Cherry BERNARDO-LAZARO, MD 12 February 2010 ASMPH YL6 GRIEF and BEREAVEMENT Cherry BERNARDO-LAZARO, MD 12 February 2010 ASMPH YL6

DEATH

SEATWORK Have you experienced death of a loved one? If yes, who and how is he/she related to you? How were you notified of the death? What did you feel then? How long did you grieve? How did you cope with the loss?

SEATWORK Have you experienced death of a loved one? If yes, who and how is he/she related to you? How were you notified of the death? What did you feel then? How long did you grieve? How did you cope with the loss?

DEATH Notifying family members about the death of a loved one is a difficult and stressful task.

NOTIFYING the FAMILY about a DEATH Encourage the family to be present at the time of death if at all possible When the family is expecting the death of one of its members, ask how they would prefer to be notified if they are not present

NOTIFYING the FAMILY about a DEATH 3. Notify the family immediately at the time of death - With an expected death, call on the family as previously agreed - With an unexpected death, ask the family as a whole to come to the hospital and discuss the events leading up to the death

NOTIFYING the FAMILY about a DEATH 4. Think about what you want to say before making the call: Many people remember the exact words spoken by whoever told them of the death 5. While being sympathetic and sensitive, avoid euphemisms: Use the words “death, dying and dead.” 6. Say, “You have my sympathy” rather than “I am sorry” which could be construed as an apology

NOTIFYING the FAMILY about a DEATH 7. Give the family the opportunity to view the body and say their goodbyes. a. Arrange for the viewing to occur in a private room b. Make sure the body has been cleaned and prepared c. Offer to have a member of the healthcare team stay with the family d. Allow them to remain with the deceased as long as they wished

NOTIFYING the FAMILY about a DEATH 8. Meet the family a. Before or after the viewing to show concern and facilitate a healthy grieving process b. Provide information about the cause of death: Solicit and answer any questions c. Answer any questions about autopsy and organ donation d. Use active listening skills: Expect expressions of intense emotions

NOTIFYING the FAMILY about a DEATH 8. Meet the family e. Make yourself available as a support for the family: Offer to have follow-up meetings, either to discuss autopsy results or questions about the deceased that will likely arise in the future f. Remind the family to call their funeral director g. Encourage the family to include children, especially those older than 5 years, in the funeral and other family gatherings

NOTIFYING the FAMILY about a DEATH 9. With an unanticipated or traumatic death, consider making a home visit soon thereafter: With an anticipated death, send a sympathy card and/or attend the calling hours or funeral 10. With an anticipated death, telephone the family 1-2 weeks after the death to inquire about them, answer any questions, and encourage any necessary follow-up

SEATWORK Have you experienced death of a loved one? If yes, who and how is he/she related to you? How were you notified of the death? What did you feel then? How long did you grieve? How did you cope with the loss?

DEFINITION OF TERMS What is the difference between GRIEF and BEREAVEMENT? GRIEF: internal feeling one experiences in reaction to a loss; refers to the loss of loved one through death BEREAVEMENT: state of having experienced loss

DEFINITION OF TERMS MOURNING Outward expression of that loss Usually involves culturally determined rituals that help the bereaved individuals make sense of the end of their loved one’s life & give structure to what can feel like a very confusing time Examples? Grief: INTERNAL: Mourning: EXTERNAL

GRIEF Normal grieving is characterized by intellectual and emotional awareness of the loss and feelings of guilt, stress, pain, anger and hostility Grief is typically a cyclical process in which all these feelings may be present at any time and, but certain feelings may dominate at different points in the cycle

SEATWORK Have you experienced death of a loved one? If yes, who and how is he/she related to you? How were you notified of the death? What did you feel then? How long did you grieve? How did you cope with the loss?

STAGES OF GRIEF Shock or disbelief Denial Anger Bargaining Guilt Depression Acceptance/hope

STAGES OF GRIEF Difficulty believing what has happened DENIAL Wishing to make a deal with fate to gain more time with the one who was lost BARGAINING

STAGES OF GRIEF Questioning the fairness of the loss ANGER Getting in touch with how very sad they are about losing their loved one DEPRESSION

STAGES OF GRIEF Feelings of regret about difficult aspects of the relationship with the deceased GUILT Numbness associated with initially receiving the news of the death of a loved one SHOCK Feeling of resolution to their grief and more ability to go on with their own life ACCEPTANCE

PHASES OF GRIEF ACUTE PHASE SECOND PHASE RESOLUTION PHASE

PHASES OF GRIEF ACUTE PHASE Begins with the notification of death and is characterized by emotional shock Typically lasts up to 2 weeks Depression and somatic symptoms are common and persist into the SECOND PHASE

PHASES OF GRIEF SECOND PHASE Characterized by rumination over memories of the deceased During this phase, people may withdraw and become introverted as they may examine what recent death means for their own life Typically takes from 3 to 6 months

PHASES OF GRIEF RESOLUTION PHASE Somatic symptoms and preoccupation with the deceased lessen Bereaved family members begin to plan for the future and participate again in activities that were an important part of their lives prior to the death Punctuated by the anniversary of the loved one’s death

SEATWORK Have you experienced death of a loved one? If yes, who and how is he/she related to you? How were you notified of the death? What did you feel then? How long did you grieve? How did you cope with the loss?

