Dying, death, and grief. Helping patients and their families through the process.

When a patient has terminal illness and death is imminent, grief is a normal reaction. Primary care physicians can help patients and their families by talking with them about the five stages of grief (denial, anger, bargaining, depression, and acceptance), providing grief counseling and appropriate pharmacotherapy, and being supportive. Grief often manifests with features similar to those of depression, and it is critical for the clinician to distinguish between the two. One distinguishing feature is that self-esteem in the grieving person is usually uncompromised, whereas a depressed person often has decreased self-esteem. Physicians should also watch for signs of mood disorders or abnormal grief. When grief is present more than 2 months after a loss, a diagnosis of major depression should be considered. Dysfunctional grief accompanied by severe depression and suicidal intent generally calls for psychiatric referral, hospitalization, or both.