พญ.รจนพรรณ นันทิทรรภ กลุ่มงานจิตเวช รพ.นครพิงค์ Grief and Bereavement พญ.รจนพรรณ นันทิทรรภ กลุ่มงานจิตเวช รพ.นครพิงค์

Psychological Aspects in Terminal illness-Palliative Care

Continuum of care

Definition Bereavement State of being deprived of something. Doesn’t have to refer to death but usually does.

Grief: the reaction to bereavement. Many dimensions Grief: the reaction to bereavement. Many dimensions. A normal and healthy reaction. Feelings Cognitions (preoccupation, disbelief) Physical sensations Behaviors (sleep, eating disturbances) Social difficulties Increased risk of illness? Spiritual searching

Mourning Process which grief reslove Social expression of postbereavement Accept the reality of the loss : includes funeral process, social validation, sharing of memories, talking about the death, maintaining security and routine. Experience the pain of the loss : permit grief, allow to express feelings, permit respite from grief. Problem occur when grief is hidden by drug use and denial.

Variables that influence Grief Nature of prior attachment/perceived value of loss. Way in which the loss occurred: e.g., shocking, gradual, young. Coping strategies of the bereaved. Social support available. Persons lacking or withdrawing from support may have worse outcomes

Variables that influence Grief - A previous history of psychiatric problems or addictions like alcoholism. - Aged of bereaved

Grief in child and adolescent เด็กเล็กๆมักยังไม่เข้าใจความหมายของการตายว่าเป็นการจากไปอย่างถาวร จนกระทั่งอายุประมาณ9-10ปี จึงเข้าใจว่าความตายเป็น permanent biological process เด็กจะมีปฏิกริยาต่อการตายของพ่อแม่ได้หลายวิธี บางคนอาจนิ่งเงียบและแยกตัว แต่บางคนอาจกรีดร้องหรือเรียกร้องความรักความสนใจ

Grief in child and adolescent ในวัยรุ่น ความคิดหรือความรู้สึกมักใกล้เคียงกับในผู้ใหญ่ แต่เนื่องจากวัยรุ่นเป็นวัยที่ต้องเผชิญกับความเปลี่ยนแปลงและการปรับตัวในหลายๆด้านอยู่แล้ว ควรให้ความช่วยเหลือ โดยรับฟังและให้โอกาสเขาได้ระบายความรู้สึก ในด้านต่างๆ ไม่ว่าจะเป็นความโกรธ ความรู้สึกผิด หรือความเศร้า

Variables that influence Grief SEX: Inconclusive evidence that men do more poorly than women but there are differences in the way grief may be handled.

Variables that influence Grief Past or current experiences with grief. Current other psychological or social problems or crises. Culture, ethnicity & religion.

Personal Meaning of illness Threaten Loss - concrete - symbolic Gain/Relief Challenge Insignificance

Phases of Grief 1.Initial shock, disbelief and denial Period of weeks Common early symptoms: Almost universal: intrusive thoughts of deceased, sadness and yearning; depression-style sleep problems Farily common: feelings of unreality and acting if person still alive; hallucinations More uncommon: feelings of disorganization, guilt, anger Lower functioning

Phases of Grief 2.Acute anguish (weeks, months) : -Intense somatic distress -Thoughts of the deceased preoccupy the survivor -survivors may accuse themselves of having mistreated or neglected the dead

Phases of Grief - Irritation and anger are directed at themselves, the deceased, friends, relatives, doctors - Restlessness, agitation, aimlessness, and lack of motivation - Identification phenomena, the adoption of traits and behaviors of the deceased

Phases of Grief 3.Resolutions ( months , years) : Have grieved Return to work   Resume old roles    Acquire new roles    Reexperience pleasure   Seek companionship and love of others

Stage of Death and Dying Elisabeth Kubler –Ross, 1969

Stage of Death and Dying Shock and Denial — Dazed refuse to believe; "This can't be happening, not to me.“ Denial is usually only a temporary defense for the individual Help: communicate facts to patients, reassure patients that they will not be abandoned

Stage of Death and Dying Anger — "Why me? It's not fair!"; "How can this happen to me?" - anger that may be directed towards physicians and other health care team members. - very difficult to care for due to misplaced feelings of rage and envy

Stage of Death and Dying Bargaining — "I will give my life savings if..." The third stage involves the hope that the individual can somehow postpone or delay death. Usually, the negotiation for an extended life is made with a higher power in exchange for a reformed lifestyle.

