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88 Chapter 7
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Handbook of Palliative Care, Fourth Edition. Edited by Richard Kitchen, Christina Faull, Sarah Russell and Jo Wilson.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
89
8
defined as the Bereavement Pathway. This pathway is
explored along with the losses these experiences incur for
patients, carers, and practitioners. A family systems approach
is used to engage with the relationship dynamics of those at
the centre of receiving and delivering palliative care.
3.
Integrating new perspectives into palliative care prac-
tice. The final section describes how the new perspectives,
described in sections 1 and 2, might be integrated into pal-
liative care and a case study is presented to exemplify how
these ideas might be used in practice.
Understanding Loss and Grief
What Does Loss Look Like?
Anything that you have you can lose; anything you are
attached to, you can be separated from; anything you love
can be taken away from you. Yet, if you really have nothing
to lose, you have nothing. [7, p. 211].
Loss is a universal human experience woven into
everyday life. Experiences of loss can be both:
• part of the common journey through life e.g., leaving
school, moving house, retirement, timely death.
or arise
•
from more particular individual circumstances e.g.,
relationship changes and loss such as separation and
divorce; health changes and losses, such as disability and
illness; unfulfilled hopes such as childlessness; social or
economic disadvantage such as unemployment, poverty;
untimely bereavement [2, 5].
The impact of the worldwide COVID-19 pandemic has
introduced a new and extensive range of losses into life and
these include [8] the loss of everyday normal activities:
•
loss of connectivity with others
• loss of finances and jobs
Integrating New Perspectives:
Working with Loss and Grief in
Palliative Care
Nikki Archer and Linda Machin
Introduction
It’s so hard when you go in to visit them. You can feel
the tension. It’s there but invisible. Roger just avoids
talking about things. I think he knows what is hap-
pening but doesn’t want to talk. Elizabeth is making
plans for when she is not here. She got upset the other
day talking about the life they’ve shared. He was like
“come on we need to be strong”. I just smiled and got
on with what I needed to do. He knows she is dying
but he just copes by getting on with the practicalities.
I felt helpless and didn’t know what to say.
Joyce, Staff Nurse.
Working with dying, death, and bereavement is a central
part of palliative care. The ability to deal sensitively with
the consequent, often complex, and demanding landscape
of loss and grief is the basis for providing high quality pal-
liative care. However, it is a challenging area of practice
which remains largely invisible, unplanned for, and misun-
derstood [1–3].
This chapter addresses the centrality of loss and grief,
generated by dying, death, and bereavement. It sets out a
practice framework for the Bereavement Pathway in pallia-
tive care [4], that incorporates the theory and practice of the
Range of Response to Loss model (RRL) [5] and a family
systems approach [6]. The chapter has three sections:
1. Understanding loss and grief. This section explores
loss and grief as fundamental, human experiences and
introduces the RRL model as a contemporary framework
for understanding and assessing the spectrum of reactions
and coping responses prompted by grief.
2. Loss and grief in palliative care. This section explores the
palliative care context of dying, death, and bereavement,
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90 Chapter 8
What is Grief?
Grief is an experience prompted by a significant loss and is
uniquely and individually expressed through the reactions to
it and the adjustments which must be made to its conse-
quences [3, 10]. Grief is not just an emotional phenomenon,
but it impacts on all dimensions of experience: physical,
cognitive, behavioural, spiritual, and social (see Figure 1). The
wider culture, including ethnicity, race and belief systems, and
more immediate social context, within which a loss occurs,
shape perceptions about the relative significance of a loss and
how people respond to it [3, 11]. For instance, an older Indian
widow with a strong belief in an afterlife is likely to respond
very differently to the experience of a terminal illness, from
the way a young Western atheist does, who believes strongly
in control of one’s own life and that there is no afterlife. How
an individual, and their family network makes sense of the
•
loss of safety and security
•
loss of opportunity for marking key life events
•
loss through death of a family member.
