Strategies for Teaching Loss,Grief, and Bereavement

Marianne LaPorte Matzo, PhD, APRN, BC, FAANDeborah Witt Sherman, PhD, APRN, BC, FAANKaren Lo, MS, RN, CRNHKathleen A. Egan, MA, RN, CHPNMarcia Grant, DNSc, RN, FAANAnne Rhome, MPH, RN

Teaching loss, grief, and bereavement to nursing students should bean interactive process to stimulate critical thinking and address theaffective domain of learning. Lecture as a teaching methodologymay be the easiest to prepare and deliver; however, used alone, it isineffective in identifying perceptions, fears, and issues related todying and death. Personal and professional experiences of loss, grief,and bereavement are central to student’s learning of effective andcompassionate care of the dying patient and their family. Strategiesthat explore such experiences allow students to move forward andfocus on the cognitive retention of content related to loss, grief, andbereavement, as well as the ability to learn related psychomotorskills.The authors discuss pedagogical methods for teaching studentnurses about loss, grief, and bereavement utilizing the End of LifeNursing Education Consortium (ELNEC) curriculum trainingmaterials.

In the last 5 years, numerous projectshave been initiated throughout theUnited States intended to improveend-of-life care, as well as promotinga peaceful, respectful death. Millionsof dollars in funding have beenawarded by the Soros Foundation andthe Robert Wood Johnson Foundationto facilitate the actualization of thesegoals. The wide range of projects thatthey have funded places them as na-tional leaders in the development ofeducational tools for health profes-sionals regarding the provision ofcompetent end-of-life care.

The End of Life Nursing Educa-tion Consortium (ELNEC) is a 3-mil-lion dollar project funded by theRobert Wood Johnson Foundation toinvestigators at the City of Hope Med-ical Center in collaboration with theAmerican Association of Colleges ofNursing. This consortium of nursingorganizations ensures that the ELNECproject brings together importantnursing constituencies and expertclinicians and educators in pallia-tive/hospice care to develop a cur-riculum to improve nursing care at theend of life. The ELNEC curriculumwas developed through the work ofproject consultants with extensiveinput from the Advisory Board and re-viewers. It was developed as a “Trainthe Trainers” course, with the inten-tion that those trained in the ELNECcurriculum would be vital forces in itsdissemination in undergraduate nurs-ing and continuing education pro-grams.

Over a 3-day program, 9 moduleswere presented in didactic and inter-active learning training sessions. Thetopics of the 9 modules address thecritical aspects of end-of-life care, asfollows:

• Module 1: Nursing Care at theEnd of Life;

• Module 2: Pain Management; • Module 3: Symptom Manage-

ment; • Module 4: Ethical/Legal Issues;

NURSE EDUCATORVolume 28, Number 2 pp 71-76© 2003; Lippincott Williams & Wilkins, Inc.

• Module 5: Cultural Considera-tions in End of Life Care;

• Module 6: Communication; • Module 7: Grief, Loss, Bereave-

ment; • Module 8: Preparation and Care

for the Time of Death; and • Module 9: Achieving Quality Care

at the End of Life.

The ELNEC curriculum also in-cludes several common threads inte-grated throughout all of the modules.The themes are as follows: the familyas the unit of care; the important roleof the nurse as advocate; the impor-tance of culture as an influence at theend of life; the critical need for atten-tion to special populations such aschildren, the elderly, the poor, and theuninsured; end-of-life issues impactall systems of care across all settings;critical financial issues influence end-of-life care; end-of-life care is not con-fined only to cancer or AIDS, but

rather is essential across all life-threat-ening illnesses and in cases of suddendeath; and interdisciplinary care is es-sential for quality care at the end oflife.

