END-OF-LIFE CARE Identifying and Managing Preparatory Grief and Depression at the End of Life VYJEYANTHI S. PERIYAKOIL, M.D., and JAMES HALLENBECK, M.D. Stanford University School of Medicine, Stanford, California Grief and depression present similarly in patients who are dying. Conventional symp- toms (e.g., frequent crying, weight loss, thoughts of death) used to assess for depres- O A patient infor- sion in these patients may be imprecise because these symptoms are also present in mation handout on dying and prepara- preparatory grief and as a part of the normal dying process. Preparatory grief is expe- tory grief, written by rienced by virtually all patients who are dying and can be facilitated with psychosocial the authors of this support and counseling. Ongoing pharmacotherapy is generally not beneficial and may article, is provided even be harmful to patients who are grieving. Evidence of disturbed self-esteem, hope- on page 897. lessness, an active desire to die and ruminative thoughts about death and suicide are indicative of depression in patients who are dying. Physicians should have a low thresh- old for treating depression in patients nearing the end of life because depression is associated with tremendous suffering and poor quality of life. (Am Fam Physician 2002;65:883-90,897-8. Copyright© 2002 American Academy of Family Physicians.) istinguishing between grief physiologic changes associated with dying. and depression in patients Survey instruments designed to detect depres- who are dying can be difficult. sion have not been well studied in patients Many of the signs and symp- who are dying and lack specificity because toms traditionally used to questions addressing somatic, functional and Ddiagnose depression are also present in affective criteria can generate false-positive patients who are grieving (Figure 1).Weight results. The Geriatric Depression Scale,1 for loss, anorexia and sleep disturbance, for example, rates frequent crying. Crying can example, might reflect depression, grief, poor reflect depression or normal grief in dying control of physical symptoms or the normal patients. Differentiating between preparatory grief and depression is essential because of therapeutic implications. While some re- searchers have suggested that grief and Overlap of Processes at the End of Life depression differ in significant ways, evidence supporting such distinctions is lacking.2 Normal processes Pathologic processes Illustrative Case An 82-year-old man with a history of Common symptoms metastatic prostate cancer was admitted to an Preparatory grief • Appetite changes Depression inpatient hospice unit because of progressive • Weight changes debilitation. His pain was well controlled, but • Fatigue he had a poor appetite, was losing weight and • Low energy Response to poorly Normal process controlled physical had crying spells. When asked about possible of dying • Sleep disturbances • Sexual dysfunction symptoms depression, he replied that he was not sure if he was depressed. One of his daughters who lived near him and helped care for him felt that his crying indicated that he was finally coming to terms with his terminal diagnosis; another daughter felt that he was depressed. FIGURE 1. Algorithm showing the overlap of processes at the end of life. Statements the patient made like, “I can’t MARCH 1, 2002 / VOLUME 65, NUMBER 5 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 883 believe I’m dying,” suggested that he was grieving. The physician treating him was Preparatory Grief unsure whether he might also be depressed. Grief is a reaction to any loss. As Freud4 The patient received psychologic counseling observed, grief is “the reaction to the loss of a and started taking a selective serotonin reup- loved person, or to the loss of some abstraction take inhibitor (SSRI) antidepressant. He which has taken the place of one, such as one’s demonstrated a good response—his affect liberty…”. Grief manifests as a progression of and energy level improved. The patient died emotional, social, spiritual, physical, cognitive peacefully a few weeks later. and behavioral changes through which a per- son attempts to reorganize and resolve or Depression adjust to the loss at his or her own pace.5,6 Virtually all patients who are faced with Preparatory grief, as introduced by Kubler- dying experience episodes of sadness. These Ross in “On Death and Dying,” 7 is “that [grief sad feelings are usually very intense for a vari- that] the terminally ill patient has to undergo able period of time and then often gradually in order to prepare himself for his final sepa- diminish in intensity. In some patients, dys- ration from this world.” Preparatory grief is phoria is persistent and is associated with a the normal grief reaction to perceived losses sense of hopelessness and disturbed self- experienced by persons who are dying. (The image. An estimated 22 to 75 percent of terms anticipatory grief and anticipatory patients who are dying experience clinical mourning are commonly used to refer to depression.3 