65
Bereavement, Loss and Grief, Survival strategies for primary care Dr Peter Nightingale Macmillan GP GP Rosebank Surgery Clinical Assistant St John’s Hospice

Bereavement, Loss and Grief, Survival strategies for primary care

  • Upload
    felcia

  • View
    103

  • Download
    9

Embed Size (px)

DESCRIPTION

Bereavement, Loss and Grief, Survival strategies for primary care. Dr Peter Nightingale Macmillan GP GP Rosebank Surgery Clinical Assistant St John ’ s Hospice. Objectives. - PowerPoint PPT Presentation

Citation preview

Page 1: Bereavement, Loss and Grief, Survival strategies for primary care

Bereavement Loss and Grief

Survival strategies for primary care

Dr Peter NightingaleMacmillan GP

GP Rosebank SurgeryClinical Assistant St Johnrsquos

Hospice

Objectives

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

CERTAINTY

IGNORANCE

Pattern recognition

Anecdotechance recognition

Organised observation

Prospective RCT

Systematic Review

Based on Dudley 1983

Limitations of Empirical Studies Dominance of Widows (young white

and middle class) Age cohort effect The social norms of

the 1970rsquos 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

Overview

Definitions

Bereavement Theory

Health Professional Perspective

Definitions

LossWhen you no longer have something because you donrsquot know where it is or it has been taken away from you

Grief Emotional and psychological reaction to loss

BereavementReaction to the loss of a loved person by death

The Gold Standard Framework Communication Ca registerMDT meetings Co-ordination Key person Control of Symptoms Assessment treatment

and patient centred care Continuity Handover to out-of-hoursprotocol

Information to ptscarers Continued Learning Practice-based

learningreflection on experiences Carer Support Practical emotional bereavement

Care of the Dying Liverpool Integrated care pathway(48 hours of life)

Models of Adaptation to loss1 Traditional Models Based on the work of Bowlby

Parkes Kubler-Ross and Worden All can be referred to as lsquoPHASE MODELSrsquo

2 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 as-

1 Numbness2 Yearning3 Despair4 Recovery

1) Numbness Disbelief and unreality-feelings of

functioning on lsquoAutomatic Pilotrsquo Can occur even if death expected Unreality interspersed by bouts of

anger and despair Somatic symptoms common

2) Yearning Numbness replaced by lsquopangs of griefrsquo 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)

Loss

Shock

Yearning

Disorder and despair

Adaptation

Bowlby Firmly believed that working through

the phases of grief was a necessary aspect of successful mourning

He hypothesised three disordered forms of attachment in Childhood that could lead to vulnerability following bereavement-

1 Anxious attachment2 Compulsive self-reliance3 Compulsive caregiving

Attachment Theory

(John Bowlby)

diams All Social Animals become attached to

each other

diams The main function of attachment is to

provide security

diams The function of crying and searching

following separation is to promote

reunion

diams The nuclear source of security is the

Family

Separations from Parents in

Childhood predict Insecurity

and other Problems Later

(Bowlby)

Secure Attachment

diams lsquoMotherrsquo Sensitively Responsive and

Protective only when necessary

diams Child in lsquoStrange Situationrsquo Some anxiety

but easily reassured when mother returns

diams Later Develops autonomy with trust in

self and others

SECURE PARENTING

bullOverall Parenting Good

1048788

1)Childhood Vulnerability Low

1048788

2)Harmony in Adult Attachments

1048788

3)Overall Coping Good

1048788

DisorganisedDisoriented Attachment

bullFamily RejectionViolence Danger ampor Depression increases the risk that the child will be unhappy

bullAdult then lacks trust in self amp others may harm self

bullBereavement reaction associated with AnxietyPanic

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 bereavement

1 Denial and isolation2 Anger3 Bargaining4 Depression5 Acceptance

Kubler - Ross Not everyone will progress through all

five stages They may not be in the same order Denial and acceptance can be hard to

differentiate Danger of dying patients fears and

concerns being dismissed as lsquojust a stage they are passing throughrsquo

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 Loss1) Control2) Self-esteem3) Self-image4) Role 5) Work6) Independence7) Stigma

8) Abandonment9) Isolation10) Of Future11) Threat of Death12) Reduced ability13) Confidence in professionals drugs treatments 14) Loss of support

Worden Refined the phases of grief Drew on Freudrsquos concept of grief work Drew on Engelrsquos theory of grief as an

illness-ie the psychological trauma is analogous to the physiological trauma of severe injury

Conceptualised as four overlapping tasks

Wordenrsquos Tasks of MourningRather than seeing that there are lsquostagesrsquo 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

Wordenrsquos 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 onersquos 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 lsquonormalityrsquo can occur Research (Shuchter and Zisbrook) has

suggested grief is individualised and variable

Kubler-Rossrsquo stage theory was not developed for bereavement and has been misinterpreted

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 2: Bereavement, Loss and Grief, Survival strategies for primary care

Objectives

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

CERTAINTY

IGNORANCE

Pattern recognition

Anecdotechance recognition

Organised observation

Prospective RCT

Systematic Review

Based on Dudley 1983

Limitations of Empirical Studies Dominance of Widows (young white

and middle class) Age cohort effect The social norms of

the 1970rsquos 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

Overview

Definitions

Bereavement Theory

Health Professional Perspective

Definitions

LossWhen you no longer have something because you donrsquot know where it is or it has been taken away from you

Grief Emotional and psychological reaction to loss

BereavementReaction to the loss of a loved person by death

The Gold Standard Framework Communication Ca registerMDT meetings Co-ordination Key person Control of Symptoms Assessment treatment

and patient centred care Continuity Handover to out-of-hoursprotocol

Information to ptscarers Continued Learning Practice-based

learningreflection on experiences Carer Support Practical emotional bereavement

Care of the Dying Liverpool Integrated care pathway(48 hours of life)

Models of Adaptation to loss1 Traditional Models Based on the work of Bowlby

Parkes Kubler-Ross and Worden All can be referred to as lsquoPHASE MODELSrsquo

2 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 as-

1 Numbness2 Yearning3 Despair4 Recovery

1) Numbness Disbelief and unreality-feelings of

functioning on lsquoAutomatic Pilotrsquo Can occur even if death expected Unreality interspersed by bouts of

anger and despair Somatic symptoms common

2) Yearning Numbness replaced by lsquopangs of griefrsquo 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)

Loss

Shock

Yearning

Disorder and despair

Adaptation

Bowlby Firmly believed that working through

the phases of grief was a necessary aspect of successful mourning

He hypothesised three disordered forms of attachment in Childhood that could lead to vulnerability following bereavement-

1 Anxious attachment2 Compulsive self-reliance3 Compulsive caregiving

Attachment Theory

(John Bowlby)

diams All Social Animals become attached to

each other

diams The main function of attachment is to

provide security

diams The function of crying and searching

following separation is to promote

reunion

diams The nuclear source of security is the

Family

Separations from Parents in

Childhood predict Insecurity

and other Problems Later

(Bowlby)

Secure Attachment

diams lsquoMotherrsquo Sensitively Responsive and

Protective only when necessary

diams Child in lsquoStrange Situationrsquo Some anxiety

but easily reassured when mother returns

diams Later Develops autonomy with trust in

self and others

SECURE PARENTING

bullOverall Parenting Good

1048788

1)Childhood Vulnerability Low

1048788

2)Harmony in Adult Attachments

1048788

3)Overall Coping Good

1048788

DisorganisedDisoriented Attachment

bullFamily RejectionViolence Danger ampor Depression increases the risk that the child will be unhappy

bullAdult then lacks trust in self amp others may harm self

bullBereavement reaction associated with AnxietyPanic

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 bereavement

1 Denial and isolation2 Anger3 Bargaining4 Depression5 Acceptance

Kubler - Ross Not everyone will progress through all

five stages They may not be in the same order Denial and acceptance can be hard to

differentiate Danger of dying patients fears and

concerns being dismissed as lsquojust a stage they are passing throughrsquo

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 Loss1) Control2) Self-esteem3) Self-image4) Role 5) Work6) Independence7) Stigma

8) Abandonment9) Isolation10) Of Future11) Threat of Death12) Reduced ability13) Confidence in professionals drugs treatments 14) Loss of support

Worden Refined the phases of grief Drew on Freudrsquos concept of grief work Drew on Engelrsquos theory of grief as an

illness-ie the psychological trauma is analogous to the physiological trauma of severe injury

Conceptualised as four overlapping tasks

Wordenrsquos Tasks of MourningRather than seeing that there are lsquostagesrsquo 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

Wordenrsquos 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 onersquos 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 lsquonormalityrsquo can occur Research (Shuchter and Zisbrook) has

suggested grief is individualised and variable

Kubler-Rossrsquo stage theory was not developed for bereavement and has been misinterpreted

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 3: Bereavement, Loss and Grief, Survival strategies for primary care

CERTAINTY

IGNORANCE

Pattern recognition

Anecdotechance recognition

Organised observation

Prospective RCT

Systematic Review

Based on Dudley 1983

Limitations of Empirical Studies Dominance of Widows (young white

and middle class) Age cohort effect The social norms of

the 1970rsquos 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

Overview

Definitions

Bereavement Theory

Health Professional Perspective

Definitions

LossWhen you no longer have something because you donrsquot know where it is or it has been taken away from you