This article presents some of thestrategies and resources to teach theELNEC module entitled Grief, Loss,and Bereavement. This module ad-dresses the challenging aspects ofloss, grief, and bereavement of pa-

NURSE EDUCATOR Volume 28, Number 2 March/April 2003 71

Authors’ affiliations: Union Institute andUniversity, Cincinnati, Ohio (Dr. Matzo);New York University, New York, NY (Dr.Sherman); The Hospice Institute of theFlorida Suncoast, Largo, Fla (Ms. Lo andEgan); City of Hope National Medical Cen-ter, Duarte, Calif (Dr. Grant), American As-sociation of Colleges of Nursing, Washing-ton, DC (Ms. Rhome).

Corresponding author: Marianne La-Porte Matzo, PhD, APRN, BC, FAAN, POBox 342, Goffstown, NH 03046-1342(mmatzo@tui.edu).

tients and their families, as well as theloss experiences of nurses them-selves. The 3 key messages thatshould be communicated to learnersare as follows: (1) Even with the pro-vision of excellent palliative care,losses—of one’s own life, or that of aloved one—create intense grief. (2)Palliative care can facilitate adapta-tion to loss and greatly relieve dis-tress and suffering. (3) Nurses also re-quire support for their own grief incaring for the terminally ill. The ob-jectives for this module are that par-ticipants will define loss, mourning,grief, and bereavement; distinguishbetween anticipatory grief, normalgrief, complicated grief, and disen-franchised grief; describe the tasks ofgrief and list factors that may signifi-cantly affect the grief process; pro-vide interventions that may be appro-priate to facilitate normal grief; definepersonal death awareness and cumu-lative loss associated with profes-sional caregiving; and identify sys-tems of support the nurse can accessto assist in coping with death anxietyand loss. This article includes peda-gogical techniques and key contentareas (Figure 1) for including the de-velopment of coping and supportskills for loss, grief, and bereavementin the undergraduate nursing curricu-lum.

Loss, Grief, andBereavement Competenciesin Nursing EducationLoss, grief, and bereavement can af-fect the patient, family, and nurse.Each survivor and professional care-giver experiences grief in their ownway, and with their own coping skills.Grief is experienced within the con-text of the individual’s cultural norms,belief systems, faith systems, and lifeexperiences, and affects survivorsphysically, psychologically, socially,and spiritually.1

The American society is a death-denying society. As such, Americansoften deny the need to express griefand feel the pain that accompanies aloss, which are both beneficial tohealing. The nurse’s role includes fa-cilitating the grief process by assess-ing grief and assisting the survivor tofeel and express the loss, and com-plete the tasks of the grief process.

Nurses should utilize an interdiscipli-nary team (nurses, social workers,volunteers, grief and bereavementcounselors, physician) to facilitate the

72 NURSE EDUCATOR Volume 28, Number 2 March/April 2003

Grief, Loss, and Bereavement Module Content

Introduction

1. Patient, family, and nurse2. Nurse’s role

The Grief Process1. The process2. Loss, mourning, grief and bereavement

a. Lossb. Mourningc. Griefd. Bereavemente. Cultural considerations

3. Types of griefa. Anticipatory griefb. Normal griefc. Complicated grief

iii. Typesiii. Risk factorsiii. Complicated reactions

1. Disenfranchised grief2. Children’s grief

a. Based on age and developmental levelb. Symptoms of grief in younger childrenc. Symptoms of grief in older children

i. Stages and tasks of griefii. Factors affecting the grief process

Grief Assessment1. Who2. When3. Nursing assessment of grief

a. Type of griefb. Grief reactionsc. Stages and tasks of griefd. Factors that affect the grief processe. Assessmentf. Bereavement assistance

Bereavement Interventions1. Plan of care2. Attitude3. Cultural practices4. What to say5. Anticipatory grief

a. Emotional supportb. Encourage verbalizationc. Assist with role change, education and/or resourcesd. Encourage life reviewe. Educate the patient/family about dying processf. Encourage patient/family to complete unfinished businessg. Provide presence, active listening, touch and reassuranceh. Decrease sense of loss

6. Grief interventionsa. Presence, active listening, touch, silenceb. Identify and facilitate support systemsc. Use of bereavement specialists, bereavement resourcesd. Normalizing grief process and individual differencese. Actualizing the loss and facilitating living without the deceasedf. Identifying and expressing feelingsg. Disenfranchised grief-acknowledgmenth. Public funerals, memorial services, rites, rituals and traditions; private ritualsi. Spiritual carej. Identifying need for additional assistance and making referrals

7. Bereavement interventions for children and parents8. Completion of the grieving process

Figure 1. Grief, Loss, and Bereavement Module Content. (Continues)

grief process of patients experiencinglife-limiting illness as well as that oftheir family. Each discipline can con-tribute expertise to the plan of care

for those experiencing grief and be-reavement.

