Low preparedness before the loss of a wife to cancer and the widower's chronic pain 4-5 years later-a population-based study

Spousal bereavement and four-year trajectories of medication use: A nationwide register-based study in Swedish older adults

BACKGROUND

Medication use around widowhood has been poorly described for most medication classes. Medication use patterns can reflect health consequences of spousal loss, as previously shown for psychotropic drugs.

METHODS

We used data from nationwide health registers (2008-2020) to describe the patterns of use of dispensed medications in all widowed Swedes aged ≥65 years followed between 2 years before and 2 years after spousal death. All prescription drugs used by at least 5% of the cohort were considered according to their therapeutic subgroups (Anatomical Therapeutic Chemical [ATC] classification system 2nd level). We used group-based trajectory models to cluster widowed individuals into up to 4 distinct longitudinal patterns of monthly medication use. We ranked the therapeutic subgroups with similar patterns according to their plausibility to reflect potential health effects of spousal loss, compared to those of psycholeptics (mainly anxiolytics, hypnotics) and psychoanaleptics (mainly antidepressants) as the references.

RESULTS

From 212,111 widowed adults included (68% female and 70% aged ≥75 years), we observed a significant increasing trend in medication use, especially after spousal death, for 21 out of the 39 different therapeutic subgroups that were used by at least 5% (most represented pharmacological groups: cardiovascular system, nervous system, and alimentary tract and metabolism). This increasing trend often concerned only a small proportion of individuals, with varying magnitude and speed of change in medication use across therapeutic subgroups. The patterns of use of antiepileptics, laxatives, skin emollients/protectives, analgesics, and drugs for anemia, constipation, or peptic ulcers, were the closest to those of references, displaying the largest changes in use, and were therefore ranked as the most likely to reflect health effects of spousal loss.

CONCLUSION

Our results confirmed the increase in psychotropic medications' use in widowed older adults and identified several potential physical health effects of spousal loss that warrant further research.

Factors associated with the preparedness for bereavement in families of patients with cancer: A secondary analysis of a nationwide bereaved family survey

OBJECTIVES

Insufficient preparedness for bereavement can affect a family's psychological health status after bereavement. However, factors associated with preparedness remain unclear. This study aimed to identify factors associated with preparedness for bereavement in families of patients with cancer.

METHODS

We conducted a secondary analysis of a nationwide bereaved family survey in Japan, analyzing data from 9123 family members of patients with cancer. Logistic regression analysis was conducted to explore how sociodemographic factors, health status, and perceived care for patients and families were associated with preparedness for bereavement.

RESULTS

Of the 9123 families, 1338 (15.1%) were not prepared for bereavement. Factors associated with insufficient preparedness for bereavement (all p < 0.001) were found as follows: patients' spouses (OR = 2.54), receiving care in acute hospitals (OR = 1.83), worse psychological health status during caregiving (OR = 2.13), lower social support for family members (OR = 1.90), wrong patients' awareness of medical condition from family's perspective (OR = 1.75-2.12), family preference of more aggressive treatment rather than palliative care (OR = 1.71) or not sure (OR = 2.31), not wanting to know information about the patient's prognosis (OR = 1.64-1.77), end-of-life discussion with physician 1 month before patient's death (OR = 1.45), and late or early end-of-life discussions with physician and family (OR = 1.78-1.95).

CONCLUSIONS

This study's results might assist clinicians in assessing and identifying families who are not prepared for bereavement; however, preparedness for bereavement may have been associated with other factors.

Spousal loss and cognitive function: the importance of gender and multiple dimensions of marital quality

Objectives: Research suggests that the death of a spouse has an adverse effect on a widow(er)'s cognition. However, little research has examined how the marital context before widowhood and gender influence this association. Guided by the social ambivalence and disease (SAD) model, this study examined the associations between spousal loss and cognition , with moderating effects of gender and pre-loss marital quality.Method: We analyzed a national longitudinal data, Midlife in the United States (MIDUS), specifically MIDUS 2 (2004-2005) and MIDUS 3 (2013-2014). The analytic sample consisted of (1) 146 participants who experienced the death of their spouse between MIDUS 2 and MIDUS 3 and (2) 144 age- and gender-matched comparison participants who did not lose their spouse during the period.Results: Adverse influence of widowhood on cognition was more pronounced among bereaved men than bereaved women. Widowed individuals whose relationships with their deceased spouse were ambivalent had poorer cognition than widowed individuals who had aversive relationships with their deceased spouse.Conclusion: Findings suggest that the influence of spousal death on cognitive functioning depends on gender and pre-loss marital quality, emphasizing the importance of considering pre-loss marital relationship and gender dynamics in developing efficient interventions for the widowed.

