Counseling/Pastoral Care

American Journal of Hospice

& Palliative Medicine®
Palliative Care Caregivers’ Grief Mediators: 1-8
ª The Author(s) 2015
Reprints and permission:
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DOI: 10.1177/1049909114565660
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Alexandra M. Coelho, MD1, Mayra A. Delalibera, MD2,

and António Barbosa, PhD1

Abstract
The aim of the study is to identify the mediators of complicated grief in a Portuguese sample of caregivers. Grief mediators were
prospectively evaluated using a list of risk factors completed by the palliative care team members, during the predeath and
bereavement period. More than 6 months after the death, we applied PG-13 to diagnose prolonged grief disorder (PGD). The
sample was composed of 64 family caregivers. Factors associated with PGD were insecure and dependent relationship, unre-
solved family crisis, and the perceived deterioration and disfigurement of the patient. The results show relational factors are rel-
evant, but we must consider the reciprocal influence among factors, as well as their impact on specific symptoms.

Keywords
grief, mediators, risk factors, caregivers, palliative care, prospective study

Introduction seem to be a significant mediator in spouse loss: widowhood was

A substantial number of family caregivers of seriously ill
patients are at risk of developing symptoms of complicated grief
following the patient’s death.1 The early identification of those
at risk of developing grief complications is useful as a main indi-
cator of the individual vulnerability, so it became a current prac-
tice in palliative care, allowing a preventive intervention, as well
as the rational allocation of resources in bereavement support.2
Many authors3-6 aimed to identify the personal, interpersonal,
and situational mediators that affect the bereavement outcomes.
Based on the most recent conceptualization of Stroebe and
Shut,7 we developed a comprehensive classification of grief
mediators applied to caregivers’ population which distinguishes
between specific and general factors. Specific ones are related to
characteristics of loss; general factors do not result from loss, but
from personal and social causes, and affect the health of the glo-
bal population (eg, depression), although they might, as well,
interfere in grief reaction. The first group includes, on the one
hand, the demographic characteristics of the patients who died
and the relational aspects with the object of loss; on the other
hand, the situational factors specifically related to care-giving
process. The general factors are classified as intrapersonal (demo-
graphic characteristics of bereaved, psychiatric antecedents,
attachment style, way of coping, and personality) and interperso-
nal (family dynamics, cultural, and religious aspects).
Respecting the object of loss, in the specific factors group,
Ringdal et al8 found that the youth of the deceased is the demo-
graphic characteristic that interferes most in the process of grief.
However, the death of a spouse or child has been also strongly
associated with complicated grief.9,10 The relational aspects
associated with anxiety in those who were highly dependent on
their partners; yearning and longing for the deceased spouse was
also correlated with proximity and dependency. This is more evi-
dent in widows who received instrumental support from the
deceased, when compared with the masculine population that
presented the same level of dependency.11
Regarding the situational factors, literature focuses on the
circumstances of death. In case of advanced disease, the vul-
nerability comes from the insufficient communication that hin-
ders the awareness of the impending death.12,13 Taking into
account the importance of quality of end-of-life care, place
of death also becomes an important mediator.14 The death in
context of hospice is associated with a better outcome com-
pared to intensive care unit.15 The perception of medical neg-
ligence was equally related to difficulties in grief due to the
anger and revolt that it causes on the bereaved person.16
Beyond that, caregivers’ grief is affected by the physical and
emotional effort dispended during patient’s assistance.17-21 The
distress level is associated with the perception of increased
1
Palliative Care Unit, Hospital Santa Maria, Academic Center of Studies and
Intervention in Grief, Bioethics Center, Faculty of Medicine, University of
Lisbon, Lisbon, Portugal
2
Palliative Care Unit, Hospital Santa Maria, Higher Institute of Applied
Psychology, Lisbon, Portugal
Corresponding Author:
Alexandra M. Coelho, Centro de Bioética da Faculdade de Medicina da
Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal.
Email: alexandra.moura.coelho@gmail.com

