OMEGA, Vol.

13(3), 1982-83

EFFECTS OF SUDDEN VS. CHRONIC ILLNESS

DEATH ON BEREAVEMENT OUTCOME

CATHERINE M. SANDERS
University of North Carolina at Charlotte

ABSTRACT
Eighty-six bereaved participants were interviewed shortly after the death of a close
family member and again eighteen months later. The Grief Experience Inventory
and MMPI were administered on both occasions. Responses were separated into
three groups according to the mode of death; sudden death (N = 33), long-term
chronic illness (N = 2 3 , and short-term chronic illness death (N= 26). Analysis of
data yielded no statistically signifcant differences among groups but indicated some
important trends. The short-term chronic illness group made the most favorable
adjustment to bereavement. While the sudden death and long-term chronic illness
death groups sustained higher intensities of bereavement at eighteen months, there
appeared to be both qualitative and quantitative differences between the reactions of
these two groups. The sudden death group indicated an internalized emotional
response described as an “anger-in’’ or intropunitive response causing them to sustain
prolonged physical stress. The long-term chronic illness group expressed an
“anger-out” response which, while creating a picture of dejection, frustration, and
loneliness, did not cause them to sustain the prolonged physiological component

Does sudden death produce more intense grief reactions than chronic illness
death? This question has been widely debated. The concept of “anticipatory
grief’ is commonly used to describe the separation anxiety experienced by
patients’ families who witness a slow painful death. Some feel emotional
preparation may ease the intensity of grief after death, diminishing the risk of
serious medical, psychological, and social reactions [I] . Many clinicians agree
that anticipatory grief seems to possess natural adaptational value 12-41. An
individual will partially work through emotional reactions usually seen after the
loss and will anticipate, as well as prepare for, necessary social adjustments. In
fact, researchers who have explored the concept of anticipatory grief in the
context of wartime separation and death report cases where grief work has been

227

0 1982. Baywood Publishing Co., Inc.

doi: 10.2190/RTPF-M5EA-6N7A-7D0D
http://baywood.com
228 I CATHERINE M. SANDERS

accomplished so successfully in missing-in-action situations, that when soldiers

return unexpectedly, wives have difficulty reattaching to their husbands [5-71.
Parents of fatally-ill children often show a tendency to detach and weaken the
investment in the child, especially if the illness lasts for three to four months. In
this way, the child becomes more of an object (almost a memory while still
alive), thus enabling the parent to react to the death in a more subdued manner
than if they had not been prepared. These writers refer to this detachment as
philosophical resignation and indicate that it has adaptive value in permitting
gradual decathexis from the fatally-ill child. More often, however, the chronic
illness led the parents to make apparently straight-forward expressions indicating
the wish for the ordeal to end [ 2 ] .
Anticipatory grief for the aged has been examined by several writers who
report that older survivors did not differ significantly in depression after one year
from those who did not experience anticipation of the death [8,9] - Conversely,
it has been shown in a sample of older surviving relatives that when illness lasted
one year or longer, 68 per cent showed intense grief reactions. Of those whose
relatives died of illnesses less than one year’s duration, only 30 per cent showed
intense grief reactions [ 101 . Advance warning of impending death is also
important in that it allows time for making restitution by means of devoted
care and attention. It has been reported [ 111 that anticipation is one of the
most important determinants of good outcom: in bereavement. On the other
hand, when death is sudden or time for adequate preparation not available, grief
reactions tend to be more intense and longer lasting [4,12] . Sudden death can
be such a shock that the capacity to cope is diminished and full functioning not
realized by some even several years after the death [ 111.
Engel studied 170 cases of sudden death ostensibly searching for precipitating
causes of death. Of these cases, eighty-one died following a significant loss-many
within hours of the death of a loved person. A typical example cited by Engel
is as follows:
A sixty-four year old woman who was said never to have recovered
from the death of her son in an auto accident fourteen years earlier died
four days after her husband was murdered in a holdup [ 131.
While the cases presented by Engel are anecdotal, there is compelling evidence
of psychological stress sustained by bereaved individuals he describes [13]. The
shock of the event produces cognitive disorganization as well as intense
emotional trauma.
Of those studying short-term versus long-term illness, Clayton et al. separated
bereaved participants into groups by length of the deceased’s illness [ 141. After
analyzing the results, the only symptom attaining significance was anorexia, and
t h i s was exhibited more often in participants whose relatives died of short-term
illnesses (less than six months). The authors explained this difference as a
disruption of home life schedules (such as erratic meal times), which occurred
 SUDDEN VS. CHRONIC ILLNESS DEATHS / 229

