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.

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

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Video
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Loss, grief

• Patients and family face illness-related losses
• Sense of future
• Functional capacities
• Relationships

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Loss, grief

• Reactions to loss as strong
• Coping strategies vary
• Helpful
• Destructive

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Patient losses adaptation . . .

• Losses in all dimensions
• Repeated and severe
• Adaptation with declining resources
• Difficult but possible

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. . . Patient losses adaptation . . .

• Understanding, accepting the loss
• Disengagement and reflection
• Creative adaptation, experimentation
• Reintegration

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. . . Patient losses adaptation

• Sense of future
• Function
• Self image
• Social role
• Relationships
• Material matters

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Roles

• Sick role
• Caregiver role
• Dying role
• Bereaved and successor roles

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Family losses adaptation

• Replace patients lost capacities
• Roles and relationships change
• Entails losses and adaptations
• Patient depends on family adaptation

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Grief process

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

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Normal grief

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

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Tasks of grief

• Acceptance of the reality
• Experience the pain of loss
• Adjust
• Transfer emotional investments

Worden JW. Semin Oncol. 1985.
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Benchmarks of resolution

• Talk about without fresh feelings
• Invest in new relationships, roles
• Without disabling guilt
• Without feeling disloyal

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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.
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Assessment of grief

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

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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

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Evolution of grief process

• Denial
• Anger
• Bargaining
• Depression
• Acceptance

Kubler-Ross
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Grief vs. depression

• Loss not recognizable
• Consistently low mood, early waking
• History of depression
• Preoccupied with self, self punitive,
  self-directed anger
• Little response to others

• Loss recognizable, current
• Labile mood, behavior variable waking
• No history of depression
• Preoccupied with loss, confusion
• Responsive to others

Cook AS, Dworkin DS. 1992.
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Grief management

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

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Support during grief

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

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Interventions for depression

• Antidepressants
• Anxiolytics
• Psychotherapy
• Supportive
• Cognitive behavioral
• Combination medication and psychotherapeutic
• Consultation if suicidal

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Summary

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