# 01 - 34.1 Death, Dying, and Bereavement

# 34.1 Death, Dying, and Bereavement

End-of-Life Issues
 34.1 Death, Dying, and Bereavement
DEATH AND DYING
Definitions
The terms death and dying require definition: Whereas death may be considered the
absolute cessation of vital functions, dying is the process of losing these functions. Dying
may also be seen as a developmental concomitant of living, a part of the birth-to-death
continuum. Living may entail numerous mini-deaths—the end of growth and its
potential, health-compromising illnesses, multiple losses, decreasing vitality and
growing dependency with aging, and dying. Dying, and the individual’s awareness of it,
imbues humans with values, passions, wishes, and the impetus to make the most of time.
Two terms that have been used with increased frequency in recent years refer to the
quality of living as death comes near. A good death is one that is free from avoidable
distress and suffering for patients, families, and caregivers and is reasonably consistent
with clinical, cultural, and ethical standards. A bad death, in contrast, is characterized by
needless suffering, a dishonoring of the patient or family’s wishes or values, and a sense
among participants or observers that norms of decency have been offended.
Uniform Determination of Death Act.
 The President’s Commission for the
Study of Ethical Problems in Medicine and Biomedical and Behavioral Research
published its definition of death in 1981. Working with the American Bar Association,
the American Medical Association (AMA), and the National Conference of
Commissioners on Uniform State Laws, the Commission established that one who has
sustained either (1) irretrievable cessation of circulatory and respiratory functions or (2)
irretrievable cessation of all functions of the entire brain, including the brainstem, is
dead. Determination of death must be in accordance with accepted medical standards.
Generally accepted criteria for determining brain death require a series of
neurological and other assessments. For children, special guidelines apply. They
generally specify two assessments separated by an interval of at least 48 hours for those
between the ages of 1 week and 2 months, 24 hours for those between the ages of
2 months and 1 year, and 12 hours for older children; additional confirmatory tests may
also be advisable under some circumstances. Brain death criteria are normally not
applied to infants younger than 7 days. Table 34.1-1 lists the clinical criteria for brain
death in adults and children.

Table 34.1-1
Clinical Criteria for Brain Death in Adults and Children
Legal Aspects of Death
According to law, physicians must sign the death certificate, which attests to the cause of
death (e.g., congestive heart failure or pneumonia). They must also attribute the death
to natural, accidental, suicidal, homicidal, or unknown causes. A medical examiner,
coroner, or pathologist must examine anyone who dies unattended by a physician and
perform an autopsy to determine the cause of death. In some cases, a psychological
autopsy is performed: A person’s sociocultural and psychological background is
examined retrospectively by interviewing friends, relatives, and doctors to determine
whether a mental illness, such as a depressive disorder, was present. For example, a
determination can be made that a person died because he or she was pushed (murder) or
because he or she jumped (suicide) from a high building. Each situation has clear
medical and legal implications.
Stages of Death and Dying
Elisabeth Kübler-Ross, a psychiatrist and thanatologist, made a comprehensive and
useful organization of reactions to impending death. A dying patient seldom follows a
regular series of responses that can be clearly identified; no established sequence is
applicable to all patients. Nevertheless, the following five stages proposed by KüblerRoss are widely encountered.
Stage 1: Shock and Denial.
 On being told that they are dying, persons initially
react with shock. They may appear dazed at first and then may refuse to believe the