when the patient was hospitalized. Because eating is normally a social event, it
can be hypothesized that the relatives in Clayton’s study bypassed meals and
ate haphazardly, which further reduced social interaction and resulted in
continued loss of appetite. Other writers report that wives devote less time to
other relationships as their dying husbands become their constant preoccupation.
Relatives are often caught up in an extended crisis situation without much relief.
This constant approach-avoidance condition could result in conflicts which
might very well produce chronic anorexia.
In a longitudinal study, Gerber and his colleagues examined the differences
between reactions to acute illness death (little or no opportunity for
anticipatory grief) and chronic illness death (where anticipatory grief is expected)
.
[ l ] Results indicated no significant differences between the two groups in
initial bereavement adjustment. However, these writers did find that the
survivors who had protracted anticipatory grief revealed poorer medical health
six months after the death, and that in cases where there was an extended death
watch, widowers did more poorly than did widows. These results were
explained as the debilitating effects of caring for a loved person over an extended
period of time as well as the possibility of exacerbating unrealistic attitudes
concerning plans for their lives after the death of a spouse [ 13. These authors
caution that realistic social planning may be just as important as emotional
preparation. Perhaps, based upon longevity statistics, the widower is surprised
and therefore unprepared, to survive his wife. One problem with Gerber’s study
and others concerning anticipatory grief among aging spouses is the lack of a
clear definition of anticipation in this context. By the time one has reached
sixty-seven years (mean age in Gerber’s study), some serious thought and
planning has probably already been undertaken related to concurrent losses and
concerning one’s own demise. Whether this constitutes anticipatory grief as
defined by others is open to conjecture.
Phyllis Silverman feels strongly that anticipatory grief is not possible if the
relative stays actively involved with the patient through the illness. She writes [ 151 :
Real grieving and coming to terms with the changes death makes in a
wife’s life can come only after the husband has died. When he lives it is her
reality to care for him, to be his wife in sickness and so forth . . Some
people even talk about the coming death but this is not grieving in advance.
Engagements are not marriages. Neither is a rehearsal for widowhood the
real thing. This only happens when the other person is no longer there to
interact with-no matter what shape he is in [ 15, p. 21 1,
In an earlier cross sectional report of the present data [16], participants who
were divided into two groups (those whose relative died within seven days of onset
of illness or accident and those whose relatives died of illnesses of longer duration),
indicated no significant differences in bereavement intensities two months after
the death. This lack of difference carried over to home deaths vs. hospital deaths
as well.
230 1 CATHERINE M. SANDERS

The purpose of this study is to assess grief reactions eighteen months after the
death to determine if differences in mode of death had an effect on bereavement
outcome. Three modes of death were identified: 1) sudden, unexpected death,
2) short-term chronic illness death (less than six months), and 3) long-term
chronic illness death. These data may provide a basis for intervention strategies
useful in helping bereaved persons cope with their particular loss. While it is
always worthwhile to approach questions in terms of their heuristic value, it is
ultimately most important to know where to place limited supportive resources.

METHOD
Participants
Eighty-six participants were selected from a large study of bereaved
individuals based upon the criterion of having been interviewed both shortly
after the death and again eighteen months to two years later. Selection of
participants has been described in an earlier paper [ 161 .
Participants were white, had a mean age of fifty-two years, were
predominately Protestant (84%), and were of American birth and ethnic
background. They were interviewed in their homes an average of 2.2 months
following the death and again at eighteen months after the bereavement.

