Commentary
American Journal of Hospice
Anticipatory Grief: A Mere Concept?
Paul J. Moon, PhD1
Abstract
Anticipatory grief (AG) has been studied, debated, and written about for several decades. This type of grief is also recognized in
hospice and palliative care (HPC). The question, however, is whether the reality of AG is sufficiently upheld by professionals at
the point of concrete service delivery. In other words, is AG a mere concept or is everyday practice of HPC duly informed of
AG as evidenced by the resulting care delivery?
Keywords
anticipatory grief, hospice, palliative care, loss, complicated grief, reflective practice
Anticipatory grief (AG) has been studied, debated, and written
about for several decades. This type of grief is also recognized
in hospice and palliative care (HPC). Since Lindemann’s pub-
lication in 1944,1 AG has gained traction in terms of becoming
a commodity in the discourse among professionals in related
arenas of research and practice.
The question, however, is whether the reality of AG is suf-
ficiently upheld (or esteemed) by professionals at the point of
concrete service delivery. In other words, is AG a mere con-
cept (a stationary item in professionals’ minds) or is everyday
practice of HPC duly informed of AG as evidenced by the
resulting care delivery? The concern is that AG may predomi-
nantly remain a mere concept in the field of HPC instead of an
operationalized reality.
Anticipatory Grief Background
Lindemann, a psychiatrist, coined anticipatory grief in his oft-
referenced article.1 In that piece, an instance is described where
a soldier returning home from deployment is thoroughly
rejected by his wife, which is attributed to the wife’s processing
of AG toward psychoemotionally relinquishing the marital
relationship. In other words, the wife worked through the antic-
ipation of her husband’s unlikely return home from war to such
a degree that reestablishing the living bond, when he survived
the mission and reappeared at stateside, became an ordeal. For
clarity, Lindemann’s illustration will make more sense in light
of his understanding that the aim of grief process was to eman-
cipate (sever) the relational bond to the died person.1 This
is what has traditionally been called grief work, a Freudian
notion.
In history, there has been a distinction between a family
member’s AG and AG of the sick (or dying) person. Kubler-
Ross mentioned preparatory grief of the dying person.2 Pre-
paratory grief is conceived as AG experienced by the dying
& Palliative Medicine®
2016, Vol. 33(5) 417-420
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patient. The range of dynamics may be similar to AG, but dis-
similar issues exist such as a dying person grieving the separa-
tion from multiple persons versus a single person from AG
person’s stance3 as well as a gravely sick person grieving literal
losses of body part, body function, future possibilities on earth,
and so on as opposed to vicarious losses from AG person’s
perspective (see subsequently on Rando).
As AG was considered more in depth over time, ques-
tions emerged concerning the notion, including contesting
its validity and function.4 For instance, the validity of the
very construct of AG has been considered suspect, by some,
due to seeming difficulties and lack of distinct uniformity
regarding its definition, scope of experiential phenomenol-
ogy (subjective experiences), and an elusive nature of being
duly measureable.4 In fact, a string of disputations has been
raised by some in the field to counterarguments for the exis-
tence and advancement of AG. Ranging from the complex-
ity of individual differences in perception, belief system,
and grief processing styles4,5 as well as kinship type to the
sick person,6 AG, on some level, can be a ghostly concept
to demarcate. Also, it has been asserted that AG is funda-
mentally different than postloss (or bereavement) grief.7,8
Moreover, it may seem that uncritical presumptions of ‘‘lin-
earity of mourning,’’4(p349) a step-wise perspective of human
grief,2,3 and a predictable static cultural ambience4 may
have shaped the notion of AG.
Another vein of debate has been whether AG has a salutary
impact upon postloss grief. Although studies exist positing
1
Alacare Home Health & Hospice, Birmingham, AL, USA
Corresponding Author:
Paul J. Moon, PhD, Alacare Home Health & Hospice, 2400 John Hawkins
Parkway, Birmingham, AL 35244, USA.
Email: paul.moon@alacare.com
418
correlations between AG and postloss grief,9 the evidence of
the nature of correlations appears to be mixed.8 For instance,
it is no mystery that personal differences and cultural forces
will be part and parcel of the algorithm of grief in both pre-
and postloss domains.5,10,11 Thus, given the diversity of per-
sonal backgrounds, traits, and propensities, not to mention
cultural rules, orientations, and customary practices, it is of
little doubt the study of AG will produce an array of findings.
