end of life: grief and bereavement
TRANSCRIPT
End of Life: Grieving and Bereaving
Andrea Chatburn, DO, MAWOMA Winter Seminar
12.5.2015
No Financial Disclosure
Objectives
• Revisit grief theory & tool of mindful presence
• Examine grief related screening tools • Distinguish between typical, complicated
grief• Determine when structured psychotherapy
and pharmacotherapy is indicated for grief• Apply bereavement interventions to special
populations
Awareness & Noting
U.S. Army
Won’t be covering
• Specific grief resources for Military or Post-combat PTSD & bereavement
• Specific grief, PTSD resources for Refugees
• Grief & funeral traditions across cultures and world religion
Why talk about grief & bereavement?
“ICU Bereave” – staff & family survey
Downar, J. et al. The desirability of an ICU Clinician-Led Bereavement Screening and Support Program for Family members of ICU Decedents. Journal of Critical Care. 29(2014) 311.e9-e16.
Family• 64 contacted & 32
participated• 9 (28%) - complicated grief
or prolonged grief disorder• 7 (22%) - social distress• 10 (31%) - professional
support for emotional symptoms
• 2 (6%) - professional support for social symptoms
• 68% - wanted more support
Staff• 94 contacted & 57
participated• 85% reported providing
emotional support at time of death
• 56 (98%) willing to participate in formal bereavement screening and support program
Barriers to Supporting Bereaved Family Members
• Not knowing what to say• Not sure how to deal with emotion• Lack of knowledge about community
resource• High clinical workload• Lack of continuity or established relationship
with the patient or family member
Downar, J. et al. The desirability of an ICU Clinician-Led Bereavement Screening and Support Program for Family members of ICU Descendants. Journal of Critical Care. 29(2014) 311.e9-e16.
Desires for bereavement support
• Training in how to support the bereaved• List of available community resources• Dedicated time after the death and at a
later date to provide support
Downar, et al.
Grief is centered in relationship
Sam Caplet “Don’t Let Go”
WHO Guidelines for Bereavement
• Recommend AGAINST offering structured psychological interventions to all bereaved adults or children (w/o mental disorder)
• Benzodiazepines should NOT be offered to bereaved adults or children (w/o mental disorder)
• Grief and mourning are natural responses to loss, most people navigate w/o clinical intervention
Wietse A., et al. WHO Guidelines for Management of Acute Stress, PTSD, and Bereavement: Key Challenges on the Road Ahead.” PLOS Medicine. December 2014, Vol 11, Issue 12.
Molly Fumia
“I started missing you long before
you were gone …I’ll keep loving you
long after the memories
bring you back”
Grief Theories
• Elizabeth Kubler Ross- 5 stages• Ken Doka• William Warden• Alan Walset*• Teresa Randall*• “Integrated grief”
45 years since On Death and Dying
Grief is related to all types of loss
• Loss of relationship• Loss of role (mother/sister/daughter)• Loss of function- Debility• Loss of health• Loss of home• Loss of independence• Loss of job
Expression of Grief
• Emotional response• Physical• Social• Spiritual• Thought Process/Cognitive
Vincent van Gogh “Old Man Crying”
Georg Sander “Tomb of a Mourning Woman”
Gtneil
Action- 5K, Ice bucket challenge, etc.
Acceptance?
Griefwatch.com
Ministry of Presence
Legacy Work
Cueva de las Manas, Argentina by Xipe Totec39
Byock- 4 things that matter most
• Thank you• Please forgive me• I forgive you• I love you
Dignity Therapy
• Chochinov- Manitoba. • Life survey by patient &
loved ones • Gave a sense of
purpose & meaning to life
• Assisted in “living with” grief
Suffering and Meaning
Ethical Will
• Zava’ah• Values• Blessings• Life lessons• Hopes for future
Typical Grief
• Normal emotional reaction to loss• Resolves in < 6 months• No residual serious social,
psychological or medical consequences
Interventions for All Bereaved
• Support by provider at time of death• Contact in weeks to months after a death• Customized bereavement care plan
Screening Tools
• Start with symptoms: – Eating?– Sleeping?
• 5 item Brief Grief Questionnaire • 19 item Inventory of Complicated Grief– Score 25-30 significant symptoms– Score >30 threshold for treatment research
Brief Grief Questionnaire0 1 2
How much are you having trouble accepting the death of ____?How much does your grief still interfere with your life?How much are you having images or thoughts of ___ when they died or other thoughts about the death that really bother you?Are there things you used to do when ____ was alive that you do not feel comfortable doing anymore, that you avoid? Like going somewhere you went with them, or doing things you used to enjoy together? Or avoiding looking at pictures or talking about ____? How much are you avoiding these things?How much are you feeling cut off or distant from other people since _____ died, even people you used to be close to like family or friends?
When is psychotherapy indicated?
When are prescriptions indicated?
PublicDomainPictures
Complicated Grief (CG) or Prolonged Grief Disorder (PGD)
• Grief resulting in severe social, psychological, or medical consequences• Persists beyond 6 months• Social distress: marked by difficulties
with ADLs, financial matters, and social interactions
Prolonged Grief Disorder
A. Loss of a significant personB. Separation distress: feelings of yearning that
occur daily or cause disabilityC. At least 5 specific cognitive, emotional or
behavioral symptomsD. Timing >6 months since lossE. Significant Social, occupational, or functional
impairmentF. Not caused by other psychiatric disorder
Shear MK, et al. Complicated grief and related bereavement issues for DSM-5. Depression Anxiety. Feb 2011; 28(2):103-17.
