Bereavement

Bereavement or grief may be defined as deep or intense sorrow or distress following loss. 9 Raphael uses the term to connote 'the emotional response to loss: the complex amalgam of painful affects including sadness, anger, helplessness, guilt, despair'. 10

The general practitioner will see grief in all its forms over a wide variety of losses. Although the nature of loss and patient reaction to it varies enormously the principles of management are similar.

Stages of normal bereavement

1. Shock or disbelief. Feelings include numbness and emptiness, searching, anxiety, fear and suicidal ideation, 'I don't believe it'. Concentration is difficult and spontaneous emotions such as crying, screaming or laughing tend to occur. There may be a sense of the deceased's presence, and hallucinations (visual and auditory) may occur.

2. Grief and despair. Feelings include anger, 'Why me?', guilt and self-blame, and yearning. Social withdrawal and memory impairment may occur. The feeling of intense grief usually lasts about 6 weeks and the overall stage of grief and despair for about 6 months, but it can resurface occasionally for a few years. The last few months involve feelings of sadness and helplessness.

3. Adaptation and acceptance. Features of the third stage include significant feelings of apathy and depression. This phase takes a year or more. Physical illness is common and includes problems such as insomnia, asthma, bowel dysfunction, headache and appetite disturbances.

Pathological bereavement

Pathological bereavement can occur and may manifest as intense emotion, particularly anger, and multiple visits with somatic complaints; the patient often gets around to long dissertations about the deceased and the circumstances surrounding death. Extreme anger is likely when the sense of rejection is great as with divorce or sudden death. Guilt can also be intense. 9

Raphael's classification of the patterns of pathological grief and its various resolutions are presented in Table 5.2 . 10

Table 5.2 Patterns and resolution of pathological grief 10

Morbid or pathological patterns

• Absence, inhibition or delay of bereavement

• Distorted bereavement

• Chronic grief (intense anguish continues unabated) Outcome

• Normal resolution, satisfactory adjustment; reintegration in life, satisfying attachments

• General symptomatology (leading to increased care eliciting behaviour)

• Depression, suicidal behaviour

• Other psychiatric disorders (anxiety state, phobia, mania, alcoholism, criminal activity such as shoplifting)

• Altered relationship patterns

• Vulnerability to loss

• Anniversary phenomenon

• Death (more likely in the first 12 months)

The GP as counsellor 1

Important rules to bear in mind:

• The bereaved may be feeling very guilty.

• They may be angry towards their doctor or the medical profession in general.

• They need a clear explanation as to the exact cause and manner of death. Autopsy reports should be obtained and discussed.

• The bereaved tend to view an apparent lack of concern and support as disinterest or guilt. 9

• Early intervention averts pathological grief.

The general practitioner probably had a close relationship with the deceased and the family. The GP will have a special awareness of those at risk and the nature of the relationships within the family. The family is likely to maintain the relationship with the GP, expressing the physical and psychological effects of grief and consulting about intercurrent problems. 9

Working through the stages of grief with patients will allow general practitioners to reach some acceptance of their own emotions, as well as ensure that patients feel supported and cared for, rather than distanced by embarrassment.

Help from religious sources is highly valued as it can meet both spiritual and personal needs. Other resources include funeral directors, hospice (and other) counsellors and support groups such as those for sudden infant death syndrome. 9 At least 30 minutes should be allowed for consultations.

Long-term counselling

Normal bereavement can persist for years. Ongoing counselling is indicated if it continues unabated or psychiatric referral sought if grief is extreme. Regular enquiries during routine consultations or meetings are important if the patient appears to be coping.

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