Stage of Death and Dying Depression — "I'm so sad, why bother with anything?"; "I'm going to die... What's the point?"; "I miss my loved one, why go on?" Acceptance — "It's going to be okay."; "I can't fight it, I may as well prepare for it." In this last stage, the individual begins to come to terms with her/his mortality or that of a loved one

Duration of grief bereaved is expected to return to work or school in a few weeks to establish equilibrium within a few months capable of pursuing new relationships within 6 months to 1 year.

Anticipatory Grief Grief may begin before the actual death grief reactions are brought on by Slow dying process of loved one through injury, illness, or high-risk activity

Complicated Grief Reactions Although grief is normal and appropriate, like everything else it can become unhealthy. Excessive Distorted Unproductive

Complicated Grief Reactions Preoccupation with yearning for, and searching for the deceased Intrusive images, ideas, recurrent dreams/nightmares Active avoidance of thoughts, communication, or action associated with the loss Interference with daily functioning Persistent symptoms

Complicated Grief Reactions Marked functioning impairment Preoccupation with worthlessness Suicidal ideation Psychotic symptoms Psychomotor retardation

Complicated Grief Reactions 1. Delayed or absent grief. 2. Hypertrophic grief. 3. Chronic grief. 4. Psychiatric disturbances associated with grief. 5. Physical illness associated with grief

Constructive Suggestions for Helpers Understanding Empathy Sincerity Non-judgemental attitude

Management: Basic Issues 1. Begin grief counseling if possible while the patient is still alive.

Grief Counseling Goals To increase the reality of the loss. To help the bereaved deal with both experienced & latent affect. To help the bereaved overcome impediments to readjustment. To encourage the bereaved to make a healthy emotional withdrawal from the deceased & reinvest energy into other relationships

Management: Basic Issues 2. The family is the unit of care. 3. Grief is a normative process and requires much listening and often not a lot of intervention on the part of the counselor.

Management: Basic Issues 4. Allow sufficient time to grieve. Most people resolve to a level of functioning around one year. Some individuals and families will accomplish the tasks of grieving in two years. Advocate for sufficient time off from work for the bereaved especially in the first few weeks of bereavement. Discuss the fact that grief spikes continue for life through events, holidays and .anniversary. reactions

Management: Basic Issues 5. Emphasize the role of the funeral and of memorial service: Encourage families to bring children to these rites. Consider having memorial services in hospitals, agencies and palliative care programs for bereaved families and for staff. 6. Medications, particularly tranquillizers and antidepressants are usually not needed for any sustained period of time

Management: Basic Issues 7. Contact the bereaved at regular intervals. Definitely monitor any families with high risk for grief problems. 8. Identify concurrent problems that may interfere with normal grief

Management: Basic Issues 9. Use resource books that have been written on grief to help the bereaved. 10. Monitor children at school for grief problems manifesting as school problems. 11. Investigate to see what types of bereavement programs exist in your community.

Response to grieving families “ เสียใจด้วยนะคะ ” “ เสียใจด้วยสาหรับการสูญเสียครั้งนี้ ” “ เรารู้สึกเป็นห่วงคุณแม่/คุณพ่อนะคะ ” “ มีอะไรให้ทางเราช่วยเหลือไหมคะ บอกได้เลยนะคะ ” “ ถ้ารู้สึกไม่สบายใจอย่างไร สามารถเล่าให้ฟังได้นะคะ หมอยินดีรับฟัง ”

Response to grieving families “ ช่วงเวลานี้ดูเหมือนเป็นช่วงเวลาที่ยากลำบากของคุณ แต่หมอเชื่อว่าคุณจะผ่านมันไปได้ ... “ เป็นกำลังใจให้นะคะ”

Response to grieving families

Responseto grieving families สิ่งที่ไม่ควรพูด “คุณแม่/ พ่อ อายุยังน้อย ยังสามารถมีลูกได้อีก” “คุณแม่ /พ่อ ยังโชคดีที่ยังเหลือลูกอีกหนึ่งคน” “ลืมมันซะ ทิ้งมันไว้ข้างหลัง ชีวิตยังต้องก้าวเดินต่อไป” “ อย่าไปคิดมากเลย ไม่ว่าวันไหนทุกคนก็ต้องตาย”

Quality End-of-Life care “ To Live Until We Say Good bye”

Quality End-of-Life care “ Good Death” Adequate pain and symptom management Avoiding inappropriate prolongation of dying Achieving a sense of control Relieving burden strengthening relationships with loved one

Psychological Support Hope Caring- pain free physical, psychological, social ,spiritual Sharing – attitude communication experiences environment responsibility

Essential Treatment Recommendation Competence Concern Comfort Communication Children Family cohesion& integration Cheerfulness Consistency&perseverance Equanimity ( calmness of mind+ temper)

p.s. I love you

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