Journal of Gerontological Nursing

EPILOGUE 

Coping with Anticipatory Grief

Pamela M Enlow, MSN, RN

Abstract

My mother and I had a very special relationship. Somehow, in her wisdom, she guided my adolescence so that rebelliousness, confrontation, and hostility were not a required response. Now, even in her helplessness, she has motivated me toward a positive, creative release of painful, harmful emotions.

This release is a very personal catharsis of an anguished daughter who only coincidentally happens to be a nurse. It is, however, likely that my years of nursing experience helped to shape my attitudes about death, dying, and nursing home commitments. These attitudes reflect my feelings about the quality of life versus the quantity of life . They also mirror my mother's deepest wishes: a life of independence and a death with dignity.

My mother's most intense fear, cancer, was followed closely by the fear of becoming a burden to her loved ones. However reasonable these terminal desires appear, reality was less kind to my mother. All her greatest fears were realized. A series of serious illnesses, surgeries, and a traumatic head injury left her at death's door three times.

Three times I prepared for the death of her body and prayed for the release of her soul. The pain of anticipatory grief was intense, but promised resolution. But, my mother lives, lives on in a nursing home, debilitated, unable to walk, unable to talk coherently, mentally confused, her unhealed broken right arm in a burdensome cast.

This daughter could handle the death of her beloved mother, but this living death, the loss of mother as I once knew her is a loss that leaves grief unresolved. It is a morbid grief that persists with great tenacity.

It is not unusual to think and speak of a loved one so altered by age and disease in the past tense, as if she were really dead. I vividly recall forgetting to send my mother a card on Valentine's Day. In a spontaneous thought I chastised myself with, "You would never have forgotten the card when she was alive. " Horror flooded my realization that to me, my mother was already dead.

Anticipatory grief, a process that assists a person in preparing for the death of a loved one, can assume emotional responses similar to the phases of death preparation identified by KublerRoss.1 As a person prepares for death, that person experiences various phases of adjustment, but perhaps in differing sequence and degree of intensity. It appears that as people prepare for the death of a loved one, they also can experience one or more of these stages:

1. Denial and isolation

2. Anger

3. Bargaining

4. Depression

5. Acceptance

If the termination of life proceeds as predicted, the survivors complete their developmental task and come to acceptance. However, when death is aborted, the grief process may become fixated and, therefore, morbid and destructive.

An example of this fixation comes when anger, frustration, hopelessness, and helplessness dominate the grief process because a loved one's life continues to lack quality, and is denied the release of death. This surviving daughter identifies with a prolonged, extensive anger directed mostly toward God for not intervening on my mother's behalf.

The continuous questioning, Why? Why has God turned his back? Why has God denied release? These questions erode the foundations of faith. Many people have found comfort in Kushner's, When Bad Things Happen to Good People.2 He believes that many people have unreasonable expectations: expectations that the events of life, suffering, and death serve some grand purpose; and that God is somehow in charge and responsible for these events. In searching for a reason, a purpose to the cruel events…

My mother and I had a very special relationship. Somehow, in her wisdom, she guided my adolescence so that rebelliousness, confrontation, and hostility were not a required response. Now, even in her helplessness, she has motivated me toward a positive, creative release of painful, harmful emotions.

This release is a very personal catharsis of an anguished daughter who only coincidentally happens to be a nurse. It is, however, likely that my years of nursing experience helped to shape my attitudes about death, dying, and nursing home commitments. These attitudes reflect my feelings about the quality of life versus the quantity of life . They also mirror my mother's deepest wishes: a life of independence and a death with dignity.

My mother's most intense fear, cancer, was followed closely by the fear of becoming a burden to her loved ones. However reasonable these terminal desires appear, reality was less kind to my mother. All her greatest fears were realized. A series of serious illnesses, surgeries, and a traumatic head injury left her at death's door three times.

Three times I prepared for the death of her body and prayed for the release of her soul. The pain of anticipatory grief was intense, but promised resolution. But, my mother lives, lives on in a nursing home, debilitated, unable to walk, unable to talk coherently, mentally confused, her unhealed broken right arm in a burdensome cast.

This daughter could handle the death of her beloved mother, but this living death, the loss of mother as I once knew her is a loss that leaves grief unresolved. It is a morbid grief that persists with great tenacity.

It is not unusual to think and speak of a loved one so altered by age and disease in the past tense, as if she were really dead. I vividly recall forgetting to send my mother a card on Valentine's Day. In a spontaneous thought I chastised myself with, "You would never have forgotten the card when she was alive. " Horror flooded my realization that to me, my mother was already dead.

Anticipatory grief, a process that assists a person in preparing for the death of a loved one, can assume emotional responses similar to the phases of death preparation identified by KublerRoss.1 As a person prepares for death, that person experiences various phases of adjustment, but perhaps in differing sequence and degree of intensity. It appears that as people prepare for the death of a loved one, they also can experience one or more of these stages:

1. Denial and isolation

2. Anger

3. Bargaining

4. Depression

5. Acceptance

If the termination of life proceeds as predicted, the survivors complete their developmental task and come to acceptance. However, when death is aborted, the grief process may become fixated and, therefore, morbid and destructive.

