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Bereavement, Loss and Grief, Survival strategies for primary care


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Title: Bereavement, Loss and Grief, Survival strategies for primary care

Bereavement, Loss and Grief,Survival strategies
for primary care
  • Dr Peter Nightingale
  • Macmillan GP
  • GP Rosebank Surgery
  • Clinical Assistant St Johns Hospice

  • By the end of this presentation I hope to have
    enabled you to consider aspects of the current
    debate about the process of loss and grief. I
    also hope to consider how best to help yourselves
    and also bereaved people.

Systematic Review
Prospective RCT
Organised observation
Pattern recognition
Anecdote/chance recognition

Based on Dudley 1983
Limitations of Empirical Studies
  • Dominance of Widows (young, white and middle
  • Age cohort effect. The social norms of the 1970s
    may no longer apply
  • Ethnicity
  • High refusal rates
  • Lack of control groups
  • Lack of reliable measures of grief
  • Self reporting

Health Warning
  • I have tried to be objective in this
    presentation, but inevitably strong emotions may
    arise in any of us due to the nature of the
    subject being discussed. (It actually happened to
    me in producing this presentation)
  • Please feel free to leave or stop me if required.

  • Definitions
  • Bereavement Theory
  • Health Professional Perspective

  • Loss
  • When you no longer have something because you
    dont know where it is, or it has been taken away
    from you.
  • Grief
  • Emotional and psychological reaction to loss
  • Bereavement
  • Reaction to the loss of a loved person by death

The Gold Standard Framework
  • Communication Ca register/MDT meetings.
  • Co-ordination Key person
  • Control of Symptoms Assessment, treatment and
    patient centred care.
  • Continuity Handover to out-of-hours/protocol.
    Information to pts/carers.
  • Continued Learning Practice-based
    learning/reflection on experiences.
  • Carer Support Practical, emotional, bereavement.
  • Care of the Dying Liverpool Integrated care
    pathway(48 hours of life).

Models of Adaptation to loss
  • Traditional Models
  • Based on the work of Bowlby, Parkes,
    Kubler-Ross and Worden. All can be referred to as
  • New models of Grief
  • The multidimensional model
  • Dual process model
  • Biographical models

Phase Models
  • The number and duration of these phases varies
    but are remarkably similar and can be summarised
  • Numbness
  • Yearning
  • Despair
  • Recovery

1) Numbness
  • Disbelief and unreality-feelings of functioning
    on Automatic Pilot
  • Can occur even if death expected
  • Unreality interspersed by bouts of anger and
  • Somatic symptoms common

2) Yearning
  • Numbness replaced by pangs of grief
  • Pining interspersed with anxiety, tension anger
    and self-reproach
  • Restless searching, auditory and sensory
    awareness of deceased
  • Crying common-deep sighing respirations
  • Sleep disturbance and loss of appetite common

3) Despair
  • Permanence of loss recognised
  • Pangs replaced with despair and apathy
  • Social withdrawal common
  • Poor concentration and inability to see anything
    worthwhile in the future common

4) Recovery
  • With great effort identity rebuilt
  • New skills acquired
  • Purpose for living re-established
  • Some positive feelings return
  • Energy levels return
  • BUT-pangs of grief at anniversaries, hearing a
    special song etc can persist for years

Bereavement Models (Linear)
Disorder and despair
  • Firmly believed that working through the phases
    of grief was a necessary aspect of successful
  • He hypothesised three disordered forms of
    attachment in Childhood that could lead to
    vulnerability following bereavement-
  • Anxious attachment
  • Compulsive self-reliance
  • Compulsive caregiving