The definitions, assessment, andinterventions related to loss, grief,mourning, and bereavement are fun-damental in most nursing curricula andcomprehensively outlined in thisELNEC module (Figure 1). Althoughthese foundations are at least mini-mally laid in most undergraduate nurs-ing curricula, the issues of death anxi-ety, grief, and cumulative lossesexperienced by nurses throughouttheir careers should also be addressed;they are the focus of this article. Inmost healthcare settings, nurses carefor patients with life-threatening ill-nesses and experience the death ofmany patients over the course of theirprofessional careers. Working withdying patients can trigger the student’sawareness of personal losses and fearsabout their own death and mortality.Death anxiety can occur when the stu-dent nurse is confronted with theirfears about death and has few re-

sources or support systems to exploreand express thoughts and emotionsabout dying and death.2

When overwhelmed by deathanxieties, the student may use de-fenses to allay fears, including focus-ing only on physical care needs oftheir patients, evading emotionallysensitive conversations with patientsand families, speaking only whenspoken to by patients, and talkingonly about topics that are comfortablefor them. These behaviors result inemotional distancing, avoidance, andwithdrawal from dying patients andtheir families at a time when patientsat the end of life need intensive inter-personal care and active involvementfrom their nurse. Student nursesshould have educational opportunitieswhere they become aware of theirown feelings, responses, and reac-tions to death so they can providetouch; convey caring, acceptance, andrespect for patients and families; andcommunicate effectively.3

Cumulative loss is a succession oflosses experienced by nurses whowork with patients with life-threaten-ing illnesses and their families, oftenon a daily basis. Nurses can experi-ence anticipatory and normal grief be-fore and after the death of a patient.Not only is loss painful, but when thenurse is exposed to death frequently,he/she may not have time to resolvethe grief issues of one patient beforeanother patient dies. Nurses new toworking with dying patients need tobe emotionally and spiritually adept atcaring for the terminally ill.4

According to Vachon,4 there are 4primary factors that influence thenurse’s emotional and spiritual refor-mation in providing competent nurs-ing care to terminally ill patients. First,the educational process influencesearly professional development so-cialization. In the past, healthcare pro-fessionals were often told to controlemotions and to distance themselvesemotionally from patients and fami-lies. As educators, we must help ourstudents to realize that patients at theend of life require intense interper-sonal involvement and compassionatecare. Verbalizing feelings and express-ing emotions helps the nurse processloss and grief and provide quality careat the end of life.

Second, the students’ past experi-ences with death on a personaland/or professional level and possi-ble unresolved grief issues can influ-ence their professional ability to copewith the care of dying patients andtheir families. Third, the student nurseshould be aware of anticipated andongoing changes in their lives. Lifechanges may include a death in thefamily, caring for elder parents, sepa-ration from loved ones, children leav-ing home, divorce, and illness. Thesechanges may signify losses, triggergrief responses, and make it difficult for them to provide effectiveand compassionate end-of-life care.Lastly, the presence or absence ofsupport systems can influence thestudents’ ability to move through thestages of adaptation. Emotional sup-ports provided by peers, family,coworkers, and instructors greatly in-crease the capacity to adapt to andcope with the care of the dying pa-tient and their family and the result-ing bereavement issues.

