Death and Grief

Question 1

What is grief?

Answer 1

• natural response to loss of a loved one

- grief rxns are often painful and impairing with emotional and somatic distress

Question 2

What is bereavement?

Answer 2

situation in which someone who is close dies - stressor that can precipitate or worsen mental disorders
- this can lead to complicated grief

Question 3

What is complicated grief?

Answer 3

• forms of acute grief that is usually prolonged, intense, and disabling

Question 4

What is mourning?

Answer 4

• process of adapting to a loss and integrating grief

Question 5

Main features of grief?

Answer 5

• hallmark is intense focus on thoughts and memories of deceased person, accompanied by sadness and yearning
• can occur in response to other meaninguful losses, like separation from a loved one through divorce, or loss of pet, job, property, or community
• sxs of separation distress: yearning for and seeking proximity to deceased, loneliness, crying, sadness and other painful emotions
• sxs of trauma/stress rxn:
  disbelief and shock
  numbness
  impaired attention, concentration or memory
• difficult to feel connected and withdrawn, sometimes transiently wish they had died with their loved one or instead of deceased (assess for suicide risk)
• thoughts and images of deceased occur frequently and may become hallucinatory

Question 6

Course of grief?

Answer 6

• usually time limited
• progress in adapting to loss occurs w/in 6 months, with restoration of ongoing life w/in 6-12 months
• response to loved one doesn’t end
• certain kinds of thinking and behavior impede the process of adapting to loss - only if….

Question 7

What does bereavement require? Types of loss?

Answer 7

• requires people to redefine goals and plans
• most adapt to loss with support from family and friends
• differs from other adverse life events

types of loss:

• type of lost relationship - if a child was lost - parent feels like failure, guilty
• sudden lost: homicide/suicide, higher rate of depression, PTSD, substance abuse
• chronic illness: can adapt, know that it is coming
• terminal illness: have hospice care to help with grieving

Question 8

Assoc psychopathology of bereavement?

Answer 8

• major depression:
  DSM V: doesn’t preclude the dx, but is regarded as stressor that can trigger a depressive episode
• anxiety disorder
• PTSD: can trigger onset and may occur more often in response to bereavement than other traumas or stressors
• suicidality
• other mental disorders: sleep disorders, mania, substance abuse, eating disorders
• complicated grief

Question 9

Management of grief and bereavement?

Answer 9

• general approach: summon families prior to expected death, call immediate family members
• grief typically doesn’t reqr tx
• grief counseling can be helpful
• support: family, friends, clergy, clinicians
• encourage pts to maintain regular patterns activity: sleep, exercise and nutrition

Question 10

Epidemiology of complicated grief (persistent complex bereavement disorder)? RFs?

Answer 10

• 5-7% of general pop
• clinical settings: pts with mood disorders the incidence is 20%
• RFs: older age (older than 61), femal sex, low socioeconomic status

Question 11

Pathogenesis of complicated grief?

Answer 11

• neurobio:
  link to area of brain assoc with pain (anterior cingulate cortex)
• also link to reward center of brain (nucleus accumbens)
• loss of attachment relationship:
  attachment system motivates people to form close relationships
  loss of this type of relationship entails intense activation of emotions

Question 12

Clinical features of complicated grief?

Answer 12

• acute grief lasting 6-12 months after the loss:
  separation distress
  inhibition exploration of the world, traumatic distress
• complicated grief:
  maladaptive rumination about circumstances of death
  intense emotional and/or physical rxns
  dysfxnl behaviors
  inadequate regulation of emotions
• 2 of the most common sxs:
  yearning (diff from MDD)
  feeling upset by memories of deceased (inability to accept death)
• suicidality: ideation and behavior occurs in 40-60% of people, risk: greater number of years elapsed since death, depression and anxiety

Question 13

Asverse consequences of complicated grief?

Answer 13

• increase use of alcohol and tobacco
• poor quality of life
• general medical illness and suicide

Question 14

Course of complicated grief?

Answer 14

• sxs that last at least one month after 6 months of bereavement who are significantly and functionally impaired
  pts seek tx on avg 2-4 yrs after loss

Question 15

Assessment of complicated grieving pt?

Answer 15

• H&P
• MSE
• labs:
  CBC, CMP, UA, TSH
• address suicide risk
• brief grief questionnaire

Question 16

Dx criteria for complicated grief?

Answer 16

• pt has experienced death of loved one for at least 6 months

at least one of following sxs has been present:

• persistent, intense yearning or longing for person who died
• frequent preoccupying thoughts about the deceased
• frequent intense feelings of loneliness or that life is empty or meaningless w/o person who died
• recurrent thoughts that it is unfair or unbearable to live w/o deceased, or a recurrent urge to find or join the deceased

at least 2 of the following have to also be present:

• freq troubling rumination about circumstance of death
• recurrent disbelief or inability to accept death
• persistently feeling shocked, stunned, dazed, or numb since death
• anger or bitterness about the death
• intense emotional or physiological rxns (insomnia) to reminders of loss
• marekd change in behavior, characterized by eithe of the following or both: avoiding people, places, or situations that remind one of loss, wanting to see, touch, hear, or smell things to feel close to the persons who died

Question 17

Manigement goals of complicated grief?