Everyone is faced with managing and integrating a wide
range of change and loss into their lives. Some people manage
this well, while others struggle. The impact of a loss and the
ability to manage it will depend upon the nature and visibility
of the loss, personal and circumstantial factors, and the way
these might promote resilience or result in vulnerability. The
culture within which a loss occurs can be the context of effec-
tive support or the context of misunderstanding and unavail-
able support. While some losses can be remedied, for many,
including death, dying, and bereavement there is no possible
reversal, only an adjustment to the reality of what has been
lost [5]. Death, dying, and bereavement are usually seen as the
hardest and greatest losses which we face within our lives [9].
Culture. Ethencity. Beliefs.
Social and Economic
Grief as a
multidimentional
response to loss
Family and Friends
PHYSICAL
REACTIONS
EMOTIONAL
REACTIONS
BEHAVIOURAL
REACTIONS
SPIRITUAL
REACTIONS
SOCIAL AND
PRACTICAL
REACTIONS
COGNITIVE
REACTIONS
Figure 1
Grief: a multidimensional response to loss and the external factors which influence it.
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Integrating New Perspectives: Working with Loss and Grief in Palliative Care 91
are persistent yearning for the deceased; prolonged and
persistent negative cognitive, emotional, and behavioural
symptoms; difficulty in functioning in work and social
relationships; a sense of meaninglessness and disruption in
beliefs which are present for at least six months.
However, the nature and diversity of grief reactions, are
often misunderstood and many normal reactions or
“symptoms” e.g. being emotional, wanting to talk about the
illness or the deceased are seen as indications of not coping
or of mental-health difficulties. This risk of pathologising
grief ignores new understandings and insight about the
human capacity for resilience in the face of loss [21]. Most
people, although challenged by the impact of loss and their
experience of grief, do possess sufficient inner resourceful-
ness or resilience to manage and get through traumatic and
disturbing loss events. Resilience is characterised by qual-
ities of flexibility and courage, by a capacity to make sense
of experience and to retain some positivity, set alongside
the availability and the willingness to access support [5, 22,
23]. These characteristics will be evidenced where people
are able to effectively balance the emotional component of
grief with ongoing life demands [24]. In the face of testing
life experiences opportunities for growth in psychological,
social, and spiritual maturity are possible [22, 25, 26] but
there will be a journey to take in achieving resilience,
which may be punctuated with periods of vulnerability.
There are numerous factors which have been identified
as promoting adaptive grief responses or exacerbating
experience of loss will be significantly influenced by the cul-
turally derived and personally developed, life perspectives.
The nature and level of distress experienced within the
different domains (see Table 1) will range in intensity from
little or none, to heightened suffering that can lead to
depression, anxiety, panic, social isolation, and existential
and spiritual crisis [12].
What are the Risks? What Does
Resilience Look Like?
The experiences of loss can have a profoundly negative
impact on the lives and wellbeing of individuals, families,
and the wider community. For a proportion of grieving
people these negative outcomes will include emotional
distress, anxiety, and depression [14]. It has been esti-
mated that:
•
Around one in four palliative care patients will
experience these more severe levels of emotional and
psychological distress [15] in response to the losses associ-
ated with their illness.
•
Evidence has shown the negative impact of losses asso-
ciated with caring for family members at end-of-life
including depression and anxiety [16, 17].
•
An estimated 10–15 per cent of bereaved people will be
affected by complex grief with increased risk of depression,
anxiety, substance abuse, suicidal thinking, and abnormal-
ities in immune functioning [18]. The characteristics of
Complicated Grief [19] or Prolonged Grief Disorder [20]
Table 1 How people react to loss [13].
Dimension Reactions people experience in response to loss
Emotional Numbness, sadness, anger, fear, relief, irritability, guilt, loneliness, apathy, longing, anxiety,
meaninglessness, apathy, abandonment, envy.
