No human being can know how he or she will feel when a parent dies. An unexpected call from a coworker, whose father had died a week earlier, prompted a conversation with the second author (P.G.C.) that was not what it seemed. P.G.C.’s father had died more than 20 years earlier in the same inpatient oncology unit as the coworker’s father, a service on which both P.G.C. and the coworker practice today. Although her call was related to a work issue, P.G.C. knew instinctively the call was about something else. Such solicitation for human connection, the need for empathy, and urgency for support prompts a need for all health care workers to examine their role when working with dying patients and their families. This is true whether one or both parents have died. The death of the last parent, however, brings a unique set of feelings and experiences that are sometimes distressingly different from any other human loss.
When the last parent dies, there is no “home” for the child to return to. The parents are dead. Relationships, however, never die. Children or young adults who lose parents are usually acknowledged for their loss and may receive ongoing support and care. When an adult, especially an older adult, loses a parent, the psychological pain can be equally traumatic. In fact, the longer the parent lives, the more difficult the death may be for surviving children. Although the death of the first parent may be traumatic, the death of the second parent may destabilize surviving children, perhaps for an extended period.
No one makes plans to lose his or her parents. For many adults, losing parents may be something for which they believe they are prepared. A colleague recently shared with the first author that her parents were thoughtful and nurtured autonomy, self-sufficiency, and an ability to move forward that have allowed her personal experience of losing both parents to be a somewhat predictable growth occurrence. However, some adults are overwhelmed when parents die and are unprepared for the changes that occur.
The concept of adult orphans may seem insignificant to some health care professionals. Adults are generally seen as understanding that parents will die and are expected to somehow plan for the event and what will follow. Although uncomplicated grief is something nurses understand, today’s more mobile adult orphan may have fewer resources, supportive friends, or family members available when parents die. In addition, a culture that values quick recovery, control of grief, and a return to productivity may exacerbate suffering. Increased mobility of nuclear families may also mean that adult orphans are leaving support systems behind as they cope with the issues surrounding the death of the last parent.
As older adults live longer, children may be older themselves at the time of the last parent’s death. Genetically transmitted chronic illnesses may be affecting the surviving child, even at the time of the parent’s death. Heightened anxiety over personal mortality may influence survivors in ways that have yet to be documented. Studies indicate that if the adult was a caregiver for the dying parent, a variety of outcomes may be predicted, which is important information for health care workers to know (Schulz, Hebert, & Boerner, 2008). As described in this article, many authors have studied the range of responses experienced by newly orphaned adults, giving direction to those who care for dying parents and their adult children. The unexpected changes that may occur when an adult is orphaned, which can disrupt functioning and change relationships, may respond to anticipatory guidance, referral, and support from those health care workers closest to the dying patient.
Personal Impact of Parental Loss
Nurses who work with elderly clients may assume that surviving children are equipped to manage the impending loss of their last parent. In many instances, this is not the case. Parental death in midlife may lead to loneliness, a review of previous losses and conflicts, and a forced examination of life goals and accomplishments (Levy, 1999). The burden of maintaining or ending family traditions is now one of many responsibilities and choices required of the surviving adult children (Levy, 1999).
From a family systems theory perspective, families play a vital role in the processes involved with individual meaning-making and the construction of personal reality. It is from this construction of reality the individual develops lifelong problem-solving responses to physical, psychological, emotional, social, and spiritual challenges (Freeman, 1992). With the loss of the remaining parent, the context of the meaning of family changes substantially. Loss of a parent, and especially the last parent, can herald a change in one’s personal context which, in turn, may change the meaning of one’s own life, construction of reality, and approaches to problem solving.
In Losing Your Parents, Finding Your Self: The Defining Turning Point of Adult Life, Secunda (2000) discusses in depth the changes in an adult’s life created by becoming an adult orphan. One example described in her work is when adult orphans leave or change a career they had pursued, sometimes unknowingly, to please their parents. This example of a significant life change following the death of the last parent may be the result of an intense urge to find a sense of purpose. Similarly, a sense of vocational failure may accompany the death. Secunda (2000) reported that 69% of respondents surveyed said they had changed careers as a result of becoming orphaned.
