Continuing Education Activity

Grief is a natural and universal response to the loss of a loved one. The grief experience is not a state but a process. Most individuals recover adequately within a year after the loss; however, when individuals experience an extension of the standard grieving process, they are said to be experiencing prolonged grief disorder, thought to result from failure to transition from acute to integrated grief. Symptoms of acute grief include tearfulness, sadness, and insomnia—typically requiring no treatment. Intense grief may trigger other medical concerns, including the acute onset of myocardial infarction, especially in those with higher cardiovascular risk. This activity reviews the evaluation of patients suffering from a grief reaction, prolonged grief disorder, and the role of the interprofessional team in helping patients deal with the loss of a loved one.

Objectives:

• Differentiate between the normal grief process and prolonged grief disorder, recognizing the key distinctions and criteria for each.

• Screen for risk factors that may predispose patients to prolonged grief.

• Apply evidence-based treatments and therapeutic approaches in managing prolonged grief disorder, tailoring them to the individual patient's needs.

• Improve care coordination among interprofessional team members when planning therapy to optimize patient outcomes.

Introduction

Grief is a natural and universal response to the loss of a loved one. The grief experience is not a state but a process. Most individuals recover adequately within a year after the loss; however, some individuals experience an extension of the grieving process. This condition, identified as prolonged grief disorder, results from failure to transition from acute to integrated grief.[1] Symptoms of acute grief include sadness, tearfulness, and possibly insomnia, and typically require no treatment. Prolonged grief disorder involves intense, painful emotions associated with a lack of adapting to the loss of a loved one that persists for more than 1 year in adults and more than 6 months in adolescents or children. This condition is estimated to affect as many as 7% of bereaved individuals.[2][3]

The terms grief, mourning, and bereavement have slightly different meanings:

• Grief is a person's emotional response to loss.
• Mourning is an outward expression of that grief, including cultural and religious customs surrounding the death. Mourning is also the process of adapting to life after loss.
• Bereavement is a period of grief and mourning after a loss.
• Anticipatory grief is a response to an expected loss. It affects both the person diagnosed with a terminal illness as well as their families.[4]
• Disenfranchised grief, as defined by Kenneth Doka (1989), is "grief that persons experience when they incur a loss that is not or cannot be openly acknowledged, publicly mourned, or socially supported." Some examples could include grief related to the loss of a pet, perinatal losses, and loss of a body part, and this condition can be present in healthcare workers, with losses in the form of patient deaths. 

Intense grief can have physical consequences and may trigger the acute onset of myocardial infarction, particularly in people with higher baseline cardiovascular risk.[5] There is a correlation between complicated grief and acute coronary syndrome. Takotsubo cardiomyopathy, also called broken heart syndrome or stress cardiomyopathy, is another cardiovascular syndrome triggered by intense grief. This condition is a weakening of the left ventricle leading to apical ballooning caused by severe emotional or physical stress, such as losing a loved one, sudden illness, a severe accident, or a natural disaster (eg, earthquake). Takotsubo cardiomyopathy occurs in women 90% of the time, most commonly in postmenopausal women, and often resolves within a month.[6]

Etiology

Factors Increasing Risk for Prolonged Grief 

Traumatic circumstances such as the death of a spouse or a child, the death of a parent in early childhood or adolescence, sudden, unexpected, and untimely deaths (particularly if associated with horrific circumstances), multiple deaths (particularly disasters), and deaths by murder or manslaughter can prolong grief.

Vulnerable people such as those with low self-esteem, low trust in others, previous psychiatric disorders, previous suicidal threats or attempts, young age of the deceased, lower perceived social supports, an ambivalent attachment to deceased people, dependent or interdependent attachment to the deceased person, and insecure attachment to parents in childhood (mainly learned fear or learned helplessness).[7][8]

Epidemiology

Gender

Results from studies evaluating gender differences in prolonged grief show mixed results, with some showing little difference.[9] Other study results showed that men tended to exude higher levels of acute distress that decreased over time, while women tended to have increasing symptoms over time.[10] Other results have reported female gender and low social support as risk factors for prolonged grief.[11] There are likely significant personal and cultural variances affecting these outcomes. 

Age

Grief can manifest differently in patients of varying ages. Children and adolescents will grieve differently according to their developmental stages. Identifying prolonged grief in children can be challenging, depending on the child's ability to communicate their emotions and needs. Increased grief and distress can be anticipated if the loss was of a primary attachment or caregiver. Grieving children may display delays in meeting developmental milestones or anger and frustration at their needs not being met. Children rely heavily on adults and social support to help them cope and navigate the grieving process. Some specific types of distress seen in children after loss include separation distress and existential or identity distress.

