Introduction    Grief is a normal response to loss, any loss: a job, a limb, a life. Clinicians have an important role in facilitating healthy grieving, and observing for signs of complicated grief.  Grief experienced by dying patients and loved-ones prior to and in anticipation of death is called anticipatory grief (or mourning); grief of loved-ones following a death is termed bereavement.  This Fast Fact provides an overview of grief and bereavement. 

What is Grief?   Grief is a normal response to loss that involves processes and tasks at emotional, cognitive and behavioral levels. The initial shock of learning of impending or actual loss evolves into a process of creating a new relationship between the grieving person and the person (or object) of loss.  Grief tends to be experienced in waves, triggered predictably by new losses (such as a loss of functional status) or unpredictably, by seemingly trivial events. Over time the intensity of these waves tends to decrease. Grief does not have a set schedule; individuals progress through the grief process at different speeds. However, no progress, getting stuck in one phase of grief, can be cause for concern. 

What is Anticipatory Grief?    Anticipatory grief for patients involves reviewing one’s life; for families/friends it means looking to a future without the dying person. Byock has suggested that patients and families may wish to say to each other, in some way, “Forgive me, I forgive you, thank you, I love you and good-bye.” People from different cultural backgrounds may differ in terms of how and what they want to say or do in preparation for death.  Not knowing or acknowledging that a person is dying will likely delay or interfere with normal anticipatory grief.  Grief reactions in dying patients may be confused with pain, depression, and even imminent death (e.g. social withdrawal may imply pain, depression, or anticipatory grief).

Distinguishing Grief from Depression    Neither pain nor depression are normal aspects of the dying experience, they should be carefully evaluated as both are treatable (See Fast Fact #43).   Grief tends to be experienced as sadness, whereas depression is associated with lack of self-worth. The question, “Are you sad or are you feeling depressed?” may help begin a dialog to help you distinguish between grief and clinical depression.

What is Complicated Grief?    About 10-20% of the bereaved can experience a persistent or prolonged period of intense loss.  There is debate regarding the precise diagnostic criteria for complicated grief and duration of symptoms (see Fast Fact # 254 for further information).  However, insecure attachment styles, weak parental bonding in childhood, childhood abuse and neglect, female gender, low perceived social support, supportive marital relationships, and low preparation for the loss are all felt to be risk factors. 

What can the physician do to facilitate normal grieving?

Be honest when discussing prognosis, goals and treatment options; nothing inhibits normal anticipatory grief more than ambiguity from the physician. Listen; open the door to meaningful discussion.  Ask, “How are you doing with this recent news?” “Are you scared?” “Tell me what is going through your mind?”  Ask for help – you are not the only health professional available to help with grief.  Contact a nurse, social worker, chaplain or psychologist/psychiatrist if you need assistance.  Assess for and aggressively treat pain and depression.

References

1. Byock I. The Four Things that Matter Most. New York, NY: Simon & Schuster; 2004.
2. Markowitz AJ, Rabow MW. Caring for bereaved patients: “All the doctors just suddenly go.” JAMA.  2002; 287(7):882. 
3. Rando TA. Clinical Dimensions of Anticipatory Mourning. Champaign, IL: Research Press; 2000.

Version History:  This Fast Fact was originally edited by David E Weissman MD.  2nd Edition published August 2005; 3rd Edition May 2015. Current version re-copy-edited March 2009; then again May 2015.