(No Transcript)
Attachment Theory (John Bowlby) ? All Social
Animals become attached to each other. ? The main
function of attachment is to provide security ?
The function of crying and searching following
separation is to promote reunion ? The nuclear
source of security is the Family
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Separations from Parents in Childhood predict
Insecurity and other Problems Later (Bowlby)
Secure Attachment ? Mother Sensitively
Responsive and Protective only when necessary. ?
Child in Strange Situation Some anxiety but
easily reassured when mother returns ? Later
Develops autonomy with trust in self and others.
SECURE PARENTING Overall Parenting
Good ?? 1)Childhood Vulnerability
Low ?? 2)Harmony in Adult Attachments ?? 3)Overall
Coping Good ??
  • Disorganised/Disoriented Attachment
  • Family Rejection/Violence, Danger /or
    Depression increases the risk that the child will
    be unhappy.
  • Adult then lacks trust in self others, may harm
  • Bereavement reaction associated with Anxiety/Panic

Kubler-Ross (1969)
  • Described a five stage model of the grief of
    terminally ill people derived from her clinical
    work as a psychiatrist
  • It has often been applied to grief following
  • Denial and isolation
  • Anger
  • Bargaining
  • Depression
  • Acceptance

Kubler - Ross
  • Not everyone will progress through all five
  • They may not be in the same order
  • Denial and acceptance can be hard to
  • Danger of dying patients fears and concerns being
    dismissed as just a stage they are passing
  • Simplistic and risks false assumptions being made
    and lack of exploration of concerns by caregivers

Anticipatory Grief
  • Anticipatory Grief is a progression through the
    stages of grief prior to the loss
  • Involves all losses from diagnosis to death

Key Points of Loss
  • Pre-diagnosis
  • Diagnosis
  • Treatment
  • Failure of Treatment
  • Metastatic Disease
  • Disease Recurrence
  • End of active interventions

Chronic Illness and Loss
  • Abandonment
  • Isolation
  • Of Future
  • Threat of Death
  • Reduced ability
  • Confidence in
  • professionals/ drugs/
  • treatments
  • Loss of support
  • Control
  • Self-esteem
  • Self-image
  • Role
  • Work
  • Independence
  • Stigma

  • Refined the phases of grief
  • Drew on Freuds concept of grief work
  • Drew on Engels theory of grief as an
    illness-i.e. the psychological trauma is
    analogous to the physiological trauma of severe
  • Conceptualised as four overlapping tasks

  • Wordens Tasks of Mourning.
  • Rather than seeing that there are stages of
    grief that people need to pass through (which can
    be a little rigid) it is perhaps more helpful to
    consider the tasks that the bereaved need to
    accomplish before they can move on.

Wordens Tasks of Mourning Tasks that the
bereaved need to accomplish
  1. To accept the reality of the loss
  2. To experience the emotional pain
  3. To adjust to an environment in which the deceased
    is missing
  4. To relocate the dead person within ones life and
    find ways to remember the dead person

Problems with Phase Models
  • They tend to be interpreted as linear
  • If used prescriptively hasty judgements about
    normality can occur
  • Research (Shuchter and Zisbrook) has suggested
    grief is individualised and variable.
  • Kubler-Ross stage theory was not developed for
    bereavement and has been misinterpreted

Grief Work
  • This is the cognitive process of confronting
    loss, of going over events before and after
    death, focussing on memories and working towards
    detachment from the deceased.
  • It has been suggested that this has become
    clinical lore, and this work is a necessary
    part of normal grieving

Difficulties with Grief Work(Wortman and Silver)
  • Distress and Depression are inevitable
  • Distress varies, and initial high distress
    groups can follow a chronic grief pattern.
    Depression is not inevitable
  • The expectation of Recovery
  • For a minority of individuals grief may be
    prolonged- few studies last longer than 2 years.
    Klass discusses continuing bonds

New Models of Grief
  1. The multidimensional model
  2. The Dual Process Model (DPM)
  3. Biographical Models

The Multidimentional model
  • Le Poidevin working with Parkes at St
    Christophers Hospice developed this model
  • Grief conceptualised as a process of change along
    seven dimensions.
  • Importantly this model focuses on what resources
    a person may have to help them cope

Dimensions of LossSusan le Poidevin
  • Identity How has the loss affected self-esteem?
  • Emotionally Are they at ease with expressing
  • Spiritual What meaning has been ascribed to the
  • Practical How are everyday practicalities
  • Physical What is the impact on physical health?
  • Lifestyle Has the loss caused financial problems?
  • Family/community What support is available?

