Presentation on theme: "Bereavement, Loss and Grief, Survival strategies for primary care"— Presentation transcript:
1Bereavement, Loss and Grief, Survival strategies for primary care Dr Peter NightingaleMacmillan GPGP Rosebank SurgeryClinical Assistant St John’s Hospice
2ObjectivesBy 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.
4Limitations of Empirical Studies Dominance of Widows (young, white and middle class)Age cohort effect. The social norms of the 1970’s may no longer applyEthnicityHigh refusal ratesLack of control groupsLack of reliable measures of griefSelf reporting
5Health WarningI 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.
6Overview Definitions Bereavement Theory Health Professional Perspective
7DefinitionsLossWhen you no longer have something because you don’t know where it is, or it has been taken away from you.GriefEmotional and psychological reaction to lossBereavementReaction to the loss of a loved person by death
8The Gold Standard Framework Communication Ca register/MDT meetings.Co-ordination Key personControl of Symptoms Assessment, treatment and patient centred care.Continuity Handover to out-of-hours/protocol. Information to pts/carers.Continued Learning Practice-based learning/reflection on experiences.Carer Support Practical, emotional, bereavement.Care of the Dying Liverpool Integrated care pathway(48 hours of life).
9Models of Adaptation to loss Traditional ModelsBased on the work of Bowlby, Parkes, Kubler-Ross and Worden. All can be referred to as ‘PHASE MODELS’.New models of GriefThe multidimensional modelDual process modelBiographical models
10Phase ModelsThe number and duration of these phases varies but are remarkably similar and can be summarised as:-NumbnessYearningDespairRecovery
111) NumbnessDisbelief and unreality-feelings of functioning on ‘Automatic Pilot’Can occur even if death expectedUnreality interspersed by bouts of anger and despairSomatic symptoms common
122) Yearning Numbness replaced by ‘pangs of grief’ Pining interspersed with anxiety, tension anger and self-reproachRestless searching, auditory and sensory awareness of deceasedCrying common-deep sighing respirationsSleep disturbance and loss of appetite common
133) Despair Permanence of loss recognised Pangs replaced with despair and apathySocial withdrawal commonPoor concentration and inability to see anything worthwhile in the future common
144) Recovery With great effort identity rebuilt New skills acquired Purpose for living re-establishedSome positive feelings returnEnergy levels returnBUT-pangs of grief at anniversaries, hearing a special song etc can persist for years
15Bereavement Models (Linear) LossShockYearningDisorder and despairAdaptation
16BowlbyFirmly 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:-Anxious attachmentCompulsive self-relianceCompulsive caregiving
18♦ All Social Animals become attached to Attachment Theory(John Bowlby)♦ All Social Animals become attached toeach other.♦ The main function of attachment is toprovide security♦ The function of crying and searchingfollowing separation is to promotereunion♦ The nuclear source of security is theFamily
20Separations from Parents in Childhood predict Insecurityand other Problems Later(Bowlby)
21Secure Attachment♦ ‘Mother’ Sensitively Responsive andProtective only when necessary.♦ Child in ‘Strange Situation’ Some anxietybut easily reassured when mother returns♦ Later Develops autonomy with trust inself and others.
