Grief and Bereavement Flashcards
1
Q
What is grief?
What is bereavement?
A
- Grief is a natural response to loss of a loved one
- Grief reactions are often painful and impairing with emotional and somatic distress - Bereavement is a stressor that can precipitate or worsen mental disorders
- This can lead into a condition called complicated grief
2
Q
Define the following:
1. Bereavement?
- Grief?
- Complicated grief?
- Mourning?
A
- Situation in which someone who is close dies
- Natural response to bereavement
- Form of acute grief that is usually prolonged, intense, and disabling
- Process of adapting to a loss and integrating grief
3
Q
Hallmark of Grief?
A
intense focus on thoughts and memories of the deceased person, accompanied by sadness and yearning
4
Q
Grief can occur in response to other meaningful (non-bereavement) losses, including what?
2
A
- an interpersonal loss (eg, separation from a loved one through divorce) or
- loss of a pet, job, property, or community
5
Q
Clinical Features
- Symptoms of separation distress? 3
- Symtpoms of trauma/stress reaction? 3
- Clinical Features: Other symtpoms? 3
A
- Symptoms of separation distress
- Yearning for and seeking proximity to the deceased
- Loneliness
- Crying, sadness, and other painful emotions - Symptoms of trauma/stress reaction
- Disbelief and shock
- Numbness
- Impaired attention, concentration, or memory - Other symtpoms
- Difficult to feel connected and withdraw
- Sometimes transiently wish they had died with their loved one or instead of the deceased
- Thoughts and images of the deceased occur frequently and may become hallucinatory
6
Q
Grief course
- Usually limited by what?
- Progress in adapting to loss occurs within __ months, with restoration of ongoing life within ____ months
- Response to a loved one does not end
- Certain kinds of thinking and behavior impede the process of adapting to loss
A
- Usually time-limited
2. 6, 6-12
7
Q
Bereavement
- Requires what?
- Most adapt to loss with what?
- Differs from other what?
A
- Requires people to redefine goals and plans
- support from family and friends
- adverse life events
8
Q
Bereavement: Types of losses? 4
A
Types of loss
- Type of lost relationship
- Sudden lost
- Chronic illness
- Terminal illness
9
Q
Bereavement: Associated Psychopathology?
6
A
- Major depression
- Anxiety disorder
- Posttraumatic stress disorder
- Suicidality
- Other mental disorders
- Complicated grief
10
Q
- Major depression does not preclude the diagnosis what is regarded as what?
- Posttraumatic stress disorder: WHat can this trigger?
A
- DSM V
- regarded as a stressor that can trigger a depressive episode - Can trigger onset and may occur more often in response to bereavement than other traumas or stressors
11
Q
Grief and Bereavement
Management?
5
A
- General approach
- Grief typically does not require treatment
- Grief counseling can be helpful
- Support
- Encourage patients to maintain regular patterns of activity, sleep, exercise, and nutrition
12
Q
Describe the general approach to Grief and Bereavement?
2
A
- Summon families prior to an expected death
2. Call immediate family members
13
Q
Describe the support needed for Grief and Bereavement? 4
A
- Family,
- friends
- clergy
- Clinicians
14
Q
COMPLICATED GRIEF
This disorder has been reviewed by the DSM-5 work groups, who have decided that it be called ________________________ disorder and placed it in the chapter on Conditions for Further Study in the new DSM-5
A
Persistent complex bereavement
15
Q
COMPLICATED GRIEF
1. Clinical settings
Patients with ______________ the incidence is 20%
- Risk factors? 3
A
- mood disorders
- Older age (>61 YO)
- Female sex
- Low socioeconomic status
16
Q
COMPLCIATED GRIEF Pathogenesis
2 categories?
