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Consultation via KMCN Pall Care Strategy Group. Circulated to providers and service user groups ... Specialist Pall Care Providers ... – PowerPoint PPT presentation

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Title: Kent

Kent Medway Cancer Network
Bereavement Care Standards
Improving Supportive and Palliative Care for
Adults with Cancer 2004
Chris Smith Lead Social Worker/Counsellor
Pilgrims Hospices Kent Ann McMurray Psychosocial
Services Manager The Wisdom Hospice Kent
Risk Assessment in Bereavement

  • For the majority of people, grief although
    psychologically painful and distressing is a
    normal process reflecting both the strengths and
    values of human attachments and the capacity to
    adapt to loss and adversity
  • Raphael et al (2002)

Bereavement can increase the risk
  • Mortality
  • Depression and Anxiety
  • Poor general health
  • Uptake of health services
  • Stroebe and Stroebe, Bereavement and Health,

Goal of risk assessment
  • To select and apply a preventive model of
    care to counter and minimise the likelihood of
    morbidity in a proactive and cost-effective
  • Kissane (2004)

What are risk factors?
  • Risk factors are characteristics of bereaved
    individuals or features of their situation that
    increase vulnerability to the loss experience or
    slow down adjustment to bereavement.

Classification of risk factors
  • Situational
  • Environmental
  • Individual

Situational factors
  • Circumstances of the death
  • -sudden
  • -untimely
  • -difficult/traumatic/violent
  • Concurrent life events
  • -multiple losses or bereavements
  • -socio-economic/financial distress

Individual factors
  • Relationship to the deceased
  • child. parent, partner
  • Pre-existing health problems
  • -physical
  • -mental, eg. history of depression
  • Personality
  • -interdependent relationships
  • -highly ambivalent relationships

Environmental factors the social and cultural
context of loss
  • -loss of main source of social support
  • -geographically isolated from family and friends
  • -lack of immediate family support
  • -family conflict
  • -cultural issues
  • -family culture of dealing with loss
  • -coping strategies
  • -disenfranchised grief

Although risk factors have been identified which
are associated with bereavement outcome
  • there is little evidence to support routine
    intervention with all bereaved people.
  • intervention may be harmful and inhibit
  • services must be targeted to the most vulnerable
  • risk assessment may assist the process

When assessing level if bereavement risk
  • most people do not need intervention
  • allow for uniqueness in response and coping
  • cumulative presence of risk factors may indicate
    level of support needed
  • family and individual coping styles may help to
    reduce risk
  • risk factors may be evident pre bereavement and
    early intervention appropriate
  • those identified at risk need to be offered
  • if intervention is declined - respect this!

  • Risk assessment is a clinical indicator and not a
    predictor of outcome
  • Clinical judgement needs to be based on sound

Risk assessment relies on
  • Time
  • Accurate assessment of family psychosocial and
    bereavement needs.
  • Reliable method
  • Staff knowledge and skill
  • Resources
  • Family involvement

Issues for professionals
  • Who is responsible for assessing bereavement
  • Who should be informed if person identified as
    at risk?
  • How to respond if an at risk person refuses
  • How do we develop a culture within our
    organisations that balances risk assessment and
    fosters resilience in bereavement care?
  • How to involve service users in identifying their
    bereavement needs?

  • Statistical Studies confirm secure people,
    whose experience of life has led to a reasonable
    trust in themselves and others, will cope well
    with anticipated bereavements provided they are
    well supported However, multiple, unexpected
    and untimely losses of people on whom one
    depends, or who depended on the survivor, can
    overwhelm the most secure person lack of
    security and support can undermine (the) capacity
    to cope with all types of bereavement.
  • Parkes CM (1990) 309

Bereavement Risk Assessment document/tool
  • Risk Indicators
  • Nature of relationship
  • Health history
  • Coping strategies
  • Social support
  • Family coping
  • Cultural influences
  • Concurrent life events
  • Previous losses
  • Circumstances of the death

  • Family members and carers who are bereaved
    should, in the first instance, be encouraged to
    use existing support systems. Where these prove
    insufficient, or it is predicted that those
    involved are likely to experience difficult grief
    reactions, there should be access to additional
    help and support.
  • Providers of specialist bereavement support
    should work closely with other care providers
  • (both statutory and voluntary) to ensure that
    family members can access services when needed

Component 1
  • Grief is normal after bereavement and most people
    manage without professional intervention, however
    many people lack understanding of grief after
    immediate bereavement.
  • All bereaved people should be offered information
    about the experience of bereavement and how to
    access other forms of support

Component 2
  • Some people may require a more formal
    opportunity to reflect on their loss experience,
    this does not necessarily involve professionals.
    Volunteer bereavement support workers/be-frienders
    , self help groups, faith groups and community
    groups will provide much of the support at this
    level. Those working in component two must know
    how to refer as appropriate

Component 3
  • A minority of people will require specialist
    interventions. This can involve mental health
    services, psychological support, specialist
    palliative care services and bereavement
  • Provider organisations should be equipped to
    offer the first component of bereavement support
    and have strategies in place to access the other
    components. Services should be accessible from
    all settings.