The Relationship Between Pre-Loss Grief, Preparedness and Psychological Health Outcomes in Relatives of People With Cancer

The aim of this study was to examine the simultaneous effects of pre-loss grief, preparedness for death and preparedness for caregiving on different psychological health outcomes in relatives of people with cancer. Two hundred ninety-nine relatives of people with cancer participated in a cross-sectional online survey. Participants were included if they spoke German and were 18 years or older. Multivariate regression analysis was conducted. Pre-loss grief was significantly associated with depression (β = .388, p < .001), anxiety (β = .429, p < .001), somatization (β = .221, p < .001) and satisfaction with life (β = -.205, p < .001). Preparedness for death was significantly associated with somatization (β = -.247, p < .001). Results suggest that people with high scores in pre-loss grief and low scores in preparedness for death are in need of early support. Interventions should address pre-loss grief and the various aspects of preparedness for death and take into account the psychological health in relatives of people with cancer. Future studies should investigate underlying mechanisms.

Pre-loss grief and preparedness for death among caregivers of terminally ill cancer patients: A systematic review

BACKGROUND

Cancer is one of the most common causes of death. The period of time between receiving a terminal diagnosis of cancer and the death of a loved one has been operationalized as pre-loss grief and, more recently, as preparedness for death. Originally, grief before loss was thought to have positive effects on the bereavement outcome, but some studies have revealed contradictory findings. This systematic review investigates definitions and measurement tools of pre-loss grief and preparedness for death, as well as the associations of both constructs with caregiver characteristics, pre-loss psychological aspects and post-loss adjustment among caregivers of people living with terminal cancer.

METHODS

PubMed/Medline, PsycINFO and Web of Science were searched for studies published up until October 2020. Quantitative empirical studies from peer reviewed journals were included if a measurement tool for pre-loss grief or preparedness for death was used and if they focused on adult caregivers of adult people with cancer in an end-of-life trajectory and were excluded when they were not written in English or were descriptive/qualitative studies. Quality assessment of all studies was performed.

RESULTS

Most studies used convenience samples and had a mean number of 725 participants. Overall, 16,326 participants in 35 articles were included and narratively synthesized. High levels of pre-loss grief, as well as low levels of perceived preparedness for death, were associated with poor post-loss adjustment (e.g., prolonged grief, depressive symptoms, etc.).

CONCLUSIONS

Caregivers with high levels of pre-loss grief and low levels of preparedness for the death of their loved one would benefit from targeted support for post-loss adjustment. Results are limited by an inconsistent operationalization of both constructs.

Course of Changes in Emotional Preparedness for Death and Its Associations With Caregiving Outcomes for Family Caregivers of Terminally Ill Cancer Patients Over Their Last Year of Life

BACKGROUND

Preparing family caregivers for a patient's death is an integral component of quality end-of-life care, but temporal changes in emotional preparedness for death and its associations with caregivers' psychological well-being or quality of life (QOL) while providing end-of-life caregiving are under-researched. Our study was conducted to fill this gap.

METHODS

For this prospective, longitudinal study, the course of changes in adequate emotional preparedness for death and its associations with severe depressive symptoms and QOL were examined on 309 consecutive caregivers of terminally ill cancer patients by univariate and multivariate generalized estimating equation analyses, respectively.

RESULTS

Prevalence of adequate emotional preparedness for death was 57.2%, 61.3%, 54.4%, and 46.0% at 181-365, 91-180, 31-90, and 1-30 days before the patient's death, respectively, without significant changes as the patient's death approached. Adequate emotional preparedness for death was associated with caregivers' lower likelihood of severe depressive symptoms (adjusted odds ratio [95% CI]: 0.23 [0.16, 0.32], P < 0.001) but with their better QOL (adjusted β [95% CI]: 7.65 [6.38, 8.92], P < 0.001) in the patient's last year.

CONCLUSIONS

Without active, effective clinical interventions to promote caregivers' emotional preparedness for death, they cannot automatically become more prepared for the patient's death over time. Adequate emotional preparedness for the patient's death benefits caregivers by its associations with a lower likelihood of depressive symptoms and better QOL. Supportive programs for caregivers of terminally ill cancer patients should focus on not only enhancing caregiving skills but also cultivating emotional preparedness for their relative's death to promote their psychological well-being and QOL.

Sleep disturbances in bereavement: A systematic review

Severe, persistent and disabling grief occurs among a sizable minority experiencing bereavement, with diagnostic manuals newly including complicated grief (CG) disorders. Sleep disturbances/disorders have been established as worsening affective and stress-related conditions. However, the role of sleep difficulties in bereavement and CG has not received similar scientific attention. We therefore conducted a systematic review with narrative syntheses on this topic to clarify the role of sleep in bereavement (PROSPERO: CRD42018093145). We searched PubMed, Web of Science and PsychInfo for peer-reviewed English-language articles including (at least one) bereaved sample and sleep disturbance measure. We identified 85 articles on 12.294 participants. We answered seven pre-defined research questions demonstrating: high prevalence of sleep disturbances in bereavement; positive associations of grief intensity with sleep difficulties; preliminary indications of risk factors of post-loss sleep disturbance; higher prevalence of sleep disturbances in CG, enhanced by psychiatric comorbidity (i.e., depression); and initial evidence of causal relationships between (complicated) grief and sleep. Grief therapy partly improves sleep difficulties, yet no intervention studies have specifically targeted sleep problems in bereaved persons. Causal relationships between sleep and grief require further examination in intensive longitudinal investigations, including randomized trials, thereby clarifying whether treating sleep problems enhances CG treatment effects.

