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Grief-related issues impact us every day in our role as clinicians working in an oncologic setting. However, apart from the brief time spent with patients and their loved ones at the moment of death, oncology clinicians do not typically accompany the patient's family on its journey of grief, mourning, and bereavement. This is not a criticism, but simply a statement of reality in a world where patients' homes and communities are often dislocated from the tertiary centers in which they receive medical care.

In the vast world that lies between home and the point of medical care, the bulk of grief work has been played out beyond the reach of clinicians and researchers. We struggle to know just how long "normal grief and bereavement" should actually last, and we still await longitudinal studies that will validate the concept of the "stages of grief." However, it is vital that in our attempts to develop empirical norms and debate whether more pathological forms of grief belong as disease categories in the Diagnostic and Statistical Manual of Mental Disorders (DSM),1 we recognize that grief will always be a part of the human experience.

We serve our patients and families well when we recognize that grief work has begun long before a person enters our clinical care. Journey into that private moment when a lump is felt or when bloody sputum is observed, and the realization settles in that "something's not right." Medical tests are run. The conversation comes days later. Fear and anxiety grip the heart as the words, "I want you to see an oncologist," are spoken. Grief is well under way in this person's life as he or she fights projections into an unknown future: "How far along is the cancer? What will happen to my wife and children? I can't afford to be off from work. Will my insurance cover me? We had a vacation planned next week, and I'm going to ruin it all. Who'll take care of mom and dad? What did I do to deserve this? Why is this happening to me? I'm all alone and I had trouble just getting to my doctor's appointment. Who will care for me? Will this disease take my life? I'm afraid of pain. I'm afraid of dying."

Throughout the course of cancer care, it is important to recognize that these questions multiply for the patient and family as they address a myriad of psychosocial and spiritual concerns and the grief attached to them. As oncologic professionals, we can help people prepare for the potential "long haul" of grief and bereavement by assisting them through supportive presence, listening, and counsel, and by recognizing and addressing their current losses and the anticipatory grief of an unknown future. Further, clinicians serve patient and family well when risk factors for a complicated bereavement are recognized early and appropriate referrals made.



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