Dual Process Model
  • The key concept is oscillation between coping
  • Grief Work included in Loss Orientation
  • Time needs to be taken off from strong emotions
    to avoid being overwhelmed
  • Both expressing and controlling feelings
    important in this model
  • This model remains to be tested but has been
    shown to be a useful addition

Bereavement Models (Continual)
?Grief Work ?Intrusion of Grief ?Breaking bonds/
ties ?Denial/ avoidance of changes
?Attending to life changes ?Doing new
things ?Distraction from grief ?New roles /
Loss Orientated
Restoration Orientated
(No Transcript)
Biographical Models
  • Convincing empirical research supports the
    importance of a relationship with the deceased.
  • May be best achieved by speaking to others who
    knew the deceased, constructing a biography.
  • This may help integration of this relationship
    into ongoing lives (Walter 1996)

(No Transcript)
The Whirlpool of LossDr Richard Wilson
Emotions of Bereavement
  • Disbelief
  • Anger
  • Anxiety
  • Guilt
  • Sadness
  • Pining
  • Despair
  • Crying
  • Fear
  • Unrealistic Hope

Care for the Bereaved
  • Respect
  • Dignity
  • Empathy
  • Allow disclosure of concerns
  • Allow expression of grief
  • Allow bereaved to look back over the death
  • Primary Care Support
  • Self-Help
  • Voluntary Organisations
  • Counselling

(No Transcript)
10 Ways to Help Bereaved People
  • Be There-dont offer solutions
  • Listen in an accepting and non-judgemental way
  • Show that you are listening and you recognise
    something of what they are going through
  • Encourage them to talk about the deceased
  • Tolerate silences

10 ways to help (cont)
  • Be familiar with your own feelings about loss and
  • Offer reassurance about the normality of grief
  • Do not take anger personally
  • Recognise that your own feelings may reflect how
    they feel
  • Accept that you cannot make them feel better (but
    you are still doing something useful)

Bereavement Care
  • Relf studied bereavement services in Oxford in
    1997 and found a marked reduction in the use of
    GP services in those supported.What helped was-
  • Being listened to
  • Feeling understood
  • Talking to someone outside their social network
  • Information about Grief
  • 75 found support helpful, but 25 were

Health Professionals Perspective
Mixture of Emotions
Contentment Relief Fear Guilt Sadness Anger Frustr
ation Weariness
Working with trauma and loss
  • Long term exposure can produce-
  • Helplessness
  • Fear and anxiety
  • Sense of unfairness
  • Anger
  • Sadness
  • Guilt
  • Cancer phobia

Hands up if any of you recognise any of these
psychological traits in yourself
  • Perfectionist
  • Overly conscientious
  • Tendency to seek approval-People Pleasing
  • Need to control others
  • Great sense of responsibility
  • Chronic self-doubt
  • Uncomfortable with praise
  • Ability to delay gratification

Emotional Response
  • 31 Strong emotional impact to death
  • 23 Very disturbed by death
  • 47 Upset when thinking of patient
  • 24 Numb

  • Longer care time ? Stronger emotional reaction
  • Longer care time ? Increased satisfaction

Top 5 Soul Killers
  • Isolation
  • Anger
  • Fear
  • Exhaustion
  • Shame
  • A difficult palliative care case can provide
    opportunities for all these!

