Family Grief

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Palliat Med. Author manuscript; available in PMC 2023 April 13.
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Published in final edited form as:

Palliat Med. 2022 April ; 36(4): 581–608. doi:10.1177/02692163221074540.
An Examination and Proposed Definitions of Family Members’

Grief Prior to the Death of Individuals with a Life-limiting Illness:
A Systematic Review
Jonathan Singer, Ph.D.,
Department of Psychological Science, Texas Tech University, Lubbock, TX
Kailey E. Roberts, Ph.D.,

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Ferkauf Graduate School of Psychology, Yeshiva University
Elisabeth McLean, B.A.,

Department of Psychology, University of Nevada, Reno
Carol Fadalla, B.A.,

Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center
Taylor Coats, M.A.,

Madeline Rogers, M.S.W.,

Center for Research on End-of-Life Care, Weill Cornell Medicine
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Madeline K. Wilson, B.A.,

Department of Psychology, University of Nevada, Reno
Kendra Godwin, M.L.I.S.,

Medical Library, Memorial Sloan Kettering Cancer Center
Wendy G. Lichtenthal, Ph.D., F.T.

Abstract
Background: Research has extensively examined family members’ grief prior to the death of an
individual with a life-limiting illness but several inconsistencies in its conceptualization of related
constructs, yet significant conceptualization issues exist.
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Declarations
Authorship:
J.S. was responsible for the planning, design, conduct, and reporting of the work. J.S. K.R. and W.L. were responsible for significant
edits to the manuscript and conceptually proposing the definitions in this systematic review. C.F. and T.C. helped with building the
tables and figures. K.G. performed the search in all databases and uploaded the studies into Covidence. J.S. K.R. E.M. C.F. T.C M.R.
M.W performed the study selection and data extraction. J.S. K.R. E.M. C.F. T.C M.R. M.W were involved in the data analysis and
synthesis process. All authors contributed and agreed to the final manuscript.
Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship,
and/or publication of this article.
Singer et al. Page 2
Aim: This study aimed to identify and characterize studies published on family members grief
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before the death of an individual with a life-limiting illness, and propose definitions based on past
studies in order to initiate conceptual clarity.
Design: A mixed-method systematic review utilized six databases and was last conducted July
10, 2021. The search strategy was developed using Medical Subject Headings. This study was
prospectively registered on PROSPERO (CRD42020166254).
Results: 134 full-text articles met inclusion criteria. This review revealed across studies a wide
variation in terminology, conceptualization, and characterization of grief before the death. More
than 18 terms and 30 definitions have been used. In many cases, the same term (e.g., anticipatory
grief) was defined differently across studies.
Conclusions: We found grief occurring before the death of a person with a life-limiting illness,
which we termed pre-death grief, is comprised of two distinct constructs: anticipatory grief
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and illness-related grief. Anticipatory grief is future-oriented and is characterized by separation

distress and worry about a future without the person with the life-limiting illness being physically
present. Illness-related grief is present-oriented and is characterized by grief over current and
ongoing losses experienced during the illness trajectory. These definitions provide the field with
uniform constructs to advance the study of grief before the death of an individual with a life-
limiting illness.
Keywords
Palliative care; Grief; Family; Caregivers; Terminally ill
Most deaths worldwide are attributed to a chronic or life-limiting illness1. In response

to continued improvements in medicine, including advancements in early detection of
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medical conditions, the length of time between diagnosis and death has increased. While
the increase in life expectancy for individuals living with a life-limiting illness may have
notable benefits, there are also negative consequences for the patient2, 3 and their family
members 4, 5. For example, increasing data trends indicate that family members are likely
to experience some level of grief before the person with a life-limiting illness dies6,7. The
extent to which a family member experiences grief prior to a death occurring has been
found to predict long-term functioning in bereavement, including developing depression8
or prolonged grief disorder9, 10. However, our current understanding of grief experiences
in family members prior to the death is hampered by the lack of a universal definition,
the use of multiple terms, and inconsistent operationalization of constructs. By gaining a
comprehensive understanding of the literature examining grief in family members before
the death, researchers will be better equipped to understand what constitutes normative and
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non-normative experiences of grief before the death, and to identify key intervention targets
that may decrease family members’ risk for and experience of debilitating psychological
symptoms both in the short- and long-term. Therefore, the current systematic review
aimed to identify and characterize the studies published on grief before a death for family
members5 and propose definitions grounded in extant research for the types of grief that can
occur before a death.

There has been an abundant amount of research examining family members’ grief prior to
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the death of an individual with a life-limiting illness. The earliest documented definition of
this form of grief came from Lindemann11, who described it as a grief process that begins
when family members are provided advance warning of a patient’s impending death. In
her work on this topic, Rando then12 defined it as a “reaction to the impending loss of
a terminally ill loved one and to all other past and present losses related to the illness,
in addition to the mourning and all other psychosocial processes stimulated by these
losses” (p. 24). The most prominent and well-known term to describe this experience is
anticipatory grief, but a recent review of articles examining anticipatory grief found ten
different definitions used within studies13. In this review, Coelho and Barbosa13 concluded
that, when examining grief before the death, there are conceptualization issues, thereby
limiting the ability to make comparisons of findings across studies. This is problematic for
many reasons, as it hinders the potential advancement of the field in differentiating typical
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grief from more impairing grief before the death.
Further complicating the picture is the sheer number of terms used to describe grief before
death; a concept analysis by Lindauer and Harvath14 found that there were more than 20
terms other than anticipatory grief used in the literature between 2000 and 2013. The authors
compared three terms found to be the most utilized in the literature: anticipatory grief,
pre-death grief, and chronic sorrow.14 They noted that one conceptual difference between
anticipatory grief, pre-death grief, and chronic sorrow was the likely amount of time the
person with life-limiting illness had left to live. While this effort to distinguish terms is
useful, further clarity is needed for several reasons. First, determining a patient’s prognosis
is notoriously challenging15, and so defining grief before death based on prognosis would
be correspondingly difficult. This concept analysis set important groundwork for the current
review by identifying 20 different terms (see Appendix A) to examine grief before the death,
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but they only compared the three most used terms to exclusively provide a definition for
pre-death grief.
Given these limitations and an increase in studies since 20147, there is a need for an
updated and systematic understanding of the full body of literature that comprehensively
examines terms used to describe family members’ grief before the death of an individual
with a life-limiting illness. Thus, the present systematic review was undertaken to increase
conceptual clarity on this grief experience and develop a consistent definition. To advance
the field and allow for direct comparison between studies, a consistent definition is crucial.
Additionally, the use of a uniform definition could provide clearer benchmarks of what
constitutes debilitating grief before a death in order to appropriately develop and tailor
interventions.
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Methods
This systemic review aimed to (1) identify and characterize the studies published on family
member grief before a death of an individual with life-limiting illness, and (2) propose a
definition for such grief that has conceptual clarity and precision and is grounded in past
research.

Systematic Review Design

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This mixed-method systematic review and protocol were prospectively registered on

PROSPERO on January 1, 2020 (Registration Number: CRD42020166254). This study
used a phenomenological approach in which we integrated findings of primary quantitative
and qualitative studies to build a network of related concepts that together provide a
comprehensive understanding of grief before the death of a person with a life-limiting
illness.
Search Strategy and Data Sources

Procedures were conducted and reported according to Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) guidelines 16. Six databases were
selected: PubMed (via National Library of Medicine’s PubMed.gov), Embase (via Elsevier’s
Embase.com), Cochrane Central Register of Controlled Trials / Cochrane CENTRAL
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(via Wiley’s Cochrane Library), PsycINFO (via Ovid), Web of Science Core Collection
(via Clarivate Analytics), and Cumulative Index to Nursing and Allied Health Literature
(CINAHL) (via EBSCO). Concepts were combined with the Boolean AND operator, and the
Cochrane Handbook filter was used to exclude animal-only studies 17. A second research
informationist performed a Peer Review of Electronic Search Strategies (PRESS), and
edits were implemented 18. For a complete strategy, see the accompanying PubMed search
displayed in Appendix B. The six databases were comprehensively searched on February
24, 2020. The first author (JS) later conducted two updates (April 1, 2021; July 10, 2021)
and searched the six databases to identify if any new articles should be added to the review
that were published after February 24, 2020. Results were entered as Research Information
System files (i.e., standardized tag format) in Covidence, a web-based software platform for
systematic review development 19.
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Selection Strategy
Studies were considered eligible for inclusion if they evaluated family members’ or friend’s
grief related to an individual currently living with a life-limiting illness. Studies that
evaluated grief after the death had occurred or did not explicitly measure or refer to grief or
examined grief related to non-life limiting illness (e.g., diabetes) were excluded.
Screening Process
After duplicates were removed, abstracts were reviewed by two independent reviewers for
initial eligibility. Articles were considered for full-text review if both reviewers agreed they
met inclusion criteria. When there was disagreement between two reviewers, discrepancies
were discussed with the first and second authors. All studies that met criteria for full-text
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evaluation were then independently reviewed by two reviewers and disagreements between
reviewers were discussed with the first and second author. A standardized template was
developed to extract pre-specified information from the final set of included articles.
For each article, a reviewer completed the coding template to extract the pre-determined
information from each article.

Data Synthesis and Analysis

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After studies were selected, they were individually entered by the authors into an Excel
table for data extraction. Authors were instructed to indicate title, authors, whether the study
was qualitative, quantitative, or mixed methods, design of the study, whether prospective
or retrospective, purpose of the study, sample details (mean age, gender, race/ethnicity,
relationship to patient/deceased, disease status), key qualitative and quantitative findings,
term used to describe grief (e.g., anticipatory grief), and implications related to defining
the term. The first author (JS) organized the studies by the grief term used and conducted
a thematic synthesis of the definitions used within the terms. To interpret the results, a
thematic synthesis was performed. The synthesis began with ‘line-by-line’ coding of the
included articles (n=132), which were put into categories (i.e., term used; definition used;
measure used). These were then aggregated by term used.
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Results
A total of 9,568 records were reviewed. A final set of 132 full-text articles underwent
qualitative synthesis (see Figure 1 for PRISMA). Two studies 7,20 were added from the
review of the databases on April 1, 2021 and another on July 10, 2021. Therefore, 134
full-text articles underwent thematic synthesis (see Figure 1).
The studies were predominantly quantitative (N=77; 57.46%). Thirty-three (23.88%) were
qualitative and 24 (17.91%) used mixed methods. Most of the studies were prospective
(N=110; 82.09%). Twenty (14.93%) were retrospective and four (3.00%) included both
prospective and retrospective analyses.
Participants in these studies primarily endorsed their family member was diagnosed with
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dementia (N=51; 38.1%) or cancer (N=39; 29.1%) broadly. When examining the prognosis
of the individual with the life-limiting illness, most studies stated that they had “late-stage
dementia” or “advanced cancer.” For the studies that provided the relationship to the person
with the life-limiting illness, 58.0% were adult children, 28.1% were spouses/partners, and
13.9% were other relatives/friends (e.g., parents).
There were 18 different terms used to describe grief in family members of individuals
who have a life-limiting illness. The terms used were anticipatory grief (N=34), pre-death
grief (N=18), grief (N=12), pre-loss grief (N=6), caregiver grief (N=5), grief in caregivers
(N=4), and anticipatory mourning (N=4). Nineteen studies used multiple terms throughout
a single article. There were also 10 other terms that were each used only once in separate
studies. Due to the large number of articles in this systematic review, we limited our in-text
analysis to articles where the term (e.g., pre-death grief) was used in more than one article.
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Therefore, we did not analyze these 10 studies. However, they are described in Table 1.
Also, there were two studies that described grief in family members of individuals who have
a life-limiting illness but did not use a specific term to describe their experience.
In addition to varied terms used to characterize grief in family members of individuals with
life-limiting illness, studies used 19 different scales to measure grief. The most prominent

were the Marwit-Meuser-Caregiver Grief Inventory (n=28), the Anticipatory Grief Scale
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(n=18), and the Prolonged Grief-12 (n=13).
Anticipatory Grief
There were 54 studies identified that used anticipatory grief to describe family members’
grief while a person with a life-limiting illness was alive. However, the definitions used
for anticipatory grief differed drastically (see Table 1), and many studies used the term
anticipatory grief but failed to define it. For example, one study 21 stated that anticipatory
grief includes emotions associated with the fear of losing their significant other, whereas
another study 22 stated anticipatory grief is a profound emotional response to impending,
irreversible loss that is experienced by a family member. Overall, the first definition is
related to worry about life without the person with the life limiting illness (e.g., what am I
going to do when they pass away). However, the other study22 appears to define anticipatory
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grief as a feeling of loss following diagnosis of the life limiting illness (e.g., I feel I have
already lost the person). Nine studies 23–31 used Rando’s12 definition of anticipatory grief
and two 32,33 used Lindemann’s 11 definition of anticipatory grief. Ten studies34–43 used
the term anticipatory grief, but did not define it beyond using a measure conceptualized as
measuring anticipatory grief. Finally, there was one study44 that defined anticipatory grief
as being an emotional response that is specific to a dementia (i.e., “a specific feeling of
pre-death grief in response to compound serial losses in the dementia process;” p. 1).
Of the studies that used anticipatory grief, 16 were qualitative. The remaining 38
quantitative studies used a variety of measures, with five studies using author-generated
questions that had not been psychometrically validated21,22,28,45,46. The studies using
anticipatory grief were mostly conducted with family members of patients with dementia
(N=17) or cancer (N=15). Lastly, of the studies that used the term anticipatory grief, the
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Anticipatory Grief Scale was the most used measure (14 studies; 25,29,36,41,45,47–53). The
Marwit-Meuser-Caregiver Grief Inventory 26,27,54–58 and Marwit-Meuser-Caregiver Grief
Inventory- Short Form 24,35,40,44 was used in 11 studies.
Pre-death grief
There were 18 studies identified that used pre-death grief to describe grief experienced by
family members of a person with a life-limiting illness. Almost all 18 studies differed in
their definitions of pre-death grief. For example, Rankin and colleagues 59 defined pre-death
grief as grief experienced by family members prior to the death of the patient in response
to losses that accompany the diagnosis of a family member, whereas Mulligan 60 defined
pre-death grief as yearning for the family member to be healthy again and feeling shocked
about the person’s illness. One study 61 used Lindemann’s definition 11. Another study 62
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framed grief as a spectrum, which they termed “triple grief” (i.e., grieving the loss of the
patients’ personhood, the family’s experience of loss at the time of hospice admission, and
the loss when the person dies). Two studies 20,63,64 used the term pre-death grief but did not
define it.
Most studies that used pre-death grief were quantitative (N=16) and the remainder were
qualitative (N=2). The studies that used the term pre-death grief were mostly with family

