Mary Leslie Caldwell,
Charlotte Razvi, RN, MSN, PhD
Deidra Gradishar, RNC, BS
NANDA: Intellectual and emotional responses and behaviors by
which individuals work through the process of modifying self-concept based on
the perception of potential loss
Anticipatory grivien is a state in which an individual grieves
before an actual loss. It may apply to individuals who have had a perinatal
loss or 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 experienced 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 factors such as age, gender, and culture, as well as personal and
intrafamilial reserves and strengths. The nurse must recognize that
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 patients 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 to help patient and family members
begin the process of grieving.
- Perceived potential loss of any sort
- Perceived potential loss of physiopsychosocial well-being
- Perceived potential loss of personal possessions
- Patient and family members express feelings reflecting a sense
- Patient and family members begin to manifest signs of grief
- Denial of potential loss
- Anger or hostility
- Changes in eating habits
- Alteration in activity level
- Altered libido
- Altered communication patterns
- Distortion of reality
Patient or family verbalizes feelings, and establishes and
maintains functional support systems.
- (i) independent
- (i) Identify behaviors suggestive of the
grieving process (see Defining Characteristics).
- Manifestations of grief are strongly influenced by factors
such as age, gender, and culture. What the health care provider observes is a
product of these feelings after they have been modified through these layers.
The health care provider can enter dangerous territory when he or she attempts
to categorize grief as appropriate, excessive or inappropriate. Grief simply
is. If its expression is not dangerous to anyone, then it is normal and
- (i) Assess stage of grieving being experienced
by patient or significant others: denial, anger, bargaining, depression, and
- Although the grief is anticipatory the patient may move
from stage to stage and back again before acceptance occurs. This system for
categorizing the stages of grief has been helpful in teaching people about the
process of grief.
- (i) Assess the influence of the following
factors on coping: past problem-solving abilities, socioeconomic background,
educational preparation, cultural beliefs, and spiritual beliefs.
- These factors play a role in how grief will manifest in
this particular patient or family. The nurse needs to restrain any notion that
individuals of a given culture or age will always manifest predictable grief
behaviors. Grief is an individual and exquisitely personal
- (i) Assess whether the patient and significant
others differ in their stage of grieving.
- People within the same family system may become impatient
when others do not reconcile their feelings as quickly as they do.
- (i) Identify available support systems, such
as the following: family, peer support, primary physician, consulting
physician, nursing staff, clergy, therapist or counselor, and professional or
lay support group.
- If the patient's main support is the object of perceived
loss, the patient's need for help in identifying support is
- (i) Identify potential for pathological
- Anticipatory grief is helpful in preparing an individual to
do actual grief work. Those who do not grieve in anticipation may be at higher
risk for dysfunctional grief.
- (i) Evaluate need for referral to social
security representatives, legal consultants, or support groups.
- It may be helpful to have patients and family members
plugged into these supports as early as possible so that financial
considerations and other special needs are taken care of before the anticipated
- (i) Observe nonverbal communication.
- Body language may communicate a great deal of information,
especially if the patient and his or her family is unable to vocalize their
- (i) independent
- (i) Establish rapport with patient and
significant others; try to maintain continuity in care providers. Listen and
encourage patient or significant others to verbalize feelings.
- This may open lines of communication and facilitate
eventual resolution of grief.
- (i) Recognize stages of grief; apply nursing
measures aimed at that specific stage.
- Shock and disbelief are initial responses to loss. The
reality may be overwhelming; denial, panic, and anxiety may be seen.
- (i) Provide safe environment for expression of
- This assumes a tolerance for the patient's expressions of
grief (i.e., the ability to see a man cry, to see mourners make wide gestures
with hands and their bodies, loud vocalizations and crying).
- (i) Minimize environmental stresses or
stimuli. Provide the mourners with a quiet, private environment with no
- (i) Remain with patient throughout difficult
times. This may require the presence of the care provider during procedures,
difficult discussions, conferences with other family members or other members
of the health care team.
- The patient or family may need a trusted person present to
represent their interest or feelings if they feel unable to express them. They
may require someone to "witness" with them.
- (i) Accept the patient or the family's need to
deny loss as part of normal grief process.
- The nurse needs to see these events as a time during which
the individual or family member consolidates his or her strength to go on to
the next plateau of grief. Others mourners will need to stop progressing
through the process of anticipatory grief, unable to grieve the loss any
further until the loss actually happens. Realization and acceptance may only
occur weeks to months after loss. Reality may continue to be overwhelming;
sadness, anger, guilt, hostility may be seen.
- (i) Anticipate increased affective
- All affective behavior may seem increased or exaggerated
during this time.
- (i) Recognize the patient or family's need to
maintain hope for the future.
- They may continue to deny the inevitability of the loss as
a means of maintaining some degree of hope. As the loss begins to manifest, the
mourners start accepting aspects of the loss, piece by piece, until the whole
is actually grasped.
- (i) Provide realistic information about health
status without false reassurances or taking away hope.
- Defensive retreat can occur weeks to months after the loss.