Grief Emotional and psychological reaction to loss

BereavementReaction to the loss of a loved person by death

The Gold Standard Framework Communication Ca registerMDT meetings Co-ordination Key person Control of Symptoms Assessment treatment

and patient centred care Continuity Handover to out-of-hoursprotocol

Information to ptscarers Continued Learning Practice-based

learningreflection on experiences Carer Support Practical emotional bereavement

Care of the Dying Liverpool Integrated care pathway(48 hours of life)

Models of Adaptation to loss1 Traditional Models Based on the work of Bowlby

Parkes Kubler-Ross and Worden All can be referred to as lsquoPHASE MODELSrsquo

2 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 as-

1 Numbness2 Yearning3 Despair4 Recovery

1) Numbness Disbelief and unreality-feelings of

functioning on lsquoAutomatic Pilotrsquo Can occur even if death expected Unreality interspersed by bouts of

anger and despair Somatic symptoms common

2) Yearning Numbness replaced by lsquopangs of griefrsquo 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)

Loss

Shock

Yearning

Disorder and despair

Adaptation

Bowlby Firmly believed that working through

the phases of grief was a necessary aspect of successful mourning

He hypothesised three disordered forms of attachment in Childhood that could lead to vulnerability following bereavement-

1 Anxious attachment2 Compulsive self-reliance3 Compulsive caregiving

Attachment Theory

(John Bowlby)

diams All Social Animals become attached to

each other

diams The main function of attachment is to

provide security

diams The function of crying and searching

following separation is to promote

reunion

diams The nuclear source of security is the

Family

Separations from Parents in

Childhood predict Insecurity

and other Problems Later

(Bowlby)

Secure Attachment

diams lsquoMotherrsquo Sensitively Responsive and

Protective only when necessary

diams Child in lsquoStrange Situationrsquo Some anxiety

but easily reassured when mother returns

diams Later Develops autonomy with trust in

self and others

SECURE PARENTING

bullOverall Parenting Good

1048788

1)Childhood Vulnerability Low

1048788

2)Harmony in Adult Attachments

1048788

3)Overall Coping Good

1048788

DisorganisedDisoriented Attachment

bullFamily RejectionViolence Danger ampor Depression increases the risk that the child will be unhappy

bullAdult then lacks trust in self amp others may harm self

bullBereavement reaction associated with AnxietyPanic

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 bereavement

1 Denial and isolation2 Anger3 Bargaining4 Depression5 Acceptance

Kubler - Ross Not everyone will progress through all

five stages They may not be in the same order Denial and acceptance can be hard to

differentiate Danger of dying patients fears and

concerns being dismissed as lsquojust a stage they are passing throughrsquo

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 Loss1) Control2) Self-esteem3) Self-image4) Role 5) Work6) Independence7) Stigma

8) Abandonment9) Isolation10) Of Future11) Threat of Death12) Reduced ability13) Confidence in professionals drugs treatments 14) Loss of support

Worden Refined the phases of grief Drew on Freudrsquos concept of grief work Drew on Engelrsquos theory of grief as an

illness-ie the psychological trauma is analogous to the physiological trauma of severe injury

Conceptualised as four overlapping tasks

Wordenrsquos Tasks of MourningRather than seeing that there are lsquostagesrsquo 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

Wordenrsquos 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 onersquos 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 lsquonormalityrsquo can occur Research (Shuchter and Zisbrook) has

suggested grief is individualised and variable

Kubler-Rossrsquo stage theory was not developed for bereavement and has been misinterpreted

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 4: Bereavement, Loss and Grief, Survival strategies for primary care

Limitations of Empirical Studies Dominance of Widows (young white

and middle class) Age cohort effect The social norms of

the 1970rsquos 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

Overview

Definitions

Bereavement Theory

Health Professional Perspective

Definitions

LossWhen you no longer have something because you donrsquot know where it is or it has been taken away from you

Grief Emotional and psychological reaction to loss

BereavementReaction to the loss of a loved person by death

The Gold Standard Framework Communication Ca registerMDT meetings Co-ordination Key person Control of Symptoms Assessment treatment

and patient centred care Continuity Handover to out-of-hoursprotocol

Information to ptscarers Continued Learning Practice-based

learningreflection on experiences Carer Support Practical emotional bereavement

Care of the Dying Liverpool Integrated care pathway(48 hours of life)

Models of Adaptation to loss1 Traditional Models Based on the work of Bowlby

Parkes Kubler-Ross and Worden All can be referred to as lsquoPHASE MODELSrsquo

2 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 as-

1 Numbness2 Yearning3 Despair4 Recovery

1) Numbness Disbelief and unreality-feelings of

functioning on lsquoAutomatic Pilotrsquo Can occur even if death expected Unreality interspersed by bouts of

anger and despair Somatic symptoms common

2) Yearning Numbness replaced by lsquopangs of griefrsquo 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)

Loss

Shock

Yearning

Disorder and despair

Adaptation

Bowlby Firmly believed that working through

the phases of grief was a necessary aspect of successful mourning

He hypothesised three disordered forms of attachment in Childhood that could lead to vulnerability following bereavement-

1 Anxious attachment2 Compulsive self-reliance3 Compulsive caregiving

Attachment Theory

(John Bowlby)

diams All Social Animals become attached to

each other

diams The main function of attachment is to

provide security

diams The function of crying and searching

following separation is to promote

reunion

diams The nuclear source of security is the

Family

Separations from Parents in

Childhood predict Insecurity

and other Problems Later

(Bowlby)

Secure Attachment

diams lsquoMotherrsquo Sensitively Responsive and

Protective only when necessary

diams Child in lsquoStrange Situationrsquo Some anxiety

but easily reassured when mother returns

diams Later Develops autonomy with trust in

self and others

SECURE PARENTING

bullOverall Parenting Good

1048788

1)Childhood Vulnerability Low

1048788

2)Harmony in Adult Attachments

1048788

3)Overall Coping Good

1048788

DisorganisedDisoriented Attachment

bullFamily RejectionViolence Danger ampor Depression increases the risk that the child will be unhappy

bullAdult then lacks trust in self amp others may harm self

bullBereavement reaction associated with AnxietyPanic

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 bereavement

1 Denial and isolation2 Anger3 Bargaining4 Depression5 Acceptance

Kubler - Ross Not everyone will progress through all

five stages They may not be in the same order Denial and acceptance can be hard to

differentiate Danger of dying patients fears and

concerns being dismissed as lsquojust a stage they are passing throughrsquo

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 Loss1) Control2) Self-esteem3) Self-image4) Role 5) Work6) Independence7) Stigma

8) Abandonment9) Isolation10) Of Future11) Threat of Death12) Reduced ability13) Confidence in professionals drugs treatments 14) Loss of support

Worden Refined the phases of grief Drew on Freudrsquos concept of grief work Drew on Engelrsquos theory of grief as an

illness-ie the psychological trauma is analogous to the physiological trauma of severe injury

Conceptualised as four overlapping tasks

Wordenrsquos Tasks of MourningRather than seeing that there are lsquostagesrsquo 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

Wordenrsquos 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 onersquos 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 lsquonormalityrsquo can occur Research (Shuchter and Zisbrook) has

suggested grief is individualised and variable

Kubler-Rossrsquo stage theory was not developed for bereavement and has been misinterpreted

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 5: Bereavement, Loss and Grief, Survival strategies for primary care

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

Overview

Definitions

Bereavement Theory

Health Professional Perspective

Definitions

LossWhen you no longer have something because you donrsquot know where it is or it has been taken away from you

Grief Emotional and psychological reaction to loss

BereavementReaction to the loss of a loved person by death

The Gold Standard Framework Communication Ca registerMDT meetings Co-ordination Key person Control of Symptoms Assessment treatment

and patient centred care Continuity Handover to out-of-hoursprotocol

Information to ptscarers Continued Learning Practice-based

learningreflection on experiences Carer Support Practical emotional bereavement

Care of the Dying Liverpool Integrated care pathway(48 hours of life)

Models of Adaptation to loss1 Traditional Models Based on the work of Bowlby

Parkes Kubler-Ross and Worden All can be referred to as lsquoPHASE MODELSrsquo

2 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 as-

1 Numbness2 Yearning3 Despair4 Recovery

1) Numbness Disbelief and unreality-feelings of

functioning on lsquoAutomatic Pilotrsquo Can occur even if death expected Unreality interspersed by bouts of

anger and despair Somatic symptoms common

2) Yearning Numbness replaced by lsquopangs of griefrsquo 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)

Loss

Shock

Yearning

Disorder and despair

Adaptation

Bowlby Firmly believed that working through

the phases of grief was a necessary aspect of successful mourning

He hypothesised three disordered forms of attachment in Childhood that could lead to vulnerability following bereavement-

1 Anxious attachment2 Compulsive self-reliance3 Compulsive caregiving

Attachment Theory

(John Bowlby)

diams All Social Animals become attached to

each other

diams The main function of attachment is to

provide security

diams The function of crying and searching

following separation is to promote

reunion

diams The nuclear source of security is the

Family

Separations from Parents in

Childhood predict Insecurity

and other Problems Later

(Bowlby)