Answer 17

• relief of:
  ruminations, excessive proximity seeking, excessive avoidance behavior
• improve emotion regulation
• accepting finality
• a feeling of enduring connection to the deceased
• ability to envision life with possibilty for happiness
• engagement in satisfying activities and relationships
• monitor: q 1-4 weeks in outpt setting
• first line: CBT
  2nd line: should be reevaluated to determine dx if they didn’t respond to CBT

Question 18

Definition of death?

Answer 18

• absolute cessation of vital fxns:
  irretrievable cessation of circulatory and respiratory fxns
• irretrievable cessation of all fxns of the entire brain, including brainstem
• pulseless and apneic

Question 19

Signs of death?

Answer 19

• cessation of breathing
• cardiac arrest
• palor mortis
• livor mortis
• algo mortis
• rigor mortis
• decomposition

Question 20

What is the terminal state?

Answer 20

• pt has disease that is felt to be fatal
• life expectancy est to be less than 6 months
• clinicians usually slightly overestimate survival - may estimate 6 wks when 4 wks more likely

Question 21

Physiologic changes while dying?

Answer 21

• increasing weakness, fatigue: decreased ability to move - jt position fatigue, increased risk of pressure ulcers and increased need for care
• decreasing appetite/food intake: may have fear of giving in and starving, food may be nauseating and might be aspirated
• decreased blood perfusion: tachycardia, hypotension, peripheral cooling, cyanosis, mottling of skin, diminished urine output
• neuro dysfxn:
  decreasing level of consciousness, terminal delirium, changes in respiration

Question 22

Signs that suggest active dying?

Answer 22

• no intake of water or food
• sunken cheeks, relaxation of facial muscles
• respiratory mandibular movement
• dramatic skin color changes
• rattles in chest

Question 23

What occurs in the last 48 hrs b/f death?

Answer 23

• orderly loss of senses and desires
• noisy, moist breathing
• urinary incontinence, retention
• pain and dyspnea
• restlessness and agitation

Question 24

Why are advance care directives recommended?

Answer 24

• affords pts the opportunity to exercise their right to make determinations regarding their medical care in the event they become incapable
• provides pts opportunity to determine goals

Question 25

What is hospice care?

Answer 25

• focuses on caring, not curing
• services are available to pts of any age, religion, race or illness
• staff on call 24/7
• team approach
• services provided:
  manage pts pain and sxs,
  assist pt with emotional and psychological and spiritual aspects of dying, provides needed drugs, medical supplies, and equipment

Question 26

Guidelines for family with pt in hospice care?

Answer 26

• be aware fo signs of increasing pain - notify staff if pt restless, grimacing, moaning, tense
• pts close to death don’t feel hungry or thirsty: don’t force food or fluids, touch and massage them
• breathing may become nosiy and congested - sunctioning doesn’t help
• hearing is one of the last senses to go: be sure to talk to dying pt even if comatose, tell them who is there, assume they hear everything, let them know it is ok to go

Question 27

Diff age groups attitudes towards death?

Answer 27

• under 5: awareness of death only in sense of separation similar to sleep
• 5-10: developing sense of inevitable human mortality and often fear that parents will die and that they wll be abandoned
• after 9-10: realize that death can happen to them, and by puberty recognize death as universal, irreversible, and inevitable
  adolecents: understand that death is inevitable and final, broad ranges of emotions that mirror teen angsts - loss of control, being imperfect, and being different
• adults: often readily accept that their time has come, may talk or joke openly about dying, sometimes welcoming it, may either have sense of integrity or despair (reflect on their time and how it was lived)

Question 28

process of conveying bad news to loved ones?-

Answer 28

• prepare, make sure you know what you are going to say, have right facial expression
• be calm and clear
• arrange f/u, insure ongoing support

Question 29

What are the 5 stages of grief?

Answer 29

• denial
• anger
• bargaining
• depression
• acceptance

Question 30

Stages of grief - denial?

Answer 30

• normal rxn to rationalize overwhelming emotions

- it’s a defense mechanism that buffers the immediate shock

Question 31

Stages of grief - anger?

Answer 31

• as denial fades, reality and its pain re-emerges
• intense emotion is deflected from our vulnerable core, redirected, and expressed as anger
• rationally we know the person isn’t to blame, emotionally we resent the person causing pain causing pain or leaving

Question 32

Stages of grief - bargaining?

Answer 32

• normal rxn to feelings of helplessness and vulnerability to regain control
• secretly make a deal with God or higher power to postpone the inevitable-
  if only….

Question 33

stages of grief - depression?

Answer 33

• 2 types:
  a rxn to practical implications relating to loss, a quiet preparation to separate and to bid our loved one farewell
• feel like we don’t care about much of anything and wish life would just hurry up and pass on by

Question 34

Stages of grief - acceptance?

Answer 34

• not everyone reaches this stage (may take years)
• marked by withdrawal and calm
• means we are ready to move on

Question 35

Traditionally how long does grief last?

Answer 35

• 6 months to 1 yr, subsides over time and resolves

Question 36

What do you have to differentiate a normal grieving person from?

Answer 36

• from a person who has major depressive disorder