diagnosis; they may deny that anything is wrong. Some persons never pass beyond this
stage and may go from doctor to doctor until they find one who supports their position.
The degree to which denial is adaptive or maladaptive appears to depend on whether a
patient continues to obtain treatment even while denying the prognosis. In such cases,
physicians must communicate to patients and their families, respectfully and directly,
basic information about the illness, its prognosis, and the options for treatment. For
effective communication, physicians must allow for patients’ emotional responses and
reassure them that they will not be abandoned.
Stage 2: Anger.
 Persons become frustrated, irritable, and angry at being ill. They
commonly ask, “Why me?” They may become angry at God, their fate, a friend, or a
family member; they may even blame themselves. They may displace their anger onto
the hospital staff members and the doctor, whom they blame for the illness. Patients in
the stage of anger are difficult to treat. Doctors who have difficulty understanding that
anger is a predictable reaction and is really a displacement may withdraw from patients
or transfer them to other doctors’ care.
Physicians treating angry patients must realize that the anger being expressed cannot
be taken personally. An empathic, nondefensive response can help defuse patients’
anger and can help them refocus on their own deep feelings (e.g., grief, fear, loneliness)
that underlie the anger. Physicians should also recognize that anger may represent
patients’ desire for control in a situation in which they feel completely out of control.
Stage 3: Bargaining.
 Patients may attempt to negotiate with physicians, friends,
or even God; in return for a cure, they promise to fulfill one or many pledges, such as
giving to charity and attending church regularly. Some patients believe that if they are
good (compliant, nonquestioning, cheerful), the doctor will make them better. The
treatment of such patients involves making it clear that they will be taken care of to the
best of the doctor’s abilities and that everything that can be done will be done,
regardless of any action or behavior on the patients’ part. Patients must also be
encouraged to participate as partners in their treatment and to understand that being a
good patient means being as honest and straightforward as possible.
Stage 4: Depression.
 In the fourth stage, patients show clinical signs of depression
—withdrawal, psychomotor retardation, sleep disturbances, hopelessness, and, possibly,
suicidal ideation. The depression may be a reaction to the effects of the illness on their
lives (e.g., loss of a job, economic hardship, helplessness, hopelessness, and isolation
from friends and family), or it may be in anticipation of the loss of life that will
eventually occur. A major depressive disorder with vegetative signs and suicidal ideation
may require treatment with antidepressant medication or electroconvulsive therapy
(ECT). All persons feel some sadness at the prospect of their own death, and normal
sadness does not require biological intervention. But major depressive disorder and
active suicidal ideation can be alleviated and should not be accepted as normal
reactions to impending death. A person who suffers from major depressive disorder may

be unable to sustain hope, which can enhance the dignity and quality of life and even
prolong longevity. Studies have shown that some terminally ill patients can delay their
death until after a loved one’s significant event, such as graduation of a grandson from
college.
Stage 5: Acceptance.
 In the stage of acceptance, patients realize that death is
inevitable, and they accept the universality of the experience. Their feelings can range
from a neutral to a euphoric mood. Under ideal circumstances, patients resolve their
feelings about the inevitability of death and can talk about facing the unknown. Those
with strong religious beliefs and a conviction of life after death sometimes find comfort
in the ecclesiastical maxim, “Fear not death; remember those who have gone before you
and those who will come after.”
Near-Death Experiences
Near-death descriptions are often strikingly similar, involving an out-of-body experience
of viewing one’s body and overhearing conversations, feelings of peace and quiet,
hearing a distant noise, entering a dark tunnel, leaving the body behind, meeting dead
loved ones, witnessing beings of light, returning to life to complete unfinished business,
and a deep sadness on leaving this new dimension. This pattern of sensations and
perceptions is usually described as peaceful and loving; it feels real to participants, who
distinguish it from dreams or hallucinations. These experiences provoke sweeping
lifestyle changes, such as fewer material concerns, a heightened sense of purpose, a
belief in God, joy of life, compassion, less fear of death, an enhanced approach to life,
and intense feelings of love. In a similar vein, hospice nurses have described experiences
among terminally ill patients of visions that may include a sense of presence of
departed loved ones, of spiritual beings, of a bright light, or of being in a particular
place, often described with a sense of warmth and love. Although such “visions” do not
readily lend themselves to scientific investigation and thus are not legitimized, patients
may benefit from discussing them with clinicians. A term to describe this experience is
unio mystica, which refers to an oceanic feeling of mystic unity with an infinite power.
Life Cycle Considerations about Death and Dying
The clinical diversity of death-related attitudes and behaviors between children and
adults has its roots in developmental factors and age-dependent differences in causes of
death. As opposed to adults, who usually die from chronic illness, children are apt to die
from sudden, unexpected causes. Almost half of the children who die between the ages
of 1 and 14 years and nearly 75 percent of those who die in late adolescence and early
adulthood die from accidents, homicides, and suicides. With their characteristics of
violence, suddenness, and mutilation, such unnatural causes of death are special
stressors for grieving survivors. Bereaved parents and siblings of dead young children
and teenagers often feel victimized and traumatized by their losses; their grief reactions
resemble posttraumatic stress disorder (PTSD). Devastating family disruptions can occur,

