Key Takeaways
- Kubler-Ross identified five stages of grief: Denial, Anger, Bargaining, Depression, and Acceptance (not linear, may not experience all)
- Palliative care focuses on symptom management and quality of life alongside curative treatment for serious illness
- Hospice care is for clients with prognosis of 6 months or less when curative treatment has stopped; focus is entirely on comfort
- Anticipatory grief occurs before an expected loss and can help with adjustment but may also cause premature emotional detachment
- Cultural and spiritual beliefs significantly influence how individuals and families experience grief and death
Last updated: January 2026
Grief and End-of-Life Care
Death and loss are inevitable parts of life. Nurses encounter grieving clients and families regularly, whether in hospice settings, hospitals, or clinics. Understanding the grief process and providing compassionate end-of-life care are essential nursing competencies tested on the NCLEX.
Understanding Grief
Grief is the internal experience of loss. It affects every dimension of human functioning.
Types of Grief
| Type | Description |
|---|---|
| Normal/Uncomplicated | Expected response; painful but resolves over time |
| Anticipatory | Grief that occurs before an expected loss |
| Complicated/Prolonged | Grief that is intense, prolonged, or impairs functioning beyond expected timeframes |
| Disenfranchised | Grief that is not socially acknowledged (e.g., loss of a pet, ex-partner, miscarriage) |
Manifestations of Grief
Grief affects the whole person:
| Domain | Manifestations |
|---|---|
| Physical | Fatigue, changes in appetite/sleep, somatic complaints, weakened immunity |
| Emotional | Sadness, anger, guilt, anxiety, numbness, yearning |
| Cognitive | Difficulty concentrating, confusion, preoccupation with the deceased, questioning meaning |
| Behavioral | Crying, social withdrawal, restlessness, searching behaviors |
| Spiritual | Questioning faith, searching for meaning, spiritual distress or growth |
Kubler-Ross Stages of Grief
Dr. Elisabeth Kubler-Ross identified five stages of grief based on her work with dying patients. These stages are now applied to many types of loss.
The Five Stages
| Stage | Description | Client Behaviors/Statements |
|---|---|---|
| Denial | Defense mechanism; shock and disbelief | "This can't be happening." "There must be a mistake." |
| Anger | Frustration directed at self, others, God, situation | "Why me?" "It's not fair!" May lash out at staff or family |
| Bargaining | Attempting to negotiate or make deals | "If I could just live until my daughter's wedding..." |
| Depression | Deep sadness as reality sets in | Crying, withdrawal, "What's the point?" |
| Acceptance | Coming to terms with the loss | Making final arrangements, saying goodbyes, finding peace |
Important Points About the Stages
- Not linear - People do not progress neatly through stages; they may move back and forth
- Not universal - Some people may not experience all stages
- No timeline - Each person grieves at their own pace
- Individual experience - Grief is unique; there is no "right" way to grieve
- Applied broadly - Originally about dying, now used for any significant loss
Types of End-of-Life Care
Palliative Care
Palliative care focuses on improving quality of life for clients with serious illness. It can be provided alongside curative treatment.
Key features:
- Symptom management (pain, nausea, dyspnea)
- Emotional and spiritual support
- Help with decision-making
- Care coordination
- Available at any stage of illness
- Does NOT mean giving up on treatment
Hospice Care
Hospice care is for clients with a terminal prognosis of 6 months or less when curative treatment has stopped.
