Helping survivors cope with their sorrow

Observations on the state of medical practice and medical life

By Eric Anderson, MDis a semiretired family physician in San Diego. His commentaries from 2000-05 are available on amednews.com. Posted Jan. 26, 2004.

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There are patients right now in our waiting rooms whose needs may never be met. Those concerns won't be addressed because they aren't the reason for the visit as documented by the receptionist or nurse.

The unmentioned problems hovering over our patients might include the intractable difficulty of a son who refuses treatment for his schizophrenia or a granddaughter who denies her drug addiction, or could embrace the angst of a woman who is having an office affair with a married man or the ache of a husband who has just lost his wife.

Of all those concerns not broached, one of the worst must be the pain of sorrow.

Margaret, my wife, kept a magnet on our refrigerator door for years. It was still there when she dropped dead in our kitchen. It read, "Every cloud doesn't mean a storm." Such innocence! Such little knowledge of the skies above us. Because for many of us, especially if the marriage was a happy one, the death of a loved one is a storm enough to top Shakespeare's The Tempest. It may last the survivor's lifetime. And the sting of such sorrow can be almost insufferable.

Little Finland, oddly enough, is the one country that keeps immaculate data on deaths. Its statistics show the death rate for the surviving spouse increases 600% six days after the death of the first spouse. Finland's health workers believe the sixth day is, conventionally, when relatives go home and the survivors are left to themselves. To grieve alone.

Patients who are grieving may come to their doctor on many pretexts: blood pressure checks, lipid assessments, flu shots. If the booking was for a brief office visit, doctors don't want to dig too deep -- we can't afford to. Time is money. But perhaps, even briefly, we could help our patients cope better when they've had a huge loss if we better understood what's happening to them.

So how can we help our patients in this so difficult situation of death?

First, we need to understand the extent of the loss. If our patient is widowed, she might have lost the stalwart rock in her life and, if elderly, might be foundering in financial details that never were properly explained to her -- sexist though that sounds. If a wife has died, the man has probably lost much of the sweetness, the softness in his life because -- as perceptive men have said -- women are just like us but with the barbarian left out.

After a death, survivors have to confront their own mortality. They recurrently become aware of their loss as if for the first time. At times they forget and set the table for two or hear a joke and remember it to tell their spouse later. Then they realize, yet again, that there is no later.

They see young families and grow wistful for the past. They can become incoherent and disorganized and suffer panic attacks. And they don't quite know what's happening.

Second, we need to say the right things -- and mean them. Survivors say they appreciate a simple expression of sympathy, but they don't care to hear meaningless additions to that, especially, "He has gone to a better place," which makes the widow always want to say, "No. A better place is right here beside me." One useful approach is to acknowledge that the survivor has gone through an enormously difficult time. It is an observation that prompts survivors to relate to the situation in terms of their own feelings and helps them open up.

John W. James, the co-founder with Russell P. Friedman of the Grief Recovery Institute in Sherman Oaks, Calif., now an international organization, came into this field a quarter-century ago when his 3-day-old baby died and he and his wife found the medical establishment so lacking in comfort. It is said nothing can relieve the sorrow of a parent who has buried a child. The divorce rate in child-loss marriages is an unbelievable 83% within one year. His own marriage was no exception.

He doesn't say it, but one wonders: If concerned professionals were better at comforting grieving persons, maybe families would grow stronger, not weaker when members die. The Grief Recovery Institute's Web site (link) has brief articles that offer perspective, especially for survivors.

Third, we need to be there, scheduling visits for no other reason than to let them talk. We know patients often want to tell the story of the illness as well as giving symptoms, and grief is an illness like any other, a chronic, long-lasting and incurable illness for many. According to JoEllen Patterson, PhD, a San Diego psychologist, we might have to tell them that the pain in some form might last forever, but we're here to help them have some joy in their lives one day.

It may be useful if we know what books are out there that might assist. Viktor Frankl's Man's Search for Meaning has sold over 2 million copies, and How to Survive the Loss of a Love by Melba Colgrove, PhD, Harold H. Bloomfield, MD, and Peter McWilliams has 3 million copies in print. Martha Whitmore Hickman's Healing After Loss: Daily Meditations for Working Through Grief is particularly encouraging as it has a thought for each specific day of the year. We should support whatever helps, whatever it takes, whatever works.

Fourth, we need to ask the right questions, some obvious: Are they sleeping? Eating? Getting outdoors? Exercising? Staying in touch with family? Taking their medications? Coping? Do they offer us eye contact? Can they satisfy us that they still consider life worth living? That's clearly important, and we might need to solicit feedback from the family.

Fifth, we need to encourage them to talk to someone: a member of the clergy, a close relative, a friend. When people offer help, those who are grieving should respond -- not turn away. We should be prepared to suggest a therapist for this turmoil now roiling their lives. Patients must understand that this loss of a long-term partner will be the most overwhelming challenge they will ever face -- and the more happy, the more perfect the marriage, the worse the loss.

We can't let them go the "If only" route, as my mother did for 30 years of widowhood. "If only I hadn't stepped away from his hospital bed shortly before he died." Survivor guilt is common. I know that. Yes, I know that.

Bernie Siegel, MD, the author and former Yale surgeon, always said: "Dying is easy, it's the living that's hard."

If death was sudden, it may help the survivors live if they believe that's the best death for the patient, albeit the worst for the survivor because they didn't get the chance to say goodbye as they would, had the patient had a long decline.

Sixth, we need to help them to be active and engaged but not endlessly busy. They need to be doing things: picking up the pieces, plucking at life, but the pace shouldn't be frantic. They fill their time with too much work, or endless tasks and chores. At the end of any given day, asked how they feel, invariably they report that their heart still feels broken; that all they accomplished by staying busy was to get exhausted.

They should know it's OK to talk to the person who has gone and that they might have "a visit" from the departed person usually in a darkened bedroom when they are half asleep. Those things do not mean that they are losing their minds.

Finally, we need to know that there is never a wrong time to tell survivors we are or were sorry for their loss. This is especially true with parents who have lost a child. They want you to talk about the dead person. Said one mother to me in response to that question: "Oh, yes. Please talk about Patrick. If you don't, it's as if he never lived." Our comments validate the person's life. And our kindness and caring validates the lives of those who survive and carry on.

Editor's note: Dr. Anderson's wife had carried the diagnosis of idiopathic dilated cardiomyopathy for nine years and had a fatal arrhythmia on March 29, 2003. They were high school sweethearts and married in 1955 when he was in medical school.

Eric Anderson, MD is a semiretired family physician in San Diego. His commentaries from 2000-05 are available on amednews.com.

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