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2 American Journal of Hospice & Palliative Medicine®
difficulty in assistance to the patient, considering aggravating
factors such as the patient’s problematic behavior, the intensity
of care, the long duration of the disease,22 and the depletion of
the personal gains of the caregiver role.23,24 During bereave-
ment, many caregivers present intrusive thoughts related to the
end-of-life decisions25 and the constant perception of the
patient’s physical declination.26 Other situational risk factors
are the interpersonal conflicts that affect family cohesion, some
of them resulting from the difficulty in combining the caregiver
role with other family and social activities.27,28
Concerning the general factors, we start by mentioning the
intrapersonal dimension. The gender differences have been
widely studied. The female gender is often associated with
more intense manifestations of grief.8,29,30 Another demo-
graphic characteristic that influences the process of grief is the
age of the deceased. In adult life, the elderly widowers have
been identified as the most vulnerable.8,30
The predisposition to develop maladaptive patterns of grief
is also related to the presence of antecedents, such as psychia-
tric disorder history,31 separation experiences in infancy,32 pre-
vious significant losses,30 and the anxious-ambivalent style of
attachment.33 Concerning personality characteristics, neuroti-
cism assumes particular relevance in the grief process.34 Imma-
ture defensive styles, such as denial and distortion of external
reality, are considered maladaptive in grief,35 as well as avoi-
dant36 and ruminative strategies of coping.37
In the interpersonal factors group, the lack of family support
was identified as the best predictor for maladjustment to loss.38
Dysfunctional families, characterized by low cohesion, high con-
flict, and reduced capacity for emotional expression, have been
associated with worst adjustment to loss and psychosocial mor-
bidity.39-41 The family conflicts related to end-of-life decisions,
discussions, disagreements, insults, and resentments between
relatives were highlighted as an important agent of grief compli-
cations.41 An additional aspect concerns the cultural and religious
influence. There is evidence that sharing memories of the
deceased with others, the use of symbolic objects and the practice
of meaningful rituals are facilitators of adaptation to loss.42
Although there is much research on grief mediators in gen-
eral bereaved population, few studies assessed prospectively
the population of caregivers in palliative care. Kelly et al43
evaluated family carers referred to a palliative home care ser-
vice previous to the death and 4 months after it. Their results
stressed that the relationship with the patient was a significant
predictor of grief symptoms, along with other factors, such as
the greater number of adverse life events, carer’s coping
responses, past bereavement and separation experiences, and
greater severity of patient’s illness at the time of palliative care
referral. Another study assessed caregivers14 who cared for
terminally ill patients with cancer in the hospice ward or who
received shared-care consultation. The interviews were carried
out before the death and between 6 and 14 months afterward.
The results demonstrated that spouse and parent–child relation-
ship, female gender, shorter caring duration, no religious belief,
unavailable family support, history of mood comorbidity, no
medical disease history, and no hospice ward stays were
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significant determinants of complicated grief for caregivers.
A recent study44 followed the caregivers admitted to palliative
care services since the stage prior to death until 6 and 13
months after it. They identified, as risk factors for prolonged
grief symptoms, widowhood, dependency relationship with the
deceased, high impact of caring on schedule, poor family func-
tioning, and low levels of optimism.
The results from these studies are not sufficiently congruent to
identify the main mediators of grief complications in the pallia-
tive caregiver population. Moreover, according to Worden,5 the
predictors of complicated grief in a population cannot be general-
ized. This author suggests the use of a preventive model, based on
descriptive studies, in order to establish more accurately the indi-
cators of increased risk of complicated grief for each population.
This pilot study is unique in its prospective assessment of family
carers of patients referred to a palliative care service in Portugal.
Therefore, the main objective of the present study is to describe
the prolonged grief mediators in a Portuguese sample of care-
givers whose relatives were accompanied in palliative care. A
second aim is to verify whether specific risk factors are associated
with different grief symptoms. Finally, we intend to describe the
mutual relationship between risk factors. We hypothesize that,
besides relational factors, there are other situational factors,
related to care giving process, that contribute differentially to pro-
longed grief manifestation. Besides, we assume that these vari-
ables combine each other to create a complex influence system
that determines the grief trajectories.
Method
Sample and Setting
It has been constituted a convenient sample of caregivers of
patients admitted to the Palliative Care Unit of the Hospital of
Santa Maria in a 9-month period. The inclusion criteria were
older than 18 years, be a relative of a patient accompanied in pal-
liative care, and be informally involved in the care of the patient.
Instruments
The assessment of grief mediators was performed using a list of
grief mediators. To our knowledge, there is no self-report assess-
ment tool to easily identify the individual vulnerability and
describe risk factors for grief complications. Ellifritt45 developed
a Bereavement Risk Questionnaire to rate 19 possible risk fac-
tors, according to bereavement professionals, in a nationwide
study. A modified version of that list was created for this study,
based on empirical data from narrative review of literature, to
assess individual risk to grief complications. We used proxy
report from health professionals taking in account Ellifritt’s posi-
tion that health professionals are able to identify risk factors.
Besides, we assume that family caregivers, facing the terminal
illness of the patient, are affected by emotional disturbance, so
they lack insight about many problems that may interfere in grief
process (eg, relational aspects with the patient, denial/avoidance
mechanisms, and previous unresolved losses).
Coelho et al 3

