The grieving process starts long before the patient’s actual death and is known at that point as anticipatory grief. Grief takes many forms and requires ongoing assessment of both patient and family — starting the moment a patient learns he has a terminal condition.

Grief may be accompanied by many other emotions, including depression and anxiety, which also need assessment and follow-up. Factors that influence the grief response include age, culture, prior losses, the quality of the relationship with the dying person, the time to prepare for the death, and the resolution of past issues.

Grief responses are highly individualized and dependent in part on personal coping skills. In certain circumstances, grief may become chronic, delayed, exaggerated, or masked. This is known as a complicated grief reaction. (See Risk factors for complicated grief reactions, page 80.) Social workers sometimes have official responsibility for monitoring patient and family coping status. However, it’s an ongoing task of the entire palliative care team to identify and manage risk factors for particular difficulties and complications as a patient grieves his situation and the family grieves their impending loss. Keep in mind that some family members experience great relief when the suffering of their loved one ends in death.

Maintaining open lines of honest communication with the patient and family members is a central part of palliative care and is critical to developing a trusting relationship. Giving the patient and family some control over the time, place, and content of each discussion helps to build trust and rapport.
At times, the patient may want to talk only with you about the impact of his terminal illness. At other times, he may want you to lead the whole family in a discussion that helps them clarify their own responses to the loss.

If possible, set aside uninterrupted time to be with the patient. (See Finding time to talk.) Help the patient clarify his issues of loss and explore his feelings at a deeper level. Practice being comfortable with periods of silence, and don’t rush to fill gaps in the conversation. (If this is difficult for you, try role playing with another nurse.) Sometimes, patients may need your silence and a caring presence more than a discussion.

Usually, asking directly is the best way to determine the level of the patient’s anxiety. You also may be able to observe some evidence. Common
indicators of anxiety include muscle tension, irritability, and obsessive statements or behaviors. Some patients may deny being anxious but display these signs. Others will openly express their fears and may even complain of feeling panicked or out of control of their emotions around their loved ones.

You and the entire palliative care team can help the patient and family cope with anxiety by exploring how they’ve successfully coped with stress in the past. Encourage the patient to recall examples, especially humorous ones, of past problems and how the patient handled them. These interventions can serve both as opportunities for reminiscing about past life accomplishments and reminders that anxiety can be overcome.

Other interventions that the team can use to help the patient manage anxiety include reassuring the patient and family that anxiety is common and manageable. Reinforce the use of behavioral strategies that the patient has used in the past to cope with anxiety (prayer, family discussions, journaling, humor, distracting and pleasurable activities such as family visits and movies or books). Suggest complementary therapies, such as massage, meditation, or music. Another great antidote for anxiety is exercise or physical activity if the patient is able.

When a patient’s anxiety is beyond the level of self-management strategies, an anxiolytic — usually a benzodiazepine — may be helpful.

During initial and ongoing assessments, look for indications that a patient or family members could be experiencing depression. Common signs and symptoms include:

Various approaches are available to screen for depression. If you aren’t using a standardized tool, use simple but direct questions as your assessment. Even a question as simple as, “Do you feel depressed?” can be very effective in assessing a patient’s level of depression.

The management of depression in palliative care patients includes both drug and psychological therapy. Drugs may include selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and other psychostimulants. SSRIs are safer and have fewer adverse effects. However, it may take weeks for either SSRIs or TCAs to provide significant therapeutic effects. Psychostimulants such as methylphenidate (Ritalin) or dextroamphetamine (Dexedrine) may be more useful for providing better quality of life when time is short. Corticosteroids such as prednisone have a euphoric effect and stimulate appetite; they may be useful in short-term situations. Nondrug interventions include supportive counseling, spiritual counseling, and ongoing monitoring of the patient’s mental state. Complementary therapies

such as massage may also prove beneficial in a comprehensive plan to manage depression.