A
- Neurobiology
2. Loss of attachement relationship
17
Q
Describe the components of each category of PP that contributes to COMPLICATED GRIEF:
- Neurobiology? 2
- Loss of attachement relationship? 2
A
- Neurobiology
- Link to area of the brain associated with pain (anterior cingulate cortex)
- Also a link to the reward center of the 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
18
Q
- Clinical Features of Acute grief lasting 6-12 months after the loss? 3
- Complicated grief clinical features? 4
A
- Acute grief lasting 6-12 months after the loss
- Separation distress
- Inhibition exploration of the world
- Traumatic distress - Complicated grief
- Maladaptive rumination about the circumstances of the death
- Intense emotional and/or physical reactions
- Dysfunctional behaviors
- Inadequate regulation of emotions
19
Q
Clinical Features: Grief? 2
Suicidality
- Ideation and behavior occurs in _____ of people?
- Risk? 2
A
Two most common symptoms
- Yearning
- Feeling upset by memories of the deceased
- 40-60%
- Risk
- Greater number of years elapsed since death
- Depression and anxiety
20
Q
Complicated Grief: Adverse consequences? 3
Course? 2
A
- Increase use of alcohol and tobacco
- Poor quality of life
- General medical illnesses and suicide
- Symptoms that last at least one month after 6 months of bereavement who are significantly and functionally impaired
- Patients seek treatment on average 2-4 years after the loss
21
Q
Assessment
for complicated grief?5
A
- H&P
- Mental status exam
- Labs
- Address suicide risk
- Brief Grief Questionnaire
22
Q
Labs: Complicated Grief?
4
A
- CBC
- CMP
- UA
- TSH
23
Q
Diagnostic Criteria for Complicated Grief?
5
A
- Patient has experienced the death of a loved one for at least 6 months
- At least one of the following symptoms has been present
- Persistent, intense yearning or longing for the person who died
- Frequent preoccupying thoughts about the deceased
- Frequent intense feelings of loneliness or that life is empty or meaningless without the person who died
- Recurrent thoughts that it is unfair or unbearable to live without the deceased, or a recurrent urge to find or join the deceased
24
Q
COMPLICATED GRIEF dx criteria continued: At least two of the following symptoms must be present:
6
A
At least 2 of the following have also been present
- Frequent troubling rumination about the circumstances or consequences of the death
- Recurrent disbelief or inability to accept the death
- Persistently feeling shocked, stunned, dazed, or numb since the death
- Anger or bitterness about the death
- Intense emotional or physiologic reactions (eg, insomnia) to reminders of the loss
- Marked change in behavior, characterized by either of the following or both:
- Avoiding people, places, or situations that remind one of the loss
- Wanting to see, touch, hear, or smell things to feel close to the persons who died
25
Q
Management goals of complicated grief?
6
A
- 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 the possibility for happiness
- Engagement in satisfying activities and relationships
26
Q
Management
- Monitoring how?
- First line?
- Second line?
A
- Monitoring
- Every 1-4 weeks in outpatient setting - First-line
- CBT - Second-line
- Those who do not respond to an entire course of CBT specific for complicated grief should be re-evaluated to determine the diagnosis
27
Q
Definition of death?
A
Absolute cessation of vital functions
28
Q
Absolute cessation of vital functions
3 specific descriptions that are included in this?
A
- Irretrievable cessation of circulatory and respiratory functions or…
- Irretrievable cessation of all functions of the entire brain, including the brainstem
- “pulseless and apneic”
29
Q
SIGNS OF DEATH
7
A
- Cessation of breathing
- Cardiac arrest
- Palor mortis
- Livor mortis
- Algo mortis
- Rigor mortis
- Decomposition
30
Q
- Terminal State is what?
- Life expectancy estimated to be what?