Secure Attachment

diams lsquoMotherrsquo Sensitively Responsive and

Protective only when necessary

diams Child in lsquoStrange Situationrsquo Some anxiety

but easily reassured when mother returns

diams Later Develops autonomy with trust in

self and others

SECURE PARENTING

bullOverall Parenting Good

1048788

1)Childhood Vulnerability Low

1048788

2)Harmony in Adult Attachments

1048788

3)Overall Coping Good

1048788

DisorganisedDisoriented Attachment

bullFamily RejectionViolence Danger ampor Depression increases the risk that the child will be unhappy

bullAdult then lacks trust in self amp others may harm self

bullBereavement reaction associated with AnxietyPanic

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 bereavement

1 Denial and isolation2 Anger3 Bargaining4 Depression5 Acceptance

Kubler - Ross Not everyone will progress through all

five stages They may not be in the same order Denial and acceptance can be hard to

differentiate Danger of dying patients fears and

concerns being dismissed as lsquojust a stage they are passing throughrsquo

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 Loss1) Control2) Self-esteem3) Self-image4) Role 5) Work6) Independence7) Stigma

8) Abandonment9) Isolation10) Of Future11) Threat of Death12) Reduced ability13) Confidence in professionals drugs treatments 14) Loss of support

Worden Refined the phases of grief Drew on Freudrsquos concept of grief work Drew on Engelrsquos theory of grief as an

illness-ie the psychological trauma is analogous to the physiological trauma of severe injury

Conceptualised as four overlapping tasks

Wordenrsquos Tasks of MourningRather than seeing that there are lsquostagesrsquo 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

Wordenrsquos 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 onersquos 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 lsquonormalityrsquo can occur Research (Shuchter and Zisbrook) has

suggested grief is individualised and variable

Kubler-Rossrsquo stage theory was not developed for bereavement and has been misinterpreted

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 6: Bereavement, Loss and Grief, Survival strategies for primary care

Overview

Definitions

Bereavement Theory

Health Professional Perspective

Definitions

LossWhen you no longer have something because you donrsquot know where it is or it has been taken away from you

Grief Emotional and psychological reaction to loss

BereavementReaction to the loss of a loved person by death

The Gold Standard Framework Communication Ca registerMDT meetings Co-ordination Key person Control of Symptoms Assessment treatment

and patient centred care Continuity Handover to out-of-hoursprotocol

Information to ptscarers Continued Learning Practice-based

learningreflection on experiences Carer Support Practical emotional bereavement

Care of the Dying Liverpool Integrated care pathway(48 hours of life)

Models of Adaptation to loss1 Traditional Models Based on the work of Bowlby

Parkes Kubler-Ross and Worden All can be referred to as lsquoPHASE MODELSrsquo

2 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 as-

1 Numbness2 Yearning3 Despair4 Recovery

1) Numbness Disbelief and unreality-feelings of

functioning on lsquoAutomatic Pilotrsquo Can occur even if death expected Unreality interspersed by bouts of

anger and despair Somatic symptoms common

2) Yearning Numbness replaced by lsquopangs of griefrsquo 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)

Loss

Shock

Yearning

Disorder and despair

Adaptation

Bowlby Firmly believed that working through

the phases of grief was a necessary aspect of successful mourning

He hypothesised three disordered forms of attachment in Childhood that could lead to vulnerability following bereavement-

1 Anxious attachment2 Compulsive self-reliance3 Compulsive caregiving

Attachment Theory

(John Bowlby)

diams All Social Animals become attached to

each other

diams The main function of attachment is to

provide security

diams The function of crying and searching

following separation is to promote

reunion

diams The nuclear source of security is the

Family

Separations from Parents in

Childhood predict Insecurity

and other Problems Later

(Bowlby)

Secure Attachment

diams lsquoMotherrsquo Sensitively Responsive and

Protective only when necessary

diams Child in lsquoStrange Situationrsquo Some anxiety

but easily reassured when mother returns

diams Later Develops autonomy with trust in

self and others

SECURE PARENTING

bullOverall Parenting Good

1048788

1)Childhood Vulnerability Low

1048788

2)Harmony in Adult Attachments

1048788

3)Overall Coping Good

1048788

DisorganisedDisoriented Attachment

bullFamily RejectionViolence Danger ampor Depression increases the risk that the child will be unhappy

bullAdult then lacks trust in self amp others may harm self

bullBereavement reaction associated with AnxietyPanic

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 bereavement

1 Denial and isolation2 Anger3 Bargaining4 Depression5 Acceptance

Kubler - Ross Not everyone will progress through all

five stages They may not be in the same order Denial and acceptance can be hard to

differentiate Danger of dying patients fears and

concerns being dismissed as lsquojust a stage they are passing throughrsquo

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 Loss1) Control2) Self-esteem3) Self-image4) Role 5) Work6) Independence7) Stigma

8) Abandonment9) Isolation10) Of Future11) Threat of Death12) Reduced ability13) Confidence in professionals drugs treatments 14) Loss of support

Worden Refined the phases of grief Drew on Freudrsquos concept of grief work Drew on Engelrsquos theory of grief as an

illness-ie the psychological trauma is analogous to the physiological trauma of severe injury

Conceptualised as four overlapping tasks

Wordenrsquos Tasks of MourningRather than seeing that there are lsquostagesrsquo 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

Wordenrsquos 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 onersquos 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 lsquonormalityrsquo can occur Research (Shuchter and Zisbrook) has

suggested grief is individualised and variable

Kubler-Rossrsquo stage theory was not developed for bereavement and has been misinterpreted

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 7: Bereavement, Loss and Grief, Survival strategies for primary care

Definitions

LossWhen you no longer have something because you donrsquot know where it is or it has been taken away from you

Grief Emotional and psychological reaction to loss

BereavementReaction to the loss of a loved person by death

The Gold Standard Framework Communication Ca registerMDT meetings Co-ordination Key person Control of Symptoms Assessment treatment

and patient centred care Continuity Handover to out-of-hoursprotocol

Information to ptscarers Continued Learning Practice-based

learningreflection on experiences Carer Support Practical emotional bereavement

Care of the Dying Liverpool Integrated care pathway(48 hours of life)

Models of Adaptation to loss1 Traditional Models Based on the work of Bowlby

Parkes Kubler-Ross and Worden All can be referred to as lsquoPHASE MODELSrsquo

2 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 as-

1 Numbness2 Yearning3 Despair4 Recovery

1) Numbness Disbelief and unreality-feelings of

functioning on lsquoAutomatic Pilotrsquo Can occur even if death expected Unreality interspersed by bouts of

anger and despair Somatic symptoms common

2) Yearning Numbness replaced by lsquopangs of griefrsquo 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)

Loss

Shock

Yearning

Disorder and despair

Adaptation

Bowlby Firmly believed that working through

the phases of grief was a necessary aspect of successful mourning

He hypothesised three disordered forms of attachment in Childhood that could lead to vulnerability following bereavement-

1 Anxious attachment2 Compulsive self-reliance3 Compulsive caregiving

Attachment Theory

(John Bowlby)

diams All Social Animals become attached to

each other

diams The main function of attachment is to

provide security

diams The function of crying and searching

following separation is to promote

reunion

diams The nuclear source of security is the

Family

Separations from Parents in

Childhood predict Insecurity

and other Problems Later

(Bowlby)

Secure Attachment

diams lsquoMotherrsquo Sensitively Responsive and

Protective only when necessary

diams Child in lsquoStrange Situationrsquo Some anxiety

but easily reassured when mother returns

diams Later Develops autonomy with trust in

self and others

SECURE PARENTING

bullOverall Parenting Good

1048788

1)Childhood Vulnerability Low

1048788

2)Harmony in Adult Attachments

1048788

3)Overall Coping Good

1048788

DisorganisedDisoriented Attachment

bullFamily RejectionViolence Danger ampor Depression increases the risk that the child will be unhappy

bullAdult then lacks trust in self amp others may harm self

bullBereavement reaction associated with AnxietyPanic

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 bereavement

1 Denial and isolation2 Anger3 Bargaining4 Depression5 Acceptance

Kubler - Ross Not everyone will progress through all

five stages They may not be in the same order Denial and acceptance can be hard to

differentiate Danger of dying patients fears and

concerns being dismissed as lsquojust a stage they are passing throughrsquo

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 Loss1) Control2) Self-esteem3) Self-image4) Role 5) Work6) Independence7) Stigma

8) Abandonment9) Isolation10) Of Future11) Threat of Death12) Reduced ability13) Confidence in professionals drugs treatments 14) Loss of support

Worden Refined the phases of grief Drew on Freudrsquos concept of grief work Drew on Engelrsquos theory of grief as an

illness-ie the psychological trauma is analogous to the physiological trauma of severe injury

Conceptualised as four overlapping tasks

Wordenrsquos Tasks of MourningRather than seeing that there are lsquostagesrsquo 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

Wordenrsquos 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 onersquos 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 lsquonormalityrsquo can occur Research (Shuchter and Zisbrook) has

suggested grief is individualised and variable

Kubler-Rossrsquo stage theory was not developed for bereavement and has been misinterpreted

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 8: Bereavement, Loss and Grief, Survival strategies for primary care

The Gold Standard Framework Communication Ca registerMDT meetings Co-ordination Key person Control of Symptoms Assessment treatment

and patient centred care Continuity Handover to out-of-hoursprotocol

Information to ptscarers Continued Learning Practice-based

learningreflection on experiences Carer Support Practical emotional bereavement

Care of the Dying Liverpool Integrated care pathway(48 hours of life)