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The Nurse: Death Anxiety, Cumulative Loss, Grief

1. Death anxiety2. Defenses3. Personal death awareness4. Cumulative loss5. Stages of adaptation for the nurse6. Factors influencing the nurse’s adaptation process

a. Professional trainingb. Personal death historyc. Life changesd. Support systems

7. System of supporta. Balanceb. Assessing support systemsc. Formal support systemsd. Preplanned gatheringse. Postclinical debriefingf. Ceremonies, programsg. Informal supporth. Instructor supporti. Spiritual supportj. Educationk. Individual facilitated support

vvi. Acknowledge limitationsv viii. Ask for helpv viii. Journal writing

viv. Exercisev viv. Relaxation

iivi. Socializationivii. Hobbiesviii. Play

Conclusion

End of Life Nursing Education Consortium (ELNEC) Course Syllabus, copyright ©2000 American Association of Colleges of Nursing and the City of Hope NationalMedical Center.

Figure 1. (Continued) Grief, Loss, and Bereavement Module Content.

Teaching and SupportStrategies

Consequently, faculty should incorpo-rate strategies necessary to develop asystem of support as a part of profes-sional role development. These strate-gies include finding balance, develop-ment of support systems, andeducation in end-of-life care. Balanceis the ability to find equilibrium be-tween the stresses of providing com-passionate, quality care to dying pa-tients and their families, and findingthe personal satisfaction and rewardsin this work. The purpose of a systemof support is to reduce the effects ofdeath anxiety and cumulative loss byassisting the student nurse in explor-ing and expressing feelings associatedwith anxiety, loss, and the grief expe-rienced when caring for dying pa-tients and their families.4

Utilization of formal support systems can include preplanned gath-erings where students can expressfeelings in a safe environment. Post-clinical debriefing after the death canhelp relieve anxieties by allowing thestudent to relate the emotion to theexperience and explore and expressfeelings related to dying and death.Ceremonies and programs to ac-knowledge and express grief, such asplanned memorial services for all pa-tients who have died, are formal sup-port rituals that the student nurse canshare, not only with each other, butalso with the professional nursingstaff and bereaved family members.

Informal support is one-to-onesharing of experiences with the nurs-ing staff, peers, instructor, pastoral careworkers, and physicians. Instructorsupport occurs via the presence of asupervisor, mentor, or faculty duringthe care of the dying, when a familymember visits, and/or at the time ofthe patient’s death. This supportivepresence can greatly decrease anxietyand provide immense support to thestudent nurse; the student will oftenfind comfort in knowing she/he is notalone. Spiritual support from pastoralcare workers and/or spiritual advisorscan assist the student in spiritual re-flection, exploration, and spiritual re-plenishment. Failure to effectively sup-port a student’s grieving can be a factorin attrition. Lastly, student nurses can-not practice what they do not know;

knowledge and skills in end-of-lifecare promote competence and self-confidence, which decreases anxiety incaring for patients at the end of life andsupports them through the process ofloss, grief, and bereavement.

Recognizing the cultural, educa-tional, and age diversity of nursingstudents, and modeling compassion-ate care are vital to the success oflearning experiences. The didacticand experiential presentation of theELNEC teaching materials is aug-mented with literature, exemplars,and case studies. As faculty, our ex-perience has taught us that experien-tial learning and role modeling areequally as important as the didacticcontent that is presented.

At the very start of the ELNEC ed-ucational session, participants are re-minded that there will always besomeone in their audience who hasexperienced a recent death and/ormay have unresolved grief issues. Toillustrate, participants are asked toraise their hands in response to a se-ries of questions (with the option ofparticipating or not). These questionsinclude whether they have lost a closefriend or family member to death,how long ago this death was, howmany are experiencing an anniversaryof the death, and how many weretaught in their basic educational pro-gram about the grief process.

Throughout the didactic presenta-tion various teaching strategies areutilized. During the discussion aboutchildren’s grief, The Fall of Freddie theLeaf by Leo Buscaglia5 is read, startingfrom the section about “fall” to theend of the story. This story can raisestrong emotional reactions in learners,and faculty should be prepared tosupport students who have an emo-tional response to the story.

