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End of Life: Grieving and Bereaving Andrea Chatburn, DO, MA WOMA Winter Seminar 12.5.2015

End of Life: Grief and Bereavement

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Page 1: End of Life: Grief and Bereavement

End of Life: Grieving and Bereaving

Andrea Chatburn, DO, MAWOMA Winter Seminar

12.5.2015

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No Financial Disclosure

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Objectives

• Revisit grief theory & tool of mindful presence

• Examine grief related screening tools • Distinguish between typical, complicated

grief• Determine when structured psychotherapy

and pharmacotherapy is indicated for grief• Apply bereavement interventions to special

populations

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Awareness & Noting

U.S. Army

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Won’t be covering

• Specific grief resources for Military or Post-combat PTSD & bereavement

• Specific grief, PTSD resources for Refugees

• Grief & funeral traditions across cultures and world religion

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Why talk about grief & bereavement?

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“ICU Bereave” – staff & family survey

Downar, J. et al. The desirability of an ICU Clinician-Led Bereavement Screening and Support Program for Family members of ICU Decedents. Journal of Critical Care. 29(2014) 311.e9-e16.

Family• 64 contacted & 32

participated• 9 (28%) - complicated grief

or prolonged grief disorder• 7 (22%) - social distress• 10 (31%) - professional

support for emotional symptoms

• 2 (6%) - professional support for social symptoms

• 68% - wanted more support

Staff• 94 contacted & 57

participated• 85% reported providing

emotional support at time of death

• 56 (98%) willing to participate in formal bereavement screening and support program

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Barriers to Supporting Bereaved Family Members

• Not knowing what to say• Not sure how to deal with emotion• Lack of knowledge about community

resource• High clinical workload• Lack of continuity or established relationship

with the patient or family member

Downar, J. et al. The desirability of an ICU Clinician-Led Bereavement Screening and Support Program for Family members of ICU Descendants. Journal of Critical Care. 29(2014) 311.e9-e16.

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Desires for bereavement support

• Training in how to support the bereaved• List of available community resources• Dedicated time after the death and at a

later date to provide support

Downar, et al.

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Grief is centered in relationship

Sam Caplet “Don’t Let Go”

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WHO Guidelines for Bereavement

• Recommend AGAINST offering structured psychological interventions to all bereaved adults or children (w/o mental disorder)

• Benzodiazepines should NOT be offered to bereaved adults or children (w/o mental disorder)

• Grief and mourning are natural responses to loss, most people navigate w/o clinical intervention

Wietse A., et al. WHO Guidelines for Management of Acute Stress, PTSD, and Bereavement: Key Challenges on the Road Ahead.” PLOS Medicine. December 2014, Vol 11, Issue 12.

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Molly Fumia

“I started missing you long before

you were gone …I’ll keep loving you

long after the memories

bring you back”

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Grief Theories

• Elizabeth Kubler Ross- 5 stages• Ken Doka• William Warden• Alan Walset*• Teresa Randall*• “Integrated grief”

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45 years since On Death and Dying

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Grief is related to all types of loss

• Loss of relationship• Loss of role (mother/sister/daughter)• Loss of function- Debility• Loss of health• Loss of home• Loss of independence• Loss of job

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Expression of Grief

• Emotional response• Physical• Social• Spiritual• Thought Process/Cognitive

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Vincent van Gogh “Old Man Crying”

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Georg Sander “Tomb of a Mourning Woman”

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Gtneil

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Action- 5K, Ice bucket challenge, etc.

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Acceptance?

Griefwatch.com

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Ministry of Presence

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Legacy Work

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Cueva de las Manas, Argentina by Xipe Totec39

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Byock- 4 things that matter most

• Thank you• Please forgive me• I forgive you• I love you

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Dignity Therapy

• Chochinov- Manitoba. • Life survey by patient &

loved ones • Gave a sense of

purpose & meaning to life

• Assisted in “living with” grief

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Suffering and Meaning

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Ethical Will

• Zava’ah• Values• Blessings• Life lessons• Hopes for future

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Typical Grief

• Normal emotional reaction to loss• Resolves in < 6 months• No residual serious social,

psychological or medical consequences

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Interventions for All Bereaved

• Support by provider at time of death• Contact in weeks to months after a death• Customized bereavement care plan

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Screening Tools

• Start with symptoms: – Eating?– Sleeping?

• 5 item Brief Grief Questionnaire • 19 item Inventory of Complicated Grief– Score 25-30 significant symptoms– Score >30 threshold for treatment research

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Brief Grief Questionnaire0 1 2

How much are you having trouble accepting the death of ____?How much does your grief still interfere with your life?How much are you having images or thoughts of ___ when they died or other thoughts about the death that really bother you?Are there things you used to do when ____ was alive that you do not feel comfortable doing anymore, that you avoid? Like going somewhere you went with them, or doing things you used to enjoy together? Or avoiding looking at pictures or talking about ____? How much are you avoiding these things?How much are you feeling cut off or distant from other people since _____ died, even people you used to be close to like family or friends?

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When is psychotherapy indicated?

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When are prescriptions indicated?

PublicDomainPictures

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Complicated Grief (CG) or Prolonged Grief Disorder (PGD)

• Grief resulting in severe social, psychological, or medical consequences• Persists beyond 6 months• Social distress: marked by difficulties

with ADLs, financial matters, and social interactions

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Prolonged Grief Disorder

A. Loss of a significant personB. Separation distress: feelings of yearning that

occur daily or cause disabilityC. At least 5 specific cognitive, emotional or

behavioral symptomsD. Timing >6 months since lossE. Significant Social, occupational, or functional

impairmentF. Not caused by other psychiatric disorder

Shear MK, et al. Complicated grief and related bereavement issues for DSM-5. Depression Anxiety. Feb 2011; 28(2):103-17.

