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Modules:

  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
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    Back to Module 12: Last Hours of Living
    Part III: Loss, Grief, and Coping

    Loss, Grief, and Coping During Life-threatening Illness
    Normal Grief
    Complicated Grief
    Tasks of the Grieving
    Assessment of Loss, Grief
    Grief Management

    Loss, Grief, and Coping During Life-threatening Illness

    • As patients and families confront life-threatening illness, they are vulnerable to many different anticipated, if not actual, losses, including:
      • Loss of functional capabilities
      • Loss of control
      • Loss of independence
      • Loss of body image
      • Loss of dignity
      • Loss of relationships
      • Loss of sense of future
    • As illness progresses, the risk of losing control over fundamentally important aspects of their lives increases, at times dramatically
    • Grief reactions
      • Are the emotional reactions to loss
      • Frequently run very high as everyone confronts the possibility of the end of the patient’s life and the change death will bring
    • Multiple coping strategies may occur simultaneously
      • Some will be helpful
      • Others may become destructive
    • To be effective in end-of-life care, physicians need to be able to recognize grief and assist with appropriate interventions

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    Normal Grief

    • Normal grief reactions include a whole range of physical, emotional, and cognitive behaviors
      Normal physical grief reactions include:
      • Feelings of hollowness in the stomach
      • Tightness in the chest
      • Heart palpitations
      • Weakness
      • Lack of energy
      • Gastrointestinal disturbances
      • Weight gain or loss
      • Skin reactions
      Normal emotional grief reactions include feelings of:
      • Emotional numbness
      • Relief
      • Sadness
      • Fear
      • Anger
      • Guilt
      • Loneliness
      • Abandonment
      • Despair
      • Ambivalence
      Normal cognitive grief reactions include:
      • Disbelief
      • Confusion
      • Inability to concentrate
      • Preoccupation with or dreams of the deceased
    • There are many different reactions to normal grief
      • Some people will make a conscious effort to deal with the loss
      • Others will deny what is happening and avoid dealing with the loss
    • Some coping strategies may accelerate and even become destructive, especially in the face of seemingly insurmountable loss
      • Increased smoking/alcohol/medication intake
      • Overworking
      • Suicidal ideation
    • Recently bereaved may seek assistance from their physicians for these symptoms. Recognition of the cause is important if useless or misleading investigations or medication trials are to be avoided

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    Complicated Grief

    • When grief reactions occur over long periods of time, are very intense, or interfere with the survivor’s physical or emotional well-being, they become symptoms of complicated grief
    • There are 4 categories of complicated grief reactions:
        1. Chronic grief is characterized by normal grief reactions that do not subside and continue over very long periods of time

        2. Delayed grief is characterized by normal grief reactions that are suppressed or postponed. The survivor consciously or unconsciously avoids the pain of the loss

        3. In exaggerated grief, the survivor may resort to self-destructive behaviors such as suicide

        4. In masked grief, the survivor is not aware that the behaviors that interfere with normal functioning are a result of the loss
    • The physician needs to be attuned to behaviors that might indicate complicated grief, especially if these continue beyond 6 to 12 months
      • The survivor may not be able to speak of the deceased without experiencing intense sadness

      • Themes of loss may continue to occur in every topic during a clinical interview

      • Minor events may unexpectedly trigger intense grief and sadness

      • The survivor may be unwilling to move possessions belonging to the deceased

      • Sometimes the survivor will develop symptoms similar to those of the deceased
    • When complicated grief is suspected, referral for specialized help is warranted

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    Tasks of the Grieving

    • After a major loss, there are typically 4 tasks the bereaved must complete before they will effectively deal with their loss
      • These tasks apply to the many losses that precede the death, as well as to the death itself
      • While the tasks are interdependent, they are not necessarily completed in sequence
        1. Accepting the reality of the loss
      • For many, realization and acceptance that the loss or death has actually occurred can be a major hurdle

      • If such individuals spent little or no time at the bedside after the death realizing what happened, they may continue for months to deny that anything has occurred

      • Denial can be unwavering. Some bereaved may even continue to look for the person, waiting for his or her telephone call and/or return

      • Until such people realize that the person has died, they cannot begin to resolve what has happened and move on
        2. Experiencing the pain caused by the loss
      • Knowing that the death has occurred is not enough

      • To be able to move on, the bereaved need to experience the pain caused by their loss

      • As this can be very distressing, many who are bereaved try to avoid the pain, and physicians frequently try to blunt it with medication

      • While this may be necessary for temporary management of destructive reactions, if overdone, medication may prolong both the grief reactions and the pain associated with the loss
        3. Adjusting to the new environment after the loss
      • Once they have realized what has happened and the pain that the loss has caused, the bereaved need to recognize the significance of their losses and the changes to their lives
        4. Rebuilding a new life
      • Finally, as grief proceeds, the bereaved need to reinvest their energy into new activities and relationships
    • Grieving can be a difficult, lengthy process
      • All of these tasks may seem relatively straightforward to the inexperienced onlooker

      • However, for the person who is emotionally distraught and now feels very lonely and abandoned, each task may seem insurmountable and may take months or even years to resolve
    • Grieving may be made more difficult by a lack of support from others
      • While support from family and caregivers may be intense for the first few days or weeks after the death, the degree of support inevitably diminishes as others less affected get on with their lives

      • If the person who has suffered the greatest loss is unable to move on and dwells on his or her loss, impatience for change may create a rift and increase tensions between the bereaved and other members of the family/caregivers

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    Assessment of Loss, Grief

    • To effectively anticipate and reduce the grief reactions of our patients and families, physicians must repeatedly assess:
      • Anticipated and actual losses
      • Emotional responses
      • Coping strategies
    • Gentle inquiry may provide support to the bereaved, and help the physician understand how the survivor is coping
    • Other professionals, such as hospice nurses, social workers, and chaplains, can greatly facilitate the assessment and monitoring of grief
    • While religion may be an important component of coping, it is beyond the scope of this module to discuss it in any detail. Use a chaplain or pastoral care professional to help determine and understand the religious background and framework held by each family member

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    Grief Management

    If the loss, grief reactions, and coping strategies appear to be appropriate and effective...

    • The situation can be monitored and supportive counseling provided
    • Survivors may feel they are "going crazy" or "losing their mind"
      • Permit them to discuss their feelings
      • Reinforce that grief is painful and prolonged, but normal
    • Encouraging the survivor to talk about what it is like to live without the deceased
    • Encourage participation in rituals such as attending the funeral or memorial services, or identifying personal rituals
    • Explain that the length of time needed for the grief process will vary with each person and situation
      • There is no "right" way to grieve
      • Each person will have his/her own way
    • In general, most people who are bereaved are able to reenter the world after 1 to 3 weeks
      • However, active grieving can go on for a year or more
      • Sadness can continue for much longer but typically does not intrude on or prevent new life

    If loss, grief reactions, and coping strategies appear to be inappropriate or ineffective and/or they have the potential to cause harm (e.g., destructive behaviors or suicide)...

    • Assessment and intervention will need to occur quickly
    • Consult someone who is skilled in loss, grief, and bereavement care so that therapy can be instigated quickly to reduce the risk of harmful/destructive activities
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