Learning Objectives
By the end of this section, you will be able to:
- Examine influencing factors affecting grief, loss, death, and dying
- Recognize psychological factors affecting grief, loss, death, and dying
- Analyze the types of death and how they affect grief, loss, death, and dying
The processes of death, dying, grief, and loss are highly personal experiences, but they also affect family, friends, and the wider community in a variety of ways. In addition to cultural or religious views on death, many factors affect how individuals, families, and communities respond to a death, care for a dying individual, and process the loss and grief after death. Many factors play a role, including the cause of death, the relationships and family dynamics that existed prior to death, and the ages of the affected individuals.
Influencing Factors
As you have learned, the pathophysiological and physical progressions of death follow a predictable pattern regardless of cause of death or age. However, many other factors contribute to an individual's experience of death or the experience of loss through death. These factors relate to developmental stages, life stages, and family interactions. In addition, nurses may need to focus on cultural, socioeconomic, and psychological factors when providing care for individuals experiencing death or grief.
Developmental Considerations
Developmental considerations for the nurse include the life stage of the dying individual as well as the social stage of the family. The treatment plans, terminal illness progression, family expectations, and grief response to loss will vary, and individuals will experience loss and grief differently, depending on these factors. Age considerations are most pronounced in children; however, the life stage and age of adults also play a role in grief response. Social considerations such as family stage and family cohesiveness affect grief both individually and collectively.
Age Considerations
Individuals’ attitudes toward death and dying are linked to their cognitive ability to understand these processes. Infants and toddlers cannot understand death. They function in the present and are aware of loss, separation, and disruptions in their routines. They are also attuned to the emotions and behaviors of significant adults in their lives, so the death of a loved one may cause a young child to become anxious and irritable, cry, or change their sleeping and eating habits in response to the altered behavior of their caregivers.
A preschooler may approach death by asking when a deceased person is coming back; they might even search for the deceased person, thinking that death is temporary and reversible. They may experience brief but intense reactions, such as tantrums or other behaviors like frightening dreams and disrupted sleep, bedwetting, clinging, and thumb-sucking. Similarly, those in early childhood (ages 1–5) may regress to younger behaviors. They might also think that the person’s death is their fault, based on their developmental belief in the power of their thoughts and “magical thinking.” Their grief might be expressed through play rather than verbally (HealthyChildren.org, 2015).
Those in middle childhood (ages 6–11) begin to see death as final, irreversible, and universal. However, they may not believe that death could happen to them or their family—they may assume it happens only to the very old or sick, or they may view death as a punishment for bad behavior. They may engage in personification, seeing death as a human figure who carried their loved one away (HealthyChildren.org, 2015). Children at this developmental stage may try to keep a bond with the deceased by taking on that person’s role or behaviors.
Preadolescents (ages 10–12) are better able to understand both biological and emotional processes of death. However, they may try to hide their feelings, seem indifferent, or have outbursts following the death of a friend or loved one.
Adolescents (ages 12–17) begin to apply logic to abstractions; they spend more time pondering the meaning of life and death and what comes after death (HealthyChildren.org, 2015). Their understanding of death becomes more complex as they move from a binary logical concept (alive or dead) to a more nuanced understanding—including the potential for life after death, for instance. This transition reflects a deeper comprehension of death that acknowledges its complexity and allows for broader interpretations beyond a simple binary classification. Adolescents are also tasked with integrating these beliefs into their identity development.
Young adults (ages 18–35) rely heavily on social support systems for coping strategies. They may have children and, therefore, view mortality and death in relation to the impact on their family. In addition, career plays a large role in the identities of young adults, who may have concerns about the impact of death and grief on their career and financial security.
Middle-aged adults (ages 36–64), when confronted with death and mortality, tend to reflect on life choices and may begin to take personal health considerations more seriously. Adults in this stage more often encounter the loss of parents, and the deaths of other friends and family members become more frequent.
Older adults (ages 65+) may struggle with frequent loss of friends and peers. In addition to grief associated with death, older adults may also struggle with grief related to the loss of function and physical decline. Spiritual reflection is common and may help older adults cope with these losses and the possibility of their own death.
Family Considerations
Family dynamics vary widely, and family members may have differing views on death, dying, grieving, and coping with loss. These views may be affected by the developmental stages of the various family members as well as the age of the dying person. Varying dynamics occur in the context of the loss of a child, parent, grandparent, or sibling. Other factors also play a role, such as whether the death is anticipated or sudden, as well as environmental factors associated with the death. For example, deaths occurring in peaceful and familiar surroundings, with supportive family members and healthcare professionals present, may facilitate a more peaceful and dignified experience for both the dying individual and their loved ones. Conversely, deaths occurring in chaotic or traumatic environments, such as accidents or disasters, may exacerbate feelings of distress, confusion, and grief.
