Follow-up of grieving families in general and family medicine: a cross-sectional study on the practices and attitudes of family doctors

Abstract

Introduction

Family physicians (FPs) provide essential support during life’s most challenging moments, including experiences of grief and loss. After a patient’s death, FPs are expected to provide information and emotional support to bereaved family members. Prior research suggests that bereaved relatives expect follow-up contact from their FP, acknowledging it as part of the physician’s role. This study aims to explore the practices and attitudes of FPs towards bereaved family members.

Methods

A cross-sectional, descriptive study was conducted through an online questionnaire, exploring participants’ perceived role in bereavement care, the type of support offered to families, available resources in primary care, as well as personal knowledge and approach on grief. This questionnaire was distributed via digital platforms to general and family medicine doctors.

Results

A total of 210 physicians participated (84.3% female; 53.8% in residency), with a median age of 32 years old. On average, each FP experienced five patient deaths, most often reported by family members. More than half (53.3%) contacted bereaved families in fewer than 25% of cases, typically within 7 days of the death, most commonly by phone (76.5%).

Conclusion

This study highlights significant gaps in the bereavement follow-up practices of FPs in Portugal. Findings emphasise the need for integrated bereavement care guidelines in primary care, institutional policies and investment in targeted training programmes to enhance grief’s approach. The reported lack of grief training reinforces the need to integrate grief education into medical curriculum and continuous professional development. Structural improvements, such as the implementation of automatic death notifications within the healthcare system, are also critical for enabling timely and effective support.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Bereavement care has a significant impact on patients’ mental and physical health. Family physicians can play an important role in providing this support. However, evidence of showing this engagement in bereavement care is limited, as well as challenges faced in clinical practice.

WHAT THIS STUDY ADDS

• This study shows a national-level insight into bereavement practices, perceived barriers and training needs of family physicians on follow-up of grieving families.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• This study highlights the need for training in bereavement care for family physicians, as well as the lack of standardised guidelines and health policies that can improve bereavement follow-up in primary care settings.

Introduction

Throughout the life course, from birth to death, family physicians (FPs) play a central role in a patient’s health journeys. Health systems in which primary care is structured around family medicine, FPs act as gatekeepers, ensuring continuity and person-centred care.¹ According to the World Organization of Family Doctors Europe’s definition, “the approach of general practice must be constant from birth (and sometimes before) until death (and sometimes afterwards)”.² This continuity allows FPs to be present during critical life transitions, including bereavement. Significant events in a family’s life cycle, such as birth, serious illness or death, deserve special attention from FPs for their unique abilities to identify concerns, negotiate care plans and help families manage difficult transitions. These abilities are based on essential skills of FPs in observation, communication, understanding and management of uncertainties.³ In this context, bereavement support and follow-up with grieving families are increasingly recognised as part of the holistic role of FPs,² though they remain understudied and are often shaped by physicians’ personal attitudes and comfort levels.

Grief is a natural and universal response to the loss of a loved one. The manifestations of grief are diverse, varying not only between individuals but also within the same individual over time, often resulting in complex somatic, emotional and psychological symptoms. While most bereaved individuals gradually adapt to their loss within 6 months to 2 years,⁴ a significant minority may develop persistent, intense and disabling grief reactions, known as prolonged grief (PG).5,8 PG is estimated to affect 9.8% of bereaved adults,⁹ with significant impacts on mental health, physical health and quality of life.¹⁰ Given that these individuals often present to primary care with a wide range of symptoms, FPs are in an important position to identify those individuals at risk of PG, provide early support and refer to specialised care when needed.¹¹ Yet, despite this opportunity, little is known about FPs’ attitudes towards grief support and how these attitudes influence their actual clinical practices.

After a patient’s death, FPs can play an important role in supporting grieving family members. Their long-standing relationship with the family, combined with their holistic approach to care, positions them to provide not only medical information about the deceased but also emotional and psychosocial support.¹² In some health systems, FPs adopt structured grief follow-up practices, which may include planned home visits, telephone appointments and sending condolence letters, integrating bereavement care as part of their continuity of care. However, evidence suggests that despite recognising its importance, FPs frequently report a lack of confidence and insufficient training to manage bereavement-related needs effectively.¹³ These attitudes may strongly influence whether and how FPs engage in bereavement follow-up, including perceived responsibility, comfort level and perceived competence.