It seems how AG impacts postloss grief continues to be a
motley state of affairs.12-14
However, even in light of opposing argumentation, the logic
of AG may yet hold value. Although some have opined ambi-
guity of the moniker itself (AG),14 the sensibility of grieving
prior to an expected loss of some significance rings true to lived
experiences. On explaining AG, Rando (preferring anticipatory
mourning)14 stated how it is not only impending death loss that
pertains to AG but also nondeath losses, such as body parts
(amputation, etc), body functions (incontinence, etc), personal
abilities (ambulation, memory, etc), certain future plans, unre-
solved issues, and a host of additional circumstances in the per-
sonal world of a gravely sick person and his or her significant
others. Further, although ‘‘forewarning of death’’13(p23) does
not automatically trigger AG in a person, there is empirical
evidence that persons who act on such foreknowledge may
experience an easing (to varying degrees) of the intensity of
postloss grief.15
More recently, further nuances of AG have been asserted,
namely, current absence and future absence. The former relates
to a family member’s AG due to the current absence of the sick
person in home environment because of admission into a facil-
ity. The latter type relates to the classical notion of AG, which
is projecting into future (pending) losses.16 Both current and
future absences are applicable to everyday HPC practices. As
such, along with other aspects delineated previously, there is
viable reason to perceive that AG is a real dynamic to be mind-
ful of when interacting with care recipients.
Anticipatory Grief and Complicated Grief
It is worthy to briefly note the potential relationship between
AG and complicated grief (CG). But first, in considering CG,
the notion remains under debate.17 What Freud alluded to as
melancholia (a pathological condition),18 but now referenced
as prolonged grief disorder19 or CG,20 the recent publication
of Diagnostic and Statistical Manual of Mental Disorders V
includes the disorder of Persistent Complex Bereavement,
marked as an item for further study.21
The issue of CG must be considered with care as theoretical
and empirical evidences are mixed. As Hippocrates is recog-
nized for cautioning how ‘‘it is more important to know what
sort of person has a disease than to know what sort of disease
a person has,’’22(p174) so it may be more important to know the
person who is bereaved than the type of bereavement the per-
son is faced with. Indeed, it cannot be denied that even with
what can be codified as severe or traumatic loss (eg, death of
a child), not all such grievers have CG.23-25 Specifically, grief
American Journal of Hospice & Palliative Medicine® 33(5)
itself may not be the rudimentary culprit of CG but rather per-
sonal differences and the ‘‘presence of antecedents,’’26(p2) such
as extant psychiatric conditions, previously unresolved losses,
neurotic tendencies, inchoate perspective of reality, avoidant
coping style, and so on. As a result, with particular persons fac-
ing losses, their overt grief process may be complicated and
exacerbated by already existing (perhaps latent) underlying
issues, rather than the grief dynamic generating or contracting
(from external environment) any new dysfunction or syndro-
mic elements. Thus, it may not be grief, per se, that needs tend-
ing to but rather the substrate of extant issues ‘‘complicating’’
the perceived loss.
Albeit the still equivocal picture concerning the phenom-
enon of CG, it can nevertheless be postulated as to the logic
of how a harsh or negative AG experience may redound (in
like terms) over into postloss grief (and, inversely, a healthily
processed AG experience may have an ameliorative effect
upon postloss grief). Again, related literature contains some
evidence of AG impacting subsequent postloss grief.27 In fact,
a recent literature review indicates that a lack of AG processing
can be a possible risk factor for (postloss) CG.28 Moreover, it is
averred that unresolved preloss (or predeath) grief can contrib-
ute to particularly distressful grief episodes even years after a
death event.29 In this way, the grief trajectory from AG to post-
loss grief may be conceptualized as a continuum, hence the
vital importance of giving attention to persons during the spec-
trum of circumstances involving movement from AG to
bereavement toward minimizing preventable complications
of postloss grief.
Anticipatory Grief Dynamics in HPC Practice
It is argued here that there is crucial overlap in symptomology
between AG and postloss grief. Among a vast array of com-
mon and idiosyncratic AG presentations, the following may
be of particular impact in context of caregiving interactions.
For instance, given AG signs of changes in appetite and sleep
patterns, energy level (fatigue), fear, anxiety, or helpless-
ness,12 it is worthwhile to carefully distinguishing between
AG and clinical depression. Case in point, psychotropic med-
ication dispensed to someone undergoing the natural process
of preparatory grief or AG may not be indicated.3 Indeed,
‘‘grief per se rarely requires pharmacologic intervention.
Inappropriate use of antidepressants or anxiolytics for treating
grief may result in iatrogenic complications that have little,
if any, benefit.’’30(p885) Moreover, inadvertent (iatrogenic)
effects of being prescribed medication can potentially affect
a person’s cogitations and self-perceptions, along with dam-
pening the true emotions and affective displays that may
usefully serve to arouse necessary responses from other
important persons involved.