Coping after a family member’s death will depend on family cohesiveness, communication patterns, and expression of emotions. Family roles may change in response to a terminal illness, a death, or the grief process. These changes may include home care patterns, work hours, financial responsibilities, and childcare (Table 36.6). Since many families rely on extended family for support, a loss may trigger a change in living situation, such as an elderly father moving in with his daughter after the death of his wife.
| Family Considerations | Possible Family Changes |
|---|---|
| Cohesiveness of the family |
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| Family structure and role changes |
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| Communication patterns and expressiveness |
|
| Support systems |
|
| Pre-existing family stressors/loss |
|
The death of a neonatal child can take the form of a miscarriage, stillbirth, neonatal death, or sudden infant death syndrome (SIDS), a term for deaths of children under the age of one which have no identifiable cause. Like people in every age group, children also die from accidents and illnesses. In most cases, parents find the grief almost unbearably devastating, and it tends to hold greater risk factors than any other loss. This loss also bears a lifelong process: one does not “get over” the death but instead must assimilate and live with it. Intervention and comforting support can make all the difference to the survival of a parent in this type of grief, but the risk factors are great and may include family breakup or suicide. Feelings of guilt, whether legitimate or not, are pervasive, and the dependent nature of the relationship disposes parents to a variety of problems as they seek to cope with this great loss. Grieving parents may also experience resentment toward others who experience successful pregnancies.
Patient Conversations
SIDS: Sibling Grief
Scenario: Darcey is a 28-year-old mother. Her living children are Kaylee, age 6, and Darien, age 4. Darcey and her family recently experienced the death of their youngest child, Aiden, from SIDS four months ago. Aiden was 11 months old. Darcey is struggling with anxiety and depression. She is following up today with her primary care provider after starting an antidepressant.
Nurse: How are your symptoms of anxiety and depression?
Patient: I’ve been able to get through the day and care for my other children, but I’m worried about my daughter and that I don’t know how to help her cope with Aiden’s death. She wants to talk about Aiden all the time, set up puppet shows like she used to for him, and draw pictures of him. I sometimes feel angry when she does these things. I know it is helpful for her, but sometimes I don’t want to participate.
Nurse: Do you feel that the medication is helping?
Patient: I do feel the medication is helping, but I don’t understand why I am having such strong reactions to my daughter’s grief.
Nurse: Your feelings are normal during this time of grief. I can see that you know that your daughter’s emotions and actions are also normal. Children often process grief through play.
Patient: I don’t know what to do. How can I support my daughter without feeling even more guilty?
Nurse: Asking for help is the first step. We can provide you with a list of adult and child grief counselors. This may help your daughter work through her grief with therapeutic play while you work through your grief in the way that is most beneficial to you.
Patient: I didn’t know grief therapy was available for children. I would feel relieved to know someone else could help her without feeling angry or sad about her actions. Thank you for helping me find the right resources.
For a child without support to manage the effects of the grief, the death of a parent may result in long-term psychological harm. This is more likely if the adult caregivers are struggling with their grief and are psychologically unavailable to the child. There is a critical role for the surviving parent or caregivers in helping children adapt to a parent’s death. Studies have shown that losing a parent at a young age did not lead to negative outcomes only; there are some positive effects. Some children had increased maturity, better coping skills, and improved communication. Adolescents valued other people more than those who had not experienced such a close loss (Ellis et al., 2013).
When an adult child loses a parent in later adulthood, the experience may be considered “timely” or a normative life course event. This allows adult children to feel a permitted level of grief. However, research shows that the death of a parent in an adult’s midlife is not a normative event by any measure but is a major life transition causing an evaluation of one’s own life or mortality. Some adults may shut out friends and family in processing the loss of someone with whom they have had the longest relationship (American Cancer Society, 2023).
Socioeconomic Considerations
Socioeconomic factors may play a role in access to care and financial resources available to individuals coping with death and grief. Access to care may be directly related to insurance coverage, transportation, and living situation. Quality of care may be dependent on physical location, finances, and ability to seek care in a timely manner. The impact of a terminal illness is significant, as it hinders not only the well-being of the affected individual but also the capacity of family members to maintain employment. This may put a further burden on already strained financial situations. Struggles with insurance companies to get coverage, particularly for new treatments, are common and add strain for caregivers and individuals experiencing the illness. Other economic considerations in death and dying may involve paying for the care of the body, funeral costs, and the resolution of estates or debts. The financial strain of medical bills following a death can further intensify the financial difficulties families face.
