A scoping review of bereavement risk assessment measures: Implications for palliative care

The meaning and experience of bereavement support: A qualitative interview study of bereaved family caregivers

Objective:

Experiences of bereavement can be stressful and are frequently complicated by emotional, familial, and financial issues. Some—though not all—caregivers may benefit from bereavement support. While considered standard within palliative care services in Australia, bereavement support is not widely utilized by family caregivers. There is little research focused on the forms of bereavement support desired or required by family caregivers, how such care is viewed, and/or how bereavement support is experienced. This study examined the experiences of bereaved family caregivers and their impressions of and interactions with bereavement support.

Method:

This paper reports on one aspect of a broader study designed to explore a range of experiences of patients and caregivers to and through palliative care. Focusing on experiences of bereavement, it draws on qualitative semistructured interviews with 15 family caregivers of palliative care patients within a specialist palliative care unit of an Australian metropolitan hospital. The interviews for this stage of the study were initiated 3–9 months after an initial interview with a family caregiver, during which time the palliative patient had died, and they covered family caregivers' experiences of bereavement and bereavement support. Interviews were digitally audiotaped and transcribed in full. A thematic analysis was conducted utilizing the framework approach wherein interview transcripts were reviewed, key themes identified, and explanations developed.

Results:

The research identified four prevalent themes: (1) sociocultural constructions of bereavement support as for the incapable or socially isolated; (2) perceptions of bereavement support services as narrow in scope; (3) the “personal” character of bereavement and subsequent incompatibility with formalized support, and (4) issues around the timing and style of approaches to being offered support.

Significance of results:

Systematic pre-bereavement planning and careful communication about the services offered by palliative care bereavement support centers may improve receipt of support among bereaved family caregivers in need.

A process evaluation of systematic risk and needs assessment for caregivers in specialised palliative care

Background

Caregiving is strenuous and it may be associated with adverse psychological outcomes. During the palliative care trajectory, there are unique opportunities for providing support and preventing poor bereavement outcome. However, the tasks of palliative care staff in relation to caregivers are often unclear in the daily practice. Assessment is recommended to establish risk and needs and standards for caregiver support are available. Still, the feasibility of applying these standards among caregivers in everyday clinical practice has not been tested so far.

Methods

This study tested the feasibility of an intervention based on key elements of the “Bereavement support standards for specialist palliative care services” in a Danish specialised palliative home care team. We followed the UK Medical Research Council’s guidelines for the process evaluation of complex interventions. The intervention consisted of: 1. Systematic risk and needs assessment for caregivers at care entry; 2. Interdisciplinary conference to prepare a support plan; 3. Targeted support; 4. The establishment of an electronic medical record for caregivers to document targeted support. Outcomes included the reach, fidelity and acceptability of the intervention as well as the assessment of contextual factors.

Results

The intervention reached 76 of 164 caregivers (46%). The interdisciplinary risk assessment and documentation of a support plan was conducted in 57 (75%) of the enrolled caregivers. Finally, a separate medical record was established according to the intervention blueprint for 62% of caregivers receiving targeted support. After managing initial challenges, palliative care staff reported that the intervention was useful and acceptable.

Conclusion

The intervention proved feasible and useful. Still, we identified barriers to the implementation which should be taken into consideration when planning implementation of a systematic risk and needs assessment and in the establishment of medical records for caregivers.

Prevalence of prolonged grief disorder in adult bereavement: A systematic review and meta-analysis

BACKGROUND

Prolonged grief disorder (PGD) is a bereavement-specific syndrome expected to be included in the forthcoming ICD-11. Defining the prevalence of PGD will have important nosological, clinical, and therapeutic implications. The present systematic review and meta-analysis aimed to estimate the prevalence rate of PGD in the adult bereaved population, identify possible moderators, and explore methodological quality of studies in this area.

METHODS

A systematic literature search was conducted in PubMed, PsycINFO, Embase, Web of Science, and CINAHL. Studies with non-psychiatric, adult populations exposed to non-violent bereavement were included and subjected to meta-analytic evaluation.

RESULTS

Fourteen eligible studies were identified. Meta-analysis revealed a pooled prevalence of PGD of 9.8% (95% CI 6.8-14.0). Moderation analyses showed higher mean age to be associated with higher prevalence of PGD. Study quality was characterized by low risk of internal validity bias but high risk of external validity bias.

LIMITATIONS

The available studies are methodologically heterogeneous. Among the limitations are that only half the studies used registry-based probability sampling methods (50.0%) and few studies analyzed non-responders (14.3%).

CONCLUSIONS

This first systematic review and meta-analysis of the prevalence of PGD suggests that one out of ten bereaved adults is at risk for PGD. To allocate economic and professional resources most effectively, this result underscores the importance of identifying and offer treatment to those bereaved individuals in greatest need. Due to heterogeneity and limited representativeness, the findings should be interpreted cautiously and additional high-quality epidemiological research using population-based designs is needed.