Based on the classification described earlier (specific Table 1. Demographic Characterization.

and general factors), the risk factors were distributed in the
Participants (n ¼ 64) Patients who died
following categories: specific factors: (1) object of loss: demo-
graphics of deceased, kinship, relational aspects (eg, ambiva- Age, mean (SD) 58.20 (14.07) 69.07 (10.85)
lence, dependency, high-intensity relationship, and insecure Amplitude 15-84 40-89
relationship) and (2) loss circumstances, for example, uncon- Gender, n (%)
trolled symptoms, prolonged disease, dysfunctional relation with Male 11 (17.2) 33 (51.6)
Female 53 (82.8) 31 (48.4)
professionals, concurrent stressors; general factors: (1) intraper-
Marital status, n (%)
sonal factors, for example, youth of deceased, psychopathological Single 5 (8.3) 0 (0)
antecedents, denial/avoidance coping mechanisms, previous Married 20 (33.3) 46 (71.9)
unresolved grief, lower resistance to stress, reduced expression Widower 34 (56.7) 15 (23.4)
of feelings and (2) interpersonal factors, for example, lack of Divorced 1 (1.7) 3 (4.7)
social support, presence of children at home, family conflicts, Kinship, n (%)
impossibility to accomplish religious rituals. The mediators were Partner 33 (51.6)
Offspring 20 (31.2)
evaluated in a dichotomous scale (present/absent).
Parent 2 (3.1)
To assess prolonged grief disorder (PGD), we used the Brother 3 (4.7)
PG-13, developed by Prigerson et al,46 validated to Portuguese Others 6 (9.4)
population by Delalibera et al47 It consists of 13 items, each
expressed in a Likert-type symptom frequency scale, ranging Abbreviation: SD, standard deviation.
from 1 (almost never) to 5 (several times a day), for example,
‘‘in the past month, how often have you felt yourself longing or Table 2. Circumstances of Illness and Death.
yearning for the person you lost?’’ ‘‘have you had trouble
Time since diagnosis n (%) Months after death
accepting the loss?’’ except for the answers to items 2 and
13, which are dichotomous (categorized as yes/no), for exam- Until 6 months 22 (40.0) Mean (SD) 7.09 (2.97)
ple ‘‘have you had the experience at least daily, for a period 6-12 months 10 (18.2) Mode 6.00
of at least 6 months?’’ and ‘‘have you experienced a significant 1-2 years 5 (9.1) Amplitude 6-18
reduction in social, occupational, or other important areas of 2-3 years 8 (14.5)
More than 3 years 10 (18.2)
functioning (eg, domestic responsibilities)?’’ Collectively,
these items are a set of symptoms and signs (feelings, thoughts, Follow-up period in
and actions) in response to the loss of a significant loved one Palliative Care (PC) n (%) Place of death n (%)
who are persistently demonstrated for a minimum period of 6
Single assessment 12 (19.7) Hospital Santa Maria 42 (67.7)
months and are associated with a significant degree of func-
Up to 1 week 9 (14.8) Home 13 (21.0)
tional disorder, such as occupational or social disability. 1-4 weeks 18 (29.5) Palliative Care Unit 2 (3.2)
Detailed information about the course of illness and death was 1-3 months 13 (21.3) Other hospital 4 (6.5)
obtained by consulting the deceased patient’s medical record. 3-6 months 7 (11.5) Other institution 1 (1.6)
6 months-1 year 2 (3.3)

Procedure Abbreviation: SD, standard deviation.

