3b: Death, dying and bereavement Flashcards
What issues result from chronic illness
Presents challenges to HCP: shifting focus from cure to symptom management
Ethical issues in medicine: How do we decide who gets a transplant and who does not? When should we stop resuscitation
Individual patient: profound changes that can lead to a significant reduction in QoL and wellbeing
Outline the invidual challenges that come with chronic illness
Adjusting to symptoms and disability
Maintaining a reasonable emotional balance
Preserving a satisfactory self-image and sense of competence
Learning about symptoms, treatment procedures and self-management
Sustaining relationships with family and friends
Forming and maintaining relationships with healthcare providers
Preparing for an uncertain future
Outline the self regulatory model
STAGE 1: interpretation (the patient’s attempts to make sense of their perceived symptoms)
STAGE 2: coping (adaptive and maladaptive ways of dealing with the problem in order to regain a sense of balance);
STAGE 3: appraisal (the assessment of how successful, or otherwise that the coping stage has been)
What might affect representation of health threat in the self regulatory model
Identiy Cause Consequence Time line Cure/control
What does the self regulator model propose
The model proposes that illness disrupts normality and the individual is motivated to return to a “normal”, healthy state.
However, for patients who have a terminal illness the ability to return to health is not possible and coping becomes more about the psychological response to the inevitability of death and dying
How does physical health affect mental health
People with one LTC are two to three times more likely to develop depression than the rest of the population
How does mental health affect physical health
Having a M/H problem increases the risk of physical ill health. Co-morbid depression doubles the risk of coronary heart disease in adults and increases the risk of mortality by 50 per cent
People with mental health problems such as schizophrenia or bipolar disorder die, on average, 16–25 years younger than the general population.
What are illness narratvies
The events surrounding chronic illness, positive and negative changes, become part of people’s story
Give examples of the impact of illness narratives
Transform events and construct meaning from the illness
Help people to reconstruct their Hx to incorporate the illness and reconstruct their identity to retain a sense of self-worth in the face of illness
Help people explain and understand their illness
Relate the illness to their values and life priorities
Make illness a collective experience
Where do most people die
Hospitals (57%), Home (19%), Care Homes (17%) Hospices/Elsewhere (7%)
T/F most people want to die in hospital
F… only 3% say this
What are the ethical issues surrounding death and dying
Medicine is rightly focused on how best to “treat disease” and “cheat death”
Just because you “can” doesn’t always mean that you “should” and that’s where decisions sometimes get very complicated
What is palliative care
Founded on providing terminally ill people with compassionate care
Relieving/managing symptoms (e.g., pain, breathlessness) rather than curing disease
What do people find most important when coming to end of life
Higginson et. al
Improve quality of life for the time they had left (57% - 81%)
Only 2% said that extending life was most important
What does Gomes et al show
Examined the difference home palliative care made ti people’s chances of dying at home, also issues for patients towards the end of life, and family distress…
findings….
home palliative care:
-Doubles their chances of dying at home
- Helps to reduce the symptom burden
- Does not increase grief for family/caregivers after death
- Above benefits does not raise cost
Recommendation: Patients who wish to die at home should be offered home palliative care
What does etkind et al show
predict that the need for palliative care is only going to increase over the next 20 years
Recommendation: Health and social care systems must now start to adapt – boosting palliative care
However – only half of the health and wellbeing strategies in England mention end-of-life care, few prioritise it and none cite evidence for effective interventions
GUIDE: What are the 5 reactions to dying KUBLER ROSS STAGE THEORY
Denial Anger Bargaining Depression Acceptance
GUIDE: What happens in denying
The person may think “This isn’t really happening”
May lie about the situation and tell themselves it is temporary and things will return to normal
Used as psychological defence to cushion the impact of the source of grief
G: What happens in anger
The person may think “why me?” or “how could God do this to me?”