Models of Adaptation to loss1 Traditional Models Based on the work of Bowlby

Parkes Kubler-Ross and Worden All can be referred to as lsquoPHASE MODELSrsquo

2 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 as-

1 Numbness2 Yearning3 Despair4 Recovery

1) Numbness Disbelief and unreality-feelings of

functioning on lsquoAutomatic Pilotrsquo Can occur even if death expected Unreality interspersed by bouts of

anger and despair Somatic symptoms common

2) Yearning Numbness replaced by lsquopangs of griefrsquo 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)

Loss

Shock

Yearning

Disorder and despair

Adaptation

Bowlby Firmly believed that working through

the phases of grief was a necessary aspect of successful mourning

He hypothesised three disordered forms of attachment in Childhood that could lead to vulnerability following bereavement-

1 Anxious attachment2 Compulsive self-reliance3 Compulsive caregiving

Attachment Theory

(John Bowlby)

diams All Social Animals become attached to

each other

diams The main function of attachment is to

provide security

diams The function of crying and searching

following separation is to promote

reunion

diams The nuclear source of security is the

Family

Separations from Parents in

Childhood predict Insecurity

and other Problems Later

(Bowlby)

Secure Attachment

diams lsquoMotherrsquo Sensitively Responsive and

Protective only when necessary

diams Child in lsquoStrange Situationrsquo Some anxiety

but easily reassured when mother returns

diams Later Develops autonomy with trust in

self and others

SECURE PARENTING

bullOverall Parenting Good

1048788

1)Childhood Vulnerability Low

1048788

2)Harmony in Adult Attachments

1048788

3)Overall Coping Good

1048788

DisorganisedDisoriented Attachment

bullFamily RejectionViolence Danger ampor Depression increases the risk that the child will be unhappy

bullAdult then lacks trust in self amp others may harm self

bullBereavement reaction associated with AnxietyPanic

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 bereavement

1 Denial and isolation2 Anger3 Bargaining4 Depression5 Acceptance

Kubler - Ross Not everyone will progress through all

five stages They may not be in the same order Denial and acceptance can be hard to

differentiate Danger of dying patients fears and

concerns being dismissed as lsquojust a stage they are passing throughrsquo

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 Loss1) Control2) Self-esteem3) Self-image4) Role 5) Work6) Independence7) Stigma

8) Abandonment9) Isolation10) Of Future11) Threat of Death12) Reduced ability13) Confidence in professionals drugs treatments 14) Loss of support

Worden Refined the phases of grief Drew on Freudrsquos concept of grief work Drew on Engelrsquos theory of grief as an

illness-ie the psychological trauma is analogous to the physiological trauma of severe injury

Conceptualised as four overlapping tasks

Wordenrsquos Tasks of MourningRather than seeing that there are lsquostagesrsquo 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

Wordenrsquos 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 onersquos 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 lsquonormalityrsquo can occur Research (Shuchter and Zisbrook) has

suggested grief is individualised and variable

Kubler-Rossrsquo stage theory was not developed for bereavement and has been misinterpreted

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 9: Bereavement, Loss and Grief, Survival strategies for primary care

Models of Adaptation to loss1 Traditional Models Based on the work of Bowlby

Parkes Kubler-Ross and Worden All can be referred to as lsquoPHASE MODELSrsquo

2 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 as-

1 Numbness2 Yearning3 Despair4 Recovery

1) Numbness Disbelief and unreality-feelings of

functioning on lsquoAutomatic Pilotrsquo Can occur even if death expected Unreality interspersed by bouts of

anger and despair Somatic symptoms common

2) Yearning Numbness replaced by lsquopangs of griefrsquo 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)

Loss

Shock

Yearning

Disorder and despair

Adaptation

Bowlby Firmly believed that working through

the phases of grief was a necessary aspect of successful mourning

He hypothesised three disordered forms of attachment in Childhood that could lead to vulnerability following bereavement-

1 Anxious attachment2 Compulsive self-reliance3 Compulsive caregiving

Attachment Theory

(John Bowlby)

diams All Social Animals become attached to

each other

diams The main function of attachment is to

provide security

diams The function of crying and searching

following separation is to promote

reunion

diams The nuclear source of security is the

Family

Separations from Parents in

Childhood predict Insecurity

and other Problems Later

(Bowlby)

Secure Attachment

diams lsquoMotherrsquo Sensitively Responsive and

Protective only when necessary

diams Child in lsquoStrange Situationrsquo Some anxiety

but easily reassured when mother returns

diams Later Develops autonomy with trust in

self and others

SECURE PARENTING

bullOverall Parenting Good

1048788

1)Childhood Vulnerability Low

1048788

2)Harmony in Adult Attachments

1048788

3)Overall Coping Good

1048788

DisorganisedDisoriented Attachment

bullFamily RejectionViolence Danger ampor Depression increases the risk that the child will be unhappy

bullAdult then lacks trust in self amp others may harm self

bullBereavement reaction associated with AnxietyPanic

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 bereavement

1 Denial and isolation2 Anger3 Bargaining4 Depression5 Acceptance

Kubler - Ross Not everyone will progress through all

five stages They may not be in the same order Denial and acceptance can be hard to

differentiate Danger of dying patients fears and

concerns being dismissed as lsquojust a stage they are passing throughrsquo

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 Loss1) Control2) Self-esteem3) Self-image4) Role 5) Work6) Independence7) Stigma

8) Abandonment9) Isolation10) Of Future11) Threat of Death12) Reduced ability13) Confidence in professionals drugs treatments 14) Loss of support

Worden Refined the phases of grief Drew on Freudrsquos concept of grief work Drew on Engelrsquos theory of grief as an

illness-ie the psychological trauma is analogous to the physiological trauma of severe injury

Conceptualised as four overlapping tasks

Wordenrsquos Tasks of MourningRather than seeing that there are lsquostagesrsquo 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

Wordenrsquos 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 onersquos 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 lsquonormalityrsquo can occur Research (Shuchter and Zisbrook) has

suggested grief is individualised and variable

Kubler-Rossrsquo stage theory was not developed for bereavement and has been misinterpreted

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 10: Bereavement, Loss and Grief, Survival strategies for primary care

Phase Models The number and duration of these

phases varies but are remarkably similar and can be summarised as-

1 Numbness2 Yearning3 Despair4 Recovery

1) Numbness Disbelief and unreality-feelings of

functioning on lsquoAutomatic Pilotrsquo Can occur even if death expected Unreality interspersed by bouts of

anger and despair Somatic symptoms common

2) Yearning Numbness replaced by lsquopangs of griefrsquo 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)

Loss

Shock

Yearning

Disorder and despair

Adaptation

Bowlby Firmly believed that working through

the phases of grief was a necessary aspect of successful mourning

He hypothesised three disordered forms of attachment in Childhood that could lead to vulnerability following bereavement-

1 Anxious attachment2 Compulsive self-reliance3 Compulsive caregiving

Attachment Theory

(John Bowlby)

diams All Social Animals become attached to

each other

diams The main function of attachment is to

provide security

diams The function of crying and searching

following separation is to promote

reunion

diams The nuclear source of security is the

Family

Separations from Parents in

Childhood predict Insecurity

and other Problems Later

(Bowlby)

Secure Attachment

diams lsquoMotherrsquo Sensitively Responsive and

Protective only when necessary

diams Child in lsquoStrange Situationrsquo Some anxiety

but easily reassured when mother returns

diams Later Develops autonomy with trust in

self and others

SECURE PARENTING

bullOverall Parenting Good

1048788

1)Childhood Vulnerability Low

1048788

2)Harmony in Adult Attachments

1048788

3)Overall Coping Good

1048788

DisorganisedDisoriented Attachment

bullFamily RejectionViolence Danger ampor Depression increases the risk that the child will be unhappy

bullAdult then lacks trust in self amp others may harm self

bullBereavement reaction associated with AnxietyPanic

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 bereavement

1 Denial and isolation2 Anger3 Bargaining4 Depression5 Acceptance

Kubler - Ross Not everyone will progress through all

five stages They may not be in the same order Denial and acceptance can be hard to

differentiate Danger of dying patients fears and

concerns being dismissed as lsquojust a stage they are passing throughrsquo

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 Loss1) Control2) Self-esteem3) Self-image4) Role 5) Work6) Independence7) Stigma

8) Abandonment9) Isolation10) Of Future11) Threat of Death12) Reduced ability13) Confidence in professionals drugs treatments 14) Loss of support

Worden Refined the phases of grief Drew on Freudrsquos concept of grief work Drew on Engelrsquos theory of grief as an

illness-ie the psychological trauma is analogous to the physiological trauma of severe injury

Conceptualised as four overlapping tasks

Wordenrsquos Tasks of MourningRather than seeing that there are lsquostagesrsquo 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

Wordenrsquos 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 onersquos 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 lsquonormalityrsquo can occur Research (Shuchter and Zisbrook) has

suggested grief is individualised and variable

Kubler-Rossrsquo stage theory was not developed for bereavement and has been misinterpreted

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 11: Bereavement, Loss and Grief, Survival strategies for primary care

1) Numbness Disbelief and unreality-feelings of

functioning on lsquoAutomatic Pilotrsquo Can occur even if death expected Unreality interspersed by bouts of

anger and despair Somatic symptoms common

2) Yearning Numbness replaced by lsquopangs of griefrsquo 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)