Bereavement outcomes: A quantitative survey identifying risk factors in informal carers bereaved through cancer

BACKGROUND

Enabling patients to die in their preferred place is important but achieving preferred place of death may increase the informal carer's risk into bereavement.

AIM

To determine risk factors of family carers bereaved through cancer in Northern Ireland.

DESIGN

These results form part of a larger QUALYCARE-NI study which used postal questionnaires to capture quantitative data on carer's bereavement scores using the Texas Revised Inventory of Grief.

SETTING/PARTICIPANTS

Participants were individuals who registered the death of a person between 1 December 2011 and 31 May 2012; where cancer (defined by ICD10 codes C00-D48) was the primary cause; where the deceased was over 18 years of age and death occurred at home, hospice, nursing home or hospital in Northern Ireland. Participants were approached in confidence by the Demography and Methodology Branch of the Northern Ireland Statistics and Research Agency. Those wishing to decline participation were invited to return the reply slip. Non-responders received a second questionnaire 6 weeks after initial invitation. Results indicated that risk factors positively influencing bereavement outcomes included patients having no preference for place of death and carers remaining in employment pre- or post-bereavement. In contrast, patients dying in hospital, carers stopping work, being of lower socio-economic status and close kinship to the deceased negatively affected bereavement scores. Family carers should be adequately supported to continue in employment; priority should be given to assessing the financial needs of families from lower socio-economic areas; and bereavement support should focus on close relatives of the deceased.

The presence and predictors of complicated grief symptoms in perinatally bereaved mothers from a bereavement support organization

The present study investigated the presence and possible predictors of complicated grief symptoms in perinatally bereaved mothers (N = 121) up to 5 years postbereavement. The presence of complicated grief scores in the clinical range was 12.4%, which is higher than in many other bereaved populations, and the presence of other living children may protect against the development of complicated grief symptoms. The majority of the women were able to negotiate a perinatal loss without developing complicated grief; however, there remains an important group of women who up to 5 years later score in the clinical range for complicated grief symptoms.

Psychosocial Well-Being of Young People Who Participated in a Support Group Following the Loss of a Parent to Cancer

Despite the evidence of unmet support needs among young people who have lost a parent to cancer, only a few support group initiatives have been reported. This observational prospective study explored the psychosocial well-being of young people who participated in support groups at a Swedish specialist palliative care setting. On three occasions, 29 participants, aged 16-28 years, answered questionnaires covering characteristics of the participants, circumstances of the losses, psychosocial well-being of the young people, and their own assessment of the support groups. The support groups attracted mostly young women who were often unprepared for the loss. The living arrangements differed between younger and older participants; however, the loss-related variables did not differ. Significant positive changes were found regarding a sense of meaning in their future life and life satisfaction. The helpfulness of the group was assessed as high/very high and the group brought a valuable fellowship with others in a similar situation. Universality and beneficial interactions were reported and strengthened psychosocial well-being developed over time. This change, according to the young people themselves, may be attributed to the group support. The findings are useful for planning interventions to support young people in bereavement in order to enhance their psychosocial well-being.

Initial Validation of a Comprehensive Assessment Instrument for Bereavement-Related Grief Symptoms and Risk of Complications: The Indicator of Bereavement Adaptation-Cruse Scotland (IBACS)

Objective

This study assessed the validity of the Indicator of Bereavement Adaptation Cruse Scotland (IBACS). Designed for use in clinical and non-clinical settings, the IBACS measures severity of grief symptoms and risk of developing complications.

Method

N = 196 (44 male, 152 female) help-seeking, bereaved Scottish adults participated at two timepoints: T1 (baseline) and T2 (after 18 months). Four validated assessment instruments were administered: CORE-R, ICG-R, IES-R, SCL-90-R. Discriminative ability was assessed using ROC curve analysis. Concurrent validity was tested through correlation analysis at T1. Predictive validity was assessed using correlation analyses and ROC curve analysis. Optimal IBACS cutoff values were obtained by calculating a maximal Youden index J in ROC curve analysis. Clinical implications were compared across instruments.

Results

ROC curve analysis results (AUC = .84, p < .01, 95% CI between .77 and .90) indicated the IBACS is a good diagnostic instrument for assessing complicated grief. Positive correlations (p < .01, 2-tailed) with all four instruments at T1 demonstrated the IBACS' concurrent validity, strongest with complicated grief measures (r = .82). Predictive validity was shown to be fair in T2 ROC curve analysis results (n = 67, AUC = .78, 95% CI between .65 and .92; p < .01). Predictive validity was also supported by stable positive correlations between IBACS and other instruments at T2. Clinical indications were found not to differ across instruments.