The person feels generalised rage at the World for allowing something like this to happen
They feel isolated and furious that this is happening to them
They think it’s unfair and may feel betrayed
Outbursts of anger in unrelated situations
G: What is bargaining
The person thinks “If I do this, I can make it better, I can fix things.“
One may feel guilt and feel it is their responsibility to fix the problems
They make an attempt to strike bargains with God, spouses, HCPs e.g. “I’ll be a good person, if I get another chance”
G: What happens during the depression stage
The person thinks “my heart feels broken” or “this loss is really going to happen and it’s really sad”
At this stage, the person is absorbed in the intense emotional pain that they feel from having their world come apart
They can be overwhelmed with feelings of helplessness and sadness
“Anticipatory grief”
G: What happens in accetpance
The person thinks “this did occur, but I have great memories” or “it is sad but I have so much to live for and so many to love”
The loss is accepted and we work on alternatives to coping with the loss and to minimise the loss
How is stages mode important in western colutre
Linear progression – gives conceptual order to a complex process – degree of predictability & control
desire to “make sense” of the uncertain
Developed when limited literature on death & dying existed
Applied to different situations (including bereavement)
G: What are te weakesses of the stage theroy (=5 myths)
Stages are prescriptive and place patients in a passive role
Do not account for variability in response (e.g., “people deal with things differently”)
Focus on emotional responses and neglect cognitions and behaviour
Fail to consider social, environmental or cultural factors (e.g., a patient in a positive and supportive environment is likely to exhibit very different stages than those who are not)
Pathologise people who do not pass through stages
Outline the problem of pathologising associated with the stage teories
Distress or depression is not inevitable:
- ->Many report valuable changes from experiencing illness
- ->Some even report benefits
“Acceptance” might not be achieved
- ->Reaching a state of resolution may not be possible for some
- ->Complex cognitive and emotional responses may continue to be present (Parkes & Weiss, 1983; Shadish et al., 1981)
“Good” patients vs “Bad” patients (Taylor, 2006)
What does Tedeshi & Calhoun show
Some people positively grow following terminal illness or chronic illness diagnosis
What does weinman et al show
Many people report significant and valuable changes from the experience of the illness
What is bereavement
“Bereavement” refers to the situation of a person who has recently experienced the loss of someone significant in their lives through that person’s death
What is grief
Grief is a normal BPS reaction to loss (e.g., sleep, anger, work)
What determines how we grieve
How we grieve is strongly influenced by cultural customs and norms (differences seen in many cultures)
Range of established theoretical approaches which consider responses to the process of bereavement
What do stress theroeis of bereavement show us
Emphasise stress and coping with bereavement as a dynamic process
Involves changes in orientation toward loss or restoration
Give examples of orientation towards loss
Preoccupation
Think and yearn for the person lost
Seeking out places as reminders or searching for the person
Give examples of oritentation toward restoration
Adjustments to lifestyle
Coping with day-to-day life
Building a new identity
Distracting away from painful thoughts
What does the severity of grief depend on
How attached they were to the deceased person
The circumstances of death and the situation of loss
How much time they had to work through anticipatory mourning
What % of people adjust by the second year of bereavement
85%
What does Bonanno and Kaltamn show
In the first year of bereavement,
- 15-50% experience minimal grief
- 50-85% experience common grief
In second year of bereavement,
- 85% face minimal fried
- 15% face chronic gried
What is common gried
Cognitive disorganisation
Dysphoria
Health defecits
Disrupted social and occupation functioing
What is chronic grief
Chronic grief: people are more severely affected
Can be associated with worsening mental health (e.g., depression, anxiety)
When is chronic grief more likely to occur
The death was sudden or unexpected
The deceased was a child
There was a high level of dependency in the relationship
The bereaved person has a history of psychological problems, poor support and additional stresses (e.g., financial)
How can chronic gried be treated
- Psychological interventions:
- Little effect on mood, grief or physical symptoms
- Some impact in high risk individuals such as those with existing mental health problems (Jordan & Neimeyer, 2003)
Support appears to help bereaved people generally but does not buffer them against the grief
Suggests Bereavement is a process that most people will have to go through
Support or intervention may be a comfort, but is unlikely to “solve” their grief
What does strobe and colleagues show abou understading of grief
Further development of cross-cultural theoretical approaches
Sound empirical testing
More focussed efforts to better understand those who suffer extremely
Continued development of effective psychological interventions to help support those who experience chronic grief