FPs’ role often extends beyond individual patient care, with some doctors developing long-term and close relationships not only with patients but with their family.¹⁴ Despite these bonds, FPs are rarely notified about a patient’s death, sometimes becoming aware of the loss only weeks or months later.¹⁵ This lack of information leads to frustration and dissatisfaction among FPs as it limits their ability to offer appropriate follow-up care and emotional support to bereaved families.¹⁶ The death of a loved one is widely recognised as one of the most stressful life events.^{17 18} After the death of a patient, families may experience a sudden discontinuity of care and a loss of support from healthcare providers, contributing to feelings of abandonment and emotional vulnerability.¹⁹ In this context, the FP’s potential role in proactively following up with grieving families becomes even more relevant. However, how frequently this happens, and which factors influence these practices—particularly physicians’ own attitudes, perceived responsibilities and sense of preparedness—remains insufficiently explored.

Charlton and Dolman²⁰ consider bereavement as one of the most neglected areas of health promotion, despite the fundamental role that primary healthcare can play in supporting and assisting bereaved patients.²⁰ The importance of bereavement care within primary care settings is widely recognised,²¹ given the position of FPs to provide early identification of complicated grief and timely interventions. The continuity of the FP–patient relationship has been associated with protective health benefits, including reduced mortality.²² These benefits are attributed to factors such as trust, a sense of security, the avoidance of repetitive clinical narratives and support in navigating the healthcare system.²³ Furthermore, early psychotherapeutic interventions offered by FPs to bereaved relatives have been shown to reduce the long-term risk of mental health complications.²⁴ Despite this, bereavement follow-up remains inconsistent, and the likelihood of such care being offered may depend heavily on physicians’ attitudes—including their sense of responsibility, comfort with discussing grief and perceived competence—as well as on the presence or absence of structured practices and system-level supports.

Several studies suggest that bereaved relatives often expect follow-up contact from their FP—whether through a telephone call, condolence letter or other forms of acknowledgement—recognising this as part of the healthcare professional’s broader mission of care and continuity.25,28 However, not all bereaved individuals share this expectation; some do not consider FP involvement in bereavement as relevant or necessary.²⁶ This duality highlights the need for a personalised, patient-centred approach that considers individual preferences and cultural context.

On average, an FP experiences approximately 20 patient deaths each year,²⁹ and these losses can also have a significant emotional impact on the doctor.³⁰ Unaddressed emotional strain may contribute to professional dissatisfaction and burnout.^{30 31} Involvement in end-of-life care and subsequent bereavement support has been shown to strengthen the FP–patient–family relationship, reinforcing trust and fostering more meaningful care.^{31 32} Understanding these factors is essential to inform training needs, develop clear guidelines and support FPs in providing effective grief care.

In Portugal, there is a notable lack of research on the follow-up care provided by FPs to grieving families. One of the few studies in this area, conducted by Santos and Barbosa³³, explored the experiences of FPs when dealing with patient deaths and how these losses impact their relationships with bereaved family members. Their findings showed that, in the face of an expected death, FPs often experience feelings of sadness, uncertainty, self-doubt regarding their clinical decisions and isolation. Despite these emotions, many FPs adopt a supportive and available posture towards grieving families, which strengthens the doctor–patient relationship.³³ These findings highlight the emotional complexity of bereavement care from the physician’s perspective and suggest that both attitudes and emotional readiness may influence the likelihood of proactive follow-up care.

The follow-up of grieving patients by FPs is a highly relevant issue with significant implications for the mental health of both bereaved individuals and healthcare professionals. In Portugal, recognition of this need is reflected in official policy. The General Directorate of Health issued Norm No. 003/2019 on 23 April 2019, establishing a Differentiated Intervention Model for Prolonged Grief Disorder in Adults. This national directive proposes criteria for the diagnosis, identification, monitoring and referral of individuals experiencing prolonged grief disorder.¹¹

This study aims to fill the gap in research concerning the attitudes and practices of FPs in the follow-up of grieving family members in Portugal, serving as a foundation for future research and contributing to improved clinical practice. Despite the central role that FPs play in providing continuous, holistic and person-centred care, little is known about how they perceive their responsibilities towards bereaved families and how these perceptions influence their clinical actions. This lack of evidence limits the development of consistent, evidence-based practices and hinders the integration of bereavement care into routine primary care, both nationally and internationally. Understanding these dynamics is essential to inform medical training, support FPs in this emotionally demanding aspect of care and promote more humanised and responsive healthcare.

