The American College of Physicians Home Care Guide for Advanced Cancer when quality of life is the primary goal of care
Understanding the Problem
Normal feelings to expect after the death of a loved one
Each person’s reaction to the loss of a loved one is different, and each person must work
through grief in his or her own way
There is no “right” or “wrong” way to feel after someone dies
Most people who are very upset over someone’s death take months to get beyond the
most severe emotional stress. Grief beyond a year is common but may require help
When To Get Help
Start with your family doctor
Symptoms indicating the need for professional help
Information to have ready when you call for help
What to say when you call
What You Can Do To Help Yourself
Allow yourself to experience the pain of grief
Select a person to share your grief with
Find what works for you in returning to normal routines
Read books or poetry on the subject
Keep a diary or journal
Encourage others to talk about the deceased
Talk out loud to the person who has died
Find out about a bereavement support group
“People say I should be over this.”
“People give me advice that I don’t want to take.
“Nobody wants to talk about Dad when they’re around me.”
Carrying Out and Adjusting Your Plan
Checking on results
If your plan does not work
Topics with an arrow in front of them are actions you can take or symptoms you can look for.
The information in this home care plan fits most situations, but yours may be different. If
a doctor, nurse, or counselor tells you to do something other than what is recommended
here, consider all of the information and apply what is meaningful to your own needs. Understanding the Problem
People who lose a friend or family member to cancer face the same issues as anyone who
experiences the death of a loved one, whether by accident or illness. Your feelings and
emotions after someone’s death can profoundly affect how you relate to others and get
through your daily routine. Depending on your personality, you may find it helpful to
confide your feelings to another person-sometimes a friend is best, sometimes a family
member, and sometimes a professional such as a nurse, a counselor, or a member of the
clergy. You may find consolation through sharing or listening at a group-sharing session
involving others who have had a recent loss; such groups usually are led by a counseling
professional. On the other hand, if you have never been open about your feelings, it is
unlikely that you will suddenly change now. Well-meaning people may insist that you must
talk it out, but they may not understand you, your past, or your methods of dealing with
life’s difficult moments.
Each person must work through grief in his or her own way-and it is work (even if not
always of the physical kind). Despite the existence of widely published “stages” of grief,
each survivor deals with loss as an individual, and the ways in which people handle their loss
vary widely. When you are struggling to deal with your own loss, it is useless to worry about
whether you are following somebody else’s timetable.
The range of reactions to someone else’s death is broad. Some people are devastated when it
occurs, and others feel very little emotion. Sometimes, people feel their grief only later, and
some people never have strong feelings. Different people also may experience different
emotions. They may feel guilt, remorse, sadness, or resentment toward others, such as
doctors, nurses, hospice workers, or even God. Some people who lose a family member or
close friend feel anger and ask questions such as “Why did this happen to him (the one who
died)?” and “Why did this happen to me?” Anger also may reach back to events that
occurred during diagnosis and care, and you may ask, “Why didn’t the doctors find the
cancer soon enough?” or, “Why did mother suffer so?”
You may think that you hear the deceased person’s voice calling to you, or you may want to
have a conversation with that person. You may experience flashbacks, such as remembering
the funeral or even the moment of death itself, for no apparent reason. In addition, you may
feel as if you are making progress but then suddenly feel worse, and without knowing what
triggered it. Although upsetting, these are normal experiences for people who grieve.
Even if the illness was prolonged and you anticipated the death of your loved one, you still
may encounter both shock and numbness in the same way as if the death had occurred
unexpectedly. During this time, which may last from only a few up to 6 weeks, you may
experience a sense of “just going through the motions,” as if you were in shock.
When this feeling of numbness and shock begins to subside, you may feel as if you might be
overcoming it-thinking “I’m getting back to normal.” Just then, however, you unexpectedly
may encounter a deeper sense of grief or sadness as reality sets in. When this occurs, you
may experience symptoms of grief like those of acute depression-being unable to sleep
soundly, losing your appetite, not wanting to get up in the morning, or not wanting to be
around other people.
Whatever happens, understand that there is no “right” or “wrong” way to feel after
someone’s death. Most people’s feelings, even if they seem extreme at the time, fall within a
range of normal reactions.
Most people who lose someone close to them take months to get over the most severe
part of their emotional stress, and for most, it will take at least a year to work through
the grieving process. Counselors often consider how a person is doing at the 1-year
anniversary of the death as an indicator of how well he or she has adjusted to the loss.
Grief that lasts beyond a year is common but may require help.
Remember that life will never again be exactly the way it was before your loved one died. If
you are expecting things to “get back to normal” after awhile, you may be disappointed or
frustrated to find that the new “normal” is not like the old “normal.” Your life will go on,
but-precisely because the person was important to you-it will not be the same without him or
Know when to get professional help with grief.