Steps towards implementation
  • Psychosocial sub group (K M C N) work on
    development on Guidance docs on Ber Risk
    Assessment and Standards Tools
  • Completion in 1 year.
  • Consultation via KMCN Pall Care Strategy Group
  • Circulated to providers and service user groups
  • Documents amended in light of feedback
  • Adopted by KMCN Nov 06
  • Network training programme planned and delivered
  • Organisations consider how Guidance can be
    adopted to meet local service requirements

Local implementation
  • Provider organisations to provide Training for
    all staff involved in assessment of psychosocial
    and bereavement care needs
  • Training to include Bereavement theory, risk
    assessment, resilience, guidance and exploration
    of tools, and challenges to organisations
  • Action plan for local implementation
  • Pilot and evaluation at 6 months

How have organisations adopted it.
  • Reflects the uniqueness of each care setting and
    the specific needs of the service users
  • Acute hospitals
  • Adopting minimum standard (information) and
    working towards a model to meet (NICE 1-2)
  • Specialist Pall Care Providers
  • Adapting tools to include pre and post death
    assessment (NICE 1-3)

Kent and Medway Cancer Network
  • Guidance on Bereavement Care Standards and
    Bereavement Risk Assessment in Adult Palliative

Part 1 Bereavement Care Standards
  • Guiding Principles
  • Providers should ensure that
  • Bereavement care is incorporated fully into the
    philosophy of care.
  • Bereavement and the pain of grief is affirmed as
    a natural human experience.
  • Bereavement care is provided with respect to the
    individual and their needs, within a safe,
    appropriate, ethical and boundaried
    relationship/context. Is sensitive to the life
    style, developmental stage, experience, culture
    and community within which the person lives.

Guiding Principles contd.
  • Potential beneficiaries are aware of the services
    available and the boundaries/limitations of the
    support offered.
  • Volunteers and paid staff are reflective in their
    practice, receive appropriate levels of training,
    supervision and support.

Guiding Principles contd.
  • Risk of psychological and physical complications
    associated with bereavement are minimised.
  • The service is monitored and evaluated involving
    feedback from users and other stakeholders to
    support effective change and development.

Bereavement Care Standards
  • In relation to the Service Providers ensure
  • Confidentiality and privacy of clients is
    respected, that personal information is
    safeguarded and any information disclosed is done
    so in an ethical manner and on a need to know
  • All documentation complies with relevant legal
  • As far as reasonably practical there is equality
    of access to the service.
  • Support is offered in a healthy, safe and
    accessible environment.
  • Service is provided in a responsible and
    professional manner.
  • Bereavement services are reviewed and evaluated
    in order to improve practice and inform services
  • All stakeholders, (eg. users, volunteers,
    practitioners, managers, commissioners, are
    included in the planning, development of services.

Bereavement Care Standards
  • In relation to Staff Providers ensure that
  • Paid staff and volunteers providing the service
    have appropriate qualities, qualifications,
    knowledge and skills relevant to their role.
  • Paid staff and volunteers are CRB checked.
  • Paid staff and volunteers receive appropriate
    on-going training, support and supervision
    relevant to the level of involvement (NICE 12.35,
    12.38) and which enables them to address loss and
    bereavement issues encountered in their work
    (NICE 12.12).
  • Where a member of staff or volunteer experiences
    a significant, personal bereavement, their need
    for support and time-out from involvement with
    the service is assessed on an individual basis.

Bereavement Care Standards
  • In relation to the Bereaved Person Providers
    ensure that
  • Bereaved people are routinely given information
    about the experience of bereavement and services
    they can access for support (Component 1, NICE
    Guidance, 12.34). Those with responsibility for
    bereaved children and young people are routinely
    offered relevant information.
  • A system is in place to identify those who may be
    more vulnerable during their bereavement by
    developing a Bereavement Risk Assessment Process
    and documentation (NICE 12.33), (see Document
    Part 2).
  • When psychological risk, or more complex needs
    (including specialist needs of children and young
    people), is identified, access to appropriate
    specialist intervention should be facilitated.
    (Component 3 NICE Guidance).

Bereavement Care Standards
  • In relation to the Bereaved Person Providers
    ensure that
  • Bereavement services are proactive in contacting
    those identified to be at risk via follow-up
    telephone calls or letter to individuals at about
    8 weeks after death (NICE 12.33).
  • When a bereaved person requires a formal
    opportunity to reflect on their experience
    appropriate referrals are facilitated.
    (Component 2 NICE Guidance).
  • The bereaved person is aware of the nature and
    limitations of support provided by the particular
    service. When referral on to more appropriate
    services is indicated, the client must be
    consulted and fully informed.

Part 2 Guidance for Bereavement Risk Assessment
  • Recommendations
  • Where possible Bereavement Risk Assessment is
    regarded as an ongoing process, commencing when a
    family is received into the service, evolving as
    knowledge of the patient and family develops
    through the illness journey and at the time of
  • A standard document (eg. Appendix 1) is available
    to record any indicators of risk and coping
    mechanisms. This supports the ongoing process of
    assessment and review (ideally by a
    multi-professional team) of psychosocial needs.

Guidance for Bereavement Risk Assessment
  • Recommendations contd
  • Where indicators are identified and found to be
    significantly affecting the individual
    pre-bereavement, early referral for additional
    intervention/support can be made.
  • Where there is a cumulative presence of risk
    factors indicating a potential high risk of poor
    bereavement outcome, active follow-up is made to
    offer appropriate information and services if

Part 2 Guidance for Bereavement Risk Assessment
  • Recommendations contd
  • Where there is cumulative presence of risk
    factors indicating a risk of poor bereavement
    outcome and no specific follow-up service is
    available eg. acute settings written
    information about the experience of bereavement
    and how to access services should be provided and
    with the persons permission a summary of risk
    indicators identified, sent to the GP.
  • Where there are few or no risk indicators
    present, information about the experience of
    bereavement and how to access services should be
    routinely provided.
  • Key professionals should have an awareness of
    current bereavement theory and indicators of risk
    through relevant guidance, literature and further