The grief mediator’s inventory was completed by the Palliative

Care Team members during the period of illness. It results from
the informal evaluation of complicated grief mediators, which
is part of professionals’ current practice during assistance in
palliative care, before and after the patient’s death. The fami-
lies were selected to participate in the study only when the team
had sufficient information on the dimensions assessed. The
PG-13 was systematically administered by telephone contact
to all bereaved relatives, 6 months after the death of the patient,
during 8 months. Data concerning diagnosis, length of disease,
and place of death were collected from the patients’ clinical files.
For the statistical analysis, we used the SPSS 20.0 program.
The occurrence rate of grief mediators was assessed based on
percentage value. Given the nominal nature of the variables,
we conducted the chi-square test to relate grief mediators with
PGD scores, with a level of significance set at 0.05. The
research project was approved by the Ethics Committee of the
Santa Maria Hospital (CHLN-HM).
Results
This study’s sample is composed of 64 family caregivers. The
majority is female (82.8%), widows (56.7%), with a mean age
of 58.20. Mostly, they have lost their partner (51.6%) or a par-
ent (31.3%). The mean age of deceased was 69.07 (Table 1).
The patients were almost exclusively oncologic (96.6%), the
most frequent gastric cancer (27.2%). The other patients had
cardiovascular disease. Most patients had a relatively brief
period of disease, considering that in 40% of the cases, there
were only 6 months between diagnosis and death. The time
of assistance in palliative care was, in most cases, until 3
months (81.3%); few patients were followed for a longer
period. The place of death was mostly in hospital (67.7%),
although 21% died at home. The time since death was, on aver-
age, 7.09 months, ranging from 6 to 18 months (Table 2).
In the population of 64 bereaved, a total of 17 (26.6%)
met the diagnostic criteria for PGD. The influence of

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4 American Journal of Hospice & Palliative Medicine®

Table 3. Grief Mediators Frequency and Association With PGD.

% Chi-square P

FEO Specific factors–object of loss

FEO1 High intensity of relationship 37.5 0.64 .42
FEO2 Ambivalent relationship 50.0 0.08 .77
FEO3 Dependency relationship 26.6 4.98 .05a
FEO4 Conflictual relationship 25.0 1.30 .32
FEO5 Youth of deceased 1.6 0.36 1.00
FEO6 Truncated projects/pending issues 23.4 4.05 .09
FEO7 Insecure relationship 28.1 7.05 .01b
FES Specific factors—situational
FES1 Lack of symptom control 35.9 0.42 .51
FES2 Dysfunctional relationship with health professionals 18.8 0.01 1.00
FES3 Death associated with therapeutic obstinacy 9.4 2.39 .18
FES4 Diagnosis difficulties 20.3 0.14 .73
FES5 Process of disease too long 9.4 0.15 .65
FES6 Patient deteriorated, disfigured 29.7 3.56 .05a
FES7 Responsibility for the death 6.3 1.54 .56
FES8 Concurrent stressors/secondary losses 45.3 0.54 .46
FES9 Low socioeconomic level 10.9 0.01 1.00
FES10 Exclusively domestic activities 28.1 0.58 .53
FIA General factors—intrapersonal
FIA2 Psychopathological antecedents 18.8 0.34 .71
FIA3 Previous attempts of suicide 1.6 2.80 .26
FIA4 Early loss of parents 1.6 0.36 1.00
FIA5 Previous unresolved grief processes 14.1 1.71 .23
FIA6 Youth of bereaved 10.9 2.84 .17
FIA7 Very intense reactions of bitterness/anger 23.4 0.46 .51
FIA8 Reduced expression of feelings 40.6 1.45 .22
FIA9 Feelings of guilt 20.3 0.14 .73
FIA10 Low tolerance to stress 23.4 4.05 .09
FIA11 Low self-esteem 34.4 0.47 .49
FIA12 Denial/avoidance mechanisms 21.9 0.76 .49
FIE General factor—interpersonal
FIE1 Lack of social and family support 17.2 0.65 .46
FIE2 Presence of children (<14) at home 17.2 2.07 .26
FIE3 Unresolved family crisis 32.8 4.25 .03a
FIE4 Social isolation 32.8 2.13 .14

Abbreviations: PGD, prolonged grief disorder.

a
Notes a significance value of P  .05.
b
Notes a significance value P  .01.

