Anticipatory Grief

Anticipatory grief is the response to a real or perceived loss before it occurs—a dress rehearsal, so to speak. One observes grief in preparation for a potential loss, such as loss of belongings (e.g., selling a home), moving (e.g., into a nursing home), or knowing that a body part or function is going to change (e.g., a mastectomy), or in anticipation of the death of a loved one. Behaviors that may signal anticipatory grief include preoccupation with the particular loss, unusually detailed planning, or a sudden change in attitude toward the thing or person to be lost.

If the loss is certain but the timing is either uncertain or it does not occur when or as expected, those awaiting the loss may become irritable or impatient, not because they want the loss to occur but in response to the emotional ups and downs of the waiting. Glaser and Strauss (1968) describe what they call an interruption in the sentimental order of a nursing unit when this occurs—no one quite knows how to behave. Family and friends as well as professional grievers, such as nurses, usually deal much more easily with known losses at a known time or in a set manner (Glaser and Strauss, 1968). Some individuals feel more in control of the situation because anticipatory grief facilitates planning and preparation for death by saying goodbyes in special ways (Zilberfein, 1999).

Anticipatory grief also can result in the phenomenon of premature detachment from an individual who is dying or detachment of the dying person from the environment. Pattison (1977) calls this premature withdrawal of others sociological death and premature withdrawal from loved ones prior to death psychological death. In either case, the person who is dying is no longer involved in day-to-day activities of living and essentially suffers a premature death.

Acute Grief

Acute grief is a crisis. It has a definite syndrome of somatic and psychological symptoms of distress that occur in waves lasting varying periods of time. These symptoms may occur every time the loss is acknowledged, others are informed, or another person offers condolences. Preoccupation with the loss is a phenomenon similar to daydreaming and is accompanied by a sense of unreality. Depending on the situation, feelings of self-blame or guilt may be present and manifest themselves as hostility or anger toward usual friends, depressive signs, or withdrawal.

It is often difficult for persons who are acutely grieving to accomplish their usual activities of daily living or meeting other responsibilities (functional disruption). Even if the tasks are accomplished, the person may complain of feeling distracted, restless, and “at loose ends.” Common, simple activities, such as dressing, that normally take a few minutes may take much longer. Deciding which clothing to wear may seem too complex a task. Fortunately, the signs and symptoms of acute grief do not last forever, or none of us could survive. Acute grief will be the most intense in the months immediately after the loss, with the intensity of feelings lessening over time. Acute grief is experienced at a national or global level after catastrophic events, such as the attack of the World Trade Centers in New York City or the Indonesian tsunami.

Chronic Grief

Grieving takes time, sometimes much longer than anyone anticipates. In most cases, the acute grief comes to some resolution as memories are reframed. For many, there is a lingering sadness referred to as shadow grief (Horacek, 1991). It may temporarily inhibit some activity but is considered a normal response. The intermittent pain of grief may be triggered by anniversary dates (birthdays, holidays, anniversaries) or by sensory stimuli, such as the smell of perfume, a color, or a sound (Box 23-1). For the survivors of major tragedies, war, or crime, the “shadows” may never completely go away. Persons may deal with this response to their loss in many different ways. Each year, individuals visit the Vietnam War Memorial in Washington, D.C., to remember and leave items that connect them to those who have died. Similarly, individuals make pilgrimages to the Wailing Wall in Jerusalem, praying and placing prayer papers in the crevices of the wall. In Mexico, the annual holiday “Day of the Dead” is a time when people visit the graves of their family members, leave food, grieve anew, and feel a renewed sense of connection with those who have died before them. These practices may instead be considered healthy and restorative for those who participate. Other chronic grief is a form of complicated grieving.

Complicated Grief

Some chronic grief is more than that of shadow and crosses over the boundary to what we call complicated grief. It has been thought that complicated grief begins with chronic, uncomplicated grief but that obstacles interfere with its evolution toward adjustment, so that the reestablishment of equilibrium is distrubed. The memories resist being reframed for many months and even years. Issues of guilt, anger, and ambivalence toward the individual who has died are factors that will impede the grieving process until these issues are resolved. Reactions are exaggerated and memories are experienced as recurrent acute grief—repeatedly, months and years later. Signs of possible complicated grief include excessive and irrational anger, outbursts in social settings, and insomnia that lingers for an extended time or surfaces months or years later. The grief may also trigger a major depressive episode. Cognitive difficulties that accompany a major depressive episode may be misinterpreted as dementia in the very frail and result in inappropriate treatment. This type of grief requires the professional intervention of a grief counselor, a psychiatric nurse practitioner, or a psychologist who is skilled in helping grieving elders (Corless, 2006).

