Death elicits a series of predictable and painful emotions in the bereaved. Initially, the mourner may appear to be in shock—in a dreamlike state—or in actual denial, talking about the deceased as though he or she were still alive and carrying out usual daily activities as if nothing had changed. The acutely bereaved patient may look shocked or startled, or may be crying or sobbing. The bereaved person may be angry or hostile, especially if he or she believes that negligent medical care prompted the death.

As the news of the death is absorbed over the following several days, the numbed disbelief and shock is punctuated by acutely painful feelings of despair and emptiness, a deep pining and yearning for the deceased, a transient sense of worthlessness, and feelings of anger and rage. Crying spells, anxiety, feelings of abandonment, and guilt over actions taken—or not taken—for the deceased may occur. Lindemann (2) described somatic sensations of tightening in the throat, a choking sensation, and empty feelings in the abdomen whenever the deceased is mentioned. Sleep and appetite are disturbed. Transient suicidal ideation is not uncommon, and usually takes the form of wishing to join the deceased. These intense emotions wash over the bereaved suddenly, without warning, and leave just as suddenly. Some bereaved people believe that they are “going crazy” from the intensity of feelings; others believe that the lull between these intense emotional waves indicates that they are not properly mourning the deceased or not taking the death seriously enough.

Bereaved people may believe that they see the deceased or can still hear their voices, and may call their names. There is a dissonance: While the world is functioning as always, bereaved people are amazed and sometimes angry that the world has not stopped to acknowledge the enormity of their loss. Keeping objects or making sure that nothing is disturbed and that the deceased’s things are the way they have left them are ways of holding on to the deceased, and can serve as an unconsciously magical belief that the deceased is still alive and coming home (3,4). Such behavior is not necessarily pathologic if it does not interfere with the person’s postmourning functioning. Although in the past it was believed that keeping objects of the deceased indicated pathologic
mourning, this is not the current view. This author has met many elderly persons who function well but who keep objects of their deceased spouses, including their clothes, for years.

The acute grief process, which has a time frame of approximately 6 to 12 weeks, may be smooth or complicated, depending on the nature of the death. By the end of the first year after the death, there is usually an integration of the loss; the deceased is remembered, new relationships have been made, and life has gone on. The importance of the lost relationship is not diminished, but has changed. Thus, there remains a place in one’s heart for the deceased, but it does not interfere with forming new relationships (5). For spiritual or religious persons, there may be an understanding regarding the meaning of the loss that has helped them come to terms with it. It is postulated that the biologic (hormonal) response to grief is similar to those seen in acute and chronic stress (6).

In 2007, the first evidence-based study (7) studied the response to death by natural causes. The responses of the bereaved were as follows:

The mode of death was important: Although survivors of traumatic or sudden losses were not studied per se, the authors found evidence that disbelief was higher after a traumatic death than after a natural or prepared-for death. In natural death responses, acceptance increased steadily through the postloss periods. Yearning, not depressive mood, was the salient psychological response to natural death.

The authors found that if symptoms of disbelief, yearning, anger, and depression lasted beyond 6 months postloss, there was indication that the person might fit the criterion for prolonged or complicated grief, and suggest that because of these findings, the DSM IV-TR criteria (8) of 2 months for uncomplicated bereavement be changed to 6 months. The authors believe that their study provides clinicians a clear idea of what to expect following the death of a family member, and can be useful for the emergency clinician with regard to diagnosis and psychoeducation of the mourner and his or her family.

Most bereaved persons do not come to the attention of clinicians. When this does occur, the bereaved person may appear inconsolable, but it is the job of the emergency clinician to offer comfort and consolation. In the emergency department, the bereaved need to be met with kindness, comfort, and solace. Common sense is the best intervention. A touch on the shoulder, telling the person how sorry you are for his or her loss, and offering food or water are commonsense techniques that make a huge difference to the bereaved. Allowing the bereaved to talk about the deceased is crucial. Essentially, the clinician should not get in the way of the grieving process. Psychoeducation is useful to help the mourner predict the course of the bereavement and the vicissitudes of emotions it will bring. Conditions that allow for effective mourning include social supports for the bereaved, the mourner’s functional status and personal resiliency prior to the death, and his or her success at dealing with prior losses.

The use of pharmacologic agents is generally minimal. If the patient complains about insomnia, a few doses of a short-acting benzodiazepine (5) or one of the newer nonbenzodiazepine soporifics may be helpful for restorative sleep if it helps the person feel rested enough to use his or her daytime hours more effectively (e.g., to manage financial matters or attend to the person’s own medical needs or to his or her children). However, if medication is required for more than 2 weeks, the possibility of a comorbid condition should be explored (5).

