Following up the Bereaved

Key points

• Most bereaved people do not require counselling or specialist support. Be aware that simple reassurance, acknowledgment of their loss, and access to information may be all that is required. 

• Identify those factors contributing to resilience during bereavement.  Resilient people tend to:
  • Make use of their experiences of previous losses
  • Make family and community connections
  • Draw on religious, spiritual, and social resources for comfort and support
  • Be able to make sense of their loss, and accept death.
• Recognise reactions that are commonly seen as part of normal grief, which include:
  • Physical:
    • Hollowness in stomach; tightness in the throat or chest; over-sensitivity to noise; sense of de-personalisation;  breathlessness, dry mouth; muscle weakness, lack of energy
  • Behavioural:
    • Crying, sighing; sleep disturbance; restlessness and over-activity; appetite disturbances; absentmindedness; social withdrawal; dreams of the deceased; avoiding reminders; searching and calling out; visiting places associated with the deceased; carrying reminders
  • Mental:
    • Disbelief; confusion; preoccupation
  • Emotional:
    • Anxiety; fear; sadness; anger; guilt; inadequacy; hurt; relief; loneliness.
• Be aware that bereavement is known to have a significant impact on the health of surviving family members, and is associated with increases in mortality. Issues to consider include:
  • Clinicially significant depression (may occur in 10-20% of bereaved people)
  • Sleep problems and fatigue
  • Worsening memory
  • Alcohol use
  • Changed social circumstances can affecting the bereaved person’s physical activity levels, nutritional status, and self-management of chronic health problems
  • Social isolation and changes in work and other important relationships.
• In the first months of bereavement, mortality appears to be mostly due to accidental and violent deaths including suicide, alcohol related deaths, and an increase in deaths from ischaemic heart disease.
• Although the use of medications and medical services often increases in the bereavement period, the most at risk patients may not seek medical assistance.
• Risk factors in bereavement may include:
  • Situational Risk Factors:
    • Sudden death; death of a child; traumatic death; preventable death; overly prolonged dying; absence of body
  • Individual Risk Factors:
    • Past history of psychiatric illness; previous depression; alcohol or drug abuse, eating disorders; concurrent crises; gender; religious beliefs; low self-esteem
  • Inter-personal risk factors:
    • Centrality of the relationship with the deceased; decreased role diversity; lack of social support; ambivalence; unavailability of social and emotional support from family and friends.
• Be aware of the phenomenon of disenfranchised grief: ie, grief related to a loss that is not, or cannot, be openly acknowledged, publicly mourned, or socially supported.  
  • Situations where this may occur include death from a stigmatising illness eg, HIV AIDS, of a partner from an ex-marital affair, death of a former spouse, or sometimes after death by suicide.

• Consider possible strategies to actively follow up the recently bereaved, such as:
  • The offer of an appointment to talk about what happened with a GP; this may be appreciated, particularly if the GP cared for both deceased and bereaved
  • Flagging bereaved patients for the practice nurse to contact by a phone call with an offer of a check up may be appropriate
  • When a bereaved person attends the clinic, offer to review their overall health status and all active medical conditions.

• It is important to identify bereaved persons who need specialist support. A small proportion may be at risk for prolonged grief disorder (PGD):
  • PGD is defined as a grief response that persists beyond 12 months following the loss
  • Occurs in approximately 5-10% of bereaved individuals
  • Is characterised by unremitting and disabling yearning for the deceased, distress, disengagement and functional impairment
  • Can be distinguished from normal grief, depression and post-traumatic stress disorders

• Symptoms include:
  • Separation distress, such as longing and searching for the deceased, loneliness, preoccupation with thoughts of the deceased
  • Symptoms of traumatic distress, such as feelings of disbelief, mistrust, anger, shock, detachment from others, and experiencing somatic symptoms of the deceased.

• Patients who request help for themselves or a family member should be referred for specialist bereavement support.
• Exacerbation of pre-existing mental health problems can occur. Major depression and post-traumatic stress disorder can occur in bereaved patients, and should be distinguished from complicated bereavement.