members of dementia (N=12) and cancer patients (N=3). The remaining studies included
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family members of individuals with other types of life-limiting illnesses, a mixed sample,
or did not specify the illness. Of the 15 quantitative studies, most studies used the
Marwit-Meuser-Caregiver Grief Inventory (n=4; 65–68,68, the Marwit-Meuser-Caregiver
Grief Inventory- Short Form (n=4; 60,69–71), or the Prolonged Grief-12 (n=4; 20,60,62,63).
Two of the studies used multiple measures 60,63.
Grief
Twelve studies used the term, grief, to describe family members’ grief while a person with
a life-limiting illness was still alive. Five 72–76 of these studies did not provide a definition
of the term. The six studies that used grief differed in their definition of the construct.
One study 77 defined grief as the reaction to the perceived loss following the diagnosis
of a life-limiting illness. However, another study77 defined it as a “multifaceted caregiver
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response” (p. 198) to death and losses of all kinds associated with the illness, including
grief related to “social” death and intellectual deterioration of a person with some form of
dementia.
Most of the studies that used the term, grief, to describe the experience of grief before
the death used mixed methods (N=7). Four were quantitative, and one qualitative. Studies
were predominantly conducted with family members of cancer (N=5) and dementia (N=4)
patients. Two of the studies used the Marwit-Meuser-Caregiver Grief Inventory72,79 and
three used the Marwit-Meuser-Caregiver Grief Inventory- Short Form 73,77,80.
Pre-Loss Grief
There were six studies identified that used pre-loss grief to describe family members’
grief while a person with a life-limiting illness was still alive 7–9,81–83. There were two
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studies 7,81 that defined pre-loss grief, whereas the remaining four studies 8,9,82,83 did not
define the construct. Hudson and colleagues 81 defined pre-loss grief as follows: “Grief is
a process involving some elements of ‘loss,’ which starts before the bereavement and can
be onerous” (p.523). Singer and colleagues 7 similarly used pre-loss grief as more of an
umbrella term, defining it as either family members’ grief related to the impending loss of
their loved one and/or the loss of components of the relationship with the loved one that
existed pre-diagnosis.
All studies that used pre-loss grief were quantitative. Most of the pre-loss grief studies
included a mixed sample with respect to illness type. Only one study 8 focused on a single
specific illness (i.e., family members of individuals with a dementia). All the studies used
the Prolonged Grief-12 to measure pre-loss grief.
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Caregiver Grief
There were five studies identified that used the term, caregiver grief, to describe family
members’ grief while a person with a life-limiting illness is still alive. Three of the articles
were led by the same first author and described caregiver grief as anticipation of future
losses related to physical death of a person with dementia 84–86. Marwit and Meuser
87 discussed caregiver grief as a stage-determined, internally consistent construct that is

measurable but did not provide an explicit definition. Guerrero 88 defined caregiver grief
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as feelings of grief, including sadness, longing, worry, felt isolation, personal sacrifice, and
burden prior to the death of the care recipient.
Most of the studies that used caregiver grief were quantitative studies (n=4), and one used
mixed methods. The studies using the term caregiver grief were predominately conducted
with family members of dementia patients and one study included family members of
individuals with frontotemporal lobar degeneration. All five studies used some form of the
Marwit-Meuser-Caregiver Grief Inventory.
Anticipatory Mourning
There were four studies that used the term, anticipatory mourning, to describe family
members’ grief while a person with a life-limiting illness is still alive. Each of the
four studies differed in their definition. One study 89 used Rando’s 12 definition. Clukey
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90 described anticipatory mourning as a set of dynamic processes involving emotional
and cognitive transitions made in response to an expected loss. Angela-Cole 91 defined

anticipatory mourning as uncertainty surrounding the amount of time a person with a
life-limiting illness has left, which creates a heightened grieving experience before the
person dies. Bielek and colleagues 92 defined anticipatory mourning as the act of mourning
when facing a loss, whether it is sudden or prolonged. All the studies using anticipatory
mourning were qualitative. Two studies 91,92 recruited participants whose family members
had “terminal cancer” and two included family members of individuals with any “terminal
illness.”
Grief in Caregivers
Four studies used the term, grief in caregivers, to describe family member’s grief while a
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person with a life-limiting illness is still alive. Two studies 93,94 offered definitions of grief
in caregivers, whereas two studies did not define the construct 95,96. Ott and colleagues
(2007) 93 used Rando’s 12 definition. Li and colleagues 94 defined grief in caregivers as
various physical and emotional reactions due to the various losses associated with dementia.
Three of the four studies were quantitative, and the other study used a mixed design. Three
of the studies enrolled family members of dementia patients, and one study enrolled family
members who had an acquired brain injury. One of the studies used the Marwit-Meuser-
Caregiver Grief Inventory 95, and three used the Marwit-Meuser-Caregiver Grief Inventory-
Short Form 93,93,94
Multiple Terms Used

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There were 19 studies that used multiple terms (e.g., anticipatory grief and pre-loss grief)
within a single article to describe family members’ grief experiences. In all cases, each
of the terms were used interchangeably with the same definition applied. For example,
Carter and colleagues 97 used pre-death grief, caregiver grief, and grief interchangeably.
This study applied the same definition for each of these terms. All three constructs were
characterized as involving personal sacrifice and burden, worry and feelings of isolation,

and heartfelt sadness and longing, which are key subscales in the Marwit-Meuser-Caregiver
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Grief Inventory.
Discussion
This systematic review on grief experienced by family members prior to an individual’s
death to life-limiting illness revealed wide variation in the terminology used and
characterization of such grief across studies. More than 18 terms and more than 30
definitions have been used to describe this form of grief. Further, in many cases, even when
certain terms were frequently used (e.g., anticipatory grief, pre-death grief), the same term
was often defined differently across studies. For example, one study 49 defined anticipatory
grief as the process associated with grieving the eventual loss of a family member in advance
of their inevitable death, whereas another study 98 defined anticipatory grief as a series of
losses based on a loved one’s progression of cognitive and physical decline. As is evident
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in this example, these definitions differ drastically, which limits the reliability and validity
of the construct and, in turn, constrains the utility of the term anticipatory grief. Similar
conceptual issues were found with and across other terms. Several studies (N=24; 17.9%)
did not define the construct at all nor provide a citation for a past study that defined
the construct. The net result is that the current conceptualization of a family member’s
grief experience prior to death lacks conceptual clarity and a precise, consistently applied
definition.
Conceptual Problems with the Construct and Measures Used

The lack of consensus in defining the construct of grief before a death occurs across studies
presents problems for comparing study findings, in advancing research, and in providing
appropriate clinical care to grieving families. The most frequently used definitions were
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those of Lindemann’s 11 and Rando’s 12, yet less than 15% of the studies used one of these
two definitions. Other studies either used their own definition, which differed drastically
across studies using the same terms, or did not define the construct being examined. A
recent systematic review 99 examining pre-loss grief with cancer patients stated that their
results (i.e., higher pre-loss grief results in worse post-loss adjustment) were limited by
an inconsistent operationalization of pre-loss grief. Clear and consistent definitions are
necessary for other researchers to replicate findings and increase our understanding of
theoretical constructs 100. Further, Drost 101 found using multiple definitions to define the
same construct can diminish reliability, as well as internal and external validity. Therefore,
providing a universal definition of a construct can lead to an advancement of the field,
allowing multiple researchers to examine the same construct and compare studies. For
example, Holley’s 49 study and Pote and colleagues’ 57 investigation, which both used the
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term anticipatory grief, could not be appropriately compared because their definitions varied.
The lack of uniformity of the definitions, coupled with studies not defining the construct,
further increases the difficulty of comparing research findings and, importantly, limits the
clinical utility of the constructs.
It was beyond the scope of this systematic review to examine the psychometric properties of
individual instruments and homegrown questions used to measure grief in family members

of individuals with a life-limiting illness; however, examination of the connection between

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the definitions used and the measures used is salient to the focus of the paper. There
were numerous instruments used to measure grief before death, which is not uncommon or
specific to the grief literature. However, the articles that were identified in this systematic
review differed drastically in their definition of the construct of grief before a death,
despite often using the same scale. For example, Guererro 88 used the Marwit-Meuser-
Caregiver Grief Inventory and defined the construct as sadness, longing, worry, felt isolation,
personal sacrifice, and burden, whereas York and colleagues 58 also used the Marwit-
Meuser-Caregiver Grief Inventory and defined the construct as grief related to anticipation
of the forthcoming loss of a family member. Not only were different definitions used in
studies using the same scales, but the same scale was used across terms, such as use of
the Marwit-Meuser-Caregiver Grief Inventory to measure more than 6 different constructs.
Thus, it is unclear whether the terms and the measures in fact reflect separate, distinct
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constructs or a single grief phenomenon.
Limitations
Findings from this systematic review should be considered in the context of some
limitations. First, this systematic review only focused on articles that were published in
English or for which translations were available. It should be noted that 14 studies during the
initial review were excluded for which translation could not be found. Second, this review
only included studies that examined grief in family members of individuals with life-limiting
illnesses and not other chronic medical (e.g., diabetes) or mental (e.g., schizophrenia)
illnesses over which family members may grieve. Third, this study was limited in that it only
examined published research articles and thus may have missed studies that were started
during the pandemic that examined COVID-19 and grief before the loss. Finally, we did not
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include conference abstracts, which could limit the studies identified.
Proposed Definitions
In synthesizing the results of this study, two overarching conceptualizations of grief
occurring before the person with a life-limiting illness has died emerged: grief around the
anticipated death of the person and grief associated with losses that occur throughout the
illness trajectory. In light of the differences between definitions noted in this systematic
review and the overlaps between constructs, we have attempted to provide clarity in the
following proposed definitions. Under the umbrella category that we propose be termed pre-
death grief, we propose two separate constructs: anticipatory grief and illness-related grief.
Anticipatory grief is future-oriented and defined as a family members’ grief experience
while the person with the life-limiting illness is alive but that is focused on feared or
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anticipated losses that will occur after the person’s death. Anticipatory grief includes worry
about a future without the person with the life-limiting illness being physically present and
feeling sad about future losses related to the deceased person. Many studies defined the
construct of grief prior to a loss as the anticipation of future losses related to the physical
death of a person (e.g., 23,24,26–28). Using our proposed definition, these studies would be
measuring anticipatory grief.

Illness-related grief is, on the other hand, present-oriented. More specifically, illness-related
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grief includes grief related to current or ongoing losses experienced during the illness
trajectory, such as loss of roles or loss of physical functioning. Some studies (e.g., 7,60)
provided a definition of grief before a death that would fit under illness-related grief when
they defined the construct as longing and yearning for the family member to be as they were
before the illness. We would expand on this definition and state that illness-related grief is
the experience of grief before the death of a family member that relates to the numerous,
multiplicative losses that can be incurred when a family member has a life-limiting illness.
For example, a person might experience intense feelings of emotional pain, sorrow, or pangs
of grief related to the family member’s functional impairment and wish they were able to do
what they used to be able to do.
Consistent use of these two constructs as we have defined them could provide the field
with uniformity, facilitating advancement of the study of pre-death grief. Importantly, the
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definitions identified through this systematic review would not be able to differentiate if
a person has anticipatory grief, illness-related grief, or both anticipatory grief and illness-
related grief. While anticipatory grief and illness-related grief, may be distinguished, they
may both be experienced by family members. Future research can further examine methods
of measuring these distinct constructs in order to more effectively identify family members
in need of support for pre-death grief and to establish intervention targets relevant to the type
of grief they are experiencing.
Despite grief before the death of an individual with life-limiting illness being studied for
more than 80 years with more than 130 studies identified, this systematic review provides
evidence that there is no consistent definition of this construct and identifies numerous
related limitations within the current body of literature that examines grief before death.
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These limitations appear to be hindering the advancement of the grief field. This study
is novel as it provides the field with consistent terms: pre-death grief, anticipatory grief,
and illness-related grief, as described above, which will facilitate clinical research to
1) replicating results, 2) better differentiating normative pre-death grief from impairing
pre-death grief, 3) identifying of risk and protective factors for developing impairing
pre-death grief, as well as the extent to which pre-death grief may be a risk factor for
negative bereavement outcomes such as prolonged grief disorder, 4) developing and testing
interventions to reduce distressing and impairing pre-death grief, and 5) understanding
if there are differences in presentation of pre-death grief depending on the patient’s
illness (e.g., cancer; dementia). In a future report, we will also examine the psychometric
properties of the scales identified in this systematic review to continue refining the
field’s conceptualization grief before death and to ultimately offer guidance on which
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measures may be most clinically useful. Additionally, future work should aim to examine
pre-death grief from an interdisciplinary perspective by identifying possible biological,
neuropsychological, and developmental influences in order to create more interdisciplinary
interventions to mitigate pre-death grief. More specifically, due to the interdisciplinary
nature of the work examining pre-death grief, a greater understanding of the neurobiological
underpinnings of pre-death grief in family members is warranted and if these underpinnings
differ depending on the patient’s illness,

Such work has the potential to improve family-centered, bereavement-conscious, palliative

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care for family members of individuals with life-limiting illness before and after
bereavement. A central component of palliative care is attending to the needs of family
members through bereavement, but palliative care clinicians are understandably fulfilling
many roles that hinder their ability to do so. In the context of the COVID-19 pandemic,
palliative care professionals are spread thinner156, 157. Having a greater understanding of
the manifestations of pre-death grief, as well as ways to briefly assess for pre-death grief
and provide targeted intervention could better equip palliative care clinicians to provide
care to those most in need. Further, intervening to assuage pre-death grief can place family
members in a better position to cope with the challenges of bereavement and reduce their
risk for bereavement-related mental health challenges158.
It would be neglectful to not mention the relationship between pre-death grief and family
members’ experiences during the COVID-19 pandemic. At this time, there are no empirical
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studies that have examined COVID-19 and pre-death grief, but several commentaries
and reviews have discussed the implications of COVID-19 on pre-death grief. First, one
commentary159, which used the term pre-loss grief, highlights that families face novel
challenges when the person with COVID-19 becomes critically ill, including physical
separation due to fear of COVID-19 being spread and the lack of preparedness for the death,
which has been shown to increase pre-death grief and prolonged grief disorder. Another
commentary160 focused on the role of front-line workers who are uniquely positioned
to provide critically needed psychosocial support to bereaved family members, yet who
are also experiencing unprecedented levels of burnout. This speaks to the need for brief
assessment and interdisciplinary intervention approaches that not only provide bereavement-
conscious care to families but also seek to reduce systemic barriers to providing care. Also,
palliative care clinicians could be involved earlier in the illness trajectory to help reduce
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pre-death grief in the family member. Therefore, palliative care doctors should be trained on
assessing pre-death grief in family members of individuals with COVID-19. This systematic
review and proposed definitions provide the ability to differentiate normative pre-death grief
from impairing levels of grief and identify risk factors for developing pre-death grief in
family members of individuals with life-limiting illness. This will hopefully result in an
increase in targeted interventions for family members who have pre-death grief as well as
the provision of support to reduce poor bereavement outcomes.
Acknowledgment:
We would like to thank Anthony Papa for his thoughtful comments during this project.
Funding:
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The author(s) received no financial support for the research, authorship, and/or publication of this article
Data management and sharing:

All relevant data are within the manuscript. Any other data are available upon request from
the corresponding author.

