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1 Sara Dado, LCSW

2 As Required, this presenter would make you aware of any and all potential conflicts of interest(s). This presentation is being given with no bias or conflict of interest(s)

3 Define both Normal and Complicated Grief Identify Risk Indicators for Complicated Grief Discuss assessment tools that can be used to determine increased risk Learn interventions and strategies to improve bereavement care planning

4 is a multifaceted response to loss, particularly to the loss of someone or something that has died, to which a bond or affection was formed. Although conventionally focused on the emotional response to loss, it also has physical, cognitive, behavioral, social, and philosophical dimensions. Grief

5 is the period of grief and mourning after a death. When you grieve, it's part of the normal process of reacting to a loss. You may experience grief as a mental, physical, social or emotional reaction. Mental reactions can include anger, guilt, anxiety, sadness and despair. Bereavement United States Library of Medicine

6 Grief- when normal grief reactions become so severe and last so long as to significantly impair one s functioning in the world: socially, occupationally, and in activities of daily living. Sometimes referred to as Persistent Complex Bereavement Disorder, Prolonged (Complicated) Grief Disorder, Traumatic Grief or Pathological Grief Complicated Mayo Clinic

7 Everyone who experiences a loss (of any kind) will experience grief. It is a natural human reaction. Grief is not a disorder, a disease or a sign of weakness. It is an emotional, physical and spiritual necessity, the price you pay for love. The only cure for grief is to grieve. Dr. Earl A. Grollman

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9 Complicated bereavement risk assessment involves four key categories: 1) The Illness, Terminal Care and Nature of the Death 2) Characteristics of the Bereaved 3) Interpersonal Relationships, including family functioning. 4) Characteristics of the deceased.

10 There is greater risk for complicated grief when: The death is sudden or unexpected particularly if: The death occurred under traumatic circumstances The death is stigmatized ( i.e suicide, murder, HIV/AIDS, etc) The bereaved did not have the opportunity to discuss death with the deceased before the death occurred (there was no warning or period of anticipation) Guidelines for the Assessment of Bereavement Risk in Family Members Receiving Palliative Care- Ch 2

11 Stage of Life of Bereaved Person Child or adolescent who loses a parent A young spouse with or without children Elderly spouse after a long marriage Adult Child who was a long time caregiver History of Previous Losses Other deaths Divorce Miscarriage Recent Job loss Guidelines for the Assessment of Bereavement Risk in Family Members of People Receiving Palliative Care Ch 2

12 Presence of Additional Stressors Family tension, Comprised Financial Status, Addiction, Caregiving for other family members Physical and Mental Illness Current/past history of mental health problems, Family history of psychiatric disorders, Current or chronic illness Poor Coping Skills Lack of self care, attributing meaning to the loss, poor community or social support system. Guidelines for the Assessment of Bereavement Risk in Family Members of People Receiving Palliative Care Ch 2

13 The availability of social support Bereaved ability to find outside connections Disturbance of social support prior to death (lost touch with family/friends during an illness) Level of satisfaction with care prior to death Support System weans after death An ambivalent or dependent relationship between the deceased and the bereaved An unusually long term and exclusive marriage Unresolved traumatic issues between family members (guilt and loss)

14 The Deceased is a child The Death was sudden or violent The Deceased is a parent of young children The Deceased was abusive The Deceased was well known and highly respected Guidelines for the Assessment of Bereavement Risk in Family Members of People Receiving Palliative Care

15 Bereavement Risk Assessment Tool The Two-Track Bereavement Questionnaire for Complicated Grief Family Relationship Index Complicated Anticipatory Inventory Grief Assessment Grief Scale of Complicated Grief

16 Persistent intense longing for the deceased Frequent feelings of intense loneliness or emptiness Recurrent negative thoughts about life without the deceased or recurrent urges to join the deceased Preoccupying thoughts about the deceased that impair daily functioning Frequent inability to accept the death Persistent feelings of being shocked, stunned or numb after the death Recurrent feelings of anger or bitterness regarding the death Hearing the voice of or seeing the deceased person frequently Excessive avoidance or preoccupation with places, people and things related to the death or deceased

17 All of these symptoms can be a part of the normal grief process. Complicated grief is characterized by debilitating or prolonged denial, avoidance, anxiety, intrusive thoughts, suicidal ideation, and isolation.

18 Medicare hospice CoP: (d) Standard: Counseling services - Bereavement counseling. (1) Bereavement counseling. The hospice must: (i) Have an organized program for the provision of bereavement services furnished under the supervision of a qualified professional with experience or education in grief or loss counseling (ii) Make bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/MR when appropriate and identified in the bereavement plan of care (iii) Ensure that bereavement services reflect the needs of the bereaved. (iv) Develop a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery. NHPCO Compliance Tip Sheet

19 Medicare expects Hospice Bereavement Programs to be individualized and meet the needs of complicated bereaved individuals. A cookie cutter approach to grief work will not be effective In reviewing bereavement records, one should find that documentation paints the picture to convey the impact the death has had on a particular individual.

