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Bereavement Interventions: Evidence and Ethics: Margaret M. Eberl, MD, MPH June 16th, 2008
Bereavement Interventions: Evidence and Ethics: Margaret M. Eberl, MD, MPH June 16th, 2008
Overview
Definitions. Types of grief. Risk factors for complicated grief. Interventions: pre and post-bereavement. Review of the Evidence. Ethical considerations. Future directions.
Definitions
Bereavement = the state of loss resulting from death; the time period following a loss.
Grief = the strong, complex emotion that accompanies a loss. Mourning = the process of adaptation; public rituals associated with bereavement.
Bereavement
Broad term that encompasses the entire experience of family members and friends in the anticipation, death and subsequent adjustment to living following the death of a loved one. Internal psychologic processes + adaptation of family members and experiences of griefencompasses changes in external circumstances including alterations in relationships and living arrangements.
Report on Grief and Bereavement Research. Center for the Advancement of Health, 2004.
Grief
Grief is a more specific phenomenon Complex set of cognitive, emotional, and social difficulties that follow the death of a loved one. Individuals vary enormously is the type of grief they experience.
Langston Hughes
POEM I loved my friend. He went away from me. Theres nothing more to say. The poem ends, Soft as it began I loved my friend.
Normal Grief
Somatic distress. Emotional distress. Physical responses. Behavioral changes. Physiologic changes.
1) 2) 3)
4)
Initial numbness, sense of unreality. Waves of distress occur as bereaved suffer intense pining, yearning. Disorganization emerges as loneliness sets in. Re-organization, recovery. Personal growth, creativity.
Features
Avoidance postpones expression
Chronic grief
Traumatic grief Depressive d/o Anxiety d/o Alcohol and SA/dependence PTSD Psychotic d/o
Range of Circumstances
Untimely within life-cycle; sudden, unexpected, traumatic, stigmatized.
Nature of the relationship w/ the Overly dependent, ambivalent. deceased Family and support network Dysfunctional family, isolated, alienated.
Family Grief
Family dysfunction predicts inc rates of psychosocial morbidity in bereaved. Five classes of families (supportive, conflict resolving, hostile, sullen, intermediate). Dysfunctional families carry the bulk of the psychosocial morbidity observed to occur during bereavement. Screening families on admission to PC (FRI).
Bereavement Follow-Up
Expression of condolence; an observing model of follow-up. Generally until shortly after 1st anniversary. For individuals and/or families judged to be at greater risk emphasis is ideally on preventive interventions. Attempts to establish bereavement counseling only after death meet with much avoidance.
Grief Therapies
Most basic is a supportive-expressive intervention (bereaved person shares his/her feelings about the loss), shift in cognitive appraisal of the reality that is forever altered. Formal Interventions: spectrum spans individual, group, and family-oriented therapies, all schools of psychotherapy and pharmacotherapies. Variation influenced by age, perception of support, nature of the death, personal health/co-morbidities of the bereaved.
Measurement in Bereavement
A number of self-report measures of bereavement phenomena are available; reliable, valid instruments. Make it possible to specifically evaluate the process, outcome of both the grief over the loss + supportive services used by PC services to intervene.
Evidence Review:
Eligible studies had to evaluate whether the treatment of bereaved individuals reduced bereavement related sx. Of 74 studies, other than efficacy for pharmacologic tx of bereavement related depression, no consistent pattern of tx benefit among other interventions. No rigorous evidence based recommendation regarding the tx of bereaved persons!
Forte et al, Bereavement care interventions: a systematic review. BMC Palliative Care. 3:3, 2004.
Forte et al, Bereavement care interventions: a systematic review. BMC Palliative Care. 3:3, 2004.
Individ.
Individ. Individ.
Adult
Adult Adult
General health.
Avoidance/intrusion, depression, anxiety, total pathology, stress-intrusion, neurotic sx. Depression, grief, phobic avoidance, hostility/anger/guilt, attitude to self/deceased, avoidance, physical sx, compulsive behavior, social adjustment.
Individ. Group
Ethical Issues
there are norms of propriety that prevent the systematic gathering of data from recently bereaved persons
Ethical Issues
Bereaved people are considered vulnerable. Bereaved are not included in federal regulations for research w/ special populations. Many pervasive assumptions, attitudes. Socially sensitive proposals twice as likely to be rejected (Ceci, Peters, Plotkin, 1985); affects researchers choice of topics (Seiler and Murtha, 1980).
Future Directions
Additional research is needed to determine what constitutes best practice. Forte et al: consensus building conference (set research agenda), focus on interventions to improve key outcomes valued by bereaved individuals, target well-defined patient populations, conduct high-quality RCT research designs, incentivize replication studies, uniform reporting standards. Roswell: PC can identify families at risk and intensify bereavement follow-up through Pastoral Care.
Summary
There is a spectrum of normal grief, very individualized. ~20% at risk for complicated grief; family dysfunction may be predictive. While many interventions available, no consensus as to best practice. Targeting interventions to populations at risk likely to have most benefit. 21st century: ethical bereavement research can be conducted; paradigm shift in attitudes toward research with the bereaved.
References
Cook AS. Ethical Issues in Bereavement Research: an overview. Death Studies. 19: 103-122, 1995. Forte et al. Bereavement Care interventions: a systematic review. BMC Palliative Care. 3:3, 2004. Hynson JL. Research with bereaved parents: a question of how not why. Palliative Medicine, 20: 805-811; 2006. Oxford Textbook of Palliative Medicine, Third Edition. Eds. Doyle D, Hanks G, Cherny N, Calman K. Oxford University Press, 2005. Parkes CM. Guidelines for conducting ethical Bereavement research. Death Studies, 19: 171-181; 1985. Steeves R. Ethical Considerations in Research with bereaved families. Family and Community. 23 (4): 75-83; 2001. Stroebe M. Bereavement Research: methodological issues and ethical concerns. Palliative Medicine. 17: 235-240; 2003. Report on Bereavement and Grief Research. Center for the Advancement of Health. Death Studies. 28: 491-575; 2004.
Thank You!
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