APPENDIX
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Appendix
Appendix A.
Terms for Pre-death grief found in the literature, 2000– 2013 in Lindauer & Harvath (2014)
study
Anticipatory grief Latent grief
Anticipating grief Sorrow
Living grief Anticipatory mourning
Masked grief Bereavement
Mourning Caregiver grief
Ongoing mourning Chronic grief

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Pre-bereavement grief Chronic grief reaction
Pre-death grief Chronic sorrow
Pre-loss grief Disenfranchised grief
Preparatory grief Grief
Appendix B: Database Search Strategies

1. PubMed (via National Library of Medicine’s PubMed.gov)
(“Caregivers” [Mesh] OR “Family” [Mesh:NoExp] OR “Adult Children” [Mesh] OR
“Family Relations” [Mesh] OR “Grandparents” [Mesh] OR “Nuclear Family” [Mesh] OR
“Friends” [Mesh] OR caregiver [TIAB] OR “care giver” [TIAB] OR caregivers [TIAB]
OR “care givers” [TIAB] OR caretaker [TIAB] OR “care taker” [TIAB] OR caretakers
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[TIAB] OR “care takers” [TIAB] OR caregiving [TIAB] OR “care giving” [TIAB] OR

caretaking [TIAB] OR “care taking” [TIAB] OR carer [TIAB] OR carers [TIAB] OR
family [TIAB] OR families [TIAB] OR relative [TIAB] OR relatives [TIAB] OR spouse
[TIAB] OR spouses [TIAB] OR wife [TIAB] OR wives [TIAB] OR husband [TIAB]
OR husbands [TIAB] OR fiancée [TIAB] OR fiancées [TIAB] OR fiancé [TIAB] OR
fiancés [TIAB] OR “domestic partner” [TIAB] OR “domestic partners” [TIAB] OR
girlfriend [TIAB] OR girlfriends [TIAB] OR boyfriend [TIAB] OR boyfriends [TIAB]
OR daughter [TIAB] OR daughters [TIAB] OR son [TIAB] OR sons [TIAB] OR child
[TIAB] OR children [TIAB] OR offspring [TIAB] OR parent [TIAB] OR parents [TIAB]
OR stepparent [TIAB] OR “step-parent” [TIAB] OR stepparents [TIAB] OR “step-parents”
[TIAB] OR mother [TIAB] OR mothers [TIAB] OR father [TIAB] OR fathers [TIAB]
OR sister [TIAB] OR sisters [TIAB] OR brother [TIAB] OR brothers [TIAB] OR sibling
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[TIAB] OR siblings [TIAB] OR aunt [TIAB] OR aunts [TIAB] OR uncle [TIAB] OR

uncles [TIAB] OR niece [TIAB] OR nieces [TIAB] OR nephew [TIAB] OR nephews
[TIAB] OR cousin [TIAB] OR cousins [TIAB] OR grandparent [TIAB] OR grandparents
[TIAB] OR grandmother [TIAB] OR grandmothers [TIAB] OR grandfather [TIAB] OR
grandfathers [TIAB] OR friend [TIAB] OR friends [TIAB] OR companion [TIAB] OR
companions [TIAB] OR acquaintance [TIAB] OR acquaintances [TIAB] OR friendship
[TIAB] OR friendships [TIAB]) AND (((“Bereavement” [Mesh] OR grief [TIAB] OR

grieve [TIAB] OR grieves [TIAB] OR grieving [TIAB] OR bereavement [TIAB] OR

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bereaved [TIAB] OR sorrow [TIAB] OR sorrowful [TIAB] OR mourning [TIAB] OR

mourn [TIAB] OR mourns [TIAB] OR mournful [TIAB]) AND (“Catastrophic Illness”
[Mesh] OR “Critical Illness” [Mesh] OR “Terminal Care” [Mesh:NoExp] OR “Terminally
Ill” [Mesh] OR “Hospice Care” [Mesh] OR “Palliative Care” [Mesh] OR “catastrophic
illness” [TIAB] OR “catastrophic illnesses” [TIAB] OR “catastrophic disease” [TIAB] OR
“catastrophic diseases” [TIAB] OR “prolonged illness” [TIAB] OR “prolonged illnesses”
[TIAB] OR “prolonged disease” [TIAB] OR “prolonged diseases” [TIAB] OR “critical
illness” [TIAB] OR “critical illnesses” [TIAB] OR “critical disease” [TIAB] OR “critical
diseases” [TIAB] OR “critically ill” [TIAB] OR “life-limiting condition” [TIAB] OR
“life-limiting conditions” [TIAB] OR “life-limiting illness” [TIAB] OR “life-limiting
illnesses” [TIAB] OR “life-limiting disease” [TIAB] OR “life-limiting diseases” [TIAB] OR
“life-threatening health condition” [TIAB] OR “life-threatening health conditions” [TIAB]
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OR “life-threatening condition” [TIAB] OR “life-threatening conditions” [TIAB] OR “life-

threatening illness” [TIAB] OR “life-threatening illnesses” [TIAB] OR “life-threatening
disease” [TIAB] OR “life-threatening diseases” [TIAB] OR “advanced medical illness”
[TIAB] OR “advanced medical illnesses” [TIAB] OR “advanced illness” [TIAB] OR
“advanced illnesses” [TIAB] OR “advanced disease” [TIAB] OR “advanced diseases”
[TIAB] OR “terminal care” [TIAB] OR “terminal illness” [TIAB] OR “terminal illnesses”
[TIAB] OR “terminal disease” [TIAB] OR “terminal diseases” [TIAB] OR “terminally
ill” [TIAB] OR “terminal stage” [TIAB] OR “terminal stages” [TIAB] OR “fatal illness”
[TIAB] OR “fatal illnesses” [TIAB] OR “fatal disease” [TIAB] OR “fatal diseases” [TIAB]
OR “pre-loss” [TIAB] OR preloss [TIAB] OR “pre-death” [TIAB] OR predeath [TIAB]
OR “end of life” [TIAB] OR “hospice care” [TIAB] OR “bereavement care” [TIAB] OR
“palliative care” [TIAB] OR “supportive care” [TIAB])) OR (“pre-bereavement” [TIAB]
OR prebereavement [TIAB] OR “caregiver grief” [TIAB] OR “caregiver bereavement”
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[TIAB] OR “caregiver distress” [TIAB] OR “carer distress” [TIAB] OR “anticipatory grief”

[TIAB] OR “anticipatory bereavement” [TIAB] OR “anticipatory mourning” [TIAB] OR
“pre-death grief” [TIAB] OR “predeath grief” [TIAB] OR “pre-loss grief” [TIAB] OR
“preloss grief” [TIAB] OR “preparatory grief” [TIAB])) NOT (“Animals” [Mesh] NOT
“Humans” [Mesh])
2. Embase (via Elsevier’s Embase.com)

(‘caregiver’/exp OR ‘relative’/exp OR ‘family’/de OR ‘adopted child’/exp OR ‘adult
child’/exp OR ‘aunt’/exp OR ‘cousin’/exp OR ‘extended family’/exp OR ‘family
health’/exp OR ‘family life’/exp OR ‘family relation’/exp OR ‘family service’/exp OR
‘foster child’/exp OR ‘grandchild’/exp OR ‘grandparent’/exp OR ‘great-grandparent’/exp
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OR ‘nephew’/exp OR ‘niece’/exp OR ‘nuclear family’/exp OR ‘parenthood’/exp OR

‘stepfamily’/exp OR ‘uncle’/exp OR ‘friend’/exp OR caregiver:ab,ti OR ‘care giver’:ab,ti
OR caregivers:ab,ti OR ‘care givers’:ab,ti OR caretaker:ab,ti OR ‘care taker’:ab,ti OR
caretakers:ab,ti OR ‘care takers’:ab,ti OR caregiving:ab,ti OR ‘care giving’:ab,ti OR
caretaking:ab,ti OR ‘care taking’:ab,ti OR carer:ab,ti OR carers:ab,ti OR family:ab,ti
OR families:ab,ti OR relative:ab,ti OR relatives:ab,ti OR spouse:ab,ti OR spouses:ab,ti
OR wife:ab,ti OR wives:ab,ti OR husband:ab,ti OR husbands:ab,ti OR fiancée:ab,ti
OR fiancées:ab,ti OR fiancé:ab,ti OR fiancés:ab,ti OR ‘domestic partner’:ab,ti OR

‘domestic partners’:ab,ti OR girlfriend:ab,ti OR girlfriends:ab,ti OR boyfriend:ab,ti

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OR boyfriends:ab,ti OR daughter:ab,ti OR daughters:ab,ti OR son:ab,ti OR sons:ab,ti

OR child:ab,ti OR children:ab,ti OR offspring:ab,ti OR parent:ab,ti OR parents:ab,ti
OR stepparent:ab,ti OR ‘step-parent’:ab,ti OR stepparents:ab,ti OR ‘step-parents’:ab,ti
OR mother:ab,ti OR mothers:ab,ti OR father:ab,ti OR fathers:ab,ti OR sister:ab,ti
OR sisters:ab,ti OR brother:ab,ti OR brothers:ab,ti OR sibling:ab,ti OR siblings:ab,ti
OR aunt:ab,ti OR aunts:ab,ti OR uncle:ab,ti OR uncles:ab,ti OR niece:ab,ti OR
nieces:ab,ti OR nephew:ab,ti OR nephews:ab,ti OR cousin:ab,ti OR cousins:ab,ti OR
grandparent:ab,ti OR grandparents:ab,ti OR grandmother:ab,ti OR grandmothers:ab,ti OR
grandfather:ab,ti OR grandfathers:ab,ti OR friend:ab,ti OR friends:ab,ti OR companion:ab,ti
OR companions:ab,ti OR acquaintance:ab,ti OR acquaintances:ab,ti OR friendship:ab,ti
OR friendships:ab,ti) AND (((‘bereavement’/exp OR ‘grief’/exp OR grief:ab,ti OR
grieve:ab,ti OR grieves:ab,ti OR grieving:ab,ti OR bereavement:ab,ti OR bereaved:ab,ti OR
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sorrow:ab,ti OR sorrowful:ab,ti OR mourning:ab,ti OR mourn:ab,ti OR mourns:ab,ti OR

mournful:ab,ti) AND (‘terminal disease’/exp OR ‘critical illness’/exp OR ‘terminal care’/de
OR ‘terminally ill patient’/exp OR ‘hospice care’/exp OR ‘palliative therapy’/exp OR
‘catastrophic illness’:ab,ti OR ‘catastrophic illnesses’:ab,ti OR ‘catastrophic disease’:ab,ti
OR ‘catastrophic diseases’:ab,ti OR ‘prolonged illness’:ab,ti OR ‘prolonged illnesses’:ab,ti
OR ‘prolonged disease’:ab,ti OR ‘prolonged diseases’:ab,ti OR ‘critical illness’:ab,ti
OR ‘critical illnesses’:ab,ti OR ‘critical disease’:ab,ti OR ‘critical diseases’:ab,ti OR
‘critically ill’:ab,ti OR ‘life-limiting condition’:ab,ti OR ‘life-limiting conditions’:ab,ti OR
‘life-limiting illness’:ab,ti OR ‘life-limiting illnesses’:ab,ti OR ‘life-limiting disease’:ab,ti
OR ‘life-limiting diseases’:ab,ti OR ‘life-threatening health condition’:ab,ti OR ‘life-
threatening health conditions’:ab,ti OR ‘life-threatening condition’:ab,ti OR ‘life-threatening
conditions’:ab,ti OR ‘life-threatening illness’:ab,ti OR ‘life-threatening illnesses’:ab,ti
OR ‘life-threatening disease’:ab,ti OR ‘life-threatening diseases’:ab,ti OR ‘advanced
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medical illness’:ab,ti OR ‘advanced medical illnesses’:ab,ti OR ‘advanced illness’:ab,ti

OR ‘advanced illnesses’:ab,ti OR ‘advanced disease’:ab,ti OR ‘advanced diseases’:ab,ti
OR ‘terminal care’:ab,ti OR ‘terminal illness’:ab,ti OR ‘terminal illnesses’:ab,ti OR
‘terminal disease’:ab,ti OR ‘terminal diseases’:ab,ti OR ‘terminally ill’:ab,ti OR ‘terminal
stage’:ab,ti OR ‘terminal stages’:ab,ti OR ‘fatal illness’:ab,ti OR ‘fatal illnesses’:ab,ti
OR ‘fatal disease’:ab,ti OR ‘fatal diseases’:ab,ti OR ‘pre-loss’:ab,ti OR preloss:ab,ti
OR ‘pre-death’:ab,ti OR predeath:ab,ti OR ‘end of life’:ab,ti OR ‘hospice care’:ab,ti
OR ‘bereavement care’:ab,ti OR ‘palliative care’:ab,ti OR ‘supportive care’:ab,ti)) OR
(‘pre-bereavement’:ab,ti OR prebereavement:ab,ti OR ‘caregiver grief’:ab,ti OR ‘caregiver
bereavement’:ab,ti OR ‘caregiver distress’:ab,ti OR ‘carer distress’:ab,ti OR ‘anticipatory
grief’:ab,ti OR ‘anticipatory bereavement’:ab,ti OR ‘anticipatory mourning’:ab,ti OR ‘pre-
death grief’:ab,ti OR ‘predeath grief’:ab,ti OR ‘pre-loss grief’:ab,ti OR ‘preloss grief’:ab,ti
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OR ‘preparatory grief’:ab,ti)) NOT ((‘animal’/exp OR ‘nonhuman’/exp) NOT ‘human’/exp)
3. Cochrane Central Register of Controlled Trials / Cochrane CENTRAL (via Wiley’s

Cochrane Library)
#1) MeSH descriptor: [Caregivers] explode all trees
#2) MeSH descriptor: [Family] this term only

#3) MeSH descriptor: [Adult Children] explode all trees

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#4) MeSH descriptor: [Family Relations] explode all trees
#5) MeSH descriptor: [Grandparents] explode all trees
#6) MeSH descriptor: [Nuclear Family] explode all trees
#7) MeSH descriptor: [Friends] explode all trees
#8) caregiver:ab,ti OR “care giver”:ab,ti OR caregivers:ab,ti OR “care givers”:ab,ti

OR caretaker:ab,ti OR “care taker”:ab,ti OR caretakers:ab,ti OR “care takers”:ab,ti
OR caregiving:ab,ti OR “care giving”:ab,ti OR caretaking:ab,ti OR “care taking”:ab,ti
OR carer:ab,ti OR carers:ab,ti OR family:ab,ti OR families:ab,ti OR relative:ab,ti OR
relatives:ab,ti OR spouse:ab,ti OR spouses:ab,ti OR wife:ab,ti OR wives:ab,ti OR
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husband:ab,ti OR husbands:ab,ti OR fiancée:ab,ti OR fiancées:ab,ti OR fiancé:ab,ti OR

fiancés:ab,ti OR “domestic partner”:ab,ti OR “domestic partners”:ab,ti OR girlfriend:ab,ti
OR girlfriends:ab,ti OR boyfriend:ab,ti OR boyfriends:ab,ti OR daughter:ab,ti OR
daughters:ab,ti OR son:ab,ti OR sons:ab,ti OR child:ab,ti OR children:ab,ti OR
offspring:ab,ti OR parent:ab,ti OR parents:ab,ti OR stepparent:ab,ti OR “step-parent”:ab,ti
OR stepparents:ab,ti OR “step-parents”:ab,ti OR mother:ab,ti OR mothers:ab,ti OR
father:ab,ti OR fathers:ab,ti OR sister:ab,ti OR sisters:ab,ti OR brother:ab,ti OR
brothers:ab,ti OR sibling:ab,ti OR siblings:ab,ti OR aunt:ab,ti OR aunts:ab,ti OR uncle:ab,ti
OR uncles:ab,ti OR niece:ab,ti OR nieces:ab,ti OR nephew:ab,ti OR nephews:ab,ti
OR cousin:ab,ti OR cousins:ab,ti OR grandparent:ab,ti OR grandparents:ab,ti OR
grandmother:ab,ti OR grandmothers:ab,ti OR grandfather:ab,ti OR grandfathers:ab,ti
OR friend:ab,ti OR friends:ab,ti OR companion:ab,ti OR companions:ab,ti OR
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acquaintance:ab,ti OR acquaintances:ab,ti OR friendship:ab,ti OR friendships:ab,ti
#9) #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8
#10) MeSH descriptor: [Bereavement] explode all trees
#11) grief:ab,ti OR grieve:ab,ti OR grieves:ab,ti OR grieving:ab,ti OR bereavement:ab,ti OR

bereaved:ab,ti OR sorrow:ab,ti OR sorrowful:ab,ti OR mourning:ab,ti OR mourn:ab,ti OR
mourns:ab,ti OR mournful:ab,ti
#12) #10 OR #11
#13) MeSH descriptor: [Catastrophic Illness] explode all trees