The death of the last parent may also lead to unresolved feelings of loss for the first parent. Brooks (1999) noted that adult children may focus on the needs of the surviving parent to the exclusion of satisfactory resolution of the loss of the first parent. The unique reflection and sense of history parents bring to their adult children, their children’s children, and to the lives and futures of family members cannot be replaced (Brooks, 1999).
Impact of Parental Loss on Intrafamilial Relationships
In supportive families, surviving aunts, uncles, siblings, and others may lend support to the successful transition of the adult orphan. However, those same family members may disagree about end-of-life care, inheritances, funeral arrangements, organ donation, and other vital and inescapable decisions (Brooks, 1999). These and other unforeseen events that surround the death of the last parent can increase distress and complicate the grief and recovery of surviving adult children.
The newly orphaned adult’s relationships with partners and spouses may also be unexpectedly affected. Brooks (1999) discussed how partner sympathy may not necessarily be forthcoming, exacerbating the adult orphan’s sense of loss. Unexpected resentment on the part of the newly orphaned adult may occur when the spouse or partner has parents who are still living. These feelings alone may be the source of additional guilt, burden, and isolation for the adult orphan. Brooks (1999) concluded that adult orphans are required to review their past, including the memories and expectations associated with their loss.
Unmarried adult orphans may decide to marry and create a new context for family. Married couples may find a greater source of strength in their marriages, and those in unhappy marriages may choose to end them (Secunda, 2000). For adults whose marriages have provided shelter from real or imagined conflicted parent-child relationships, the death of the last parent may result in a variety of emotional responses with associated opportunities and possible consequences.
Similarly, adult orphans are likely to experience changes in sibling relationships as each experiences the loss of the remaining parent differently. Secunda (2000) referenced Dr. Harvey Rich, president of the American Psychoanalytic Foundation, who indicated that losing a parent may bring siblings closer, depending on the relationships they had as children. A feeling of being disconnected from one’s history may encourage sibling closeness, even if driven by narcissistic needs. As an opposite consequence of becoming an adult orphan, siblings may find themselves having nothing more in common with one another. In either case, siblings see themselves as a reflection of their parents. When parents die, siblings have no choice but to deal with one another differently (Secunda, 2000). Although approximately half of Secunda’s survey respondents stated they had become closer to one or more of their siblings, nearly a quarter reported distancing and sometimes ending any connectedness with their siblings. According to Secunda’s (2000) findings, sibling relationships change in somewhat predictable ways. This knowledge can be useful to health care providers who are often a source of guidance and information at the time of the parent’s death.
Parental Death and the Baby Boomer Generation
The aging and death of Baby Boomers’ parents have unique implications for health care workers. Begley (2000) discussed the large numbers of adult orphans among Baby Boomers, noting that 25% of 50-year-olds had lost their mothers and 50% had lost their fathers. Begley (2000) noted that the Baby Boomer generation is more likely to look for personal meaning related to current life goals and accomplishments. Death of the last parent may cause newly orphaned Baby Boomers to focus on the life they might have chosen without the influence of the deceased parent (Begley, 2000).
According to Begley (2000), by the time Baby Boomers had reached the age at which they were most likely to marry, one half of all marriages had ended in divorce. Begley (2000) reported that economic changes and increased mobility have led the average Baby Boomer to careers of seven or more jobs. As a result, parents, rather than other family members or work supervisors, may have provided the only context for “family” in the surviving adult child’s life.
Similarly, family resilience and connections to one’s community can become threatened at the time of the last parent’s death. Geographic mobility, often a requisite for economic survival, has led to a lack of bonding among members of local communities. At the time of parental loss, adult orphans can find themselves as virtual unknowns among neighbors, and unsupported by geographically fragmented family members. Michael Lyndon, director of a grief support center in California, noted in Begley’s (2000) article that support previously provided by churches and neighbors may be missing for a growing segment of aging Baby Boomers. As a generation of optimists with a sense of immortality, the awareness brought about by the death of the last parent can become a difficult and painful time of transition for this large group of adult orphans (“The Peculiar Grief,” 2003).
