then will feel okay leaving this earth." That's bargaining. Or I might say, "I just want my dad to be here for my wedding. That's all I want and then I'll be okay with it." That's bargaining. "Please let this person stay a little bit longer," or "I'll give up this. I'll give up all of my vices if I can live a little bit longer."
Now, depression is going to be that really deep sadness point in time. That's when I'm feeling that emptiness, that sadness, and that withdrawal, maybe, from other people. Then, acceptance is going to be that point in time where I've come to terms with what's going on. I maybe feel at peace with something. It does not mean that I'm okay with the loss or the impending loss, or anything like that. It just means that I found a way to intergrade that grief into my life and continue functioning.
Now, let's talk about the different types of grief, and there's a few on this card, so I really want you to pay attention because it's different. There's different types. So the first is anticipatory. Anticipatory, same root word as anticipating, right? This is a loss I have not yet experienced but is impending. It's upcoming. So, for instance, when my dad was diagnosed with terminal pancreatic cancer, he was still alive and I could still call him and talk to him at any time, but my grief was anticipatory because I knew that he was terminally ill. Normal grief. Normal is what we refer to as uncomplicated or what the patient experiences on average. So most people are going to feel grief for 6 to 12 months. That grief will resolve to the point that they can continue functioning. It does not impair their ability to function. Now, complicated grief, see, we don't call it abnormal grief. It's complicated grief because grief is complicated, but complicated grief is grief that persists for longer than one year and interferes with the individual's ability to function. So examples of this might be if somebody experiences a loss and they won't touch any of their loved one's items. They keep their side of the bed and the room completely as it is, and they can't get out of bed. They're devastated. They can't work because they are so overcome with grief. That would be complicated grief because it is actually impairing their ability to function on a daily level.
Now, disenfranchised grief. So I want to give you a brief content warning. I'm going to discuss miscarriage here. So when you talk about disenfranchised grief, this means a loss or grief that is not publicly acknowledged. Now, one of the examples on the card is miscarriage, and the reason I want to bring this up is not all miscarriages are going to be disenfranchised grief. Personally, I have experienced eight miscarriages. My first three, I would say, were disenfranchised. I did not share with anybody. I did not tell anyone. I just kept it to myself and suffered in silence, and that is what I want you to think of with disenfranchised, suffering in silence. For some reason, I don't feel comfortable or it's taboo, or I don't want to share this loss with somebody, that's disenfranchise. Now, when I did choose to share about it and talk to my friends and family and tell them what I was going through, it was no longer disenfranchised. So I just want to put a little parenthetical there and say, "Not all miscarriages will be disenfranchised, but they can be." Another example on this card is the death of an extramarital lover. So if somebody is having an extramarital affair and that lover dies, they may not be able to grieve that publicly. That's going to be disenfranchised grief. So I hope that makes sense. Let me know in the comments if you have any other examples of disenfranchised grief because I would like to hear them.
Okay. So moving on, our last card that we're going to cover here is types of comfort care. There's a lot of bold, red text here, so I would really pay attention to this. So palliative care versus hospice. Palliative. The word palliative means to provide comfort, to take away pain. So palliative care is aimed at reducing a patient's pain or symptoms of a disease or illness, but usually, we are managing their symptoms and pain along with having curative treatment. So for instance, a friend of mine had bone cancer when she was a child, and she had curative treatment. Right? She underwent chemotherapy and radiation. She also received palliative treatment, meaning that she was seeing a pain management specialist to manage her symptoms and her pain. So this is focused on increasing quality of life and decreasing suffering but can be for someone who is not terminally ill. Can be for somebody terminally ill also, but both. Okay?
Now hospice care. Hospice care is going to be symptom management for life-threatening-- or life-limiting illness. I'm sorry. Let's say it that way. So terminal illnesses. So when my father was dying of pancreatic cancer, he was on hospice care. This was not a location. He was in his own home. He didn't go to the hospital or anything. This was a philosophy of care that was aimed at decreasing his symptoms and managing his pain as he was exiting this earth. So this is typically for people who have a diagnosis of terminal illness with estimated - meaning we're guessing - less than six months to live. What happens if you live longer than six months? Nothing. You stay on hospice. That's okay. It's just that's the physician's best estimate. Now, for Medicaid-- excuse me, for Medicare, you do have to have that prognosis. For private insurance, it may be different based on the timing of an individual's disease progression. It does not require DNR status. I know that might seem counterintuitive, but just pay attention to that. You do not have to be DNR to be in hospice care. And then the other thing is, if the prognosis changes, if the physician thought you were terminally ill and now you are not, you can be discharged from hospice care, and that's okay. Big takeaways here: palliative care, we are treating symptoms, we are managing pain, and this can be for people who are terminally ill or who have a chronic, lifelong condition. Hospice care typically is going to be six months or less to live, and this is going to be not aimed at curative treatment. This is going to be more about managing pain as a person is actively dying.
Okay. So that is it for talking about the different stages and types of grief and the different types of comfort care. If you liked this review, please like this video. It would mean a lot to us. And if you have anything to add in the comments, you know I love to hear it. Be sure to subscribe to our channel so that you can be the first to know when the next video posts. And in that video, I'm going to be talking about effects of immobility, deep vein thrombosis, and nursing care for immobility. I'm just going to give you a heads-up. That is very important content for nursing school and the NCLEX, so you don't want to miss it. Thanks so much, and happy studying.
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