Materials
The Grief Experience Inventory [ 171, the MMPI, and a demographic
questionnaire were used. The Grief Experience Inventory (GEI) is a self-report
inventory consisting of 135 true-false items and is designed to assess experiences,
feelings, symptoms, and behaviors of individuals during the grief process. The
inventory is comprised of eleven scales which are seen to adequately tap the
multidimensional quality of the bereavement syndrome. These scales include
three validity scales (Denial, Atypical Responses, and Social Desirability) as well
as nine clinical scales (Despair, Anger, Guilt, Social Isolation, Loss of Emotional
Control, Rumination, Depersonalization, Somatization, and Death Anxiety). In
addition, there were six research scales which, because of the small number of
items, were included for exploratory purposes. The first four of these are
subscales of the Somatization scale; Sleep Disturbance, Loss of Appetite, Loss
of Vigor, and Physical Symptoms. The remaining two research scales are
Optimism/Despair and Dependency. The MMPI was used to examine
personality correlates as they relate to the grief experience.

RESULTS
Data analysis was based upon eighty-six bereaved persons who were
subsequently separated into three groups according to the deceased family
member’s mode of death. The three modes include sudden death (SD), N = 33;
 S U D D E N VS. CHRONIC ILLNESS D E A T H S / 231

short-term chronic illness (STC) (less than six months), N = 26; and long-term
chronic illness (LTC), N = 27. The average age and make-up of each group is
shown in Table 1. It should be noted that the average age is comparatively close
among groups, while the modes of death differ with the STC group having a
larger percentage of parent deaths over spouse deaths. The SD group has, as we
might expect, the largest percentage of child deaths.

GEI Profiles
Composite GEI profiles were plotted using the mean of that group for both
the initial and follow-up interviews. Repeated measures analyses of variance,
performed on each scale of the GO, failed to indicate significance between
initial and follow-up interviews, although several interesting trends were noted.
In the initial interview (see Figure l), the STC group showed greater social
desirability and death anxiety than did the other groups. The LTC group
evidenced greater social isolation, rumination, loss of vigor and physical
symptoms, while the SD group indicated higher levels of denial, loss of emotional
control, depersonalization and low optimism. However, intensities of grief for
all groups fall within a fairly close range (see Table 2). On follow-up greater
disparities were noted (Figure 2). The STC group showed the best adjustment to
grief of the three groups although still evidencing the highest intensity of death
anxiety. The LTC group displayed the greatest degrees of denial, social isolation,
loss of emotional control, rumination, and loss of vigor which points to the
psychophysical depletion suffered during the long death watch. The SD group
showed greater anger, guilt, depersonalization, somatization, and physical
symptoms than did the other two groups. The effects of the shock of sudden
death were still evident eighteen months later (see Table 3).

MMPI Profiles
When composite MMPI profiles were plotted, it was found at follow-up that
the STC group indicated less depression, fewer somatic complaints, and a higher

Table 1. Average Age and Make-up of Group by Mode of Death

SD STC L TC
Average Age = 55 Average Age = 49 Average Age = 54

Spouses = 17 (52%) Spouses = 9 (35%) Spouses = 19 (70%)

Parents = 6 (18%) Parents = 15 (58%) Parents = 2 ( 7%)
Child = 10 (30%) Child = 2 ( 8%) Child = 2 ( 7%)
Total = 33 Total = 26 Total = 27
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234 1 CATHERINE M. SANDERS

Table 2. Means and Standard Deviations for Three

Modes of Death at Initial Interview

SD STC L TC
Standard Standard Standard
Scale Mean Deviation Mean Deviation Mean Deviation

