Clinical Care Considerations for Bereaved Patients

“The reality is that you will grieve forever. You will not ‘get over’ the loss of a loved one; you will learn to live with it. You will heal and you will rebuild yourself around the loss you have suffered. You will be whole again but you will never be the same. Nor should you be the same nor would you want to.

–Elisabeth Kubler-Ross”

Introduction

Grief is associated with a variety of features and each person may experience it differently. As clinicians, recognizing the limits of normative grief reactions in our patients can be challenging due to the variable and sometimes unfamiliar presentation. However, bolstering our awareness of these limits can greatly improve our clinical care practices. Based on available literature and clinical experience, care of bereaved patients can be distilled into a few main tenants.

This includes psychoeducation about grief itself, prudent diagnostic evaluation of symptoms that are uncharacteristic of grief, monitoring of known comorbidities to grief, and referral to counselling and other supports when indicated.

Background

Case 1

A 55-year-old female with no psychiatric history presents to her primary care provider three weeks after the death of her wife. Since the funeral, she has been having odd experiences at home. She divulges that she feels her late-wife’s presence at times, and has seen her sitting in her usual spot in the living room. She does not feel particularly distressed by the experience itself, yet worries that she might be “going crazy.” She denies associated fluctuations in attention, memory, and alertness, which is corroborated by her family.

Definitions

The Fifth Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines bereavement as the state of having lost, through death, someone with whom one had a close relationship.¹ It may also present in the context of gradual deterioration of a loved one suffering from a chronic degenerative disease such as dementia.² Grief often centers around feelings of deprivation and desolation, though can involve a variety of thoughts, feelings, behaviors, and physiologic reactions which are often influenced by a multitude of social, cultural, and individual factors.² Likewise, duration and intensity of the experience can vary greatly. ² Nevertheless, it is frequently described as one of the most painful experiences an individual faces during their lifetime.³

Common Grief Reactions

Research in this area describes a number of common grief reactions, including waves of deep sorrow, numbness, disconnectedness, anger, and even transient physical symptoms.⁴ It is not unusual to dream of deceased loved ones, sense their presence, or have auditory and visual hallucinations of them.⁵ In fact, World-War-II era scientific literature describes numerous accounts of widows of veterans who had auditory and visual hallucinations of “seeing” their husbands.^6,7 This occurred in various countries and was usually perceived as comforting. Sometimes, a sense of connection is maintained by keeping certain beloved objects like clothing, writings, or jewelry.² Other times, efforts are made to continue their living legacies by taking on their life’s mission or making memorial donations.²

Case 2

A 61-year-old male with hypertension, hyperlipidemia, and obesity presents to the emergency department (ED) after being found by his daughter in bed confused and unable to speak. Since his father passed away last week, he has been drinking heavily “to numb the pain.” Basic labs are unremarkable and he is discharged home. His family is told that this is just a reaction to grief. Two days later, he continues to be dysarthric and disoriented. The family brings him back to the ED and requests further workup. Imaging reveals sub-acute stroke and he is admitted to the hospital.

Exceptions to Grief Designation

In grieving patients, certain situations indicate a need for further diagnostic workup and clinical management. First, if criteria for major depressive disorder are met, it should be managed as such.^1,4 While grief can appear similar to depression and can function as a trigger for a depressive episode, the two are managed differently.^3,4 Second, any patient experiencing acute changes in attention, consciousness, or memory should be evaluated for delirium. Grief, alone, does not cause delirium. As demonstrated by Case 2, knowledge of these principles is important to avoid misattribution of vague or subtle symptomology to grief.

Epidemiology

Prevalence

As currently conceptualized, estimating prevalence rates of normal grief reactions can be challenging given lack of well-validated standardized measurements. Another way of examining this issue involves measurement of “complicated grief.¹” Described by DSM-5, this more standardized condition, constitutes grief that is unusually prolonged, intense, disabling, and associated with dysfunctional behaviors, emotions, and thoughts that impede healthy adaptation to loss (Table 1).¹ It can be measured using instruments such as the Inventory of Complicated Grief Scale⁸ or by clinician interview using proposed DSM-5 diagnostic criteria.¹ Available literature suggests that 7% of adults experience complicated grief after loss of a loved one.^9,10 Individuals at highest risk are those over age 61, females, Black, Indigenous, and People of Color (BIPOC), and those with lower socioeconomic status.⁶ Other risk factors include loss of a child, spouse, or young person,⁸ or loss by unexpected or violent means.¹¹ While useful for epidemiologic purposes, the clinical reliability of this diagnosis remains in question. The DSM-5 considers it to be a condition in need of more research that is not yet appropriate to be used in routine clinical practice.¹

Table 1.