The Hospice Foundation of America notes that not all racial and ethnic groups feel the same way about hospice care. Certain groups may believe that medical treatment should be pursued on behalf of an ill relative as long as possible and that only God can decide when a person dies. Others may feel very uncomfortable discussing issues of death or being near the deceased family member’s body. Not everyone holds the view that hospice care should always be used, and healthcare providers must be sensitive to the wishes and beliefs of those they serve. Similarly, the population of individuals using hospice services is not divided evenly by race. Approximately 76 percent of hospice patients are White, while 11 percent are Black, 8.5 percent are Hispanic, 2.5 percent are Asian/Pacific Islander, 0.5 percent are American Indian, and 1.5 percent are unknown or other (NHPCO, 2023).
Cultural Considerations
Nurses must consider cultural factors when caring for individuals encountering death and grief. Cultural values influence how people experience death and whether they respond with particular rituals or mourning practices. Cultural awareness and an atmosphere of inclusiveness must guide nursing care. See Chapter 35 Spirituality to learn more about how several major religions view the concept of death. Individuals who do not identify with a specific religion also have views about death and expectations for care after death, which should be addressed with the same respect shown to individuals identifying as a particular religion.
Psychological Factors
Dealing with death and dying and subsequent grief is a deep burden. Individuals may feel many negative emotions during these processes, including sadness, guilt, fear, and anxiety. These emotions can trigger a new onset of depression or the recurrence of clinical depression. This is particularly true in individuals with poor coping skills or those who are unable to process the death and move through the grieving process. Underlying mental health disorders affect the psychological stability of individuals experiencing grief. These individuals require sensitive support and straightforward discussions about their mental health and safety.
Life-Stage Context
Grief in the Teen Years
Grief is a universal feeling after a loss; however, teens may require special interventions to help them process loss and grief. Teen reactions can be highly variable, even from day to day. Teens who connect with and trust their peers may succeed in peer counseling groups. These groups may involve sharing and talking, but other activities may also help teens. In the same way that younger children express grief through play, teens may find relief in guided activities such as the following:
- storytelling
- drawing
- creating art
- creating a book
- creating a memorial
- visiting a place that holds meaning with the deceased
Nurses must always be alert for signs of depression, withdrawal, violence, substance misuse, and suicidal ideation in grieving teens. If guided grief therapy or peer interactions are not enough, nurses should not hesitate to refer teens for specialized mental health care.
Fear
Fear may be felt in both dying individuals and individuals fearing the loss of a loved one. Common fears involve their own mortality, their ability to care for themselves, and the potential for financial instability or loneliness. Individuals may not be able to see how they will “go on” after a death. Fear of the unknown is also common pertaining to death. Individuals experiencing the dying process may worry about what comes after death. Those experiencing the death of a loved one may worry about how their life will look and feel after this death.
People experiencing the dying process may fluctuate between periods of fear of dying, fear of pain, and feelings of peace at the end of their lives. Fear may be exacerbated by reactions from family, friends, or even religious leaders.
Anxiety
An overwhelming feeling of apprehensiveness, nervousness, and worry about real or perceived events that have an uncertain outcome is known as anxiety. Anxiety and depression are closely linked; one may trigger or exacerbate the other, or they may occur simultaneously. Individuals who struggle with anxiety may find themselves ruminating and fixating on guilt. Individuals experiencing guilt or regret may have difficulty coming to terms with death. Nurses can encourage individuals to make amends and work through underlying guilt and regret to create a smooth psychological passage through death. Anxiety can be debilitating, particularly if the sensation of anxiety escalates into panic. Anxiety can trigger frightening physical symptoms that are often mistaken for other disorders, including the following:
- chest pain
- trouble breathing
- heart palpitations
- nausea
- tingling face or lips
In chronic anxiety, stress hormones continue to be produced even after the stressful event has passed, creating ongoing physiological changes similar to the response shown in an acute fight-or-flight situation. According to the Mayo Clinic (2023), a chronic stress response leads to changes in mood, digestive alterations, increased blood sugar, and changes in the immune system. Chronic anxiety also causes adverse physical symptoms and problems with maintaining daily life functions, including the following:
- trouble sleeping
- focusing on wrongs from the past, or rumination
- unpredictable energy levels
- headaches
- muscle tension and pain
- high blood pressure
- weight gain
- trouble concentrating
- brain fog
- forgetfulness
- increased or decreased appetite
- digestive problems
Guilt
Guilt is a common symptom associated with processing death and grief. After the loss of a loved one, particularly from a traumatic event, individuals may experience survivor’s guilt: an overwhelming feeling that it is wrong for them to have survived when others did not. Guilt can also be associated with regrets that surface after a loss. These regrets may be related to unresolved conflicts, relationship tension, or simply unfinished plans. Moving forward is difficult after experiencing loss through death, and the timeline is different for each person. Some individuals may feel guilty for experiencing joy or starting a new relationship, but with support they typically can move past their guilt in a healthy way while maintaining important memories.
Guilt is closely linked with anxiety and often results in cyclic rumination, as the afflicted individual cannot stop thinking about past wrongs. The emotion can be crushing and lead to negative self-reflection and depression, which is best addressed with the help of a therapist.