If the death occurred in a traumatic fashion, it may bring up recurrent images of the trauma or complicated emotions ranging from self-blame to fear or desires for vengeance. Well-intentioned adults may limit the information given to children about death to protect them. However, they could also limit their ability to process death due to a lack of clarity of information.[12] A child's ability to conceptualize loss and death is influenced by their developmental stage, for example, an ability to comprehend abstract concepts. It is advised to seek the consultation of a professional trained in developmental stages and their influence on the grieving process to support a child's grief.

Pathophysiology

Physiologic stress resulting from intense grief can have a wide range of consequences. Increased cardiovascular and cerebrovascular events have been associated with intense grief, in some cases leading to myocardial infarctions or cardiomyopathy. Various mechanisms have been theorized to explain this association. Emotional triggers are linked to increases in stress hormones, catecholamine release, and increased sympathetic nervous system stimulation. This stress can result in hemodynamic changes, including the following:

• Vasoconstriction
• Increased blood pressure
• Increased heart rate
• Arrhythmias 
• Increased platelet activity and aggregation
• Release of proinflammatory cytokines
• Increased release of endothelin 
• Production of fibrinogen (which promotes plaque destabilization and a prothrombotic state)[5]

Prolonged grief can also give rise to more subtle physiological consequences, potentially stemming from anhedonia or social isolation. People may be less prone to address their healthcare needs, decrease their nutritional intake, exercise, and sleep, and become socially isolated—all of which have negative mental and physical health consequences. 

History and Physical

Creating a safe space for patients to discuss their grief is essential during an evaluation, as they may be reluctant to bring it up and may need an invitation or direct question to begin talking about their grief. Patients may also not be fully aware of how their grief is manifesting and may not be aware that it could lead to many common physical complaints. 

Common grief reactions: Reactions to loss are called grief reactions and vary from person to person and within the same person over time. Grief reactions lead to complex somatic and psychological symptoms.

Feelings: The person who experiences a loss may have a range of feelings, including shock, numbness, sadness, denial, anger, guilt, helplessness, depression, and yearning. A person may cry for no reason.

Thoughts: Grief can cause a sense of disbelief, confusion, difficulty concentrating, preoccupation, and hallucinations.

Physical sensations: Grief can cause physical sensations like tightness and heaviness in the chest or throat, nausea or stomach upset, dizziness, headaches, numbness, muscle weakness, gastrointestinal upset, tension, or fatigue. 

Behaviors: Difficulty sleeping, loss of interest in daily activities, and becoming more aggressive or irritable may be expected in those experiencing grief.

Somatic symptoms: Chest tightness and choking, shortness of breath, abdominal distress, decreased muscle power, and lethargy.

Psychological symptoms: Guilt, anger, hostility, restlessness, inability to concentrate, lack of capacity to initiate and maintain an organized pattern of activities.

Takosubo cardiomyopathy: Chest pain and shortness of breath after severe stress (emotional or physical), electrocardiogram changes that mimic heart attack with no coronary artery occlusion, movement abnormalities of the left ventricle, and ballooning of the left ventricle.

Evaluation

The DSM-5 and the ICD-11 have defined prolonged grief disorder. While they vary slightly, an overall description of the criteria includes the death of a person who was close to the bereaved patient occurring at least 12 months ago (or 6 months ago for children and adolescents), with a persistent grief response including intense yearning or longing for the deceased person or a preoccupation with thoughts or memories of the deceased person occurring most days. Some of the following also accompany this condition:

• Identity disruption 
• Disbelief about the death
• Avoidance of reminders of the fact that the person is deceased
• Intense emotional pain
• Difficulty reintegrating into relationships and activities
• Inability to experience a positive mood
• Emotional numbness

The disturbance causes impairment in social, educational, occupational, or other essential aspects of daily function, and the symptoms exceed the cultural or religious norms for the patient and are not better attributed to another psychological diagnosis or substance use. [13]

Screening questionnaires such as the Brief Grief Questionnaire (BGQ) and the Inventory of Complicated Grief (ICG) can reliably identify complicated grief. [14][15] There are some screening tools designed to predict complicated grief in the spouses of cancer patients. These 2 scales, the Family Adaptability and Cohesion Evaluation Scale (FACES III) and the Brief Symptom Inventory (BSI), assess family functioning, psychological functioning, and grief reaction. 

The grief evaluation measure (GEM) can also assist in identifying the development of complicated grief symptoms in a mourning adult. This evaluation assesses qualitative and quantitative risk factors, including the mourner's loss and medical history, financial resources before and after the loss, and circumstances surrounding the death. The GEM also provides in-depth information on bereaved individuals' subjective grief symptoms and associated experiences.[16]

Treatment / Management

Normal Grief: Most bereaved persons adapt over 6 months to 1 year.

Complicated grief: This condition is managed best with complicated grief therapy, which incorporates elements of cognitive behavioral therapy and other techniques aimed at promoting adaptation to the loss, including acceptance of the loss and restoring a sense of meaning and satisfaction in life without the deceased loved one.[17][18][19] Patients experiencing complicated grief may also benefit from pharmacological treatment of bereavement-related depression.