demographics, causes, and circumstances of illness and death
in the PGD was not significant. This diagnosis is prevalent in
the widows group (53.3%).
Frequency analysis of grief mediators (Table 3) reveals the
prevalence of ambivalent relationship (50%), followed by con-
current stressors and secondary losses (45.3%). The third most
frequent mediator is intrapersonal, namely the reduced expres-
sion of feelings (40.6%). Concerning the interpersonal issues,
the most frequent are social isolation and unresolved family
crises (both with 32.8%). In the factors related to object of loss,
we highlight the high intensity of relationship (37.5%). From
the situational factors, the most prevalent factor is lack of
symptom control (35.9%).
Among all the mediators, those statistically associated with
PGD are insecure pattern of relationship (w2 ¼ 7.05, P ¼ .01),
the dependency relationship (w2 ¼ 4.25, P ¼ .03), the unre-
solved family crisis (w2 ¼ 4.25, P ¼ .03), and the perceived
deterioration and disfigurement of the patient (w2 ¼ 3.56; P
¼ .05; Table 3).
There were reciprocal influences between these mediators
in the group of persons diagnosed with PGD (Table 4). The
results indicate that the dependency relationship is statisti-
cally associated with truncated projects/pending issues (r ¼
.419, P < .001), exclusively domestic activities (r ¼ .332,
P < .001), social isolation (r ¼ .409, P < .001), and low toler-
ance to stress (r ¼ .335, P < .001). This last factor is also
related to insecure relationship style (r ¼ .392, P < .001), as
well as psychopathological antecedents (r ¼ .501, P <
.001), previous unresolved grief processes (r ¼ .447, P <
.001), low self-esteem (r ¼ .498, P < .001), and the presence
of concurrent stressors/secondary losses (r ¼ .408, P < .001).
The image of the patient deteriorated or disfigured is corre-
lated with low tolerance to stress (r ¼ .360, P < .001). The
unresolved family crisis is associated with several factors,

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Coelho et al 5

Table 4. Correlation Between Mediators Within PGD Group. Table 5. Correlation Between Grief Mediators and PG-13 Items.

FEO3 FIA1 FES6 FIE3 FEO3 FIA1 FES6 FIA10 FIE2 FIE4

FIE1 .387a P2 .330a

a a a
FEO6 .419 P5 .385 .325
FES10 .332a P6 .379a .361a
FIE4 .409a .362 a
P7 .344a
FIA10 .335a .392a .360a .477a P8 .404a
FIA2 .501a .346a P9 .375a
FIA5 .447a P10 .324a
FIA11 .498a .545a P11 .396a .366a
FES8 .408a .367a P12 .360a
FEO2 .366a P13 .328 a