Another cluster of AG symptoms concerns forgetfulness,
compromised attention, and difficulty concentrating or deci-
sion making.12 In HPC situations, some sick persons and (more
frequently) family members are provided specific information
and asked to render a range of important decisions, many of
Moon
which can be laden with intense emotions. As may be obvious,
the sick persons and family members are dealing with a frus-
trating tension in that HPC professionals functionally demand
answers during a time of AG (progressive loss), whereby
clarity of mind is hard to muster or adequate concentration and
deductive/inductive skills for decision making can be lacking.
What is called for in this instance is the extending of patience,
sympathy, reassurance, and gentle repetition of clarification
by HPC professionals regarding the response-requiring issues
at hand (for additional key factors to help prepare families for
impending death, see Kehl).31 Moreover, simple yet clear
information on AG dynamics can be provided by HPC profes-
sionals to care recipients, and this type of education or presen-
tation can potentially assuage care recipients’ burden to some
degree.9
Relatedly, the value of advance directives or preparatory
conversations on end-of-life care issues is here underlined,
given AG dynamics that can potentially hamper decision-
making capacity. However, even certain predated decisions
are not altogether static but can be fluid in nature, depending
on the circumstances at any given moment. As such, even
appropriately laid plans, based on seemingly productive con-
versations in the past, may be subject to alterations, if not
altercations. The dynamics of AG may disturb lucidity when
it may be most needed.32
Anticipatory Grief of HPC Professionals
and Care Recipients
The HCP professionals, who are conscientious of others’ AG
syndromes, can be of substantial help during the distresses of
visible decline and sorrow. This AG awareness may be framed
in 2 ways, namely, professionals’ AG and care recipients’ AG.
Regarding the first, professionals’ personal vulnerabilities must
be self-admitted in terms of its reality and significance.33
Anticipatory grief, in this instance, can influence professionals’
decision making as well as interactional approach with dying
persons and family members.34 Continued self-monitoring,
along with supervisory and peer support, can assist toward
obviating professionals’ misjudgments. Practical exercises to
process professionals’ AG may be via purposefully scheduled
staff support group discussions and writing subjectivity
statements.35 These types of activities are recommended for
purposes of debriefing select loss experiences (for sake of
making sense of perceived loss and gaining psychoemotive
support from others)32 as well as to prepare for continuing
HPC work by intentionally tending to identifiable current
complex or unresolved grief dynamics, as cumulative losses
can influence future grief bouts via mechanisms of delayed
or masked grief reactions.3
As for care recipients’ AG, HPC professionals must remain
alert and cognizant of this dynamic. As part of AG which dying
persons and family members may experience, there can be
cloaked or hidden issues straining both parties, such as fear
of abandonment, differing styles of grieving and communicat-
ing, anhedonic variances,36 and the meanings and displays of
419
hope. These are all issues that may plague AG and, to further
complicate matters, can present themselves incongruently in
terms of timing, quality, and degree between dying persons and
their significant others (eg, a dying person espousing the hope
of rest by foregoing curative treatment and its physical impacts,
while the next of kin clings to hope for complete cure via a push
for ongoing curative efforts, and this differential in hope can
inhibit open dialogue; a dying person struggling with ines-
capable fatigue that a family member misinterprets as either
anticipatory or consummatory anhedonia, and, as a result, feels
personally dejected).37 Professionals who observe such intrafa-
milial transactions can tactfully intervene to help clarify each
party’s meaning or contextualize their AG ambience. This type
of intervention will necessitate HPC professionals to become
conversant in AG concepts as well as hone the skills of parti-
cipatory observation (observing family dynamics in the midst
of engaging with them versus only impersonally observing),
inquisitive listening, collaborative conversation (vs didactic,
1-way information disclosures), and a useful degree of emotive
involvement (applying reflective practice31 and reflection-
in-action38,39). Although adopting these skills will take time
to develop and nurture, the payoff will be a higher level of
HPC service delivery, which in turn can enrich professionals’
self-concept and sense of vocational reward.
Concluding Thoughts
The issue of AG, it is here argued, is no mere concept but an
active dynamic in the midst of HPC scenarios. When HPC pro-
fessionals are not attentive then AG presentations may be mis-
construed as care recipients’ dismissing attitude, disrespect,
disinterest, or clinical depression. Expanding professionals’
knowledge on AG, its dimensions and practical implications,
may lend to framing care delivery actions that will generate
an atmosphere of increased patience and compassion in which
dying persons and their significant others can make better
choices and communicate. This would contribute toward
improving both hospice care and palliative care.
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author received no financial support for the research, authorship,
and/or publication of this article.
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