Denial 4.18 2.04 3.23 2.29 4.00 3.06

Atypical Responses 5.27 2.58 4.39 258 5.52 3.14
Social Desirability 4.42 1.37 4.85 1.12 4.44 1.34
Despair 7.94 5.35 7.27 4.54 7.74 4.67
Anger 3.70 2.51 3.62 2.39 3.22 2.39
Guilt 1.33 1.63 1.39 1.50 1.44 1.37
Social Isolation 2.39 1.69 2.15 1.12 2.48 1.74
Loss Emotional Control 5.15 1.82 4.96 1.87 4.59 2.23
Rumination 4.61 1.98 4.54 2.53 4.74 2.54
Depersonalization 4.97 2.14 4.81 2-37 3.74 2.67
Somatization 6.46 3.93 5.62 3.83 6.74 4.07
Death Anxiety 4.79 2-18 5.31 2.48 4.63 2.45
Sleep Disturbance 1.88 .95 1.04 .77 1.19 .88
Loss of Vigor 284 1.84 2.73 1.80 3.26 1.70
Physical Symptoms 3.21 2.42 2.62 1.81 3.41 2.42
Opti mism/Despair 1.79 1.75 1.39 1.55 1.52 1.34

Table 3. Means and Standard Deviations

for Three Modes of Death at Follow-up

SD STC L TC
Standard Standard Standard
Scale Mean Deviation Mean Deviation Mean Deviation

Denial 3.73 2.57 3.15 2.46 4.19 2.34

Atypical Responses 6.12 3.23 4.65 2.90 5.70 3.15
Social Desirability 4.61 1.25 4.54 1.36 4.56 1.55
Despair ci.27 5.41 4.42 3.73 6.19 4.88
Anger 3.46 2.49 2.69 2.11 2.37 2.06
Guilt 1.42 1.62 .a9 1.11 32 1.18
Social Isolation 2.21 1.75 1.65 1.20 2.37 1.88
Loss Emotional Control 4.27 2.11 4.19 2.14 4.52 2.44
Rumination 4.39 2.60 3.86 2.93 4.89 2.97
Depersonalization 3.97 249 3.50 229 3.67 2.40
Somatization 5.67 3.93 3.62 2.95 4.59 3.30
Death Anxiety 4.91 2.54 5.08 2.83 4.15 2.45
Sleep Disturbance -79 .60 .65 .80 .79 .70
Loss of Vigor 2.73 1.79 1.96 1.25 3.11 1.48
Physical Symptoms 291 244 1.69 209 2.26 2.23
Optimism/Despair 1.33 1.47 1.04 1.34 1.33 1.30
 SUDDEN VS. CHRONIC ILLNESS DEATHS / 235

level of energy than did either the SD or the LTC groups. This group also had
higher elevations on Ego Strength and K. The LTC group showed higher
elevations on Hysteria (Hy), Depression (D), and Psychasthenia (Pt) at initial
interview. At follow-up, there was a reduction of Hy as well as D although not
to a significant degree. Psychopathic Deviate (Pd), Paranoia (Pa), Schizophrenia
(Sc), and Social Introversion (Si) scales were higher than they had been at
initial interview. Yet, both K and Ego Strength were elevated indicating that
these participants were feeling somewhat better about themselves. Despite this,
the LTC group was still seen as depressed, anxious, and isolated.
For the SD group at follow-up, the mean MMPI profile showed more
depression with a larger number of physical complaints than they had evidenced
earlier. Pt and Sc were both elevated over initial testing, giving evidence of the
shock-producing effects of systemic stress brought about by abrupt loss.

Hospitalizations
During the eighteen months following the death, eight of the SD (24%), two
of the LTC (7%), and five of the STC (19%) group were admitted to a hospital.
All of the participants who were hospitalized had medical treatment for a
nonpsychiatric condition. These conditions were reported by participants as
heart attack (three months following death of son), two with urinary tract
infections, pneumonia (on anniversary month of death of husband), broken
ankle, phlebitis, foot operation, and a participant who was hospitalized six weeks
as a result of a reaction to a flu shot (four months after the death). Of the two
hospital admissions for the LTC group, one had a heart attack (same month one
year following husband's death) and another had four disks removed. There were
five admissions among the STC group which included surgery for diverticulitis,
heart attack, broken foot, broken rib, and back problems.