Understand that people handle loss with a wide range of emotions, none of which is
“right” or “wrong.” Grieve for your loss in your own way rather than feeling that you should be the same
as other people you have known or read about.
Understand that most people who grieve return to their daily routines in 2 to 4
months, but healing often takes a year or longer. Each person’s reactions are unique,
so be wary of timetables that others may try to force on you.
When to Get Help
The first question you should ask is whether you need help from other people. If you do, an
excellent place to start is with your family doctor. He or she may help you directly or aid
you in finding the right group session, counselor, or clinic. You should seek help if any of
the following is true:
? Continued difficulty in sleeping.
If you are losing sleep or feel tired all the time, the first place to go for help is your
family doctor. A physician who knows you and your medical history can make an
informed decision whether to prescribe medication and, if so, what kind. ? Substantial weight gain or loss.
Any substantial change in eating, such as loss of all appetite or a sudden increase in
appetite, may be the result of emotional distress. Again, consult your family doctor
first, because he or she already knows you and can make an informed judgment
? Prolonged emotional distress.
If, after 6 months, you do not see a marked improvement of your ability to function
in daily life, you should consider seeking help. It is natural to want to withdraw from
others after losing a loved one, but if you still cannot enjoy a reasonable quality of
life after 6 months, this is a signal that you may need help working through your
? If you are overcome by suicidal thoughts.
If suicidal thoughts become central to your thinking and you are encountering them
every day, seek help from your family doctor, a counselor, member of the clergy, or
a mental health clinic.
Have the answers to the following questions ready when you call your family doctor,
counselor, or clinic:
1. How much does grief interfere with my ability to do my job or normal daily
2. Am I having difficulty sleeping?
3. Is my appetite gone, or do I eat significantly more than before the person died?
4. Is suicide an option I would consider?
Here is an example of what someone might say when calling for help:
“I’m David Winters, son of Katherine Winters, who died of cancer 6 months ago. Ever since
my mother’s death, I’ve been very upset. I’ve also been having trouble sleeping through the
night since about 2 weeks after she died, and I never had trouble before. I think I may need What You Can Do To Help Yourself some help.” You can do many things on your own to handle the emotional stress of grief, and you can get
help from others as well. You may need one or both forms of help to successfully restore
your sense of well-being.
? Allow yourself to experience the pain of grief.
What this means is to work through your emotions in the best way you can. If this
means crying, screaming, talking to the person who has died, or doing physical
activity such as punching a pillow or lifting weights, do that. To heal emotionally,
many people need to express their feelings. If you are embarrassed about crying in
front of other family members such as your children (whether younger or adult), you
may need to tell them: “It may be upsetting to you, but I need to cry and express my
feelings. I need to work through this grief.”
? Select a person to share your grief with.
Find a good listener who has experienced a similar loss, although it probably is best
to choose someone who is not grieving over the same person as you are. Someone
outside of your immediate family often is a good choice. You want someone who
will let you express yourself, not someone who will try to reason you out of your
feelings. Candidates might be a member of the clergy or a sympathetic friend or
coworker. Although you may expect family members to be supportive, they most
likely are burdened with that very same loss as well. For example, if your spouse
dies and you want to share with your adult children, remember that they are grieving
the loss of their parent. As a result, they may be unable to give you the compassion Grieving 6
you need. In addition, it often is painful for an adult child to see a parent grieving, and they may want you to “get over it” so that their lives can return to some form of “normal.” Be aware that some people, even professionals such as clergy, may not be personally prepared to deal with death-perhaps because of their own grief over someone they have lost or feelings about their own mortality. If you are unable to relate to one person, find another. Many hospice programs offer a one-on-one assignment of a bereavement volunteer to aid families after a death, one of many programs typically extended by hospice to help with grief. Others might include newsletters, a library of books about grieving, or information about bereavement support groups.
? Find what works for you in returning to normal routines.
If certain activities such as reading or swimming were relaxing for you before, try to pursue them now. See if that will help you to get back to a normal cycle of living. For some people, losing a loved one is so upsetting that they cannot resume these activities until their grief subsides to some extent.
? Read books or poetry on the subject.
Many books, including those with first-person accounts, about working through and overcoming grief are available at your local public library. As with other techniques, however, this will not help everyone. Some people will react by saying, “I have enough to worry about without reading someone else’s grief,” while others will find direction, a sense of what is normal to experience, and a feeling of connection with others who have had this experience. Similarly, reading poetry, whether alone or aloud in a group, can help by giving artful expression to feelings that often are hard to express or even identify.
