1. The Professional Response to Bereavement Leila Francis Executive Director LF Consultancy Services Ltd

2. Who and what? Bereavement, loss and grief Is grief a medical problem? Complicated grief Health outcomes of bereavement Professional grief Supporting professionals Sibling bereavement Children of service personnel killed in action 2LF Consultancy Services Ltd June 2011

3. Who and what? Professionals Supporting the bereaved 3LF Consultancy Services Ltd June 2011

4. Bereavement, Loss & Grief Bereavement “The situation of having recently lost a significant person through death” (Stroebe et al, 2001) Loss “Being deprived of something one has had, or hopes to have, but does not attain (i.e. parenthood, fertility, marriage, a reconciled relationship)” (Clark, 2009) Grief “The mainly emotional reaction to bereavement, incorporating diverse psychological and physical reactions” (Stroebe et al, 2001) 4LF Consultancy Services Ltd June 2011

5. Is grief a medical problem? Grief and depression have become over- medicalised and over-diagnosed with too much emphasis put on ‘treating’ grief (Parker, 2007) Grief, especially following a sudden death, can be a serious clinical issue that should be recognised swiftly and treated intensively (Hawton, 2007) 5LF Consultancy Services Ltd June 2011

6. Complicated grief “A deviation from the normal (in societal and cultural terms) grief experience in either time course, intensity or both, entailing a chronic and more intense emotional experience or an inhibited response, which either lacks the usual symptoms or in which onset of symptoms is delayed” (Stroebe et al, 2001) 6LF Consultancy Services Ltd June 2011

7. Criteria for complicated grief Criterion A – chronic and disruptive yearning, pining, longing for the deceased Criterion B Trouble accepting the death Inability to trust others Excessive bitterness or anger related to the death Uneasy about moving on Numbness or detachment Feeling life is empty or meaningless without the deceased Bleak future Agitated 7LF Consultancy Services Ltd June 2011

8. Criteria for complicated grief Criterion C – the above symptom disturbance causes marked and persistent dysfunction in social, occupational or other important domains Criterion D – the above symptom disturbance must last at least 6 months Diagnostic and Statistical Manual of Mental Disorders, 5 th edition, Prigerson and Maciejeski 2005 8LF Consultancy Services Ltd June 2011

9. Health outcomes of bereavement Mortality Physical ill health Psychological symptoms and ill health Additional medical implications Risk factors Intervention efficacy (Stroebe et al, 2007) 9LF Consultancy Services Ltd June 2011

10. Mortality Bereavement is associated with an increased risk of mortality from many causes, including suicide Individuals who have been bereaved for a short time are at greater risk of mortality than those bereaved for longer, although raised risk might persist for bereaved parents. 10LF Consultancy Services Ltd June 2011

11. Physical ill health People who have been bereaved are more likely to have physical health problems, particularly those who have been bereaved recently Bereaved individuals also have higher rates of disability, medication use and hospitilisation than non-bereaved counterparts 11LF Consultancy Services Ltd June 2011

12. Psychological symptoms Bereavement is associated with various psychological symptoms that may be affective, cognitive, behavioural or psycho-somatic A wide range of psychological symptoms are associated with bereavement causing researchers to regard grief as a complex emotional syndrome 12LF Consultancy Services Ltd June 2011

13. Additional medical implications Impaired memory performance Nutritional problems Work and relationship difficulties Difficulties in concentrating Decreases in social participation Health care costs for bereaved individuals have been shown to be higher 13LF Consultancy Services Ltd June 2011

14. Risk factors Situation and circumstance of the death Interpersonal risk or protective factors Interpersonal or non-personal resources and protective factors Coping styles, strategies, processes 14LF Consultancy Services Ltd June 2011

15. Intervention efficacy No evidence that all bereaved people will benefit from counselling and research has shown no benefits to arise from routine referral to counselling for no other reason than that they have suffered a bereavement Grief interventions can be primary, secondary or tertiary preventive interventions 15LF Consultancy Services Ltd June 2011

16. Professional grief High loss work environments Bereavement overload Hidden grief 16LF Consultancy Services Ltd June 2011

17. Professional grief Professionals are distant mourners Professional losses accumulate Professional grief is a significant cause of burnout Professionals working in high loss environments need a balance between engagement and detachment 17LF Consultancy Services Ltd June 2011

18. Supporting professionals Learning to manage grief responses to patient deaths is a crucial yet underemphasized skill for health care professionals Without the ability to manage one’s grief in healthy ways, a health care professional may find his or her personal and professional life affected, resulting in less-than-optimal care for patients and families (International Work Group on Death, Dying and Bereavement, 2006) 18LF Consultancy Services Ltd June 2011

19. Supporting professionals 6 ways the loss of a patient could affect a health care professional when a child is dying:  Loss of relationship with patient  Loss related to identification with pain experienced by parents  Loss of assumptions about one’s worldview  Unresolved previous personal losses  Loss related to facing personal mortality  Loss related to professional expectations (Papadatou, 2000) 19LF Consultancy Services Ltd June 2011

20. Supporting professionals - Bereavement Debriefing Sessions Format Welcome and introductions Factual information Case review Grief responses Emotional Strategies for coping with grief Lessons learned Conclusion (Keene et al, 2010) 20LF Consultancy Services Ltd June 2011

21. Supporting professionals - Bereavement Debriefing Sessions Reason for requesting sessions 21LF Consultancy Services Ltd June 2011 ReasonNumber of Occurrences Professional distress97 Sudden/unexpected death39 Multiple units involved in care8 Long term relationship with patient6 Multiple deaths in a short period5 Critical incident2 Team conflict1

22. Supporting professionals - Bereavement Debriefing Sessions Most distressing aspect of the case 22LF Consultancy Services Ltd June 2011 ThemeNumber of occurrences Long term relationship with patient/family 81 Provided aggressive treatment whilst patient was dying 34 Unexpected death23 Conflict with family21 Different cultural values/practices12 No end-of-life discussion with patient /family 12 Did not know patient well11 Did not know enough9

23. Supporting professionals - Bereavement Debriefing Sessions Most satisfying aspect of the case 23LF Consultancy Services Ltd June 2011 ThemeNumber of occurrences Working as a team51 Being instrumental in helping patient die respectfully 47 Felt a sense of closure36 Good relationship with family18 Good relationship with patient6 Joy from caring for patient2

24. Sibling bereavement A Review of Sibling Bereavement – Impact and Interventions Author - Jennifer Holliday, August 2002 Source – www.barnardos.org.uk/resourceswww.barnardos.org.uk/resources 24LF Consultancy Services Ltd June 2011

25. Children of service personnel killed in action Article in Nursing Children and Young People – Understanding a child’s grief takes care and compassion Author – Doreen Crawford Source Number 5, Volume 25, June 2011 25LF Consultancy Services Ltd June 2011

26. The end! Thank you for your attention 26LF Consultancy Services Ltd June 2011