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#14) MeSH descriptor: [Critical Illness] explode all trees
#15) MeSH descriptor: [Terminal Care] this term only
#16) MeSH descriptor: [Terminally Ill] explode all trees
#17) MeSH descriptor: [Hospice Care] explode all trees

#18) MeSH descriptor: [Palliative Care] explode all trees

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#19) “catastrophic illness”:ab,ti OR “catastrophic illnesses”:ab,ti OR “catastrophic

disease”:ab,ti OR “catastrophic diseases”:ab,ti OR “prolonged illness”:ab,ti OR “prolonged
illnesses”:ab,ti OR “prolonged disease”:ab,ti OR “prolonged diseases”:ab,ti OR “critical
illness”:ab,ti OR “critical illnesses”:ab,ti OR “critical disease”:ab,ti OR “critical
diseases”:ab,ti OR “critically ill”:ab,ti OR “life limiting condition”:ab,ti OR “life
limiting conditions”:ab,ti OR “life limiting illness”:ab,ti OR “life limiting illnesses”:ab,ti
OR “life limiting disease”:ab,ti OR “life limiting diseases”:ab,ti OR “life threatening
health condition”:ab,ti OR “life threatening health conditions”:ab,ti OR “life threatening
condition”:ab,ti OR “life threatening conditions”:ab,ti OR “life threatening illness”:ab,ti OR
“life threatening illnesses”:ab,ti OR “life threatening disease”:ab,ti OR “life threatening
diseases”:ab,ti OR “advanced medical illness”:ab,ti OR “advanced medical illnesses”:ab,ti
OR “advanced illness”:ab,ti OR “advanced illnesses”:ab,ti OR “advanced disease”:ab,ti OR
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“advanced diseases”:ab,ti OR “terminal care”:ab,ti OR “terminal illness”:ab,ti OR “terminal

illnesses”:ab,ti OR “terminal disease”:ab,ti OR “terminal diseases”:ab,ti OR “terminally
ill”:ab,ti OR “terminal stage”:ab,ti OR “terminal stages”:ab,ti OR “fatal illness”:ab,ti OR
“fatal illnesses”:ab,ti OR “fatal disease”:ab,ti OR “fatal diseases”:ab,ti OR “pre-loss”:ab,ti
OR preloss:ab,ti OR “pre-death”:ab,ti OR predeath:ab,ti OR “end of life”:ab,ti OR
“hospice care”:ab,ti OR “bereavement care”:ab,ti OR “palliative care”:ab,ti OR “supportive
care”:ab,ti
#20) #13 OR #14 OR #15 OR #16 OR #17 OR #18 OR #19
#21) #12 AND #20
#22) “pre-bereavement”:ab,ti OR prebereavement:ab,ti OR “caregiver grief”:ab,ti OR

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“caregiver bereavement”:ab,ti OR “caregiver distress”:ab,ti OR “carer distress”:ab,ti

OR “anticipatory grief”:ab,ti OR “anticipatory bereavement”:ab,ti OR “anticipatory
mourning”:ab,ti OR “pre death grief”:ab,ti OR “predeath grief”:ab,ti OR “pre loss
grief”:ab,ti OR “preloss grief”:ab,ti OR “preparatory grief”:ab,ti
#23) #21 OR #22
#24) #9 AND #23
#25) MeSH descriptor: [Animals] explode all trees
#26) MeSH descriptor: [Humans] explode all trees

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#27) #25 NOT #26
#28) #24 NOT #27
4. PsycINFO (via Ovid)

(exp caregivers/ or family/ or exp biological family/ or exp extended family/ or exp family
members/ or exp family relations/ or exp family structure/ or exp nuclear family/ or exp
stepfamily/ or exp friendship/ or caregiver.ti,ab. or “care giver”.ti,ab. or caregivers.ti,ab.

or “care givers”.ti,ab. or caretaker.ti,ab. or “care taker”.ti,ab. or caretakers.ti,ab. or

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“care takers”.ti,ab. or caregiving.ti,ab. or “care giving”.ti,ab. or caretaking.ti,ab. or “care

taking”.ti,ab. or carer.ti,ab. or carers.ti,ab. or family.ti,ab. or families.ti,ab. or relative.ti,ab. or
relatives.ti,ab. or spouse.ti,ab. or spouses.ti,ab. or wife.ti,ab. or wives.ti,ab. or husband.ti,ab.
or husbands.ti,ab. or fiancee.ti,ab. or fiancees.ti,ab. or fiance.ti,ab. or fiances.ti,ab. or
“domestic partner”.ti,ab. or “domestic partners”.ti,ab. or girlfriend.ti,ab. or girlfriends.ti,ab.
or boyfriend.ti,ab. or boyfriends.ti,ab. or daughter.ti,ab. or daughters.ti,ab. or son.ti,ab. or
sons.ti,ab. or child.ti,ab. or children.ti,ab. or offspring.ti,ab. or parent.ti,ab. or parents.ti,ab.
or stepparent.ti,ab. or “step-parent”.ti,ab. or stepparents.ti,ab. or “step-parents”.ti,ab. or
mother.ti,ab. or mothers.ti,ab. or father.ti,ab. or fathers.ti,ab. or sister.ti,ab. or sisters.ti,ab.
or brother.ti,ab. or brothers.ti,ab. or sibling.ti,ab. or siblings.ti,ab. or aunt.ti,ab. or
aunts.ti,ab. or uncle.ti,ab. or uncles.ti,ab. or niece.ti,ab. or nieces.ti,ab. or nephew.ti,ab. or
nephews.ti,ab. or cousin.ti,ab. or cousins.ti,ab. or grandparent.ti,ab. or grandparents.ti,ab.
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or grandmother.ti,ab. or grandmothers.ti,ab. or grandfather.ti,ab. or grandfathers.ti,ab. or

friend.ti,ab. or friends.ti,ab. or companion.ti,ab. or companions.ti,ab. or acquaintance.ti,ab.
or acquaintances.ti,ab. or friendship.ti,ab. or friendships.ti,ab.) and (((exp bereavement/
or grief.ti,ab. or grieve.ti,ab. or grieves.ti,ab. or grieving.ti,ab. or bereavement.ti,ab. or
bereaved.ti,ab. or sorrow.ti,ab. or sorrowful.ti,ab. or mourning.ti,ab. or mourn.ti,ab. or
mourns.ti,ab. or mournful.ti,ab.) and (exp terminally ill patients/ or exp hospice/ or
palliative care/ or ‘catastrophic illness’.ti,ab. or ‘catastrophic illnesses’.ti,ab. or ‘catastrophic
disease’.ti,ab. or ‘catastrophic diseases’.ti,ab. or ‘prolonged illness’.ti,ab. or ‘prolonged
illnesses’.ti,ab. or ‘prolonged disease’.ti,ab. or ‘prolonged diseases’.ti,ab. or ‘critical
illness’.ti,ab. or ‘critical illnesses’.ti,ab. or ‘critical disease’.ti,ab. or ‘critical diseases’.ti,ab.
or ‘critically ill’.ti,ab. or ‘life-limiting condition’.ti,ab. or ‘life-limiting conditions’.ti,ab. or
‘life-limiting illness’.ti,ab. or ‘life-limiting illnesses’.ti,ab. or ‘life-limiting disease’.ti,ab.
or ‘life-limiting diseases’.ti,ab. or ‘life-threatening health condition’.ti,ab. or ‘life-
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threatening health conditions’.ti,ab. or ‘life-threatening condition’.ti,ab. or ‘life-threatening

conditions’.ti,ab. or ‘life-threatening illness’.ti,ab. or ‘life-threatening illnesses’.ti,ab. or
‘life-threatening disease’.ti,ab. or ‘life-threatening diseases’.ti,ab. or ‘advanced medical
illness’.ti,ab. or ‘advanced medical illnesses’.ti,ab. or ‘advanced illness’.ti,ab. or ‘advanced
illnesses’.ti,ab. or ‘advanced disease’.ti,ab. or ‘advanced diseases’.ti,ab. or ‘terminal
care’.ti,ab. or ‘terminal illness’.ti,ab. or ‘terminal illnesses’.ti,ab. or ‘terminal disease’.ti,ab.
or ‘terminal diseases’.ti,ab. or ‘terminally ill’.ti,ab. or ‘terminal stage’.ti,ab. or ‘terminal
stages’.ti,ab. or ‘fatal illness’.ti,ab. or ‘fatal illnesses’.ti,ab. or ‘fatal disease’.ti,ab. or ‘fatal
diseases’.ti,ab. or ‘pre-loss’.ti,ab. or preloss.ti,ab. or ‘pre-death’.ti,ab. or predeath.ti,ab.
or ‘end of life’.ti,ab. or ‘hospice care’.ti,ab. or ‘bereavement care’.ti,ab. or ‘palliative
care’.ti,ab. or ‘supportive care’.ti,ab.)) or (‘pre-bereavement’.ti,ab. or prebereavement.ti,ab.
or ‘caregiver grief’.ti,ab. or ‘caregiver bereavement’.ti,ab. or ‘caregiver distress’.ti,ab. or
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‘carer distress’.ti,ab. or ‘anticipatory grief’.ti,ab. or ‘anticipatory bereavement’.ti,ab. or

‘anticipatory mourning’.ti,ab. or ‘pre-death grief’.ti,ab. or ‘predeath grief’.ti,ab. or ‘pre-loss
grief’.ti,ab. or ‘preloss grief’.ti,ab. or ‘preparatory grief’.ti,ab.))
5. Web of Science Core Collection (via Clarivate Analytics)

TS=(caregiver OR “care giver” OR caregivers OR “care givers” OR caretaker OR “care
taker” OR caretakers OR “care takers” OR caregiving OR “care giving” OR caretaking

OR “care taking” OR carer OR carers OR family OR families OR relative OR relatives

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OR spouse OR spouses OR wife OR wives OR husband OR husbands OR fiancée

OR fiancées OR fiancé OR fiancés OR “domestic partner” OR “domestic partners” OR
girlfriend OR girlfriends OR boyfriend OR boyfriends OR daughter OR daughters OR
son OR sons OR child OR children OR offspring OR parent OR parents OR stepparent
OR “step-parent” OR stepparents OR “step-parents” OR mother OR mothers OR father
OR fathers OR sister OR sisters OR brother OR brothers OR sibling OR siblings OR
aunt OR aunts OR uncle OR uncles OR niece OR nieces OR nephew OR nephews OR
cousin OR cousins OR grandparent OR grandparents OR grandmother OR grandmothers
OR grandfather OR grandfathers OR friend OR friends OR companion OR companions
OR acquaintance OR acquaintances OR friendship OR friendships) AND ((TS=(grief OR
grieve OR grieves OR grieving OR bereavement OR bereaved OR sorrow OR sorrowful
OR mourning OR mourn OR mourns OR mournful) AND TS=(“catastrophic illness”
Author Manuscript
OR “catastrophic illnesses” OR “catastrophic disease” OR “catastrophic diseases” OR

“prolonged illness” OR “prolonged illnesses” OR “prolonged disease” OR “prolonged
diseases” OR “critical illness” OR “critical illnesses” OR “critical disease” OR “critical
diseases” OR “critically ill” OR “life-limiting condition” OR “life-limiting conditions”
OR “life-limiting illness” OR “life-limiting illnesses” OR “life-limiting disease” OR
“life-limiting diseases” OR “life-threatening health condition” OR “life-threatening health
conditions” OR “life-threatening condition” OR “life-threatening conditions” OR “life-
threatening illness” OR “life-threatening illnesses” OR “life-threatening disease” OR “life-
threatening diseases” OR “advanced medical illness” OR “advanced medical illnesses”
OR “advanced illness” OR “advanced illnesses” OR “advanced disease” OR “advanced
diseases” OR “terminal care” OR “terminal illness” OR “terminal illnesses” OR “terminal
disease” OR “terminal diseases” OR “terminally ill” OR “terminal stage” OR “terminal
stages” OR “fatal illness” OR “fatal illnesses” OR “fatal disease” OR “fatal diseases”
Author Manuscript
OR “pre-loss” OR preloss OR “pre-death” OR predeath OR “end of life” OR “hospice

care” OR “bereavement care” OR “palliative care” OR “supportive care”)) OR TS=(“pre-
bereavement” OR prebereavement OR “caregiver grief” OR “caregiver bereavement”
OR “caregiver distress” OR “carer distress” OR “anticipatory grief” OR “anticipatory
bereavement” OR “anticipatory mourning” OR “pre-death grief” OR “predeath grief” OR
“pre-loss grief” OR “preloss grief” OR “preparatory grief”))
6. Cumulative Index to Nursing and Allied Health Literature (CINAHL) (via EBSCO)
((MH “Caregivers+”) OR (MH “Family”) OR (MH “Adult Children+”) OR (MH
“Extended Family+”) OR (MH “Family Characteristics”) OR (MH “Parenthood+”) OR
(MH “Stepfamilies+”) OR (MH “Family Functioning+”) OR (MH “Family Relations+”) OR
Author Manuscript
(MH “Nuclear Family+”) OR (MH “Friendship+”) OR TI(caregiver OR “care giver” OR

caregivers OR “care givers” OR caretaker OR “care taker” OR caretakers OR “care takers”
OR caregiving OR “care giving” OR caretaking OR “care taking” OR carer OR carers OR
family OR families OR relative OR relatives OR spouse OR spouses OR wife OR wives
OR husband OR husbands OR fiancée OR fiancées OR fiancé OR fiancés OR “domestic
partner” OR “domestic partners” OR girlfriend OR girlfriends OR boyfriend OR boyfriends
OR daughter OR daughters OR son OR sons OR child OR children OR offspring OR parent
OR parents OR stepparent OR “step-parent” OR stepparents OR “step-parents” OR mother

OR mothers OR father OR fathers OR sister OR sisters OR brother OR brothers OR sibling

Author Manuscript
OR siblings OR aunt OR aunts OR uncle OR uncles OR niece OR nieces OR nephew

