1. The EPEC-O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation. Education in Palliative and End-of-life Care - Oncology The Project EPEC-O TM

2. EPECEPECOOEPECEPECOOO EPECEPECOOEPECEPECOOO Module 4 Loss, Grief, and Bereavement Module 4 Loss, Grief, and Bereavement EPEC - Oncology Education in Palliative and End-of-life Care - Oncology

3. Objectives l Define loss, grief and bereavement l Facilitate creative adaptation to losses l Screen for, assess grief reactions l Manage reactions to loss Anxiety, depression l Follow through with bereaved family l Define loss, grief and bereavement l Facilitate creative adaptation to losses l Screen for, assess grief reactions l Manage reactions to loss Anxiety, depression l Follow through with bereaved family

4. Video

5. Loss, grief… l Patients and family face illness- related losses Sense of future Functional capacities Relationships l Patients and family face illness- related losses Sense of future Functional capacities Relationships

6. … Loss, grief l Reactions to loss as strong l Coping strategies vary HelpfulDestructive l Reactions to loss as strong l Coping strategies vary HelpfulDestructive

7. Patient losses & adaptation... l Losses in all dimensions l Repeated and severe l Adaptation with declining resources l Difficult but possible l Losses in all dimensions l Repeated and severe l Adaptation with declining resources l Difficult but possible

8. ... Patient losses & adaptation... l Understanding, accepting the loss l Disengagement and reflection l Creative adaptation, experimentation l Reintegration l Understanding, accepting the loss l Disengagement and reflection l Creative adaptation, experimentation l Reintegration

9. ... Patient losses & adaptation l Sense of future l Function l Self image l Social role l Relationships l Material matters l Sense of future l Function l Self image l Social role l Relationships l Material matters

10. Roles l Sick role l Caregiver role l Dying role l Bereaved and successor roles l Sick role l Caregiver role l Dying role l Bereaved and successor roles

11. Family losses & adaptation l Replace patient’s lost capacities l Roles and relationships change l Entails losses and adaptations l Patient depends on family adaptation l Replace patient’s lost capacities l Roles and relationships change l Entails losses and adaptations l Patient depends on family adaptation

12. Grief process l A response to loss l Part of the healing process l Multidimensional l A process l Tasks of grieving l A response to loss l Part of the healing process l Multidimensional l A process l Tasks of grieving

13. Normal grief l Physical H ollowness in stomach, tightness in chest, heart palpitations H ollowness in stomach, tightness in chest, heart palpitations l Emotional N umbness, relief, sadness, fear, anger, guilt l Cognitive D isbelief, confusion, inability to concentrate l Physical H ollowness in stomach, tightness in chest, heart palpitations H ollowness in stomach, tightness in chest, heart palpitations l Emotional N umbness, relief, sadness, fear, anger, guilt l Cognitive D isbelief, confusion, inability to concentrate

14. Tasks of grief l Acceptance of the reality l Experience the pain of loss l Adjust l Transfer emotional investments l Acceptance of the reality l Experience the pain of loss l Adjust l Transfer emotional investments Worden JW. Semin Oncol. 1985.

15. Benchmarks of resolution l Talk about without fresh feelings l Invest in new relationships, roles Without disabling guilt Without feeling disloyal l Talk about without fresh feelings l Invest in new relationships, roles Without disabling guilt Without feeling disloyal

16. Types of grief l Masked (suppression) l Delayed (displacement) l Many forms Less emotion may be normal Resilience may be higher than expected l Masked (suppression) l Delayed (displacement) l Many forms Less emotion may be normal Resilience may be higher than expected Worden JW. Semin Oncol. 1985.

17. Assessment of grief l Repeated assessments Anticipated, actual losses Emotional responses Coping strategies Role of religion l Interdisciplinary team assessment, monitoring l Repeated assessments Anticipated, actual losses Emotional responses Coping strategies Role of religion l Interdisciplinary team assessment, monitoring

18. Prognosis for grief l Normal grief 6 mo – several years Child, spouse, parent, other Mode of death Social and cultural context l Depression, complicated grief History of depression, stress Personality l Normal grief 6 mo – several years Child, spouse, parent, other Mode of death Social and cultural context l Depression, complicated grief History of depression, stress Personality

19. Evolution of grief process l Denial l Anger l Bargaining l Depression l Acceptance l Denial l Anger l Bargaining l Depression l Acceptance Kubler-Ross

20. Grief vs. depression  Loss not recognizable  Consistently low mood, early waking  History of depression  Preoccupied with self, self punitive, self- directed anger  Little response to others  Loss recognizable, current  Labile mood, behavior; variable waking  No history of depression  Preoccupied with loss, confusion  Responsive to others Cook AS, Dworkin DS. 1992.

21. Grief management l If reactions, coping strategies appropriate MonitorSupportCounselingRituals l If inappropriate, potentially harmful Rapid, skilled assessment, intervention l If reactions, coping strategies appropriate MonitorSupportCounselingRituals l If inappropriate, potentially harmful Rapid, skilled assessment, intervention

22. Support during grief l Time and presence l Education about grief, adaptation l Affirm normal range of responses l Acknowledge, encourage l Counseling l Time and presence l Education about grief, adaptation l Affirm normal range of responses l Acknowledge, encourage l Counseling

23. Interventions for depression l Antidepressants l Anxiolytics l Psychotherapy Supportive Cognitive behavioral l Combination medication and psychotherapeutic l Consultation if suicidal l Antidepressants l Anxiolytics l Psychotherapy Supportive Cognitive behavioral l Combination medication and psychotherapeutic l Consultation if suicidal

24. EPECEPECOOEPECEPECOOO EPECEPECOOEPECEPECOOO Summary l Illness related losses l Grief and creative adaptation l Grief of bereavement l Depression l Supportive interventions l Consultation for suicidal ideation l Illness related losses l Grief and creative adaptation l Grief of bereavement l Depression l Supportive interventions l Consultation for suicidal ideation