This research aims to explore the attitudes and practices of FPs towards the family members of deceased patients. Additionally, it examines how the personal experiences and values of FPs influence their follow-up with grieving families and assess their level of preparation in addressing this issue.

Methods

Study design

This was a cross-sectional, descriptive study.

Setting

A questionnaire was distributed via Google Forms and made available from 1 February 2022 to 30 June 2022. The survey link was disseminated through multiple channels, including WhatsApp groups, social media platforms (Facebook and Instagram), medical education forums and online communities of family medicine trainees and practitioners. By completing the questionnaire, participants informed consent and confirmed their eligibility under a pledge of honour, affirming their professional status as residents or specialists in general and family medicine (GFM).

Participants

A convenience sample of medical professionals, primarily residents and specialists in GFM in Portugal, was used. Eligibility criteria required that participants spend >50% of their working hours in GFM practice. Physicians who did not practise medicine, who worked outside Portugal or who did not have regular patient contact in their daily clinical activities were excluded from the study.

Data sources/measurements

A questionnaire was specifically developed for this study, informed by a literature review on bereavement care in primary care settings and expert consultation. Peer discussions with clinicians experienced in family medicine and palliative care also contributed to item development. The instrument comprised 37 questions, divided into three sections, using multiple response formats: short answers, open-ended responses, multiple-choice questions and Likert scales.

The first section included 12 questions about sociodemographic and professional information, such as age, gender, professional category, clinical practice and patient contact time, previous training in palliative care and grief, personal experiences of significant losses, religious beliefs and geographic location of clinical practice.

The second section assessed practices and attitudes of FPs towards end-of-life care and follow-up with grieving families. This included questions about their perceived role in bereavement care, the type of support offered to families and available resources in primary care settings.

The third section assessed knowledge about prolonged grief disorder, perceived competence and comfort levels in addressing grief-related issues during appointments. This section had 21 questions: seven short-answer questions, three questions requiring percentage-based responses (0%, 1–25%, 26–50%, 51–75% or 76–100%), one single-choice question (on preferred modes of contact, such as phone call, email, SMS/WhatsApp, letter/condolence card or appointment) and three questions asking respondents to rate 16 statements using Likert scale. Eight of these statements were rated on a 6-point scale (0=I do not identify at all to 5=I identify completely), while the remaining eight were rated on a 5-point scale (0=completely disagree to 4=completely agree). Additionally, four items were evaluated using a 5-point Likert scale (0=not prepared at all/no impact/very negative to 5=fully prepared/very impactful/very positive). An open-ended field allowed respondents to share recommendations for grief management in family medicine and general feedback about the survey.

This tripartite structure was chosen to comprehensively explore the factors that may influence physicians’ practices, acknowledging that bereavement follow-up is a multifactorial process shaped by personal, professional and systemic factors. The decision to include multiple question formats (short answer, percentage-based, multiple-choice, Likert scales and open-ended responses) was intended to capture both objective behaviours and subjective perceptions in depth.

The survey was pilot tested with seven FPs who met the inclusion criteria and one clinical psychologist with expertise in bereavement, ensuring face validity, clarity and content consistency. In addition to face validity, the questionnaire was reviewed for clarity and internal consistency during the pilot phase, based on received feedback. No formal reliability testing was conducted due to the exploratory nature of the study and limited sample size of the pilot test.

Statistical analysis

Descriptive statistics were used to summarise categorical and continuous variables. Open-ended responses were coded based on thematic content and analysed qualitatively through thematic analysis by the principal investigator and validated by a second reviewer. Data were analysed using SPSS Statistics 28.1 software, using descriptive statistics to summarise collected data.

Results

A total of 210 validated questionnaire responses were obtained, with no exclusions. Most participants were female (84.3%, n=177), and 53.8% (n=113) were GFM residents. The median age of participants was 32 years (range 26–69 years). The median duration of clinical practice was 5 years (range 1–44 years), and the median number of weekly working hours was 40 hours (range 6–60 hours).

