Bereavement refers to the situation of losing to death a person to whom one is attached. Grief refers to the emotional response to that loss. Bereavement and grief are universal experiences that almost all adults must confront at some point in their lifetime. Nearly 2.5 million US citizens died in 2003 each leaving behind many to grieve their loss (1). Approximately 9.7% of women and 2.5% of men in the United States are widows and widowers, respectively (2). Most of those experiencing widowhood are older than 64, when their health is likely to be already compromised, and bereavement may compound their health difficulties.

Bereavement has been considered as one of the most stressful events experienced in one’s life (3, 4). It has been associated with an increased risk of cardiac events, hypertension, cancer, and suicidal ideation (5, 6, 7, 8, 9, 10). It has also been associated with reduced quality of life, disability, functional impairments (social, family, and occupational), adverse health behaviors such as alcohol and cigarette consumption, hospitalizations, and increased risk for morbidity and mortality (11, 12, 13, 14, 15). Bereavement is a well-established risk factor for elevated depressive symptomatology and an increased likelihood of major depressive episodes (16, 17, 18, 19, 20, and anxiety-related symptoms and disorders (21, 22, 23). In light of these health risks, clinicians need to strive to minimize the potential negative health consequences of bereavement. Additionally, bereavement care should be the final phase of any comprehensive palliative care plan. One must look at the family as the unit of care when providing palliative services and hence bereavement care becomes an essential aspect to complete and facilitate the family’s healing process.

Normal, or uncomplicated, grief reactions are those that, though painful, move the survivor toward an acceptance of the loss and an ability to carry on with his or her life. Approximately, 80–90% of bereaved individuals experience normal or uncomplicated grief (24). It is important to recognize that most people are able to adjust to the loss over time in a fairly satisfactory way.

One of the main myths concerning uncomplicated grief is that it follows a direct stage-by-stage pathway from denial to anger, separation distress, depression, and finally recovery (25). In fact, data suggest that there are no clear stages of grief resolution. In contrast to the hypothesized grief resolution graph [Figure 59.1 (25)], the data reveal a gradual reduction in distress over time from loss. Contrary to the stage theory of the course of grief, disbelief was not found to be the most frequently endorsed initial reaction to loss. The predominant symptom throughout the first 6 months post-loss was yearning. Depressed mood did not peak after disbelief, yearning and anger had subsided; rather, disbelief, yearning, and depressed mood all declined significantly from 2 to 20 months post-loss. As shown in Figure 59.1, levels of anger remained stably low and did not peak after disbelief had faded. Additionally, acceptance of death increased significantly over time and revealed a pattern inverse to disbelief and yearning. Figure 59.1 suggests a parallel shift downward in all the grief indicators over time from loss. These data are inconsistent with the phases of grief resolution model.

While uncomplicated grief can be an extremely painful and sad experience, by 6 months the bereaved individuals develop some sense of acceptance and are capable of finding some meaning or purpose in their lives. They see the future holding potential enjoyment for them and are capable of engaging in productive activities. They are also able to maintain connections with others and their sense of competence and self-esteem are not markedly changed by their loss. They are capable of functioning without substantial impairment (24). Survivors may initially exhibit many symptoms of complicated grief, but by 6 months post-loss there is usually improvement in their ability to focus on other things and move beyond the loss. Those who have elevated levels of a specific set of symptoms [Table 59.1 (24)] for more than 6 months after the death may cause concern.

Studies have found that complicated grief symptoms form a coherent cluster of symptoms distinct from bereavement-related depressive and anxiety symptom clusters (7, 8, 10, 12, 26). Bereaved individuals with complicated grief, experience disruptive and distressing yearning, pining, and longing for the deceased that endures for longer than 6 months. They also report extreme difficulty “moving on” with their life (feeling “stuck” in their grief), as well as feelings of numbness and detachment, bitterness, and a lack of meaning in life without the deceased. They have trouble accepting the death and see no potential for future happiness. Bereaved individuals experiencing complicated grief report having these symptoms
several times a day and find these symptoms impair their ability to function normally (7, 12, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37). [Table 59.1 (24)].

It is important to note that this conceptualization of complicated grief specifies that these particular distress symptoms persist for at least 6 months, regardless of when those 6 months occur. Hence, delayed and chronic subtypes of grief may both come under the complicated grief diagnosis as long as, whatever the delay in onset, symptoms continue for 6 months. Typically, however, the overwhelming feelings of those who are diagnosed with complicated grief are not delayed; it is much more often the case that their grief has been intense and unrelenting since the death (24).

Recent research demonstrates that bereaved individuals with high levels of complicated grief symptoms have substantially greater dysfunction than those with lower levels of these symptoms. Complicated grief symptoms may endure for several years and predict substantial morbidity and adverse health behaviors beyond depressive symptoms (5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15). Complicated grief has been shown to be a substantial risk for suicidal thoughts and behaviors, with incidence of cardiac events, high blood pressure, and even cancer, in studies that took into account the effect of major depression and generalized anxiety disorder (5, 6, 7, 8, 9, 10, 24). It is a risk factor for quality of life impairments such as poor social interactions and role functioning, loss of energy, and self perception of illness, disability and functional impairments, loss of work days, and adverse health behaviors such as changes in patterns of consumption of alcohol, food, and tobacco (5, 6, 7, 8, 9, 10, 24). It has also been shown that complicated grief increases the risk for ulcerative colitis (11). Table 59.2 provides a summary of the several negative health consequences associated with complicated grief.

Research suggests that complicated grief at 6 months predicts impairment and complications at 13–23 months post-loss (6, 7, 8, 10). Hence, recognizing the signs and symptoms of complicated grief at 6 months would be a good way for health care professionals to identify survivors who may experience further adjustment difficulties in the future.

When looking at the outcomes of complicated grief, one is able to see why physicians should play a role in all aspects of bereavement care. There remains little doubt about the excess morbidity associated with bereavement, and with complicated grief, specifically. Additionally, bereavement tends to occur most often in later life, when health and adaptive capacities may already be compromised and hence physicians need to play an integral role in caring for bereaved patients and in preventing the unchecked progression of complicated grief.

There are several compelling reasons for physicians to actively engage themselves in bereavement care. First, they are already involved in caring for bereaved patients and will become increasingly so as the population ages. Empathic “aftercare” for bereaved patients demonstrates the physicians’ respect for the deceased and concern for the surviving family members. It may reduce the family’s sense of abandonment by the health care system and soften the psychological blow of losing a loved one. Enhanced discussion between bereaved family members and physicians may help both in attaining a sense of closure. Finally, engaging in the active care of bereaved individuals may reduce the negative health consequences and complications associated with the bereavement process in the surviving family members.