Physical Hyperactivity or underactivity, physical distress, chest pain, abdominal pain, headaches, nausea, panic
attacks, changes in appetite and weight, fatigue, sleeping problems, restlessness, insomnia, crying and
sighing, menstrual irregularities, sensitivity to noise, shortness of breath, and tightness of throat.
Cognitive Worry about own/other’s reactions. Attempts to rationalise and make sense of the loss. Thoughts focus
on loss or work hard to think about other things. Difficulty in concentrating.
Social and practical Avoid contact with others, lack interest in contact with others, struggles to be on own, engages with
available support network. Social support unavailable.
Behavioural Forgetfulness, slowed thinking, dreams about the loss, wandering aimlessly, crying, outward expressions
of varied emotions, adapt behaviour to respond to others needs, need to share narrative of what has/is
happening.
Spiritual Existential questions raised, reappraisal of purpose and meaning of life, belief systems challenged or
reaffirmed, searching for answers and reasons for the loss, meaning making.
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92 Chapter 8
on these “traditional” conceptualisations means practi-
tioners risk pathologising and undermining natural resil-
ience [38].
Contemporary theories have brought a new focus to
address the limitations of earlier ideas, and to give fuller
recognition to the importance of cultural determinants of
grief and insight into the nature of resilience. The Dual
Process Model of grief emerged from research which
sought to test the validity of the traditional “grief work”
hypotheses [24]. It proposes that adaptation to grief con-
sists of a two-dimensional process: loss orientation, with a
focus on the distress of grief, and restoration orientation,
attending to ongoing life demands. The ability to move or
oscillate between the two modes is seen as necessary for
successfully adapting to loss. Further explanations and
discussions of grief theory have been published [36, 39].
The Range of Response to Loss Model
(RRL): A Framework for Practice
The RRL model developed by Machin, was conceptual-
ised as a result of listening to grieving people in practice
and research [5, 40]. It provides a framework in which
grief is conceptualised as a two-dimensional process. In
the first of these dimensions, initial intuitive grief
reactions are triggered and can be seen expressed in a
range from:
• An overwhelmed reaction, where the distress of grief
dominates
to
•
A controlled reaction, where emotion is suppressed or
avoided, and the focus is on ongoing life demands.
distress (see Table 2). The complex interplay of risk and
resilience is part of each grief experience. Even where
there are multiple risk factors some people will be able to
accommodate their loss effectively. While for others
where there are fewer indications of risks, loss is experi-
enced as distressing and debilitating grief [5, 27]. Where
the risk includes complex mental-health issues, including
potential self-harm or suicide further prompt assessment
and referral to mental-health specialist will be required.
Theories Which Have Helped Us
Understand Grief
Over the last one hundred years, grief theories, along with
the extensive literature and research associated with them,
have provided a conceptual base for understanding the
nature of dying and bereavement. Early theoretical per-
spectives were influenced by Freud’s psychodynamic
school of thought [32]. The clinical work undertaken by
Kubler-Ross [33] with dying patients and Bowlby’s evolv-
ing ideas about the nature of human attachment [34] led
to notions of stages or phases of grief. These theories
focused on grief as an intrapsychic, time-bound experi-
ence with a bias towards a predominantly emotion-
focused view of grief. The absence of, or too much,
emotional expression of grief was seen as problematic.
Implicit in this notion is that there is a predictable, ideal
way for grief to be experienced, expressed, and worked
through. The limitations of these perspectives have been
widely recognised over 20 years and yet they remain
embedded as the dominant discourse within western
clinical healthcare practice [35–37]. Continued reliance
Table 2 Factors identified as promoting adaptive grief responses or exacerbating distress.
