GP BEREAVEMENT TRAINING Wednesday 30 January 2012 Tuesday 12 March 2012 Jane Cato Counsellor

1. GP BEREAVEMENT TRAINING Wednesday 30 January 2012 Tuesday 12 March 2012 Jane Cato Counsellor The Martlets Hospice WELCOME

2. Aims and objectives for session • To gain knowledge of NICE guidelines in relation to delivery of bereavement support. • Identifying normal grief. • Identifying complicated grief. • A model of bereavement support: The Martlets Hospice • What you can do at your GP practice. • Any questions?

3. ‘The loss of a loved is one of the most intensely painful experiences any human being can suffer and not only is it painful to experience but also painful to witness, if only because we are so impotent to help’ Bowlby: Attachment and Loss Vol 3 1981

4. Bereavement • Mourning is the process occurring after a loss. • Grieving is the personal experience of the loss. (Worden) • Bereavementis a turning point in personal development, a psychological transition that causes an increased risk to physical and mental health. (Colin Murray-Parkes)

5. NICE guidelines (2004) • Level 1: All bereaved people should be offered information about grief and about how to access support services. • Level 2: About 33% may require additional support over the emotional and psychological impact of loss by death. • Level 3: Specialist interventions are required by a small proportion (7 – 10%) provided by counsellors.

6. NICE guidelines 2011 • Draft Spiritual Support and Bereavement Care Quality Markers and Measures for End of Life Care. • Statement 13: Family and carers of people who have died receive timely verification and certification of death. • Statement 14: People closely affected by a death are communicated with in a sensitive way and are offered immediate and on-going bereavement, emotional and spiritual support appropriate to their needs and preferences.

7. Service providers need to ensure that systems are in place for people closely affected by a death that include sensitive communications and provision for immediate and on-going bereavement, emotional and spiritual support appropriate to their needs and preferences. • This may include information about practical arrangements and local support services, supportive conversations with staff and in some cases referral for counselling and more specialist support. • Recommends bereaved people are offered support at the time of the death that is culturally and spiritually appropriate, immediate and available shortly afterwards. It is not limited to immediately after the death, but may be required on a longer term basis, and in some cases, may begin before death.

8. What this may look like for your service? A stepped approach to emotional and bereavement support may be appropriate, which could include but is not limited to: • Information about local support services. • Practical support such as advice arranging a funeral, information on who to inform of a death, help with contacting other family members and information on what to do with equipment and medication. • General emotional and bereavement support, such as supportive conversations with generalist health and social care workers or support from voluntary, community and faith sectors. • Referral to more specialist support from bereavement counsellors and mental health care workers.

9. Sources of information • When a patient dies: guidance for professionals on developing bereavement services (DOH 2005) • Model of bereavement support NICE Cancer Service Guidance recommendations 2011 • UK Standards for Bereavement (London Bereavement Network) • Guidance for bereavement needs assessment in palliative care 2nd edition 2010 HelptheHospices

10. Normal manifestations of grief • Physical: nausea, hollowness in stomach, tightness in chest, dry mouth, feeling short of breathe, lack of energy, headaches, low level viral/bacterial infections, repeating symptoms of loved ones illness, may think they have a serious illness, muscle weakness, reduced appetite, insomnia, sexual sensations. • Cognitive: disbelief, sense of unreality, pre-occupation with thoughts of the deceased person, a sense of the presence of the deceased e.g.: smell, hear, see, short-term memory loss, reduced sense of purpose, dreams, loss of concentration, foggy mind.

11. Emotional: shock, numbness, anger, guilt/regret, yearning, anxiety, helplessness, disorganisation, sad, depressed, relief. • Behaviour: social withdrawal, avoiding reminders of the deceased, acting absent mindedly, restless over activity, planning radical changes, seeking sexual contact, changes in habits and routines e.g. eating, sleeping, over emphasis t routine.

12. Factors influencing grief • Suddenness of death • Anticipated death • Cause of death e.g. Accident, illness, suicide, murder • Meaning of relationship to deceased • Personal vulnerability/resilience of bereaved • Social support • Economic resources • Mental health history • Past coping strategies • Nature of previous losses

13. Complicated grief • Intensity of reaction to loss • Length of time passed since death • Continued high levels of distress • Preoccupation with loss • Confused and unpredictable behaviour • Isolated • High anxiety • Doesn’t expect death • Dominant feelings e.g. Anger, sadness • Doesn’t access support • Can’t see a future

14. Complicated grief cont. • Secondary losses: - health - work - money - relationships - identity - home • Developed health problems • Self destructive behaviour • Compulsive need to keep dead person in the present

15. The Martlets Bereavement Model • Make appointment for Bereavement Meeting within 48 hours of the death with next of kin and appropriate family and friends with an IPU trained nurse and member of Patient and Family Support Team (counsellor, social worker or chaplain) • Give next of kin and family bereavement information leaflet ‘the next steps.....helping you during the first days after your bereavement’. • At Bereavement Meeting give the medical certificate, talk through registration of death, funeral arrangements, care deceased and family received at the Hospice, any unanswered questions or remaining concerns and give information on Bereavement Service. Confirm names and contact details of significant bereaved.

16. Bereavement Service • Bereavement profile form: complete bereavement assessment of all significant bereaved, where possible, and record on bereavement profile form. • Routine letter: send routine letter to all identified significant bereaved individuals at 6 weeks following the death, inviting them to contact the bereavement service if they would like bereavement support. • Bereavement assessment: face-to-face meeting by Hospice counsellor to assess level of support needed.

17. Bereavement support • Counselling: an agreement to provide weekly/fortnightly counselling for an agreed period of time. This can be anything from a one-off session, 6 sessions and review to agree further sessions or end counselling. Very occasionally an individual with very complex needs may receive up to 24 sessions over a year. • Following assessment some clients are referred externally to more appropriate services. • As completion of the bereavement counselling approaches occasionally clients are referred on to further psychological support. • Counselling is provided by experienced, qualified counsellors who are BACP accredited or UKCP registered.

18. Bereavement visiting: Clients are supported in their homes by trained bereavement visitors. • The team of bereavement visitors are Hospice volunteers who have undergone a robust recruitment process and thorough bereavement training programme and are supervised monthly by the bereavement counsellors. • The bereaved are offered up to 12 visits usually on a fortnightly basis which can change to monthly visits if appropriate as the client moves through their bereavement.

19. Children and families are also offered bereavement assessment and support which is provided by the counsellors. • Occasionally pre-death support provided by our social worker or chaplain may move into bereavement follow-up when appropriate. • Time to Remember events are held at the Hospice between 6-9 months following the date of death, where the bereaved are invited to attend a formal act of remembrance and meet other people who have been bereaved around the same time. This is led by the bereavement team and other members of the Hospice team, such as IPU nurses, social workers, the chaplain also attend. • Annual Light up a Life event is held in the community before Christmas where the bereaved can come and remember their loved one. Some people continue to attend these years after the death of their loved one. • Memorial book lives in The Sanctuary at the hospice, which holds the name of the people who died at the Hospice on the date of their death. People can come and visit the Sanctuary at any time.

20. What can you do? • Primary Care and GSF • Acknowledge the death ASAP by phone/letter/card/visit • Record contact details of relative/carer • Marker of death in relative/carer’s notes • Inform colleagues/professionals internally & externally • Give information • Offer follow-up appointment after death • Anniversary card • Assessment tool • Designated person to lead on bereavement care in GP practice • Pool resource from all GP practice’s through GSF

21. Thank you And I hope this presentation has provided you with some information and some ideas on how to strengthen and develop bereavement care in your GP practices. Best wishes  Jane Cato