20 How to meet the needs of younger bereaved families How to fully assess needs with quick turn around admissions Resources within hospice programslimited/ no reimbursement Knowledge of changing or limited community resources

21 Early and Ongoing Assessment Education Interdisciplinary Team Ownership

22 Social Workers complete a comprehensive anticipatory grief assessment within 5 days of hospice admission All families are provided with an education packet of information upon admission that includes a self assessment and materials on grief and loss All team members are responsible for addressing and care planning for bereavement needs- real interdisciplinary team work

23 Early identification of risk factors and referral to support services can reduce risk and improve results Hospice has a responsibility to provide additional support and referrals to those identified as being at High Risk Additional IDT staff training may be needed. It can be easy to overlook triggers if we don t know what to look for.

24 Studies show that a good death can improve bereavement outcomes Hospice s goal should be to make every death a good death and provide support and assistance to families. Identifying risk factors and care planning appropriately will improve outcomes The more we know, the better we can do

25 Unable to move on: A case study of complicated grief Mr. C, age 67, presents to a local emergency department (ED) with his daughter. His daughter reports that he has not been himself since his wife died in a car accident 2 years ago. He continues to live in the house he shared with his wife, despite not needing the extra space and being unable to maintain it. Although Mr. C and his daughter used to talk about her mother a great deal, she says she now tries to avoid the subject because it upsets him. More recently she became concerned when Mr. C began to tell her that his life was meaningless without his wife. He said he frequently thinks about taking his own life to end his pain and loneliness. Mr. C tells the ED psychiatrist he feels an intense wave of grief and loneliness every morning when he realizes his wife is not with him. He often stays in bed for hours, longing for her and thinking about their time together. At times, he thinks he hears her voice downstairs but when he searches for her, she is not there. Mr. C has been unable to go through his wife s belongings, and feels nothing should be moved in their home. He will look at her photos, yet avoids other reminders of her (eg, partaking in their favorite hobbies, going to their favorite restaurants). He feels bitter and angry about his wife s death, and becomes agitated when describing the car accident that took her life. Mr. C feels guilty for not being with his wife when she died. He assures the psychiatrist that he loves his children, but says he feels increasingly distant from them and doesn t understand how they can move on after their mother s death. Mr. C reports symptoms consistent with a diagnosis of complicated grief. Further assessment is appropriate to determine if his symptoms are severe enough to warrant treatment. Robinaugh "Recognizing and treating complicated grief

26 Complicated Grief Therapy 16 session program developed by Dr. Katherine Shear. Based on attachment model and cognitive behavioral therapy principles Individualized Psychotherapy Outpatient Grief Counseling Individualized Services under the hospice bereavement program Hospices may not have all of these resources within their programs. Know the resources in your community

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28 Sara Dado, LCSW Sara is the Vice President of Compliance at Transitions Hospice where she is responsible for the daily operations of home-based health care service provision. She is a national speaker on the topic of quality hospice care and advanced care planning. She has experience in policy development, elder law, home health, skilled nursing, and hospice. Sara is an MSW field instructor and was recently selected to serve as faculty member for the NASW Supervisory Leaders in Aging Program. She received a BSW from the University of Northern Iowa and an MSW from The University of New York.

29 Aranda, S & Milne, D (2000) : Guidelines for the Assessment of Bereavement Risk in Family Members of People Receiving Palliative Care Centre for Palliative Care Davis, D (2012) DSM-5 Controversy Rages on in the Bereavement Community Psychology Today Holahan, CJ & Moos, R.H (1981): Family Relationship Index Neimeyer, Robert (2016) Techniques of Grief Therapy: Assessment and Intervention NHPCO (2011) CMS FY 2010 Top Ten Hospice Survey Deficiencies Compliance Tip Sheet NHPCO Medicare Hospice Conditions of Participation Bereavement Pies, R; Sheer, K; Zisook, S (2014) Distinguishing Grief, Complicated Grief and Depression MedScape Prigerson, H & Maciejewski, P : Complicated Grief Assessment Prigerson et al (1995) Inventory of Complicated Grief Psychiatry Research Robinaugh, Donald J (2012) Recognizing and Treating Complicated Grief Current Psychiatry Tousley, Marty (2011) What is Complicated Grief Grief Healing Blog Bereavement Risk Assessment Tool (2008) Victoria Hospice Society Zisook, S; Sher, K (2009) Grief and Bereavement; what psychiatrists need to know Department of Psychiatry, University of California at San Diego

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