and surviving siblings risk having their emotional needs put on the back burner,
ignored, or completely unnoticed.
Children.
 Children’s attitudes toward death mirror their attitudes toward life.
Although they share with adolescents, adults, and elderly adults similar fears, anxieties,
beliefs, and attitudes about dying, some of their interpretations and reactions are age
specific. None welcome it without ambivalence, and all temper their acceptance with
healthy doses of denial and avoidance. Dying children are often aware of their condition
and want to discuss it. They often have more sophisticated views about dying than their
medically well counterparts, engendered by their own failing health, separations from
parents, subjection to painful procedures, and the deaths of hospital chums.
At the preschool, preoperational stage of cognitive development, death is seen as a
temporary absence, incomplete and reversible, like departure or sleep. Separation from
the primary caretaker(s) is the main fear of preschool-age children. This fear surfaces as
an increase in nightmares, more aggressive play, or concern about the deaths of others
rather than in direct discourse. Terminally ill children may assume responsibility for
their death, feeling guilty for dying. Preschool children may be unable to relate the
treatment to the illness, instead viewing treatment as punishment and family separation
as rejection. They need reassurance that they are loved, have done nothing wrong, are
not responsible for their illness, and will not be abandoned.
School-age children manifest concrete-operational thinking and recognize death as a final reality. They, however, view
death as something that happens to old people, not to them. Between the ages of 6 and 12 years, children have active
fantasies of violence and aggression, often dominated by themes of death and killing. School-age children ask questions
about serious illness and death if encouraged to do so; however, if they receive cues that the subject is taboo, they may
withdraw and participate less fully in their care. Facilitating open discussion and updating children with important
information, including prognostic changes, can be very helpful. In addition, children may need help coping with peers and
school demands. Teachers should be informed and updated. Classmates may need education and assistance to help them
understand the situation and respond appropriately.
Adolescents.
 Capable of formal cognitive operations, adolescents understand that
death is inevitable and final but may not accept that their own death is possible. The
major fears of dying teenagers parallel those of all teenagers—losing control, being
imperfect, and being different. Concerns about body image, hair loss, or loss of bodily
control can generate great resistance to continuing treatment. Alternating emotions of
despair, rage, grief, bitterness, numbness, terror, and joy are common. The potential for
withdrawal and isolation is great because teenagers may equate parental support with
loss of independence or may deny their fears of abandonment by actually repulsing
friendly gestures. Teenagers must be included in all decision-making processes
surrounding their deaths. Many are capable of great courage, grace, and dignity in
facing death.
Adults.
 Some of the most often expressed fears of adult patients entering hospice