In terms of previous training, 53.8% (n=113) had no formal training in palliative care, and 74.8% (n=157) reported no prior training in grief. Regarding personal experiences with significant losses, 75.2% (n=158) reported having experienced substantial losses, with a median time since loss of 5 years (range 4 days to 31 years).

Most participants identified as Christian (77.6%, n=163), followed by atheist (19.5%, n=41) and agnostic (2.9%, n=6). The geographic distribution is presented in table 1.

Table 1. Geographic distribution of the participants.

HA	%	N
Lisbon and Tagus Valley HA	37.1	78
North HA	28.1	59
Center HA	18.6	39
Azores Regional HD	9.5	20
Autonomous Region of Madeira Health Service HD	3.3	7
Alentejo HA	1.9	4
Algarve HA	1.4	3

HA, health administration; HD, health directorat.

Regarding end-of-life situations in the previous year, clinicians reported being aware of a median of four patients (range 0–50). Of the participants, 55.7% (n=117) followed up on 0–25% (median; range: 0–25% to 75–100%) of these cases. Participants were aware of five deceased patients during the previous year (median; range 0–30). The most common method of receiving notification about a patient’s death was through family members (70.0%, n=147), followed by digital access to the patient’s file (13.6%, n=27).

In terms of contact with grieving relatives, 53.3% (n=112) of FPs reported contacting bereaved families in 0–25% of cases, 21.9% (n=46) reported contact in 26–50% of cases, 11.9% (n=25) in 51–75% of cases and 12.9% (n=27) in 76–100% of cases. This contact was typically made within 7 days of the patient’s death (median; range: 1–35 days), primarily by phone (76.5%, n=78/102), although 11.0% (n=23/102) scheduled an in-person appointment.

Regarding the availability of programmes or services for the follow-up of grieving families at primary care centres, only 2.4% (n=5) reported having such services. These included home visits by the family health team, evaluation by psychology (from the Shared Resources Unit of Primary Care), condolence cards or scheduling an appointment.

When evaluating participation in the funerals of deceased patients, 91.9% (n=193) of FPs reported not attending, while 8.1% (n=17) indicated that they attend. The reasons for non-participation are presented in table 2.

Table 2. Reasons for non-participation in funerals: participants’ rankings.

Sentence	Median	IQR (Q1–Q3)	Mean (SD)	% min	% max
I do not like funerals	1	0–4	1.93 (1.93)	38.1	18.1
Lack of trust with the family	2	0–4	2.17 (1.73)	26.7	11.0
Ethically questionable	2	0–4	2.26 (1.84)	26.2	17.6
It is not part of my job objectives	2	0–4	2.30 (1.95)	30.5	22.9
Lack of time for personal reasons	3	1–4	2.46 (1.83)	24.3	17.1
It does not make sense to me	3	0–4	2.45 (1.86)	25.7	19.0
It exceeds my professional role	3	1–4	2.84 (1.76)	16.2	24.3
Lack of time due to my work	3	1–5	2.77 (1.91)	22.4	25.2

% min: percentage of respondents who selected the minimum score; % max: percentage of respondents who selected the maximum score.

Scale 0—do not relate at all; 5—completely agree.

Other reasons for non-participation in funerals were cited as shown in table 3.

Table 3. Other reasons for not participating in funerals.

Reason	N
Irrelevant for clinical practice	12
Unfamiliarity with deceased patients	8
Notification to the family physician after a patient’s funeral	5
Principle of equity and justice for all patients	4
Concern that the family might interpret attendance as an admission of clinical error	1
Lack of available time	1

Regarding the role of FPs in supporting grieving relatives, as support provided to grieving families, different perspectives were provided, with detailed responses presented in table 4.

Table 4. Support, follow-up and response to grieving relatives: participant’s classification.

