Understanding Death, Grief, and Bereavement Processes

The dying process evokes complex fears and emotions, with Kübler-Ross's stages guiding understanding of grief and acceptance.

### Understanding the Dying Process, Grief, and Bereavement
* 💀 The dying process involves physical changes like **cooling of the body, confusion, loss of appetite, and changes in breathing patterns**, as well as emotional and spiritual changes such as **withdrawal, visions, and making confusing statements**.
* 🌟 Dr. Elizabeth Kübler-Ross is known for her five stages of grief: **denial, anger, bargaining, depression, and acceptance**, which can be experienced in any order and may not be sequential.
* 📚 Kübler-Ross's theory has been expanded by David Kessler, who introduced the concept of **finding meaning as a sixth stage of grief** in their book "Finding Meaning: The Sixth Stage of Grief."
* 🔄 Other grief and bereavement theories include Bowlby and Parkes' four phases (**shock, search and yearning, disorganization and repair, rebuilding and healing**), James Watkins' three-phase model (**shock, preoccupation, resolution**), and Warden's four tasks of mourning (**accepting the reality of the loss, processing the pain of grief, adjusting to the world without the loved one, finding an enduring connection with the deceased**).
* 💔 "Acceptance is not necessarily a happy stage. It's almost void of feelings. It's almost like a, it's just a, **an empty space as if pain is dissipated**."
* 🧠 "These authors emphasize that grief is not linear. There are these stages that are identifiable: the **shock and disbelief phase**, the **search and yearning**, which is similar to Kübler-Ross's **anger and bargaining stages**."
* 💡 "They talked about **rebuilding and healing**. That's when they move forward into **more control of their destiny**."
* 📖 "So, they're not forgotten. They're part of our history and part of our life, but we move forward in **creating a new life** in their absence."

so in this mini lecture, we're going to discuss some more detail about the dying process, grief, and bereavement. So when we talk about the dying process, there are a number of fears related to death and in late adulthood. In our last topic, we talked about some of the fears that older adults begin to think about, and fear of death is one of those that comes up. So the fears related to death include things like fear of the unknown, of the loneliness that may be left if we're the one left behind, fearing the loss of family and friends, the loss of the physical body, the loss of self-control, and fear of pain. A little pain is a very big one, and it's not only for the person who may be approaching their death but also for the family and loved ones. They fear and assume that there is going to be a lot of pain in the dying process, and then also then there's a sphere of loss of identity. So at end of life, there are a number of changes that occur in the physical

body, and there are changes that occur in the emotional and spiritual body. So, the physical changes, as in the dying process, are things like physical cooling, where the body may not feel as warm to the touch as the peripheral circulation begins to shut down. Confusion or delirium, obviously, the person is reducing their intake of food as their internal digestive organs are no longer able to process food. There's a loss of ability to swallow. There may be loss of bowel and bladder control, a lot of sleepiness, and perhaps a loss of consciousness or floating in and out of consciousness. And there are changes in the breathing patterns. At the emotional and spiritual level, there may be a withdrawal as they go inward. They may see visions, and they may make some confusing statements. Now, there's some very good information for you on the Palliative Care Australia website. They have a number of resources, not only for health professionals but also for family and friends. Palliative Care Organisation in Australia is a very active organisation in terms of providing support and

information. So, if we look at some of the death and grief theories, Dr. Elizabeth Kübler-Ross is one that many of you may have already heard of. She is one of the most influential psychologists of all time when it comes to having open conversations and talking about these processes around death and bereavement. She initially interviewed over 200 terminally ill people, and she devised a theory called the five stages of death. We better know it as the five stages of grief. So, she examined the grief that people experience when they were told that they were dying. She has been criticized, but it's still a very useful framework for meeting those psychological needs of dying patients. So, if we have a look at Elizabeth Kübler-Ross's theory, she has five stages: denial and isolation, anger, bargaining, depression, and acceptance. Now, the processes can be arrested or stopped or stuck at any stage, and what a lot of people don't understand about Elizabeth Kübler-Ross's theory is that she never meant that these stages would

be worked through in a sequential, orderly fashion. In actual fact, people go back and forth and vacillate between these stages, and they don't have to be achieved in a certain order. Now, she also worked with this fellow called David Kessler several years later, and he was an expert in grief and the co-author with Elizabeth Kübler-Ross, talking about the sixth stage of grief. They published a book called Finding Meaning: The Sixth Stage of Grief. So, that's a really interesting work to explore. So, if we look at those initial five stages of her theory, she talks about this denial at the beginning and then goes into this frustration, anger, depression, and then they begin to explore and accept and go through decisions and integration. So, that little model gives you an understanding of how those stages actually work because initially, there's that denial that it actually happened, and then you go through an anger phase or a frustration phase, and then that may collapse into depression until eventually it comes into this rebuilding and integration.

this is where she's talking about that sixth stage of finding meaning, as in finding a purpose and a process in it to be able to move forward. This is referred to as the Kubler-Ross curve. So, if we look at those stages, the first one is denial and isolation. It's not happening. It's not me. It's not real. And so, that can actually function as a buffer to give us a little bit of time to start processing some news that may be shocking to us. It allows the individual to collect themselves and use less radical defense mechanisms, and it's usually temporary. Individuals recuperate gradually, and they can move out of that denial and start to recognize that it is a reality. It actually is really happening. Then, they may move into anger. Why me? When denial can no longer be maintained, it can often be replaced by anger, rage, envy, resentment. It may be projected at other people, blaming other people, and health professionals may be the target. And we try to give the per... It tries to