22SECURE PARENTING•Overall Parenting Good1)Childhood Vulnerability Low2)Harmony in Adult Attachments3)Overall Coping Good
23Disorganised/Disoriented Attachment •Family Rejection/Violence, Danger &/or Depression increases the risk that the child will be unhappy.Adult then lacks trust in self & others, may harm self.Bereavement reaction associated with Anxiety/Panic
24Kubler-Ross (1969)Described a five stage model of the grief of terminally ill people derived from her clinical work as a psychiatristIt has often been applied to grief following bereavementDenial and isolationAngerBargainingDepressionAcceptance
25Kubler - Ross Not everyone will progress through all five stages They may not be in the same orderDenial and acceptance can be hard to differentiateDanger of dying patients fears and concerns being dismissed as ‘just a stage they are passing through’Simplistic and risks false assumptions being made and lack of exploration of concerns by caregivers
26Anticipatory GriefAnticipatory Grief is a progression through the stages of grief prior to the lossInvolves all losses from diagnosis to death
27Key Points of Loss Pre-diagnosis Diagnosis Treatment Failure of TreatmentMetastatic DiseaseDisease RecurrenceEnd of active interventions
28Chronic Illness and Loss ControlSelf-esteemSelf-imageRoleWorkIndependenceStigmaAbandonmentIsolationOf FutureThreat of DeathReduced abilityConfidence inprofessionals/ drugs/treatmentsLoss of support
29Worden Refined the phases of grief Drew on Freud’s concept of grief workDrew on Engel’s theory of grief as an illness-i.e. the psychological trauma is analogous to the physiological trauma of severe injuryConceptualised as four overlapping tasks
30Worden’s Tasks of Mourning. Rather than seeing that there are ‘stages’ 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.
31Worden’s Tasks of Mourning Tasks that the bereaved need to accomplish To accept the reality of the lossTo experience the emotional painTo adjust to an environment in which the deceased is missingTo relocate the dead person within one’s life and find ways to remember the dead person
32Problems with Phase Models They tend to be interpreted as linearIf used prescriptively hasty judgements about ‘normality’ can occurResearch (Shuchter and Zisbrook) has suggested grief is individualised and variable.Kubler-Ross’ stage theory was not developed for bereavement and has been misinterpreted
33‘Grief Work’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 ‘clinical lore’, and this work is a necessary part of normal grieving
34Difficulties with Grief Work (Wortman and Silver) Distress and Depression are inevitableDistress varies, and initial high distress groups can follow a chronic grief pattern. Depression is not inevitableThe expectation of RecoveryFor a minority of individuals grief may be prolonged- few studies last longer than 2 years. Klass discusses ‘continuing bonds’
35The multidimensional model The Dual Process Model (DPM) New Models of GriefThe multidimensional modelThe Dual Process Model (DPM)Biographical Models
36The Multidimentional model Le Poidevin working with Parkes at St Christopher’s Hospice developed this modelGrief conceptualised as a process of change along seven dimensions.Importantly this model focuses on what resources a person may have to help them cope
37Dimensions of Loss Susan 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?Family/community What support is available?
38Dual Process ModelThe key concept is oscillation between coping behavioursGrief Work included in Loss OrientationTime needs to be taken off from strong emotions to avoid being overwhelmedBoth expressing and controlling feelings important in this modelThis model remains to be tested but has been shown to be a useful addition
39Bereavement Models (Continual) Grief WorkIntrusion of GriefBreaking bonds/ tiesDenial/ avoidance of changesAttending to life changesDoing new thingsDistraction from griefNew roles / relationshipsEVERYDAYLIFE EXPERIENCELoss OrientatedRestorationOrientated
41Biographical ModelsConvincing 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)
44Emotions of Bereavement DisbeliefAngerAnxietyGuiltSadnessPiningDespairCryingFearUnrealistic Hope
45Care for the Bereaved Respect Dignity Empathy Allow disclosure of concernsAllow expression of griefAllow bereaved to look back over the deathPrimary Care SupportSelf-HelpVoluntary OrganisationsCounselling
4710 Ways to Help Bereaved People Be There-don’t offer solutionsListen in an accepting and non-judgemental wayShow that you are listening and you recognise something of what they are going throughEncourage them to talk about the deceasedTolerate silences
