Education in Palliative and End-of-life Care - Oncology

1. The EPEC-O TM Education in Palliative and End-of-life Care - Oncology Project The EPEC-O Curriculum is produced by the EPECTM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

2. EPEC - Oncology Education in Palliative and End-of-life Care - Oncology Module 4 Loss, Grief, and Bereavement

3. Objectives • Define loss, grief and bereavement • Facilitate creative adaptation to losses • Screen for, assess grief reactions • Manage reactions to loss • Anxiety, depression • Follow through with bereaved family

4. Video

5. Loss, grief… • Patients and family face illness-related losses • Sense of future • Functional capacities • Relationships

6. … Loss, grief • Reactions to loss as strong • Coping strategies vary • Helpful • Destructive

7. Patient losses & adaptation . . . • Losses in all dimensions • Repeated and severe • Adaptation with declining resources • Difficult but possible

8. . . . Patient losses & adaptation . . . • Understanding, accepting the loss • Disengagement and reflection • Creative adaptation, experimentation • Reintegration

9. . . . Patient losses & adaptation • Sense of future • Function • Self image • Social role • Relationships • Material matters

10. Roles • Sick role • Caregiver role • Dying role • Bereaved and successor roles

11. Family losses & adaptation • Replace patient’s lost capacities • Roles and relationships change • Entails losses and adaptations • Patient depends on family adaptation

12. Grief process • A response to loss • Part of the healing process • Multidimensional • A process • Tasks of grieving

13. Normal grief • Physical Hollowness in stomach, tightness in chest, heart palpitations • Emotional Numbness, relief, sadness, fear, anger, guilt • Cognitive Disbelief, confusion, inability to concentrate

14. Tasks of grief • Acceptance of the reality • Experience the pain of loss • Adjust • Transfer emotional investments Worden JW. Semin Oncol. 1985.

15. Benchmarks of resolution • Talk about without fresh feelings • Invest in new relationships, roles • Without disabling guilt • Without feeling disloyal

16. Types of grief • Masked (suppression) • Delayed (displacement) • Many forms • Less emotion may be normal • Resilience may be higher than expected Worden JW. Semin Oncol. 1985.

17. Assessment of grief • Repeated assessments • Anticipated, actual losses • Emotional responses • Coping strategies • Role of religion • Interdisciplinary team assessment, monitoring

18. Prognosis for grief • Normal grief 6 mo – several years • Child, spouse, parent, other • Mode of death • Social and cultural context • Depression, complicated grief • History of depression, stress • Personality

19. Evolution of grief process • Denial • Anger • Bargaining • Depression • Acceptance Kubler-Ross

20. Grief vs. depression • Loss recognizable, current • Labile mood, behavior; variable waking • No history of depression • Preoccupied with loss, confusion • Responsive to others • Loss not recognizable • Consistently low mood, early waking • History of depression • Preoccupied with self, self punitive, self-directed anger • Little response to others Cook AS, Dworkin DS. 1992.

21. Grief management • If reactions, coping strategies appropriate • Monitor • Support • Counseling • Rituals • If inappropriate, potentially harmful • Rapid, skilled assessment, intervention

22. Support during grief • Time and presence • Education about grief, adaptation • Affirm normal range of responses • Acknowledge, encourage • Counseling

23. Interventions for depression • Antidepressants • Anxiolytics • Psychotherapy • Supportive • Cognitive behavioral • Combination medication and psychotherapeutic • Consultation if suicidal

24. Summary • Illness related losses • Grief and creative adaptation • Grief of bereavement • Depression • Supportive interventions • Consultation for suicidal ideation