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Palliative Medicine (SB) > 13.5 (17.7) Bereavement > Flashcards

13.5 (17.7) Bereavement Flashcards

1
Q

Define the following terms:
1. Bereavement
2. Grief
3. Mourning
4. Anticipatory grief
5. Pathological grief (list 2 variants)(!!!)
6. Disenfranchised grief

A
  1. Bereavement - STATE of loss (usually referring to loss of life)
  2. Grief - RESPONSE associated with loss (emotional, physical, cognitive, behavioral)
  3. Mourning - process of adaptation including cultural and social RITUALS prescribed as accompaniments
  4. Anticipatory grief: precedes the death and results from expectation of that event
  5. Pathological grief: abnormal outcome involving psychological, social, or physical morbidity
    (variants: COMPLICATED grief, PROLONGED grief)
  6. Disenfranchised grief: HIDDEN sorrow of the MARGINALIZED where there is less social permission to express many dimensions of loss
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2
Q

List four types of theory to explain the phenomenon of bereavement*

A

See table 13.5.1 (17.7.1):
1. attachment theory*
(secure/insecure attachment influences impact of loss)
2. psychodynamic theory*
(early relationships lay down template for future relationships)
3. interpersonal model
4. psychosocial transition
5. sociological model*
(cultural influences shape form/content of grief)
6. family systems theory
6.Cognitive stress coping theory
7. traumatic model
8. ethology
9. meaning-centered model
Cognitive behavioural theories*

*4 categories of predominant explanatory models

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3
Q

What are the two orientations described by the dual process model of grief - What is focused on in each state?

Where does active grief work take place?

A

LOSS orientation - a focus on the loss itself

RESTORATION orientation - focus shifts to attending to ongoing life, counter negative emotions with some positive reappraisal/construction of meaning of event

Active experience of grief sits in a dynamic equilibrium with some avoidance of grief. Bereaved adjust balance via emotion-based coping

active grief work occurs when the bereaved are loss oriented (*not mentioned in 6th edition)

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4
Q

List 4 dimensions of grief

A
  1. Emotional
  2. Physical
  3. Cognitive
  4. Behavioural
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5
Q

List four emotional displays of normal grief

A

unavoidable crying
loss of concentration and purpose
preoccupation with thoughts of deceased
sadness
anger
despair
Anxiety
guilt

FS: emotions aspect of MSIGECAP (no suicidal ideation) and BESKIM

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6
Q

List 1 common cognitive manifestation of grief

A

Cognitive processes dominated by MEMORIES (reflected in storytelling, reminiscences, conversations about the deceased)

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7
Q

List four physical manifestations of grief

A

numbness
restlessness
tension
tremors
sleep disturbance
anorexia
weight loss
fatigue
aches and pains

FS: physical aspect of MSIGECAP and BE SKIM (anxiety)

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8
Q

list three behavioural manifestations of normal grief

A

social withdrawal
seeking company and consolation
wandering
searching

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9
Q

Beside loss of life - list four other domains where loss is expected

A

loss of :
work
leisure activities
financial security
independence
sense of certainty about life
further physical impairments
body image change
altered perception of well being
loss of health

FS: health, wealth, independence, work, leisure

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10
Q

List four emotional indicators for risk of complicated grief in a person/family experiencing anticipatory grief

A

intense distress
Anger
denial of the seriousness of the threat
protective avoidance

withdrawal from involvement

FS: DADA
Distress, anger, denial, avoidance

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11
Q

List 2 ways clinicians can help a family experiencing anticipatory grief

A
  1. Encourage them to openly share their feelings
  2. Recognize saying goodbye as a process over time - support opportunities for reminiscence, celebration of life/contribution of dying person, expressions of gratitude, completion of unfinished business

FS: encourage (1) share feelings (2) saying goodbye

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12
Q

Family and friends are gathered around the death bed of a loved one who is dying.