Conclusions

The IBACS offers effective grief symptom and risk assessment for use by non-clinicians. Indications are sufficient to support intake assessment for a stepped model of bereavement intervention.

Development of the Bereavement Risk Inventory and Screening Questionnaire (BRISQ): Item generation and expert panel feedback

OBJECTIVE

Following the loss of a loved one to cancer, a significant subset of bereaved family members are at heightened risk for mental and physical health problems; however, these family members often "fall through the cracks" of the healthcare system. A brief, clinically useful self-report bereavement risk-screening tool could facilitate more effective identification of family members in need of psychosocial support before and after a cancer loss. Thus, the purpose of this study was to develop and refine the Bereavement Risk Inventory and Screening Questionnaire (BRISQ), a self-report bereavement screening tool, and to assess its utility using feedback from bereavement experts.

METHOD

Quantitative and qualitative feedback from a panel of 15 clinical and research experts in bereavement was obtained through an online survey to identify the most clinically useful items and understand expert opinion on bereavement screening.

RESULTS

The qualitative and quantitative feedback were synthesized, resulting in a 22% reduction of the item pool. While there was a general consensus between experts on the most clinically useful risk factors for bereavement-related mental health challenges and on the utility of screening, they also offered feedback on language and formatting that guided substantial revisions to the BRISQ.

SIGNIFICANCE OF RESULTS

These findings were utilized to refine the BRISQ in preparation for a second study to obtain family member feedback on the measure. By incorporating both expert and family member feedback, the intention is to create a screening tool that represents top clinical and research knowledge in bereavement in a way that effectively addresses barriers to care.

Building Community Capacity in Bereavement Support

Background:

Most bereaved people do not require specialist intervention, yet building community capacity in providing bereavement support is underdeveloped. While family caregivers indicate a need for more information about bereavement, there is little evidence to guide what this information might contain.

Objective:

The study’s purpose was to inform bereavement support by determining the advice people bereaved through expected deaths in palliative care have for others in that situation.

Design:

Four funeral providers posted a questionnaire to previous clients who had used their services 6 to 24 months prior and 678 bereaved people responded.

Setting/Participants:

The sample size for this study comprised 265 bereaved people whose relative used palliative care services.

Measurements:

The questionnaire comprised 82 questions about caregiving, bereavement support, current bereavement-related distress, and 2 open-ended questions concerning their bereavement, one of them on advice they have to other people in the same situation.

Results:

Family caregivers (n = 140) of people who received palliative care responded to the open-ended question about advice for others. An open content analysis yielded 3 themes—preparations for bereavement, utilizing social networks, and strategies for dealing with grief.

Conclusions:

Bereaved family caregivers’ experiential knowledge can be harnessed to progress the development of bereavement care strategies for the good of the community. These responses could be incorporated into information brochures, posters, and other community education avenues in order to upskill palliative care bereavement volunteers and the wider community so that bereaved family caregivers are best supported.

Exploring barriers to assessment of bereavement risk in palliative care: perspectives of key stakeholders

Background

Palliative care standards advocate support for grieving caregivers, given that some bereaved people fail to integrate their loss, experience ongoing emotional suffering and adverse health outcomes. Research shows that bereavement support tends to be delivered on an ad hoc basis without formal assessment of risk or need. To align support with need, assessment of bereavement risk is necessary. The overall aim is to develop a bereavement risk assessment model, based on a three-tiered public health model, congruent with palliative care bereavement standards for use in palliative care in Western Australia. The specific aim of this phase of the study was to explore the perspectives of key stakeholders and to highlight issues in relation to the practice of bereavement risk assessment in palliative care.

Methods

Action research, a cyclical process that involves working collaboratively with stakeholders, was considered as the best method to effect feasible change in practice. The nine participants were multidisciplinary health professionals from five palliative care services, and a bereaved former caregiver. Data were obtained from participants via three 90 min group meetings conducted over five weeks. An inductive thematic analysis approach was used to analyse data following each meeting until saturation was reached, and the research team was satisfied that the themes were congruent with research aims.

Results

Existing measures were found unsuitable to assess bereavement risk in palliative care. Assessment following the patient’s death presented substantial barriers, directing assessment to the pre-death period. Four themes were identified relating to issues in need of consideration to develop a risk assessment model. These were systems of care, encompassing logistics of contact with caregivers; gatekeeping; conflation between caregiver stress, burden and grief; and a way forward.

Conclusions

These group discussions provide a data-driven explanation of the issues affecting bereavement risk assessment in palliative care settings. A number of barriers will need to be overcome before assessment can become routine practice. We recommend the development of a brief, pre-death caregiver self-report measure of bereavement risk that may empower caregivers, lead to early intervention, and allow staff to remain focused on patient care, reducing burden on staff and palliative care services.