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Palliative Care Perspectives : Chapter 7: Psychosocial and Spiritual Aspects of Care : Grief: An overview

The longer I work in palliative care, the more I appreciate grief.16 We tend to have a narrow concept of grief: someone dies, someone grieves. In fact, grief as a process seems central to human adaptation to the inevitability of change. Grief is usually the major issue for those who have lost a loved one. This is the grief of bereavement, yet we all grieve when we loose something or someone to whom we are attached. In seeing my grey and disappearing hair, I grieve my youth. I grieve the loss of a great nurse on our unit who just moved on to a new job. Even if they never treat a dying patient, clinicians come up against grief every day, whether they recognize it or not.

Several years ago, after lifting a heavy patient during an emergency, I noticed that one of my calves seemed a bit swollen and tender. I had also recently taken a long car trip. I imagined the worst: a deep vein thrombosis (DVT). I went to the ER to get an ultrasound of my leg. Over the next few hours I experienced an acute grief reaction. Anticipating a DVT, I looked into a future ruled by anticoagulants. How my life would change! I would have to be careful about how I exercised. Certain activities would have to be curtailed. I looked into my past and thought about what I would have to give up. I looked into the future, trying to figure out some way to adapt to this loss. Perhaps there was some less strenuous way I could exercise.... The ultrasound was normal. As quickly as I began this grief process, it was forgotten. I was able to return to a self-image of good health. Hence, it is not just dying that stimulates grief. Receiving a diagnosis of hypertension or diabetes can result in a grief reaction. As referred to elsewhere throughout this book, withdrawal of any care to which the patient and family have become accustomed can be experienced as grief. So, what is grief?

Grief is often experienced as a painful, tearing sensation, much like two strips of Velcro being pulled apart. The person's world has been ripped apart, opening a painful wound, which we call grief. However, grief is also a process wherein the grieving person works to create a new self in a new relationship with a changing world. Grief is a process of healing this wound. On one side of the wound is a self that has been torn from some object of attachment on the other side, the loss-object. Grief as a process can be understood as the adjustment to this radical change in the relationship between the self and the loss-object. Loss-objects may be people or something as simple as the pleasure of drinking coffee in the morning. The loss-object can even be one's own self-image. In the story of my possibly having a DVT, I was grieving an image of myself in a certain state of health. Grief can be understood as a process of physical, affective, and cognitive change that occurs in response to an abrupt alteration in the relationship between the grieving person and the loss-object. A central task in grieving is to redefine this relationship.17 The grieving person moves, sometimes slowly, sometimes quickly, toward a new equilibrium as he or she redefines the relationship with the loss-object.

In considering this process, a paradox arises. Although the grieving person experiences a sense of separation or dislocation from the loss-object, in fact, the relationship continues between the grieving person and the loss-object. Grief as a process is not about completing a partial separation, like amputating a partially severed limb, but is about an evolving, changing, and ultimately new relationship between the self and the loss-object. Understanding this is critical to grief work. Bereaved individuals, if told that they must "get over" their grief, for example, may react by "freezing" their grief. They may fear that if they were to finish grieving by completing a psychic "amputation," they would truly lose their loved one forever. Many would prefer the pain of frozen grief to the prospect of such permanent loss. As bereaved people can readily tell you, they still have a relationship with the deceased; it just changes. My father died ten years ago. I am still grieving this loss, albeit in a softer way. I will continue to have a relationship with my father as long as I have a self. Over the years this relationship has changed and will continue to change. Such continuity between the living and the dead is suggested in the following passage:

Death is nothing at all. I have only slipped away into the next room. I am I and you are you. Whatever we were to each other, that we are still. Call me by my old familiar name, speak to me in the easy way you always use. Put no difference into your tone, wear no forced air of solemnity or sorrow.... What is death but negligible accident? Why should I be out of mind because I am out of sight? I am waiting for you, for an interval, somewhere very near just around the corner. All is well.

Henry Scott Holland (1847-1918), British Anglican clergyman

How does this process of grief occur? There is no simple answer. In complex ways, a new self evolves. One's self changes, as does one's image or understanding of the loss-object. In this process a new relationship is formed, and the wound heals. My grief for my father did not begin with his death, but with his growing infirmity and dependence well prior to his death. In the process of this grief I needed both to create a new self relative to my father, as a responsible adult son, and conversely to change my image of him from that of a powerful, independent father to one of a dependent father who needed care. It is a tribute to the human psyche that we can create new relationships in this way without destroying old ones.

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Palliative Care Perspectives

James L. Hallenbeck, M.D.

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Copyright 2003 by Oxford University Press, Inc.

The online version of this book is used with permission of the publisher and author on web sites affiliated with the Inter-Institutional Collaborating Network on End-of-life Care (IICN), sponsored by Growth House, Inc.