Grief, Loss, and End-of-Life Care
The Kubler-Ross stages of grief, denial, anger, bargaining, depression, and acceptance, are not a sequence, so a client who is angry is not behind one who has reached acceptance, and telling a client to move on or be at a different stage is a wrong answer. At the end of life the goal shifts from cure to comfort: treat pain aggressively, and fear of addiction is never a reason to withhold pain medication from a dying client.
Free sample lesson: depression and grief, including what to say and how to support the family.
From the Intensive NCLEX Course. This lesson is a free sample: watch it with a free account.
The stages of grief
Kübler-Ross described five responses: denial, anger, bargaining, depression, acceptance.
The most important thing to know: these are not a sequence.
People move between them, skip some, and return to earlier ones. There is no correct order and no timetable. A client who is angry is not “behind” a client who has reached acceptance.
A wrong answer is telling a client they should be at a different stage, or that they need to “move on.”
Recognizing them in questions:
- Denial — “The test must be wrong.”
- Anger — “Why me? This is the doctors’ fault.”
- Bargaining — “If I can just see my daughter graduate…”
- Depression — withdrawal, sadness, crying, loss of interest
- Acceptance — calm, making plans, putting affairs in order
What to say
Therapeutic:
- “Tell me what you’re feeling.”
- “I’ll sit with you.”
- Silence — often the best answer
- “That sounds very hard.”
- “What would be most helpful right now?”
Never say:
- “I know how you feel.” — You do not.
- “He’s in a better place.” — Imposes your beliefs.
- “At least she didn’t suffer.” — Minimizes.
- “You need to be strong.” — Denies them permission to grieve.
- “Everything happens for a reason.”
- “You’ll feel better with time.”
Presence matters more than words. Sitting quietly with someone is a real nursing intervention and is frequently the correct answer.
End-of-life care
The goal shifts from cure to comfort.
- Treat pain aggressively. At the end of life, comfort is the priority.
- Fear of addiction is not a reason to withhold pain medication from a dying client. This is heavily tested.
- Give medication regularly, not only when the client asks
- Assess pain even in clients who cannot speak — look at facial expression, restlessness, guarding, and vital signs
Common symptoms and care:
- Noisy breathing from secretions — reposition, mouth care, medication as ordered. Suctioning often causes more distress than it relieves. Explain to the family that it usually does not distress the client.
- Shortness of breath — position upright, a fan moving air, oxygen, opioids as ordered
- Dry mouth — frequent mouth care, ice chips, lip balm
- Reduced eating and drinking — this is normal at the end of life. Forcing food and fluid can cause discomfort. Teach families this gently, because not feeding someone feels wrong to them.
- Restlessness — check for pain, a full bladder, or constipation first
Hearing is often the last sense to go. Encourage the family to keep talking to the client, and always speak to the client yourself as if they can hear.
Supporting the family
- Allow them to be present as much as they wish
- Explain what is happening and what to expect
- Let them help with care if they want to
- Allow time with the body after death
- Respect cultural and religious practices around death — ask, do not assume
- Offer to contact spiritual support
Anticipatory grief — grieving before the death — is normal and healthy.
Hospice and palliative care
Palliative care — comfort-focused care that can be given at any stage of a serious illness, alongside treatment aimed at cure.
Hospice — comfort care when curative treatment is stopped, usually with a limited expected prognosis.
The distinction is commonly tested: palliative care does not require stopping treatment. Hospice generally does.
Advance directives and DNR
See Article 51 for the full detail. The key points:
- A DNR means do not attempt resuscitation. It does not mean less care.
- Comfort, pain relief, hygiene, and dignity continue fully
- An able adult can change their mind at any time
After death
- Follow facility policy and any cultural or religious requirements
- Ask the family what they need
- Handle the body with respect
- Provide privacy
- Offer bereavement resources
Caring for yourself
Nurses grieve too. Repeated loss without support leads to burnout and compassion fatigue.
Seeking support is professional, not a weakness. This appears in questions about nurse wellbeing.
The short version
- Grief stages are not a sequence. Never tell a client where they should be.
- Silence and presence are real interventions
- Never say “I know how you feel”
- Treat pain aggressively. Addiction fear is not a reason to withhold.
- Reduced eating at the end of life is normal — do not force
- Hearing is the last sense to go
- Palliative care can happen alongside treatment. Hospice generally does not.
End-of-life protocols and hospice eligibility criteria vary. Follow current guidelines and facility policy.
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Frequently asked questions
Common follow-up questions on Psychosocial & Mental Health.
Are the stages of grief a fixed order?
No. People move between them, skip some, and return to earlier ones, so there is no correct order and no timetable. A wrong answer is telling a client they should be at a different stage or that they need to move on.
What should a nurse say to a grieving client?
Therapeutic responses include inviting the client to say what they are feeling, offering to sit with them, and acknowledging that something sounds very hard. Silence is often the best answer, and presence matters more than words. Never say I know how you feel, he is in a better place, at least she did not suffer, or you need to be strong.
How is pain managed at the end of life?
Treat pain aggressively, because comfort is the priority, and fear of addiction is not a reason to withhold pain medication from a dying client, a point that is heavily tested. Give medication regularly rather than only when the client asks. Assess pain even in clients who cannot speak by looking at facial expression, restlessness, guarding, and vital signs.
Is reduced eating and drinking normal in a dying client?
Yes, reduced eating and drinking is normal at the end of life, and forcing food and fluid can cause discomfort. Teach families this gently, because not feeding someone feels wrong to them. Noisy breathing from secretions is managed with repositioning and mouth care, since suctioning often causes more distress than it relieves.
What is the difference between palliative care and hospice?
Palliative care is comfort-focused care that can be given at any stage of a serious illness, alongside treatment aimed at cure, and it does not require stopping treatment. Hospice is comfort care when curative treatment is stopped, usually with a limited expected prognosis. The distinction is commonly tested: palliative care can happen alongside treatment, while hospice generally does not.
Sources and references
- Potter PA, Perry AG, Stockert PA, Hall AM. Fundamentals of Nursing. 10th ed. Elsevier; 2021; Chapter: Loss and Grief.
- Harding MM, Kwong J, Hagler D, Reinisch C. Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 12th ed. Elsevier; 2023; Chapter: Palliative and End-of-Life Care.
Reviewed by the NCLEXPace team, October 2026.
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