Loss

Shock

Yearning

Disorder and despair

Adaptation

Bowlby Firmly believed that working through

the phases of grief was a necessary aspect of successful mourning

He hypothesised three disordered forms of attachment in Childhood that could lead to vulnerability following bereavement-

1 Anxious attachment2 Compulsive self-reliance3 Compulsive caregiving

Attachment Theory

(John Bowlby)

diams All Social Animals become attached to

each other

diams The main function of attachment is to

provide security

diams The function of crying and searching

following separation is to promote

reunion

diams The nuclear source of security is the

Family

Separations from Parents in

Childhood predict Insecurity

and other Problems Later

(Bowlby)

Secure Attachment

diams lsquoMotherrsquo Sensitively Responsive and

Protective only when necessary

diams Child in lsquoStrange Situationrsquo Some anxiety

but easily reassured when mother returns

diams Later Develops autonomy with trust in

self and others

SECURE PARENTING

bullOverall Parenting Good

1048788

1)Childhood Vulnerability Low

1048788

2)Harmony in Adult Attachments

1048788

3)Overall Coping Good

1048788

DisorganisedDisoriented Attachment

bullFamily RejectionViolence Danger ampor Depression increases the risk that the child will be unhappy

bullAdult then lacks trust in self amp others may harm self

bullBereavement reaction associated with AnxietyPanic

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 bereavement

1 Denial and isolation2 Anger3 Bargaining4 Depression5 Acceptance

Kubler - Ross Not everyone will progress through all

five stages They may not be in the same order Denial and acceptance can be hard to

differentiate Danger of dying patients fears and

concerns being dismissed as lsquojust a stage they are passing throughrsquo

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 Loss1) Control2) Self-esteem3) Self-image4) Role 5) Work6) Independence7) Stigma

8) Abandonment9) Isolation10) Of Future11) Threat of Death12) Reduced ability13) Confidence in professionals drugs treatments 14) Loss of support

Worden Refined the phases of grief Drew on Freudrsquos concept of grief work Drew on Engelrsquos theory of grief as an

illness-ie the psychological trauma is analogous to the physiological trauma of severe injury

Conceptualised as four overlapping tasks

Wordenrsquos Tasks of MourningRather than seeing that there are lsquostagesrsquo 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

Wordenrsquos 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 onersquos 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 lsquonormalityrsquo can occur Research (Shuchter and Zisbrook) has

suggested grief is individualised and variable

Kubler-Rossrsquo stage theory was not developed for bereavement and has been misinterpreted

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 12: Bereavement, Loss and Grief, Survival strategies for primary care

2) Yearning Numbness replaced by lsquopangs of griefrsquo 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)

Loss

Shock

Yearning

Disorder and despair

Adaptation

Bowlby Firmly believed that working through

the phases of grief was a necessary aspect of successful mourning

He hypothesised three disordered forms of attachment in Childhood that could lead to vulnerability following bereavement-

1 Anxious attachment2 Compulsive self-reliance3 Compulsive caregiving

Attachment Theory

(John Bowlby)

diams All Social Animals become attached to

each other

diams The main function of attachment is to

provide security

diams The function of crying and searching

following separation is to promote

reunion

diams The nuclear source of security is the

Family

Separations from Parents in

Childhood predict Insecurity

and other Problems Later

(Bowlby)

Secure Attachment

diams lsquoMotherrsquo Sensitively Responsive and

Protective only when necessary

diams Child in lsquoStrange Situationrsquo Some anxiety

but easily reassured when mother returns

diams Later Develops autonomy with trust in

self and others

SECURE PARENTING

bullOverall Parenting Good

1048788

1)Childhood Vulnerability Low

1048788

2)Harmony in Adult Attachments

1048788

3)Overall Coping Good

1048788

DisorganisedDisoriented Attachment

bullFamily RejectionViolence Danger ampor Depression increases the risk that the child will be unhappy

bullAdult then lacks trust in self amp others may harm self

bullBereavement reaction associated with AnxietyPanic

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 bereavement

1 Denial and isolation2 Anger3 Bargaining4 Depression5 Acceptance

Kubler - Ross Not everyone will progress through all

five stages They may not be in the same order Denial and acceptance can be hard to

differentiate Danger of dying patients fears and

concerns being dismissed as lsquojust a stage they are passing throughrsquo

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 Loss1) Control2) Self-esteem3) Self-image4) Role 5) Work6) Independence7) Stigma

8) Abandonment9) Isolation10) Of Future11) Threat of Death12) Reduced ability13) Confidence in professionals drugs treatments 14) Loss of support

Worden Refined the phases of grief Drew on Freudrsquos concept of grief work Drew on Engelrsquos theory of grief as an

illness-ie the psychological trauma is analogous to the physiological trauma of severe injury

Conceptualised as four overlapping tasks

Wordenrsquos Tasks of MourningRather than seeing that there are lsquostagesrsquo 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

Wordenrsquos 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 onersquos 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 lsquonormalityrsquo can occur Research (Shuchter and Zisbrook) has

suggested grief is individualised and variable

Kubler-Rossrsquo stage theory was not developed for bereavement and has been misinterpreted

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 13: Bereavement, Loss and Grief, Survival strategies for primary care

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)

Loss

Shock

Yearning

Disorder and despair

Adaptation

Bowlby Firmly believed that working through

the phases of grief was a necessary aspect of successful mourning

He hypothesised three disordered forms of attachment in Childhood that could lead to vulnerability following bereavement-

1 Anxious attachment2 Compulsive self-reliance3 Compulsive caregiving

Attachment Theory

(John Bowlby)

diams All Social Animals become attached to

each other

diams The main function of attachment is to

provide security

diams The function of crying and searching

following separation is to promote

reunion

diams The nuclear source of security is the

Family

Separations from Parents in

Childhood predict Insecurity

and other Problems Later

(Bowlby)

Secure Attachment

diams lsquoMotherrsquo Sensitively Responsive and

Protective only when necessary

diams Child in lsquoStrange Situationrsquo Some anxiety

but easily reassured when mother returns

diams Later Develops autonomy with trust in

self and others

SECURE PARENTING

bullOverall Parenting Good

1048788

1)Childhood Vulnerability Low

1048788

2)Harmony in Adult Attachments

1048788

3)Overall Coping Good

1048788

DisorganisedDisoriented Attachment

bullFamily RejectionViolence Danger ampor Depression increases the risk that the child will be unhappy

bullAdult then lacks trust in self amp others may harm self

bullBereavement reaction associated with AnxietyPanic

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 bereavement

1 Denial and isolation2 Anger3 Bargaining4 Depression5 Acceptance

Kubler - Ross Not everyone will progress through all

five stages They may not be in the same order Denial and acceptance can be hard to

differentiate Danger of dying patients fears and

concerns being dismissed as lsquojust a stage they are passing throughrsquo

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 Loss1) Control2) Self-esteem3) Self-image4) Role 5) Work6) Independence7) Stigma

8) Abandonment9) Isolation10) Of Future11) Threat of Death12) Reduced ability13) Confidence in professionals drugs treatments 14) Loss of support

Worden Refined the phases of grief Drew on Freudrsquos concept of grief work Drew on Engelrsquos theory of grief as an

illness-ie the psychological trauma is analogous to the physiological trauma of severe injury

Conceptualised as four overlapping tasks

Wordenrsquos Tasks of MourningRather than seeing that there are lsquostagesrsquo 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

Wordenrsquos 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 onersquos 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 lsquonormalityrsquo can occur Research (Shuchter and Zisbrook) has

suggested grief is individualised and variable

Kubler-Rossrsquo stage theory was not developed for bereavement and has been misinterpreted

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 14: Bereavement, Loss and Grief, Survival strategies for primary care

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)

Loss

Shock

Yearning

Disorder and despair

Adaptation

Bowlby Firmly believed that working through

the phases of grief was a necessary aspect of successful mourning

He hypothesised three disordered forms of attachment in Childhood that could lead to vulnerability following bereavement-

1 Anxious attachment2 Compulsive self-reliance3 Compulsive caregiving

Attachment Theory

(John Bowlby)

diams All Social Animals become attached to

each other

diams The main function of attachment is to

provide security

diams The function of crying and searching

following separation is to promote

reunion

diams The nuclear source of security is the

Family

Separations from Parents in

Childhood predict Insecurity

and other Problems Later

(Bowlby)

Secure Attachment

diams lsquoMotherrsquo Sensitively Responsive and

Protective only when necessary

diams Child in lsquoStrange Situationrsquo Some anxiety

but easily reassured when mother returns

diams Later Develops autonomy with trust in

self and others

SECURE PARENTING

bullOverall Parenting Good

1048788

1)Childhood Vulnerability Low

1048788

2)Harmony in Adult Attachments

1048788

3)Overall Coping Good

1048788

DisorganisedDisoriented Attachment

bullFamily RejectionViolence Danger ampor Depression increases the risk that the child will be unhappy

bullAdult then lacks trust in self amp others may harm self

bullBereavement reaction associated with AnxietyPanic

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 bereavement

1 Denial and isolation2 Anger3 Bargaining4 Depression5 Acceptance

Kubler - Ross Not everyone will progress through all

five stages They may not be in the same order Denial and acceptance can be hard to

differentiate Danger of dying patients fears and

concerns being dismissed as lsquojust a stage they are passing throughrsquo

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 Loss1) Control2) Self-esteem3) Self-image4) Role 5) Work6) Independence7) Stigma