Key features:
- Focus entirely on comfort
- No curative intent
- Usually provided at home or in hospice facilities
- Includes family support
- Bereavement support for family after death
- Covered by Medicare, Medicaid, most insurance
Comparison
| Feature | Palliative Care | Hospice Care |
|---|---|---|
| Prognosis | Any serious illness | Less than 6 months |
| Curative treatment | May continue | Discontinued |
| Setting | Hospital, clinic, home | Usually home or hospice facility |
| Goals | Improve quality of life | Comfort, dignity at end of life |
| When starts | At diagnosis of serious illness | When death is expected |
Nursing Care at End of Life
Physical Comfort
| Symptom | Interventions |
|---|---|
| Pain | Opioids (morphine common); schedule medications |
| Dyspnea | Low-dose opioids, positioning, fan near face, oxygen if helpful |
| Nausea | Antiemetics, small frequent meals, avoid strong odors |
| Secretions | Positioning, gentle suctioning if distressing, scopolamine |
| Constipation | Bowel regimen with opioids, stool softeners |
| Restlessness | Assess for pain, benzodiazepines if agitated |
Signs of Approaching Death
| Sign | Explanation |
|---|---|
| Decreased food/fluid intake | Body slowing down; do not force feed |
| Increased sleep | Conservation of energy |
| Withdrawal | Detachment from environment |
| Confusion/disorientation | Decreased oxygenation, metabolic changes |
| Mottled skin | Decreased circulation |
| Changes in breathing | Cheyne-Stokes pattern, death rattle |
| Cool extremities | Blood shunting to vital organs |
| Decreased urine output | Kidney shutdown |
Supporting Grieving Clients and Families
Therapeutic Interventions
| Intervention | Example |
|---|---|
| Presence | Sitting with the client/family without need for words |
| Active listening | Giving full attention without trying to fix |
| Normalizing grief | "Grief can feel overwhelming. What you're experiencing is normal." |
| Avoiding cliches | Do NOT say "They're in a better place" or "Everything happens for a reason" |
| Encouraging expression | "Tell me about your father." |
| Providing resources | Chaplain, social worker, support groups |
What NOT to Say
| Non-Therapeutic | Why It's Harmful |
|---|---|
| "I know how you feel." | You can't; each person's grief is unique |
| "It was God's will." | May not match their beliefs; feels dismissive |
| "At least they lived a long life." | Minimizes the pain of loss |
| "You need to be strong." | Gives permission to suppress grief |
| "They're in a better place." | May not be comforting; assumes beliefs |
| "Call me if you need anything." | Too vague; offer specific help |
Therapeutic Responses
| Situation | Therapeutic Response |
|---|---|
| Family member crying | "I can see how much pain you're in. I'm here with you." |
| "Why did this happen?" | "I wish I had an answer. This must feel so unfair." |
| Anger at healthcare team | "You're angry about what happened. Tell me more." |
| Guilt about decision | "You made the best decision you could with the information you had." |
Cultural Considerations
Grief and death practices vary significantly across cultures. Nurses must:
- Ask about preferences rather than assume
- Respect religious and cultural rituals
- Accommodate family involvement in care
- Recognize diverse expressions of grief
- Provide culturally sensitive foods and practices when possible
Examples of Cultural Variations
| Culture | Practices (Generalizations) |
|---|---|
| Some Asian cultures | White is color of mourning; family prepares body |
| Some Latino cultures | Extended family vigil; open expression of grief |
| Some Jewish traditions | Prompt burial; week-long shiva period |
| Some Muslim traditions | Body washed/wrapped by same-sex family; burial within 24 hours |
| Some Native American traditions | Rituals vary by tribe; may involve extended ceremonies |
Remember: Never assume practices based on culture. Always ask the individual and family.
Anticipatory Grief
Anticipatory grief occurs before an expected loss.
Benefits:
- Time to prepare emotionally
- Opportunity to say goodbye
- Chance to complete unfinished business
- May ease adjustment after death
Challenges:
- Prolonged period of distress
- May cause premature detachment
- Others may not understand ("They're not even dead yet")
On the Exam
NCLEX focus areas:
- Kubler-Ross stages are NOT linear
- Palliative = comfort WITH curative treatment
- Hospice = comfort INSTEAD of curative treatment; <6 months prognosis
- Therapeutic presence > saying the "right" thing
- Avoid cliches and false reassurance
- Respect cultural differences in grief
Test Your Knowledge
A client diagnosed with terminal cancer says to the nurse, "If I could just live until my son graduates next month, I would accept whatever happens after that." This statement reflects which stage of grief according to Kubler-Ross?
A
B
C
D
Test Your Knowledge
What is the key difference between palliative care and hospice care?
A
B
C
D
Test Your Knowledge
A family member whose father is dying says, "I should have made him go to the doctor sooner. This is all my fault." What is the most therapeutic nursing response?
A
B
C
D