8) Dying, bereavement and sexual dysfunction

Question 1

Why are there less experiences of death in modern society?

Answer 1

• Fewer deaths at home

- Medicalisation of death

Question 2

Why are death rates falling in England and Wales?

Answer 2

• Improvements in diet
• Medical advances
• Sanitation, housing etc

Question 3

What is the current UK life expectancy at birth (2009-2011) for healthy men and women?

Answer 3

Men - 78.7 years

Women - 82.6 years

Question 4

List the main three general factors that account for the largest diversity between groups, in death.

Answer 4

• Age
• Gender
• Socioecnomic status

Question 5

What are the three main patterns of dying? (according to Clark and Seymour, 1999)

Answer 5

• Gradual death - slow decline in health/ability
• Catastrophic death - sudden/unexpected death
• Premature death - accident or illness in children

Question 6

List the 5 stages of the Grief model suggested by Kübler-Ross in 1969.

Answer 6

• Denial
• Anger
• Bargaining
• Depression
• Acceptance

Question 7

How can the first stage of the Grief model suggested by Kübler-Ross be dealt with clinically?

Answer 7

• Respect that it can be a coping mechanism and that they may desire “not to know”
• Offer written information for the patient to look at with the family
• Check and review so you can deal with it when they are ready.

Question 8

What is grief?

Answer 8

A normal set of psychological and physical reactions to bereavement

Question 9

What is mourning?

Answer 9

A process of adapting to the loss with an important focus often on the role of funeral rituals, going through their things and “saying goodbye”

Question 10

What did Engel (1962) say about the grieving process?

Answer 10

• Disbelief and shock in early stages
• Developing awareness
• Resolution

Question 11

What are some of the symptoms bereavement?

Answer 11

-Physical - shortness of breath, palpitations, fatigue, reduced immune function
-Behavioural - insomnia, irritability, crying, social withdrawal
-Emotional - depression, anxiety, anger, guilt, loneliness
–Cognitive - lack of concentration, memory loss, preoccupation, hopelessness, disturbance of identity, visual/auditory hallucinations

Question 12

What are some of the risk factors for the development of chronic grief from poor bereavement? (Sheldon,1998)

Answer 12

-Prior bereavements
-Mental health
–Type of loss (young person, nature of death, caring status)
–Lack of social support
-Stress from other crises

Question 13

Suggest two factors that can lead to complications in the grieving process.

Answer 13

-Expression of grief discouraged

–Ending of grief discouraged

Question 14

Approximately what percentage of people adjust to bereavement within two years? (Parkes and Weiss 1983)

Answer 14

85%

N.B. 15% therefore experience chronic grief (PTSD, anxiety, depression)

Question 15

How many people expressed a wish to die at home? How many actually did?

Answer 15

Between 56% and 74% people express a preference to die at home , but in 2006, only 35% of people died at home or in a care home

Question 16

What is the Liverpool Care Pathway? What is its aim?

Answer 16

• The Liverpool Care Pathway for the Dying Patient (LCP) is a UK care pathway (excluding Wales) covering palliative care options for patients in the final days or hours of life.
• It has the aim to aid members of a multi-disciplinary team in matters relating to continuing medical treatment, discontinuation of treatment and comfort measures during the last days and hours of a patient’s life.

Question 17

What are the main aims of palliative care?

Answer 17

• Improve quality of life
• Manage emotional and physical symptoms
• Support patients to live productively
• Give patients some control

Question 18

How may a doctor feel when a patient they like dies?

Answer 18

• Failure
• Sadness
• Guilt/anger
• Reminder of mortality or own personal loss

Question 19

Does the doctor have a right to express emotion after the death of the patient? What are the risks of showing emotion?

Answer 19

You can argue either way. If you agree you would say things like it’s a caring, holistic profession (empathy), acknowledging it with relatives, you are only human etc. If you don’t you say what the risks are:

• Burnout
• Different relationship with patient’s family - professionalism issues
• Affect clinical judgements

Question 20

What are sexual dysfunctions?

Answer 20

A disturbance in sexual desire and in the psychophysiological changes that characterise the sexual response cycle and cause marked distress and interpersonal difficulty

Question 21

What are the three components of the sexual response cycle? What has been suggested as the fourth one?

Answer 21

• Desire
• Arousal
• Orgasm

Resolution has been suggested as the fourth one

Question 22

What are the three components required to diagnose a sexual dysfunction according to DSM IV?

Answer 22

1) Disruption in one of phases of the sexual response cycle
2) Marked distress
3) Interpersonal difficulties

Question 23

What is the difference between primary and secondary vaginismus?

Answer 23

Primary vaginismus is here the muscles around the vagina suddenly and painfully contract (tighten) upon penetration. If it is primary this has happened since birth (tampon issues) and secondary (after a life event)

Question 24

How might a sexual dysfunction occur?

Answer 24

• Problems may be lifelong
• Problems may be acquired
• Problems may be generalised or situational.
• Problems may be due to physical and/or psychological difficulties

Question 25

What type of referral pathways are available to patients with sexual dysfunction?

Answer 25

• GUM
• Gynaecology units
• Ante or post natal services
• Family planning services
• Urology
• Psychiatry
• Pelvic pain clinic
• Voluntary sector

Question 26

List the four main factors that can lead to sexual problems.

Answer 26

• Precipitating factors - history
• Predisposing factors - thoughts/past experience
• Perpetuating factors (self) - how you feel
• Perpetuating factors (partner) - how they feel

Question 27

Describe what Masters and Johnson introduced in the 1970s. What was their basic assumption?

Answer 27

Introduced a behavioural approach, focusing on immediate causes in short-term, target directed therapy. With the assumption that attitudes, ignorance and anxiety are responsible for the majority of sexual dysfunctions.

Question 28

What are the main components of psychosexual therapy?

Answer 28

• Educative counselling
• Modification of attitudes/beliefs
• Facilitation of communication/assertiveness
• Specific directions for sexual behaviour (sensate focus, dilator therapy, stop-start)

Question 29

What physical treatments are available for sexual dysfunction in males?

Answer 29

• Oral therapy eg Viagra, Cialis, testosterone, SSRIs
• Local therapy eg EMLA cream
• Self injection therapy
• Mechanical therapy eg pumps, rings
• Surgery eg penile implant

Question 30

What physical treatments are available for sexual dysfunction in females?

Answer 30

• Testosterone
• Lubricants
• Oestrogen
• Clitoral Therapy Device (EROS)
• Zestra gel