Disenfranchised Grief

The person whose loss cannot be openly acknowledged or publicly mourned experiences what is called disenfranchised or unspeakable grief. The grief is socially disallowed or unsupported (Doka, 1989). The person does not have a socially recognized right to be perceived or function as a bereaved person. In other words, a relationship is not recognized; the loss is not sanctioned; or the griever is not recognized. Disenfranchised grief has frequently been associated with domestic partnerships (e.g., same-sexed partner) and marriages (e.g., bi-racial), in which the family of the deceased does not acknowledge the partner, or in secret relationships (e.g., extra-marital), in which the involved party cannot tell others of the meaning or depth of the attachment. Disenfranchised grief can also occur in situations of family discord, in which a member of the family is considered the “black sheep.” An unspeakable grief may follow a suicide or death due to AIDS. The person in late life can experience disenfranchised grief when family or friends do not understand the full meaning, for example, of a retiree’s retirement, the death of a pet, or gradual losses caused by chronic conditions. Families coping with a member who has Alzheimer’s disease may also experience disenfranchised grief when others perceive the death of the elder as a blessing and fail to support the griever or caregiver who has struggled for years with anticipatory grief and now must cope with the actual death.

Loss Response Model

If it is the time of impact (e.g., just after a new serious diagnosis, at the death of a family member, or as a new but resistant resident of a long-term care facility), nurses can provide support and a safe environment ensuring that basic needs, such as meals or rest, are met. While it is tempting to give advice at this time, it is more therapeutic to provide a grieving person permission to express feelings. The nurse can soften the despair by fostering reasonable hope, such as, “You will make it through one moment at a time, and I will be here to help.”

Nurses observe for functional disruption and offer support and direction in the immediate postcrisis period. They may have to help the family figure out what needs to be done immediately and find ways to do it—the nurse either offers to complete the task or finds a friend or family member who can step in so the disruption does not have any deleterious effects and movement toward equilibrium is possible.

As grievers search for meaning, they may need help finding what they are looking for and spend time talking it out. Sometimes what they are looking for is information about a disease, a situation, or a person, and the nurse can assist in obtaining the information whenever possible. Talking it out requires active listening when grievers are trying to make sense of the loss and find meaning in it, questioning their values, and constructing new ones to account for the change in their reality.

The expressions of grief and emotion, be they moments of panic or hysteria, and sharing them with others help make the grief less frightening. The nurse can help the person “feel it out.” Feeling it out is a cathartic experience. In many instances, the nurse facilities the griever’s expressions of hurt, anger, crying, and so forth. The nurse may have to say, “It’s okay to [have whatever feelings the griever has].” Sometimes it is a spiritual search and help is in the form of finding a resource or a place of peace, such as the chapel. Often, what is needed most is someone to listen to the existential and unanswerable questions, the “whys” and “hows.”

Sometimes nurses offer to inform others for the grievers, thinking that this is something that will help. Because it usually is therapeutic for grievers to talk to others about the losses, nurses should refrain from helping in this way. Instead, the nurse can offer to find a phone number or hold the griever’s hand during the conversation or just “be there” when the news is being shared. In this way, the nurse provides support when the griever’s emotions engage.

As the person or family moves toward equilibrium after a loss, be it a death, a move from home to a nursing home, or other change with meaning, the nurse can help the person reorganize this new life. The nurse talks with the elder about what was most valued about living at home and what habits were comforting and finds ways to incorporate these in a new way to the new environment. For example, if the person always had a cup of tea before bed but now does not have access to a kitchen, “cup of tea at h.s.” can become part of the individualized plan of care.

For the cycle of grieving to reach some level of resolution, new memories are needed. The grandmother who had always hosted her eldest daughter’s birthday party can still do that even if she is now a resident in a long-term care facility. When the nurse has the information about this important ritual, he or she can help the person reserve a private space within the facility, send out invitations, and have the birthday party as always but now reframed as it is catered by the facility in the elder’s new “home.”

Reminiscence is often helpful in creating new memories (see Chapter 6). Listening to the story, endlessly repeated, is difficult to do. The story is likely to change with each retelling as new memories or perspectives develop. Reminiscence is a means by which denial can fall by the wayside and allow reality of the loss to filter slowly into the conscious mind. Reminiscence helps the griever acknowledge that the loss is indeed real and that life can go on, even though the future may be experienced in a different way.

By incorporating the loss and putting the deceased into the life story in a new way (re-forming the story), energy can be invested in all other relationships that exist or may come to be. Drawing out anecdotes and vignettes of the relationship helps the griever keep control over the story of his or her life and reframe it into a new, updated memory. Encourage the griever to talk and tell the story of the relationship as it had been.

The nurse’s role is also as an advocate who displays the behavioral qualities of responsiveness, authenticity, commitment, and competence, that is, caring (Krohn, 1998) (Table 23-1).

Countercoping

Weisman (1979) described the work of health care professionals related to grief as “countercoping.” Although he was speaking of working with people with cancer, it is equally applicable to working with people who are grieving for other losses. “Countercoping is like counterpoint in music, which blends melodies together into a basic harmony. The patient copes; the therapist [nurse] countercopes; together they work out a better fit” (Weisman, 1979, p. 109). Weisman suggests four specific types of interventions or countercoping strategies: (1) clarification and control, (2) collaboration, (3) directed relief, and (4) cooling off.