tures him before he became ill. Viewing the grieving
process more positively, she believes that his death
in some way has encouraged her to become more in-
dependent and to participate in new opportunities.
DIMENSIONS OF GRIEVING
People have many and varied responses to loss. They
express their bereavement in their thoughts, words,
feelings, and actions as well as their physiologic re-
sponses. Therefore, nurses must use a holistic model of
grieving that encompasses cognitive, emotional, spiri-
tual, behavioral, and physiologic dimensions (Davis &
Nolen-Hoeksema, 2001; Bonano & Kaltman, 1999).
Cognitive Responses to Grief
In some respects, the pain that accompanies griev-
ing results from a disturbance in the person’s beliefs
(Parkes, 1998). The loss disrupts, if not shatters, basic
assumptions about life’s meaning and purpose. Griev-
ing often causes a person to change beliefs about self
and the world such as perceptions of the world’s
benevolence, the meaning of life as related to justice,
and a sense of destiny or life path. Other changes in
thinking and attitude include reviewing and ranking
values, becoming wiser, shedding illusions about im-
mortality, viewing the world more realistically, and
re-evaluating religious or spiritual beliefs (Zisook &
Downs, 2000).QUESTIONING AND TRYING TO MAKE
SENSE OF THE LOSS
The grieving person needs to make sense of the loss.
He or she will undergo self-examination and question
accepted ways of thinking. The loss challenges old as-
sumptions about life. For example, when a loved one
dies prematurely, the grieving person often questions
the belief that “life is fair” or that “one has control12 GRIEF ANDLOSS 243
“If I had known what the grief process was like, I would
never have married, or I would have prayed every day
of my married life that I would be the first to die,” re-
flects Margaret, 9 years after the death of her husband.
She recalls her initial thought, denying and acknowl-
edging reality simultaneously, when James was diag-
nosed with multiple myeloma in October 1987: “It’s a
mistake... but I know it isn’t.”
For 2^1 ⁄ 2 years, Margaret and James diligently fol-
lowed his regimen of treatment while taking time for work
and play, making the most of their life together in the
moment. “We were not melodramatic people. We told
ourselves, ‘This is what’s happening; we’ll deal with it.’ ”
For Margaret, it was a shock to realize that some
friends who had been so readily present for social gath-
erings were no longer available. She waited alone in the
wee hours of the night when James had emergency
surgery. Again, she was shocked when she told a priest
who came into the room, “My husband is having
surgery,”and his reply was “Oh, sorry to bother you;
I’m looking for the paper.”
Margaret began to undergo a shift in her thinking:
“You begin to evaluate your perceptions of others. I
asked myself, ‘Who is there for me?’ Friends, arethey
really?it can be painful to find out they really aren’t. It
frees you later though. You can let them go.”
When James died, Margaret remained “level-headed
and composed” until one day shortly after the funeral
when she suddenly became aware of her exhaustion.
While shopping, she found herself in protest of the emo-
tional pain and wanting to shout, “Doesn’t anybody
know that I have just lost my husband?”CLINICALVIGNETTE: GRIEF
Surprised with how overwhelmed she felt, one of
her hardest moments was putting her sister on the plane
and going home to “an empty house.” It was at this time
that she began to feel the initial shock of her loss. Her
body felt like it was “wired with electricity.” She felt as
though she was “just going through the motions,” doing
routine chores like grocery shopping and putting gas in
the car, all the while feeling numb.
Crying spells lasted 6 months. She became “tired of
mourning” and would ask herself, “When is this going
to be relieved?” She also felt anger. “I was upset with
James, wondering why he didn’t go for his complete
physical. Maybe James’ death may not have happened
so soon.”
After a few months and well into the grief process,
Margaret knew she needed to “do something construc-
tive.” She did. She attended support groups, traveled,
and became involved with church activities.
Her faith in God was a plus. Exercising this faith, she
trusted that eventually her emotions would catch up with
the intellectual understanding of all that had transpired
in James’ dying. She developed an “inner knowing that
God is all-seeing, all-knowing.” This belief gave her spir-
itual strength and empowered her as she grieved.
Nearly a decade after James’ death, Margaret views
the grief process as a profound and poignant “search for
meaning in life. If he had not gone, I would not have
come to where I am in life. I am content, confident, and
happy with how authentic life is.”
Even so, a sense of James’ presence remains with
her as she pictures the way he was before he became ill.
She states, “This is good for me.”