Managing Bereavement within the Health Care System

1. ManagingBereavement within the Health Care System Kara Z. McDaniel, NCC, LPC, Ph.D. Department of Family and Preventive Medicine-PA Program Behavioral Medicine Course

2. Life is a series of experiences, each one of which makes us bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and griefs which we endure help us in our marching onward. -Henry Ford

3. OBJECTIVES • Participants will learn the definition of bereavement and grief in addition to the basic tasks/phases of grieving • Participants will learn the psychological, social, and physiological effects of bereavement and factors that influence the process of grief • Participants will learn the importance of their role in identifying and treating bereaved patients

4. WHAT IS BEREAVEMENT? • “To be deprived by death” (NMHA, p.1) • “The state of having suffered a loss” (Rando, p. 16). • Feelings of grief experienced following the death of loved one

5. WHAT IS GRIEF? • The process in which one reacts, psychologically, socially, and somatically, to the perception of loss • Develops continuously and involves many changes • Reaction that is natural and expected • Reaction to many types of loss, not just death • Loss does not need to be recognized or validated by others in order for person to experience grief (Rando, 1984).

6. TYPES OF LOSSES • Physical (tangible) • Loss of possession or death of loved one • House fire • Pet loss • ??????

7. TYPES OF LOSSES, cont. • Symbolic (psychosocial) • usually not identified as a loss • persons may not realize that time is needed to grieve • Some losses are clearly recognized • e.g. death or theft • Other losses may not be recognized as clearly and may not result in negative events. • Response to normal change and growth • e.g. having a baby • Some are competency-based • e.g. terminating therapy, graduating from college • Why am I feeling sad during a time that is supposed to bring happiness?

8. TYPES OF LOSSES , cont. • Physical loss may also result in symbolic loss • e.g. mastectomy associated with breast cancer (Rando, 1984). • Additional types of symbolic losses • divorce • Loss of job • Demotion • Move • Empty nest • children leaving home to go to college, get married, etc.

9. BASIC TASKS OF GRIEF • Must understand the basic tasks of grief in order to fully understand what one experiences during the grief process • Conceptualized by pioneer in grief investigation, Erich Lindemann, in 1944 • Three tasks constitute what Lindemann termed “grief work” (Rando, 1984, p. 18). • Can be applied to both symbolic and physical losses • Basic Tasks of Grief • Emancipation • Readjustment • Formation • (See Tasks/Phases of Grief handout on Blackboard)

10. PROCESS OF GRIEF • There exists numerous conceptualizations describing the process of grief • may have different names and focus on different topics but all entail loss • e.g. Elisabeth Kubler-Ross’ work with death and dying (Kubler-Ross, 1969) • Theory was developed by Bowlby in 1961; included last three phases (Bowlby, 1980) • In 1974, Parkes revealed that Bowlby omitted one important phase, numbness (Parkes & Weiss, 1983).

11. PHASES OF GRIEF • Numbness • Yearning and searching • Disorganization and despair • Reorganization • See Tasks/Phases of Grief handout on Blackboard

12. EXPRESSION OF LOSS • Utilize conceptualization to explain loss in terms of reactions, not stages • Reactions do not form rigid phases • Person grieving may move back and forth; not sequential • Person may not experience all the reactions presented • Respond to those grieving based on needs at that time, not in terms of what stage • Duration may last from months to years and may experience ups and downs during this time

13. EXPRESSION OF LOSS, cont. • Psychological • View within three categories • Avoidance Phase • Confrontation Phase • Reestablishment Phase • Social • Physiological

14. EXPRESSION OF LOSS, cont. • Psychological • Avoidance • avoid the acknowledgement of loss • shocked • physically and psychologically • confused, dazed, unable to comprehend, numbness • denial once shock wears off and one begins to recognize the loss

15. EXPRESSION OF LOSS, cont. • Psychological • Confrontation • Intense grief • Shock wears off although denial may still exist • Emotional extremes • New reactions may prompt fear and anxiety • Panic or generalized anxiety • (e.g. unknown and unfamiliar) • Angry • (e.g. may be displaced onto other persons) • Guilt • (e.g. may remember just the negative about relationship; feeling guilty because loved one died and he/she didn’t )

16. EXPRESSION OF LOSS, cont. • Psychological • Confrontation, cont. • Depression • Inability to concentrate • Feeling of “mutilation” • (expressing loss in physical terms) (Rando, 1984, p. 33) • Preoccupation with deceased • (e.g. obsessive rumination; dreaming) • Yearning • Psychological • Reestablishment • Grief gradually declines • One begins to reinvest in other things and relationships • Feelings of guilt and betrayal are possible as one moves forward in spite of loss