However, depression is not grief experienced by family members or inevitable and should not be considered a friends before the death of a loved one. The normal part of the dying process. grief experienced by patients as they prepare Depression shares common features with for their impending death is different from grief. Misdiagnosis can result in overlooking anticipatory grief as defined by the extensive depression when it is present or inappropri- body of existing literature. Consequently, ately treating grief. Depression and grief are preparatory grief, as defined by Kubler-Ross7 different conditions that require different in reference to grief experienced by the dying treatments although, clinically, they often person, is used here.) overlap. Patients with depression may benefit Persons who are dying prepare for their from counseling and pharmacotherapy. death by mourning the losses implicit in death. The anticipated separation from loved ones is an obvious one. Simple pleasures of living may be grieved. People may reflect on The Authors their past and relive great moments and dis- VYJEYANTHI S. PERIYAKOIL, M.D., is medical director of Stanford Hospice, Stanford, appointments, and mourn for missed oppor- Calif., and a staff physician with the Palo Alto Veterans Affairs Health Care System, tunities. Looking to the future, they may Palo Alto, Calif. Dr. Periyakoil earned her medical degree from the University of grieve the loss of much-anticipated experi- Madras, Madras, India. She completed a residency in internal medicine at San Joaquin General Hospital in Stockton, Calif., and a fellowship in geriatrics at the Stanford Uni- ences such as a child’s graduation or the birth versity School of Medicine, Stanford, Calif. of a grandchild.8 In the present, the person JAMES HALLENBECK, M.D., is clinical associate professor of medicine at the Stanford who is dying usually experiences a radical University School of Medicine and medical director of the Veterans Affairs Hospice change in self-image. Previously independent, Care Center, Palo Alto, Calif. Dr. Hallenbeck earned his medical degree from Emory the person may now be weak and dependent University School of Medicine, Atlanta, Ga., and completed a residency in internal medicine at the University of California, San Francisco, School of Medicine. on others for even the most basic needs. The old self-image has been lost and is grieved as Address correspondence to Vyjeyanthi S. Periyakoil. M.D., Hospice Care Center, Bldg. 100-2C, 3801 Miranda Ave., Palo Alto, CA 95304. Reprints are not available from the the person who is dying and their family authors. adjusts to a new, more fragile sense of self. 884 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 65, NUMBER 5 / MARCH 1, 2002 Grief & Depression Grief, which is often experienced as a Temporal Variation. Grief is often experi- painful tearing sensation, is also a process by enced in waves, which are usually triggered in which the grieving person adjusts to a radical response to a specific loss. New waves of grief change in the relationship between the self may be “predictably” triggered in response to and that which is being lost—an object of a new loss (e.g., when an ambulatory patient attachment or love called the “loss object.”9 becomes bedridden), or “unpredictably” trig- Loss objects can be people or they can be sim- gered by seemingly minor incidents (e.g., ple pleasures like drinking coffee in the hearing a treasured song or noticing a morning. The loss object can be a person’s self stranger’s resemblance to a loved one). image. Grief can be understood as the physi- In contrast, persistent flat affect or dyspho- cal, psychological and cognitive changes that ria that pervades all aspects of patients’ lives is occur in response to an abrupt change in the characteristic of depression. relationship between the grieving person and Progress with Time. In most cases, patients the loss object. The grieving person moves, progress through grief and it slowly dimin- sometimes slowly, sometimes quickly, toward ishes in intensity over time. Patients may peri- a new equilibrium as the changed relation- odically experience intense waves of grief (an ship is redefined with the loss object. acute grief reaction), but the overall intensity Preparatory grief, while normal, can be wanes. facilitated through proper support. Grief per Depression is a pathologic state. Patients can se rarely requires pharmacologic interven- “get stuck” in this state without treatment. tion. Inappropriate use of antidepressants or Negative Self-Image. Patients who are anxiolytics for treating grief may result in grieving usually have a normal self-image. iatrogenic complications that have little, if Some patients may have a loss of self-esteem any, benefit. because of the debilitation and dependency caused by progressing disease. When these Differentiating Between Preparatory feelings are disproportionate to a patient’s Grief and Depression: A Diagnostic situation, underlying depression should be Dilemma considered.