List 4 things you will discuss with them as a physician

A
  1. comment on the process of dying explaining breathing patterns etc
  2. normalize experience empathetically
    reassure family when a concern develops
  3. discuss pain
  4. discuss reasons for medications
  5. skilled prediction of events
  6. ask about and facilitate religious rituals
  7. expression of sympathy

FS
1) signs of dying
2) symptoms (pain)
3) meds
4) rituals
5) empathy

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13
Q

List 3 post-mortem practices that MD can provide to be supportive for family/friends of the deceased (immediately after death)

A
  1. Respecting post-mortem cultural approaches
  2. If relatives not present at time of death, invite to attend based on a deterioration and shares news on arrival
  3. Unless there is a legal requirement for coroner’s postmortem, respect family’s views on autopsy
  4. If concerns about emotional response of bereaved, consult cultural intermediary, support with short acting benzo Rx, follow up phone call next day

FS:
1) share news on arrival of family
2) respect rituals/autopsy views
3) bereavement call

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14
Q

List 4 scenarios in which grief could be marginalized or disenfranchise the bereaved from usual supports

A
  1. Ageism (death is normalized because it appears in step with life cycle & family members given less support)
  2. Suicide
  3. Homicide
  4. Euthanasia
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15
Q

The duration of grief is based on what two major factors

A

strength of attachment to the lost person

cultural expression

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16
Q

What are the four general phases of acute grief

A
  1. initial numbness and sense of unreality
  2. waves of distress begin to occur as the bereaved yearn for lost loved one
  3. phase of disorganization emerges as loneliness resulting from the loss sets in
    (periods of restlessness/inattention/sadness/despair/social withdrawal can last for several months)
  4. phase of reorganization and recovery - altered world view constructed + personal growth

FS:
Numb
Distress
Disorganized
Reorganize

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17
Q

List 3 factors that help to differentiate normal from pathological grief

A
  1. time course
  2. intensity of reaction
  3. presence of range of grief related behaviours

FS: think of DSM

18
Q

List four common psychiatric conditions that accompany grief and are separate entities from complex grief

A
  1. PTSD
  2. EtOH or other substance abuse/dependence
  3. MDD
  4. anxiety disorders
  5. psychotic disorders
19
Q
  1. Name the diagnosis proposed by DMS-5 for complex grief
  2. What are the general diagnostic criteria for this
A
  1. Persistent Complex Bereavement Disorder
  2. a) for at least 12 months (if bereaved adult) otherwise 6 months (if child) following the death, there is:
    b) persistent longing for the deceased
    c) intense sorrow and
    d) preoccupation with the deceased
    e) at least 6/12 symptoms of reactive distress
    d) significant social/occupational impairment
    e) bereavement reaction is out of proportion to cultural/religious/age-approp norms

FS: SLP SOS - ABCDEF (12 months in adults, 6 months in child)

Sorrow (intense)
Longing
Preoccupation

Social/occupational impairment
Out of proportion
Symptoms min 6/12 (ABCDEI): see below

Anger
Blame (self)
Cancelling positive memories of loved ones
Denial
Empty
“Few” Interest

20
Q

Prolonged grief can lead to a range of health problems - list 4

A
  1. cardiac distress
  2. hypertension
  3. increased ETOH and cigarette consumption
  4. suicidal ideation
21
Q

List 5 signs of pathological grief*

A
  1. greater degrees of separation distress
  2. emotional numbing and dissociation
  3. mood symptoms
  4. impaired social functioning
  5. maladaptive coping styles

FS: think of DSM 5 criteria

22
Q

List 2 maladaptive coping strategies seen in pathological grief

A

avoidance or denial*
distortion through excessive anger*
despair
guilt
idealization or somatization
prolongation that culminates in chronicity

FS: think of DSM

23
Q

The husband of a patient who has died does not demonstrate distress after his partner dies. Does this suggest a superficial bond? Is this pathological?

A

does not suggest superficial bond

may indicate normal emotional response to grief (ie numbess) or pathological

(in those with other signs of complicated grief, may require intervention)

24
Q

What is 1 major risk factor for chronic grief

A

Chronic grief - particularly associated with overly dependent relationships (!!!) in which a sense of abandonment is avoided by perpetuation of relationship through memorialization of deceased

25
Q

What causes traumatic grief?

List 2 unique symptoms of traumatic grief

A

Death is UNEXPECTED or SHOCKING (ie traumatic, violent or stigmatized or perceived as undiginified)

Intensive recollections including flashbacks and nightmares***

recurrent intrusive memories** causing hyperarousal, disbelief, insomnia, irritability, disturbed concentration

shock of death can lead to mistrust, anger, detachment, unwillingness to accept reality

FS: denial, anger, flashbacks, intrusive memories - kind of like PTSD?

