II. Definition

  1. Grief experienced by a dying patient

III. Signs (as differentiated from Depression)

  1. Grief waxes and wanes over time
    1. Depression is constant dysphoria and flat affect
  2. Grief often diminishes over time
    1. Depression does not improve without treatment
  3. Grief maintains some self image, pleasure, and hope
    1. Depression loses these out of proportion to condition
    2. Depression associated symptoms
      1. Sense of worthlessness
      2. Anhedonia
      3. Hopelessness
  4. Grief allows for intermittent social withdrawal
    1. Depression associated with constant isolation
    2. Depressed patients do not enjoy social interaction
  5. Grief may cause Agitation early in the course
    1. Depression may cause persistent Agitation
  6. Grief may desire an early death (e.g. suffering, pain)
    1. Depression: Suicidal despite adequate symptom relief

IV. Differential Diagnosis: Major Depression

  1. See Depression in Cancer
  2. Focus questions to differentiate grief from depression
    1. Are you feeling depressed most of the time?
    2. Are you better off than others in similar situation?
  3. References
    1. Periyakoil (2002) Am Fam Physician 65(5):883-98 [PubMed]

V. Management (Mnemonic: RELIEVER)

  1. Reflect (acknowledge feelings about condition, death)
  2. Empathize (identify with their condition)
  3. Lead (hone in on areas of concern, coping strategies)
  4. Improvise (adapt to individual patient's needs)
  5. Educate (discuss grief features - see signs above)
  6. Validate (grief is a normal reaction to dying)
  7. Recall (discuss accomplishments or special times)
  8. Reference

VI. Management: Additional Measures

  1. Addressing spiritual issues may be helpful
    1. Listening to patient talk about faith and end-of-life
    2. Be supportive, without offering spiritual advice
    3. Physician should avoid discussing own beliefs
    4. Avoid persuading patients and family against faith
      1. Example: Resuscitation in context of religion
      2. Religious leaders best suited to put in perspective
  2. Reference
    1. Lo (2002) JAMA 287:749-54 [PubMed]

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