care, listed in the approximate order of frequency, include fears of (1) separation from
loved ones, homes, and jobs; (2) becoming a burden to others; (3) losing control; (4)
what will happen to dependents; (5) pain or other worsening symptoms; (6) being
unable to complete life tasks or responsibilities; (7) dying; (8) being dead; (9) the fears
of others (reflected fears); (10) the fate of the body; and (11) the afterlife. Problems in
communication arise out of trepidation, making it important for those involved in
health care to provide environments of trust and safety in which people can begin to
talk about uncertainties, anxieties, and concerns.
Late-age adults often accept that their time has come. Their main fears include long,
painful, and disfiguring deaths; prolonged vegetative states; isolation; and loss of
control or dignity. Elderly patients may talk or joke openly about dying and sometimes
welcome it. In their 70s and beyond, they rarely harbor illusions of indestructibility—
most have already had several close calls: Their parents have died, and they have gone
to funerals for friends and relatives. Although they may not be happy to die, they can be
reconciled to it.
According to Erik Erikson, the eighth and final stage in the life cycle brings a sense of
either integrity or despair. As elderly adults enter the last phase of their lives, they
reflect on their pasts. When they have taken care of their affairs, have been relatively
successful, and have adapted to the triumphs and disappointments of life, they can look
back with satisfaction and only a few regrets. Integrity of the self allows people to
accept inevitable disease and death without fear of succumbing helplessly. If elderly
individuals look back on life as a series of missed opportunities or personal misfortunes,
however, they feel a sense of bitter despair, a preoccupation with what might have been
if only this or that had happened. Then death is fearsome because it symbolizes
emptiness and failure.
Management
Caring for a dying patient is highly individual. Caretakers need to deal with death
honestly, tolerate wide ranges of affects, connect with suffering patients and bereaved
loved ones, and resolve routine issues as they arise. Although each therapeutic
relationship between a patient and health provider has a uniqueness derived from the
patient’s and health provider’s gender, constitution, life experience, age, stage of life,
resources, faith, culture, and other considerations, major themes confront all health
providers caring for dying patients. End-of-life care and palliative medicine are
discussed in Section 34.2.
BEREAVEMENT, GRIEF, AND MOURNING
Bereavement, grief, and mourning are terms that apply to the psychological reactions of
those who survive a significant loss. Grief is the subjective feeling precipitated by the
death of a loved one. The term is used synonymously with mourning, although, in the
strictest sense, mourning is the process by which grief is resolved; it is the societal
expression of postbereavement behavior and practices. Bereavement literally means the

state of being deprived of someone by death and refers to being in the state of
mourning. Regardless of the fine points that differentiate these terms, the experiences of
grief and bereavement have sufficient similarities to warrant a syndrome that has signs,
symptoms, a demonstrable course, and an expected resolution.
Normal Bereavement Reactions
The first response to loss, protest, is followed by a longer period of searching behavior. As
hope to reestablish the attachment bond diminishes, searching behaviors give way to
despair and detachment before bereaved individuals eventually reorganize themselves
around the recognition that the lost person will not return. Although the bereaved
ultimately learn to accept the reality of the death, they also find psychological and
symbolic ways of keeping the memory of the deceased person very much alive. Grief
work allows the survivor to redefine his or her relationship to the deceased person and
to form new but enduring ties.
Duration of Grief.
 Most societies mandate modes of bereavement and time for
grieving. In contemporary America, bereaved individuals are expected to return to work
or school in a few weeks, to establish equilibrium within a few months, and to be
capable of pursuing new relationships within 6 months to 1 year. Ample evidence
suggests that the bereavement process does not end within a prescribed interval; certain
aspects persist indefinitely for many otherwise high-functioning, normal individuals.
The most lasting manifestation of grief, especially after spousal bereavement, is
loneliness. Often present for years after the death of a spouse, loneliness may, for some,
be a daily reminder of the loss. Other common manifestations of protracted grief occur
intermittently. For example, a man who has lost his wife may experience elements of
acute grief every time he hears her name or sees her picture on the nightstand. Usually,
these reactions become increasingly short lived over time, dissipating within minutes,
and become tinged with positive and pleasant affects. Such bittersweet memories may
last a lifetime. Thus, most grief does not fully resolve or permanently disappear; rather,
grief becomes circumscribed and submerged only to reemerge in response to certain
triggers.
Anticipatory Grief
In anticipatory grief, grief reactions are brought on by the slow dying process of a loved
one through injury, illness, or high-risk activity. Although anticipatory grief may soften
the blow of the eventual death, it can also lead to premature separation and withdrawal
while not necessarily mitigating later bereavement. At times, the intensification of
intimacy during this period may heighten the actual sense of loss even though it
prepares the survivor in other ways.
Anniversary Reactions.
 When the trigger for an acute grief reaction is a special
occasion, such as a holiday or birthday, the rekindled grief is called an anniversary

