End-of-life discussions benefit patients and caregivers
A study of 332 terminally ill cancer patients at the Dana-Farber Cancer Institute revealed that patients who said they did not discuss end-of-life issues received more aggressive medical care in their final week of life.

Such aggressive treatment was linked to lower quality of life for the patients and their caregivers, who also experienced feelings of regret and an increased risk of depression. Those who reported engaging in end-of-life discussions, on the other hand, were more likely to receive hospice services, and their loved ones reported a better quality of life during bereavement.

Doctor-patient discussions result in less aggressive treatment, lower costs
Meanwhile, the March 9 issue of the Archives of Internal Medicine included a report on a study of 603 terminally ill cancer patients, which was funded by the National Institute of Mental Health and the National Cancer Institute as part of the ongoing Coping With Cancer study.

According to the report, when doctors and patients talked about whether treatment should focus on prolonging life or controlling symptoms, patients were more likely to die at home and spend less time pursuing aggressive treatments. Researchers say these patients had a better quality of life and survived as long as those who did not discuss end-of-life options with their physicians.

The benefits of open communication between doctors and their dying patients include not only physical and emotional comfort, but also cost savings. The cost of providing health care in the last week of life was 36 percent lower for patients who reported having end-of-life discussions with their doctors, and researchers estimate that more than $76 million could be saved annually if just half of the people who die from cancer each year had those discussions with their physicians.

With such a wide spectrum of “normal” in the grieving process, how can we know when grief is spinning out of control? Bereavement counselors and therapists who differentiate normal grief from “complicated grief” are leading a movement to establish “Prolonged Grief Disorder” as a new mental-health diagnosis for clients who, six months after the loss of a loved one, are showing no signs of being able to recover or move on with their lives.

Normal response or mental disorder?
Holly Prigerson, who studies bereavement at Dana Farber Cancer Institute, says the key symptom that makes Prolonged Grief Disorder different from depression or anxiety is an intense yearning. Prigerson says that normal grief is “wanting what you can’t have. That hankering and yearning and pining and craving for something that you think is essential to your sense of happiness and well-being.”

In complicated grief, the intense yearning, preoccupation with the deceased, and feelings of emptiness do not lessen with time. In other words, complicated grief is the inability to recover after the death of a loved one. Prigerson’s research suggests that 10 to 20 percent of Americans who suffer a loss experience prolonged grief.

The current Diagnostic and Statistical Manual of Mental Disorders (DSM) defines grief as the normal response to loss rather than a medical diagnosis, and doctors are not paid to treat it. If complicated grief is approved as a new disorder, symptoms and treatment protocols would be established, and doctors could be reimbursed for treating patients with the disorder.

How to recognize complicated grief
According to the National Institutes for Mental Health (NIMH), the following symptoms may indicate complicated grief when they persist, with no sign of abating, for more than six months following the death of a loved one:
•    Strong yearning for the person who died
•    Waves of intense sadness and longing
•    Feeling of disbelief or difficulty accepting the death
•    Avoiding people, places or things that call to mind the loss
•    Pervasive bitterness or anger
•    Feeling intensely alone or lonely
•    Inability to control thoughts, memories, or images of the person who died
•    Seeing life as empty or meaningless without the lost loved one
•    Belief that grieving less would be a betrayal of the deceased

Study to explore complicated grief in older adults
In April, NIMH began recruiting 200 older adults who suffer from unrelenting symptoms of complicated grief to participate in a four-month, non-drug clinical trial. Dr. M. Katherine Shear of Columbia University is the psychiatrist conducting the study. “The death of a loved one can take an especially devastating toll on an older adult,” says Shear. “Older people may experience a cascade of losses as their social circles become smaller. The death of a spouse, adult child, friend, parent, or sibling — along with the social, financial and medical issues that accompany it — can throw an individual into a discouraging downward spiral. People who continue to struggle with bereavement after more than six months may be experiencing complicated grief. We believe we can help.”

Source: Reuters, WBUR.org