When the focus of the contentturns to the nurse’s grief and bereave-ment issues, interventions for facultyto help the beginning nursing studentprocess these feelings is discussed.Figure 2 offers specific suggestionsthat faculty can use to support the stu-dent through the learning process.

Cumulative loss exercises mayprovide exploration and expression ofthe feelings associated with loss andgrief. A loss exercise (Figure 3) can bea powerful methodology to assist theparticipant in identifying these feel-

ings and evoke compassion and em-pathy for those who have experi-enced loss. In a loss exercise, partici-pants are asked to identify and makea list of things, people, hobbies, bodyparts, and/or values that are importantto them. Then, a scenario of a patientwith a life-limiting illness is read. Atintervals when the patient experi-ences decline, the participant is askedto cross out several items, eventuallyleaving them with nothing on thepage. It is important for a discussionsession to follow this exercise. Insmall groups, students should beasked to try to get in touch with theirmost predominant feelings during theexercise. What was it like to have toselect and cross off items? What didthey cross out first? Last? Was it harderto cross out as they went through theexercise, or did they give up? Eventhough this is a paper-and-pencil ex-ercise related to loss, students con-ceptually experience loss as it relatesto them and can better connect withtheir patient’s experiences.

The loss history and the loss ex-ercise can trigger emotions in partici-pants and memory of resolved, unre-solved, or imagined losses. Adultstend to prefer an informal, nonthreat-ening learning environment, andsometimes loss exercises can bethreatening. It is crucial that a quali-fied leader with strong grief and be-reavement background and groupprocess skills facilitate this exercise tominimize associated threats. These ex-ercises should be introduced to par-ticipants with an understanding of theresponses that might be felt, and withthe knowledge that someone will sup-port them if needed. Adequate de-briefing of thoughts, feelings, and atti-tudes should also be done aftercompletion of the exercise.

Case studies provide a morecomplex learning experience; theycan involve patient, family, or sur-vivor grief and bereavement-relatedscenarios. The participant can beasked to do a bereavement assess-ment, identify signs and symptoms ofanticipatory grief, describe losses ex-perienced by a patient, discuss be-reavement interventions, and/or de-termine normal versus complicatedsurvivor grief reactions. A case studyallows the educator to stimulate criti-cal thinking, match the case to the

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goals of the training, and provide acontrolled environment in which theparticipant can practice skills learned.

One case study presented in theELNEC module is about Brenda, a 14-year-old girl who was baby-sitting her

3-year-old brother while her parentsattended a church function. Brendadiscovered her brother had gone out-side and crossed the street, where hewas petting a neighbor’s dog. Brendaran across the street to get him, and

was hit by a truck; she was thrown100 yards and sustained multiple frac-tures, head injury, and extensive in-ternal injuries. Her parents were in-formed on arrival at the ER that herchances for survival were extremelylow. She was taken to the operatingroom, but after 3 hours of surgerywith uncontrollable bleeding and sev-eral resuscitation attempts, she died inthe operating room. Discussion ques-tions for this case study are as follows:How is grief from this sudden deathlikely to differ from grief over a deathresulting from chronic illness? Whatcommunication strategies would behelpful with her parents on their ar-rival at the ER? While she is insurgery? At the time of her death?What care could be provided to thisfamily to facilitate their immediate andlong-term grief?

Storytelling, testimonials, poetry,and pictures can also be used as af-fective-type teaching methodologies.Patient stories related to anticipatorygrief and loss and survivor testimoni-als about how they felt at variousstages in the grief process are helpfulto learners, evoking emotional re-sponses and a connection to real pa-tients and survivors. Stories and testi-monials can be delivered via readingsand videos. Poetry has the added ben-efit of encouraging self-reflection andpromoting critical thinking throughanalysis of the poem. Pictures of thoseexperiencing grief can be powerfulalone, and showing a picture fol-lowed by group discussion can stimu-late critical thinking. Facilitated dis-cussion might include asking thegroup what they think the person isfeeling; this can be a teaching strategyfor nonverbal communication relatedto grief assessment.