? Keep a diary or journal.
Some people find it helpful and therapeutic to write their thoughts and feelings in a diary as they proceed through the process of grieving. The British author, critic, and novelist C.S. Lewis (1898Ð1963), after losing his wife, kept a journal (A Grief
Observed) of how he was feeling. A private person for whom neither a support
group nor reading a book is helpful may find comfort in keeping such a journal. Some people also find it helpful to write their feelings in a letter to the person who has died, which can help to resolve unfinished business or feelings.
? Encourage others to talk about the deceased.
Friends and family frequently avoid discussing the deceased to avoid upsetting the person who is grieving. If you want to talk about the person who has died, you should reassure others that it is okay. All you have to do is say, “I’d like to talk about Dad.” Reassure your visitors that while you may cry or become upset, you would rather do that than awkwardly skirt the subject, because he or she was very important to you. Most people can accept your crying or being upset if you are the one who brought up the subject.
? Talk out loud to the person who has died.
In much the same manner as the letter noted earlier, it is not unreasonable to want to resolve issues with a person who has died by holding a one-sided conversation, aloud, with the deceased. Do this if it makes you feel better.
? Find out about a bereavement support group.
Bereavement support groups can help to make the process of dealing with loss easier. Signing up for a bereavement support group may be a difficult decision, however, because many people think of their grief as something that is private. You may feel uneasy talking with strangers about your feelings or your loved one. Keep in mind, however, that such groups have helped many people get through their grief and, therefore, may help you.
In a bereavement group, participants learn from each other about normal reactions to grief. Because of their shared experiences, group members often come to care about and to support each other emotionally, and they often share practical ideas for working through their grief as well. In addition, a support group also can help you to get through difficult times like holidays or anniversaries.
Most support groups meet for a limited time, such as six weekly sessions. Others run continuously, and people come in and out as their emotional needs dictate. Most are free; some require a fee. Call a hospice, counseling clinic, member of the clergy, your local Area Agency on Aging, or a hospital to find out about bereavement groups. If that does not work, check your newspaper or the human-services listings of a phone book. It often is good to talk with the leader of a group in advance to learn what is expected and how the group is conducted. Some people attend with a family member or a friend.
If you decide to attend a support group, understand that you may feel worse when
you go home after the first session. The reason is that you are dealing with your
feelings openly (as well as hearing about everyone else’s). In the long run, however,
this can be helpful. It also is important to realize that a support group will not restore
you to the way you were before the person’s death, but it will help you to cope with Possible Obstacles your new life without the deceased.
Here are some obstacles that other caregivers have faced:
1. “People say I should be over this.”
Response: Everyone deals with grief at his or her own pace. You may need to say,
“We each go at our own pace. I guess my pace is slower than you expected.”
2. “People give me advice that I don’t want to take.”
Response: Well-meaning advice is not always helpful advice. One example might
be if you regularly walked with your deceased spouse and now can no longer bear
the thought of walking alone. When people offer advice to take walks, do your best
to be gracious and thank them, but then do what you feel is best.
3. “People avoid the subject of Dad when they’re around me.”
Response: Take charge of the conversation, and reassure them: ”I want to talk
about Dad, and it makes me feel better to talk about him.” Your family and friends
may not know that you feel this way, so it is important to tell them.
Think of other obstacles that could interfere with carrying out your plan
What additional roadblocks could get in the way of the recommendations in this plan? For
example, will other people help? How will you explain your need for help to other people?
Do you have the time and energy to carry out the plan?
You need to develop plans for getting around these roadblocks. Use the COPE ideas (creativity, optimism, planning, and expert information), and see Solving Problems Using This Guide for a discussion of how to use these ideas in overcoming your obstacles.
Carrying Out and Adjusting Your Plan
Carrying out your plan
The process of grieving is unique for each person, so you need to find your own, special way of dealing with it. Experiment, and let your feelings tell you which are helping. Checking on results
The important thing to remember is that people respond to grief in widely varying ways, and that you will have both ups and downs, good days and bad. Healing takes time. You will know that you are successfully working through grief when your stronger emotions begin to dissipate, such as when you no longer feel anger or deep sadness, and when your interest and involvement in outside activities return to their normal level.
If your plan does not work
Grieving is a difficult but natural process. If you cannot resume some of your normal activities or do not seem to feel better after 6 months, you may want to review When to Get Help.
The American College of Physicians gives permission to reproduce and distribute copies of this plan provided it is not altered and its use is not for profit. For information on translation, subsidiary, and for-profit use, contact David Myers. Phone: 215-351-2642; fax: 215-351-2644; e-mail: email@example.com.