Processes of adjustment to end-of-life losses: a reintegration model

The processes surrounding psychological adjustment to losses due to advancing and end-stage illness have not been well delineated. While adjustment to losses due to death are often thought of as the bereaved's lot, dying persons experience multiple, accumulating, and profound losses of functions, abilities, roles, and relationships and therefore have to adjust as well. Many people who are facing death in the near future negotiate these losses, still achieving quality of life in all dimensions. Others fare less well. It is hard to intervene helpfully without a clear understanding of how either trajectory occurs. Building from current literature on loss and adjustment, we describe a conceptual framework of key adjustment processes that allow for quality of life during terminal illness. We term this the reintegration model. It has comprehension, creative adaptation and reintegration components, each involving the physical, psychological, social, and existential domains in ways that are characteristic of the needs, tasks and options available to a seriously ill and dying person. In this paper, we discuss the model, focusing on normal adjustment processes, and describe the implications of the framework for the dying person, caregivers, and the palliative care team.