The patient attempts to maintain what has been lost; denial, wishful thinking,
unwillingness to participate in self-care, and indifference may be
- (i) Recognize that regression may be an
- The sheer volume of emotional reconstituting and
reconstruction, which must be accomplished after a loss occurs, makes it
reasonable to assume that time to restore energy will be needed at
- (i) Show support and positively reinforce the
patient's efforts to go on with his or her life and normal activities of daily
living (ADLs), stressing the strength and the reserves that must be present for
the patient and family to feel enabled to do this.
- This is the same strength and reserve each of them will use
to reconstitute their lives after the loss.
- Offer encouragement; point out strengths and progress to
- Patients often lose sight of the achievements while engaged
in the struggle.
- (i) Discuss possible need for outside support
systems (i.e., peer support, groups, clergy).
- Acknowledgment occurs months to years after loss. Patient
slowly realizes the impact of loss; depression, anxiety, and bitterness may be
seen. Support groups composed of persons undergoing similar events may be
- (i) Help patient prioritize importance of
- This allows the health care provider and patient to focus
rehabilitative energy on those things that are of greatest importance to the
- (i) Encourage patient's or significant others'
active involvement with rehabilitation team.
- (i) Continue to reinforce strengths,
- Adaptation occurs during the first year or later, after the
loss. Patient continues to reorganize resources, abilities, and self-image.
Mourning is a unique and individual process that occurs over time.
- (i) Recognize patient's need to review
(relive) the illness experience.
- This is one way in which the patient or the family
integrate the event into their experience. Telling the event allows them an
opportunity to hear it described and gain some perspective on the
- (i) Facilitate reorganization by reviewing
- When seen as a whole, the process of reorganization after a
loss seems enormous, but reviewing the patient's progress toward that end is
very helpful and provides perspective on the whole process.
- (i) Discuss possible involvement with peers or
organizations (e.g., stroke support group, arthritis foundation) that work with
patient's medical condition.
- Support in the grieving process will come in many forms.
Patients and family members often find the support of others encountering the
same experiences as helpful.
- (i) Recognize that each patient is unique and
will progress at own pace.
- Time frames vary widely. Cultural, religious, ethnic, and
individual differences affect the manner of grieving.
- Carry out the following throughout each stage:
(i) Provide as much privacy as possible.
- (i) Allow use of denial and other defense
- (i) Avoid reinforcing denial.
- (i) Avoid judgmental and defensive responses
to criticisms of health care providers.
- (i) Do not encourage use of pharmacological
- (i) Do not force patient to make
- (i) Provide patient with ongoing information,
diagnosis, prognosis, progress, and plan of care.
- (i) Involve the patient and family in decision
making in all issues surrounding care.
- This acknowledges their right and responsibility for
self-direction and autonomy.
- (i) Encourage significant others to assist
with patient's physical care.
- The desire to provide care to and for each other does not
disappear with illness; involving the family in care is affirming to the
relationship the patient has with their family.
- (i) When the patient is hospitalized or housed
away from home, facilitate flexible visiting hours and include younger children
and extended family.
- No individual should be excluded from being with the
patient unless that is the wish of the patient. Hospital guidelines for
visiting serve staff members who organize care more than they serve
- (i) Help patient and significant others share
mutual fears, concerns, plans, and hopes for each other including the
- Secrets are rarely helpful during these times of crisis. An
open sharing and exchange of information makes it easier to address important
issues and facilitates effective family process. These times of stress can be
used to facilitate growth and family development. They can be important and
sometimes final opportunities for resolving conflict and issues. They can also
be used as times for potential personal and intrafamilial growth.
- (i) Help the patient and significant others to
understand that anger expressed during this time may be a function of many
things and should not be perceived as personal attacks.
- (i) Encourage significant others to maintain
their own self-care needs for rest, sleep, nutrition, leisure activities, and
time away from patient.
- Somatic complaints often accompany mourning; changes in
sleep and eating patterns, and interruption of normal routines is a usual
occurrence. Care should be taken to treat these symptoms so that emotional
reconstitution is not complicated by illness.
- If the patient's death is expected:
(i) Facilitate discussion with patient and significant
other on "final arrangements"; when possible discuss burial, autopsy, organ
donation, funeral, durable power of attorney, and a living will.
- (i) Promote discussion on what to expect when
- (i) Encourage significant others and patient
to share their wishes about which family members should be present at time of
- (i) Help significant others to accept that not
being present at time of death does not indicate lack of love or caring.
- (i) When hospitalized, use a visual method to
identify the patient's critical status (i.e., color-coded door marker).
- This will inform all personnel of the patient's status in
an effort to ensure that staff do not act or respond inappropriately to a
- (i) Initiate process that provides additional
support and resources such as clergy or physician.
- (i) Provide anticipatory guidance and
follow-up as condition continues.
Education/Continuity of Care
- (i) independent
- (i) Involve significant others in discussions.
This helps reinforce understanding of all individuals involved.
- (c) Refer to other resources: counseling,
pastoral support, group therapy, and others.
- Patient or significant other may need additional help to
deal with individual concerns.
Grief Work Facilitation; Presence; Emotional Support
- See also:
Death and dying, Chapter 15, p.
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