reaction. It is not unusual for anniversary reactions to occur each year on the same day
the person died or, in some cases, when the bereaved individual becomes the same age
the deceased person was at the time of death. Although these anniversary reactions tend
to become relatively mild and brief over time, they can be experienced as the reliving of
one’s original grief and prevail for hours or days.
Mourning
From earliest history, every culture records its own beliefs, customs, and behaviors
related to bereavement. Specific patterns include rituals for mourning (e.g., wakes or
Shiva), for disposing of the body, for invocation of religious ceremonies, and for
periodic official remembrances. The funeral is the prevailing public display of
bereavement in contemporary North America. The funeral and burial service
acknowledge the real and final nature of the death, countering denial; they also garner
support for the bereaved, encouraging tribute to the dead, uniting families, and
facilitating community expressions of sorrow. If cremation replaces burial, ceremonies
associated with dissemination of the ashes perform similar functions. Visits, prayers, and
other ceremonies allow for continuing support, coming to terms with reality,
remembering, emotional expression, and concluding unfinished business with the
deceased. Several cultural and religious rituals provide purpose and meaning, protect
the survivors from isolation and vulnerability, and set limits on grieving. Subsequent
holidays, birthdays, and anniversaries serve to remind the living of the dead and may
elicit grief as real and fresh as the original experience; over time, these anniversary
grievings become attenuated but often remain in some form.
Bereavement
Because bereavement often evokes depressive symptoms, it may be necessary to
demarcate normal grief reactions from major depressive disorder (Table 34.1-2). In the
fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a new
condition has been proposed for further study called persistent complex bereavement
disorder to account for bereavement that lasts for more than 1 year (Table 34.1-3). This
disorder may resemble symptoms of a major depressive episode, which is characterized
by severe functional impairment and includes morbid preoccupation with worthlessness,
suicidal ideation, psychotic symptoms, or psychomotor retardation. This is discussed
further below.
Table 34.1-2
Differentiating the Depressive Symptoms Associated with Bereavement from
Major Depression

Table 34.1-3
DSM-5 Diagnostic Criteria for Persistent Complex Bereavement Disorder
Complicated Bereavement
Complicated bereavement has a confusing array of terms to describe it—abnormal,
atypical, distorted, morbid, traumatic, and unresolved, to name a few types. Three patterns
of complicated, dysfunctional grief syndromes have been identified—chronic,
hypertrophic, and delayed grief. These are not diagnostic categories within DSM-5 but
are descriptive syndromes that, if present, may be prodromata of a major depressive
disorder.

