Following up the bereaved

The GP role

Where others in the family come to your practice, ask how they are going. Simple reassurance can be helpful, and it can also help identify any grief concerns they may have.

Key points

• Most bereaved people do not require counselling or specialist support. Be aware that simple reassurance, acknowledgment of their loss, and access to information may be all that is required.
• Identify those factors contributing to resilience during bereavement. Resilient people tend to:
  • Make use of their experiences of previous losses
  • Make family and community connections
  • Draw on religious, spiritual, and social resources for comfort and support
  • Be able to make sense of their loss, and accept death.
• Recognise reactions that are commonly seen as part of normal grief, which; include:
  • Physical:
    • Hollowness in stomach; tightness in the throat or chest; over-sensitivity to noise; sense of de-personalisation;  breathlessness, dry mouth; muscle weakness, lack of energy
  • Behavioural:
    • Crying, sighing; sleep disturbance; restlessness and over-activity; appetite disturbances; absentmindedness; social withdrawal; dreams of the deceased; avoiding reminders; searching and calling out; visiting places associated with the deceased; carrying reminders
  • Mental:
    • Disbelief; confusion; preoccupation
  • Emotional:
  • Anxiety; fear; sadness; anger; guilt; inadequacy; hurt; relief; loneliness.
• Be aware that bereavement is known to have a significant impact on the health of surviving family members, and is associated with increases in mortality. Issues to consider include:
  
• Clinically significant depression (may occur in 10-20% of bereaved people)
• Sleep problems and fatigue
• Worsening memory
• Alcohol use
• Changed social circumstances can affecting the bereaved person’s physical activity levels, nutritional status, and self-management of chronic health problems
• Social isolation and changes in work and other important relationships.
• In the first months of bereavement, mortality appears to be mostly due to accidental and violent deaths including suicide, alcohol related deaths, and an increase in deaths from ischaemic heart disease.
• Although the use of medications and medical services often increases in the bereavement period, the most at risk patients may not seek medical assistance.
• Risk factors in bereavement may include:
• Situational Risk Factors:
• Sudden death; death of a child; traumatic death; preventable death; overly prolonged dying; absence of body.
• Individual Risk Factors:
• Past history of psychiatric illness; previous depression; alcohol or drug abuse, eating disorders; concurrent crises; gender; religious beliefs; low self-esteem.
• Inter-personal risk factors:
• Centrality of the relationship with the deceased; decreased role diversity; lack of social support; ambivalence; unavailability of social and emotional support from family and friends.
• Be aware of the phenomenon of disenfranchised grief: i.e. grief related to a loss that is not, or cannot, be openly acknowledged, publicly mourned, or socially supported.
• Situations where this may occur include death from a stigmatising illness e.g. HIV AIDS, of a partner from an ex-marital affair, death of a former spouse, or sometimes after death by suicide.
• Consider possible strategies to actively follow up the recently bereaved, such as:
• The offer of an appointment to talk about what happened with a GP; this may be appreciated, particularly if the GP cared for both deceased and bereaved
• Flagging bereaved patients for the practice nurse to contact by a phone call with an offer of a check up may be appropriate
• When a bereaved person attends the clinic, offer to review their overall health status and all active medical conditions.
• It is important to identify bereaved persons who need specialist support. A small proportion may be at risk for prolonged grief disorder (PGD):
• PGD is defined as a grief response that persists beyond 12 months following the loss
• Occurs in approximately 5-10% of bereaved individuals
• Is characterised by unremitting and disabling yearning for the deceased, distress, disengagement and functional impairment
• Can be distinguished from normal grief, depression and post-traumatic stress disorders
• Symptoms include:
  • Separation distress, such as longing and searching for the deceased, loneliness, preoccupation with thoughts of the deceased
  • Symptoms of traumatic distress, such as feelings of disbelief, mistrust, anger, shock, detachment from others, and experiencing somatic symptoms of the deceased.
• Patients who request help for themselves or a family member should be referred for specialist bereavement support.
• Exacerbation of pre-existing mental health problems can occur. Major depression and post-traumatic stress disorder can occur in bereaved patients, and should be distinguished from complicated bereavement.