give them more control, and it can provoke rejection and anger in others, so it pushes other people away who might otherwise come forward and offer support. If someone is very angry and blaming other people, then it kind of isolates them; it pushes others away from them, and other people may actually avoid them. Then they start to bargain, and as we said, people can go through these stages in any order; it doesn't have to be in a certain sequence. So, the bargaining is about, Yes, okay, it's happening, but... and this is an attempt to postpone or to make some bargains with people. If I do certain things, then I might be able to put off the inevitable or make it different. The person sets them self-imposed deadlines and promises that they won't ask for anything else if you'll just, you know, save me now. And often, they're most made with a divine being where they pray to God, they make bargains with God or whoever they say that their divine being actually is. So, it often involves this um

you know making some bargains. If something happens, then I won't ever ask for anything again, etc. So, it's an interesting phase where they try to postpone the initial, and then, of course, that's not going to really change anything. A person may lapse into a period of depression, experiencing their sense of loss. And if it's their own death, then they may be looking at changes in their body image, changes in their roles as they're no longer able to function. They may have periods of hospitalization, the financial changes, the loss of dreams and plans for the future. They can be reactive, or they can be preparatory. They can begin at this stage, might begin putting plans in place. And then finally, acceptance. And acceptance is a term that is often misunderstood. It's not acceptance that the death is okay; it's more about acceptance of the reality that it's actually happening and finding a peace with that. So, the individual, they're not depressed, they're not angry about the impending death or the loss. So, it may be their own

death or it may be the death of a loved one. They are able to express their feelings. They have expressed feelings about the impending loss. They begin to just contemplate. They may become tired, weak. They sleep often to gain relief from some of the discomfort or the overwhelming feelings. So, there is a sense that the reality, it's really happening, and it's an acceptance of the reality and working with the reality rather than saying it's okay that I die or it's okay that my loved one has died. So, it's a different understanding of what acceptance actually means. So, for the person who themselves are actually dying, they're saying that I'm okay with, it's not, it's okay. It's more about I'm okay with the fact that of this reality. I hope that makes sense. So, acceptance is not necessarily a happy stage. It's almost void of feelings. It's almost like a, it's just a, an empty space as if pain is dissipated. The individual is taking their final rest before they pass over.

family may need more support than the dying person at this time. Their circle of interest diminishes, and they may disengage as they just become literally completely self-involved or self-centered in that space and peace that they've found. Communication is often very non-verbal at this stage. Now, there are other theorists who discuss grief and death. So, Bowlby and Parkes have one and talked about four phases of grief, and these authors emphasize that grief is not linear. And that was a mistake that people made about Kübler-Ross, is that they thought it was linear. They thought that she meant people progress through those stages in a sequence, and that's not what she really means at all. And she's written further books after that initial book explaining that. So, Bowlby and Parkes really emphasize that grief is not linear. There are these stages that are identifiable: the shock and disbelief phase, the search and yearning, which is similar to Kübler-Ross's anger and bargaining stages. Then there's this

disorganization and repair, where eventually there is acceptance of the reality, but there's signs of depression, and then they talked about rebuilding and healing. That's when they move forward into more control of their destiny. James Watkins also talked about grief and bereavement, and he proposed a three-phase model: simply shock, disbelief, preoccupation, and resolution. So again, not linear, but identifiable phases in that grieving process. And the final one that we were going to talk about is Warden's model, and he talks about the four tasks of mourning. Task one, he said, is about accepting the reality of the loss and moving past the initial disbelief. So this is about when someone has already passed away. Then the second task was to process the pain of grief, allowing the safe expression of those grief reactions. And task three is to adjust to the world without the loved one, external adjustments including things like taking on different responsibilities and learning new skills now that that person is no longer here. And task four is to find an enduring connection with the deceased.

and that could be in terms of memories and keeping track of the place that they served in our life while we embark on a new life. So, they're not forgotten. They're part of our history and part of our life, but we move forward in creating a new life in their absence. And if those of you that may want to actually look up on wardens four tasks of mourning, that's the actual text there, the grief counseling group therapy, a handbook for mental health practitioners.

Dying, grief and bereavement   part 1

BNursing

Understanding the Dying Process, Grief, and Bereavement

The dying process is often accompanied by various fears, including the fear of the unknown, loneliness, loss of loved ones, pain, and loss of identity.

Physical changes during this process may include cooling of the body, confusion, loss of appetite, and changes in breathing patterns, while emotional and spiritual changes may involve withdrawal and confusing statements.

Elizabeth Kübler-Ross's five stages of grief—denial and isolation, anger, bargaining, depression, and acceptance—provide a framework for understanding the psychological needs of dying patients, though the stages can be fluid and not linear.

The Stages of Grief: A Non-Linear Process

The stages of grief, as proposed by Elizabeth Kübler-Ross, include denial, frustration, anger, depression, exploration, acceptance, and integration.

These stages do not occur in a specific order and individuals may vacillate between them.

The sixth stage, introduced by David Kessler, focuses on finding meaning and purpose in the grieving process to move forward.

The process of grief can provoke rejection and anger, isolating individuals from potential support.

Bargaining is a common response, where individuals make deals or set deadlines in an attempt to postpone the inevitable.

The final stage, acceptance, involves coming to terms with the reality of the loss and finding peace with it, rather than accepting that the loss is okay.

Understanding the Acceptance Stage of Dying

The acceptance stage of dying involves individuals coming to terms with the reality of their situation, often feeling tired and disengaged.

This stage is not necessarily happy, but rather an empty space where pain dissipates.

Communication becomes non-verbal, and the individual's circle of interest diminishes as they focus on finding peace.

Disorganization and repair in grief lead to acceptance and signs of depression, ultimately driving individuals to rebuild and heal.

James Watkins proposed a three-phase model of grief: shock, disbelief, preoccupation, and resolution.

Warden's model outlines four tasks of mourning: accepting the reality of the loss, processing grief pain, adjusting to life without the loved one, and finding an enduring connection with the deceased.