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 complicated grief or prolonged grief disorder, which is thought to result from failure to transition from acute to integrated grief. Symptoms of acute grief include tearfulness, sadness and insomnia and typically require no treatment. Intense grief may trigger the acute onset of myocardial infarction (MI), especially in those with higher cardiovascular risk. This activity reviews the evaluation of patients suffering from a grief reaction and the role of the interprofessional team in helping patients deal with the loss of a loved one.

Objectives:

• Distinguish the terms grief, mourning and bereavement.
• List the five stages of grief.
• Summarize strategies for managing grief.
• Explore modalities to improve care coordination among interprofessional team members in order to optimize outcomes for patients who are grieving.

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 standard grieving process. This condition has been identified as complicated grief or prolonged grief disorder, and it results from failure to transition from acute to integrated grief. [1]Symptoms of acute grief include tearfulness, sadness, and insomnia and typically require no treatment. Intense grief over the loss of a significant person may trigger the acute onset of myocardial infarction (MI). The impact may be higher with cardiovascular risk.[2] Complicated grief has prolonged symptoms of painful emotions and sorrow for more than one year. Complicated grief has also been termed as, 'prolonged grief disorder', 'persistent complex bereavement disorder', 'pathological grief' and 'traumatic grief'.[3] All of these conditions depict intense, impaired and prolonged grief.[4] Patients show a preoccupation with the deceased and feel inner emptiness, no interest in life, and sleep poorly. There is a correlation between complicated grief and acute coronary syndrome (ACS). It has been estimated that 7-10% of those bereaved do not adapt to the loss and inturn develop complicated grief.[5]

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. It 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. [6]
• Disenfranchised grief as defined by Kenneth Doka (1989) is a "grief that persons experience when they incur a loss that is not or cannot be openly acknowledged, publicly mourned, or socially supported." Physicians regularly encounter losses in the form of patient deaths. Grief in healthcare providers is unsanctioned and may play a role in physician burnout. To adequately address the crisis on physician burnout, we need to address the under-recognized role of grief in the physician's clinical experience.[7]  
• Takosubo Cardiomyopathy (Broken Heart Syndrome): is a weakening of the left ventricle caused by severe emotional or physical stress such as loss of a loved one, sudden illness, a serious accident, or a natural disaster (e.g., earthquake). It almost exclusively occurs in women and resolves within a month.[8]

Etiology

Five Stages of Grief

1. Denial and Isolation
2. Anger
3. Bargaining
4. Depression
5. Acceptance

Cardiac Outcomes of Grief

• Heart Attack
• Takosubo cardiomyopathy (broken heart syndrome): Occurs predominantly in postmenopausal women soon after exposure to sudden, unexpected physical and emotional stress.
• Atrial Fibrillation: Heart rhythm disorders or arrhythmias, such as atrial fibrillation, can result from stress. Studies report stress and mental health issues worsening atrial fibrillation symptoms.

Factors Increasing Risk After Bereavement

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), deaths by murder or manslaughter.

Vulnerable people such as those with low self-esteem, low trust in others, previous psychiatric disorder, previous suicidal threats or attempts, and/or absent or unhelpful family are more likely to experience increased symptoms.

These factors also specifically include an ambivalent attachment to deceased people, dependent or interdependent attachment to the deceased person, insecure attachment to parents in childhood (particularly learned fear or learned helplessness).[9]

Epidemiology

Gender

The loss of a spouse typically causes greater negative consequences in men than women. Mortality rates for both men and women who have lost a loved one are increased when compared to nonbereaved people, with the mortality rate higher for males as compared to females. Men experience greater depression and a higher overall health consequence than women.

Age

Younger bereaved persons have more consequences following a loss than older people, including more severe psychological and physical health consequences. These age-related symptoms may be because younger people often experience sudden and unexpected loss. Younger bereaved persons may have more difficulty in the initial period after a loss but may recover sooner because they have access to more social resources.