Teaching methodologies relatedto grief and bereavement can be usedin preceptor/mentor programs andthe development of clinical compe-tency. In the clinical setting, thelearner can practice facilitating thegrief process, complete a grief andbereavement assessment with a sur-vivor, and sit in or participate in asupport group. Clinical competenciesallow learners to gain knowledge inthe real work setting, at their ownpace and independently. Althoughthese methods are best paired withother classroom-based methodolo-

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Student nurses need support when patients are imminently dying, atthe time of death, and after the death. The following suggestions mayhelp to provide experiences to support them.

• Knowledge about end-of-life care and what to expect during the dyingprocess can promote confidence and decrease anxiety when caringfor a dying patient. Instruct students on the physical, psychosocial,and spiritual signs and symptoms of the dying process, commonquestions asked by patients and families, signs of death, andpostmortem care procedures. Provide practice, preferably throughrole-play, regarding “what to say” to a dying patient and/or thepatient’s family.

• Encourage the student to ask questions at any time.• The student may fear being alone with a dying or dead patient.

Students may fear not knowing what to do or be concerned abouthow they will react. Provide reassurance that someone is alwaysavailable. Simply knowing they are not alone can be enough support.The presence of the preceptor, mentor, or pairing with anotherstudent in the care of the dying can also greatly decrease fear andanxiety.

• The student may feel as though he/she does not have the expertiseto meet the needs of a dying patient. Encourage the student to askfor help as needed. Offer and encourage the support of othermembers of the team, including the social worker, spiritual careprovider, and/or volunteer.

• The student’s first experience of the death of a patient andsubsequent exposure to dying and death can provoke deep emotion.Provide presence and active listening before, during, and after thedeath of the patient.

• Allow time for postclinical debriefing to assist the students inexploration and expression of feelings of anxiety, loss, and grief. Besensitive to the student’s need to tell the story of the death andexpress feelings related to the experience.

• Give the student the opportunity to experience and express feelingsabout the death in his/her own way. Follow the student’s lead inproviding presence after the death. The student may choose toparticipate in group discussion, one-on-one discussion with apreceptor, a peer, mentor, and/or spiritual care provider, and/orchoose self-reflection.

• Remember that tears can be a normal, nonverbal expression offeelings related to loss. Providing a private place for students to crymay be helpful.

• Plan activities that can assist the student in expression of loss andgrief. Activities can include creating and taking part in aceremony/memorial service for patients who have died in their careand/or journaling reactions and feelings about the death of a patient.

End of Life Nursing Education Consortium (ELNEC) Course Syllabus,copyright © 2000 American Association of Colleges of Nursing and theCity of Hope National Medical Center.

Figure 2. End-of-Life Nursing Education Consortium (ELNEC) Grief and BereavementSuggestions for Support.

gies, they are valuable because theyallow for skill practice in the bestlearning environment: the real world.

Conclusion

As of July 2002, 646 nursing facultyparticipants and 277 continuing edu-cation faculty received ELNEC trainingduring a total of 10 courses. The in-

structive and practical presentation ofthe teaching materials related to loss,grief, and bereavement was aug-mented with literature, assessmenttechniques, and case studies. Personaland professional experiences of loss,grief, and bereavement are central tostudent nurses’ learning of effectiveand compassionate care of the dyingpatient and their family. Strategies that

explore such experiences allow par-ticipants to move forward and focuson the cognitive retention of contentrelated to loss, grief, and bereave-ment, as well as the ability to learn re-lated psychomotor skills.

Nursing care and responsibilities tothe dying patient and their family donot end with the death of the patient.Potential loss and grief issues should beassessed upon admission of the patient,and bereavement care should continueafter their death. Like all healthcare pro-fessionals, nurses must recognize andrespond to their own grief in order toprovide quality palliative care to thedying patient and their family.

We encourage educators in allsettings to attend an ELNEC trainingcourse to learn more about all 9 of theend-of-life nursing education topics.The ELNEC Web site (www.aacn.nche.edu/elnec/) will also help edu-cators gain information about futureELNEC courses and to identify othersin their state who have been ELNECtrained and to collaborate with themin planning educational activities.