17. EXPRESSION OF LOSS, cont. • Social reactions to loss • Restlessness • Social withdrawal

18. EXPRESSION OF LOSS, cont. • Physiological reactions to loss • Anorexia • GI distress • Insomnia • Crying • Weight loss • Physical exhaustion • Symptoms of anxiety • e.g. heart palpitations; shortness of breath • Lack of energy • Loss in sexual desire

19. FACTORS INFLUENCING REACTIONS TO GRIEF • Psychological • Social • Physiological

20. FACTORS INFLUENCING REACTIONS TO GRIEF, cont. • Psychological • nature and meaning of loss to person grieving • e.g. pet loss vs. loss of parent • quality of relationship • e.g. conflicted • Role-loss and object-loss • role of deceased lost • coping behaviors, personality, and mental health • maturity and intelligence • background, socially, culturally, religiously • sex role • characteristics of deceased

21. FACTORS INFLUENCING REACTIONS TO GRIEF, cont. • Psychological, cont. • unfinished business • sudden vs. expected death • fulfillment in life • issues surrounding death • timeliness • e.g. death of child vs. death of aging person • preventability • length of illness; anticipatory grief and involvement with dying loved-one • concurrent stresses (Rando, 1984)

22. FACTORS INFLUENCING REACTIONS TO GRIEF, cont. • Social • social support system • religious/cultural/and ethnic background • educational, economic and occupational status

23. FACTORS INFLUENCING REACTIONS TO GRIEF, cont. • Physiological • Drugs and sedatives • Need to be able to vent during crucial time when support available • Heavy vs. mild sedation • Nutrition • Anorexia; taste altered; GI distress • Encourage to maintain good eating habits to maintain strength • Rest and sleep • Some sleep distress is normal • May result in further problems if insomnia exists • Physical health • Some physical distress is normal • Attend to any physical symptoms to prevent further complications • Exercise • Not only keeps body healthy but serves as a good emotional outlet

24. IS IT BEREAVEMENT OR DEPRESSION? • Grieving individual may present symptoms that are similar to Major Depressive Episode (e.g. sadness, insomnia, poor appetite, weight loss) depressive symptoms usually transient and not many (Prigerson et al, 2001). • Many bereaved persons meet criteria for MDD during first few months after loss (Bruce et al., 1990; Clayton et al., 1972; Prigerson et al., 1997) • Diagnosis of MDD is usually not given until symptoms are still present 2 months following loss • Differentiating between normal grief reaction and depression • Morbidity and Mortality

25. IS IT BEREAVEMENT OR DEPRESSION?, cont. • Minority experience depressive syndromes beyond one year • 1 month-42% • 1 year-16% (Clayton et al., 1972) • Bereaved individual may view depressed mood as normal but seeks treatment for alleviation of associated symptoms

26. IS IT BEREAVEMENT OR DEPRESSION?, cont. • There are specific symptoms that are not characteristic of a normal reaction to grief • Assist in differentiating between MDD and bereavement • “guilt about things other than actions taken or not taken by the survivor at the time of the death” • “thoughts of death other than the survivor feeling that he or she would be better off dead or should have died with the deceased person” • “morbid preoccupation with worthlessness” • “marked psychomotor retardation” • “prolonged and marked functional impairment” • “hallucinatory experiences other than thinking that he or she hears the voice of, or transiently sees the image of, the deceased person” (DSM-IV-TR, p. 741)

27. BEREAVEMENT • Bereavement • Morbidity • studies have shown that bereavement has a negative impact on health (Rogers & Reich, 1988). • associated with • high blood pressure (Prigerson et al., 1997) • heart disease, and depressive and anxiety disorders (Chen et al., 1999; Devries et al., 1997). • Heightens risk for • sleep disruption (McDermott et al., 1997) • increase in consumption of alcohol, tranquilizers, and tobacco (Maddison & Viola, 1968; Glass et al., 1995) • suicide attempts (Birtchnell, 1970; Gregory, 1994) • mortality (Schaefer et al., 1995 & Kaprio et al., 1987).