Potential Risks
  • We are repeatedly faced with loss and grief, and
    grief can be cumulative
  • Staff grieve for patients lost and perceived or
    actual failure to achieve quality care
  • Lack of closure
  • Conflict within staff and team
  • Unresolved grief or recent personal bereavement

Five ways to survive as a doctor
  • Make sure you do other things other than work
  • Create your dream work schedule
  • Learn to say No- without feeling guilty
  • If you need help , ask for it
  • Seek peer support

Are you burning out?
  • Chronic fatigue - exhaustion, tiredness, a sense
    of being physically run down
  • Anger at those making demands
  • Self-criticism for putting up with the demands
  • Cynicism, negativity, and irritability
  • A sense of being besieged
  • Exploding easily at seemingly inconsequential
  • Frequent headaches and gastrointestinal
  • Weight loss or gain
  • Sleeplessness and depression
  • Shortness of breath
  • Suspiciousness
  • Feelings of helplessness
  • Increased degree of risk taking

  • Belief in yourself
  • Unconditional Positive Regard For Others
  • Regular exercise and social contact
  • Never lose sense of humour
  • Outings and Holidays
  • Understand Hardiness
  • Commitment
  • Control
  • Challenge
  • Competent
  • Composed
  • Time Management

How to beat stress
Holiday - try to plan at least one each year with
a change in activities and surrounding.Open up -
if your relationship is part of the problem.
Communication is very important.Work - is that
the problem? What are your options? Could you
retrain? What aspects are stressful? Could you
delegate? Could you get more support?Try to
concentrate on the present don't dwell on the
past or future worries.Own up to yourself that
you are feeling stressed - half the battle is
admitting it!Be realistic about what you can
achieve. Don't take too much on.Eat a balanced
diet. Eat slowly and sit down allowing at least
half an hour for each meal.Action plans - try to
write down the problems in your life that may be
causing stress, and as many possible solutions as
you can. Make a plan to deal with each
problem.Time management - plan your time, doing
one thing at a time and building in breaks. Don't
make too many changes at one in your life.Set
priorities - if you could only do one thing, what
would it be?Talk things over with a friend or
family member or someone else you can trust and
share your feelings with.Relaxation or leisure
time each day is important. Try new ways to relax
such as yoga, aromatherapy or reflexology.Exercis
e regularly - at least 20 minutes 2 or 3 times a
week. This is excellent for stress control.
Walking is good - appreciate the countryside.Say
no and don't feel guilty.Seek professional help
if you have tried these things and still your
stress is a problem.
Slow Dance
Have you ever watched kids On a merry-go-round?
Or listened to the rain Slapping on the ground?
Ever followed a butterfly's erratic flight? Or
gazed at the sun into the fading night? You
better slow down. Don't dance so fast. Time is
short. The music won't last. Do you run through
each day On the fly? When you ask How are you?
Do you hear the reply? When the day is done Do
you lie in your bed With the next hundred chores
Running through your head? You'd better slow
down Don't dance so fast. Time is short. The
music won't last.
Ever told your child, We'll do it tomorrow? And
in your haste, Not see his sorrow? Ever lost
touch, Let a good friendship die Cause you
never had time To call and say,"Hi" You'd
better slow down. Don't dance so fast. Time is
short. The music won't last. When you run so
fast to get somewhere You miss half the fun of
getting there. When you worry and hurry through
your day, It is like an unopened gift....
Thrown away. Life is not a race. Do take it
slower Hear the music Before the song is over.
  • Complex and difficult issues-
  • help available from Hospice or Cancer Care
  • Potential strong emotional reactions
  • Potential satisfaction and reward for staff
  • Coping Strategies

Specialist local help
  • CancerCare is a local charity with centres in
    Lancaster and Kendal, providing bereavement
    support for all those affected by cancer.
  • Psychological and emotional support, creative and
    social groups, information and complementary
    therapies are available free of charge from
    professionally qualified and experienced staff.
  • CancerCare also offers a Children and Young
    Persons Service supporting families before and
    after bereavement.
  • Clients can either self refer or be referred by
    others eg GPs, Macmillan nurses, Cancer
    specialist nurses.

If you ever need hospice help
  • David Barnett
  • Hospice Chaplain with wealth of experience and
  • Christine Townson
  • Bereavement counsellor