DSM-5 Proposed Diagnostic Criteria for Persistent Complex Bereavement-Related Disorder

Criterion A	The individual has experienced the death of a loved one
Criterion B	Presence of at least one of the following symptoms, experienced on most days for at least twelve months after the death: Persistent yearning/longing for the deceased Intense sorrow and emotional pain in response to the death Preoccupation with the deceased Preoccupation with the circumstances of the death
Criterion C	Presence of at least of the following symptoms, experienced on most days for at least 12 months after the death: Marked difficulty accepting the loss Experiencing disbelief or emotional numbness Difficulty with positive reminiscing about the deceased Bitterness or anger related to the loss Self-blame Excessive avoidance of reminders of the loss Desire to reunite with the deceased Difficulty trusting other individuals Feeling alone or detached from other individuals Feeling that life is meaningless or empty without the deceased, or the belief the one cannot function without the deceased Confusion about one’s role in life, or a diminished sense of one’s identity Difficulty or reluctance to pursue interests since the loss or planning for the future
Criterion D	The disturbances cause clinically significant distress or impairment
Criterion E	The bereavement reaction is out of proportion to or inconsistent with cultural/religious norms

Comorbidities and Suicide Risk

Grief is known to confer increased risk of a number of psychiatric disorders, including major depression, post-traumatic stress disorder, anxiety disorders, and substance use disorders.^3,12 Suicidal ideation is seen in up to 57% of older adults who lost their spouse.¹³ Bereavement is also known to compromise physical health as well. The sudden intense emotional stress associated with grief, can for example, precipitate stress cardiomyopathy, also known as takotsubo cardiomyopathy or “broken heart syndrome.” This poorly understood condition is believed to be related to transient left ventricular dysfunction, and presents very similarly to acute coronary syndrome, with chest pain, ST-segment elevation and T wave changes on ekg, and moderate troponin elevations.¹⁴ Finally, although the mechanisms are not clear, death of a child appears to be associated with an overall increased mortality in grieving mothers.¹⁵ It is critical that providers have an awareness of these vulnerabilities and consider screening for mental health symptoms in grieving patients.

“O happy dagger! This is thy sheath; there rust, and let me die.”

– Juliet before she commits suicide, in Romeo and Juliet by William Shakespeare Act 5 (1597) ¹⁶

Understanding and Coping with Grief

This excerpt from William Shakespeare’s beloved tragedy, “Romeo and Juliet,” touches on some of the darkest complexities of grief and loss. In this tale of double suicide, Juliet fakes her death to avoid marrying Paris, the man chosen for her by her parents. Romeo, believing Juliet is dead, ends up killing Paris before taking his own life. Juliet then “happily” stabs herself with Romeo’s dagger. This passage powerfully illustrates the deep suffering, confusion, irrationality, and vulnerability that characterizes bereavement. As clinicians and scientists, we may wonder how to best understand this process and support our bereaved patients.

Stages of Grief Framework

The quote in the introduction is from Elisabeth Kubler-Ross, a Swiss-American psychiatrist who pioneered important and highly influential theories in this realm based upon clinical work with those dying and their loved ones. In her cornerstone work, On Death and Dying (1969), she outlined the stages of grief.¹⁷ It emphasized the highly individualized nature of grief while hypothesizing that there are five stages: denial, anger, bargaining, depression, and acceptance.¹⁷ Not everyone goes through every stage, and there is no prescribed order.¹⁶ Her work aimed to provide a conceptual structure to aid those experiencing grief and to facilitate development of healthy coping strategies.¹⁷ Subsequent work on grief has echoed this framework over the past four decades.^18,19,20,21 This model continues to be a useful patient education tool that can validate and provide structure to the experiences of many (Table 2).