Acknowledgment

This article is based on the End of LifeNursing Education Consortium Project(ELNEC), which is supported by a grantfrom the Robert Wood Johnson Foun-dation to the American Association ofColleges of Nursing (Geraldine Bed-nash, PhD, FAAN, Principal Investiga-tor) and City of Hope National MedicalCenter (Betty Ferrell, PhD, FAAN, Prin-cipal Investigator).

References

1. Potter M. Loss, suffering, bereavementand grief. In: Matzo ML, Sherman DW,eds. Palliative Care Nursing: Quality Careto the End of Life. New York, NY:Springer; 2001:275-306.

2. Harper B. Death: The Coping Mechanismof the Health Professional. Greenville, SC:Southeastern University Press; 1994.

3. Rando AT. Grief, Dying and Death: Clini-cal Interventions for Caregivers. Cham-paign, Ill: Research Press; 1984.

4. Vachon M. The nurse’s role: the world ofpalliative care nursing. In: Ferrell BR,Coyle N, eds. Textbook of Palliative Nurs-ing. New York, NY: Oxford UniversityPress; 2001:647-662.

5. Buscaglia L. The Fall of Freddie the Leaf.Thorofare, NJ: Slack; 1982.

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First, list...• your 5 most prized possessions (material things)• your 5 favorite activities• your 5 most valuable body parts• the 5 values that are most important to you• the 5 people whom you love the most

Next, as I tell you this story, cross out as many items on your list as I tell you.Imagine it is a lovely spring day-you know the kind, one of the first days when the snowhas melted and the flowers are blooming up north or down here the temperatures arecomfortable and the birds are singing. You are young and successful and happy withyour life.You step in the shower anxious to get on with the day. While you soap yourselfyou discover a small lump on your neck and another in your breast.

Cross Out Two ItemsProbably swollen glands from your recent cold (premenstrual changes) you think, andignore it and go on with your life. Two and one-half weeks later it is still there.

Cross Out Two ItemsProbably cold returning-you’ve been busy, not resting.You’ve had cystic breasts, you ra-tionalize, and life goes on; but, something keeps nagging at you so you make an ap-pointment to see your doctor.

Cross Out One ItemThe doctor, after examining you and ordering a mammogram, says, “I’m sure it’s noth-ing but I’d like to biopsy it just in case, so we’ll schedule you for surgery the end of theweek.”

Cross Out Three ItemsYou decide to have a biopsy (frozen section) done, and to go ahead with a mastectomyif the lump is malignant (though everyone assures you that it is not).

Cross Out Two ItemsYou pull your way up through the fog in the recovery room and feel the mass of ban-dages on your chest. Your worst fears have been confirmed!

Cross Out Four ItemsYou recover and have radiation treatment, just in case.

Cross Out Two ItemsSlowly you recover your strength and life returns to normal-almost. It is spring again, 2years later.You have a cold.You ignore it as usual but it doesn’t go away; one morning,to your surprise, you find it difficult to breathe.

Cross Out Two ItemsLung metastasis. You feel your world turn upside down again. That wonderful defensemechanism of denial must be let go. You begin chemotherapy and are very sick, weak,and angry.You lash out at your family, doctors, and friends.You want to live but you can-not eat.

Cross Out Two ItemsOne morning you do not have enough energy to sit in a chair; the doctor tells you thechemotherapy is not working and he wants to stop it.

Cross Out Three ItemsIt seems like life goes on around you in slow motion. Days and nights blur. How odd youthink, starring at your bony hand, as your body deteriorates your spirit seems to be with-drawing also. You wonder if it’s the pain medication or if it’s the first taste of death, butyou do not have the energy to ask anyone.

Cross Out The Last Two Items

Figure 3. Loss Exercise. Reprinted with permission from Fauser M, Lo K, Kelly R,Trainer Cer-tification Program [Manual]. Largo, FL: The Hospice Institute of the Florida Suncoast, 1996.