3b: Death, dying and bereavement

Question 1

What issues result from chronic illness

Answer 1

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

Question 2

Outline the invidual challenges that come with chronic illness

Answer 2

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

Question 3

Outline the self regulatory model

Answer 3

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)

Question 4

What might affect representation of health threat in the self regulatory model

Answer 4

Identiy 
Cause 
Consequence 
Time line 
Cure/control

Question 5

What does the self regulator model propose

Answer 5

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

Question 6

How does physical health affect mental health

Answer 6

People with one LTC are two to three times more likely to develop depression than the rest of the population

Question 7

How does mental health affect physical health

Answer 7

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.

Question 8

What are illness narratvies

Answer 8

The events surrounding chronic illness, positive and negative changes, become part of people’s story

Question 9

Give examples of the impact of illness narratives

Answer 9

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

Question 10

Where do most people die

Answer 10

Hospitals (57%), Home (19%), Care Homes (17%) Hospices/Elsewhere (7%)

Question 11

T/F most people want to die in hospital

Answer 11

F… only 3% say this

Question 12

What are the ethical issues surrounding death and dying

Answer 12

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

Question 13

What is palliative care

Answer 13

Founded on providing terminally ill people with compassionate care

Relieving/managing symptoms (e.g., pain, breathlessness) rather than curing disease

Question 14

What do people find most important when coming to end of life

Answer 14

Higginson et. al

Improve quality of life for the time they had left (57% - 81%)
Only 2% said that extending life was most important

Question 15

What does Gomes et al show

Answer 15

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

Question 16

What does etkind et al show

Answer 16

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

Question 17

GUIDE: What are the 5 reactions to dying KUBLER ROSS STAGE THEORY

Answer 17

Denial
Anger
Bargaining
Depression
Acceptance

Question 18

GUIDE: What happens in denying

Answer 18

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

Question 19

G: What happens in anger

Answer 19

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

Question 20

G: What is bargaining

Answer 20

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”

Question 21

G: What happens during the depression stage

Answer 21

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”

Question 22

G: What happens in accetpance

Answer 22

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

Question 23

How is stages mode important in western colutre

Answer 23

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)

Question 24

G: What are te weakesses of the stage theroy (=5 myths)

Answer 24

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

Question 25

Outline the problem of pathologising associated with the stage teories

Answer 25

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)

Question 26

What does Tedeshi & Calhoun show

Answer 26

Some people positively grow following terminal illness or chronic illness diagnosis

Question 27

What does weinman et al show

Answer 27

Many people report significant and valuable changes from the experience of the illness

Question 28

What is bereavement

Answer 28

“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

Question 29

What is grief

Answer 29

Grief is a normal BPS reaction to loss (e.g., sleep, anger, work)

Question 30

What determines how we grieve

Answer 30

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

Question 31

What do stress theroeis of bereavement show us

Answer 31

Emphasise stress and coping with bereavement as a dynamic process

Involves changes in orientation toward loss or restoration

Question 32

Give examples of orientation towards loss

Answer 32

Preoccupation
Think and yearn for the person lost
Seeking out places as reminders or searching for the person

Question 33

Give examples of oritentation toward restoration

Answer 33

Adjustments to lifestyle
Coping with day-to-day life
Building a new identity
Distracting away from painful thoughts

Question 34

What does the severity of grief depend on

Answer 34

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

Question 35

What % of people adjust by the second year of bereavement

Answer 35

85%

Question 36

What does Bonanno and Kaltamn show

Answer 36

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

Question 37

What is common gried

Answer 37

Cognitive disorganisation
Dysphoria
Health defecits
Disrupted social and occupation functioing

Question 38

What is chronic grief

Answer 38

Chronic grief: people are more severely affected

Can be associated with worsening mental health (e.g., depression, anxiety)

Question 39

When is chronic grief more likely to occur

Answer 39

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)

Question 40

How can chronic gried be treated

Answer 40

1. 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

Question 41

What does strobe and colleagues show abou understading of grief

Answer 41

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