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Grief

Table of Contents

Grief is the natural response to loss—whether of a loved one, a relationship, a job, or even physical function. Clinicians play a vital role in supporting healthy grieving and identifying when grief becomes complicated.

  • Anticipatory grief (mourning): The grief experienced by patients and families before and in preparation for death.
  • Bereavement: The grief experienced by loved ones after a death.

What Is Grief?

Grief is a normal process that affects emotions, thoughts, and behaviors. It begins with the shock of loss and evolves into reworking the relationship with the person—or object—lost. Grief often comes in waves, sometimes triggered predictably and other times by seemingly minor events. Over time, the intensity of these waves usually lessens.

Grief has no fixed timeline. Each individual progresses at their own pace. Concern arises when someone becomes “stuck” and shows little or no movement through the grief process.

What Is Anticipatory Grief?

For patients, anticipatory grief may involve reviewing life and preparing for death. For families, it often means imagining a future without the dying person. Ira Byock suggests five important messages to exchange: “Forgive me, I forgive you, thank you, I love you, and good-bye.”

Cultural differences shape how individuals prepare for death. Lack of awareness or acknowledgment of impending death may interfere with anticipatory grieving. Significantly, grief-related behaviors in dying patients (e.g., social withdrawal) may be misinterpreted as pain, depression, or even imminent death.

Distinguishing Grief from Depression

Neither pain nor depression is a “normal” part of dying; both should be assessed and treated

  • Grief is primarily sadness.
  • Depression includes persistent hopelessness and loss of self-worth.

A useful clinical question: “Are you sad, or are you feeling depressed?”

What Is Complicated Grief?

Approximately 10–20% of bereaved individuals experience prolonged, intense grief—sometimes called complicated or prolonged grief disorder. Risk factors include:

  • Insecure attachment styles or poor childhood bonding
  • Childhood trauma, abuse, or neglect
  • Female gender
  • Low perceived social support
  • Strong dependency within marital relationships
  • Limited preparation for the loss

How Can Clinicians Support Healthy Grieving?

  • Communicate honestly about prognosis, goals, and treatment options. Ambiguity disrupts anticipatory grief.
  • Listen actively: Ask open questions such as, “How are you coping with this news?” or “What worries you most right now?”
  • Engage the team: Nurses, social workers, chaplains, psychologists, and psychiatrists can all provide valuable support.
  • Treat symptoms: Address pain and depression promptly and aggressively.

References

  • Byock I. The Four Things That Matter Most. New York: Simon & Schuster; 2004.
  • Tantrarungroj, T., Ocharoen, P., & Sachdev, V. (2022). Grief reaction, depression, anxiety, and coping of relatives after palliative patients’ death in Thailand. PLoS One, 17(10), e0276583.
  • Markowitz AJ, Rabow MW. Caring for bereaved patients: “All the doctors just suddenly go.” JAMA.2002;287(7):882.

Rando TA. Clinical Dimensions of Anticipatory Mourning. Champaign, IL: Research Press; 2000.