Symptoms- PGD
• Diminished sense of self• Difficulty accepting loss• Avoidance of reminders of loss• Inability to trust others• Bitterness or anger related to loss• Difficulty moving on with life• Emotional numbness• Feeling that life is meaningless• Feeling stunned/dazed/shocked by the loss
Shear et al.
Complicated Grief
A. Loss of a loved one >6 months agoB. At least one symptom of acute grief present for
longer than expected in the person’s cultureC. At least 2 of the following symptoms present for >1
mo. (see next slide)D. Duration: symptoms and impairment >1 mo.E. Impairment: significant social, occupational, or
functional impairment caused by symptoms and not better explained as a culturally appropriate response
Shear et al.
B. Symptoms of Acute Grief - CG
• Persistent intense yearning• Frequent intense loneliness/emptiness• Recurrent feelings of meaninglessness of
life, or a desire to die in order to rejoin the deceased
• Frequent intrusive thoughts about the deceased
Shear et al.
C. Symptoms in CG (2 or more)• Rumination about the death and its consequences• Disbelief, inability to accept death• Feeling of shock, numbness• Bitterness or anger related to loss• Inability to trust others• Experiencing pain/symptoms that deceased person
experienced• Intense reaction to memories/reminders of loss• Excessive avoidance/proximity seeking relevant to
deceased
Shear et al.
CG New to DSM-5
“Persistent Complex Bereavement Disorder”Subtype of :– “Other specified trauma” – “Stressor-related disorders”
• Estimated prevalence 7% of bereaved people• Symptoms “out of proportion or inconsistent
with cultural, religious, or age-appropriate norms”
Risk factors for Complicated Grief
• Pre-loss factors:– Female–Preexisting trauma (particularly childhood)-
ACE–Prior loss– Insecure attachment–Preexisting mood and anxiety disorders–Nature of the relationship
Simon, N. Treating Complicated Greif. JAMA July 24, 2013 Vol 310, No 4. p 416-423
Loss related Risks for CG
• Relationship and caretaking roles– Spouses–Mothers of dependent children– Caretakers for chronically ill
• Nature of the death itself– Violent, sudden, prolonged, suicide
• Mortality in Intensive Care Unit– 34 to 67% of surviving family members have CG
Simon, N.
Other Risk Factors
• Social circumstances• Resources available after death• Unknown: Lack of information/understanding
of the circumstances of the death event• Interference with natural healing process:– Inability to follow usual cultural mourning– Alcohol or substance abuse– Lack of social support
Simon, N.
Differential Dx for CG
• Trigger for Comorbid Major Depressive Disorder, PTSD, Substance Abuse
• Of patients with CG:– 25% had no comorbid conditions– 55% had comorbid Major Depressive Disorder– 49% had PTSD– 36% had both MDD and PTSD
• Difference btn CG and PTSD: Fear
Simon, N.
CG: Deficits in
imagining a future w/o the
deceased
MDD: inability to
experience positive emotions when
contemplating the deceased
PTSD: Presence of
Fear
When to Intervene?
• Persistently high sx severity• Lack of temporal involvement in the
grief response• Functional Impairment• Treatment-seeking behaviors• Hopelessness• Suicidal ideation or behaviors
Simon, N.
Targeted Complex Grief Therapy
• Motivational interviewing & CBT techniques• Discussing positive and negative memories of the
deceased• Repeatedly retelling the story of the death• Addressing errors in thoughts- cognitive restructuring• Communication with the deceased exercise• Encourage reduced avoidance behavior• Goal setting• SSRI improved adherence to therapy
Simon, N.
When are prescriptions indicated?
PublicDomainPictures
• Persistent symptoms• Significant comorbidities• Suicidal ideation or behaviors
Grief & Bereavement in Special Populations
• Perinatal loss• Grieving children and teens• Parents who have lost a child• Mortality risk in older couples• Provider Grief
Grayerbaby
Reji Jacob “Tears”
MyStuart “Helping Hands in Ashville”
Bibliography1. Bruinsma, S., et al. Risk Factors for Complicated Grief in Older Adults. Journal of Palliative
Medicine. Vol 18, No. 6, 2015. p 438-444.2. Doka, K. and J. Davidson. Living with Grief. Who We Are, How We Grieve. Hospice
Foundation of America, Philadelphia, 1998.3. Downar, J. et al. The desirability of an ICU Clinician-Led Bereavement Screening and
Support Program for Family members of ICU Descendants. Journal of Critical Care. 29(2014) 311.e9-e16.
4. Hirano, Kummet, Schlenker. Grief and Bereavement. Presented at AAHPM/HPNA 2015 Annual Assembly. Philadelphia, PA.
5. Iglewicz, A., et al. The Removal of the Bereavement Exclusion in the DMS-5: Exploring the Evidence. Curr Psychiatry Rep (2013) 15:413.
6. Kubler-Ross, E. On Death and Dying. MacMillan Publishing Co., Inc. New York, 1969.7. Shear, MK. Complicated Greif. N Eng J Med 372;2 Jan 8 2015. 8. Shear MK, et al. Complicated grief and related bereavement issues for DSM-5. Depression
Anxiety. Feb 2011; 28(2):103-17.9. Wietse A., et al. WHO Guidelines for Management of Acute Stress, PTSD, and
Bereavement: Key Challenges on the Road Ahead.” PLOS Medicine. December 2014, Vol 11, Issue 12.