___________________________________________ Palliative Care and Pain Management at the End of Life
Many experts believe that people can handle grief better if they spend time with a loved one immediately after death. Family members should be allowed to touch, hold, and kiss their loved one as they feel comfortable. The healthcare team should respect the needs of the family to conduct personal, cultural, or religious traditions, rites, and rituals. GRIEF, MOURNING, AND BEREAVEMENT Palliative care extends beyond the patient’s death, with the focus shifting to support of the family during bereavement and mourning. Although the terms “grief,” “mourning,” and “bereavement” are often used interchangeably, their definitions are different. Grief is a normal reaction to a loss; mourning is the process by which individuals adjust to the loss; and bereavement is the period of time during which grief and mourning occur [67; 442]. Psychosocial support of the family is essential throughout the duration of palliative care and can help to decrease the risks of morbidity, substance abuse, and mortality that have been found among spouses and other loved ones of patients who have died [6]. Grief Grief comprises a range of feelings, thoughts, and behaviors that fall in the realm of the physical, emotional, and social domains [67]. Individuals may have trouble sleeping, changes in appetite, or other physical symptoms or illness. Emotions can include sadness, anxiety, guilt, and anger. Return to work, activities with friends, and taking care of family can be beneficial. Grief counseling for the family and patient should begin when the patient is alive, with a focus on life meaning and the con- tributions from the patient’s family. An understanding of the mediators of the grief response can help physicians and other members of the healthcare team recognize the family members who may be at increased risk for adapting poorly to the loss [443]. These mediators are: • Nature of attachment (how close and/or dependent the individual was with regard to the patient) • Mode of death (the suddenness of the death) • Historical antecedents (how the individual has handled loss in the past) • Personality variables (factors related to age, gender, abil- ity to express feelings) • Social factors (availability of social support, involve- ment in ethnic and religious groups) • Changes and concurrent stressors (number of other stressors in the individual’s life, coping styles) Prolonged grief disorder was added to the DSM-5-TR in 2022, after several decades of studies that suggested many people were experiencing persistent difficulties associated with bereavement that exceeded expected social, cultural, or religious expecta- tions [378]. It is defined as “intense yearning or longing for the deceased (often with intense sorrow and emotional pain) and preoccupation with thoughts or memories of the deceased. In
children and adolescents, this preoccupation may focus on the circumstances of the death” [378]. In adults, this intense grief must still be present one year after a loss to be considered pro- longed grief disorder; in children, the timeframe is six months. Additionally, the individual with prolonged grief disorder may experience significant distress or problems performing daily activities at home, work, or other important areas [378]. Clinical assessment should be carried out for individuals at risk of prolonged grief. Distinguishing between prolonged grief disorder and major depression can be challenging, as many signs and symptoms are similar. However, the characteristic symptoms of prolonged grief disorder are [378]: • Identity disruption (e.g., feeling as though part of oneself has died) • A marked sense of disbelief about the death • Avoidance of reminders that the person is dead • Intense emotional pain (e.g., anger, bitterness, sorrow) • Difficulty reintegrating (e.g., unable to engage with friends, pursue interests, plan for the future) • Emotional numbness • Feeling that life is meaningless • Intense loneliness and feeling of being detached from others
The British Columbia Medical Services Commission asserts that the relationship between the physician and the patient is one of the most potent therapeutic tools for assisting patients who are dealing with grief. Reassurance about the normal pattern
of grief and a commitment to supporting the patient in an ongoing way is the mainstay of care. It may involve scheduled follow-up visits as necessary. (https://www2.gov.bc.ca/assets/gov/health/practitioner- pro/bc-guidelines/palliative3.pdf. Last accessed October 14, 2024.) Level of Evidence : Expert Opinion/Consensus Statement Mourning Satisfactory adaptation to loss depends on “tasks” of mourn- ing [443]. Previous research referred to “stages” of mourning, but the term “task” is now used because the stages were not clear-cut and were not always followed in the same order. The tasks include: • Accepting the reality of the loss • Experiencing the pain of the loss • Adjusting to the environment in which the deceased is missing (external, internal, and spiritual adjustments) • Finding a way to remember the deceased while moving forward with life
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