Pathophysiology

Grief related stress can lead to high blood pressure, tachycardia, and increased levels of cortisol. It can disrupt cholesterol-filled plaques that line coronary arteries and constrict blood vessels. These changes can increase the risk of myocardial infarction. Increased levels of stress lead to catecholamine surge, which increases the platelet aggregation. If a plaque ruptures, platelets form a blood clot on top of the ruptured plaque obstruct blood supply.

Takosubo cardiomyopathy is caused by grief or fear that leads to stimulation of adrenal glands and progresses to elevated levels of adrenaline, which creates reduced blood flow to the heart.

History and Physical

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 feelings 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, tension, or fatigue. It will make the person vulnerable to illness.

Behaviors: Difficulty sleeping, loss of interest in daily activities, and becoming more aggressive or irritable. 

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), ECG changes that mimic heart attack with no coronary artery occlusion, movement abnormalities of left ventricle and ballooning of left ventricle.

Evaluation

Screening questionnaires such as the Brief Grief Questionnaire (BGQ) and the Inventory of complicated grief (ICG) can reliably identify complicated grief. [10][11] There are some screening tools designed to predict complicated grief in the spouses of cancer patients. These two scales, Family Adaptability and Cohesion Evaluation Scale (FACES III), and 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. It assesses both qualitative and quantitative risk factors including mourner's loss and medical history, financial resources both before and after the loss, and circumstances surrounding the death. It provides in-depth information on bereaved the individuals' subjective grief symptoms and associated experience.[12]

In the majority of the patients with Takosubo cardiomyopathy, a coronary angiogram may be inconspicuous. Cardiac imaging plays an important role and shows left ventricular dysfunction.

Treatment / Management

Normal Grief: Most bereaved persons adapt over six months to 2 years.

Complicated grief is best-managed by complicated grief therapy.[3] Complicated grief therapy removes the impediment and promotes the adaptation to the loss. This therapy is more effective than citalopram and interpersonal therapy. [13][14] Patients experiencing complicated grief may require psychological treatment in the form of cognitive-behavioral therapy (CBT) and pharmacological bereavement-related depression.[15]

Takosubo cardiomyopathy (TCM): Patients with TCM will require inpatient cardiology service. Treatment options are empiric and supportive; however, beta-blockers can be helpful when hemodynamics permit. Serial imaging studies may be necessary. These patients should follow-up with a cardiologist within one week of diagnosis to resolve cardiomyopathy with echocardiograms.

Differential Diagnosis

Complicated grief should be differentiated from major depressive disorder(MDD) and post-traumatic 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 from MDD and PTSD.[3]

Complications

Physical Complications

• Impairment of immune response system
• Increased adrenocortical activity
• Increased serum prolactin and increased serum growth hormone. 
• Increased mortality from heart disease (especially in elderly widowers)

Psychosomatic disorders 

Psychiatric (nonspecific) 

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

Psychiatric (specific)

• Post-traumatic stress disorders
• Chronic grief
• Delayed or inhibited grief

Deterrence and Patient Education

Deterrence and Patient Education

It is important to consider the following before disclosing bad news: [16]

• It is essential to have social support and place where to meet (setting). 
• Try to establish a relationship of mutual trust and respect. 
• Provide information at a speed and language that is easily understood.
• Try to 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.
• It is important to 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.[17]

Preparedness for End-of-Life Care

It is important to prepare spouses of terminally ill patients mentally. Preparedness for death and coping with bereavement play a crucial role in complicated grief.[18]

Enhancing Healthcare Team Outcomes

Management of the grieving patient is optimal with an interprofessional team that includes a mental health nurse, palliative care team, psychiatrist, primary care provider, social worker, and other support teams. Even temporary grieving can affect patients both physically and mentally, and it is best to have a mental health nurse involved in the care early on. For most patients, time will help heal the grieving process, but some patients may benefit from counseling or temporary use of pharmacotherapy.