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Palliative Care Perspectives : Chapter 7: Psychosocial and Spiritual Aspects of Care : Bereavement

Bereavement is the grief that occurs after a death. Much has been written about bereavement grief.20,23-28 In many ways bereavement has served as a model for understanding grief in other situations. Grief patterns in bereavement vary greatly among different cultures and individuals.29 However, the essential processes of grief are similar. Waves of strong emotions, often triggered irregularly and unpredictably, wash up. In this process a new relationship is forged between the bereaved and the deceased, and over time these waves diminish in intensity.

The reader may wonder, why talk about bereavement in a text for clinicians, primarily physicians. In our medical culture we tend to see our relationships with the patient and family as ending with the death of the patient. Families often share this view. If bereavement is complicated (see below), this is best addressed by mental health workers. So why talk about bereavement?

There are three major reasons why the (non-mental health) clinician should be concerned about bereavement. First, the bereaved may have explicit needs that can be addressed only by a medical practitioner. Second, virtually everyone becomes bereaved at some point in life. How people cope in their bereavement can have a major effect on their health and health care decisions. You may not have cared for the person who died, but the bereaved spouse in your office who complains of insomnia or lack of appetite may be your patient. Finally, all clinicians need to be alert to signs that point to complicated bereavement so we can rally resources to help.

Questions for the medical practitioner

Bereaved individuals may have questions that only a medical practitioner can answer. Second thoughts may occur regarding treatment choices that were made. "I can't help wondering, doctor, if we made the right choice when we decided to take George off life support...." Having recovered from the shock phase of grief upon learning of the death of a loved one, some people may later need to come back to hear more explicitly the circumstances of the death. Autopsy results and their implications, both related to care that had been delivered and for future generations, may need to be discussed. These tasks cannot be relegated to counselors.

Bereavement as a health care risk factor

Recently bereaved people, especially geriatric patients, are at substantially higher risk for adverse events, including mortality. Parkes, in a study of 4486 widowers over the age of 55, found a 40% increased mortality rate compared to age-matched controls over six months.30 Bereaved individuals may present with a variety of complaints, such as insomnia, anorexia, anxiety, and body pains, that may be manifestations of grief or grief that has transformed into clinical depression.31 Some recently bereaved individuals may be concerned that they are "going crazy" if they see or hear the recently deceased. Rees interviewed 293 bereaved individuals and found that 47% had experienced such "hallucinations." The majority of those interviewed found such hallucinations (visual and auditory) helpful. Rees noted that, "It seems reasonable to conclude from theses studies that hallucinations are normal experiences after widowhood, providing helpful psychological phenomena to those experiencing them."32 Thus, this phenomenon is not rare and can be considered to be within the normal range of grief reactions. People may need reassurance that these experiences are common and do not reflect psychosis. On the other hand, bereaved individuals may truly be unable to bear a loss and may suffer complicated grief reactions that require professional attention.

Complicated bereavement

Although grief in bereavement is itself a normal process, it can become complicated and harmful.20,31,33 The best way to address complicated bereavement is to identify those individuals at high risk for it, work with them, if possible, before an anticipated death, and subsequently follow them closely. Unlike the healing process of normal bereavement, complicated bereavement is destructive to the individual. It results in dysfunctional behavior, poor quality of life, and, at times, even suicide. The more terrible the death and the more limited the coping abilities of the bereaved person, the greater is the risk of complicated bereavement. Violent or sudden deaths, deaths in which the bereaved may feel some sense of responsibility (such as the driver of a car in an auto accident), and deaths of young people result in a higher complicated bereavement risk.25 Bereaved individuals who were highly dependent on the deceased, such as elderly spouses, are at higher risk, as are those who have earlier histories of mental illnesses. Poverty and cultural isolation also limit coping abilities. The clinician can be of great service in identifying such individuals as early as possible, because counseling and supportive services can be of immense help.

One hint of complicated bereavement to watch for is grief that appears to be frozen at a certain stage. In this case grief becomes less a process than a way of life. The parents of a child who died in an accident may preserve the child's room, like a shrine, for years following the death. The process of normal grief is not linear. Sometimes it proceeds very slowly and sometimes quickly. However, no change is worrisome. Individuals stuck in their grief generally benefit from counseling.

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Keywords: Grief, bereavement, complicated grief, complicated mourning, multiple loss
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Palliative Care Perspectives

James L. Hallenbeck, M.D.

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Copyright 2003 by Oxford University Press, Inc.

The online version of this book is used with permission of the publisher and author on web sites affiliated with the Inter-Institutional Collaborating Network on End-of-life Care (IICN), sponsored by Growth House, Inc.