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Symptoms- PGD

• Diminished sense of self• Difficulty accepting loss• Avoidance of reminders of loss• Inability to trust others• Bitterness or anger related to loss• Difficulty moving on with life• Emotional numbness• Feeling that life is meaningless• Feeling stunned/dazed/shocked by the loss

Shear et al.

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Complicated Grief

A. Loss of a loved one >6 months agoB. At least one symptom of acute grief present for

longer than expected in the person’s cultureC. At least 2 of the following symptoms present for >1

mo. (see next slide)D. Duration: symptoms and impairment >1 mo.E. Impairment: significant social, occupational, or

functional impairment caused by symptoms and not better explained as a culturally appropriate response

Shear et al.

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B. Symptoms of Acute Grief - CG

• Persistent intense yearning• Frequent intense loneliness/emptiness• Recurrent feelings of meaninglessness of

life, or a desire to die in order to rejoin the deceased

• Frequent intrusive thoughts about the deceased

Shear et al.

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C. Symptoms in CG (2 or more)• Rumination about the death and its consequences• Disbelief, inability to accept death• Feeling of shock, numbness• Bitterness or anger related to loss• Inability to trust others• Experiencing pain/symptoms that deceased person

experienced• Intense reaction to memories/reminders of loss• Excessive avoidance/proximity seeking relevant to

deceased

Shear et al.

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CG New to DSM-5

“Persistent Complex Bereavement Disorder”Subtype of :– “Other specified trauma” – “Stressor-related disorders”

• Estimated prevalence 7% of bereaved people• Symptoms “out of proportion or inconsistent

with cultural, religious, or age-appropriate norms”

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Risk factors for Complicated Grief

• Pre-loss factors:– Female–Preexisting trauma (particularly childhood)-

ACE–Prior loss– Insecure attachment–Preexisting mood and anxiety disorders–Nature of the relationship

Simon, N. Treating Complicated Greif. JAMA July 24, 2013 Vol 310, No 4. p 416-423

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Loss related Risks for CG

• Relationship and caretaking roles– Spouses–Mothers of dependent children– Caretakers for chronically ill

• Nature of the death itself– Violent, sudden, prolonged, suicide

• Mortality in Intensive Care Unit– 34 to 67% of surviving family members have CG

Simon, N.

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Other Risk Factors

• Social circumstances• Resources available after death• Unknown: Lack of information/understanding

of the circumstances of the death event• Interference with natural healing process:– Inability to follow usual cultural mourning– Alcohol or substance abuse– Lack of social support

Simon, N.

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Differential Dx for CG

• Trigger for Comorbid Major Depressive Disorder, PTSD, Substance Abuse

• Of patients with CG:– 25% had no comorbid conditions– 55% had comorbid Major Depressive Disorder– 49% had PTSD– 36% had both MDD and PTSD

• Difference btn CG and PTSD: Fear

Simon, N.

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CG: Deficits in

imagining a future w/o the

deceased

MDD: inability to

experience positive emotions when

contemplating the deceased

PTSD: Presence of

Fear

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When to Intervene?

• Persistently high sx severity• Lack of temporal involvement in the

grief response• Functional Impairment• Treatment-seeking behaviors• Hopelessness• Suicidal ideation or behaviors

Simon, N.

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Targeted Complex Grief Therapy

• Motivational interviewing & CBT techniques• Discussing positive and negative memories of the

deceased• Repeatedly retelling the story of the death• Addressing errors in thoughts- cognitive restructuring• Communication with the deceased exercise• Encourage reduced avoidance behavior• Goal setting• SSRI improved adherence to therapy

Simon, N.

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When are prescriptions indicated?

PublicDomainPictures

• Persistent symptoms• Significant comorbidities• Suicidal ideation or behaviors

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Grief & Bereavement in Special Populations

• Perinatal loss• Grieving children and teens• Parents who have lost a child• Mortality risk in older couples• Provider Grief

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Grayerbaby

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Reji Jacob “Tears”

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MyStuart “Helping Hands in Ashville”

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Bibliography1. Bruinsma, S., et al. Risk Factors for Complicated Grief in Older Adults. Journal of Palliative

Medicine. Vol 18, No. 6, 2015. p 438-444.2. Doka, K. and J. Davidson. Living with Grief. Who We Are, How We Grieve. Hospice

Foundation of America, Philadelphia, 1998.3. Downar, J. et al. The desirability of an ICU Clinician-Led Bereavement Screening and

Support Program for Family members of ICU Descendants. Journal of Critical Care. 29(2014) 311.e9-e16.

4. Hirano, Kummet, Schlenker. Grief and Bereavement. Presented at AAHPM/HPNA 2015 Annual Assembly. Philadelphia, PA.

5. Iglewicz, A., et al. The Removal of the Bereavement Exclusion in the DMS-5: Exploring the Evidence. Curr Psychiatry Rep (2013) 15:413.

6. Kubler-Ross, E. On Death and Dying. MacMillan Publishing Co., Inc. New York, 1969.7. Shear, MK. Complicated Greif. N Eng J Med 372;2 Jan 8 2015. 8. Shear MK, et al. Complicated grief and related bereavement issues for DSM-5. Depression

Anxiety. Feb 2011; 28(2):103-17.9. Wietse A., et al. WHO Guidelines for Management of Acute Stress, PTSD, and

Bereavement: Key Challenges on the Road Ahead.” PLOS Medicine. December 2014, Vol 11, Issue 12.