Factors increasing the risk of negative outcomes following loss [27–30]
Factors which support resilience following loss
[22, 23, 31]
Other concurrent stresses and losses within the family (poor housing, debt,
relationship issues)
Absence of concurrent stresses
History of multiple losses – previous experiences of death and loss how have
these been managed? Quantity of losses which have been managed and
personal resourcefulness or capacity for managing the loss
Positive life perspectives and personal
resourcefulness
Strong dependency issues, difficult relationships Previous positive experiences of managing loss
Pre-existing mental illness Capacity to make sense of experiences
Untimely deaths Culturally sensitive available support
Perceived lack of social support Capacity to access available support
The nature of the death (in bereavement)
e.g. Traumatic/unexpected
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Integrating New Perspectives: Working with Loss and Grief in Palliative Care 93
situation, is seen as an indication of resilient coping i.e.,
emotions are accepted and faced, and the practical conse-
quences of loss are approached with realism and a sense of
engagement. In contrast, where the capacity to balance
feelings and functioning is impeded or absent and
managing the changed life situation is problematic, vulner-
ability is indicated. Figure 2 shows the RRL model, and the
two-dimensions integrated to provide a framework for
practice. It is important to recognise that the concepts in
the model are influenced by the wider context of culture,
circumstances, and personal factors. Factors which will
affect the propensity for vulnerability and resilience.
These core grief reactions reflect the emotional and
cognitive tensions prompted by loss and reflect language
heard in practice and everyday life, for example:
•
It’s just so overwhelming, I can’t stop myself from crying
and thinking about what has happened all of the time.
•
I just need to stay strong and be there for the children, I’ve
got to manage looking after them, I can’t let him down.
The second dimension of the RRL is described as a coping
response, in which there is a conscious process involving
facing the loss and managing its consequences. The ability
to balance the overwhelmed and controlled reactions and
to respond effectively to the reality of the changed life
Vulnerable
Resilience
Resilience enhanced by: personal
resourcefulness, positive life
perspectives, social embeddedness.
Risk factors: Co-existing stressful
personal/circumstantial/social factors
make coping with grief difficult
Feelings of grief
dominate and
make day to day
functioning
difficult
Strong emotions
are accepting as
part of the
experinces of loss
Effective
engagement with
the reality of the
loss
Denial of, or
struggle with the
reality of loss, may
result in fragile
functioning
Current
social
circum-
stances
ethincity
culture
family
religion
beliefs
Key:
Core grief reactions
Coping Responses
OVERWHELMED
CONTROLLED
Figure 2 The range of response to loss model: the interacting dimensions of core grief reactions and coping responses, influenced by the wider
cultural context [5].
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94 Chapter 8
The concepts in the RRL model are echoed in other the-
ories particularly those influential theories used in pallia-
tive and bereavement care i.e. attachment theory [41] and
the Dual Process Model [24].
The RRL is increasingly being used within palliative care
settings as a framework to help practitioners identify
individual and family responses to loss. A measure which
is based on the RRL, is the Adult Attitude to Grief Scale
(AAG) providing a tool for understanding the individual
dynamics of a person’s grief [5, 40]. The AAG is a validated
nine statement, five-point Likert tool which provides a
grief-specific measure of vulnerability and resilience [42].
Interest and enthusiasm, within palliative care psychoso-
cial services, for the practice usefulness of the RRL model
and the AAG scale in bereavement support, has led to the
development of two pre-bereavement measures. These are
the Attitude to Health Change scales (AHC), one for use
with patients and one for use with their carers or family
members. The AHCs help to provide practitioners with a
measure for assessing patient and carer support needs and
is a tool which also facilitates conversations about the
experience of life limiting illness. Research is being under-
taken to validate the AHCs. The concepts in the RRL are
reflected in the AAG and AHC statements (see Table 3).
Table 3 Comparing the AHC statements (one for patients and one for carers) with the AAG statements [5].
3(i) Overwhelmed reactions
AHC (patient) AHC (carer) AAG
I find it difficult to switch off thoughts
about my health
I find it difficult to switch off thoughts
about …….’s health
For me, it is difficult to switch off
thoughts about the person I have lost
I often feel emotional about my health
e.g. fearful, anxious, sad ……….