Sentence	Completely disagree	Disagree	Neither disagree nor agree	Agree	Completely agree
	N (%)	N (%)	N (%)	N (%)	N (%)
Supporting grieving relatives is a task of the family doctor	4 (1.9)	4 (1.9)	14 (6.7)	90 (42.9)	98 (46.7)
Supporting grieving relatives is a task of the family doctor only if they are also patients of the family doctor	30 (14.3)	63 (30.0)	38 (18.1)	59 (28.1)	20 (9.5)
My participation in funerals of my patients is appropriate	48 (22.9)	47 (22.4)	80 (38.1)	26 (12.4)	9 (4.3)
The doctor’s follow-up during the grieving period helps the family to reduce the suffering associated with grief	3 (1.4)	4 (1.9)	17 (8.1)	86 (41.0)	100 (47.6)
The health unit where I work has the necessary resources (eg, psychology, grief protocols) to meet the needs of grieving patients	88 (41.9)	79 (37.6)	24 (11.4)	18 (8.6)	1 (0.5)
My daily workload prevents me from carrying out the approach I consider ideal in the follow-up of grieving patients	5 (2.4)	7 (3.3)	23 (11.0)	98 (46.7)	77 (36.7)
Grieving patients tend to schedule more appointments with the attending doctor than before the loss	7 (3.3)	34 (16.2)	63 (30.0)	74 (35.2)	32 (15.2)
The symptoms that bring the grieving patient to the consultation are associated with their grief	5 (2.4)	13 (6.2)	67 (31.9)	103 (49.0)	22 (10.5)

Regarding the impact of spirituality on clinical practice, 91.4% (n=192) acknowledged its relevance. Of these, 33.3% (n=70) rated spirituality as ‘somewhat important’, another 33.3% (n=70) as ‘moderately important’, and 24.8% (n=52) as ‘very important’.

Prolonged grief disorder

Participants were asked to rate their familiarity with the concept of prolonged grief disorder using a Likert scale ranging from 0 (not familiar) to 4 (fully familiar). The distribution of responses was as follows: 46.7% (n=98) rated their familiarity as 3, 26.7% (n=56) as 4, 18.1% (n=38) as 2 and 4.1% (n=9) each rated their familiarity as 1 or 0.

When asked about their perception of the percentage of relatives diagnosed with this condition, the median estimate was 10% (range 0–75%). A majority of 57.5% (n=77) believed that the percentage of relatives diagnosed with prolonged grief disorder was ≤10%, while 16.4% (n=22) estimated it to be between >10% and ≤20%, and 26.1% (n=35) believed it to be >20%. Detailed findings on the approach to grief in clinical practice and the impact of personal experiences are presented in table 5.

Table 5. Participants’ responses to the approach to grief in clinical practice.

Sentence	Median	IQR (Q1–Q3)	Mean (SD)	% min	% max
To what extent do you feel prepared to address the issue of grief with bereaved relatives? (0—not prepared at all; 5—fully prepared)	3	2–4	2.99 (1.10)	2.9	4.3
To what extent do you feel comfortable addressing the issue of grief with bereaved relatives? (0—not comfortable at all; 5—fully comfortable)	3	3–4	3.25 (1.09)	2.4	9.0
To what extent do you think your personal griefs have an impact on how you approach (or not) the theme? (0—no impact; 5—very high impact)	4	3–4	3.47 (1.31)	3.3	23.3
If there is an impact (score>2), to what extent is this impact? (0—negative impact; 5—positive impact)	4	3–5	3.77 (1.01)	4.2	25.6

% min: percentage of respondents who selected the minimum score; % max: percentage of respondents who selected the maximum score.

FPs involved in this study suggested several recommendations, including the need to emphasise training and the establishment of protocols for addressing grief, sending condolences messages to families following the loss of a loved one, scheduling an appointment with grieving family members and allocating additional time during these appointments to provide more comprehensive support for their grief.