8) Abandonment9) Isolation10) Of Future11) Threat of Death12) Reduced ability13) Confidence in professionals drugs treatments 14) Loss of support

Worden Refined the phases of grief Drew on Freudrsquos concept of grief work Drew on Engelrsquos theory of grief as an

illness-ie the psychological trauma is analogous to the physiological trauma of severe injury

Conceptualised as four overlapping tasks

Wordenrsquos Tasks of MourningRather than seeing that there are lsquostagesrsquo 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

Wordenrsquos 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 onersquos 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 lsquonormalityrsquo can occur Research (Shuchter and Zisbrook) has

suggested grief is individualised and variable

Kubler-Rossrsquo stage theory was not developed for bereavement and has been misinterpreted

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 15: Bereavement, Loss and Grief, Survival strategies for primary care

Bereavement Models (Linear)

Loss

Shock

Yearning

Disorder and despair

Adaptation

Bowlby Firmly believed that working through

the phases of grief was a necessary aspect of successful mourning

He hypothesised three disordered forms of attachment in Childhood that could lead to vulnerability following bereavement-

1 Anxious attachment2 Compulsive self-reliance3 Compulsive caregiving

Attachment Theory

(John Bowlby)

diams All Social Animals become attached to

each other

diams The main function of attachment is to

provide security

diams The function of crying and searching

following separation is to promote

reunion

diams The nuclear source of security is the

Family

Separations from Parents in

Childhood predict Insecurity

and other Problems Later

(Bowlby)

Secure Attachment

diams lsquoMotherrsquo Sensitively Responsive and

Protective only when necessary

diams Child in lsquoStrange Situationrsquo Some anxiety

but easily reassured when mother returns

diams Later Develops autonomy with trust in

self and others

SECURE PARENTING

bullOverall Parenting Good

1048788

1)Childhood Vulnerability Low

1048788

2)Harmony in Adult Attachments

1048788

3)Overall Coping Good

1048788

DisorganisedDisoriented Attachment

bullFamily RejectionViolence Danger ampor Depression increases the risk that the child will be unhappy

bullAdult then lacks trust in self amp others may harm self

bullBereavement reaction associated with AnxietyPanic

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 bereavement

1 Denial and isolation2 Anger3 Bargaining4 Depression5 Acceptance

Kubler - Ross Not everyone will progress through all

five stages They may not be in the same order Denial and acceptance can be hard to

differentiate Danger of dying patients fears and

concerns being dismissed as lsquojust a stage they are passing throughrsquo

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 Loss1) Control2) Self-esteem3) Self-image4) Role 5) Work6) Independence7) Stigma

8) Abandonment9) Isolation10) Of Future11) Threat of Death12) Reduced ability13) Confidence in professionals drugs treatments 14) Loss of support

Worden Refined the phases of grief Drew on Freudrsquos concept of grief work Drew on Engelrsquos theory of grief as an

illness-ie the psychological trauma is analogous to the physiological trauma of severe injury

Conceptualised as four overlapping tasks

Wordenrsquos Tasks of MourningRather than seeing that there are lsquostagesrsquo 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

Wordenrsquos 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 onersquos 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 lsquonormalityrsquo can occur Research (Shuchter and Zisbrook) has

suggested grief is individualised and variable

Kubler-Rossrsquo stage theory was not developed for bereavement and has been misinterpreted

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 16: Bereavement, Loss and Grief, Survival strategies for primary care

Bowlby Firmly believed that working through

the phases of grief was a necessary aspect of successful mourning

He hypothesised three disordered forms of attachment in Childhood that could lead to vulnerability following bereavement-

1 Anxious attachment2 Compulsive self-reliance3 Compulsive caregiving

Attachment Theory

(John Bowlby)

diams All Social Animals become attached to

each other

diams The main function of attachment is to

provide security

diams The function of crying and searching

following separation is to promote

reunion

diams The nuclear source of security is the

Family

Separations from Parents in

Childhood predict Insecurity

and other Problems Later

(Bowlby)

Secure Attachment

diams lsquoMotherrsquo Sensitively Responsive and

Protective only when necessary

diams Child in lsquoStrange Situationrsquo Some anxiety

but easily reassured when mother returns

diams Later Develops autonomy with trust in

self and others

SECURE PARENTING

bullOverall Parenting Good

1048788

1)Childhood Vulnerability Low

1048788

2)Harmony in Adult Attachments

1048788

3)Overall Coping Good

1048788

DisorganisedDisoriented Attachment

bullFamily RejectionViolence Danger ampor Depression increases the risk that the child will be unhappy

bullAdult then lacks trust in self amp others may harm self

bullBereavement reaction associated with AnxietyPanic

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 bereavement

1 Denial and isolation2 Anger3 Bargaining4 Depression5 Acceptance

Kubler - Ross Not everyone will progress through all

five stages They may not be in the same order Denial and acceptance can be hard to

differentiate Danger of dying patients fears and

concerns being dismissed as lsquojust a stage they are passing throughrsquo

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 Loss1) Control2) Self-esteem3) Self-image4) Role 5) Work6) Independence7) Stigma

8) Abandonment9) Isolation10) Of Future11) Threat of Death12) Reduced ability13) Confidence in professionals drugs treatments 14) Loss of support

Worden Refined the phases of grief Drew on Freudrsquos concept of grief work Drew on Engelrsquos theory of grief as an

illness-ie the psychological trauma is analogous to the physiological trauma of severe injury

Conceptualised as four overlapping tasks

Wordenrsquos Tasks of MourningRather than seeing that there are lsquostagesrsquo 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

Wordenrsquos 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 onersquos 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 lsquonormalityrsquo can occur Research (Shuchter and Zisbrook) has

suggested grief is individualised and variable

Kubler-Rossrsquo stage theory was not developed for bereavement and has been misinterpreted

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 17: Bereavement, Loss and Grief, Survival strategies for primary care

Attachment Theory

(John Bowlby)

diams All Social Animals become attached to

each other

diams The main function of attachment is to

provide security

diams The function of crying and searching

following separation is to promote

reunion

diams The nuclear source of security is the

Family

Separations from Parents in

Childhood predict Insecurity

and other Problems Later

(Bowlby)

Secure Attachment

diams lsquoMotherrsquo Sensitively Responsive and

Protective only when necessary

diams Child in lsquoStrange Situationrsquo Some anxiety

but easily reassured when mother returns

diams Later Develops autonomy with trust in

self and others

SECURE PARENTING

bullOverall Parenting Good

1048788

1)Childhood Vulnerability Low

1048788

2)Harmony in Adult Attachments

1048788

3)Overall Coping Good

1048788

DisorganisedDisoriented Attachment

bullFamily RejectionViolence Danger ampor Depression increases the risk that the child will be unhappy

bullAdult then lacks trust in self amp others may harm self

bullBereavement reaction associated with AnxietyPanic

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 bereavement

1 Denial and isolation2 Anger3 Bargaining4 Depression5 Acceptance

Kubler - Ross Not everyone will progress through all

five stages They may not be in the same order Denial and acceptance can be hard to

differentiate Danger of dying patients fears and

concerns being dismissed as lsquojust a stage they are passing throughrsquo

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 Loss1) Control2) Self-esteem3) Self-image4) Role 5) Work6) Independence7) Stigma

8) Abandonment9) Isolation10) Of Future11) Threat of Death12) Reduced ability13) Confidence in professionals drugs treatments 14) Loss of support

Worden Refined the phases of grief Drew on Freudrsquos concept of grief work Drew on Engelrsquos theory of grief as an

illness-ie the psychological trauma is analogous to the physiological trauma of severe injury

Conceptualised as four overlapping tasks

Wordenrsquos Tasks of MourningRather than seeing that there are lsquostagesrsquo 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

Wordenrsquos 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 onersquos 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 lsquonormalityrsquo can occur Research (Shuchter and Zisbrook) has

suggested grief is individualised and variable

Kubler-Rossrsquo stage theory was not developed for bereavement and has been misinterpreted

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 18: Bereavement, Loss and Grief, Survival strategies for primary care

Separations from Parents in

Childhood predict Insecurity

and other Problems Later

(Bowlby)

Secure Attachment

diams lsquoMotherrsquo Sensitively Responsive and

Protective only when necessary

diams Child in lsquoStrange Situationrsquo Some anxiety

but easily reassured when mother returns

diams Later Develops autonomy with trust in

self and others

SECURE PARENTING

bullOverall Parenting Good

1048788

1)Childhood Vulnerability Low

1048788

2)Harmony in Adult Attachments

1048788

3)Overall Coping Good

1048788

DisorganisedDisoriented Attachment

bullFamily RejectionViolence Danger ampor Depression increases the risk that the child will be unhappy

bullAdult then lacks trust in self amp others may harm self

bullBereavement reaction associated with AnxietyPanic

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 bereavement

1 Denial and isolation2 Anger3 Bargaining4 Depression5 Acceptance

Kubler - Ross Not everyone will progress through all

five stages They may not be in the same order Denial and acceptance can be hard to

differentiate Danger of dying patients fears and

concerns being dismissed as lsquojust a stage they are passing throughrsquo

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 Loss1) Control2) Self-esteem3) Self-image4) Role 5) Work6) Independence7) Stigma

8) Abandonment9) Isolation10) Of Future11) Threat of Death12) Reduced ability13) Confidence in professionals drugs treatments 14) Loss of support