OR nephews OR cousin OR cousins OR grandparent OR grandparents OR grandmother
OR grandmothers OR grandfather OR grandfathers OR friend OR friends OR companion
OR companions OR acquaintance OR acquaintances OR friendship OR friendships) OR
AB(caregiver OR “care giver” OR caregivers OR “care givers” OR caretaker OR “care
taker” OR caretakers OR “care takers” OR caregiving OR “care giving” OR caretaking OR
“care taking” OR carer OR carers OR family OR families OR relative OR relatives OR
spouse OR spouses OR wife OR wives OR husband OR husbands OR fiancée OR fiancées
OR fiancé OR fiancés OR “domestic partner” OR “domestic partners” OR girlfriend OR
girlfriends OR boyfriend OR boyfriends OR daughter OR daughters OR son OR sons OR
child OR children OR offspring OR parent OR parents OR stepparent OR “step-parent”
OR stepparents OR “step-parents” OR mother OR mothers OR father OR fathers OR
Author Manuscript
sister OR sisters OR brother OR brothers OR sibling OR siblings OR aunt OR aunts OR

uncle OR uncles OR niece OR nieces OR nephew OR nephews OR cousin OR cousins
OR grandparent OR grandparents OR grandmother OR grandmothers OR grandfather OR
grandfathers OR friend OR friends OR companion OR companions OR acquaintance
OR acquaintances OR friendship OR friendships)) AND ((((MH “Bereavement+”) OR
TI(grief OR grieve OR grieves OR grieving OR bereavement OR bereaved OR sorrow OR
sorrowful OR mourning OR mourn OR mourns OR mournful) OR AB(grief OR grieve
OR grieves OR grieving OR bereavement OR bereaved OR sorrow OR sorrowful OR
mourning OR mourn OR mourns OR mournful)) AND ((MH “Catastrophic Illness+”) OR
(MH “Critical Illness+”) OR (MH “Terminal Care”) OR (MH “Terminally Ill Patients+”)
OR (MH “Hospice Care+”) OR (MH “Palliative Care+”) OR TI(“catastrophic illness”
OR “catastrophic illnesses” OR “catastrophic disease” OR “catastrophic diseases” OR
“prolonged illness” OR “prolonged illnesses” OR “prolonged disease” OR “prolonged
Author Manuscript

stages” OR “fatal illness” OR “fatal illnesses” OR “fatal disease” OR “fatal diseases” OR
“pre-loss” OR preloss OR “pre-death” OR predeath OR “end of life” OR “hospice care”
Author Manuscript
OR “bereavement care” OR “palliative care” OR “supportive care”) OR AB(“catastrophic

illness” OR “catastrophic illnesses” OR “catastrophic disease” OR “catastrophic diseases”
OR “prolonged illness” OR “prolonged illnesses” OR “prolonged disease” OR “prolonged


Author Manuscript

stages” OR “fatal illness” OR “fatal illnesses” OR “fatal disease” OR “fatal diseases” OR
“pre-loss” OR preloss OR “pre-death” OR predeath OR “end of life” OR “hospice care” OR
“bereavement care” OR “palliative care” OR “supportive care”))) OR (TI(“pre-bereavement”
OR prebereavement OR “caregiver grief” OR “caregiver bereavement” OR “caregiver
distress” OR “carer distress” OR “anticipatory grief” OR “anticipatory bereavement” OR
“anticipatory mourning” OR “pre-death grief” OR “predeath grief” OR “pre-loss grief” OR
“preloss grief” OR “preparatory grief”) OR AB(“pre-bereavement” OR prebereavement OR
Author Manuscript
“caregiver grief” OR “caregiver bereavement” OR “caregiver distress” OR “carer distress”

OR “anticipatory grief” OR “anticipatory bereavement” OR “anticipatory mourning”
OR “pre-death grief” OR “predeath grief” OR “pre-loss grief” OR “preloss grief” OR
“preparatory grief”))) NOT ((MH “Animals+”) NOT (MH “Human+”))
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Key Statements
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What is already known about the topic?
• Current evidence suggests that grief before the death in family members of
individuals with a life-limiting illness is a robust predictor of prolonged grief
disorder.
• Significant conceptualization issues exist when defining and measuring grief

before the death.
What this paper adds
• This systematic review of the literature on grief experienced by family

members prior to an individual’s death to life-limiting illness revealed wide
variation in the terminology used and characterization of such grief across
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studies (e.g., more than 18 terms and more than 30 definitions have been used
to describe this form of grief).
• In many cases, even when certain terms were frequently used (e.g.,
anticipatory grief, pre-death grief), the same term was often defined
differently across studies.
• In synthesizing the results of this study, we propose the overarching term

is pre-death grief, with the two separate constructs under pre-death grief:
anticipatory grief and illness-related grief.
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Figure 1.
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PRISMA Flow Diagram

Author Manuscript Author Manuscript Author Manuscript Author Manuscript
Table 1.
Articles Examining Family Members’ Grief Prior to the Death of Individuals with a Life-limiting Illness
AG/Pre-loss
measure or
Singer et al.
Author et al. Definition of pre-grief

Methods Field Purpose of Study Illness Context Sample characteristics Qualitative Term used
(Year) term
interview
questions
Examine the self-reported
losses, grief reactions,
AD, other
Adams & and depressive symptoms n = 99
known disease, Qual interview
Sanders Mixed Neurology among caregivers of M = 59.07 (14.55) Grief Not defined
not known guide
(2004) [71] persons with Alzheimer’s f: 69; m: 30
disease
disease or other
progressive dementia
AG is the process
of mourning, coping,
Develop a modified interaction, planning
version of MM-CGI for n = 140 and psychological
Al-Gamal et the assessment of AG Mmothers = 34.4 (6.93), reorganization that are
Quant Oncology among Jordanian parents Cancer Mfathers = 39.5(8.62) MM-CGI-CC AG stimulated and are in
al. (2009) 103 of children with cancer Fnewly: 57; mnewly: 13; response to the impending
(the MM-CGI Childhood f6–12: 42; m6–12: 28 loss of a loved one and the
Cancer) recognition of associated
losses in the past, present
and future
Albinsson & Examine issues relevant n = 20

Strang (2003) to family members M = not provided, Age Qual interview
Qual Neurology Dementia AG Not defined
34 caring for patients with range = 44–80 guide
dementia f: 12; m: 8
AM is time-limited: the
uncertainty surrounding
Investigate stress, AM, n = 56 the amount of time a loved
Anngela-Cole and cultural-practices M = 57.9, SD = not Qual interview one has left often creates
Qual Oncology Terminal cancer AM
among family caregivers provided guide a more concentrated

et al. (2011) 91
different cultural groups f: 51; m: 5 and heightened grieving
experience pre-death, as
opposed to post-death
Assess the prevalence of

Areia et al. psychological morbidity n = 112
Quant Oncology in family caregivers of Terminal cancer M = 44.45 (15.32) MM-CG-SF AG Not defined
(2019) 35 persons with terminal f: 92; m: 20
cancer
Examine AG experienced Measure AG as the reaction felt

by parents when they are n = 202 (101 mother-father designed by before the actual loss of
Benefield et informed their critically Critically ill pairs) Mmaternal = 25, authors, name a loved object assumed
Quant Nursing AG
al. 45 ill infant must be newborns Mpaternal = not reported not mentioned, a different meaning in
transferred to a center for f: 50%; m: 50% included ‘7 key this context, since the
special care items from the actual loss never occurred;
Page 32
AG/Pre-loss
measure or
(Year) term
interview
questions
instead defined by these
study of
Singer et al.
seven items: feelings of

Kennell’ which
sadness, loss of appetite,
were
inability to sleep, increased
considered to
irritability, preoccupation
represent a
thinking about the baby,
measure of AG
thinking one had done
expressed after
something to cause the
transfer of their
baby’s problem (guilt), and
baby.
feelings of anger
AG is operationally
defined by the items
n = 70 (35 couples) on the included scale:
Compare the AG
Benfield Mmaternal = 28.6, SD = feelings of sadness, anger,
responses of mothers Neonatal ICU
Quant Nursing not provided, Mpaternal = AGS AG difficulty sleeping, change
(1976) 104 and fathers neonatal ICU recipients
30, SD = not provided in appetite, preoccupation
experiences over time
f: 35; m: 35 thinking or dreaming about
the baby, irritability, and
guilt
Explore the experiences

Beng et al. n = 15 Semi- Grief reaction that occurs
of informal caregivers Palliative care
Qual Nursing M = not provided structured AG before an
(2013) 105 of patients in Malaysian recipients
f: 10; m: 5 questions impending loss
palliative care
Understand the lived

Bielek (2008) Cancer, mostly n = 8 (4 couples) The act of mourning when
experience of parents Qual interview
92 Qual Oncology leukemia or M = not provided AM facing a loss whether it is
who have lost a child to guide
lymphoma w: 4, m: 4 sudden or prolonged
cancer
16 items
derived from
Examine whether the
Bonanno et al. bereaved individuals n = 205 Bereavement

Qant Psychology exhibit different patterns Unspecified M = 72, SD = not provided Index, the Chronic grief Not defined
(2002) 106 of distress following the f: 87.8%; m: 12.2% Present
loss of a spouse Feelings About
Loss Scale and
the TRIG.
Grief is a reaction to
Explore the retrospective
Bouchal et al. separation, and in the case
experiences of AG in n=8 Qual interview
Qual Oncology Cancer AG, AM of AG, it is a reaction to
(2015) 107 eight families of people M = not provided guide
the threat of death rather
with cancer
than death itself
Examine PDG as ncaregivers = 38,

a predictor for Mixed, mostly nmatchedcomparison = 32
Breen et al.
Quant Palliative Medicine outcomes among cancer (check M = not reported HGRC; PG-12 PDG Not defined
(2019) [59]
bereaved caregivers and this) fcaregivers: 68.4%;
non-caregivers mcaregivers: 26.3%;
Page 33
AG/Pre-loss
measure or
(Year) term
interview
questions
missingcaregivers: 5.3%;
Singer et al.
fcomparison: 68.8%;
mcomparison: 31.3%;
missingcomparison: 0%
Explore caregiving as n = 15
Broom et al. a social practice that M = not provided, Age Qual interview
Qual Oncology Cancer None Not defined
(2019) 108 occurs across dying and range = 40–80 guide
bereavement w: 10; m: 5
AGS- with
Explore risk factors for
“dementia” The process associated
Burke et al. AG in a sample of family Varied, mostly n = 57
replaced to with grieving the loss of
Quant Palliative Medicine members preparing for cancer (check M = 56.11 (12.97) AG
(2015) 36 “life- loved ones in advance of
the death of their veteran this) f: 42; m: 15
threatening their inevitable death
family member
illness”
AGS- with
Examine the grieving
“dementia”
Burke et al. experience of survivors of n = 35
Palliative care replaced to
Quant Palliative Medicine veterans and to determine M = 58.64 (13.25) AG Not defined
(2019) 109 recipients “life-
risk factors for PLG f: 27; m: 13
threatening
distress
illness”
Explore associations
between residual, current,
Butler et al. n = 50 AG, Partners’ feelings about
and anticipatory stressors Recurrent breast Anticipation of
Quant Oncology M = 56.5 (11.3) Anticipated the possible impact of
(2005) 110 in partners of women cancer Loss Inventory
f: 1; m: 49 loss losing their wife/partner
with metastatic breast
cancer, pre and post-loss
Examine if older adults’

n = 210 Bereavement
Carr et al. psychological adjustment Grief during
Mfemales = 69.43 (6.99), Index; Present
Quant Psychology to spousal death varies Unspecified the pre death Not defined
(2001) 111 Mmales = 73.46 (5.92) Feelings about
based on the death period
f: 151; m: 59 Loss; TRIG

context
PDG is defined by
the MM-CGI: personal
sacrifice and burden (i.e.,
MM-CGI; losses of time, freedom,
Examine caregiver grief
What would sleep, health), worry and
Carter et al. in Parkinson’s disease n = 74
Parkinson’s you say is the felt isolation (i.e., loss
Mixed Neurology across the three domains M = 69.2 (8.2) PDG, CG
(2012) 97 disease biggest barrier of personal connection to
of the MM-CGI Short f: 28%; m: 72%
you have faced others and worries about
Form
as a caregiver? the future) and heartfelt
sadness and longing (i.e.,
emotional response to loss
of relationship)
Page 34
AG/Pre-loss
measure or
(Year) term
interview
questions
The authors discuss
Singer et al.
diverging opinions for

AG in caregivers of
PWD: some use AG,
the the anticipation of
Validate the C-MMCGI-
Chan et al. n = 120 the impending death of
SF among Hong Kong
Quant Neurology Dementia M = 55.46 (14.89) C-MM-CGI Grief family members while
(2017) 73 Chinese caregivers of
f: 80; m: 40 others suggest that the
people with dementia
grief experienced by these
caregivers should include
broader physical and
emotional reactions in
response to various losses
Emotive responses as
caregivers mourn for the
psychological and physical
changes in PWD; grief
Evaluate the validity
comprise factors unique
Chan et al. and utility of MM- n = 394
to caring for PWD (i.e.,
Quant Neurology CGI dimensions in Dementia M = 53 (10.7) C-MM-CGI PDG, CG
(2019) 112 communication challenges,
a multiethnic Asian f: 236; m: 158
asynchronous loss, and
population
an ambiguous disease
trajectory leading to worry
and uncertainty about the
future)
Chapman & Examine the relationships

n = 61
Pepler (1998) among AG in family AG is grief occurring
Quant Oncology Terminal cancer M = 48 (18.3) NDGEI AG
113 members of people with before death
f: 37; m: 24
terminal cancer
Sense of loss, such as the

eroded personal qualities
Cheng et al. Validate CGQ assessing n = 173 of the care recipients and

Quant Neurology AD CGQ PDG
(2019) 114 two dimensions of PDG f: 73%; m: 27% the loss of intimacy and
companionship, across all
stages of dementia
ncaregivers = 48,
Compare the emotional ncontrols= 36
adjustment and grief Mcaregivers = 63, SD =
Chentsova- Terminal
intensity of bereaved not provided, Mcontrols =
Dutton et al. chronic illness
Quant Palliative Medicine spouses and adult 56, SD = not provided TRIG None Not defined
and hospice
(2002) 115 children caregivers’ pre- fcaregivers: 83%;
care recipients
loss throughout one-year mcaregivers: 17%;
post-loss fcontrols: 75%: mcontrols:
25%
Page 35
AG/Pre-loss
measure or
(Year) term
interview
questions
Compare AG levels
Singer et al.
between spousal and

PDG is a feeling in
Cheung et al. adult children caregivers’ n = 108
response to compound
Quant Neurology of people at earlier Dementia M = 62.9 (12.6) MM-CG-SF AG
(2018) 44 serial losses in the
or later stages of f: 85; m: 23
dementia process
dementia; to explore the
associations with AG
Were provided
Examine the symptoms The reaction seen in
symptoms
Clayton et al. of bereavement during people (usually primary
Psychology n = 81 (e.g., depressed
Quant the terminal illness of the Terminal illness AG relative) coping with the
(1973) 46 Palliative Medicine M = 61, SD = not provided mood; crying)
spouses of widows and expected death of someone
but no scale
widowers close
identified
State of transition usually

