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Palliative Care Perspectives : Chapter 7: Psychosocial and Spiritual Aspects of Care : Anticipatory (Preparatory) Grief

Kübler-Ross used the term preparatory grief explicitly in reference to the grief experienced by the dying person. Since then, the term anticipatory grief (or anticipatory mourning by Rando) has been more widely used and refers to grief and mourning before death for both patient and significant others.

Preparatory grief is the grief "that the terminally ill patient has to undergo in order to prepare himself for his final separation from this world."18 Anticipatory grief occurs both in the dying and in those close to them.19,20 Anticipatory grief is a normal grief reaction to perceived loss during the dying process. Dying people (and their loved ones) prepare for death by mourning the various losses implicit in the death. The anticipated loss of loved ones is obvious. The simple pleasures of living may also be grieved. The term anticipatory (or preparatory) grief is somewhat confusing. It is not as simple as preparing for a special event, such as a wedding, in the future. People are not preparing to grieve at some time in the future, they are grieving in the present, relative to a process of loss currently being experienced and projected into the future.

In facing death grieving people pay a great deal of attention to both the past and the future. In looking back, people often carefully examine themselves, the person(s) being lost, their relationships, their accomplishments, and their missed opportunities. It is as if they are reviewing a long story they have created, one full of heroes and villains, tragedy, comedy, and romance. How well was this story written? In this person's death, how will it end? If impending death is viewed as coming prematurely, part of the grief process can be thought of as a rewriting of this story.21

It seems most of us build our stories based on an optimistic story line in which we and our loved ones "live happily ever after." At some point, sometimes abruptly, sometimes gradually, this story line is challenged, with something like a "blank page" being introduced into the story.22 Patients and families may initially experience chaos in response to this blank page. A normal response to such chaos is to try to reconstitute the original story line and to get back on track.1 If reconstitution fails or is obviously impossible, then rewriting must begin anew. This rewriting does not begin on page one but must take up where the blank page has been introduced (although remembrance and interpretation of past events may change in light of the introduction of the blank page). Thus, people in grief engage in creating new story lines and new endings for stories begun years before. Major characters and their traits have been well defined. How they respond to this challenge of loss will be shaped by these traits. In this process hidden strengths and weaknesses may be exposed. The plot must be rewritten to accommodate an ending in which everybody does not live happily ever after. This process of rewriting is the work of grief.

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Keywords: anticipatory grief, preparatory grief
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Palliative Care Perspectives

James L. Hallenbeck, M.D.

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Copyright © 2003 by Oxford University Press, Inc.

The online version of this book is used with permission of the publisher and author on web sites affiliated with the Inter-Institutional Collaborating Network on End-of-life Care (IICN), sponsored by Growth House, Inc.