Worden Refined the phases of grief Drew on Freudrsquos concept of grief work Drew on Engelrsquos theory of grief as an

illness-ie the psychological trauma is analogous to the physiological trauma of severe injury

Conceptualised as four overlapping tasks

Wordenrsquos Tasks of MourningRather than seeing that there are lsquostagesrsquo 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

Wordenrsquos 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 onersquos 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 lsquonormalityrsquo can occur Research (Shuchter and Zisbrook) has

suggested grief is individualised and variable

Kubler-Rossrsquo stage theory was not developed for bereavement and has been misinterpreted

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 19: Bereavement, Loss and Grief, Survival strategies for primary care

Secure Attachment

diams lsquoMotherrsquo Sensitively Responsive and

Protective only when necessary

diams Child in lsquoStrange Situationrsquo Some anxiety

but easily reassured when mother returns

diams Later Develops autonomy with trust in

self and others

SECURE PARENTING

bullOverall Parenting Good

1048788

1)Childhood Vulnerability Low

1048788

2)Harmony in Adult Attachments

1048788

3)Overall Coping Good

1048788

DisorganisedDisoriented Attachment

bullFamily RejectionViolence Danger ampor Depression increases the risk that the child will be unhappy

bullAdult then lacks trust in self amp others may harm self

bullBereavement reaction associated with AnxietyPanic

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 bereavement

1 Denial and isolation2 Anger3 Bargaining4 Depression5 Acceptance

Kubler - Ross Not everyone will progress through all

five stages They may not be in the same order Denial and acceptance can be hard to

differentiate Danger of dying patients fears and

concerns being dismissed as lsquojust a stage they are passing throughrsquo

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 Loss1) Control2) Self-esteem3) Self-image4) Role 5) Work6) Independence7) Stigma

8) Abandonment9) Isolation10) Of Future11) Threat of Death12) Reduced ability13) Confidence in professionals drugs treatments 14) Loss of support

Worden Refined the phases of grief Drew on Freudrsquos concept of grief work Drew on Engelrsquos theory of grief as an

illness-ie the psychological trauma is analogous to the physiological trauma of severe injury

Conceptualised as four overlapping tasks

Wordenrsquos Tasks of MourningRather than seeing that there are lsquostagesrsquo 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

Wordenrsquos 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 onersquos 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 lsquonormalityrsquo can occur Research (Shuchter and Zisbrook) has

suggested grief is individualised and variable

Kubler-Rossrsquo stage theory was not developed for bereavement and has been misinterpreted

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 20: Bereavement, Loss and Grief, Survival strategies for primary care

SECURE PARENTING

bullOverall Parenting Good

1048788

1)Childhood Vulnerability Low

1048788

2)Harmony in Adult Attachments

1048788

3)Overall Coping Good

1048788

DisorganisedDisoriented Attachment

bullFamily RejectionViolence Danger ampor Depression increases the risk that the child will be unhappy

bullAdult then lacks trust in self amp others may harm self

bullBereavement reaction associated with AnxietyPanic

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 bereavement

1 Denial and isolation2 Anger3 Bargaining4 Depression5 Acceptance

Kubler - Ross Not everyone will progress through all

five stages They may not be in the same order Denial and acceptance can be hard to

differentiate Danger of dying patients fears and

concerns being dismissed as lsquojust a stage they are passing throughrsquo

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 Loss1) Control2) Self-esteem3) Self-image4) Role 5) Work6) Independence7) Stigma

8) Abandonment9) Isolation10) Of Future11) Threat of Death12) Reduced ability13) Confidence in professionals drugs treatments 14) Loss of support

Worden Refined the phases of grief Drew on Freudrsquos concept of grief work Drew on Engelrsquos theory of grief as an

illness-ie the psychological trauma is analogous to the physiological trauma of severe injury

Conceptualised as four overlapping tasks

Wordenrsquos Tasks of MourningRather than seeing that there are lsquostagesrsquo 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

Wordenrsquos 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 onersquos 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 lsquonormalityrsquo can occur Research (Shuchter and Zisbrook) has

suggested grief is individualised and variable

Kubler-Rossrsquo stage theory was not developed for bereavement and has been misinterpreted

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 21: Bereavement, Loss and Grief, Survival strategies for primary care

DisorganisedDisoriented Attachment

bullFamily RejectionViolence Danger ampor Depression increases the risk that the child will be unhappy

bullAdult then lacks trust in self amp others may harm self

bullBereavement reaction associated with AnxietyPanic

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 bereavement

1 Denial and isolation2 Anger3 Bargaining4 Depression5 Acceptance

Kubler - Ross Not everyone will progress through all

five stages They may not be in the same order Denial and acceptance can be hard to

differentiate Danger of dying patients fears and

concerns being dismissed as lsquojust a stage they are passing throughrsquo

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 Loss1) Control2) Self-esteem3) Self-image4) Role 5) Work6) Independence7) Stigma

8) Abandonment9) Isolation10) Of Future11) Threat of Death12) Reduced ability13) Confidence in professionals drugs treatments 14) Loss of support

Worden Refined the phases of grief Drew on Freudrsquos concept of grief work Drew on Engelrsquos theory of grief as an

illness-ie the psychological trauma is analogous to the physiological trauma of severe injury

Conceptualised as four overlapping tasks

Wordenrsquos Tasks of MourningRather than seeing that there are lsquostagesrsquo 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

Wordenrsquos 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 onersquos 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 lsquonormalityrsquo can occur Research (Shuchter and Zisbrook) has

suggested grief is individualised and variable

Kubler-Rossrsquo stage theory was not developed for bereavement and has been misinterpreted

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 22: Bereavement, Loss and Grief, Survival strategies for primary care

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 bereavement

1 Denial and isolation2 Anger3 Bargaining4 Depression5 Acceptance

Kubler - Ross Not everyone will progress through all

five stages They may not be in the same order Denial and acceptance can be hard to

differentiate Danger of dying patients fears and

concerns being dismissed as lsquojust a stage they are passing throughrsquo

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 Loss1) Control2) Self-esteem3) Self-image4) Role 5) Work6) Independence7) Stigma

8) Abandonment9) Isolation10) Of Future11) Threat of Death12) Reduced ability13) Confidence in professionals drugs treatments 14) Loss of support

Worden Refined the phases of grief Drew on Freudrsquos concept of grief work Drew on Engelrsquos theory of grief as an

illness-ie the psychological trauma is analogous to the physiological trauma of severe injury

Conceptualised as four overlapping tasks

Wordenrsquos Tasks of MourningRather than seeing that there are lsquostagesrsquo 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

Wordenrsquos 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 onersquos 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 lsquonormalityrsquo can occur Research (Shuchter and Zisbrook) has

suggested grief is individualised and variable

Kubler-Rossrsquo stage theory was not developed for bereavement and has been misinterpreted

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 23: Bereavement, Loss and Grief, Survival strategies for primary care

Kubler - Ross Not everyone will progress through all

five stages They may not be in the same order Denial and acceptance can be hard to

differentiate Danger of dying patients fears and

concerns being dismissed as lsquojust a stage they are passing throughrsquo

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 Loss1) Control2) Self-esteem3) Self-image4) Role 5) Work6) Independence7) Stigma

8) Abandonment9) Isolation10) Of Future11) Threat of Death12) Reduced ability13) Confidence in professionals drugs treatments 14) Loss of support

Worden Refined the phases of grief Drew on Freudrsquos concept of grief work Drew on Engelrsquos theory of grief as an

illness-ie the psychological trauma is analogous to the physiological trauma of severe injury

Conceptualised as four overlapping tasks

Wordenrsquos Tasks of MourningRather than seeing that there are lsquostagesrsquo 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

Wordenrsquos 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 onersquos 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 lsquonormalityrsquo can occur Research (Shuchter and Zisbrook) has

suggested grief is individualised and variable

Kubler-Rossrsquo stage theory was not developed for bereavement and has been misinterpreted

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 24: Bereavement, Loss and Grief, Survival strategies for primary care

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 Loss1) Control2) Self-esteem3) Self-image4) Role 5) Work6) Independence7) Stigma

8) Abandonment9) Isolation10) Of Future11) Threat of Death12) Reduced ability13) Confidence in professionals drugs treatments 14) Loss of support

Worden Refined the phases of grief Drew on Freudrsquos concept of grief work Drew on Engelrsquos theory of grief as an

illness-ie the psychological trauma is analogous to the physiological trauma of severe injury

Conceptualised as four overlapping tasks

Wordenrsquos Tasks of MourningRather than seeing that there are lsquostagesrsquo 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

Wordenrsquos 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 onersquos 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 lsquonormalityrsquo can occur Research (Shuchter and Zisbrook) has

suggested grief is individualised and variable

Kubler-Rossrsquo stage theory was not developed for bereavement and has been misinterpreted

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 25: Bereavement, Loss and Grief, Survival strategies for primary care

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

Chronic Illness and Loss1) Control2) Self-esteem3) Self-image4) Role 5) Work6) Independence7) Stigma

8) Abandonment9) Isolation10) Of Future11) Threat of Death12) Reduced ability13) Confidence in professionals drugs treatments 14) Loss of support

Worden Refined the phases of grief Drew on Freudrsquos concept of grief work Drew on Engelrsquos theory of grief as an

illness-ie the psychological trauma is analogous to the physiological trauma of severe injury