William Bridges spent more than 30 years studying, writing about, and working with organizations facing tremendous transition and change. His work on traumatic life transitions came from his personal experience of losing his wife to breast cancer. In his book The Way of Transition: Embracing Life’s Most Difficult Moments, Bridges (2001) describes death as a time for deeply personal reflection on the meaning of life. During this most influential transition period following the death of the last parent, confusion and a loss of purpose are common. Bridges (2001) pointed out the need to first let go of one’s grasp of the world as it is to experience a successful life transition. Bridges asks the reader a series of questions aimed at having the adult orphan become more introspective about personal meaning. He referred to managing transition following the loss of a parent as a process of helping decrease pain and avoiding as much disruption in life as possible. The death or change is unavoidable. The use of personal creativity that can lead to successful transitions and personal growth is purposeful (Bridges, 2001).
Although much is known about personal changes following the death of the last parent, the impact on the health care system of the largest number of newly orphaned adults can only be anticipated. Although some adult orphans may clearly be prepared to manage the grief that accompanies loss, others will experience more complicated emotional and behavioral responses.
Disorders Related to Grieving
Prolonged grief disorder is a term used to explain a number of symptoms that may require further assessment, treatment, and sometimes, emergent care. In a study of 346 adult mourners, emotional, cognitive, and behavioral symptoms were analyzed along with quality of life data, over time. Symptoms of prolonged grief disorder were found to be distinct from those of depression and anxiety. Boelen and Prigerson (2007) concluded that prolonged grief disorder increases the risk of impaired functioning in mourners. Significantly, screening for anxiety and/or depression by health care workers may not identify those at risk for prolonged grief (Boelen & Prigerson, 2007).
The consequences of not identifying adult orphans’ needs, sometimes unspoken, can be much more serious than previously understood by medical personnel working with family members of dying patients. Szanto et al. (2006) reported on a National Institute of Mental Health study of suicidal behavior and its correlates in 149 patients in a treatment study of complicated grief. Surprisingly, thoughts of wanting to die following the death of a loved one were reported by 65% of those studied. The participants were self-identified as bereaved and, notably, non-help seeking. Of this subset of patients, 13% had made at least one suicide attempt, and 44% reported self-destructive behaviors (Szanto et al., 2006). The frequency of self-destructive and suicidal behavior in bereaved adults with prolonged grief disorder would seem to present a serious risk as numbers of newly orphaned adults continue to grow.
In their article, Schulz et al. (2008) stated that adults who provide care before the death of parents sometimes show a much improved ability to adapt following the loss. The article cites a number of recent prospective studies suggesting that symptoms of depression and grief decline more quickly after the death of the parent and return to near-normal levels within a year for those who are primary caregivers (Schulz et al., 2008).
That the adult providing care may have time to prepare for the parent’s death, may experience relief that parental suffering has ended, and may have less guilt having provided care may all be factors associated with positive outcomes for the adult orphan (Schulz et al., 2008). Identifying which caregiving factors contribute to poor bereavement outcomes provides important indicators regarding interventions that can be delivered after the death of the last parent.
Levels of mental distress prior to the death of the parent are suggested as good predictors of bereavement outcomes (Schulz et al., 2008). Specifically, adults with depression or anxiety prior to the death are, not surprisingly, at greater risk. Other studies predictably suggest that adult orphans who report feeling exhausted and burdened, lack support, and have multiple responsibilities are more likely to have more difficulties with grief and bereavement. The finding of feeling increased burden as a risk factor for poor bereavement outcomes in the population studied may be cautionary for health care workers who are able to intervene with the adult orphan known to be distressed prior to the death of the parent (Schulz et al., 2008).
Zhang, El-Jawahri, and Prigerson (2006) characterized complicated grief—similar to bereavement—as a combination of obtrusive thoughts and resulting problematic behaviors. An intense longing for the deceased occurs as unwanted thoughts. Impaired concentration, problems engaging in potentially mitigating behaviors, and difficulty with interpersonal relationships are described as creating a distressing and potentially debilitating process (Zhang et al., 2006). Despite the generally positive prognosis for most bereaved adults who were caregivers, Zhang et al. (2006) suggested that a significant minority continue to experience high levels of stress and psychiatric problems after the death.
A specific example of an easily determined risk factor for complicated or prolonged grief has been associated with those adult caregivers who do not use hospice services compared with those who do (Zhang et al., 2006). Other risk factors for depression included lower income and educational level. African Americans were also more likely to experience depression in the populations studied (Zhang et al., 2006).
