Drs Lynsey Bennett and Sheena Sharma have created a model of how to integrate bereavement into primary care. Here, Dr Bennett explains why they believe that GPs should play a role in helping patients deal with grief.
My heart sank when I saw Mrs G’s name added again to my emergency list: ‘pulse racing, breathing probs’. I began to prepare for another 20 minute conversation with vague symptoms but just enough red flags to bring her into the surgery. I went to arm myself with caffeine, bumped into a colleague by the water heater and shared my pain.
‘Oh yes. I looked after her husband whilst he died last year. He was a strong character.’
This time when I called Mrs G, I asked about her husband and we had a very different conversation. She cried and then told me all about their happy life together. She couldn’t burden her children with her sadness – they were so busy and dealing with their own grief. At 71, she was the first of her friends to be widowed and found that many of them don’t want to talk about it. She thanked me for listening and I gave her details of a local bereavement support group. Now, I see her every few months and we enjoy talking about her husband as well as managing her chronic illness.
Grief is overwhelmingly common; not just in the context of death, but also as a reaction to significant life events – such as losing a job, ending a relationship or receiving a life-altering diagnosis. With GPs’ frontline position, helping patients navigate all sorts of conditions and illnesses, we have the potential to be there and support them through loss. It has the potential to be an enriching experience for all, but clinicians can find these conversations challenging.
The wealth of educational resources available to those working in palliative or specialist bereavement care is not always applicable to primary care. Our role is different; our appointments are much shorter but we know people before, during and after bereavement, sometimes for many years.
This discussion with Mrs G was just one of many that led myself and Dr Sharma – two GPs and educators with a special interest in bereavement care – to think about a new way to support patients with grief, and how to arm clinicians with the right tools to do so. We have combined our years of experience to develop a consultation model that aims to give clinicians a simple, memorable and easily applicable framework to use during any conversation about loss.
Grief is not linear
We based our model around a triangle, to parallel other consultation models (triaxial consultation model, transactional analysis models) and to move away from the idea that grief is a linear process with an endpoint. The points of the triangle represent different aspects of the grief journey (see below) and the two-way arrows between each demonstrate how a grieving person can move freely and frequently from one to another. We describe each point and suggest communication styles for clinicians to use at each, giving skills to navigate what can be a difficult consultation. At the centre of the model are features universal to bereavement care.
Acute grief
The emotions of acute grief are powerful and can often be negative, e.g. anger, guilt, sadness. We suggest the role of the clinician here is simply to acknowledge this. It is easy to slip into problem-solving or platitudes but try to tolerate the distress and create a space the bereaved person can come back to as needed during their grief journey. Normalise the need for support and emphasise the individuality of grief; there is no ‘correct’ way to respond to loss. Avoid using phrases which infer recovery. It is often enough to just listen for a short while, as done with Mrs G.
Grief can be an intensely physical experience – Mrs G was just one example. Ask about this to avoid unnecessary investigations. Anecdotally, women tend to feel symptoms more in the chest (heartburn, palpitations, chest pain) and men in the legs (physical pain, restlessness, weakness). Insomnia is common and can be disabling. Some people may need signing off work; there is no statutory entitlement to bereavement leave in the UK. Funeral directors, registrars, and medical examiners (England and Wales) will guide individuals through the immediate legal and practical issues around death, and excellent practical information is available via Sue Ryder and Cruse (see below).
Acute grief can last many months, so you might find yourself repeating this type of consultation several times. Some find that their own experiences of grief influence their reaction to this kind of conversation, so we discuss with colleagues if needed.
Story-telling
Recalling memories of loss helps us make sense of events and is a fundamental part of how we adjust to change. Use the name of the deceased person. Try a conversational style of consulting, with open questions; this can feel informal, but when done skillfully and with boundaries we are enabling the healing process whilst also considering whether someone is spending a lot of time in rumination – which can be a risk factor for depression or prolonged grief disorder. Encourage connection with the grief of others, via books, films, and support groups. Using the resources below, you can set up an SMS or email template to send to the patient – which is what I did with Mrs G.
Support services
- Sue Ryder’s Grief Guide
- Cruse
- Grief Works – Julia Samuel MBE (2017).
- Tools to facilitate a grief journey. Subscription only app includes live webinars with experts and a daily self-help guide.
- Good Grief Festival
- Online community bringing together grief experts and the bereaved for virtual and in person events
Looking forward
When looking forward, the bereaved person can see their future clearly but will still appreciate talking about the person who has died, like Mrs G. A coaching style of consulting is helpful here; consider where the person is versus where they would like to be. Discuss the concept of ‘growing around grief’. Perhaps talk about ‘touchstones’ – objects or rituals by which we remember the deceased.
Well-managed grief doesn’t just reduce the impact on the bereaved; it can reduce the frequency of patient contacts and make our jobs easier and more satisfying. My daily work today is very different to when I started practising 20 years ago. I consult largely over the phone, or via email, whilst simultaneously supervising the work of several patient-facing clinicians in ARRS roles.
Discussing bereavement feels like treating myself to a bit of ‘old-fashioned general practice’. I spend time over a few weeks or months getting to know someone and their family, offering regular contact, including at home if they are housebound. I have dusted off my copy of ‘The Inner Consultation’ and enjoy tuning in to what is not being said during consultations.
This might sound daunting, but with practice over the last 12 months, I have found I can fit this around checking a BP, examining a leg ulcer and maybe even ticking a QOF box. My face-to-face appointments are 15 minutes which gives me ample time to acknowledge the sadness of loss or listen to an anecdote, as I do with Mrs G. Grief is an important cause of morbidity and mortality and is therefore completely integral to our work. Helping patients deal with bereavement is holistic care at its very best, and I have personally found it the perfect antidote to burnout.
Dr Lynsey Bennett is a GP and GP trainer Oxford and a Bereavement Care Fellow at Thames Valley and Wessex Primary Care School.
Dr Sheena Sharma is a GP and GP trainer Oxford, and Associate Dean at Thames Valley and Wessex Primary Care School.