28. BEREAVEMENT • Bereavement • Mortality • studies dating back to 1959 suggest a strong mortality risk to bereavement • Heart disease • 1996 study conducted by Martikainen and Valkonen • 1.5 million adults between ages 35 to 84 • showed a 20%-35% excess mortality from ischemic heart disease within five years from spouse’s death • adverse and long-term bereavement effects from sudden or traumatic death of loved one (Rynearson & McCreery, 1993; Lehman, et al., 1987). • Showed a higher mortality and psychiatric morbidity among bereaved parents and spouses compared to nonbereaved control group 4-7 years after automobile accident that took loved one’s life (Lehman, et al., 1987)

29. BEREAVEMENT CARE • Physicians’ perception of bereavement care • Exploratory study of physicians’ perceptions of bereavement care conducted by Lemkau et al., 2000 • showed that physicians generally believed that bereavement presented significant health risks to patients and that their role in identifying and treating bereavement was important • Role of physician in bereavement care • An extremely important role • Physicians care for many patients who may be experiencing grief, ailments, and distress (Prigerson et al., 2001). • As stated previously, bereavement increases one’s risk for health problems. • Persons are living longer • According to study above, how physicians responded and treated bereavement varied

30. BEREAVEMENT CARE, cont. • Contact with bereaved patients • When bereaved is not your patient • telephone call, letter of condolence, or visit after death (Main, 2000; Bedell et al., 1998) • According to Bedell et al. (1998), physician has one final responsibility to the patient who died which is to help care for bereaved family members. • Acknowledge loss, express sympathy, and allow family to clarify unanswered questions (Prigerson, 2001) • When bereaved is your patient • offer condolences • evaluate and monitor health care needs (Main, 2000) • office visits may shift to education and support through process of grief (Prigerson, 2001) • What to and what not to say • Refer to list provided on Blackboard

31. WHAT NOT TO SAY • Call me. • Casually ask, “How are you? • I know exactly how you feel. • It was probably for the best. • He/she is happy now. • It is God’s will. • It was time to go. • I’m sorry I brought up the subject. • Let’s change the subject. • You should be getting over this by now

32. WHAT NOT TO SAY …cont • I have had other patients with the same illness and they suffered for a long time. • You should be glad your loved-one passed away so quickly. • You’re strong enough to cope with the loss. • Be thankful you have your other children. • You can always have more children. • I lost my loved one… • I understand, my loved-one was very sick too. • Be happy he/she was only 6 months old and not six years. Holly, Jacobs, & Selby, 2001; http://www.rollanet.org/~reb/docs/ThingsNotToSay.html

33. WHAT TO SAY • I’m sorry for your loss. • I can’t imagine the pain you are going through. • What do you remember about [the deceased’s name] today? • Say [deceased’s] name. • Talk about deceased. • Do you have any questions about the illness and treatment provided? • How are you feeling? • How has loss affected you? Holly, Jacobs, & Selby, 2001

34. BEREAVEMENT CARE, cont. • Facilitating healing • Develop new routines and skills • For women, financial strain links widowhood to symptoms of depression; for men, strains of household management are linked to depressive symptoms (Umberson et al., 1992) • encourage attempts to minimize strains • Maintain active routine on daily basis • Two studies involving elderly patients found that those who are bereaved and maintained a daily/busy routine slept better (Brown et al., 1996) and fewer symptoms of depression in comparison to those with less structure (Prigerson et al., 1994) • Written or verbal disclosure • e.g. journal • associated with an improvement in physical/mental health (Pennebaker et al., 2001; Esterling et al., 1994) • positive influence on one’s immune function (Esterling et al., 1994).

35. BEREAVEMENT CARE, cont. • Treatment • When to intervene and/or make referral • barriers to treatment with grieving patients • if suspect psychiatric complications, health care provider needs to diagnose and treat and/or make referral to mental health professional • e.g. psychologist, psychiatrist • if suicidality exists at any time, refer to mental health professional (Prigerson, 2001)

36. BEREAVEMENT CARE, cont. • Treatment of psychiatric complications related to bereavement • treatment chosen is dependent upon diagnosis • Bereaved patients diagnosed with MDD • SSRIs and TCAs • randomized, placebo-controlled clinical trial of bereaved patients with MDD • nortriptyline alone-56% remission rate • nortriptyline with psychotherapy-69% remission rate • psychotherapy alone-29% remission rate (Reynolds et al., 1999) • open-label trial of paroxetine, SSRI, administered weekly for 4 weeks • showed 54% decline in MDD symptoms although study is needed to confirm efficacy of SSRI for MDD secondary to bereavement, MDD following the death of loved one has been shown to not be different than MDD manifested in other ways (Reynolds et al., 1993)

37. “Physicians who aid grief-stricken patients are afforded the rewarding, quintessentially human opportunity of transforming a personal sorrow they inevitably will experience into sympathetic and supportive aftercare”-George Eliot

38. Questions or Comments?

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