Discussion

This study highlights important gaps in the bereavement follow-up practices of FPs in Portugal and reinforces their key role in supporting grieving families, despite structural and educational limitations. While FPs recognise the importance of bereavement care, their practices remain unstructured and often dependent on personal experience rather than standardised guidelines, consistent with findings from previous studies.^{12 16 25}

FPs reported being aware of five deaths among their patients in the previous year, which is lower than the figures in the literature, where a median of 20 patients’ deaths per year is reported.²⁹ This discrepancy likely reflects the absence of a structured death notification system in the national health system, leaving FPs dependent on third-party notification, often from family members themselves (reported by 74.2% of respondents). The lack of timely notification compromises the physician’s ability to provide proactive grief support, underscoring the urgent need for an automatic notification system.^{15 16}

One of the main observations of this study is the low follow-up rate among FPs, with more than half of the participants (53.3%) reporting that they contact bereaved families in only 0–25% of cases, even after death notification being made by the family itself (74.2%). This limited engagement suggests systemic barriers, discomfort with addressing grief or lack of clear expectations regarding this role. This is especially concerning given that bereaved individuals often report expecting contact from their FP,^{27 28} highlighting a disconnect between patient expectations and clinical practice.

Training and self-efficacy

Another noteworthy finding is that 74.8% of FPs reported having no formal training in grief support. This training gap likely contributes to physicians’ discomfort and lack of perceived competence, as noted in previous studies.^{13 21} Physicians with prior significant personal losses (reported by 75.2% of participants) reported a positive impact on their professional approach to grief, indicating that experiential learning may partially compensate for gaps in formal education. However, reliance on personal experience alone is insufficient and highlights the need for structured training in bereavement care in both undergraduate and postgraduate medical education, as well as ongoing professional development programmes.^{30 31}

Primary care system context and practice preferences

The practice context also influences the form of support offered. FPs in this study predominantly preferred telephone calls (76.5%) over face-to-face appointments (11.0%) as their main form of bereavement contact. While phone calls may reflect practical constraints, such as limited time and high workloads, questions arise regarding the adequacy of remote support for complex emotional needs. Institutional policies that encourage structured, multimodal bereavement interventions—including condolence letters, scheduled follow-ups and referral pathways for psychological support—are urgently needed.^{32 34} It is important not to pathologise grief; however, we must ensure that families do not feel the loss of support from the health team as reported in the literature,¹⁹ especially those with a higher risk of developing mental health conditions.

Perceived professional boundaries

The majority of FPs (91.9%) reported not attending patients’ funerals, citing reasons such as lack of time, perceived professional boundaries and ethical concerns. While some literature suggests that attending funerals may strengthen the physician—family relationship,³⁴ this remains a controversial practice with no clear consensus on its appropriateness.

Strengths and limitations

This study’s strengths include its focus on an unexplored aspect of primary care, as well as using a comprehensive questionnaire which approaches multiple dimensions of bereavement care. However, limitations include the use of convenience sampling and potential response bias as the questionnaire was disseminated exclusively through digital channels. The exclusive use of Google Forms platform for data collection may have limited participation among FP less familiar with digital tools, introducing additional selection bias. The predominance of younger physicians in the sample may limit generalisability. Additionally, the lack of subgroup analysis limits the depth of interpretation regarding how physician characteristics influence practice.

Future studies should aim for larger, more representative samples, including experienced physicians and under-represented regions. In future studies, we recommend incorporating clinical records of patients as this could also provide detailed insights into the practice of family physicians. Furthermore, exploring the impact of different interventions for managing grief in primary healthcare settings, as well as evaluating the effectiveness of various approaches in supporting grieving family members, would be valuable for improving bereavement care. A qualitative research could explore personal and professional barriers that could influence FPs’ engagement in bereavement care.

Conclusion

This study highlights significant gaps in the bereavement follow-up practices of FPs in Portugal, despite widespread acknowledgement of their central role in providing continuity of care and psychosocial support to grieving families. Key findings indicate limited follow-up contact, inadequate grief-specific training and systemic barriers such as the absence of timely death notification systems. These factors contribute to variability and inconsistency in bereavement care practices, leaving many families without the support they expect and may need. From a short perspective, improvements should focus on the development of tools to support structured follow-up of bereaved families, such as condolence letters, scheduled appointments and accessible referral pathways within primary care centres. Grief training programmes should also be implemented to enhance FPs’ confidence and competence for grief-related care. In the long term, implementation of system-level changes, such as the implementation of automatic death notifications within the healthcare system, would be essential to ensure timely and effective support for bereaved families. Promoting grief research and policy development would also help ensure sustainable improvements in bereavement care, reinforcing its main role as a central component of patient-centred healthcare.

Data availability statement

Data will be available upon reasonable request due to the sensitive nature of the content.