Illnesses
Illnesses that were reported separately from those tapped by the GEI included
a wide variety of somatic and psychosomatic problems. The distinction between
the two is not clearcut, and here they are reported together. Of the thirty-three
participants in the SD group, twenty-three (70%) reported having some specific
illness during the eighteen months following the death. These included high
blood pressure, colds, flu, arthritis, various infections (urinary, eye, tooth),
hypoglycemia, arthritis, strep throat, chest pain, diabetes, skin allergies, and a
detached retina. Among the twenty-seven LTC respondents, nine (33%)complained
of diabetes, stomach ulcer, colds (3), flu (3), and back p h . The STC group
indicated a larger number of complaints than had been expected; twelve (46%)
described problems such as colds, flu (6), hi& blood pressure, headaches, seizure
problem, ear infection, arthritis, skin allergy, and pollen infection.
236 I CATHERINE M. SANDERS

DISCUSSION
Wile there were no significant differences noted on GEI scales among groups
between initial and follow-up interviews, there were some interesting trends
which add important dimensions to the research question. Survivors of a sudden
death situation exhibited longer-lasting physical repercussions as well as more
anger and guilt than did those who survived a short-term chronic illness.
Survivors of a long-term chronic illness death showed greater feelings of isolation
and alienation, which prolonged their grief and gave rise to loss of emotional
control. The group making the best adjustment to bereavement had family
members who died of a short-term chronic ilIness. While these participants had
indicated levels of grief similar to the other two groups initially, when seen
eighteen months later, there was consistent diminishment of bereavement
reactions on all scales of the GEL From this then, there appears to be value in
some preparation for loss as long as it is not extended over a protracted time
period, resulting in withdrawal of social support.
Several writers agree that there is both a qualitative and quantitative difference
in grief resulting from a predictable death, as opposed to one that has not been
anticipated [11, 15, 181 This study supports that conclusion.

Short-Term Chronic Illness Death

The composite GEI profile at initial interview showed the STC group to have
higher elevations on Social Desirability and Death Anxiety. This desire to .

maintain socially acceptable behavior helped these individuals through the grief
process. At final interview, the STC group had made the best adjustment of
either the SD or LTC group, which can be explained in terms of a combination
of factors.
In short term illnesses, there is usually a rapid deterioration, loss of function,
and even in some cases, personality change. For those who must care for a family
member, these changes are difficult to process because they occur so rapidly. In
the present study, many spoke of feeling terror near the death after-gross
physical changes had taken place. In addition, pain was often associated with
the death producing guilt and frustration in those who attended the patient.
When death came, it was often sooner than had been anticipated. One young
wife whose husband had died of leukemia said,
One of the things that is bothering me a great deal is that I simply find
it difficult sometimes, even though I know how much I loved him and all
the good times that we had, I can’t seem to get past the horror of his dying.
I could hardly recognize him and I was literally horrified by what he looked
like. His eyes were glittering, his teeth were brown and clinched, his whole
body was swollen.
The funeral brought her much comfort in that she was able t o see him once
more looking peaceful and composed. When interviewed shortly after his death,
 SUDDEN VS. CHRONIC ILLNESS DEATHS / 237

she was still struggling with the memory of the horror. At the final interview a
year and a half later, she had begun to refocus on happier memories.
In most cases, friendships had been strengthened for this group. The short
time between onset of illness and death had not been so long that friends had
drifted away. There was still a feeling of nurturance and support as well as a
desire by the bereaved to remain strong and capable. The principal caregiver in
illness maintained the same determined position in bereavement. There was also
a large percentage of parent deaths in this group. These adult children, while
fully expressing their grief and loss, had families, jobs, and daily responsibilities
which allowed little time to dwell upon the deceased parent. Consequently,
positive outcome for this group was not only seen as a function of preparation
for loss but also as a function of perceived social support and the desire on the
part of the bereaved to maintain socially acceptable behavior, not risking further
loss. The side effects of prolonged stress, therefore, were not sustained.