Cancer Caregivers' Preparedness for Loss and Bereavement Outcomes: Do Preloss Caregiver Attributes Matter?

Past studies examining the relationship between preparedness for loss and bereavement outcomes among caregivers of spouses/partners with life-limiting illness did not adequately account for preloss caregiver attributes that could potentially confound the relationship. Using a sample of spouse/partner cancer caregivers (N = 226), we examined how preloss caregiver attributes were associated with how prepared one felt for loss and their role in the relationship between preparedness and later bereavement outcomes. Nearly half reported they were not emotionally prepared, and 35% were not prepared for the practical challenges associated with the loss. Although attributes such as depression, anxiety, competence in daily activities, and financial adequacy were associated with both preparedness and bereavement outcomes, regression analyses revealed that preparedness remained the strongest predictor in all models. We suggest that early interventions enhancing caregivers' preparedness for loss may hold considerable promise for improved bereavement outcome.

"Death from a broken heart": A systematic review of the relationship between spousal bereavement and physical and physiological health outcomes

The loss of a loved one is often associated with "death from a broken heart" for the survivor, and there is evidence that shows that widowers and widows are at risk for higher morbidity and mortality than the general population. This systematic review will summarize the physical and physiological health outcomes of spousal bereavement. A systematic database search was conducted, and 38 studies were analyzed. The majority of studies found a statistically significant and positive association between spousal bereavement and adverse physical and physiological health outcomes such as inflammation, cardiovascular risk, chronic pain, and mortality.

Using motivational interviewing to facilitate death talk in end-of-life care: an ethical analysis

BACKGROUND

Morbidity arising from unprepared bereavement is a problem that affects close personal relations of individuals at the end-of-life. The bereavement studies literature demonstrates that a lack of preparedness for a loved one's death is a risk factor for secondary psychological morbidity among survivors. Short awareness time of death negatively correlates to preparedness for bereavement. The absence of disclosure of end-of-life diagnosis and prognosis to close personal relations ('death talk') between patients and loved ones, or health professionals and loved ones, may contribute to short awareness time of death. To increase awareness time of death, we might attempt to increase patient first-personal disclosure of end-of-life diagnosis and prognosis to loved-ones, and/or patient consent to health professional disclosure of the same.

MAIN TEXT

Interventions based on motivational interviewing in end-of-life care whose aim is to facilitate death talk, either by the patient directly, or by a health professional with the patient's consent, may offer a part solution to the problem of unprepared bereavement. This paper evaluates the ethical permissibility of such interventions. We consider two ethical objections to using motivational interviewing in this way: first, that it is inappropriate for practitioners to seek disclosure as an outcome in this setting; second, that aiming at disclosure risks manipulating individuals into death talk. While it need not be impermissible to direct individuals toward disclosure of end-of-life diagnosis/prognosis, the objection from manipulation implies that it is pro tanto ethically preferable to use motivational interviewing in a non-directive mode in death talk conversations. However, insofar as non-directive motivational interviewing requires more advanced skills, and thus may be more difficult to learn and to practise, we advance that it may be ethically permissible, all things considered, to employ directional, or specific outcome-oriented, motivational interviewing.

CONCLUSION

Motivational interviewing interventions in end-of-life care whose aim is to facilitate death talk, either by the patient directly, or by a health professional with the patient's consent may be ethically permissible, all things considered.

Psychological distress, health, and socio-economic factors in caregivers of terminally ill patients: a nationwide population-based cohort study

PURPOSE

At some point in life, most people become caregivers to a terminally ill relative. Previous studies have shown that many caregivers experience psychological distress and declining physical health, but these studies have predominantly been conducted in specialized palliative care settings. Therefore, caregiver studies with a population-based approach are needed. We aimed to describe socio-economic characteristics, situational factors, pre-loss grief symptoms, depressive symptoms, caregiver burden, and health status in a general population of caregivers to terminally ill patients.

METHOD

We conducted a nationwide population-based cohort study. Caregivers were systematically recruited through patients registered with drug reimbursement for terminal illness in 2012. Data on socio-economic characteristics was mainly obtained from Danish registries, whereas data on situational factors, distress, and health was measured in questionnaires.

RESULTS

Of patients to responding caregivers (n = 3635), 89 % suffered from cancer, predominantly lung cancer (23 %). Of responding caregivers, 62 % were partners and 29 % were adult children. In total, one third of caregivers reported severe outcome, 15 % reported severe pre-loss grief symptoms, 16.1 % had moderate to severe depressive symptoms, and 12 % experienced high caregiver burden. Partners had the highest levels of pre-loss grief and depressive symptoms, while adult children reported the highest levels of caregiver burden.

CONCLUSIONS

From this cohort, which was estimated to be representative of caregivers to terminally ill relatives in the general population, we found high levels of pre-loss grief, depressive symptoms, and/or caregiver burden in one third of all caregivers. These findings call for increased focus on caregivers' need of support.