FEO4 .365a
Abbreviations: FEO3, dependency relationship; FIA1, insecure relationship
style; FES6, patient deterioration and disfiguration; FIE3, unresolved family
crisis; FIE1, lack of social and family support; FEO6, truncated projects/pending
issues; FES10, exclusively domestic activities; FIE4, social isolation; FIA10, low
tolerance to stress; FIA2, psychopathological antecedents; FIA5, previous
unresolved grief processes; FIA11, low self-esteem; FES8, concurrent stres-
sors/secondary losses; FEO2, ambivalent relationship; FEO4, conflictual rela-
tionship; PGD, prolonged grief disorder.
a moving on (eg, making new friends, pursuing new interests) would be difficult
Notes a significance value of p  .01.
namely, the lack of social and family support (r ¼ .387, P <
.001), social isolation (r ¼ .362, P < .001), low tolerance to
stress (r ¼ .477, P < .001), psychopathological antecedents
(r ¼ .346, P < .001), low self-esteem (r ¼ .545, P < .001), con-
current stressors/secondary losses (r ¼ .367, P < .001), ambiva-
lent relationship (r ¼ .366, P < .001), and conflictual
relationship (r ¼ .365, P < .001).
The results described in Table 5 are related to correlation
values between grief mediators and PG-13 items. A positive
association between the dependency relationship and the symp-
toms of shock (r ¼ .385, P < .001) and numbness (r ¼ .396, P <
.001) after the loss was demonstrated. On the other hand, the
insecure relationship style is correlated with inability to trust
others after the loss (r ¼ .404, P < .001) and significant impair-
ment in social, occupational, and other important areas of func-
tioning (r ¼ .328, P < .001). The image of the patient’s
deterioration and disfiguration was inversely correlated with
symptoms of shock (r ¼ .325, P < .001) and numbness
(r ¼ .366, P < .001). The low tolerance to stress was associ-
ated with feelings of confusion about one’s role in life (r ¼
.379, P < .001), bitterness, and anger (r ¼ .375, P < .001). The
presence of children in the home is inversely correlated with
difficulty in moving on with life (r ¼ .324, P < .001). At last,
the social isolation is related to several symptoms of prolonged
grief, namely the intense feelings of emotional pain, sorrow, or
pangs of grief (r ¼ .330, P < .001); the confusion about one’s
role in life (r ¼ .361, P < .001); difficulty in accepting loss (r ¼
.344, P < .001); and feeling that life is unfulfilling, empty, or
meaningless since the loss (r ¼ .360, P < .001).
Discussion
The present study aimed to identify the grief mediators associ-
ated with PGD in a caregivers sample accompanied in
Abbreviations: FEO3, dependency relationship; FIA1, insecure relationship;
FES6, patient deterioration and disfiguration; FIA10, low tolerance to stress;
FIE2, presence of children (<14) at home; FIE4, social isolation; P2, In the past
month, how often have you felt yourself longing or yearning for the lost of the
person you lost? P5, In the past month, how often have you felt stunned,
shocked, or dazed by the death? P6, Confusion about your role in life or a
diminished sense of self (ie, feeling that a part of yourself has died)? P7, Have
you had trouble accepting the loss? P8, Has it been hard for you to trust others
since the loss? P9, Do you feel bitter over the loss? P10, Do you feel that
for you now? P11, Do you feel emotionally numb since the loss? P12, Do you
feel that life is unfulfilling, empty, or meaningless since the loss? P13, Have you
experienced a significant reduction in social, occupational, or other important
areas of functioning (eg, domestic responsibilities)?
palliative care. The most common factors were not those that
contribute most to PGD. In this sample, ambivalent relation-
ship, concurrent factors/secondary losses, reduced expression
of feelings, and high intensity of relationship prevailed.
We found that the relational aspects, namely the insecure and
dependent relationship, were the most associated with PGD.
Although we cannot establish the correspondence between these
patterns of relationship and the attachment styles, these results
are consistent with the literature.11,48-50 Analyzing specifically
the influence of insecure relationship in grief symptomatology,
we noticed that this relational pattern contributes to a significant
reduction of social and occupational activities, accentuating the
difficulty to trust others. On the other hand, the persons with a
dependent relationship are more prone to symptoms of trauma,
such as shock, confusion, and emotional numbness. Prigerson
et al51 considered that, globally, the insecure, attached, and
dependent persons are prone to develop manifestations of trau-
matic grief disorder. The results of the present study can contrib-
ute to discriminate the impact of those 2 relational patterns,
stressing individual differences in grief manifestations.
Concerning situational factors, only the image of the
patient deteriorated and disfigured was associated with PGD.
Although it was not frequent in this sample—eventually
because of palliative care support—the image of the patient’s
deterioration and degradation must be considered an impor-
tant indicator of quality of care, with great impact on bereave-
ment. Yet, its inverse correlation with traumatic symptoms
suggests that the caregiver’s perception of the patient degra-
dation may contribute to awareness of death proximity, as
suggested by Hebert et al.52 Nevertheless, the memory of the
patient’s deterioration was correlated with low tolerance to