I often feel emotional about ….’s health e.g.
fearful, anxious, sad…….
I feel that I will always carry the pain of
grief with me
My illness makes it harder for me to make
sense of life
………’s illness makes it harder for me to
make sense of life
Life has less meaning for me after this
loss
3(ii) Controlled reactions
AHC (patient) AHC (carer) AAG
I believe I should be brave when facing
my illness
I believe I should be brave when facing
…….’s illness
I believe I must be brave in the face of
loss
It is important for me to keep my
feelings about my health under control
It is important for me to keep my feelings
about ……’s illness under control
For me, it is important to keep my grief
under control
I try to focus on day to day life rather
than my health
I try to focus on day to day life rather than
……’s health
I think it is best just to get on with life
in spite of this loss
3(iii) Resilient coping response
AHC (patient) AHC (carer) AAG
I am able to face up to the feelings
I have about my illness
I am able to face up to the feelings I have
about ……’s illness
I feel able to face the pain which comes with
grief
I feel emotionally strong enough
to cope with my illness and its
consequences
I feel emotionally strong enough to cope
with …….’s illness and its consequences
I feel very aware of my inner strength when
faced with grief
I believe that I will come to accept
my illness and its consequences
I believe that I will come to accept…….’s
illness and its consequences
It may not always feel like it but I do believe that
I will come through this experience of grief
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Integrating New Perspectives: Working with Loss and Grief in Palliative Care 95
stuff, like thinking about my own mortality, and the relent-
less treatment and the pain that often comes with it.…It
might seem odd to worry about not having children when I
don’t even know how much of a life I have left, but it’s there
… That treatment, harsh as it is, will have killed any chance
I might have had. It’s making me cry just thinking about it.
Sarah Harding, Girls Aloud 2021 p. 169
Grief is often seen as a reaction only to bereavement, but
the wider significant losses faced by patients (and their
carers), need to be seen as grief-producing and recog-
nised as such in palliative care [10, 39]. Sometimes these
losses have misleadingly been described as “anticipatory
grief,” rather than seen as the “here and now” grief of life
limiting illness [45, 46]. All practitioners are challenged
to work alongside and in response to the losses and
griefs of patients and their family carers, when
delivering
palliative care.
The Bereavement Pathway
The Bereavement Pathway [4] was developed as part of a
UK Department of Health funded project to address the
challenge of ensuring continuity of care between end-of-life
and bereavement services. It identifies the Bereavement
Pathway as being from the point of diagnosis along a con-
tinuum through end-of-life care and into bereavement,
making the important link between pre and post death
experiences. The original purpose of the pathway was to
recognise and bring together the multiple services and
aspects of support required for people and families facing
or following bereavement. It usefully provides a framework
for identifying and conceptualising the continuum of losses
experienced along this pathway (Figure 3).
Loss and Grief in Palliative Care
The Journey from Diagnosis to
Bereavement
From the moment someone has a life-limiting diagnosis
which confronts them with the real possibility of their
own death, they and their family and friends are likely to
experience a normal reaction of shock and psychological
distress [25, 28]. From this point each patient will travel
their own unique palliative care journey, accompanied by
family members and practitioners. All will be challenged
by fundamental life and death questions and multiple
losses. Along with the loss of or reduced physical func-
tioning, will be loss and change of social roles and personal
identity [39]. Such latter losses are often unrecognised
and unacknowledged or “disenfranchised” [25] even by
practitioners [3]. Individual grief response to these losses
will be unique to each patient and carer, influenced by
personal, cultural and health care setting, and involving a
period of adjustment to the changes each loss brings [3,
28]. Most people find an inner resilience enabling them to
cope with the consequences of illness induced losses, but
some people will experience more severe and prolonged
distress [28, 43].