26
Q

At what point after a death is MDD most likely to develop?

A

Within initial 2 months (per 5th edition)

27
Q

The Family Environment Scale identifies five classes of families to determine if they are at risk for complicated bereavement. What are the five classes of family? At risk families experience what three problems?*

A

See Table 13.5.2:
supportive
conflict resolving
conflictual
uninvolved
low communicating

loss of cohesiveness
communication breakdown
increased conflict

28
Q

List 4 risk factors for pathologic grief (!!!)

A

see table 13.5.3 (17.7.3)

Strengths and vulnerabilities of the bereaved*
-past history of psychiatric disorder (eg depression)
-personality and coping style (intense worrier, low self-esteem)
-cumulative experiences of losses

Nature of the death *
-untimely within the life cycle
-sudden and unexpected
-traumatic
-stigmatized (ie. HIV, suicide)

Nature of the relationship with the deceased*
-overly dependent
-ambivalent (angry, insecure, gambling, infidelity)

Family and support network*
-dysfunctional family (poor cohesiveness)
-isolated (new immigrant)
-alienated (perception of poor support)

29
Q

List 3 health related consequences of bereavement

A

-increased rate of death occurring over the first year in 45-75yr range
-increased cardiovascular events in first six months*
-accidents
-suicide*
-alcohol and substance abuse*
-Cirrhosis

-increased use of health services - consultations/hospitalizations
-increased psych distress, somatic sx
-more days of disability
-greater reliance on meds
-depressive/anxiety disorders, PTSD

30
Q

What are two types of bereavement follow up that can be offered by the treatment team to a bereaved family

A

expression of condolences via telephone, card, or visit by nurse/GP, invitation to periodic commemorative service by palliative care team

for those at risk of complex grief - preventative intervention with bereavement counselling

FS:
1) bereavement call
2) bereavement counseling

31
Q

Who should be offered grief therapies?

A

those at risk of maladaptive outcome should be treated preventatively

those who develop complicated bereavement when they are identified

FS:
1. If risk factors for PCBD are identified (4)
2. If individual presents with PCBD (DSM 5)

32
Q

List 3 therapy models for grief support

A

CBT*
complicated grief treatment*
family focussed grief therapy*

supportive-expressive therapy
interpersonal psychotherapy

33
Q

What are the four major tasks of mourning?

A

accepting the reality of loss

working through pain of grief

adjusting to a new environment without the loved person

establishing a collection of positive and useful memories of the deceased for future reference

FS: AWAKe

Accept
Work
Adjust
Kollect memories

34
Q

List four risk factors for suicide in bereavement

A
  1. Self
    those who abuse EtOH
    current or past hx of MDD
  2. Relationship with deceased
    elderly widowers
  3. Relationship with others
    socially isolated
35
Q

At what age do children start to understand the concept of death and what age do they grasp finality of death

A

5-6 years understand

9-10 years old - finality

36
Q

Personal growth and positive outcomes can be experienced after successful grief and bereavement. List 2 such outcomes

A

renewed sense of meaning
self-awareness
increased empathy*
appreciation of family and relationships*
independence
reprioritized goals and values
deepened spirituality
increased altruism

37
Q

List four bereavement symptoms in children

A

fear
insecurity
Guilt
Sadness
Behavioural problems

FS: FIGS

38
Q

Other than the family environmental scale. What tool can be used to screen families for risk of complicated reactions to stressful events?*

A

Inventory of complicated grief

39
Q

List four types of meds used for bereavement

A

Benzos - anxiety and sleep

antidepressants if bereavement complicated by depression or anxiety/pain attacks

TCAs - insomnia

occasionally antispsychotics for hypomania or other types of psychosis

40
Q

Clinician exploration of spirituality with the patient and family may help address bereavement.*

  1. How might patients/families express their spiritual dimensions or philosophy of life. List 3 ways
  2. How can clinician understanding of this be helpful to the bereaved? List 2 ways
A
  1. religious beliefs, cultural customs, traditions
  2. i) Using the above values to understand the life of the deceased helps appraise their accomplishments, worth, the meaning their life had – achieving consensus with the bereaved about this can assist in their acceptance of the death

ii) Rituals can assist bereaved in mourning. Clinicians can help the bereaved by endorsing its value

Palliative Medicine (SB) (145 decks)

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