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Grief and Bereavement: Information for Primary Care

Summary: Grief and bereavement will be faced by all of your patients at one point in time, because loss is inevitable. Most patients will go through a normal grieving process, whereas a minority will have problems with grieving, aka. complicated grief. The good news is that there are specific interventions that can help patients with complicated grief.
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Overview

  • Grief is the normal process that one encounters when faced with the loss of a loved one
  • Although grief and loss are inevitable in life, there is nonetheless “good grief” versus “complicated grief”
  • Good grief is healthy
  • Complicated grief is unhealthy
  • Definitions
  • Grief: Process of psychological, social, physical and spiritual reactions to a loss
  • Bereavement: The state of having suffered a loss
  • Mourning: The cultural response to grief
  • Complicated grief: Grief that is excessive, difficult, complicated or abnormal, e.g. where the individual develops low self-esteem, and thoughts of ending one’s life

Epidemiology

  • Grief
    • Prevalence: 100% of the population will face grief, because loss is inevitable. The majority of those facing grief will have ‘normal grief’.
  • Complicated grief
    • Prevalence: 4-7% of general population experiences complicated grief after major bereavement (Kersting, 2011)
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Signs/Symptoms

  • Mood symptoms include problems with sadness, crying spells, anxiety, but can also include irritability.
  • Neurovegetative symptoms includes problems with sleep, appetite and energy
  • Loss of function during the grieving period

Diagnosis

  • Normal grief is not a clinical diagnosis
  • Grief has been classically described as having five stages
    • These can occur in any order, and do not necessarily need to occur sequentially
    • Classic phases of grief
    • Denial, disbelief or numbness that the loss has occurred
    • Anger, blaming others for the loss
    • Bargaining (e.g. “If my cancer gets better, I promise to never smoke again”; “If my son doesn’t die, I promise I’ll never miss his hockey games”)
    • Depressed mood, sadness, crying
    • Acceptance and coming to terms with the loss
  • With normal grieving, symptoms are time-limited and improve over time, e.g. within a few days, weeks or months

DDx of Normal vs. Complicated Grief

  • Normal grief
    • Symptoms such as sadness, tearfulness following a loss
    • Generally fades within a few months
    • Does not cause significant, ongoing impairment in function
  • Complicated grief
    • Mourning and sadness that tends to persist and does not improve over time
    • Similar symptoms to major depression (e.g. poor self-esteem, hopelessness, or significant neurovegetative symptoms)
    • Causes impairment in function

Hx/Interviewing Questions

  • Screening / diagnostic tools
    • Two screening questions used together have shown sensitivity of 90% for patients with complicated grief
      • “Do you feel that you have really grieved?”
      • “Do you feel that you are now functioning about as well as you were before the death?”
    • Answering YES to both questions indicates a high risk of having complicated grief.
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  • Screening for symptoms of depression
    • Consider SIGECAPS screening, including
    • Suicide/hopelessness
      • Clinician: “With all this stress, has it gotten to the point where you’ve felt that life isn’t worth living?”
    • Self-esteem
      • Clinician: “How is your self-esteem these days?” “Have you been feeling down on yourself?”

Physical Exam (Px)

  • There are no specific physical exam findings for grief and bereavement.

Investigations

  • There are no specific laboratory investigations for grief and bereavement

Management

  • Grief counseling in primary care
    • Supportive counseling therapy techniques such as the BATHE technique can be very helpful in supporting the bereaved patient in a primary care setting
      • B)ackground
        • Clinician: Tell me about your loss
        • Clinician: I am so sorry to hear about your loss.
      • A)ffect
        • Clinician: “How are you feeling about this?” “How has this affected you?”
      • T)roubles
        • Clinician: “What troubles you the most about this?”
      • H)
        • Clinician: “How have you been handling this situation?” “For example, have you been able to get support from family or friends?” “Have you been able to cry about your loss?” “Or have the feelings been all bottled up inside?”
      • E)mpathize
        • Clinician: “Thank you for sharing this with me. You clearly cared very much for your father. Your feelings sound very normal for this situation. I can completely appreciate how you would be feeling this way.”
    • Grieving a significant loss (such as a spouse) can take 1-2 years
    • Send a personal note to the patient to express sympathies regarding the loss, which patients have cited as being particularly meaningful
       
  • Patient Education
    • Provide the patient with information about the grieving process
       
  • Workplace
    • If indicated, recommend that the bereaved take time off work

Medication Treatment

  • For simple grief, medications are usually not indicated
  • For more complicated grief, medications may have a role for specific symptoms
    • For sleep problems, consider sleep medications such as Trazodone
    • For symptoms of major depressive disorder, consider antidepressant medication such as SSRIs

When to Refer

  • When the patient is having significant stress from the loss
  • When the patient is unable to function, e.g. school, work, home and relationships

Who to Refer to

  • Consider grief and bereavement mutual support groups such as Bereaved Families of Ontario
  • For complicated grief with signs/symptoms of depression, consider referral to mental health professional, e.g. counselor/therapist, social worker, psychologist, psychiatrist

Clinical Practice Guidelines

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    Grief and Bereavement: Care for the Patient with Incurable Cancer or Advanced Disease
    Published 2011
    Produced By British Columbia Medical Association
    Ages Served All ages
    Website www.bcguidelines.ca/pdf/palliative3.pdf
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    Guidelines for the psychosocial and bereavement support of family caregivers of palliative care patients
    Published 2012
    Produced By Centre for Palliative Care at St. Vincent's Hospital & a collaborative centre of The University of Melbourne , Melbourne, Australia
    Ages Served All ages
    Website www.ncbi.nlm.nih.gov/pmc/articles/PMC336...

References

About this Document

Written by members of the eMentalHealth.ca/PrimaryCare team which includes members of the Department of Psychiatry and Family Medicine at the University of Ottawa. Reviewed by members of the Family Medicine Program at the University of Ottawa, including Dr's Farad Motamedi; Mireille St-Jean; Eric Wooltorton.

Disclaimer

Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from a health professional. Always contact a qualified health professional for further information in your specific situation or circumstance.

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Date Posted: Oct 4, 2012
Date of Last Revision: Nov 27, 2015

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