Takosubo cardiomyopathy: Patients with Takosubo cardiomyopathy require inpatient cardiology evaluation. They are initially evaluated and treated similarly to myocardial infarction. Treatment options are supportive, and symptoms often resolve along with the resolution of the inciting physical and emotional stress. However, sometimes severe symptoms of shock or heart failure develop that need more intensive interventions. 

Assessing the bereaved for ongoing unmet needs following the loss of their loved ones, including practical requirements like the ability to manage activities of daily living, is also essential. For example, it is possible that the deceased loved one was in charge of managing the finances or driving or cooking for a couple, and the bereaved may not have the ability or skills to maintain these activities without assistance. 

Differential Diagnosis

Differentiate complicated grief from major depressive disorder (MDD) and posttraumatic stress disorder (PTSD). Complicated grief's classic symptom presentation of yearning and sorrow, along with the preoccupied thoughts of the deceased and the inability to accept the reality of death, help in differentiating this condition from MDD and PTSD.[17]

Prognosis

The course depends on how patients adapt to their new reality. This is contingent upon their personal resiliency, support system, and psychiatric assistance. 

Complications

Physical Complications

• Impairment of the immune response system
• Increased adrenocortical activity
• Increased mortality from heart disease (especially in older, widowed patients)

Psychiatric Nonspecific Disorders

• Depression (with or without suicidal risk)
• Anxiety 
• Panic disorders
• Other psychiatric disorders
• PTSD

Deterrence and Patient Education

Deterrence and Patient Education

It is essential to consider the following before disclosing unfavorable news:[20]

• Have social support and a place to meet (setting)
• Establish a relationship of mutual trust and respect
• Provide information at a speed and language that is easily understood
• Discover what facts are already known by the patient and family
• Encourage questions and monitor what is understood. It takes time to hear and understand the negative news 
• Give verbal and nonverbal assurance regarding the normality of their reactions
• Give some time to the patient and family to react emotionally 
• Stay with the patient and the family until they are ready to leave and offer further opportunities for clarification, information, or support.[21]

Preparedness for End-of-Life Care

Mentally preparing spouses of terminally ill patients is essential. Preparedness for death and coping with bereavement play a crucial role in complicated grief.[22]

Enhancing Healthcare Team Outcomes

The effective management of grief reactions and prolonged grief disorder requires a comprehensive approach that involves various healthcare professionals to enhance patient-centered care, outcomes, patient safety, and team performance. The interprofessional team includes a mental health nurse, palliative care team, psychiatrist, primary care provider, social worker, and other support professionals. Even temporary grieving can affect patients both physically and mentally, and it is best to have mental health providers involved in the care early on. For most patients, time will help heal the grieving process, but some patients may benefit from counseling or the temporary use of pharmacotherapy.

Healthcare professionals must develop empathy and communication skills to engage with grieving individuals effectively. This involves active listening, empathy, and recognizing and responding to emotional cues. Additionally, professionals should be adept at assessing mental health and identifying signs of prolonged grief disorder. Developing a comprehensive strategy for grief management involves a multidisciplinary approach. This strategy should include a combination of psychotherapy, pharmacotherapy, and support groups. Tailoring the strategy to the individual's needs is crucial, considering factors such as cultural background, religious beliefs, and personal preferences. Ethical considerations play a significant role in providing care to grieving individuals. Healthcare professionals must respect the autonomy and dignity of patients while ensuring confidentiality. Ethical decision-making becomes particularly important when addressing issues such as end-of-life care and respecting the deceased's wishes.

Each healthcare professional involved in grief management has specific responsibilities. Physicians and advanced practitioners may lead the diagnostic and treatment aspects, while nurses are crucial in providing emotional support and monitoring patients' well-being. Pharmacists ensure appropriate medication management, and all professionals are responsible for educating patients and their families about the grieving process. Effective communication among healthcare professionals is essential for a cohesive and integrated approach to grief management. Regular case conferences, team meetings, and shared electronic health records contribute to a holistic understanding of the patient's condition. Clear communication helps develop a unified care plan and promptly address any emerging concerns. Coordinating care involves synchronizing efforts among healthcare professionals to ensure a seamless and integrated patient experience. This includes coordinating appointments, sharing relevant information, and facilitating transitions between different levels of care. A well-coordinated approach enhances the efficiency of interventions and improves overall patient outcomes.

In conclusion, a collaborative and well-coordinated effort among healthcare professionals is crucial for addressing grief reactions and prolonged grief disorder effectively. By combining their skills, adhering to ethical principles, and maintaining open communication, healthcare teams can provide patient-centered care that promotes positive outcomes, patient safety, and optimal team performance in the context of grief management.