Cancer, heart initiated by either the
Retrospectively explore
disease, chronic diagnosis of a terminal
Clukey (1997) the AG experience of n=22
Palliative Medicine obstructive Qual interview illness or the prognosis
116 Qual caregivers of family M = 53, SD = not provided AG
Nursing pulmonary guide from a physician that
members with terminal f: 18; m: 4
disease, no further medical
illness
Hepatitis C intervention will cure the
dying person.
AM is a dynamic
Retrospectively explore n=9
set of processes that
Clukey (2003) AM for family members Cancer, stroke, M = 52.2, SD = not
Qual interview involve emotional and
90 Qual who had not used hospice old age (check provided, Age range = 36– AM
guide cognitive transitions made
or had minimal hospice old age) 68
in response to an expected
services f: 7, m: 2
loss
AM involves a dynamic
Explore the retrospective
Dying patients set of processes that
Clukey (2008) perceptions of the AM n=9
Palliative Medicine; who did not Qual interview include emotional and
116 Qual experience of caregivers M = not provided, Age AG, AM
Nursing receive hospice guide cognitive transitions made

who had not received range = 36–68
care (check this) in response to an expected
hospice services
loss
n = 64 Modified
Coelho et al., Cancer,
Identify the mediators of M = 58.2, SD = not Bereavement
Quant Palliative Medicine cardiovascular Grief Not defined
(2016) 74 CG in caregivers provided Risk
disease
f: 82.8%; m: 17.2% Questionnaire
Personal losses (i.e.,

restrictions of autonomy
and suppression of their
Coelho et al. n = 94
Validate a Portuguese AG, PDG, own needs), relational
Quant Oncology Cancer M = 52.02 (12.87) PG-12
(2017) 13 version of the PG–12 PLG losses (i.e., deprivation of
f: 78.8%; m: 21.3
intimacy and reciprocity
with the patient) causing
intense feelings of grief
Page 36
AG/Pre-loss
measure or
(Year) term
interview
questions
while the relative is still
Singer et al.
physically present
Qualitatively explore the

experience of family
n = 26 AG is expectations and
Coelho et al. caregivers of patients
M = not provided, Age Qual interview emotions associated with
Qual Oncology with terminal cancer Cancer AG
(2019) 21 Range = 27–78 guide the fear of losing their
related to AG in
f: 23, m: 3 significant other
the context of EOL
caregiving
Examine the evolution

of PGD symptoms and
Coelho et al. the predictive role of the n=156
Quant Oncology caregiving-related factors Cancer M=51.78 (13.29) PG-12 PDG Not defined
(2021) 20 in the FCs’ grieving f: 127; m: 29
trajectory from pre- to
post-death
AG is a psychological
response initiated by
Describe family caregiver ntotal = 350, a person’s growing
Collins et al. AD, other
experiences of loss and npostbereaved = 87 Open-ended awareness of the
Qual Neurology progressive AG
(1993) 23 grief pre and post-death M = 66 (11) questions impending loss of a loved
dementia
of PWD f: 79%; m: 21% one and the associated
losses in the past, present,
and future
Explore the experiences

Collins et al. of parents who are n = 14 Semi-
Life-limiting
Qual Palliative Medicine providing care for a M = 40, SD = not provided structured AG Not defined
(2016) 37 condition
child with a life-limiting f: 12; m: 2 interviews
condition in Australia
Examine AG and AM, Mourning is a process

n=1

D’antonio comparing the terms and whereby one tries to cope
Quant Oncology Cancer M = 72, SD = N/A AGS AG
(2014) 117 examining both terms with loss and the ensuing
f: 0, m: 1
within the case study grief
AG is the process
of mourning, coping,
Examine grief reactions MM-CGI-SF-
n = 72 interaction, planning
DeCaporale et in current spousal and Cognitive and Heartfelt
M = 69.8, SD = not and psychological
Quant Palliative Medicine adult-children caregivers physical Sadness and AG
al. (2013) 24 provided reorganization’ that occurs
and in-home respite conditions Longing
f: 20.1%; m: 79.9% as a result of the
utilization over 3 months Subscale
impending loss of a loved
one
An experience of
Dempsey et al. Explore the experience n = 23
Late stage Qual interview Dementia questioning the self and
Qual Neurology of carers who provide M = not provided
(2020) 118 dementia guide grief their own sanity, struggle
EOL care for a person f: 70%; m: 30%
to care and burden of care
Page 37
AG/Pre-loss
measure or
(Year) term
interview
questions
with late-stage dementia
Singer et al.
at home
Identify concerns of
parents of children
with advanced, incurable
Dighe et al. cancers, and to elicit n = 31 Qual interview
Qual Oncology Advance cancer AG Not defined
(2008) 38 their attitudes toward M = not provided guide
revealing the diagnosis
and prognosis to the sick
child
Examine how adult-child n=3 AG can be defined as the

Dillon (2016) caregivers for parents M = 55.16, SD = not experience of grief prior
54 Quant Neurology Dementia MM-CGI AG
with dementia experience provided to the physical death of a
depression and AG f: 42; m: 8 person
Dionne-Odom Test the effect of

n = 44 Pathological grief over the
et al. (2016) palliative care telehealth
Quant Oncology Cancer M = 61.6 (10.1) PG-12 Grief past-month measured pre-
119 support on bereaved
f: 37; m: 7 death
family caregivers
NDRGEI;
Questions were
part of the
Evaluate the Living with Living with Grief that is not associated
Duggleby et Hope Program in rural n = 36 Hope Program with the death of a person
Mixed Oncology women caregivers of Cancer M = 59 (11.6) in the form of a Grief, Loss (e.g., existential concerns,
al. (2013) 120 persons with advanced f: 36; m: 0 hope directed depression, tension and
cancer journaling guilt, physical distress)
activity entitled
“Stories of the
Present”
Explore AG through Terminal

Duke (1998) a Heideggerian malignant n=4 Qual interview
39 Qual Palliative Medicine AG Not defined
phenomenological disease (cancer? M = not provided guide
approach check)
Provides an overview
of various definitions in
Illustrate the impact
Elliott & Dale literature: the emotional
of AG on people n=3 Questions
Qual Oncology Cancer AG experience a person might
(2007) 121 with learning disabilities M = not provided unspecified
have prior to losing
through three case studies
someone of significance to
him or her
AG is a profound
Explore the experience of
Evans (2009) emotional response to
AG and cancer among n = 22 Qual interview
122 Qual Oncology Cancer AG impending, irreversible
individuals living with M = not provided guide
loss, which may be
cancer, their primary
experienced by both dying
Page 38
AG/Pre-loss
measure or
(Year) term
interview
questions
caregivers, and their people and their loved
Singer et al.
families ones
Examine the lived Irreversible mental

Ford et al. n=3
experience of three wives Qual interview Psychosocial deterioration, unlike
Mixed Neurology Dementia M = not provided
(2013) 123 caring for husbands with guide death physical death that is not
f: 3; m: 0
dementia a terminal event
Measure involvement in
medical decision making AG is the process of
Fowler et al. and if AG is associated n = 73 experiencing the phases
Quant Neurology with problem-solving in Dementia M = 64.9 (11.28) AGS AG of normal bereavement in
(2013) 25 family caregivers of older f: 78.1%; m: 21.9% advance of the loss of a
adults with cognitive loved one
impairment
Explore the medical n = 199 A normative emotional

Francis et al. compared to the social M = 54.8, SD = not response to loss; extreme
Mixed Oncology Cancer BEQ Grief
(2015) 124 perspective of grief and provided sadness appropriate to the
depression f: 81.4%; m: 18.6% situation
AG comprises past,
present, and future losses;
AM is “leaving without
saying goodbye,” where
the person is still
Frank (2008) Explore links between n = 415 psychologically present
125 Mixed Neurology AG for family caregivers Dementia M = 60.5, SD = not MM-CGI AG, AM although physically absent.
of PWD provided In the second form,
the person remains
physically present but
psychologically absent
(i.e., “the goodbye without
leaving”)

Examine the relationship
n = 74
Fronzaglia between AG and Grief that occurs in
M = 65.49, SD = not
Quant Neurology satisfaction with life AD MM-CGI AG recognition of the fact that
(2009) 55 provided
in rural Alzheimer’s the person is going to die
f: 73.6%; m: 26.4%
caregivers
Examine differences
of AG between AG refers to the process
Garand et al. family caregivers of n = 73 of experiencing the phases
Quant Neurology persons with a new MCI, AD M = 64.88 (11.27) AGS AG of normal bereavement in
(2012) 126 diagnosis of mild f: 57; m: 16 advance of the loss of a
cognitive impairment and significant person
associations with AG
Giannone- The grief process that a

Understand the lived n=4 Qual interview
Qual Oncology Cancer PDG person experiences before
Tyler (2016) 32 experiences of elderly M = not provided, Age guide
a loss actually occurs
Page 39
AG/Pre-loss
measure or
(Year) term
interview
questions
giving advance warning
Singer et al.
of impending death and

women grieving the death range = 67–78
helping to mitigate grief
of their husbands f: 4; m: 0
reactions once death has
occurred
n = 93
Mpalliative = 62,
Gilliland & Assess the influence of a Mchroniccare = 68.58,
Palliative Medicine; Terminal illness Grief Grief before the loss of
Fleming number of factors on AG Mcontrol = 55.29
Quant Nursing; Oncology; unspecified Experience AG someone with a chronic
and conventional grief wpalliative: 63.3%;
(1998) 127 Neurology (check this) Inventory illness
reactions mpalliative: 36.7%;
wchronic: 53.3%;
mchronic: 46.7%
Describe pre-loss and

post-loss grief symptoms
Givens et al. among family members n = 123
Quant Neurology of nursing home residents Dementia M = 59.6 (10.6) PG-12 PLG Not defined
(2011) 8 with advanced dementia, f: 75; m: 48
and to identify predictors
of post-loss grief
n = 50
Glick et al. AG is the experience of
Evaluate AG in the ICU M = 55.5
Quant Nursing; Psychology Unspecified AGS AG grief before the death of a
(2018) 48 setting SD = not provided
mourned individual
f: 72%; m: 28%
Investigate the
relationship between
Grief prior to death of the
frontal systems
care recipient; caregiver
behavioral functioning
Guerrero Frontotemporal n = 76 grief is comprised of
and the experience
Quant Neurology lobar M = not provided MMCGI-SF CG sadness and longing, worry
(2012) 88 of grief and burden
degeneration w: 91.2%; m: 8.8% and felt isolation, and
on spousal caregivers
personal sacrifice and

of persons with
burden
frontotemporal lobar
degeneration
Gunnarsson & meaning(s) of spouses’
n = 12
Ohlen (2006) grief before their Advanced Qual interview
Qual Oncology M = not provided AG Grief before the loss
128 partners’ death after cancer guide
w: 75%; m: 25%
being admitted to a
palliative home care team
Examine if spouses AG is before the actual

Hampe (1975) caring for their terminally n = 27 loss of a valued mate;
Terminal illness Qual interview
129 Qual Nursing ill partners can recognize M = not provided AG, Grief dependent upon the
unspecified guide
their own needs and f: 42.7%; m: 57.3% spouse’s awareness of the
nurses who help them impending loss
Page 40
AG/Pre-loss
measure or
(Year) term
interview
questions
Test the efficacy of the n = 229
Singer et al.
Hicken et al. “Supporting Caregivers M = 70.16, SD = not

Mixed Neurology Check this MM-CGI-SF AG Not defined
(2017) 40 of Rural Veterans provided
Electronically” program f: 92.6%; m: 7.4%
Examine parents’
perspectives of having
Higgs et al. n=13 Grief experienced in
Nursing; Palliative a child with Spinal Spinal muscular Questions
Qual M = not provided AG anticipation of a loss that
(2016) 33 Medicine Muscular Atrophy type atrophy unspecified
f: 7; m: 6 has yet to occur
1, from diagnosis to
bereavement
Examine the role of

Unspecified, n = 95
Hill et al. anticipatory bereavement
patients had M = 66.5, SD = not Anticipatory Grief reaction before the
Quant Psychology in the adjustment to TRIG
(1988) 130 died within the provided bereavement actual death
widowhood in older
last 2–4 weeks f: 95, m: 0
women
Evaluate the
Hinton (1994) circumstances of location n = 77 No grief
75 Mixed Oncology of death and quality of Terminal cancer M = 60 (14) measure Grief Not defined
life in both relatives and w: 34; m: 43 reported
patients
AG of the family
caregivers may be a highly
Follow spouses stressful experience; their
Hisamatsu et of patients with n = 13 experiences during the
Qual interview
Qual Oncology palliative chemotherapy Cancer M = not reported AG patient’s battle with cancer
al. (2020) 131 guide
discontinuation until w: 1; m: 1 affect them even after
bereavement in Japan bereavement and have
the potential to facilitate
appropriate grief work
AG is a multifaceted

concept that encompasses
Understand which
Holley & Mast n = 80 emotional reactions to the
aspects of the caregiving
Quant Neurology Dementia M = 60.53 (12.66) MM-CGI AG impending loss of a loved
(2009) 132 situation may lead to
w: 73.8%; m: 26.2% one and associated losses
greater levels of AG
in the past, present, and
future
Investigate AG in AG is the psychological

dementia caregivers; experience occurring from
Holley & Mast n = 80
examine correlates of AGS; MM- the point of recognition
Quant Neurology Dementia M = 60.53 (12.36) AG
(2010) 26 caregiver grief; and CGI and acceptance of the
f: 59; m: 21
relationship between AG impending death until the
and caregiver burden time of death
Holm et al. Evaluate the n = 270 Grief, which is

Palliative care
Quant Palliative Medicine psychometric properties M = 61.0(14) AGS AG the psychological
(2019) 64 recipients
of AGS in a sample w: 184; m: 86 physiological response to a
Page 41
AG/Pre-loss
measure or
(Year) term
interview
questions
of family caregivers in person’s death, before said
Singer et al.
palliative care close person’s death
Grief that might begin

long before the actual
death; in some cases
already starts when they
receive information about
a diagnosis of incurable
illness, while others
continue to invest in
Investigate associations the patient’s recovery;
Holm et al. n = 128
between PDG and post- Advanced grief before an expected
Quant Palliative Medicine M = 62 (13.2) AGS PDG
(2019) 61 death grief and potential illness death has been associated
f: 66.4%; m: 33.6%
moderators with characteristics similar
to those often observed
after the death: emotional
distress, frustration, hope,
and ambivalence; PDG
aso differs from post-death
grief because it involves
losing a person who is still
physically present
Investigate longitudinal
Holm et al. variations in grief, Palliative care n = 117
Referred to as the
Quant Palliative Medicine symptoms of anxiety and recipients, M = 62(13.1) AGS PDG
(2019) 133 experience before death
depression, and self-rated mostly cancer w: 75; m: 42
health
Explore the EOL

A reaction to perceived
Hovland and PDG experiences n = 36
Qual interview losses throughout the
Qual Neurology for bereaved family Dementia M = 64, SD = not provided PDG
(2018) 134 guide caregiving process and in
caregivers of older adults f: 81%; m: 19%
anticipation of the death
with dementia

Examine the
psychological and Grief is a process
Hudson et al. social profile of n= 301 involving some elements
Cancer, non-
Quant Oncology family caregivers on M = 56.52 (13.89) PG-12 PLG of “loss,” which starts
(2011) 81 cancer
commencement of f: 220; m: 79 before the bereavement
receiving palliative care and can be onerous
services
Identify the clinical

PDG are reactions that
relationship between
may occur prior to death
Jain et al. grief, depression and n = 23
when observing and caring
Quant Neurology mindfulness and identify Dementia M = 60 (11) MM-CGI-SF PDG
(2019) 69 for a loved one afflicted
neural predictors of f: 21; m: 2
with a serious illness such
symptomatology and
as dementia
improvement
Page 42
AG/Pre-loss
measure or
(Year) term
interview
questions
AG is prolonged and
Singer et al.
occurs even before a

Johansson & person dies; compared to
AG,
Grimby (2012) Explore the feelings and n = 49 conventional grief, AG
Quant Oncology Cancer AGS Preparatory
50 expressions of AG M = 56.9 (17.4) has been associated with
grief
higher intensities of anger,
loss of emotional control,
and atypical grief
AG, compared to grief

after death, is associated
n = 102
with higher intensities of
Compare reactions on the Mdimentia = 62.3
Johansson et AGS; Semi- anger, loss of emotional
AG scale of relatives of Dementia, (13.3), Mcancer = 56.9
Mixed NeurologyOncology structured AG control, and atypical grief;
al. (2013) 135 PWD with relatives of cancer (17.4) Fdementia: 53;
questions and despite the experience
cancer patients mdementia: 53; fcancer:
of AG, the grief after the
49; mcancer: 49
death of a loved one is not
likely to be lessened
PDG is the loss

experienced by family
members of dementia
patients before their actual
death; multiple losses,
Identify factors
sometimes referred to as
associated PDG
Kiely et al. n = 315 “triple grief”: first they
symptoms among health
Quant Neurology Dementia M = 59.9 (11.5) PG-12 PDG grieve loss of the patients’
(2008) 62 care proxies of nursing
f: 63%; m: 27% personhood before their
home residents with
actual bodily death, next
advanced dementia
experience loss at the
time of nursing home
admission, finally loss
when the patient ultimately
dies