FACTORS influencing GRIEF Survivor’s own physical and emotional health before the loss The relationship between the bereaved and their family member or other loved one Nature of the death

TYPES OF GRIEF Anticipatory mourning Sudden Loss Complicated Grief

TYPES OF GRIEF ANTICIPATORY MOURNING includes feelings of loss, concern for the dying person, balancing conflicting demands and preparing for death natural process that enables the family more time to slowly prepare for the reality of the loss People are often able to complete unfinished “business” with the dying person (for example, saying “good-bye,” “I love you,” or “I forgive you”).

TYPES OF GRIEF SUDDEN LOSS experienced after a sudden, unexpected death Sudden, unexpected loss may exceed the coping abilities of a person, which often results in feelings of being overwhelmed and/or unable to function Even though one may be able to acknowledge that loss has occurred, the full impact of loss may take much longer to fully comprehend than in the case of an expected loss

TYPES OF GRIEF COMPLICATED GRIEF times when grief does not progress as expected; the intensity and duration of grief is prolonged and dramatically interferes with a person’s ability to function Symptoms of depression and anxiety may be prevalent and prolonged. Thoughts, feelings, behaviors and reactions may seem to persist over long periods of time with little change or improvement

PRIMARY CARE COUNSELING With a traumatic death, schedule an office visit soon after the funeral. With anticipated death, schedule an office visit within 1 month after the loss for interested family members to review the death and autopsy results.

PRIMARY CARE COUNSELING Encourage family members to talk about the circumstances surrounding the death, recall memories, and openly discuss feelings of sadness, anger, and guilt. Give them permission to grieve.

PRIMARY CARE COUNSELING Inquire about any significant changes in financial status. Settling an estate, the loss of income, and the lack of experience managing money can intensify grieving process. Normalize signs of grieving (eg. Crying spells, lack of energy and preoccupation with the deceased). Tell the family that normal or uncomplicated grief typically takes 1 year for active phase to resolve.

PRIMARY CARE COUNSELING Avoid the use of psychotropic medications such as sedatives or hypnotics, except in unusual circumstances or when a family member is unable to sleep. A sedated person at the funeral may not be able to participate or even remember this important time. Starting antidepressant, antianxiety or antipsychotic medications are typically NOT indicated during bereavement.

PRIMARY CARE COUNSELING Monitor closely the medical status of the recently bereaved as research indicates that the bereaved are at higher risk of serious illness and death. Encourage family members to come in for health evaluation at 6 months to assess any increased risk for illness or delayed difficulties with grieving.

PRIMARY CARE COUNSELING Refer interested family members to community-based self-help support groups. Monitor family members for signs of unresolved grief reaction. Refer is necessary.

SIGNS & SYMPTOMS of COMPLICATED/UNRESOLVED GRIEF Prolonged, severe clinical depression Prolonged social isolation, withdrawal, or alienation Emotional numbing An inability to cry Talking as if the dead person were still alive Persistent compulsive overactivity without a sense of loss

SIGNS & SYMPTOMS of COMPLICATED/UNRESOLVED GRIEF Persistence of a variety of physical complaints Profound identification with the decease and prolonged acquisition of symptoms belonging to the illness of that person Extreme , persistent anger (may be directed at the clinician)

SIGNS & SYMPTOMS of COMPLICATED/UNRESOLVED GRIEF Alcohol or drug abuse, persistent requests for sedative or narcotic medications Marital or family problems Work or school problems

COMPLICATED GRIEF Prolonged and extreme reactions to grief are themselves dangerous and necessitate referral to a specialist. Referral may be made for evaluation, bereavement counseling, psychiatric treatment or family therapy, as is appropriate.

SEATWORK Have you experienced death of a loved one? If yes, who and how is he/she related to you? How were you notified of the death? What did you feel then? How long did you grieve? How did you cope with the loss?

How can people cope with Grief? DUAL PROCESS MODEL Endorses the bereavement process as a dynamic struggle between the pain of death of a loved one (loss-oriented) and recovery (restoration-oriented) Recommends that bereaved individuals alternate between directly working on their loss (confrontation) and taking a break from that process when appropriate (avoidance).

OBJECTIVES Define grief and bereavement Compare the phases/stages of grieving Discuss the nature of grief Discuss how to notify family members about the death of a loved one

CONTENT Definition of Terms Phases/Stages of grief Factors influencing grief Types of grief Signs & symptoms of unresolved grief reaction Notifying family members of a death

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