Sudden Death
It is not surprising that anger was higher for this group than for the others.
These unexpected deaths left survivors with feelings of loss of control in a world
in which only a short time before they had placed their faith and trust. This
kind of catastrophy leaves the survivors unable to know what t o trust. Three
of the deaths were caused by murder. In another case, as a wife was driving her
husband to the hospital for routine treatment, he slumped over on her shoulder,
while she had to continue driving for fifteen minutes knowing that he had
stopped breathing. An impressive body of literature has identified lack of
control and unpredictability as etiologic factors that modify stress situations
[18-221. These writers have emphasized the importance of control for the
ongoing psychosocial development of the organism through life. Frustration
and helplessness had replaced trust for the SD group, and anger was their
response to the meaninglessness of the death.
Yet, anger was not always an immediate reaction for those who experienced
sudden death bereavements. In the case of a young widow whose husband was
murdered by an unknown assailant two months before the birth of their child,
anger did not surface until fifteen months after the death. Until then, she had
remained confident that the murderer would be caught and justice done. AS
months went by and the reality of the situation began to take shape, she felt
more victimized than immediately after the death. There were also more
friends and family helping in the beginning. When she was left with the task of
earning a living while caring for her children, the awful injustice of the death
overwhelmed her, and her anger was seen in daily irritations.
Anger can act as a motivator and have a positive effect. A deeply grieving
widow rarely left her home after her husband died and refused to drive her
care because she felt too weak. Yet one day she became enraged at the local
238 / CATHERINE M. SANDERS

Social Security office after months of frustrating negotiations over the phone,
she jumped into her car and drove t o the Social Security office “to settle things
once and for all” and has been driving every since.
Elevation on the Guilt scale can be explained in terms of the absence of an
opportunity to make restitution or complete unfinished business. The majority
of these participants spoke longingly of things they might have done. The large
percentage of children’s deaths in this group also contributed to the elevation on
this scale. These parents felt an innate responsibility for their children’s safety;
they seemed to feel that the death had occurred because they had somehow
relaxed their guard.
The shock of the death was still evident eighteen months later as indicated by
elevations on the Depersonalization scale. This scale measures the numbness,
shock, and confusion of grief, Factor analytic studies of the GEI indicate that
this scale is measuring a deeper, more intense form of bereavement showing
severe feelings of loss of control of one’s environment or universe.
Another factor that differentiates this group is the continued elevation on the
Somatization and Physical Symptoms scales. This supports the observations by
other writers of an increase in physical complaints during bereavement [3,5,
23,241. When seen only a short time following the death, the SD participants
indicated fewer physical problems than either of the other groups. At follow-up,
both the STC and LTC groups had improved dramatically while the SD group
continued to manifest a variety of problems associated with physical health. It
i s suggested that this can be traced t o the physiological stress created by the
impact of sudden death. As one attempts to make the event of death real,
adaptation is confounded by diminished physical resources. The highly aroused
sympathetic nervous system is geared to respond to the induced stress
immediately, but since the negative psychological state of grief persists, the
physiological stress response continues. It is under these circumstances that
biochemical changes associated with stress become potentially detrimental to
health.
The composite MMPI profile ofthe SD group bears out the above
observations. On retest, several scales were elevated over original testing: F,
Hi,D, Pt, and Sc. These individuals were more depressed, anxious, confused,
and were suffering with more physical symptoms than during the time
immediately following the death.

Long-Term Chronic Illness Death

As has already been noted, the LTC group responded differently from the
SD group qualitatively and quantitatively. At the initial interview, social
isolation, rumination, loss of vigor, and physical symptoms were higher than for
the STC and SD groups. At follow-up, the syndrome was made up of denial,
social isolation, loss of emotional control, rumination, and loss of vigor. This
 SUDDEN VS. CHRONIC ILLNESS DEATHS / 239