Chronic Grief.
 The most common type of complicated grief is chronic grief, often
highlighted by bitterness and idealization of the dead person. Chronic grief is most likely
to occur when the relationship between the bereaved and the deceased had been
extremely close, ambivalent, or dependent or when social supports are lacking and
friends and relatives are not available to share the sorrow over the extended period of
time needed for most mourners.
Hypertrophic Grief.
 Most often seen after a sudden and unexpected death,
bereavement reactions are extraordinarily intense in hypertrophic grief. Customary
coping strategies are ineffectual to mitigate anxiety, and withdrawal is frequent. When
one family member is experiencing a hypertrophic grief reaction, disruption of family
stability can occur. Hypertrophic grief frequently takes on a long-term course, albeit one
attenuated over time.
Delayed Grief.
 Absent or inhibited grief when one normally expects to find overt
signs and symptoms of acute mourning is referred to as delayed grief. This pattern is
marked by prolonged denial; anger and guilt may complicate its course.
Traumatic Bereavement.
 Traumatic bereavement refers to grief that is both
chronic and hypertrophic. This syndrome is characterized by recurrent, intense pangs of
grief with persistent yearning, pining, and longing for the deceased; recurrent intrusive
images of the death; and a distressing admixture of avoidance and preoccupation with
reminders of the loss. Positive memories are often blocked or excessively sad, or they are
experienced in prolonged states of reverie that interfere with daily activities. A history
of psychiatric illness appears to be common in this condition, as is a very close, identitydefining relationship with the deceased person.
Medical or Psychiatric Illnesses Associated with Bereavement.
 Medical
complications include exacerbations of existing diseases and vulnerability to new ones;
fear for one’s health and more trips to the doctor; and an increased mortality rate,
especially in men. The highest relative mortality risk is found immediately after
bereavement, particularly from ischemic heart disease. The greatest effect of
bereavement on mortality is for men younger than 65 years. Higher mortality rates in
bereaved men than in bereaved women are due to increases in the relative risk of death
by suicide, accident, cardiovascular disease, and some infectious diseases. In widows, the
relative risk of death from cirrhosis and suicide may increase. In both sexes,
bereavement appears to exacerbate health-compromising behaviors, such as increased
alcohol consumption, smoking, and the use of over-the-counter medications.
Psychiatric complications of bereavement include an increased risk for major
depressive disorder, prolonged anxiety, panic, and a posttraumatic stress–like
syndrome; increased alcohol, drug, and cigarette consumption; and an increased risk of
suicide. Because of their psychosocial, emotional, and cognitive immaturity, bereaved
children may be especially vulnerable to psychopathology.

Bereavement and Depression.
 Although symptoms overlap, grief can be
distinguished from a full depressive episode. Most bereaved individuals experience
intense sadness, but only a few meet DSM-5 criteria for major depressive episode. Grief
is a complex experience in which positive emotions take their place beside the negative
ones. Grief is fluid and changing, an evolving state in which emotional intensity
gradually lessens and positive, comforting aspects of the lost relationship come to the
fore. Pangs of grief are stimulus bound, related to internal and external reminders of the
deceased person. This differs from depression, which is more pervasive and
characterized by much difficulty experiencing self-validating, positive feelings. Grief is a
fluctuating state with individual variability, in which cognitive and behavioral
adjustments are progressively made until the bereaved individual can hold the deceased
person in a comfortable place in memory and a satisfying life can be resumed. By
contrast, major depressive episode consists of a recognizable and stable cluster of
debilitating symptoms accompanied by a protracted, enduring low mood. Major
depressive episode tends to be persistent and associated with poor work and social
functioning, pathological psychoneuroimmunological function, and other
neurobiological changes, unless treated.
Bereavement and Posttraumatic Stress Disorder.
 Unnatural and violent
deaths, such as homicide, suicide, or death in the context of terrorism, are much more
likely to precipitate PTSD in surviving loved ones than are natural deaths. In such
circumstances, themes of violence, victimization, and volition (i.e., the choice of death
over life, as in the case of suicide) are intermixed with other aspects of grief, and
traumatic distress marked by fear, horror, vulnerability, and disintegration of cognitive
assumptions ensues. Disbelief, despair, anxiety symptoms, preoccupation with the
deceased person and the circumstances of the death, withdrawal, hyperarousal, and
dysphoria are more intense and more prolonged than they are under nontraumatic
circumstances, and an increased risk may exist for other complications. Although
treatment studies in survivors of sudden death are few and far between, most experts
agree that initial attention should be focused on traumatic distress, that a role is seen for
both pharmacotherapy and psychotherapy, and that self-help support groups can be
enormously beneficial.
Biological Perspectives
Grief is both a physiological and an emotional response. During acute grief (as with
other stressful events), persons may experience disruption of biological rhythms. Grief is
also accompanied by impaired immune functioning, including decreased lymphocyte
proliferation and impaired functioning of natural killer cells. Whether the immune
changes are clinically significant has not been established, but the mortality rate for
widows and widowers following the death of a spouse is higher than that in the general
population. Widowers appear to be at risk longer than widows.