Conceptualised as four overlapping tasks

Wordenrsquos Tasks of MourningRather than seeing that there are lsquostagesrsquo 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

Wordenrsquos 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 onersquos 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 lsquonormalityrsquo can occur Research (Shuchter and Zisbrook) has

suggested grief is individualised and variable

Kubler-Rossrsquo stage theory was not developed for bereavement and has been misinterpreted

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 26: Bereavement, Loss and Grief, Survival strategies for primary care

Chronic Illness and Loss1) Control2) Self-esteem3) Self-image4) Role 5) Work6) Independence7) Stigma

8) Abandonment9) Isolation10) Of Future11) Threat of Death12) Reduced ability13) Confidence in professionals drugs treatments 14) Loss of support

Worden Refined the phases of grief Drew on Freudrsquos concept of grief work Drew on Engelrsquos theory of grief as an

illness-ie the psychological trauma is analogous to the physiological trauma of severe injury

Conceptualised as four overlapping tasks

Wordenrsquos Tasks of MourningRather than seeing that there are lsquostagesrsquo 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

Wordenrsquos 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 onersquos 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 lsquonormalityrsquo can occur Research (Shuchter and Zisbrook) has

suggested grief is individualised and variable

Kubler-Rossrsquo stage theory was not developed for bereavement and has been misinterpreted

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 27: Bereavement, Loss and Grief, Survival strategies for primary care

Worden Refined the phases of grief Drew on Freudrsquos concept of grief work Drew on Engelrsquos theory of grief as an

illness-ie the psychological trauma is analogous to the physiological trauma of severe injury

Conceptualised as four overlapping tasks

Wordenrsquos Tasks of MourningRather than seeing that there are lsquostagesrsquo 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

Wordenrsquos 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 onersquos 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 lsquonormalityrsquo can occur Research (Shuchter and Zisbrook) has

suggested grief is individualised and variable

Kubler-Rossrsquo stage theory was not developed for bereavement and has been misinterpreted

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 28: Bereavement, Loss and Grief, Survival strategies for primary care

Wordenrsquos Tasks of MourningRather than seeing that there are lsquostagesrsquo 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

Wordenrsquos 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 onersquos 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 lsquonormalityrsquo can occur Research (Shuchter and Zisbrook) has

suggested grief is individualised and variable

Kubler-Rossrsquo stage theory was not developed for bereavement and has been misinterpreted

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 29: Bereavement, Loss and Grief, Survival strategies for primary care

Wordenrsquos 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 onersquos 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 lsquonormalityrsquo can occur Research (Shuchter and Zisbrook) has

suggested grief is individualised and variable

Kubler-Rossrsquo stage theory was not developed for bereavement and has been misinterpreted

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 30: Bereavement, Loss and Grief, Survival strategies for primary care

Problems with Phase Models They tend to be interpreted as linear If used prescriptively hasty judgements

about lsquonormalityrsquo can occur Research (Shuchter and Zisbrook) has

suggested grief is individualised and variable

Kubler-Rossrsquo stage theory was not developed for bereavement and has been misinterpreted

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 31: Bereavement, Loss and Grief, Survival strategies for primary care

lsquoGrief Workrsquo 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 lsquoclinical lorersquo 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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 32: Bereavement, Loss and Grief, Survival strategies for primary care

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 lsquocontinuing bondsrsquo

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 33: Bereavement, Loss and Grief, Survival strategies for primary care

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 Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 34: Bereavement, Loss and Grief, Survival strategies for primary care

The Multidimentional model Le Poidevin working with Parkes at

St Christopherrsquos 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

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 35: Bereavement, Loss and Grief, Survival strategies for primary care

Dimensions of LossSusan le Poidevin Identity How has the loss affected self-esteem Emotionally Are they at ease with expressing

feelings Spiritual What meaning has been ascribed to the

loss Practical How are everyday practicalities

managed Physical What is the impact on physical health Lifestyle Has the loss caused financial problems Familycommunity What support is available

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 36: Bereavement, Loss and Grief, Survival strategies for primary care

Dual Process Model The key concept is oscillation between

coping behaviours 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 WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 37: Bereavement, Loss and Grief, Survival strategies for primary care

Bereavement Models (Continual)

Grief WorkIntrusion of GriefBreaking bonds tiesDenial avoidance of changes

Attending to life changesDoing new thingsDistraction from griefNew roles relationships

EVERYDAY LIFE EXPERIENCE

Loss Orientated RestorationOrientated

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 38: Bereavement, Loss and Grief, Survival strategies for primary care

13

A Dual Process Model of Coping with Loss Stroebe MS amp Schut HAW (1995)

Everyday life experience

Loss OrientatedGrief Work

Intrusion of grief

Breaking bonds or ties

Denialavoidance of restoration changes

Restoration-orientatedAttending to life changes

Doing new things

Distraction from grief

Denialavoidance of grief

New rolesidentityrelationship

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 39: Bereavement, Loss and Grief, Survival strategies for primary care

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)

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 40: Bereavement, Loss and Grief, Survival strategies for primary care

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 41: Bereavement, Loss and Grief, Survival strategies for primary care

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 42: Bereavement, Loss and Grief, Survival strategies for primary care

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

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 43: Bereavement, Loss and Grief, Survival strategies for primary care

10 Ways to Help Bereaved People Be There-donrsquot 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 grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 44: Bereavement, Loss and Grief, Survival strategies for primary care

10 ways to help (cont) Be familiar with your own feelings about

loss and grief Offer reassurance about the normality

of grief reactions 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 supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 45: Bereavement, Loss and Grief, Survival strategies for primary care

Bereavement Care Relf studied bereavement services in

Oxford in 1997 and found a marked reduction in the use of GP services in those supportedWhat helped was-

1 Being listened to2 Feeling understood3 Talking to someone outside their social

network4 Information about Grief75 found support helpful but 25 were

unsatisfied

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 46: Bereavement, Loss and Grief, Survival strategies for primary care

Health Professionals Perspective

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 47: Bereavement, Loss and Grief, Survival strategies for primary care

Mixture of EmotionsContentment

Relief

Fear

Guilt

Sadness

Anger

Frustration

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 48: Bereavement, Loss and Grief, Survival strategies for primary care

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-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 49: Bereavement, Loss and Grief, Survival strategies for primary care

Hands up if any of you recognise any of these psychological traits in yourself Perfectionist Overly conscientious Tendency to seek approval-rsquoPeople

Pleasingrsquo Need to control others Great sense of responsibility Chronic self-doubt Uncomfortable with praise Ability to delay gratification

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 50: Bereavement, Loss and Grief, Survival strategies for primary care

Emotional Response

bull 31 Strong emotional impact to death

bull 23 Very disturbed by death

bull 47 Upset when thinking of patient

bull 24 NumbGRIEFGRIEF

Longer care time Stronger emotional reaction

Longer care time Increased satisfaction

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 51: Bereavement, Loss and Grief, Survival strategies for primary care

Top 5 lsquoSoul Killersrsquo

1 Isolation2 Anger3 Fear4 Exhaustion5 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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 52: Bereavement, Loss and Grief, Survival strategies for primary care

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

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 53: Bereavement, Loss and Grief, Survival strategies for primary care

Five ways to survive as a doctor

1 Make sure you do other things other than work

2 Create your dream work schedule

3 Learn to say lsquoNorsquo- without feeling guilty

4 If you need help ask for it5 Seek peer support

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 54: Bereavement, Loss and Grief, Survival strategies for primary care

Are you burning out1 Chronic fatigue - exhaustion tiredness a sense of being physically

run down 2 Anger at those making demands 3 Self-criticism for putting up with the demands 4 Cynicism negativity and irritability 5 A sense of being besieged 6 Exploding easily at seemingly inconsequential things 7 Frequent headaches and gastrointestinal disturbances 8 Weight loss or gain 9 Sleeplessness and depression 10 Shortness of breath 11 Suspiciousness 12 Feelings of helplessness 13 Increased degree of risk taking

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 55: Bereavement, Loss and Grief, Survival strategies for primary care

BURNOUT BEATING BEHAVIOUR 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 stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 56: Bereavement, Loss and Grief, Survival strategies for primary care

How to beat stressHoliday - 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 dont 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 Dont 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 Dont 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

Exercise 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 dont 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 butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 57: Bereavement, Loss and Grief, Survival strategies for primary care

Slow Dance

Have you ever watched kids On a merry-go-round Or listened to the rain Slapping on the ground Ever followed a butterflys erratic flight Or gazed at the sun into the fading night You better slow down Dont dance so fast Time is short The music wont 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 Youd better slow down Dont dance so fast Time is short

The music wont last

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 58: Bereavement, Loss and Grief, Survival strategies for primary care

Ever told your child Well 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 sayHi Youd better slow down Dont dance so fast Time is short The music wont 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

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 59: Bereavement, Loss and Grief, Survival strategies for primary care

Conclusion 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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 60: Bereavement, Loss and Grief, Survival strategies for primary care

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 Personsrsquo Service supporting families before and after bereavement

Clients can either self refer or be referred by others eg GPrsquos Macmillan nurses Cancer specialist nurses

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor

Page 61: Bereavement, Loss and Grief, Survival strategies for primary care

If you ever need hospice help David Barnett ndash

davidsjhospiceorgukHospice Chaplain with wealth of

experience and advice Christine Townson ndash

christinesjhospiceorgukBereavement counsellor