Prior to the death of their loved one, it is possible to identify adverse effects of bereavement and deliver preventive treatments to adult orphans. Health care practitioners working with dying adults may not themselves be equipped to provide preventive treatments; however, recognizing that adults at any age can be at risk during the death of the last parent may allow for anticipatory guidance, support, and appropriate referral.
Implications for Practice
Risk factors for poor adjustment among new adult orphans can be identified, along with preventive and therapeutic strategies to help with impending loss. Health care workers have a unique opportunity to identify and support orphaned adults through awareness, questioning, providing education and guidance, and making referrals when help seems to be needed. Reduction of human suffering is possible and, at times, crucial to preventing much more serious outcomes.
Grief symptoms, including sadness, distress, guilt, anger, intrusive thoughts, and preoccupation with the death, should be declining within approximately 6 months in a “normal” grieving process. Recent work with active duty and retired military personnel suggests that veterans with untreated grief can experience debilitating symptoms decades following a loss (Pivar, 2009). Although many of the soldiers studied may have witnessed traumatic, war-related deaths, the fact that time did nothing to abate the symptoms speaks to the need for clinicians to begin early identification and referral for the growing numbers of adult orphans who may be at risk.
Several instruments may be helpful in assessing complicated grief. The Inventory of Complicated Grief-Revised (Prigerson et al., 1995) and the Texas Revised Inventory of Grief (Faschingbauer, Zisook, & DeVaul, 1987) have been used in a variety of populations and allow comparisons with normative populations (Pivar, 2009). As the number of new adult orphans continues to grow, nurses, social workers, and other health care practitioners would seem to have the highest probability of identifying and helping those in need.
Nurses may lack time and resources to intervene with adult children of dying patients. However, adult orphans at risk for negative postbereavement outcomes may be helped by providing some anticipatory guidance related to the impending loss. Questions that may be appropriate to include while working with adult children include (Schulz et al., 2008):
- Who is the primary parental care provider?
- How is caregiving perceived?
- What is the availability of support from family and friends?
- How depressed and anxious is the adult child prior to the death of the parent?
- How prepared for the death of the parent does the adult child feel?
Opening the door to an awareness of some of the possibilities an adult orphan may face is a way for health care professionals to extend support from the end of life of the parent, to transition of the adult children’s lives. In some ways, this small act may be supportive to the health care professional as well.
As health care professionals are likely to interact with the dying patient’s caregiver, there are ways to reduce burden and try to prevent more suffering. These include assistance with referral for hospice care, help from social services with care coordination and preparations for death, referral for assessment of behavioral and pharmacological treatment, and referral to support programs, counselors, and other services.
For example, in northern Virginia, a support group called Good Grief (listed on http://www.inova.org/healthcare-services/life-with-cancer-program/types-of-services/support-and-education.jsp) is facilitated by a clinical social worker within the Inova® Health System with the purpose of helping group members cope with the changes in living that follow the death of a loved one. The 8-week group provides an opportunity for members to examine their grieving processes while addressing and managing life changes in a biopsychosocial and spiritual context. Groups like Good Grief assist with managing psychological distress and support functioning in many life domains.
Those newly orphaned adults most at risk for prolonged or complicated grief reaction may benefit from additional referral and from more structured therapeutic group experiences. Cognitive-behavioral therapy, for example, has been studied in randomized trials. Results indicate higher and faster rates of improvement with patients experiencing complicated grief. Repeated retelling of the story of the death, role-playing conversations with the deceased, and working on confronting painful situations have been cited as useful (Boerner, Schulz, & Horowitz, 2004).
Although many adult orphans successfully adapt to loss, others exhibit adverse outcomes, including prolonged grief disorder, depression, and anxiety. In primary caregivers, high levels of reported burden, physical exhaustion, and lack of social support—along with more commonly associated predictors, such as prebereavement anxiety and depression—are all associated with poor postbereavement outcomes. As increasing numbers of Baby Boomers become adult orphans, nurses, social workers, and other health care workers would benefit from a better understanding of the important role they can play in identifying individuals at risk, providing anticipatory guidance, and making appropriate referrals for those who need them.
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