LAUSR

Western society consistently makes aims to deny or dispel death and avoid uncomfortable topics like grief, existential distress, and our own mortality. Unfortunately, our death-denying culture creates a barrier for persons to express normal emotions like grief and prepare for end-of-life. Preparing for death is particularly important for family caregivers of persons with dementia who may be anticipating death and grieving multiple losses for many years (Schulz et al., 2015). Family caregivers have reported experiencing a prolonged mourning which can make the intensity of emotions at end-of-life unexpected (Durepos et al., 2020 submitted for review; Marwit and Meuser, 2005). Approximately 50% of family caregivers of persons with dementia report feeling unprepared for death, which suggests those of us working in the field of palliative care are not providing effective support (Terzakis, 2019). This is problematic because feeling unprepared for death is associated with negative long-term outcomes for caregivers like complicated grief (Schulz et al., 2015; Nielsen et al., 2016). Much research has focused on exploring relationships after death when negative outcomes have already occurred (e.g., complicated grief, depression, anxiety) (Nielsen et al., 2016; Schulz et al., 2015). However, little is known about the relationship between preparedness and pre-death grief (Moore et al., 2020). In the paper by Moore et al. (2020), the authors explored the relationship between pre-death grief and death preparedness among family caregivers of persons with dementia. Moore et al. (2020) hypothesized that higher levels of pre-death grief were associated with lower levels of death preparedness. Based on this hypothesis, supportive interventions aimed at modifying or promoting preparedness could reduce pre-death grief and limit complicated grief in bereavement. Understanding the relationship between modifiable preparedness factors and grief before death was necessary to be proactive and design/deliver supportive interventions before negative outcomes occurred in bereavement. Moore et al. (2020) therefore addressed an important gap in literature. The study byMoore and colleagues used a crosssectional survey design collecting survey data from 150 family caregivers of persons with dementia living at home and in long-term care. Pre-death grief was measured using the Marwit–Meuser Caregiver Grief Inventory Short Form (Marwit and Meuser, 2005), and the authors selected five indicators to assess death preparedness. Merits of the study included the moderate sample size, assessment of health literacy prior to the study, use of measures with evidence for validity and reliability (e.g., the Dementia Knowledge Assessment Scale) (Annear et al., 2015), and broad diversity in the sample (e.g., spouse vs. adult child caregivers, dementia severity). These rigorous methods supported the validity and transferability of the findings. Limitations included the female majority in the sample (which is often the case in caregiving studies), the use of dichotomous responses as opposed to a Likert-scale for some preparedness indicators, and the lack of a holistic, tested measure for death preparedness in this population (Streiner et al., 2015). Moore et al. (2020) acknowledged that the current lack of a multidimensional questionnaire and standardized indicators for preparedness is problematic. Ideally, questionnaires and indicators are based upon a theory or model (Streiner et al., 2015). It was therefore a study strength that Moore et al. (2020) selected preparedness indicators informed by the evidence-based Theoretical Framework of Preparedness for End-of-Life (Hebert et al., 2006; Hebert et al., 2009). The indicators selected corresponded to the medical (i.e. knowledge of dementia, discussing end-of-life care, documenting wishes) and psychosocial (i.e. social support, having good relationships with staff) domains of preparedness. However, the indicators may not have sampled the spiritual domain (i.e., knowing/planning preferred rituals/traditions) and practical domain (i.e., knowing/planning preferred after-death services, completing financial/legal affairs) of preparedness. Direct relationships were not found between three indicators of preparedness, “dementia knowledge”, “formal end-of-life care documents”, “end-of-life care discussions with the person with dementia”, and pre-death grief. Hence, the authors reported finding little evidence to support their hypothesis that increased preparedness is associated with reduced pre-death grief. However, two key preparedness indicators, “social support” and “good relationships with healthcare providers”, did have statistically significant correlations with pre-death grief. In addition, “changes in closeness” or decline in the International Psychogeriatrics (2020), 32:6, 693–695 © International Psychogeriatric Association 2020