clearly indicates the level of physical strain involved in caring for a fatally ill
family member over a prolonged period. When death occurred, there was an
immediate let down and refocusing on oneself evidenced by the large number of
physical complaints recorded. However, during the ensuing bereavement, there
was opportunity t o acquire the rest and medical attention necessary for better
health.
Probably the most debilitating element in the syndome presented by this
group was the higher level of social isolation. Because of the long death watch
when the illness became the focal point, there was little energy and time to keep
up social ties. Consequently, support systems diminished. When death occurred,
general exhaustion left little reserve for effort needed to reach out to others.
There was also the “empty hand” phenomenon. Suddenly one’s purpose for
living was removed. Thus, loneliness, caused by feelings of isolation and
alienation, appeared to be the determining factor in poor outcome for this group.
Denial was elevated for this group at follow-up but it is important to point
out that this was not denial of the event of death but rather a denial of
emotional needs. These people displayed a “determined optimism;” they had to
make it through a difficult period and would do so by sheer will if nothing else.
It has been shown that individuals who use denial as a coping mechanism in
bereavement make fairly good adjustments in terms of long-term follow-up as
long as they are not attempting to deny that the death occurred [24] .
The MMPI composite profile showed that Land K were both elevated over
origional testing supporting the denial shown on the GEI. Depression, while
diminished over the initial testing, was still as high as it was for the SD group.
Paranoia (Pa) was elevated over the first testing, indicating the interpersonal
sensitivity felt by lack of contact with others. One encouraging fact is that both
K and Ego Strength (Es) were elevated, indicating that these individuals were
feeling better about themselves and their ability to cope.
Thus, differences in outcome of bereavement between the SD and LTC
groups can be summarized in terms of two discrete, dichotomized syndromes.
Symptomatology of the SD group shows an internalized emotional response
consisting of anger, guilt, depersonalization, and somatization. This syndrome
has been described as an “anger-in’’ or intropunitive response [ 2 5 ] . “Anger-in’’
respondents accepted blame, turned their anger inward, and suppressed their
hostile feelings. This, in turn, caused them to suffer more severe and prolonged
physical stress than did those who responded with “anger-out.”
On the other hand, the LTC group responded with greater social isolation,
loss of emotional control, rumination, and loss of vigor, creating a picture of
dejection, frustration, exhaustion, and loneliness. Yet, because of the
“anger-out’’ response, somatization was not excessive. Denial was an important
motivating force which enabled these individuals to keep going and even gain
some satisfaction in their ability to survive the long arduous task of working
through their grief.
240 1 CATHERINE M. SANDERS

SUMMARY
The results of t h study extend beyond the eitherlor question of sudden vs.
chronic illness death and begin to focus on qualitative differences between the
two. There appears to be no short cut to the painful “working through” after
the death of a beloved family member, and whether one anticipates the death or
not, when it comes, it will be difficult to bear. Yet, caregivers must be alert to
the various pictures that emerge as a result of mode of death. Grief must be
dealt with holistically, and physical problems given greater credence. The shock
victim at the scene of an automobile accident is, at this time, given far more
attention than the family member at the emergency room who has just received
the news of a sudden death. Grief is an indirect pathogen, and the increase in
headaches, ulcers, hypertension, and infections will attest to this fact. With the
amount of corroborating data now evident, there is urgent need for more
research into the debilitating effects of bereavement.
Bereavement is multidimensional and the ripple effect extends beyond the
emotional and physical factors. Caregivers as well as families and friends should
be encouraged to be alert to the social implications of isolation and alienation.
Churches and community organizations could also take a more active role in the
provision of support systems. It is not enough that bereaved individuals are
supported through the funeral; they need to be helped back into the social
milieu best suited for their needs and over a much longer period of time than
has heretofore seemed appropriate. Thus, intervention in bereavement should
be guided by the understanding of different needs related to specific modes of
death, as well as extended over a much longer period of time with broader-based
support strategies.

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 SUDDEN VS. CHRONIC ILLNESS DEATHS / 241

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Direct reprint requests to:
Catherine M. Sanders, Ph.D.
Doctors Building, Suite 423
1012 South Kings Drive
Charlotte, NC 28283