There are many rich personal narratives offering insight
into the experiences of grief encountered by people who
are dying and have been bereaved. In her recent biography
Sarah Harding [44] wrote about her experiences of having
terminal cancer:
It sometimes surprises me, the things that really get me down
while living with this illness. Of course, there’s the obvious
Figure 3 The Bereavement pathway and experience of loss in palliative care.
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96 Chapter 8
A Family Systems Approach to Practice
Experiences of death, dying and bereavement happen
within a family context. How family members manage
the impact of loss and grief can have positive or nega-
tive consequences for a patient’s general well-being and
symptom control [54]. It is imperative, therefore, that
practitioners incorporate a family approach to under-
standing and working with loss and grief [55]. This
approach needs to include all the interacting personal
and circumstantial factors within the family group,
including for children, young people and family mem-
bers with learning disability and impaired cognition
[56, 57].
Culture shapes how individuals and families grieve and
make meaning out of the experiences of illness, death, and
bereavement [58]. Cultural attitudes are formed to reflect
race, ethnicity, religion, and beliefs, and will contribute to
how grief is defined and what are seen as acceptable
responses to it. Other social factors too, such as, gender,
age, class, and economic status will play a part in deter-
mining how grief is experienced and expressed. Sometimes
cultural beliefs and practices are readily adopted by an
individual, their family, and the wider community and this
will provide an uncontentious supportive base within
which to cope with loss and its consequences. In other sit-
uations, incongruity between the individual lived experi-
ence, family members and cultural norms and beliefs,
create tensions for the individual and the wider social net-
work. Awareness of these dynamics and alertness to their
impact on patients and family members is central to
offering sensitive and culturally appropriate support in
palliative and bereavement care.
Alongside use of the RRL theoretical framework, adopt-
ing a family systems approach can provide a holistic
approach to practice across the Bereavement Pathway.
Integrating New Perspectives into
Palliative Care Practice
Grief is something which needs to be fully understood,
supported, and assessed by practitioners as an integral part
of delivering good palliative and end-of-life care. Good
communication skills, cultural awareness and a broad
understanding of loss and grief underpin practice. The
RRL, and where appropriate use of the AHC and AAG,
provide a simple explanation of the nature of loss and a
language for describing and discussing it within a
professional context.
The Bereavement Pathway – A Journey of
Losses for Patient, Carer, and Practitioner
Loss and change for the dying person along the
Bereavement Pathway may include [39, 47–49]:
•
loss of personal and social identity arising from loss of
health and functional abilities, loss of social status and
roles, loss of employment, loss of a sense of self, etc.
•
dealing with, and empathy for, the losses being experi-
enced by family and friends.
•
confronting impending death, the loss of everything in
the present and the future, which had made meaning of life.
Family members are likely to have similar challenges as
they too adapt to both their own losses and those of the
dying person. These may include [50]:
•
potential loss and change in personal health,
employment, identity, social connections, finance, as the
result of being a carer.
•
dealing with and empathy for the losses being experi-
enced by the dying person and other family members.
• adjusting to continual changes in the caring role.
•
confronting one’s own mortality.
Loss and change for family/friends post bereavement may
include [51]:
•
managing their experience of the death of a significant
relative/friend.
• loss of the relationship and the social significance of that role.
•
changes in lifestyle: financial, housing, social activity.
The family experience of dying and bereavement is a com-
plex one. Throughout the Bereavement Pathway each
family member, including the person who is dying, will be
dealing with the impact of each loss and their own grief
response [52]. During the COVID-19 pandemic separa-
tion from a dying relative or friend has heightened distress.
This together with depleted social support at the time of
the funeral and in subsequent weeks has intensified the
experience of grief for many people.
Practitioners who provide care for patients and fam-
ilies along the Bereavement Pathway will also be facing
losses. Loss and change for practitioners may include
[47, 53]:
• Dealing with, sympathy/empathy for the dying person,
their carers, family, and friends.
• Being the bearer of “bad news,” challenged by a sense of
powerlessness, not being able to “do” anything to make
things better.
• Identification of personal experiences with the losses
being experienced by the patients and family.