4810 ways to help (cont)Be familiar with your own feelings about loss and griefOffer reassurance about the normality of grief reactionsDo not take anger personallyRecognise that your own feelings may reflect how they feelAccept that you cannot make them feel better (but you are still doing something useful)
49Bereavement CareRelf studied bereavement services in Oxford in 1997 and found a marked reduction in the use of GP services in those supported.What helped was:-Being listened toFeeling understoodTalking to someone outside their social networkInformation about Grief75% found support helpful, but 25% were unsatisfied
51Mixture of Emotions Contentment Relief Fear Guilt Sadness Anger FrustrationWeariness
52Working with trauma and loss Long term exposure can produce:-HelplessnessFear and anxietySense of unfairnessAngerSadnessGuiltCancer phobia
53Hands up if any of you recognise any of these psychological traits in yourselfPerfectionistOverly conscientiousTendency to seek approval-’People Pleasing’Need to control othersGreat sense of responsibilityChronic self-doubtUncomfortable with praiseAbility to delay gratificationRCGP - Bereavement and Grief
54Emotional Response 31% Strong emotional impact to death 23% Very disturbed by death47% Upset when thinking of patient24% NumbGRIEFLonger care time Stronger emotional reactionLonger care time Increased satisfaction
55Top 5 ‘Soul Killers’ Isolation Anger Fear Exhaustion Shame Top 5 ‘Soul Killers’IsolationAngerFearExhaustionShameA difficult palliative care case can provide opportunities for all these!RCGP - Bereavement and Grief
56Potential RisksWe are repeatedly faced with loss and grief, and grief can be cumulativeStaff grieve for patients lost and perceived or actual failure to achieve quality careLack of closureConflict within staff and teamUnresolved grief or recent personal bereavement
57Five ways to survive as a doctor Five ways to survive as a doctorMake sure you do other things other than workCreate your dream work scheduleLearn to say ‘No’- without feeling guiltyIf you need help , ask for itSeek peer supportRCGP - Bereavement and Grief
58Are you burning out?Chronic fatigue - exhaustion, tiredness, a sense of being physically run downAnger at those making demandsSelf-criticism for putting up with the demandsCynicism, negativity, and irritabilityA sense of being besiegedExploding easily at seemingly inconsequential thingsFrequent headaches and gastrointestinal disturbancesWeight loss or gainSleeplessness and depressionShortness of breathSuspiciousnessFeelings of helplessnessIncreased degree of risk taking
59BURNOUT BEATING BEHAVIOUR BURNOUT BEATING BEHAVIOURBelief in yourselfUnconditional Positive Regard For OthersRegular exercise and social contactNever lose sense of humourOutings and HolidaysUnderstand HardinessCommitmentControlChallengeCompetentComposedTime ManagementKeep thank you cards-appraisal can be positive-audits can show how well you are doingCarl Rogers-conscious positivism-most people OKMake sure you do other things apart from workCreate your dream work scheduleLearn to say No without feeling guiltyIf you need help , ask for itSeek peer supportRCGP - Bereavement and Grief
60How 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 don't 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. Don't 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. Don't 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 don't feel guilty. Seek professional help if you have tried these things and still your stress is a problem.
61Slow DanceHave you ever watched kids On a merry-go-round? Or listened to the rain Slapping on the ground? Ever followed a butterfly's erratic flight? Or gazed at the sun into the fading night? You better slow down. Don't dance so fast. Time is short. The music won't 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? You'd better slow down Don't dance so fast. Time is short. The music won't last.
62Ever told your child, We'll do it tomorrow Ever told your child, We'll 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 say,"Hi" You'd better slow down. Don't dance so fast. Time is short. The music won't 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.
63Conclusion Complex and difficult issues- help available from Hospice or Cancer CarePotential strong emotional reactionsPotential satisfaction and reward for staffCoping Strategies
64Specialist local helpCancerCare 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 Persons’ Service supporting families before and after bereavement.Clients can either self refer or be referred by others eg GP’s, Macmillan nurses, Cancer specialist nurses.
65If you ever need hospice help David Barnett –Hospice Chaplain with wealth of experience and adviceChristine TownsonBereavement counsellor