The EPEC-O Curriculum is produced by the EPECTM 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

ProjectEPEC-OTM

EEPPEECC

OO Module 4Module 4

Loss, Grief, and Bereavement

EPEC - Oncology Education in Palliative and End-of-life Care - Oncology

Objectives Define loss, grief and bereavementDefine loss, grief and bereavement Facilitate creative adaptation to lossesFacilitate creative adaptation to losses Screen for, assess grief reactionsScreen for, assess grief reactions Manage reactions to lossManage reactions to loss

Anxiety, depressionAnxiety, depression Follow through with bereaved familyFollow through with bereaved family

Video

Loss, grief…

Patients and family face illness-Patients and family face illness-related lossesrelated lossesSense of futureSense of futureFunctional capacitiesFunctional capacitiesRelationshipsRelationships

… Loss, grief

Reactions to loss as strong Reactions to loss as strong Coping strategies varyCoping strategies vary

HelpfulHelpfulDestructiveDestructive

Patient losses & adaptation . . .

Losses in all dimensionsLosses in all dimensions Repeated and severeRepeated and severe Adaptation with declining resourcesAdaptation with declining resources Difficult but possible Difficult but possible

. . . Patient losses & adaptation . . .

Understanding, accepting the lossUnderstanding, accepting the loss Disengagement and reflectionDisengagement and reflection Creative adaptation, experimentationCreative adaptation, experimentation Reintegration Reintegration

. . . Patient losses & adaptation

Sense of futureSense of future FunctionFunction Self imageSelf image Social roleSocial role RelationshipsRelationships Material matters Material matters

Roles

Sick roleSick role Caregiver roleCaregiver role Dying roleDying role Bereaved and successor rolesBereaved and successor roles

Family losses & adaptation

Replace patient’s lost capacitiesReplace patient’s lost capacities Roles and relationships changeRoles and relationships change Entails losses and adaptationsEntails losses and adaptations Patient depends on family adaptationPatient depends on family adaptation

Grief process A response to lossA response to loss Part of the healing processPart of the healing process MultidimensionalMultidimensional A processA process Tasks of grievingTasks of grieving

Normal grief PhysicalPhysical

HHollowness in stomach, tightness in ollowness in stomach, tightness in chest, heart palpitations chest, heart palpitations

EmotionalEmotional

NNumbness, relief, sadness, fear, anger, guiltumbness, relief, sadness, fear, anger, guilt CognitiveCognitive

DDisbelief, confusion, inability to concentrateisbelief, confusion, inability to concentrate

Tasks of grief Acceptance of the realityAcceptance of the reality Experience the pain of lossExperience the pain of loss AdjustAdjust Transfer emotional investmentsTransfer emotional investments

Worden JW. Semin Oncol. 1985.

Benchmarks of resolution

Talk about without fresh feelingsTalk about without fresh feelings Invest in new relationships, rolesInvest in new relationships, roles

Without disabling guiltWithout disabling guiltWithout feeling disloyalWithout feeling disloyal

Types of grief Masked (suppression)Masked (suppression) Delayed (displacement)Delayed (displacement) Many formsMany forms

Less emotion may be normalLess emotion may be normalResilience may be higher than expectedResilience may be higher than expected

Worden JW. Semin Oncol. 1985.

Assessment of grief Repeated assessmentsRepeated assessments

Anticipated, actual lossesAnticipated, actual lossesEmotional responsesEmotional responsesCoping strategiesCoping strategies

Role of religionRole of religion Interdisciplinary team assessment, Interdisciplinary team assessment,

monitoringmonitoring

Prognosis for grief Normal grief 6 mo – several yearsNormal grief 6 mo – several years

Child, spouse, parent, otherChild, spouse, parent, otherMode of deathMode of deathSocial and cultural contextSocial and cultural context

Depression, complicated griefDepression, complicated griefHistory of depression, stressHistory of depression, stressPersonality Personality

Evolution of grief process DenialDenial AngerAnger BargainingBargaining DepressionDepression AcceptanceAcceptance

Kubler-Ross

Grief vs. depression Loss not recognizableLoss not recognizable Consistently low Consistently low

mood, early wakingmood, early waking History of depressionHistory of depression Preoccupied with self, Preoccupied with self,

self punitive, self-self punitive, self-directed angerdirected anger

Little response to Little response to othersothers

Loss recognizable, Loss recognizable, currentcurrent

Labile mood, Labile mood, behavior; variable behavior; variable wakingwaking

No history of No history of depressiondepression

Preoccupied with Preoccupied with loss, confusionloss, confusion

Responsive to othersResponsive to othersCook AS, Dworkin DS. 1992.

Grief management If reactions, coping strategies If reactions, coping strategies

appropriateappropriateMonitorMonitorSupportSupport

CounselingCounselingRitualsRituals

If inappropriate, potentially harmfulIf inappropriate, potentially harmfulRapid, skilled assessment, interventionRapid, skilled assessment, intervention

Support during grief

Time and presenceTime and presence Education about grief, adaptationEducation about grief, adaptation Affirm normal range of responsesAffirm normal range of responses Acknowledge, encourageAcknowledge, encourage CounselingCounseling

Interventions for depression AntidepressantsAntidepressants AnxiolyticsAnxiolytics PsychotherapyPsychotherapy

SupportiveSupportiveCognitive behavioralCognitive behavioral

Combination medication and Combination medication and psychotherapeuticpsychotherapeutic

Consultation if suicidalConsultation if suicidal

EEPPEECC

OO

Summary Illness related lossesIllness related losses Grief and creative adaptationGrief and creative adaptation Grief of bereavementGrief of bereavement DepressionDepression Supportive interventionsSupportive interventions Consultation for suicidal ideationConsultation for suicidal ideation