Although the clinician should know when to refer individuals with complicated grief, there is much they can do to address and facilitate grief when it arises. The acronym RELIEVER can serve as a reminder of simple interventions that anyone can do to assist the grieving, both in preparatory grief and bereavement.7
|R||Reflect back emotions (mirroring and naming).||Example: The person may say, "Why did I have to get this horrible disease." You might respond, "I can see that you are angry."|
|E||Empathize and make a personal connection.||Example: "I can imagine that you are going through rough times. What can I do to help?"|
|L||Lead.||Guided questions may help facilitate the grief process. Examples: "What concerns do you have about how your loved ones will do, after you are gone?" "When you went through difficult situations in the past, how did you handle them?"|
|I||Improvise.||Respect emotional boundaries, and support individuals within those boundaries. The clinician's approach must be tailored to suit each individual. What may work with one person may fail with another. Some may desire support through talking, for example. Others may simply want your presence. Some may wish to have time alone, while others may cope best by continuing prior routines. Individuals may suddenly change coping strategies, which requires great flexibility in response by the clinician.|
|E||Educate.||Explain that grief often comes in waves. Patients and families may need explanations of how others in the family can grieve in different ways. Recently bereaved individuals may need to be told that seeing or hearing the deceased occasionally does not mean they are going crazy.|
|VE||Validate the Experience.||Reflect back the normalcy of the experience. Example: "It is OK to cry," or "It seems to me you are responding normally to a very difficult situation."|
|R||Recall.||Many grieving people need to look back over their lives. You may help the dying by asking them about their accomplishments, special stories, and legacies they wish to hand down to future generations. Bereaved individuals may benefit from telling stories about the good times they had with the deceased.|
It is wonderful that the American Medicare hospice benefit requires bereavement support for the families of those who die in hospice. However, this has not become the standard of care for patients who die outside of hospice. This strikes me as terribly ironic. Relative to the other ways people die, hospice deaths tend to be the most peaceful and best anticipated. Support offered during the dying process probably reduces the risk of complicated bereavement in survivors. For those deaths that are most likely to result in complex bereavement - violent deaths and the deaths of young people in hospitals - no support is considered necessary, and often none is given (unless mass death occurs, as in an airplane crash or school shooting). This simply does not make sense. I suspect this results from a narrow interpretation of who the patient is and what our roles should be; according to this way of thinking, when the patient dies, the relationship between the clinician and the family ends because the patient's life has ended. Obviously, things are not so simple. It is probable that family members are also patients of our health care system and, as discussed above, bereavement is a health care risk factor for morbidity and mortality. Beyond this, it seems to me that some minimum degree of bereavement follow-up is simply the right, humane thing to do.
Establishing a comprehensive bereavement support system for the dying may not be politically feasible at the current time. However, I believe we could take one small step in the right direction. I hope that someday each hospital and each health care system will establish a policy such that if and when somebody dies in the hospital, someone will attempt to make one telephone call offering condolences on behalf of the hospital. This would not break the bank. It is only a tiny gesture. Who can argue that we should not call the parent of a child brought to the ER who was killed by a truck or the spouse of a man who died on the operating table? Is one phone call too much to ask? It is my hope that someday this will become a minimum standard of care.
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Palliative Care Perspectives
James L. Hallenbeck, M.D.
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.