An example of this fixation comes when anger, frustration, hopelessness, and helplessness dominate the grief process because a loved one's life continues to lack quality, and is denied the release of death. This surviving daughter identifies with a prolonged, extensive anger directed mostly toward God for not intervening on my mother's behalf.

The continuous questioning, Why? Why has God turned his back? Why has God denied release? These questions erode the foundations of faith. Many people have found comfort in Kushner's, When Bad Things Happen to Good People.2 He believes that many people have unreasonable expectations: expectations that the events of life, suffering, and death serve some grand purpose; and that God is somehow in charge and responsible for these events. In searching for a reason, a purpose to the cruel events of life, many people come to believe that tragedy is a lesson, a test, or a punishment. According to Kushner, these events are spontaneous and a result of chance in a normal evolution of the universe or of nature's laws and not of God's plan. Therefore, if God is not in charge, if God is not responsible for such events; He then is also unable to intervene. This rationalization may help to alleviate guilt feelings, but is something that is painful, less painful if it is random, spontaneous, and without purpose?

If God is not to blame then who is to be the target of anger? When family members or caregivers do not become scapegoats, then the individual turns anger inward. Couple anger with feelings of helplessness and hopelessness, and the result is depression.

Depression, according to Schultz,3 is one of four stages in the process of anticipatory grief. The anticipation of a loved one's death can allow a period of time to practice the grief process. If depression is overcome, one moves into the second stage of heightened concern for the ill person. Naturally, the expression of our concern will be reflected in the way we behave toward the ill, loved one.

Family who live close to the loved one can minister to his or her needs. They can participate in the role of martyred adult-child attending unselfishly to the needs of an ailing elderly parent. No doubt this is therapeutic in the reassurance that they have done all that they can do. But often the adult children live great distances from the institutionalized parent. Deprived of this visible evidence that they care for their elderly parent, a culturally imposed guilt develops.1,4 Unable to attend to the daily needs, and unable to demonstrate frequently a loving concern, the distanced adult-children wonder, "Does she think I've abandoned her?"

I still suffer from guilt about abandonment. I try to compensate. In nightly bedtime conversations with my mother, I hope by some extrasensory perception my thoughts of her will be received over the miles. I realize she does not know or remember when I have been physically present, but some desperate hope compels me to believe we still do communicate by mystical means not yet defined.

Grief can become morbid if an individual does not move beyond the depression phase. To move on in the grief process necessitates the activation of coping mechanisms that are unappealing and counter to societal norms. Those who began the healthy process of overcoming grief risk the condemnation of relatives and nursing staffs of being unloving, uncaring, and inconsiderate. Accusations of abandonment are leveled at the individual who begins to detach.

Detachment, as a coping approach, requires that the individual pull back from the lost person and that energies be redirected toward more productive activities. Those who cannot do this frequently suffer from emotional and physical complaints. Chronic illnesses often become problematic at this time. In addition, a sense of waiting for something to happen develops. This sense of task uncompleted fosters disorganization.5 Years may pass in this period where major life decisions, and consequently, accomplishments are delayed because of this morbid grief.

Despite grief, priorities must be set however undesirable they may appear. Daughters, more than sons seem to bear the responsibility for making difficult choices.6 When the daughter is also a nurse and, therefore, better prepared to care for Mom, and chooses not to take on that responsibility, the guilt is greater. Greater also is the condemnation of other family members.

Family members often react to grief with various behaviors and intensities. The degree of grief may be related to both positive and negative feelings held toward the lost loved one. Excessive acting-out behavior may be the result of unconscious guilt over an uneasy or hostile past relationship. Those who have reason to regret their behavior toward loved ones may have a very difficult grieving process. Often deeply hidden hostility may be projected onto spouse, children, or siblings. Family members become isolated and alienated from each other.2

More than three years have passed since my mother was diagnosed as terminal. More than a year has passed since she was placed in a nursing home. This is history, and now Fm beginning to cope. I am beginning to feel better, less depressed, less angry, and less hostile. But, as a result of the painful experience, I am very familiar with all the emotions of grieving. I know what it is like to be the victim of projected guilt feelings. The sharing of my feelings has helped me to cope and to be more objective, if not less sad about my mother's plight. When the tears dry, pleasant memories of an outstanding mother-daughter relationship will prevail.

References

  • 1. Kubler-Ross E: On Death and Dying. New York, Macmillan Publishing Co, Inc. 1971.
  • 2. Kushner HS: When Bad Things Happen to Good People. New York, Schocken Books, Inc, 1981.
  • 3. Schulz R: The Psychology of Death. Dying and Bereavement. Reading, Mass, 1978.
  • 4. Backer B, Hannon N, Rüssel N: Death and Dying: Individuals and Institutions. New York, John Wiley & Sons, Ine, 1982.
  • 5. Cox H: Later Life: The Realities of Aging. New Jersey, Prentice-Hall, 1984.
  • 6. Treas J: Family support systems for the aged: Some social and demographic considerations. The Gerontologist 1977; 17(6):486-491.

10.3928/0098-9134-19860701-11

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