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Technological advances in medicine during the 20th century, while
achieving marvellous gains in combating disease, have made care of
the dying harder.1 At the same time, care of the
bereaved has drastically deteriorated with the relative loss of
family medicine and increasing emphasis on specialist
care.2 Such neglect has occurred
particularly in general hospitals in Australia, in which 38 000
deaths (30% of total deaths annually in Australian hospitals) occur
each year.3 The morbidity resulting
from bereavement contributes substantially to healthcare costs. We
are challenged to redress this serious problem by adopting a more
family-centred model of care, which should begin to operate from the
time of first admission of any index patient.
The continual pressure on acute general hospital units can easily
lead to neglect of the bereaved, unless the unit leader routinely
seeks feedback on bereavement follow-up at multidisciplinary
meetings. Fleeting contact with several care providers does not
easily permit relationships to become established between staff and
patients' relatives. Clearly, continuity of care established with
relatives before death could facilitate ease of support following
the patient's death.
In their article about death in the emergency department (ED) in this
issue of the Journal, Williams and colleagues
offer guidelines for dealing with bereaved relatives.4 They describe a
sensitive approach to the communication of news of tragic death; care
of the family as they view the deceased's body and express their grief;
and a follow-up program that involves comforting bereaved relatives
and maintaining contact with them. This model utilises each member of
the multidisciplinary team and reaches out to involve the general
practitioner. It promotes continuity of care and takes medical
practice beyond the usual patient-centred approach to include the
wider community.
Bereavement support is indeed a broad community responsibility.
Medical resources should be directed to bereaved people at greatest
risk of a severe grief reaction, including those for whom the death was
unexpected or in some way shocking; those who had an ambivalent or
over-dependent relationship with the deceased; those particularly
vulnerable to depression or psychiatric illness; and those likely to
have poor support networks.5 Careful inquiry from a
practitioner adopting a family-centred model of care can help to
determine whether particular family members are at high risk. The GP
is well placed to sustain regular contact with "at risk" individuals
over subsequent months and intervene if complications develop.
The manner of death, including death by suicide or homicide, may be
associated with stigma, the horror of violence, and a pressing need
for relatives to understand the sequence of events leading up to the
death.6 In such instances, it is
vital that GPs meet with family members to address these issues and
that they continue to support the family, referring individuals to
psychological or family therapy services if appropriate.
Untimely and unexpected death occurs not only in the ED, but also
regularly within coronary and intensive care units, and
occasionally in obstetric and surgical settings, where the emphasis
is on repair and rehabilitation.7 The goal of care in such teams
is restitutive,8 and hope of recovery is high.
Any relationships between staff and relatives are likely to be brief
and tentative. Nevertheless, such units need to have established
guidelines, along the lines of those outlined by Williams and
colleagues, for responding to unexpected death.
Other units (eg, renal, oncology or geriatric services) deal with
patients who have chronic illness, with slow but steady progression,
sometimes leading to an acceptance of dying in a courageous or heroic
manner.9 Emphasis here should be on
quality of life and relief of specific symptoms. Generally, staff of
these units build good relationships with their patients' relatives
and provide a bereavement follow-up program after death.
Over the past decade, palliative care services have set up
bereavement follow-up programs similar to that described by
Williams and colleagues for the ED. They have discovered the
importance of a structured approach,10 involving selection of
the most appropriate staff member (based on continuity of care) to
sustain contact during bereavement, and provision of a written
record of outcome.
Hospice care has sought to redress the neglect of the dying that can
occur when hospitals are focused primarily on the fight for life. The
hospice tradition promotes a healthy acceptance of the dying
process, encouraging doctors to listen to and care compassionately
for the dying and their families. This healing intent must be extended
to embrace the care of bereaved relatives, not only in the context of
palliative care, but in all other areas.
A major cultural shift is needed in many Australian hospitals today to
strive for better care of the bereaved in our community. The
guidelines proposed by Williams and colleagues4 serve as a model
that warrants adoption by the whole hospital system.
David W Kissane
Professor, and Director of Palliative Medicine
Centre for
Palliative Care, University of Melbourne, Melbourne, VIC
- Seale C. Constructing death. The sociology of dying and
bereavement. Cambridge: Cambridge University Press, 1998.
-
Parkes CM. Bereavement: studies of grief in adult life. 3rd
ed. Madison, Connecticut: International Universities Press, 1998.
-
Australian Bureau of Statistics. Australia now -- a statistical
profile. Population, deaths. Canberra: ABS, 2000.
-
Williams AG, O'Brien DL, Laughton KJ, Jelinek GA. Improving
services to bereaved relatives in the emergency department: making
healthcare more human. Med J Aust 2000; 173: 480-483.
-
Kissane DW. Grief and the family. In: Bloch S, Hafner J, Harari E,
Szmukler G, editors. The family in clinical psychiatry. Oxford:
Oxford Medical Publications, 1994: 71-91.
-
Hassan R. Suicide in Australia. In: Kellehear A, editor. Death and
dying in Australia. Melbourne: Oxford University Press, 2000:
190-207.
-
Field MJ, Cassel CK, editors. Committee on Care at the End of Life,
Institute of Medicine. Approaching death: improving care at the end
of life. Washington: National Academy Press, 1997.
-
Frank A. The wounded storyteller. Chicago: University of Chicago
Press, 1995.
-
Field D. Awareness and modern dying. Mortality 1996; 1:
255-266.
-
Kissane DW. A model of family-centered intervention during
palliative care and bereavement: focused family grief therapy
(FFGT). In: Baider L, Cooper CL, Kaplan De-Nour A, editors. Cancer and
the family. 2nd ed. Chichester: Wiley, 2000: 175-197.
©MJA 2000
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