Thoughts on integrative practitioners handling grief

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By Carolina Brooks, BA, IFMCP

I recently received a call from a patient’s husband. He was apologetic that my emails attempting to check in hadn’t been answered. She had passed away during the Christmas break. I knew the family quite well as they had been very involved in her treatment protocols and he thanked me for helping to extend her life from the two-week life expectancy she had originally been given when she booked an urgent initial appointment with me six years before. He wanted to know whether any of her supplements could be used by others in the family, to avoid wasting them. His interactions with me were formal and pragmatic, while I was deeply affected by her death and grieved privately for her.

A prostate cancer patient of mine was hospitalized with a severe lung infection. His wife called and described his state of health. I tried to keep a positive frame of mind, but my rational understanding was that the odds were not good. The patient’s wife was asking for reassurance and optimism from me that her partner would pull through, but I did not feel it was appropriate to offer unrealistic expectations so I could not tell her what she wanted to hear. It was an uncomfortable situation. The patient’s wife was angry when he passed, and I sent my condolences. She lashed out, but she later apologized for taking out her grief on me.

The subject of grief is something I like to discuss with colleagues. It is an elephant in the room for many of them, especially those who have never experienced any loss of their own. Everyone grieves differently, as demonstrated by the two cases I described. People want to hear different things. How are you supposed to know what will help someone who is grieving? What if you say the wrong things and elicit an angry response? Is it normal to feel sad when a patient dies, and what is the average period of time you are supposed to grieve?

In discussions with my naturopathic colleagues, I discovered, rather depressingly, that that the fear of dealing with grief has put many of them off working with potentially terminally ill patients, and so they specialize in different fields as one of their strategies of avoidance. I firmly believe we all need more training in this area.

A 2019 article in Psych Central discusses the five stages of grief and loss as defined in Elizabeth Kübler-Ross’s 1969 book, in On Death and Dying. The five stages are denial and isolation, anger, bargaining, depression, and acceptance.

An individual often moves back and forth between stages, may not experience all stages, and the stages may not present in a consequential order. Logically, if you recognize what stage of grief someone is in, this should help with formulating the right approach for that individual at that time. They may want space, they may want support, even if this is just a shoulder to cry on.

A 2008 paper in Research in Nursing and Health looking at physiological and psychological symptoms of grief in widows saw increases in mental and physical health impairment, including depression, feelings of guilt, existential tension, autonomic symptoms, gastrointestinal symptoms, weight changes, circulation issues, fatigue, physical pain, and poor eating habits, when compared with married women who had not experienced loss of their spouse. There is also increased risk of death, known as the “bereavement effect.” Researchers have found that grief-related symptoms are within the first four months after death, and that symptoms often subside after three years.

One of the key strategies drilled into us while studying was the importance of having a reflective practice, which I have kept up. Reflecting on and evaluating experiences helps to consider how a situation might be better handled. My practice is busy, but I always make time to write some notes at the end of each day. I also have a mentor who I discuss difficult situations with.

If a patient’s caregiver is struggling, either in expectation of bereavement, or if they have already lost their loved one, I offer a session with the grieving partner or caregiver if they want one, to allow us put some strategies in place for their own health, including nutritional support and ensuring that, if they are unable to handle cooking, they have appropriate meal or recipe deliveries in place until they are able to cope again. I teach breathing exercises and Heartmath, offer ear acupuncture, and use herbal combinations of hydrosols, tinctures, powders, and energetic blends with a lot of adaptogens for resilience and immune support, and grief-appropriate plants s such as rose, hawthorn, and albizzia. I also address the physical processes taking place, such as loss of appetite or insomnia and use whatever plants may be appropriate to support their ability to cope with the stress of bereavement.

A 2011 study in Oncology Nursing Forum discussed how nurses providing patients to actively dying patients can go on to experience trust issues, decreased capacity for intimacy, anxiety, anger,  irritability, and stressful incidents can trigger intrusive imagery whereby traumatic events are repeatedly relived in their minds.  I have always worked with cancer patients, many of whom have been given a terminal diagnosis. When I first started practicing, I felt uncomfortable, never knew what to say, and I felt isolated and unsupported as a solo practitioner with little in the way of a network around me. I took on other people’s traumas and grief, I knew I had to find a better way because I did not want to end up experiencing compassion fatigue. 

Compassion or empathy fatigue is defined in a 2016 paper in the International Journal of Environmental Research and Public Health as secondary traumatic stress coupled with cumulative burnout, a state of both mental and physical exhaustion caused by loss of ability to cope with one’s everyday environment. Compassion fatigue can be experienced by those who work directly with victims of trauma, grief, illness or disasters. Symptoms may include feelings of constant stress, anxiety, isolation, low mood, negativity, headaches, and sleep disturbance. Compassion fatigue may also lead to feelings of detachment and may impact standards of care and productivity, and relationships with both patients and colleagues.

If you work for an organization, ask what support there is in place. Shockingly, many organizations have no formally structured support or procedures in place for staff yet have counsellors and quiet religious rooms available for patients and their families. If you have colleagues, foster an environment of support, teamwork, and open discussion to reduce the collective stress burden. It is easier to talk to your peers if they are experiencing the same kinds of stressors as you are.

Arrange supervision or counselling if it’s available to you. Ensure your needs are being met in terms of scheduling and time off, to allow you to balance patient demands with strategies for prioritizing self-care by taking regular breaks at work and time off where required, focusing on eating a clean, nutritious diet, exercise, mindful or spiritual practices, and good sleep. Two strategies which rarely help include increasing workload as a distraction as this can accelerate burnout and discussing work events at home. It’s crucial to maintain boundaries between work and personal life. Whatever approach you take, it is important to recognize that grief is a significant part of a practitioner’s experience and should be taken seriously. It should not prevent a practitioner from feeling capable of working with terminally ill patients.

References

Cocker F., Joss, N. (2016). Compassion Fatigue among Healthcare, Emergency and Community Service Workers: A Systematic Review. International journal of environmental research and public health, 13(6), 618. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4924075/

Kowalski S.D., Bondmass M.D. (2008) Physiological and psychological symptoms of grief in widows. Research in Nursing and Health. 2008 Feb;31(1):23-30. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/18161825

Wenzel J., Shaha M., Klimmek M., Krumm S. (2011)  Working through grief and loss: oncology nurses’ perspectives on professional bereavement. Oncologyl Nursing Forum. 2011;38(4):E272–E282. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4648272/