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Chad Merritt
Chad Merritt

Grief And Bereavement In The Adult Palliative C...



Findings: In total, 19 randomized controlled trials with an overall sample size of 2,690 participants met the inclusion criteria. The study showed that bereavement support had a significant effect on reducing grief (Hedges' g score = -0.198; 95% confidence interval [CI] -0.310 to -0.087), depression (Hedges' g score = -0.252; 95% CI -0.406 to -0.098), and anxiety (Hedges' g score = -0.153; 95% CI -0.283 to -0.023); however, high heterogeneity was present. No statistically significant difference was shown for traumatic feelings. Based on moderator analysis, a group format was more effective for grief, a combined individual and group format for depression, and an individual format for anxiety. Bereavement support was more effective when delivered by professionals, when delivered in more than six sessions, and need to be evaluated within 6 months.




Grief and Bereavement in the Adult Palliative C...



Clinical relevance: This meta-analysis provides evidence that bereavement support delivered in the palliative care setting is effective for reducing grief, depression, and anxiety. Nurses and other healthcare professionals can make recommendations for adult family caregivers based on this study in reducing psychological symptoms due to a loss in the palliative care domain.


Although grief is a natural process, in which many people adjust with support from their social networks, others require more formal forms of professional support [1, 2]. Bereavement is associated with elevated risks to mental health, morbidity and mortality [2,3,4,5], and services that provide bereavement support can be important for managing these risks [2]. The socio-economic costs of bereavement can also be considerable, affecting all sectors of society [6,7,8]. Bereavement support is an important part of palliative and end of life care, with different levels of provision recommended to meet the varying needs of bereaved individuals [1, 2, 9,10,11]. The public health approach to bereavement care [12, 13] and the UK National Institute for Health and Clinical Excellence (NICE) [10] both propose three tiers of bereavement support, to be made available according to level of need:


However, the research evidence available for these different types of support is limited. Inconclusive results and lack of positive effects are commonly reported in systematic reviews and meta-analyses of bereavement intervention studies [4, 14,15,16], with some indicating that grief interventions may only be effective for those with more severe and complicated grief symptoms [4, 16]. As also noted, however, such findings run counter to the professional experience of many clinicians in the field [15] and are challenged by the positive impacts that have been consistently reported in qualitative and mixed methods evaluations of bereavement interventions [14].


Several of these systematic reviews have identified problems with inconsistent outcome measurement [4, 14, 17,18,19]. A systematic review of the end of life and bereavement experiences of family caregivers identified 89 unique instruments, almost half of which were study specific with no psychometric testing reported [19]. A meta-analysis of the prevention and treatment of complicated grief noted the limitations caused by variation in outcome measures [4]; conclusions also mirrored in systematic reviews of the evidence for bereavement support generally [18], and in cancer and palliative care specifically [14, 17]. Some commentators have also suggested that bereavement intervention studies may fail to find an effect because they are measuring the wrong outcomes, often relying on narrowly defined and simplistic criteria such as psychiatric symptom checklists or global measures of functioning, which are not specific to bereavement [15]. These problems with outcome measurement undermine the potential for study results to be combined and compared, and the kind of robust conclusions on effectiveness that are needed to inform clinical practice and service delivery [14, 17, 18, 20]. Recent national and international programmes of work have focused on developing sets of service standards through consensus building activities with expert stakeholders [10, 21] ( -groups/task-forces/bereavement). By reaching agreement on what constitutes a good service, and commitment amongst service providers to adhere to such standards, improved outcomes for service users should be expected to follow. However, without also identifying what these outcomes should be, the impact of these services on their service users will remain difficult to determine.


Within all three groups there was talk around the need for bereavement services to enable service users to manage and cope with their grief, rather than try to treat it, and related to this a preference for coping rather than grief to be used as an outcome. Key points included:


There are several factors that may explain this apparent departure from the more disease focused outcomes used in previous studies. One reason may be the relatively high number of Randomised Control Trials (RCTs) of grief therapy interventions that were included in the mapping exercises and a possible preference amongst these researchers for pathological outcomes. The majority of participants in our consensus days and Delphi survey were service providers and service users, with researcher participants also representing a diversity of methodological backgrounds. The scope of our COS was not restricted to grief therapy, and instead intended to cover the wide-ranging types of support provided in palliative care settings, to meet the varying needs of service users. The consensus exercises therefore represented the perspectives of a much wider range of stakeholders, than those who design and test grief therapy interventions, further reinforcing the importance of wide-ranging stakeholder participation when developing COS.


Longo M, Scott H, Seddon K, Fitzgibbon J, Morgan F, Pickett S, Byrne A, Sivell S, Harrop E. Consensus and consistency: development of a core outcome set for evaluating bereavement support in palliative care. BMJ Supportive & Palliative Care 2018;8:371.


Harrop E, Scott H, Seddon K, Fitzgibbon J, Morgan F, Pickett S, Byrne A, Sivell S, Longo M. Coping with grief: identifying core outcomes for evaluating bereavement support in palliative care. BMJ Supportive & Palliative Care. 2018; 8(Suppl 2):A5.


Available to EveryoneOur professional bereavement care is free of charge and available to all. Our team of licensed grief counselors includes professionals who can meet with adults as well as a counselor who specializes in child and teen grief. We also have volunteers trained in leading bereavement support groups. A Spanish-language interpreter is available by request. Group counseling is available to organizations for a fee. Donations are always welcome for our grief services, and allow us to support the community.


Bereavement CareWe offer a wide range of services for adults: short-term individual grief counseling, support groups, and grief workshops. Seasonal remembrance events are held in the fall and winter. Dates of services are updated regularly.


For patients and family caregivers the journey through illness and transitions of care is characterized by a series of progressive physical and emotional losses. Grief reactions represent the natural response to those losses. Grief is defined by a constellation of physical, cognitive, emotional and spiritual manifestations, varying in length and severity. While grief reactions are common and expected responses to loss, they have the potential to cause significant suffering. And, while grief is not a disease, it can develop into a pathological process warranting specialized treatment. Additionally, some aspects of grief overlap with the symptoms of clinical depression and anxiety, making diagnosis difficult. Grief and Bereavement in the Adult Palliative Care Setting provides practical, evidence-based, and clinically effective approaches to understanding the multifaceted nature of grief and bereavement in patients with advanced illness and their caregivers. This handbook is an ideal tool for palliative care providers of various disciplines who provide direct clinical services to patients and family members. It assists clinicians in recognizing and identifying grief reactions as unique expressions of patients and caregivers' history and psychological functioning. Primary care physicians who provide care to patients and families will also find this practical assessment and treatment guide helpful. They will learn how to best support bereaved patients and caregivers when grief is uncomplicated, and when to choose more active interventions that may include appropriate referrals to mental health professionals.


"Grief and Bereavement in the Adult Palliative Care Setting provides practical, evidence-based, and clinically effective approaches to understanding the multifaceted nature of grief and bereavement in patients with advanced illness and their caregivers. This handbook is an ideal tool for palliative care providers of various disciplines who provide direct clinical services to patients and family members. It assists clinicians in recognizing and identifying grief reactions as unique expressions of patients and caregivers' history and psychological functioning. Primary care physicians who provide care to patients and families will also find this practical assessment and treatment guide helpful. They will learn how to best support bereaved patients and caregivers when grief is uncomplicated, and when to choose more active interventions that may include appropriate referrals to mental health professionals." - Anticancer Research, August 2013 041b061a72


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