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6 American Journal of Hospice & Palliative Medicine®
stress, which suggests that this intrapersonal characteristic
adds vulnerability in these situations, justifying the prolonged
grief reactions.
In the group of interpersonal factors, the existence of unre-
solved family crises was found to be correlated with PGD. This
is consonant with literature27,28 that states the conflicts are
harmful to the already emotionally intense family environment
during the terminal situation. Besides, the family is considered
to be the most important source of support in bereavement, spe-
cifically in widowhood.53 So, the lack of cohesion within the
family system is obviously a deleterious factor.38 Traylor
et al,27 relate family structure with the perceived lack of sup-
port, personal factors, and relationship styles, which is consis-
tent with the results of our study. Indeed, unresolved family
conflicts were correlated with the perception of less support,
social isolation, and secondary losses but were also associated
with intrapersonal factors such as psychopathological antece-
dents, low tolerance to stress, low self-esteem, ambivalence,
and conflictual relationship with the deceased. Then, we
believe that the factors that underlie the unresolved family
crises during loss tend to remain, contributing to prolonged
grief reactions.
These results support the original hypothesis that, besides
relational factors, other situational factors and concurrent stres-
sors related to the care-giving process interfere differentially in
the grief manifestations. Moreover, we found that many other
underlying factors contribute to prolonged grief manifestations.
One of them is social isolation, usually recognized as an impor-
tant mediator in adaptation to loss.54 Although we did not find
it was correlated with PGD, this factor appears to be associated
with several symptoms, like the confusion about one’s role in
life or a diminished sense of self, so life becomes unfulfilling,
empty, or meaningless. Besides, social isolation was also
related to feelings of longing or yearning for the deceased and
more difficulty in accepting loss. On the other hand, the pres-
ence of children at home may facilitate the moving on with life,
despite the difficulties in coping with loss, especially in the
case of widows.55
To better characterize the conjuncture associated with PGD,
we analyzed other mediators that interfere with those main vul-
nerability factors. The dependent relationship is related to
pending issues with the deceased, as well as situational and
interpersonal factors, such as exclusively domestic activities
and social isolation. The unique personal characteristic associ-
ated with dependency was low tolerance to stress. All these fac-
tors refer to difficulty in functioning in the absence of the
deceased, which is consistent with the position of Johnson
et al56 on bereaved dependency.
On the contrary, the insecure relationship appears mainly
associated with personal factors, namely, low tolerance to
stress, psychopathological antecedents, previous unresolved
grief processes, and low self-esteem. Besides, there are circum-
stantial factors, such as concurrent stressors and secondary
losses. In literature, it is evident the relationship between inse-
cure attachment and psychopathological symptoms. This asso-
ciation is mediated by cognitive mechanisms which contribute
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to low self-esteem and dysfunctional behaviors.57,58 It is also
understandable that the previous unresolved grief processes
promote insecure relationship patterns, given the constant
threat perception of disappearance of the object of affection
that the actual loss brings to the fore.
The common personal characteristic to both relational styles
associated with PGD was the low tolerance to stress, as argued
by Bowlby.48 The results suggest that persons with low toler-
ance to stress experience more confusion concerning one’s role
in life and feelings of bitterness after the loss of a significant
other. It is plausible that this personal characteristic is related
to intolerance to uncertainty, which is described by Boelen59
as the disposition to react negatively to situations perceived
as uncertain. The author refers that this trait, involved in neu-
roticism, preoccupation states, and generalized anxiety, is par-
ticularly associated with traumatic grief manifestations.
Conclusion
The results of this prospective study allow us to make some
observations concerning the influence of grief mediators,
detected since the pre-loss period, on the bereavement adjust-
ment. From an extensive list of factors identified in the literature,
only four were significantly associated with PGD, insecure rela-
tionship with the patient who died; dependent relationship with
the patient who died; patient deterioration and disfiguration;
unresolved family crisis. Although these mediators are not
frequent in this palliative caregivers’ sample, it is crucial to pay
attention to the particular factors associated with greater
morbidity. The reciprocal influence among factors, as well as
their impact on specific symptoms, leads us to consider the exis-
tence of a complex conjuncture of mediators associated with
PGD.
Limitations
Although the results were consistent with literature, these
remarks are conditioned by the methodological limitations of
the study. First, the small sample size does not allow the gen-
eralization of results. For this reason, also, it was not possible
to create subgroups within the caregiver’s population, accord-
ing to the kinship or the place of end-of-life care. Another lim-
itation is the method of evaluation, exclusively based on the
professional’s perception. This is still protocolled in palliative
care, given the inexistence of a valid and simple assessment
tool to evaluate grief mediators. Besides, the dichotomous scale
can be insufficient to evaluate the dispersion of results; apart
from that, it limits the statistical analysis. Given these limita-
tions, we believe that this should be considered a pilot study,
and the results should be subject to further research in a larger
sample.
Suggestions for Future Research
In future investigations, it would be important to deepen the
knowledge about the associations among the mediators for a
Coelho et al
better understanding of the mechanisms that contribute to
PGD. Specifically, little is known about the situational factor
statistically correlated with PGD—patient’s degradation or
deterioration image—and its interference in adaptation to
bereavement. Besides, it is necessary to create a reliable self-
assessment scale to evaluate grief mediators, specific to care-
giver population.
Implications for Clinical Practice
The systematization of this screening procedure in palliative
care would expedite the identification of needs and the mobili-
zation of resources in the prevention of morbidity associated
with prolonged grief. The results of this prospective study con-
tribute to a better understanding of this specific population’s
characteristics, identifying the most deleterious mediators in
grief trajectories.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the
research, authorship, and/or publication of this article: This research was
supported by funding from Calouste Gulbenkian Foundation–Lisbon.
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