Anticipatory grieving is a state in which an individual grieves before an actual loss. It may apply to individuals who have had a perinatal loss of a body part or to patients who have received a terminal diagnosis for themselves or a loved one. Intense mental anguish or a sense of deep sadness may be experiences by patients and their families as they face long-term illness or disability. Grief is an aspect of the human condition that touches every individual, but how an individual or a family system responds to loss and how grief is expressed varies widely. That process is strongly influenced by factor such as age, gender, and culture, as well as personal and intrafamilial reserves and strengths. The nurse must recognize the anticipatory grief is real grief and that, in all likelihood, as the loss actually occurs, it will evolve into grief based on an accomplished event. The nurse will encounter the patient and family experiencing anticipatory grief in the hospital setting, but increasingly, with more hospice services provided in the community, the nurse will find patient struggling with these issues in their own homes where professional help may be limited or fragmented. This care plan discusses measures the nurse can use help the patient and family members begin the process of grieving.
Grief is the emotional reaction to loss or perceived loss (is felt by the person but is intangible to others; loss of youth, financial independence, and of a valued environment), anticipatory loss, in which a person displays loss and grief behaviors for a loss that has yet to take place. Individual diagnosis with severe diseases perceives a threat to life, health, self-esteem and role. The threat may be viewed as a loss or potential loss. Grief is the process of making loss a reality. Anyone experiencing or perceiving a loss must grieve. The actual grief process may begin with anticipation for the loss.
Neal, et al, 2004; Gulanick, 2007; Taylor, et al, 2005
Intervention and Rationale
I: Assess emotional state. Note cultural beliefs, expectations.
R: Anxiety and depression are common reactions to changes/losses associated with long-term illness or debilitating condition. In addition, changes in neurotransmitter levels (e.g., increased monoamine oxidase [MAO] and serotonin levels with decreased norepinephrine) may potentiate depression in elderly patients. Personal expectations may affect response to change.
I: Determined as to what stage is the client in grieving.
R: To provide appropriate care.
I: Denial: Be aware of avoidance behaviors: anger, withdrawal, and so forth. Allow client to talk about what he or she chooses, and do not try to force client to face the facts;
R: Denying the reality of diagnosis and/or prognosis is an important phase in which client protects self from the pain and reality of the threat of loss. Each person does this in an individual manner based on previous experiences with loss and cultural/ religious factors.
I: Anger: Note behaviors of withdrawal, lack of cooperation, and direct expression of anger. Be alert to body language and check meaning with client, noting congruency with verbalizations. Encourage/allow verbalization of anger, acknowledge feelings, set limits regarding destructive behavior;
R: Denial gives way to feelings of anger, rage, guilt, and resentment. Client may find it difficult to express anger directly and may feel guilty about normal feelings of anger. Although staff may have difficulty dealing with angry behaviors, acceptance allows patient to work through the anger and move on to more effective coping behaviors.
I: Bargaining: Be aware of statements such as . . . if I do this, my problem will be fixed. Allow verbalization without confrontation about realities;
R: Bargaining with care providers or God often occurs and may be helpful in beginning resolution and acceptance. Patient may be working through feelings of guilt about things done or undone.
I: Depression: Give client permission to be where he or she is. Provide hope within parameters of individual situation without giving false reassurance. Provide comfort and availability, as well as caring for physical needs;
R: When patient can no longer deny the reality of the loss, feelings of helplessness and hopelessness replace feelings of anger. Client needs information that this is a normal progression of feelings.
I: Acceptance: Respect clients needs and wishes for
quiet, privacy, and/or talking.
R: Having worked through the denial, anger, and depression, client often prefers to be alone and does not want to talk much at this point. Client may still cling to hope, which can be sustaining through whatever is happening at this point.
I: Review past life experiences/ previous loss, role changes and coping skills, noting strengths/ success.
R: Useful in dealing with current situation and problem solving existing needs.
I: Make time to listen to client. Encourage free expression of hopeless feelings and desire to die.
R: It is more helpful to allow these feelings to be expressed and dealt with than to deny or ignore them.
I: Assess suicidal potential.
R: May be related to physical disease, social isolation, and grief. Note: Studies indicate women are three times as likely to attempt suicide; however, men are three times as likely to succeed.
I: Involve SO in discussions and activities to the level of their willingness.
R: When SOs are involved, there is more potential for successful problem solving. Note: SO may not be available or may not choose to be involved.
I: Provide liberal touching as individually accepted.
R: Conveys sense of concern/closeness to reduce feelings of isolation and enhance sense of self-worth. Note: Touch may be viewed as a threat by some patients and escalate feelings of agitation/anger.
I: Identify spiritual concerns. Discuss available resources and encourage participation in religious activities as appropriate.
R: Search for meaning is common to those facing changes in life. Participation in religious/spiritual activities can provide sense of direction and peace of mind.
I: Assist with/plan for specifics as necessary (e.g., Advance Directives to determine code status/Living Will wishes, making of will, funeral arrangements if appropriate).
R: Having these issues resolved can help client/SO deal with the grieving process and may provide peace of mind.
I: Provide an open, nonjudgmental environment. Used therapeutic communication skills of active listening acknowledgment.
R: Promotes and encourages realistic dialogue about feeling and concerns.
I: Encourage verbalization of thought/concerns
R: Client may feel supported in expression for feelings by the understanding that deep and often conflicting emotions are normal and experienced by others in this difficult situation.
I: Reinforced teaching regarding disease process and treatments and provided information as requested.
R: Client/significant others benefits from factual information. Individuals may ask direct questions and honest answers promote trust and reassurance that corrects information will be given.
I: Provided realistic information about health status without false reassurance or taking away life
R: Defensive retreat occurs weeks to months after loss. Pt attempts to maintain what he has been lost; denial, wishful thinking, unwillingness to participate in self-care and indifference may be seen.
I: Recognize that each client is unique and will progress at own pace.
R: Time frames vary widely. Cultural, religious, ethnic, individual differences impact on manner of grieving.
I: Establish rapport with client and significant others. Listen and encourage pt significant others to verbalize feelings.
R: This open lines of communication and facilitate successful resolution of grief.
I: Accepted need to deny loss as part of normal grief process.
R: Realization occurs weeks to months after loss. Reality continues to be over whelming sadness, anger, guilt, hostility may be seen.
I: Be honest in answering questions, providing information.
R: Enhances sense of trust and nurse-client relationship.
I: Discuss issues, such as what is in the power of the individual to change and what is beyond control.
R: Recognition of these factors helps client focus energy for maximal benefit/ outcome.
Doenges, et al, 2002, Gulanick, 2007; Kruse, et al, 2003