Table 2.

Kübler-Ross 5 Stages of Grief ¹⁶

NOTE: There is no specific order to the stages. Each stage may be experienced more than once or not at all.

Denial	Avoidance of painful thoughts, emotions, and behaviors related to the loss
	Disbelief, shock, numbness
	Looking for evidence that the loss did not happen
	“This can’t be happening to me.”
Anger	Recognition that things are different
	Hostility, anger, guilt
	“Why me? What did I do to deserve this?”
Bargaining	Struggling to find meaning
	Internal negotiation, hope that things can still be changed
	“I’ll do anything to go back to the way it was before.”
Depression	Beginning to face the reality of loss
	Emptiness, yearning, sorrow
	Desire to withdraw socially
Acceptance	Accepting reality of the death
	Learning to live with loss
	Reaching out to loved ones

Constructive Dealing with Grief

There are no standardized treatment modalities, however some grief therapists provide overarching ways of working through grief. For instance, there are those who believe that problematic grief reactions arise from an inability to find meaning in the loss.²² They recommend a meaning-oriented approach to grieving, which centers on narrative interventions like re-telling the story of the loss, journaling about unforeseen benefits, and enacting imaginary dialogues with the deceased.²² This can be done by patients individually, or with the assistance of a licensed therapist. Interpersonal psychotherapy is another modality which has been shown to be effective in helping patients cope with major life transitions, including grief.^1,2 Regardless of grief severity, many patients may benefit from counselling with licensed professionals or a spiritual advisor. Discussing these common therapeutic principles can be important to facilitate this process.

Certain situations may call for additional supports and considerations. For instance, those bereaved by violent or traumatic causes tend to experience more intense and prolonged stages of denial, anger, and depression.²² Parents affected by suicide of a child seem to experience higher levels of guilt and distress compared to death by accident or chronic illness.^23,24 College students affected by suicide of a loved one report greater loneliness, isolation behaviors, and survivors guilt than those affected by death by natural causes.^25,26 Finally, an astonishing 25% of high school students who lost a close friend to suicide met criteria for clinical depression in the following six months.²⁷ Adolescents, in particular, appear to be at elevated risk of imitating suicidal behaviors in response to suicides in their community or those of public figures publicized by the media.²⁸ These phenomena, known as suicide contagion and clusters, are believed to result in 100–200 deaths annually.²⁸ It follows that patients in these situations may be in need of additional resources and close monitoring by friends, family, and classmates. Research indicates that informal supports, such as support groups, tend to be favored methods in these situations.^2,26

Conclusion

Despite the near universal experience of grief and personal loss, caring for bereaved patients can feel like unfamiliar territory for clinicians. Our understanding of grief is constantly evolving, however there are key aspects to be cognizant of (Table 3). This is especially relevant today in the midst of a global pandemic, where the grieving process may be complicated by physical isolation from loved ones and travel restrictions.

Table 3.

Take Home Points

Grief has a variety of manifestations that can vary by person. DSM-V proposes certain diagnostic criteria for complicated grief reactions which persistently diminish functional capacity. These criteria are not fully validated and are not recommended for clinical use at this time. Brief psychoeducation on grief can promote healthy adaptation to loss for patients. The 5-stage model may provide a useful framework. Grief is an inadequate explanation for alerted mental status and focal neurologic deficits. The presence of these symptoms in a grieving person indicates a need for further medical work up. Grief confers increased risk of all-cause mortality, substance use disorders, depression, suicidal ideation, PTSD, and several other psychiatric conditions. Risk-management practices involves screening for cardiovascular disease, depression, PTSD, suicidal ideation, problematic substance use and other relevant conditions to the patient When appropriate, bereaved patients who meet diagnostic criteria for depression are likely to benefit from available evidence-based treatments. Bereaved patients may benefit from counseling, psychotherapy, or support groups. Interpersonal psychotherapy has been extensively studied and shown to be beneficial for grieving individuals.

Funding Statement

MOJ is supported by National Institutes of Health (NIH R25 MH112473-01).