Loss that can occur
when a family member
remains physically present,
but because of the
Explore the experience Semi- dementia process, the
Kilty et al. of family caregivers of n=6 structured AG, caregiver experiences
Qual Neurology persons with young-onset Dementia M = 55, SD = not provided interview; Ambiguous reduced connection and
(2019) 136 dementia and use of f: 3; m: 3 questions not loss support from the person
support services reported with dementia over time;
a complex concept with
grief experienced in
anticipation of future loss
of a loved one
Page 43
AG/Pre-loss
measure or
(Year) term
interview
questions
Examine the moderating
Singer et al.
effects on the relationship

Kobiske et al. n = 104
between PDG and Losses experienced by a
Quant Neurology Dementia M = 104 MM-CGI-SF PDG
(2019) 70 perceived stress among caregiver
f: 68; m: 36
young-onset dementia
caregivers
AG is a reaction that
occurs in the caregiver
Investigate the course of before an impending
psychological symptoms, loss; a psychological
emotional and social mechanism characterised
Lai et al. n = 60
abilities in caregivers by emotional stress,
Quant Oncology Cancer M = 75 (11) PG-12 AG
(2017) 137 of terminally ill cancer intense pre-occupation
f: 43; m: 17
patients from 1 months with the dying, longing for
before loss to 14 months his/her former personality,
after loneliness, fearfulness,
irritability, anger and
social withdrawal
AG is any grief occurring

n = 70 prior to a loss, as
Explore the potential
Lane (2007) 51 Quant Unspecified Unspecified M = 54.7 (12.7) AGS AG distinguished from the
predictors of AG
f: 63; m: 7 grief that occurs at or after
a loss
Grief in dementia
caregivers defined as “true
Evaluate the Mandarin grief,” which can reflect
version of the MM-CGI- the qualities and intensities
Li et al. (2019) n = 91
SF; grief of family Grief in of caregivers’ grief after
94 Quant Neurology Dementia M = 52.19 (14.35) MM-CGI-SF
caregivers of patients caregivers the dementia patient dies;
f: 65.9%; m: 34.1%
with dementia; and includes various physical
predictors of grief and emotional reactions
due to various losses of the

dementia patients
PDG is the emotional

response as dementia
Explore the prevelance of
n = 72 family caregivers mourn
pre-death grief in a multi-
Liew (2016) 65 Quant Neurology Dementia M = 50.9 (11.6) MM-CGI PDG for the psychologically
ethnic Asian population
f: 58.3%; m: 41.7% absent patient and
using the MM-CGI
anticipate impending
losses
The experience of grief

Develop a briefer scale and loss in dementia
Liew & Yap n = 394
than the MM-CGI-SF, MM-CGI; caregiving, characterized
Quant Neurology Dementia M = 53(10.7) CG
(2020) 86 while still capturing the MM-CGI-SF by multiple losses within
f: 236; m: 158
essence of caregiver grief the context of caregiving,
including the anticipation
Page 44
AG/Pre-loss
measure or
(Year) term
interview
questions
of future losses related
Singer et al.
to physical death of the

PWD and the ambiguous
loss of the PWD who
is physically present but
increasingly disconnected
from the caregiver
Emotional, cognitive,
and behavioral responses
to the multiple
losses in caregiving;
include ambiguous loss
due to increasing
Liew et al. Determine differences in n = 394
disconnectedness from
Quant Neurology the risk factors of PDG Dementia M = 53 (10.7) MM-CGI PDG
(2018) 67 the PWD who is
and caregiver burden f: 256; m: 138
physically present but
psychologically absent;
and the anticipation of
future losses relating to
the physical death of the
person
PDG is the caregivers’

responses to perceived
losses in the pre-death
context; anticipation of
Produce a Mandarin- future loss related to the
Liew et al. n = 394
Chinese version of MM- physical death of PWD;
Quant Neurology Dementia M = 53 (10.7) MM-CGI PDG
(2018) 85 CGI and evaluate its and the mourning of
f:236; m: 131
psychometric properties present loss related to
the psychological death of
PWD, whereby they are
still physically present but
emotionally disconnected

For caregivers of PWD,
bereavement that is
before the physical death;
Compare the effects of multiple losses within
Liew et al. baseline grief and burden n = 131 the context of caregiving,
Quant Neurology on caregiver depression Dementia M = 53.1 (11.0) MM-CGI CG including the ambiguous
(2019) 66 at baseline and 2.5 years f: 58.3%; m: 41.7% loss of the person with
later dementia who is physically
present but becomes
increasingly disconnected
from the caregiver
Loss and grief are

Liew et al. Construct screening n = 300
experienced by caregivers
Quant Neurology tool based on factors Dementia M = 52.1 (11) MM-CGI CG
(2019) 84 of PWD; ambiguous loss
associated with caregiver f: 60%; m: 40%
of PWD even when
Page 45
AG/Pre-loss
measure or
(Year) term
interview
questions
they are still alive; and
Singer et al.
grief to identify those at anticipation of future loss

greater risk of high grief related to their physical
death
Anticipated loss as the
Brain cancer family’s realization of the
Lou et al. maternal experiences of
(previously n = 10 Qual interview Anticipated meaning of the disease and
Qual Oncology anticipatory loss of
(2015) 138 tumor check M = 42, SD = not provided guide loss the process of facing the
families of a child with
this) loss of their child in the
advanced cancers
future
Determine the effect

n = 200
MacCourt et of a grief management
M = 64.4, SD = not Grief in
Mixed Neurology coaching intervention for Dementia MM-CGI Not defined
al. (2017) 95 provided caregivers
caregivers of individuals
f: 79%; m:21%
with dementia
Investigate the properties

Marwit & n = 28
of MM-CGI-SF for Grief in
Quant Neurology Brain injury M = 55.22 (14.25) MM-CGI-SF Not defined
Kaye (2006) 96 caregivers of patients caregivers
f: 25; m: 5
with acquired brain injury
Complicated grief as
n = 166
divided into AG reactions
Marwit & Develop an instrument Madultchild = 51.81
and bereavement; pre-
Meuser (2002) for the assessment of (8.05), Mspouse = 71.47
Mixed Neurology Dementia MM-CGI CG and post-death grief, are
87 grief in caregivers of (8.93) fadultchild: 73;
unique phenomena from
persons with AD madultchild: 10; fspouse:
each other and other
62; mspouse: 21
psychiatric diagnoses
Marwit & Derive a short-form of

n = 292
Meuser (2005) the existing MM-CGI AGS; MM-
Quant Neurology Dementia M = not provided, PDG, CG Grief before death
139 and establish preliminary CGI-SF
f: 76.4%; m: 23.6%
reliability and validity

Grief within the emotional
reactions of ‘pre-death’
loss among caregivers
of people with chronic/
debilitating and life-
threatening conditions,
Examine the MM-CGI including dementia, where
Marwit et al. n = 75
psychometric and validity a series of cognitive,
Quant Oncology Cancer M = 52.8 (12.8) MM-CGI PDG
(2008) 68 properties in caregivers of emotional, and social
f: 69.3%; m: 30.7%
persons with cancer losses precede death;
caregiver grief is
considered a unique affect,
similar to bereavement,
discriminable from
depression and anxiety,
and associated negatively
Page 46
AG/Pre-loss
measure or
(Year) term
interview
questions
with caregiver health,
Singer et al.
social relations, and post-

death bereavement
PDG experienced by AD
caregivers is similar to
AG, grief in anticipation
of death to come;
developed from deep
Understand African- feelings of loss and
McLennon et American caregivers n = 19 sadness experienced by
Qual Neurology PDG experiences; to Dementia M = 60 (13.5) MM-CGI-SF PDG caregivers as they watch
al. (2014) 140 assess the validity of f: 16, m: 3 the gradual deterioration
items on the MM-CGI-SF of the personality and
memory of their loved one
into “dependent shadows
of their former selves”,
also referred to as
“psychosocial death”
Examine the
phenomenological
McRae (2005) n = 11 The experience of current
experience of daughters- Qual interview
141 Qual Neurology Dementia M = 50, SD = not provided AG losses or the anticipation
in-law caring for guide
f: 11; m: 0 of loss and grief
a parent-in-law with
dementia
PDG is defined as the

Meichsner & Examine if a cognitive-
n = 273 ‘emotional and physical
Wilz (2018) behavioral intervention Caregiver Grief
Quant Neurology Dementia M = 64.20 (11.04) PDG response to the perceived
142 increases caregivers’ Scale
f: 80.6%; m: 19.4% losses in a valued care
coping with PDG
recipient’
Illustrate how dementia

Emotional and physical
Meichsner et caregivers experience loss
n = 273 Questions response to the perceived

Qual Neurology and PDG, and examine Dementia PDG
al. (2019) 143 M = not provided unspecified losses in a valued care
how therapists respond to
recipient
this grief
Meuser & Develop a stage-sensitive, n = 87

Marwit (2001) caregiver-specific model MAdultchild = 51.6 (9.6),
Mixed Neurology Dementia AGS; MFG AG Not defined
41 of grief for a measure of Mspouse= 71.8 (9)
dementia caregiver grief w: 20; m: 67
Symptoms include
Identify areas of overlap
Mulligan n = 202 yearning for the family
and disjunction between MM-CGI-SF;
Quant Neurology Dementia M = 67.67 (11.52) PDG member to be healthy
(2011) 60 the PG-12 and the MM- PG-12
f: 148; m: 54 again and feeling shocked
CGI-SF
about the person’s illness
Page 47
AG/Pre-loss
measure or
(Year) term
interview
questions
A syndrome characterized
Singer et al.
by emotional, behavioral
and cognitive symptoms
Examine the relationship (e.g. yearning, searching,
Nanni et al. between pre and post-loss n = 60 Pre-loss detachment, numbness,
Quant Oncology criteria for CG and the Cancer M = 60.3 (12.08) ICG-PL caregiver bitterness, emptiness, and
(2014) 144 validity of ICG for Italian f: 75%; m: 25% grief lost sense of trust
caregivers and control) named as:
complicated grief, then
traumatic grief, and, more
recently, prolonged grief
Compare AG of mothers
of children diagnosed n = 70
Neyshabouri An active process of being
with cancer within the M1month = 32.27, M6–
Quant Oncology Cancer MM-CGI AG sad that occur prior to
et al. (2018) 56 previous month to those 12month = 33.12
actual loss
diagnosed 6–12 months f: 100%; m: 0%
earlier
Describe PLG and other n = 3560

Nielsen et al. PsychologyPalliative relevant outcomes in M = 61.2, SD = not
Quant Terminal illness PG-13 PLG Not Defined
(2016) 82 Medicine caregivers to terminally provided
ill patients f: 66.6%; m: 29.4%
Investigate whether
severe preloss grief and
depressive symptoms,
n = 3635, 38% bereaved
caregiver burden,
Nielsen et al. w/in 6mo, of these 88%
preparedness for
Quant Oncology Cancer completed T2 PG-12 PLG Not defined
(2017) 83 death, communication
M = 62
about dying, and
f: 70%; m: 30%
socioeconomic factors
predict CG and postloss
depressive symptoms

PLG and AG as grief
symptoms in caregivers
Explore associations
Nielsen et al. n = 2865 before death have been;
between severe PLG
Quant Oncology Cancer M = 61, SD = not reported PG-12 AG, PLG can be described as a grief
(2017) 9 symptoms in caregivers
f: 69%; m: 31% reaction due to multiple
and modifiable factors
losses during end-of-life
caregiving
AG experienced at the end

Explore cancer carers’ of a patient’s life; AG
Olson (2014) n = 32 AG,
experiences of loss with Qual interview occurs when the emotions
145 Qual Oncology Cancer Age range = 30–89 Indefinite
Australian carers of a guide related to loss arise a
f: 14; m: 18 loss
spouse with cancer substantial time before the
person stops breathing
Page 48
AG/Pre-loss
measure or
(Year) term
interview
questions
Grief as the reaction to
Singer et al.
the perception of loss

with normative symptoms
Describe the grief
including yearning,
experience of spouses
Ott et al. n = 201 sadness, anger, guilt,
and adult children Grief in
Quant Neurology Dementia M = 64.07 (13.88) MM-CGI-SF regret, anxiety, loneliness,
(2007) 93 of individuals with caregivers
f: 80.6%; m: 19.4% fatigue, shock, numbness,
Alzheimer’s disease and
positive feelings, and
related dementias
a variety of physical
symptoms that are unique
to the individual
Determine if the Easing n = 23 Increased sadness and

Ott et al. the Way intervention is M = 73.5, SD = not longing, worry and
Quant Neurology Dementia MMCGI-SF Grief
(2010) 80 feasible for caregivers of provided isolation, and personal
spouses with dementia f: 75%; m: 25% sacrifice burden
An emotional reaction to
actual or perceived losses
among caregivers marked
by increased sadness
Examine the relationships and longing, worry and
among burnout, isolation, and personal
Park et al. n = 606
depressive symptoms, burden; in caregivers, grief
Quant Neurology Dementia M = 60.5 (10.6) MM-CGI AG, CG
(2018) 146 social support, and starts with early signs of
f: 88.9%; m: 10.6%
psychological wellbeing dementia in the family
in caregivers of PWD member and continues
through the stages of
dementia; AG is defined as
anticipation of the loss of a
family member
GEI-Loss
Ponder & Provide evidence of the n = 100 Despair Scale;
intensity, nature and M = 56.6, SD = not Stage of Grief

Pomeroy Quant Neurology Dementia AG Not defined
persistence of AG among provided Inventory; self-
(1996) 42 caregivers of PWD f: 83 m: 17 developed
scale
AG is the process whereby

individuals mourn the
Understand the effect approaching death of a
of perceived closeness n = 90 loved one, particularly
Pote (2017) 98 Quant Neurology and attachment styles Dementia M = not reported MMCGI-SF AG through the physical and
of spousal caregivers of f: 66; m: 24 cognitive decline that
individuals with dementia plagues individuals who
are at a terminal stage in
life
Page 49
AG/Pre-loss
measure or
(Year) term
interview
questions
AG is a process that
Singer et al.
Evaluate AG as a many informal caregivers

Pote & Wright moderator for marriage n = 90 go through and involves a
Quant Neurology and life satisfaction in Dementia M = 63, SD = not provided MM-CGI-SF AG series of losses that stem
(2018) 57 spousal caregivers of f: 66; m: 24 from their loved one’s
dementia patients progression of cognitive
and physical decline
Investigate effects of the