• Confronting one’s own mortality.
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Integrating New Perspectives: Working with Loss and Grief in Palliative Care 97
their experiences offers indicators to their loss response.
Table 4 outlines the narrative framework for under-
standing how the story of loss might be told within the
RRL framework.
• Guide them in their support of patients and carers to see
(i) how they might listen to and accept as normal the over-
whelmed or controlled reactions to the losses they are fac-
ing and (ii) help them explore the practical, emotional, and
social ways of coping with their illness or bereavement.
(This may sometimes require calling on specific support
from psychosocial practitioners).
•
Consider using the AAG and AHC for more in-depth
assessment and as tools to create opportunity for therapeutic
conversations. Use of these tools requires practitioners have
an understanding of their appropriate use in practice. For
further information, see https://mapping-grief.care
This RRL framework helps practitioners recognise and
understand the reactions and responses to the varied loss
experiences along the Bereavement Pathway, supports
identification of those at risk of poor outcomes, and
enhances resilience.
The level of support needed across the Bereavement
Pathway is set out in the NICE guidance [61] and the
Public Health Model of Bereavement Care [62]. Both
advocate a three-tiered component framework for the pro-
vision of support, which aligns with the three tier commu-
nication skills frame [59], for practitioners working in
palliative care:
• Component 1: A high proportion of people (50–60%)
with low vulnerability will require little formal support
[62]. Acknowledging their grief, providing information
about the normality of their grief and resources avail-
able, is an appropriate level of practitioner intervention.
Generally, people can deal with their grief using support
from their existing networks, including from family,
friends, people in their broader community and the
general support provided as an integral part of pallia-
tive care.
• Component 2: Some people (an estimated 30–40%),
experience some level of difficulty and a measure of vul-
nerability [62]. They require some additional support,
requiring basic counselling skills on a one-to-one basis or
through group and peer support.
• Component 3: Few people (10%–15%), have more com-
plex needs, with a high or severe level of vulnerability [62].
They will require more intensive interventions such as
skilled counselling or mental-health support.
Distinguishing these different levels of support is essential
for providing appropriate and effective care. All
The Role of the Practitioner: Core Skills
A person-centred approach to communication, is an under-
lying principle for working with loss and grief. This requires:
•
An empathic and compassionate attitude complemented
by good listening and communication skills to support
grieving people.
•
The ability to identify, through sensitive assessment, when
people are vulnerable to the negative outcomes of grief.
•
The ability to enhance, rather than undermine or
pathologise, inherently resilient responses.
•
Adopting a family systems perspective.
A three-tier communication skills framework for pallia-
tive care practitioners offering different levels of care [59,
p. 121]:
• Level 1: communication skills: everyone working in pal-
liative care should possess a basic level of skills which com-
municate compassion and understanding. Ability to give
and receive information, allow discussion and expression
of feelings, support and encourage resilience, and under-
take assessment.
• Level 2: basic counselling skills: practitioners working
within palliative care who have developed basic skills to
facilitate greater awareness and understanding to support
and encourage resilience.
• Level 3: qualified/experienced counselling: offering a
trusting confidential relationship over time helping people
with complex needs.
Ensuring culturally sensitive practice requires that practi-
tioners have [60]:
•
An inquisitive nature, an interest in finding out about
the life perspectives of the individual and not making
assumptions.
•
An understanding of their own culture and responses to
loss and how this can impact on how comfortable they feel
supporting someone whose experiences are culturally
different.
The Role of the Practitioner: Using the
RRL as a Framework for Practice
Often the psychological and emotional care aspects of
assessment and care planning are approached with no
rationale, frame of reference or model to guide what is
considered [28]. The theoretical principles of the RRL, and
the AAG/AHC scales, can provide a framework which
supports practitioners to:
• Use the Range of Response to Loss model as a
“compass” for understanding grief and how it is likely to
be expressed. Listening to the way in which people share
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