Types of Death
In the realm of death, the diversity of human experiences emerges in various types, each with its own distinct characteristics and implications. Types of death affect both the dying process as well as the grieving process. An individual’s reaction to death often depends on whether they have time to anticipate the death or whether it is shocking. Either can trigger a cascade of emotions associated with death, loss, and the grieving process. This section aims to delve into the multifaceted nature of death, encompassing sudden and unexpected losses, tragic accidents, acts of violence, deliberate self-inflicted harm, the progression of terminal illnesses, anticipated deaths, and those resulting from medical conditions.
Sudden Death
Sudden deaths may occur from medical issues as well as from violence, whether accidental or intentional. They may occur in seemingly healthy individuals, such as with heart arrhythmias or brain aneurysms. They may also be linked with complications of a known disease. The most common cause of sudden death in the United States is cardiovascular disease (CDC, 2023c), which can lead to cardiac arrest or a heart attack. Other common medical causes of sudden death include pulmonary embolism, which is caused by a blood clot in the lungs; aortic rupture or dissection, which may be associated with a known or unknown aortic aneurysm; stroke; and sudden infant death syndrome (SIDS).
Accident
The incidence of accidental deaths varies by age group. These are also often considered preventable deaths. In infants younger than 1-year-old, mechanical suffocation is the leading cause of preventable death (CDC, 2023a). In young children, the most common cause of accidental death is drowning (NSC, 2021). For middle-aged adults, the most common cause is poisoning, which is thought to be associated with the opioid epidemic (NSC, 2021). Motor vehicle accidents (MVAs) cause the most deaths in young adults and older adults (NSC, 2021). Older adults also have the highest incidence of death from choking and falls, especially after the age of 70. Other causes of accidental death include sports-related injuries and exposure to fire or smoke. Many of these deaths are associated with a traumatic injury sustained from an accident.
Trauma for witnesses to an accidental death is an additional source of guilt, grief, and potential depression. Individuals surviving an accident where others have died may be unable to make sense of the situation and remain stuck in a cycle of blame and guilt.
Homicide
The killing of one person by another person, homicide, can range from an individual death to mass causalities. It can result from various causes, from deliberate shootings or stabbings to random acts of violence without a specific target. Domestic violence also may result in homicide. Firearm homicides make up the majority of all homicides in the United States (NSC, 2021). The violence of homicide also has a ripple effect within the community where it happens. Homicide creates a sense of fear and shame. This may lead to complicated grief and even a sense of community grief, particularly in the wake of mass shootings.
Suicide
Death caused by intentional harm to oneself is called suicide. When a parent loses their child through suicide, it is traumatic and sudden for all loved ones impacted by the death. Suicide leaves many unanswered questions and leaves most parents feeling hurt, angry, and deeply saddened by such a loss. Parents may feel they cannot openly discuss their grief and feel their emotions because of how their child died and how the people around them may perceive the situation. Parents, family members, and service providers have all confirmed the unique nature of suicide-related bereavement following the loss of a child (HealthyChildren.org, 2023). They report a wall of silence around them and how people interact with them. One of the best ways to grieve and move on from this type of loss is to find ways to keep that child as an active part of their lives. It might be private at first, but as parents move away from the silence, they can move into a more proactive healing time.
Link to Learning
The Suicide and Crisis Lifeline is a great resource for tips on helping to prevent suicide. Don't hesitate to extend a helping hand or helpful resource to someone you suspect might be at risk of suicide.
Illness
Many types of acute illness may result in death. Deaths may occur from the progression of chronic disease states or from the rapid onset of an infectious disease. Even if death is anticipated, it may feel shocking when it finally occurs. The progression of death and symptoms depend on the specific pathophysiology of the disease process. Acute illnesses may be isolated to an individual or widespread, as in a pandemic. A population-wide illness may seem to affect individuals randomly, which may lead to fear and community grief.
Anticipated Death
Anticipated deaths often take place within the context of chronic diseases and terminal illnesses. These illnesses and diseases may be associated with a slow decline in function, use of hospice services, and progressive changes. For caregivers and family members, anticipating a death can result in layered grief where the individual experiences the loss twice: first with the decline in function and knowledge of impending death, and then with the actual death.
Medical Condition
Medical conditions are the most common cause of an anticipated death. Chronic illnesses and conditions may be lifelong disorders associated with various complications. These may include seizure disorders, genetic syndromes, cardiovascular malformations, cystic fibrosis, and autoimmune disorders. These may progress over time, or individuals may have a higher incidence of certain other diseases based on these underlying disorders. Other medical conditions may develop later in life and put people at higher risk for organ damage associated with diabetes, atherosclerosis, dementia, and other neuromuscular diseases.