This article was reviewed on 11.1.18 by Dr Ravi Ramanathan.
Bereavement will affect most of us at some point in our lives. As GPs we should be aware of what skills are necessary and what resources are available to us to help patients through the grieving process.
It is also important to be able to recognise abnormal grief should this arise. GPs are well placed to help bereaved patients as they may know the family unit and may be aware of the events leading up to the death.
As a GP, you are in a unique position, where you may have been involved with the deceased patients care for a long period of time all the way through to their end of life. You may know the family very well and this is a relationship that can provide invaluable to grieving relatives.
Patients will often remember the end-of-life care that you have provided to their loved one and the subsequent care you may have also provided to family members.
DSM-IV and ICD-10 excluded grief as a psychiatric condition so as to avoid medicalising a normal process.
Stages of bereavement
There are recognised stages to the bereavement process:
- Denial - failure to accept that the loved one has died
- Anger - either directed towards the deceased, medical professionals or a particular faith
- Bargaining - requesting the loved one to return in place of something else
- Depression - monitor for biological symptoms of depression, such as persistently low mood, fatigue, poor concentration, weight loss, suicidal ideation, early morning awakening or excessive sleeping and loss of appetite
- Acceptance - finally accepting that the loved one has died
Bereaved patients will present in a variety of ways.
Psychiatric presentations include anxiety, depression, mania, insomnia, attempted suicide, self harm or self neglect, and alcohol or substance misuse.
There maybe symptoms suggestive of post-traumatic stress disorder (PTSD) if the death was traumatic. If you suspect this, then screen for it by asking about nightmares, flashbacks, ruminations. Other symptoms to look out for include psychotic symptoms such as auditory hallucinations or visual hallucinations.
Patients may also have an exacerbation of a pre-existing mental health problem.
Physical symptoms may include generalised aches and pains, prolonged fatigue and the physiological symptoms of anxiety, such as palpitations, dyspnoea, paraesthesia, sweating, tremor or headaches.
Detailed history taking and awareness of both non-verbal and verbal cues should help you to identify a grief reaction as the cause of any of the symptoms.
An awareness of abnormal grief reactions is vital and should be considered if certain risk factors are identified. Risk factors include a pre-existing mental health problem, social isolation, substance misuse or a history of substance misuse, previous bereavements, bereavement due to a sudden death and the deaths of children.
Abnormal grief may take the form of prolonged grieving and disruption of day-to-day functioning. In addition, a delay in grieving after a death is considered abnormal. Consider pathological grief if the patients symptoms persist for longer than 12 months.
If abnormal grief is suspected, there are a number of options available to help manage the bereavement. For example, a GP could refer the patient for in-house counselling, if available.
Organisations such as Cruse, a national bereavement organisation, can provide additional support. Providing patients with written information about their services may be helpful. See below for contact details.
If a loved one has died at a hospice, then it is likely that bereavement support will be available at the hospice. This may involve bereavement support groups or formal one-to-one bereavement counselling.
Medication may be helpful in certain situations. For example, if the patient has coexisting biological depression and this has been precipitated and perpetuated by the death, then an antidepressant may be required. This has to be considered with caution due to the side effects that antidepressants may cause.
If particular symptoms are a problem, such as insomnia, a very short course of hypnotics with careful counselling may be helpful. If anxiety predominates, then a short course of benzodiazepines may also aid recovery. However, it will be essential to counsel patients about the acute nature of the prescription.
Assuming no contraindications, you may also wish to consider beta blockers such as propranolol to try and control the physical symptoms of anxiety.
Where there is a suspicion that the patient may be a risk to themselves or others, then involvement of the local community mental health team is required. if you are unaware of the social situation, then explore this further to see if you are happy that the risk maybe contained by protective factors such as family members at home or close by.
When referring patients for further intervention or further support, a GP should make decisions on a case-by-case basis.
It is important to explore the possible options with the patient, making sure you have a patient-centred approach to any decisions made. However, if there is an element of risk, you may have to proceed to referral without the input of the patient.
Referral is not always necessary and it may well be that routine follow up is all that is needed. If you know the patient well you may be able to provide all the support necessary and contain any risk that they may be exhibiting.
Grief in children
Grief in children is not always easy to identify, especially in younger infants. However, children do have an awareness of death and it is important for health professionals and family members to be honest when talking to children about the death.
Adolescents may turn to substances or other risky behaviour such involving crime or risky sexual behaviour as a source of comfort and it is important to be vigilant about this.
Hospices may provide support if applicable. If it is felt that the grief has become pathological then child and adolescent mental health services may be required.
As GPs we will often see bereaved patients. We are best placed to be alert to risk factors, the circumstances around the death, recognising abnormal grief and discussing with patients the options available to help them through a difficult time.
If you have become aware of a patient at your surgery that has died, you may wish to consider a phone call to a relative as good continuity of care.
If the death was felt to be related to a condition caused by a genetic problem, then you may have a role in initiating appropriate screening, if this has not already been discussed with the family. e.g familial colorectal carcinoma or presence or BRCA1 or BRCA 2 gene in the family.
- Dr Singh is a GP in Northumberland
These further action points may provide opportunities for further learning on this topic: