In the first of a two-part series, Susan Delaney, Irish Hospice Foundation, offers some advice to GPs on how to deal sensitively with bereaved patients and help them through their loss
Approximately 30,000 people die each year in Ireland. It is estimated that each death impacts ten people, suggesting that there are about 300,000 newly bereaved people in Ireland each year. Stroebe et al. (2007), reporting on the health outcomes of bereavement, concluded that: “Although grief is not a disease…bereavement is associated with excess risk of mortality. It is related to decrements in physical health, indicated by the presence of physical symptoms and illnesses and use of medical services.”
GPs are well-placed to act as link people in ensuring bereaved people get the appropriate support, as they are often the first port of call if the person is concerned about their mental or physical health, post bereavement.
An Irish Hospice Foundation (IHF) initiative on bereavement in the midlands found that voluntary services and education providers cited the GP practice as the favoured location if they had a concern about a bereavement issue. Most available bereavement leaflets specifically suggest a visit to the GP if the person has a concern about how they are coping with bereavement.
This article reflects on what is known about how GPs respond to bereavement and what their patients expect from them. It issues an invitation to GPs to enter into a dialogue around what they consider best practice when dealing with bereaved patients and asks what, if anything, those of us who are working in bereavement care can offer, in supporting the delivery of best practice care by GPs to bereaved patients in Ireland.
Research results
A survey by Jill Main in England (2000) concludes that in one general practice that she polled, many of the interviewees expected some contact from their GP following bereavement, although the nature of the preferred contact varied. Over half expressed dissatisfaction, either with the GP or with the hospital where their relative was treated.
Some suggested that the communication and/or the quality of the information given affected the bereavement outcome. The majority of those interviewed saw bereavement support as an important part of the GP role. Towards the end of life, the GP may be involved not just with the patient, but also with the patient’s family. One of the first Irish studies to explore general-practice experience of the care of dying patients was undertaken by Ní Rian et al. in 2001.
This study asked GPs to report on consecutive deaths over a three-month period. The findings indicated that one-third of the GP practices had at least five deaths in this time frame. Of the 297 reported deaths, 25 per cent had no contact with their GPs, while the remaining patients generated a workload of 1,600 home visits and 500 surgery consultations.
Offering support
Traditionally, GPs in Ireland have played a key role in offering support to the bereaved, and anecdotally this care seems to be quite intuitive, with GPs making personal decisions about the appropriateness of making a home visit and/or attending the funeral.
A small study by Saunderson and Ridsdale in England reported that 100 per cent of the 25 GPs interviewed felt guilty about issues relating to the deaths of patients, although most of them believed they had a responsibility to make contact with bereaved patients or family members.
It is suggested that despite the frequency with which GPs encounter bereaved patients, medical training offers little guidance in the provision of bereavement aftercare and that what is offered to bereaved clients very much depends on the individual GP.
Furthermore, there is little training available to GPs to help them distinguish between normal and pathological grief, and conflicting findings as to what patients need or expect. This suggests that there may be room for some specific training around these issues. However, this author agrees with David Jewell’s commentary on the article by Saunderson and Ridsdale that “the lived experience” should also be legitimised and that a GP’s personal experience of death and bereavement is a valuable resource in working with the bereaved.
This author would add that the personal impact of a patient’s death on a GP must also be legitimised and addressed. Howell (1992) has written about the high risk of mental illness and stress intrinsic to general practice. Rout (1996) further suggests that an emphasis on ‘getting it right’ can leave GPs feeling inadequate when things go wrong and posits that this is one likely cause of stress.
Dr Gertrude Ronan (2009) highlights this point in her bereavement protocol initiative and suggests ways that GPs might address their own loss issues (see ‘Resources’, below).
GPs’ feelings
How do GPs handle feelings of inadequacy, failure or guilt that may emerge following the death of a patient? How do GPs handle being at the receiving end of the (often) misplaced anger that is directed at them by distressed relatives? And what about the very real loss that GPs must feel when a patient for whom they have cared over a long period dies?
Undocumented and informal reporting from bereaved clients of this author suggests that a visit to their GP is often initiated by a questioning of whether their bereavement symptoms are normal and that there is an expectation that the doctor can provide reassurance or help in managing these symptoms.
Occasionally, clients have reported that while they themselves often requested medication (to help them sleep better or feel better), they sometimes left the surgery feeling their grief had been medicalised, rather than validated as a natural response to a significant loss, if a prescription was the only response they received.
As a psychologist working in the area of loss, it is neither my place nor my intention to dictate to GPs how they should manage bereavement. Rather, I hope to encourage GPs to let us know if there are ways we can work together to ensure that bereaved patients’ needs are met.
The following are some tentative suggestions:
l A dialogue concerning what bereaved people would like from their GPs and what GPs can reasonably deliver;
l In reference to this, the IHF, in partnership with the Irish College of General Practitioners (ICGP) and the Health Service Executive, has commenced a primary care/palliative care initiative (which will include bereavement issues), seeking to identify palliative-care responses within a primary care setting;
l The introduction of bereavement protocols that provide a standardised level of care to bereaved clients, while allowing for individual and cultural differences in both patients and GPs;
l Training packages on bereavement that specifically address the needs of GPs;
l Care pathways that clearly link the needs of the bereaved to appropriate services;
l Acknowledgement of the ‘wear and tear’ on GPs in dealing with bereaved patients and families.
l Susan Delaney, Psy.D. is a clinical psychologist and the Bereavement Services Manager with the Irish Hospice Foundation
Resources
l Dr Gertrude Ronan won an ICGP award for a protocol she developed as a systematic way to record and respond to bereavements. This provides simple and practical recommendations on responding to the death of a patient.
l The Irish Hospice Foundation has produced DVDs on breaking bad news and communicating in difficult circumstances, particularly geared towards health professionals. It also runs an extensive training programme in bereavement and houses a lending library with recommendations for further reading by health professionals. More information can be obtained on www.hospice-foundation.ie or by calling the office or Tel: (01) 679 3188
References
l Howell, J, Fisher, F and Morgan,DR, (Eds) (1992). Stress and the medical profession. BMA, London.
l Jewell, David (1999). Commentary: Use of personal experience should be legitimized. BMJ, Vol. 319, July.
l Prigerson, H and Maciejewski, P. (2006). A call for sound empirical testing and evaluation of criteria for complicated grief proposed for DSM-V. Omega: The journal of death & dying, 52, 1-7.
l Ronan, G (2009). Adjusting to the loss of someone special. The Forum, July 2009.
l Rout, U (1996). Stress among general practitioners and their spouses: a qualitative study. British Journal of General Practice, 46.
l Saunderson, EM and Ridsdale, L. (1999). General practitioners’ beliefs and attitudes about how to respond to death and bereavement: qualitative study. BMJ, Vol. 319.
l Shear, K. (2006). The treatment of complicated grief. The Australian journal of grief and bereavement. Vol 9: 20, 39-42.
l Shear, K, Frank, E, Houck, P and Reynolds, C. (2005) Treatment of complicated grief. JAMA, Vol 293, No.20
l Stroebe, M., Shut, H. and Stroebe, W. (2007). Health Outcomes in bereavement. Lancet, Vol. 370, December 8.
l Stroebe, M.S., Hansson, R., Stroebe, W. and Shut, H. (2001) Handbook of Bereavement Research: consequences, coping and care. APA, Washington.
l Wilkes, E. (1982). The dying patient: the medical management of incurable and terminal illness. Lancaster: MTP Press.
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