Phenomenology of Grief.
 Bereavement reactions include intense feeling states;
invoke a variety of coping strategies; and lead to alterations in interpersonal
relationships, biopsychosocial functioning, self-esteem, and world view that can last
indefinitely. Manifestations of grief reflect the individual’s personality, previous life
experiences, and past psychological history; the significance of the loss; the nature of
the bereaved person’s relationship with the deceased person; the existing social network;
intercurrent life events; health; and other resources. Despite individual variations in the
bereavement process, investigators have proposed grieving process models, which
include at least three partially overlapping phases or states: (1) initial shock, disbelief,
and denial; (2) an intermediate period of acute discomfort and social withdrawal; and
(3) a culminating period of restitution and reorganization. As with Kübler-Ross’ stages
of dying, the grieving stages do not prescribe a correct course of grief; rather, they are
general guidelines describing an overlapping and fluid process that varies with the
survivors (Table 34.1-4).
Table 34.1-4
Phases of Grief
LIFE CYCLE PERSPECTIVES ABOUT BEREAVEMENT
Bereavement During Childhood and Adolescence
Approximately 4 percent of North American children lose one or both parents by the age
of 15 years; sibling death is the second most commonly experienced bereavement. Grief
reactions are colored by developmental levels and concepts of death and may not
resemble adult reactions. Children may display minimal grief at time of death and
experience the full effect of the loss later. Grieving children may not withdraw and
dwell on the person who died, but instead, may throw themselves into activities.
Indifference, anger, or misbehavior may be displayed rather than sadness; behaviors can

be erratic and labile. Strong feelings of anger and fears of abandonment or death may
show up in the behavior of grieving children. Children often play death games as a way
of working out their feelings and anxieties. These games are familiar to the children and
provide safe opportunities to express their feelings. Although they may seem to show
grief only occasionally and briefly, in reality, a child’s grief often lasts longer than that
of an adult.
Mourning in children may need to be addressed again and again as the child gets
older. Children will think about the loss repeatedly, especially during important times in
their lives, such as going to camp, graduating from school, getting married, or giving
birth to their own children. A child’s grief can be influenced by his or her age,
personality, developmental stage, earlier experiences with death, and relationship with
the deceased person. The surroundings, cause of death, and family members’ ability to
communicate with one another and to continue as a family after the death can also
affect grief. The child’s ongoing need for care, his or her opportunity to share feelings
and memories, the parent’s ability to cope with stress, and the child’s steady
relationships with other adults are other factors that may influence grief. Even older
children frequently feel abandoned or rejected when a parent dies and may show
hostility toward the deceased or the surviving parent, now perceived as one who might
also “abandon” them. They may feel responsible because of earlier misbehavior or
because they said or wished that that person would die at some time.
Children younger than 2 years may show loss of speech or diffuse distress. Children
younger than 5 years are apt to respond with eating, sleeping, and bowel and bladder
dysfunctions. Strong feelings of sadness, fear, and anxiety can occur, but these feelings
are not persistent and tend to alternate between longer lasting normal states. Schoolage children may become phobic or hypochondriacal, withdrawn, or pseudomature, and
school performance and peer relations often suffer. Adolescents, as with adults, run the
gamut in expressing bereavement, ranging from behavioral problems, somatic
symptoms, and erratic moods to stoicism. Whereas adolescent boys losing a parent may
become delinquent, girls may turn to a sexual pattern for comfort and reassurance.
Behavioral disturbances and depression are common at all ages. Rates of depressive
episodes in bereaved children and adolescents are as high as in bereaved adults.
Bereaved children must be treated with respect to their own levels of emotional and
cognitive maturity. They need to be told that the death is real and irreversible and that
they are blameless. Feelings and concerns should be expressed, and questions should be
invited and answered with simplicity, candor, and clarity. Children, as with adults, need
rituals to commemorate their loved ones; attendance at the funeral and participation in
mourning may be beneficial first steps.
Bereavement During Adulthood
No consensus exists on which type of loss is associated with the most severe reactions.
Although the death of a spouse is often ranked as the most stressful life event, some
have argued that losing a child is even more profound. The death of a child is a special