- Clinicians usually slightly ___________ survival
- May estimate __ weeks when ___weeks more likely
A
- Patient has a disease that is felt to be fatal
- less than 6 months
(Inexact science and patients may live longer than 6 months) - overestimate
- 6 weeks, 4 weeks
31
Q
Physiologic Changes While Dying
4
A
- INCREASING WEAKNESS, FATIGUE
- DECREASING APPETITE / FOOD INTAKE
- DECREASING BLOOD PERFUSION
- NEUROLOGIC DYSFUNCTION
32
Q
Describe what symptoms the following cause:
1. INCREASING WEAKNESS, FATIGUE? 2
- DECREASING APPETITE / FOOD INTAKE? 2
- DECREASING BLOOD PERFUSION? 3
- NEUROLOGIC DYSFUNCTION? 3
A
- INCREASING WEAKNESS, FATIGUE
- Decreased ability to move – joint position fatigue
- Increased risk of pressure ulcers and increased need for care - DECREASING APPETITE / FOOD INTAKE
- May have a fear of giving in and starving
- Food may be nauseating and might be aspirated - DECREASING BLOOD PERFUSION
- Tachycardia, hypotension
- Peripheral cooling, cyanosis, mottling of skin
- Diminished urine output - NEUROLOGIC DYSFUNCTION
- Decreasing level of consciousness
- Terminal delirium
- Changes in respiration
33
Q
Signs That Suggest Active Dying
5
A
- No intake of water or food
- Sunken cheeks, relaxation of facial muscles
- Respiratory mandibular movement
- Dramatic skin color changes
- Rattles in chest
34
Q
In the Last 48 Hours, what happens? 5
A
- Orderly loss of the senses and desires
- Noisy, moist breathing
- Urinary incontinence/retention
- Pain and dyspnea
- Restlessness and agitation
35
Q
Advance Care Directives
1. Affords patients the opportunity to exercise their right to make determinations regarding their what?
- Provides patients opportunity to do what?
A
- medical care in the event they become incapable
2. determine goals
36
Q
- Hospice care focuses on what?
- Staff on call - ?
- What kind of approach?
A
- Focuses on caring, not curing
- Staff on-call 24/7
- Team approach
37
Q
Services provided by hospice?
3
A
- Manages patient’s pain and symptoms
- Assists the patient with the emotional and psychological and spiritual aspects of dying
- Provides needed drugs, medical supplies, and equipment
38
Q
Guidelines for the Family
4
A
- Be aware of the signs of increasing pain
- -Notify staff if patient seems restless, grimacing, moaning, tense - Patients close to death do not feel hungry or thirsty
- Do not force food or fluids
- Touch and massage them - Breathing may become noisy and congested
- Suctioning does not help - Hearing is one of the last senses to go
- Be sure to talk to the dying patient even if comatose
- Tell them who is there
- Assume they hear everything
- Let them know it is okay to go
39
Q
Describe the attitudes towards death at the following ages:
- Under 5 years of age?
- 5 - 10 years of age?
- After 9 - 10 years of age?
- Adolescents?
A
- Awareness of death only in the sense of a separation similar to sleep
- Developing sense of inevitable human mortality and often fear that parents will die and that they will be abandoned
- Realize that death can happen to them and by puberty recognize death as universal, irreversible, and inevitable
- Understand that death is inevitable and final
- Broad range of emotions that mirror teenage angsts:
- Loss of control, being imperfect, being different
40
Q
Attitudes Towards Death
Adults?
4
A
- Often readily accept that their time has come
- May talk or joke openly about dying and sometimes welcome it
- The older one gets… the more he/she no longer harbors illusions of indestructibility
- May either have a sense of integrity or despair (reflect on their time and how it was lived)
41
Q
Conveying Bad News
3 steps
A
- Prepare
- Be calm and clear
- Arrange follow-up – insure ongoing support
42
Q
Stages of Grief
5
A
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
43
Q
Describe the following stages of grief:
- Denial? 2
- Anger? 3
- Bargaining? 2
- Depression? 4
- Acceptance? 3
A
- Normal reaction to rationalize overwhelming emotions
- It’s a defense mechanism that buffers the immediate shock
- As denial fades, reality and its pain re-emerge
- Intense emotion is deflected from our vulnerable core, redirected and expressed as anger
- Rationally we know the person is not to blame, emotionally we resent the person causing pain or leaving
- Normal reaction to feelings of helplessness and vulnerability to regain control
- Secretly make a deal with God or higher power to postpone the inevitable
- Depression
- 2 types
- A reaction to practical implications relating to the 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 - Not everyone reaches this stage
- Marked by withdrawal and calm
- Means we are ready to move on
44
Q
Traditionally, grief lasts about how long?, subsides over time, and resolves
A
6 months to 1 year