Prigerson et al. EMPOWER intervention
Critically ill FOLLOS;
Mixed Nursing; Psychology for surrogate decision- n = 60 AG Not defined
(2019) 43 ICU patients PG-12
makers of critically ill
ICU patients
Grief experienced by
caregivers prior to the
Examine how coping
Rankin (2011) n = 103 death of the patient in
styles influence seeking
59 Quant Oncology Cancer M = 49.57 (12.43) WOC PDG response to the many
social support for carers
f: 68; m: 35 losses that accompany the
of persons with cancer
cancer diagnosis of a loved
ones
A multifaceted process
occurring over time,
involving physical,
cognitive, emotional,
Examine the effects of
n = 53 behavioral, and social
Rider (1994) ambiguity of loss and AGS-CIV;
PsychologyPalliative M = 46.4, SD = not reactions or tasks in
52 Quant type of relationship on Terminal illness RAGC; TRIG- AG
Medicine provided response to the death of
AG in family caregivers CIV1
f: 86.8%; m: 13.2% a loved one; efforts at
of chronically ill patients
coping with and resolving
the loss are part of this
grief process; also called
post-death grief

Feelings of loss
Relationship
Develop a measure nstudy1 = 51, nstudy2 = 84 and negative emotions
Birmingham continuity,
Riley et al. on spousal carers’ Mstudy1 = 73 (7.6), related to whether the
Relationship Negative
Quant Neurology perception of their Dementia Mstudy2 = 71.6 (7.8) spouse experiences the
(2013) 147 Continuity emotions
relationship as fstudy1: 23, mstudy1: 28; relationship as essentially
Measure related to the
“continuous” fstudy2: 58, mstudy2: 26 changed and radically
relationship
different relationship
AM is the process
of emotional preparatory
Describe the role of AM experience leading up to
Rini & Loriz Mixed cause of n = 11
Nursing; Palliative in parents who recently Qual interview the time of death, formerly
Qual death (check M = not provided AM
(2007) 89 Medicine experienced the death of guide termed AG; AM describes
this) f: 9; m: 2
a hospitalized child not only the process of
grief but other processes
as well; AM encompasses
Page 50
AG/Pre-loss
measure or
(Year) term
interview
questions
seven operations according
Singer et al.
to Rando (2001): grief

and mourning, coping,
interaction, psychosocial
reorganization, planning,
balancing of conflicting
demands, and facilitation
of an appropriate death
PDG results from losses in

the quality of the original
Identify predictors of
n = 66 relationship, roles, well-
Romero et al. higher levels of grief in
M = 64.3, SD = not being, intimacy, health
Quant Neurology bereaved caregivers of AD MMCGI-SF PDG
(2014) 71 provided status, social interaction,
persons with Alzheimer’s
f: 88%; m: 22% communication, and
prior to death
opportunities to resolve
issues from the past
Explore the reliability

Grief process of
Ross & of the MM-CGI and
n = 176 individuals who are
Dagley (2009) AG as a multi-cultural Dementia and
Quant Neurology M = not provided MM-CGI-SF AG losing someone slowly,
27 phenomenon among cardiac patients
f: 45.5%; m: 54.5% expectedly, and many
caregivers of patients
times, in stages
with dementia
Explore the extent

to which spouses
take advantage of
Saldinger & Cognitive, emotional,
their partner’s terminal
Cain (2004) n = 30 Qual interview practical, and interpersonal
Qual Oncology illness for cognitive, Cancer AG
148 M = not provided guide accommodation to
emotional, practical,
impending death.
and interpersonal
accommodation to
impending death

Describe the experience
of spouses and adult n = 44
Sanders et al. children who are AD and M = 65.18, SD = not The reaction to the
Mixed Neurology MM-CGI-SF Grief
(2008) 77 caregivers of persons dementia provided perception of loss
with Alzheimer’s disease f: 86%; m :14%
and related dementias.
The impending loss of

their loved one or the
loss of their pre-diagnosis
Examine changes in PLG nbaseline = 138, n1month
Singer et al. relationship or the loss
Neurology; among individuals whose Cancer, = 61
Quant PG-12 PLG of their pre-diagnosis
(2021) 7 Oncology family member has a life- dementia M = 62.81 (14.41)
relationship with the loved
limiting illness f: 70.8%; m: 29.2%
one (e.g.. yearning for the
individuals to be as they
were before the illness)
Page 51
AG/Pre-loss
measure or
(Year) term
interview
questions
n = 14
Singer et al.
Understand why some Msample1= 63, Age

Stajduhar et al. family caregivers cope rangesample2= 46–57
Questions
Mixed Oncology better than others even Cancer fsample1: 73.7%; Grief Not defined
(2010) 76 unspecified
under similar caregiving msample1: 26.3%;
demands fsample2: 92.9%;
msample2: 7.1%
The Marriage
Examine the relationship nexperimental = 114, Problems In AG, spouses can move
Various cancers,
Swensen et al. between married couples ncontrol = 100 Scale; The closer behaviorally or
others
Mixed Oncology when one of the spouses Mexperimental = 58.6, SD Scale of AG socially, while starting
(1992) 28 unspecified,
is dying of terminal = not provided, Mcontrol = Feelings and to move away intra-
healthy controls
illness 58.4, SD = not provided Behavior of psychically
Love
Assess the validity and The process of slowly

n = 27
Theut et al. reliability of the AGS experiencing the phases of
M = 68.1, SD = not
Quant Neurology scale in documenting AG Dementia AGS AG normal post-death grief in
(1991) 29 provided
in carers of spouses of the face of a potential loss
f: 100%; m: 0%
patients with dementia of a significant person
Complicated grief pre-loss

Examine differences in is an AG reaction prior
Tomarken et n = 248 Complicated
caregiver age groups and death; unique phenomena
Mixed Oncology Cancer M = 52 (13.67) Pre-ICG grief pre-
al. (2006) 149 potential risk factors for from post-death grief
f: 73%; m: 27% death
CG pre-death with different psychiatric
diagnoses
Examine the influence

Toyama & of a narrative approach n = 10 The grief reaction that
Honda (2017) Narrative
Qual Oncology AG in family caregivers Terminal illness M = not provided AG occurs in anticipation of an
30 approach
of patients with terminal f: 80%; m: 20% impending loss
illness

Certain symptoms of
grief (e.g., yearning,
Test pre-loss effects searching, preoccupation
Cancer, AD,
of having a security- with thoughts of the
stroke, heart- Depressive
van Doorn et enhancing marriage on deceased, avoidance of
Psychology related n = 59 HRSD; ITG- symptoms,
Quant traumatic grief and reminders of the deceased)
al. (1998) 150 Palliative Medicine problems, M = 66.2 (9.1) pre-loss Traumatic
depressive symptoms that predict impaired
“other” serious grief
among caregivers of global functioning, such
illness
terminally ill spouses as poor sleep, sad mood,
and low self-esteem at 18
months post-loss
The multifaceted response

n = 30
Waldrop Explore grief during a to death and losses
Patients in M = 64.1, SD = not
Mixed Palliative Medicine terminal illness and after TRIG; BSI Grief of all kinds, including
(2007) 78 hospice care provided
the care recipient’s death emotional (i.e., affective),
f: 77%; m: 23%
psychological (i.e.,
Page 52
AG/Pre-loss
measure or
(Year) term
interview
questions
cognitive and behavioral),
Singer et al.
social, and physical

reactions
AG as the “funeral that

never ends”; grieving for
losses that have already
Measure levels of and n = 100 occurred and are currently
Walker & distinguish AG and M = 56.6, SD = not GEI-Loss occurring (e.g., altered
Quant Neurology Dementia AG
Pomeroy 151 depression in caregivers provided Despair Scale relationship or lifestyle;
of patients with dementia f: 83; m: 17 dreams for the future that
will not be realized; loss of
companionship, security,
economic certainty)
AG for caregivers caring

for persons with a chronic
debilitating illness such as
Alzheimer’s disease and
other dementias, grieve for
losses that have already
Stage of Grief occurred and those that
Walker & n = 100
Examine AG and its Inventory; are occurring. Such losses
Pomeroy(1996 AD and other M = 56.6, SD = not
Quant Neurology impact on the current Grief AG may include a relationship
dementias provided
) 152 functioning of caregivers Experience and lifestyle that have been
f: 83%; m: 17%
Inventory altered, dreams for the
future that will never be
realized, companionship,
security, and economic
certainty, in addition to
the actual presence of the
loved one.
Evaluate the MM-

Psychological (emotional,
CGI for Polish n = 151

Warchol- cognitive, functional and
Biedermann et family caregivers and M = 58.9, SD = not
Mixed Neurology AD MM-CGI Grief behavioral responses)
determinants of grief in provided
al. (2014) 79 response to a loss such as
carers of Alzheimer’s f: 63%; m: 37%
a death
disease patients
AG as cyclical periods
of mental anguish and
feelings of loss that begin
12-item
at the time of initial
Welch (1982) Investigate AG in family n = 41 Faschingbauer AG,
diagnosis of a malignancy,
153 Quant Oncology members of adult cancer Cancer M = 44, SD = not provided ’s Texas Unresolved
in expectation of the
patients f: 25; m: 16 Inventory of grief
deprivation of a significant
Grief.
relationship and social role
through the expected death
of a loved one.
Page 53
AG/Pre-loss
measure or
(Year) term
interview
questions
nfcg = 19,
Singer et al.
Understand the
nhealthcareprofessionals =
Wong & Chan experiences of Chinese
14 Qual interview
Qual Oncology family members of Cancer Grief Not defined
(2007) 154 M = not provided, Age guide
terminally ill patients
range = 18–60
during the EOL
f: 80%; m: 20%
A model that is
comparable to grief, but it
Assess AG and anticipates the forthcoming
n = 66 CSI; MMCGI;
York (2017) 58 Quant Neurology relationship status along AD AG loss of a family member
M = not provided MSPSS
with other outcomes to previously experienced
losses from an incurable
disease
Evaluate AG reactions n = 120

Zamanzadeh A type of grief that
Nursing; Palliative among fathers with M = 31.8, SD = not
Quant Unspecified AGS-Farci AG happens before the actual
et al. (2013) 53 Medicine hospitalized premature provided
loss
infants f: 0%; m: 100%
nsample1 = 246, nsample2 Grief related to the illness

Prospectively evaluate = 55 rather than the death of
Zordan et al. the prevalence and long- Msample1 = 56.4 (13.93), Preloss the person being cared for
Quant Oncology term predictors of PGD Cancer Msample2 = 57.8 PG-12 prolonged (i.e., “avoiding reminders
(2019) 155 in bereaved cancer (12.40) fsample1: 175; grief of the diagnosis/prognosis”
caregivers msample1: 70; fsample2: rather than “avoiding
45; msample2: 10 reminders of the death”)
Note. Qual= Qualitaitive. Quant= Quantiative. AD=Alzheimer’s Disease. MM-CGI: Marwit-Meuser Caregiver Grief Inventory. AG=Anticipatory Grief. MM-CGI CC= Marwit-Meuser Caregiver Grief
Inventory Childhood Cancer. AM=Anticipatory Mourning. MM-CGI-SF= Marwit-Meuser Caregiver Grief Inventory Short Version. ICU=Intensive Care Unit. M=Mean. SD=Standard Deviation. TRIG=The
Texas Inventory of Grief. PDG=Pre-Death Grief. HGRC=Hogan Grief Scale. PG-12=Prolonged Grief. AGS=Anticipatory Grief Scale. PLG=Pre-loss grief. C-MMCGI-SF=Chinese Marwit-Meuser
Caregiver Grief Inventory Short Version. PWD= psychological well-being. NDGEI=Non-death Version of the Grief Experience Inventory. CGQ=Caregiver Grief Questionnaire. EOL=End of Life.
FC=Family caregivers. AGS=Anticipatory Grief Scale. BEQ=Bereavement Experience Questionnaire. MCI=Mild Cognitive Impairment. MFG=Many Faces of Grief Questionnaire. ICG=Inventory of

Complicated Grief. ICG-PL=Pre-death Inventory of Complicated Grief. EMPOWER=Enhancing & Mobilizing the POtential for Wellness & Emotional Resilience. FOLLOS=Fears of Losing Loved
Ones Scale. WOC=Ways of Coping Questionnaire. AGS-CIV=Anticipatory Grief Scale, Chronic Illness Version. TRIG-CIV1=Texas Revised Inventory of Grief Chronic Illness Version. RAGC=Rando
Anticipatory Grief Checklist. BSI=Brief Symptom Inventory. CSI=Caregiver Strain Index. MSPSS=Multidimensional Scale of Perceived Social Support.
Page 54

Family Grief

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Published in final edited form as:

An Examination and Proposed Definitions of Family Members’

Kailey E. Roberts, Ph.D.,

Ferkauf Graduate School of Psychology, Yeshiva University

Elisabeth McLean, B.A.,

Carol Fadalla, B.A.,

Taylor Coats, M.A.,

Madeline Rogers, M.S.W.,

Madeline K. Wilson, B.A.,

Kendra Godwin, M.L.I.S.,

Wendy G. Lichtenthal, Ph.D., F.T.

and illness-related grief. Anticipatory grief is future-oriented and is characterized by separation

Most deaths worldwide are attributed to a chronic or life-limiting illness1. In response

Palliat Med. Author manuscript; available in PMC 2023 April 13.

grief from more impairing grief before the death.

Palliat Med. Author manuscript; available in PMC 2023 April 13.

Systematic Review Design

This mixed-method systematic review and protocol were prospectively registered on

Search Strategy and Data Sources

Palliat Med. Author manuscript; available in PMC 2023 April 13.

Data Synthesis and Analysis

Palliat Med. Author manuscript; available in PMC 2023 April 13.

(n=18), and the Prolonged Grief-12 (n=13).

Palliat Med. Author manuscript; available in PMC 2023 April 13.

Palliat Med. Author manuscript; available in PMC 2023 April 13.

90 described anticipatory mourning as a set of dynamic processes involving emotional

and cognitive transitions made in response to an expected loss. Angela-Cole 91 defined

Multiple Terms Used

Palliat Med. Author manuscript; available in PMC 2023 April 13.

Conceptual Problems with the Construct and Measures Used

Palliat Med. Author manuscript; available in PMC 2023 April 13.

of individuals with a life-limiting illness; however, examination of the connection between

constructs or a single grief phenomenon.

include conference abstracts, which could limit the studies identified.

Palliat Med. Author manuscript; available in PMC 2023 April 13.

Palliat Med. Author manuscript; available in PMC 2023 April 13.

Such work has the potential to improve family-centered, bereavement-conscious, palliative

Data management and sharing:

Palliat Med. Author manuscript; available in PMC 2023 April 13.

Anticipatory grief Latent grief

Anticipating grief Sorrow

Living grief Anticipatory mourning

Masked grief Bereavement

Mourning Caregiver grief

Ongoing mourning Chronic grief

Pre-bereavement grief Chronic grief reaction

Pre-death grief Chronic sorrow

Pre-loss grief Disenfranchised grief

Preparatory grief Grief

Appendix B: Database Search Strategies

[TIAB] OR “care takers” [TIAB] OR caregiving [TIAB] OR “care giving” [TIAB] OR

[TIAB] OR siblings [TIAB] OR aunt [TIAB] OR aunts [TIAB] OR uncle [TIAB] OR

Palliat Med. Author manuscript; available in PMC 2023 April 13.

grieve [TIAB] OR grieves [TIAB] OR grieving [TIAB] OR bereavement [TIAB] OR

bereaved [TIAB] OR sorrow [TIAB] OR sorrowful [TIAB] OR mourning [TIAB] OR

OR “life-threatening condition” [TIAB] OR “life-threatening conditions” [TIAB] OR “life-

[TIAB] OR “caregiver distress” [TIAB] OR “carer distress” [TIAB] OR “anticipatory grief”

2. Embase (via Elsevier’s Embase.com)

OR ‘nephew’/exp OR ‘niece’/exp OR ‘nuclear family’/exp OR ‘parenthood’/exp OR