2.3.5 Care of the Dying and the Bereaved

Care of the Dying and the Bereaved

The care of the dying and the bereaved is a critical area of concern in psychiatry. As medical science has advanced, patients with terminal illnesses are living longer, and the need for palliative care has increased. Palliative care is a multidisciplinary approach that aims to improve the quality of life of patients and their families facing life-threatening illnesses, through the prevention and relief of suffering. Psychiatry plays a vital role in palliative care, especially in managing the psychological aspects of pain and distress in the dying and the bereaved.

The psychological needs of patients who are dying or bereaved can be significant. They may experience symptoms such as anxiety, depression, confusion, and delirium. These symptoms can lead to a loss of meaning, social isolation, and spiritual distress. It is important to understand the patient’s unique psychological and spiritual needs to provide appropriate care. In addition, families and caregivers of the dying may experience psychological challenges, such as grief, depression, and anxiety. Providing support to families and caregivers is also a crucial part of palliative care.

Aspects of Care	Clinical Aspects	Psychiatric Aspects	Theoretical Aspects
Palliative Care	A multidisciplinary approach, including pain management and psychosocial interventions	Psychosocial interventions, such as counselling and psychotherapy	Quality of Life Model, which emphasizes the importance of addressing the physical, psychological, social, and spiritual aspects of care
Bereavement Care	Support for families and caregivers through grief counselling and other interventions	Identification and treatment of grief-related disorders, such as complicated grief and major depressive disorder	Attachment Theory, emphasizes the importance of understanding the relationship between the bereaved and the deceased in providing appropriate care

One theoretical framework for understanding palliative care is the Quality of Life Model, which emphasizes the importance of addressing the physical, psychological, social, and spiritual aspects of care. This model recognizes that patients’ needs are unique and complex and require a multidisciplinary approach to care. Psychiatric interventions, such as counselling and psychotherapy, can help patients and their families cope with the emotional and psychological challenges of a terminal illness.

In bereavement care, it is essential to provide support for families and caregivers through grief counselling and other interventions. Grief-related disorders, such as complicated grief and major depressive disorder, can be identified and treated through appropriate psychiatric interventions. Attachment Theory provides a theoretical framework for understanding the relationship between the bereaved and the deceased and can help in providing appropriate care to families and caregivers.

Normal and Abnormal Grief

Bereavement, grief, and reactions to loss can take different forms and last varying lengths of time. Key definitions and concepts include:

• Bereavement: typically refers to the death of someone.
• Grief: encompasses the feelings, thoughts, and behaviours associated with bereavement.
• ‘Normal’ grief reaction: involves symptoms such as disbelief, shock, numbness, anger, guilt, sadness, preoccupation with the deceased, and disturbed sleep or appetite. Typically lasts up to 12 months, with the intensity gradually decreasing.
• ‘Abnormal’ (pathological/morbid/complicated) grief reaction: characterized by intense, prolonged, delayed, absent, or atypical symptoms, including feelings of worthlessness, thoughts of death, excessive guilt, slowed thoughts or movements, an extended period of dysfunction, and hallucinations beyond the image or voice of the deceased.

Prolonged grief disorder:

Prolonged grief disorder (PGD), also known as persistent complex bereavement disorder, complicated grief disorder, and traumatic grief, is a condition characterized by enduring distress and dysfunction following a significant loss. To be diagnosed with PGD, an individual must experience yearning for the deceased, along with at least five of the following nine symptoms daily or to a disabling degree:

• Emotional numbness
• Feeling stunned or that life is meaningless
• Mistrust, bitterness
• Difficulty accepting the loss
• Identity confusion
• Avoidance of the loss’s reality
• Challenges moving on

These symptoms must persist for at least six months after the death and result in functional impairment.

References:

1. Chochinov, H. M., Cann, B. J., & Pereira, J. (Eds.). (2015). Handbook of psychiatry in palliative medicine. Oxford University Press.