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Bereavement and grief: What every oncologist should know
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A medical student recently approached me to help with a seminar on grief and bereavement.
The first-year medical students had been doing rotations in the oncology clinic and had encountered patients who were dying. The students felt ill equipped to deal with the grief and bereavement issues they were experiencing.
As it turns out, after polling many of my colleagues in various specialties, we attending physicians aren’t all that well equipped to deal with those issues either. Because of the frequency with which oncology practitioners encounter death, grief and bereavement deserve special attention.
The multifaceted demands of a potentially terminal illness such as cancer put everyone involved — patients, families and practitioners — at risk for experiencing grief.
Christine A. Zawistowski
Grief represents the normal psychological reaction to a loss, an intense sorrow or distress, and has been described as a feeling of wanting what you cannot have. Bereavement is grief of loved ones after a death. Prolonged grief disorder — which has commonly been called complicated grief — is a severe and protracted reaction to loss, which manifests as extreme emotional distress and mental or physical impairment.
Theories of grief
Grief and bereavement have been well studied.
An understanding of the various models, combined with appreciation of the uniqueness of every patient and family, can allow a practitioner to have a more refined approach to helping these patients and families.
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Bowlby’s attachment theory: The loss of a loved one may be the most devastating experience a person can endure. Attachment is the intense bond children form early on with their caregivers to receive the care and nourishment they require to survive. A secure bond is stable and consistent, whereas an insecure bond is a less reliable relationship. Insecure attachment styles may be related to difficulties later in life and may contribute to greater difficulty in dealing with loss later in life. Those who have secure attachments may internalize memories of the deceased in a way that allows them to gradually accept the loss of a physical connection with that person.
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Object relations theory: The initial separation between a child and his mother is the foundation of reactions to emotional separations later in life. A constant and reliable early relationship will affect a person’s ability to separate from the lost loved one in an autonomous healthy manner.
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Interpersonal theories of grief: The quality of the relationships of those who experience a loss is significant. The way in which individuals interact with one another becomes a part of how they define themselves, regulate their emotions and develop a sense of appropriate social roles.
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Cognitive-behavioral theories: A loss must be consciously incorporated into the bereaved person’s understanding of the world and his or her place in it. This can be very challenging and may result in maladaptive thoughts, feelings and behaviors that prolong the period of grief.
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Rosenblatt: Although grief is a common human experience, there is no universal way to package all the rituals, thoughts and feelings of coping with it. Health care providers who encounter grief must become familiar with a variety of cultural ways that people have to deal with grief.
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Dual-process model: There is loss-oriented coping in which revisiting the loss and yearning for life with the deceased can bring both positive and negative emotions. The restoration-oriented coping then focuses on adjusting to life without the deceased person. Vacillating between the two processes contributes to the recovery from grief.
Clinical presentations
Anticipatory grief is grief experienced by patients and their families before death.
It often is used to describe the grief that may begin once the patient and family first recognize the terminal prognosis of an illness. It also can be a response to the recognition of major changes that will be coming.
The patient and family may experience fear about the changing roles within the family, as well as the loss of independent functioning. Some families become dysfunctional and conflicted, whereas others become more united and cohesive. Predictors for anticipatory grief include female gender, adult children, difficulty coping and high perceived stress. Some research has shown anticipatory grief to predict worse adjustment to death.
Grief also may be present during the death of the patient, as well as for months or even years after the loss. A strong trusting relationship between the physician and patient–family unit promotes healthy adjustment for the bereaved.
Information about what to expect during the dying process can help alleviate loved ones’ anxieties and provide guidance for the last hours or days of a patient’s life. Emotional expression should be supported, and religious and cultural practices should be respected. After the death, assistance can be provided with guidance regarding funeral arrangements and psychosocial support. Some families find debriefing meetings helpful. Families often appreciate letters of condolence or phone calls to express sympathy for their loss.
Maladaptive responses
It is common to experience sadness and anxiety right after the death of a loved one, but most people recover from these feelings of grief.
Extreme prolonged distress resulting from grief that causes functional impairment is not normal. Some individuals develop somatic symptoms, phobias, separation anxiety and anxiety disorder. Prolonged grief disorder is a state in which a bereaved individual is unable to move on from his grief. Symptoms of this disorder include intense longing for the deceased, a sense of bitterness regarding the loss, rumination about the loss, intense sorrow, social isolation and feelings of meaningless.
This results from the unwillingness or inability to accept the loss and move on in life without that person. This diagnosis cannot be made until 6 months after the loss. Risk factors for this disorder include a history of psychiatric illness, a history of child abuse or neglect, insecure attachment styles, low levels of family cohesion and social support in the community, and the conditions of the death itself (eg, a short time from diagnosis until death, a family’s unwillingness to accept the diagnosis or death from an abrupt event).
Interventions and treatments
Research about how to help grieving individuals has been mostly inconclusive, and such situations often require a tailored approach. If clinical staff has developed a close relationship with the patient’s family before their loss, things such as sympathy cards, condolence calls, funeral attendance and annual commemoration services can help family members cope with their loss.
Psychodynamic treatments revolve around attempts to utilize knowledge of childhood experiences, object relations and unconscious conflicts as the basis to understand a person’s response to grief. This approach works best for those with unresolved issues related to conflict and insecurity in their early relationships.
Interpersonal therapy, a form of psychodynamic treatment, develops an inventory of relationships to determine which common issues contribute to a person’s struggles. The therapist then works with the person to improve communication and problem-solving abilities.
Cognitive-behavioral therapy focuses on isolating and modifying automatic thoughts and counterproductive beliefs that are reinforced by maladaptive and avoidant behaviors. Group therapy is beneficial in that participants can provide informed support for each other because of shared experiences. Members can validate and normalize emotions and behaviors related to coping with loss, as well as share ways they have learned to cope with grief.
Family therapy is brief but focused. Families are screened before the patient’s death. If they have issues with communication, cohesion or conflict resolution, therapy begins and continues after the death of the patient. Internet-based therapy can be effective at reducing distress of bereaved individuals. It is less expensive than other forms of therapy, can be accessed from home and provides a greater sense of anonymity.
Conclusion
It is important for oncologists to understand the normal reaction of grief and be aware of risk factors for more pathologic forms.
No one treatment has been shown to be superior in supporting patients and families making an understanding of various options necessary. Support of bereaved families is part of the continuity of care for oncology patients.
References:
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Medical College of Wisconsin. End of Life/Palliative Education Resource Center. Fast Facts #032: Grief and Bereavement, 2nd Ed. Available at: www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_032.htm. Accessed Nov. 20, 2012.
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Medical College of Wisconsin. End of Life/Palliative Education Resource Center. Fast Facts #138: Grief in Children and Developmental Concepts of Death. Available at: www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_138.htm. Accessed Nov. 20, 2012.
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Medical College of Wisconsin. End of Life/Palliative Education Resource Center. Fast Facts #254: Complicated Grief. Available at: www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_254.htm. Accessed Nov. 20, 2012.
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