The bereaved may have no one to talk to about the death, and the need to tell the story in order to integrate the loss may lead a patient to the ED. For example, an elderly man whose wife had died at home had told police immediately upon his wife’s death how he had found her in bed, dead. Several months later, he still had the
story in his mind, and needed to tell it again because he was now at another point in the grief process than he had been in the beginning. He needed to retell the story to make sense of it and put it into new perspective. Thus, in addition to hearing about how he found his wife dead, the ED clinician also encouraged the patient to talk about his wife, their relationship (both the ups and the downs), and how he had been managing since her death. Initially, the patient had presented to the ED with physical complaints, but the alert ED physician was able to elicit the history of his wife’s recent death.

Signs of pathologic grief noted in the DSM-IV-TR (8) include guilt about things that are not associated with the deceased, thoughts of death other than the “survivor feeling” that he or she would be better off dead or should have died with the deceased person, marked psychomotor retardation, prolonged and marked functional impairment, and hallucinations other than transiently “seeing” or “hearing” the deceased. Other symptoms of complicated grief include the inability to feel emotions, continued disbelief that the death has occurred, the inability to move beyond pining and yearning, idealizing the deceased, somatization or even taking on physical symptoms of the deceased, impacted or misdirected anger, prolonged social withdrawal, and the feeling that there is no future and that life holds no meaning without the lost person. Intrusive thoughts of the deceased are painful and do not bring comfort. A higher risk of mortality exists among those with complicated grief; thus, attention must be paid to the physical health of the patient (9,10). The emergency clinician must also be watchful for underlying psychiatric illnesses such as clinical depression, psychoses, and substance abuse. An evaluation of suicidal thinking should be done. For patients who present to the ED with unexplainable physical complaints, an inquiry into recent loss or trauma is indicated.

Death may awaken spiritual or religious crises—some people may blame their religion or their God for their situation. A containing, sympathetic, and empathic position is essential. Consultation with chaplains in the ED can be very helpful, especially when chaplains are a part of the emergency department team.

Risk factors for the development of pathologic grief include comorbid psychiatric illnesses, a history of multiple losses or traumas, overdependence on the deceased, age (children and adolescents are at higher risk), and a loss that has occurred through traumatic or otherwise “unanticipated or societally stigmatized death” (e.g., suicide, HIV, murder) (5,9,11). Freud and other analysts who followed him believed that ambivalence in the relationship when the deceased was alive produced more complicated grief in the mourner. Prigerson (12) found that the amount of ambivalence was inversely related to severity of grief. However, the degree of dependency predicted a more difficult bereavement.

The distinctions between normal and pathologic grief, and between clinical depression and posttraumatic stress disorder (PTSD), have become even more complex as traumatologists study the issue of complicated grief or what is now referred to as “traumatic grief.” According to Gray et al. (9), complicated grief is associated with considerable morbidity and mortality in the mourner. Further, if the death was violent, surviving loved ones may experience complicated grief and symptoms that meet the criteria for PTSD, which is also referred to in the literature as “traumatic grief” (12,13,14). Studies have noted that PTSD develops in approximately one third of cases involving the sudden or unexpected death of a close friend or relative. Whether traumatic grief is a distinct diagnostic entity from PTSD or clinical depression is now being examined (13,14), and further research is needed to determine diagnostic specificity and validity (15). In light of the new research on traumatic grief, it may be necessary to reconsider Lindemann’s observations (2) as being descriptive of traumatic rather than of “normal,” uncomplicated bereavement. At this time there are no definitive guidelines for treating or preventing complicated grief (9), although Raphael (3) has written about her success with bereavement support groups.

An example of traumatic grief comes from a documentary film this author saw in 2007 regarding
students from the Danciger Comprehensive High School in Qiryat Shemona and their reactions to the July 2006 war in northern Israel. A 16-year-old girl recounts that her parents were in Thailand when the war broke out, and that she and her 19-year-old brother were home. He received a call to report to duty and called her several times during his week-long tour as he had promised. “He said he would come home that weekend.” Liran, her brother, did indeed come home that Sunday, but for his burial. He was buried while live Katyusha rockets fell in and near the cemetery. The girl reports that she has intrusive thoughts of her deceased brother that are deeply painful, with reexperiencing of the event when she was notified of his death; she has startle responses, nightmares, “screams in the night,” and desperately misses her brother. However, she is back in school and functioning. This girl’s symptoms demonstrate those of traumatic grief, and may also reflect symptoms of PTSD.