sorrow, a lifelong loss for surviving mothers, fathers, brothers, sisters, grandparents,
and other family members. A child’s death is a life-altering experience. The deaths of
parents and siblings in adult life have not achieved much systematic study, but they are
generally considered relatively mild compared with the loss of a spouse or child.
Grief appears most intense for the mother in late perinatal losses (stillbirths or
neonatal deaths rather than miscarriages) and often is reexperienced during subsequent
pregnancies. Sudden infant death syndrome is particularly problematic in that the death
is sudden and unexpected. Parents may experience extra guilt or blame each other, often
resulting in subsequent marital difficulties.
The surviving family members, friends, or lovers of individuals who have died from
acquired immunodeficiency syndrome (AIDS) are uniquely challenged. The illness carries
with it the stigmata of the illness itself and of the gay community in general; it carries
with it caretakers’ fears of contracting the illness; and it is most prevalent in people
who are in the prime of life. Asymptomatic infection may permit the infected person
and those close to him or her time to adapt to the diagnosis. When a person who is
human immunodeficiency virus (HIV) positive begins to manifest symptoms of
opportunistic infection or associated cancer, however, the illness again becomes a
threat. Coping with the emotional reality is arduous and complex. Often caretakers, as
well as HIV-positive patients, wish for death, which can evoke feelings of guilt. For
bereaved lovers, their own HIV status, multiple losses, and other concurrent stressors
can complicate recovery. Gay men who have lost lovers to AIDS may be more depressed,
consider suicide more often, and be more vulnerable to illicit drug use than are other
bereaved individuals.
Elderly adults face more losses than individuals at other phases of the life cycle, and
intense loneliness may be a lasting memorial to those who have died. For highly
impaired elders who lose a spouse they depended on for daily functions or who was
their sole source of companionship, bereavement reactions are profound.
Grief Therapy
Persons in normal grief seldom seek psychiatric help because they accept their reactions
and behavior as appropriate. Accordingly, a bereaved person should not routinely see a
psychiatrist or psychologist unless a markedly divergent reaction to the loss is noted. For
example, under usual circumstances, a bereaved person does not make a suicide
attempt; if someone seriously contemplates suicide, psychiatric intervention is indicated.
When professional assistance is sought, it usually involves a request for sleeping
medication from a family physician. A mild sedative to induce sleep may be useful in
some situations, but antidepressant medication or antianxiety agents are rarely
indicated in normal grief. Bereaved persons may have to go through the mourning
process, however painful it is, for successful resolution to occur. Narcotizing patients
with drugs interferes with the normal process that ultimately can lead to a favorable
outcome.
Because grief reactions can develop into a depressive disorder or pathological

mourning, specific counseling sessions for bereaved individuals are often valuable. Grief
therapy is an increasingly important skill. In regularly scheduled sessions, grieving
persons are encouraged to talk about feelings of loss and about the person who has died.
Many bereaved persons have difficulty recognizing and expressing angry or ambivalent
feelings toward a deceased person, and they must be reassured that these feelings are
normal.
Grief therapy need not be conducted only on a one-to-one basis; group counseling is
also effective. Self-help groups also have great value in certain cases. About 30 percent
of widows and widowers report that they become isolated from friends, withdraw from
social life, and thus experience feelings of isolation and loneliness. Self-help groups offer
companionship, social contacts, and emotional support; they eventually enable their
members to reenter society in a meaningful way. Bereavement care and grief therapy
have been most effective with widows and widowers. The necessity for this therapy
stems, in part, from the contraction of the family unit; extended family members are no
longer available to provide the needed emotional support and guidance during the
mourning period.
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