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Elderly man in grief over wife's death after operation

Dr Tanvir Jamil discusses

Dr Tanvir Jamil discusses

Case history

After 60 years of marriage, Jack lost his wife to a pulmonary embolus. She had been admitted for a routine hip replacement but died a week post-op. Ten months later Jack is still angry at the hospital but is now becoming more depressed and withdrawn.

GPs see many patients suffering from loss and bereavement. What is the size of the problem?

There are almost 600,000 deaths a year in the UK which results in about 1.5 million people being affected by this type of bereavement. As a typical GP with a list size of 2,500, you can expect 25 of your patients to die every year – almost two-thirds in hospital.

Bereavement is not really very good for your health is it?

The chances of dying after a bereavement are significantly increased in the first six months for widowers and the first two years for widows. Depending on which paper you read, figures quoted can range from a 10 to 600 per cent increase.

Coronary heart disease and alcoholism are two of the commonest causes. Suicide is more common in the first year after bereavement. Almost 25 per cent of widows and widowers suffer from anxiety and depression in the first year – some resorting to substance abuse.

Many also suffer from insomnia, self-neglect and hypochondriacal syndrome – symptoms mimic those of the deceased, such as chest pain and shortness of breath in pulmonary embolus. Other physical symptoms include fatigue, minor aches and pains, appetite changes, gastrointestinal problems and an increase in minor infections.

What are the phases of a bereavement/grief reaction?

A grief reaction can take more than a year to complete, occasionally two. Each stage can be thought of as a step in the right direction towards recovery. A typical reaction has four stages:

  • Initial shock, numbness and denial: lasts a few hours to days. The bereaved go through a sense of unreality, detachment and disbelief, hoping they might 'wake up from a nightmare'
  • Yearning: can last about one month. Episodes of intense pining and pangs of grief interspersed with anger and guilt. Occasional obsessive desire to search for the lost individual
  • Despair: the permanence of the death is realised leading to pangs of distress and despair. People may suffer from apathy, social withdrawal and poor concentration. There may be a strong sense of the deceased's presence and the bereaved may even hear their voice
  • Recovery: the longest stage, may last years. The reality of the loss is now perceptible. The bereaved can now rebuild their life and resume normal activities. Episodes of pining, distress and guilt still occur, especially during family occasions, Christmas and birthdays

How can we predict an abnormal or pathological grief reaction?

Almost 30 per cent of people bereaved will have an abnormal grief reaction. Expect it in the following situations:

  • Sudden unexpected death
  • Death of a parent when child or adolescent
  • Death due to AIDs, suicide
  • Deaths by murder or manslaughter
  • Where a post mortem and/or inquest is required
  • History of low self esteem and mental illness (especially depression) in the bereaved
  • Multiple previous bereavements
  • Where the relationship was dependent or ambivalent – expect excessive pining in the former and guilt in the latter

So what do I look for in patients with an abnormal grief reaction?

The process of grief may become stuck and not move on for many months or even years from denial or yearning.

Most people will have overcome anger by two months and depression by 12 months. Many relatives are often worried about suppressed grief, where the relative seems to have no reaction at all to the loss.

An apparent lack of reaction to loss often has its roots in culture and religion. Suppressed grief only becomes a problem if it causes other symptoms.

Feelings of guilt are often just transitory, but anything more, especially if accompanied by prolonged pining and searching, should point to an abnormal grief reaction. Most people who experience grief are able to talk about it at some stage in the process – many find it cathartic. If depth of grief is so severe that they cannot bear to talk about their loss then this may also be a pointer to an abnormal reaction. Depression is a normal part of the loss for the first six months and can affect appetite, sleep and concentration.

Watch for bereaved patients whose symptoms do not start to resolve by that time – some patients may even become suicidal.

What's the best way of handling patients like Jack who certainly seems to have an abnormal grief reaction?

  • Ideally all bereaved patients should have at least one visit from a member of the primary health care team (doctor, district nurse or health visitor) with the opportunity to talk further later on
  • Talk openly about the deceased's last illness and go through the facts of what happened if it is appropriate. Looks for signs of anger or guilt. For Jack you might need to explain that his wife's death was unforeseen. But if a medical mistake has been made, talk about it honestly and apologise if you or the practice were at fault
  • Reassure the bereaved that they did everything possible to help their loved one
  • Explain the grieving process, including anger and guilt and even the fact that they might hear the deceased's voice
  • If the grief is more severe or prolonged than normal consider referral to a counsellor
  • Antidepressants are appropriate if the depression has become prolonged and severe. Avoid tranquillisers and advise against drinking too much alcohol
  • Tell the bereaved and their carers about some of the organisations that are able to counsel and help (see above). Support from the clergy can also be particularly useful
  • You may also want to think about pre-empting an abnormal grief reaction by visiting carers of the terminally ill and getting them to talk openly about their feelings to their loved ones. Seeing the body of the deceased also often helps 'closure'

Tanvir Jamil is a GP trainer in Burnham, Buckinghamshire

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