Mohammed T. Abou-Saleh

466 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYhas both its advantages and its risks. Did this survivor start todetach him/herself emotionally while the spouse was still alive,depriving them both of the support they needed? Or did bothpartners use this time to affirm their love and consult with eachother in making plans and decisions?Physicians and other caregivers have the opportunity to makevaluable contributions to the survivor’s ability to cope with griefby sensitive response to the situation as it exists prior to the death.Offering accurate information, suggesting other options andimproving the lines of communication within the family areamong the ways in which one can help to shape the anticipatorygrief period into a source of strength rather than intensifiedanxiety. The age differential between most caregivers and theelderly bereaved people they are trying to help sometimesinterferes with communication, e.g. when elders are patronizedand their ability to cope with bad news is underestimated. There isalso an underappreciated connection between quality of terminalcare and grief recovery. A hospice physician reports that, ‘‘Thepain relief we achieve for an old man in his last weeks of life helpshis wife to be more of her normal self when he really needs her—and a widow with fewer regrets and nightmares later’’ 5 .3. What Was the Survivor’s Own Health Status Previous tothe Bereavement?This is a particularly useful question to ask with respect to theolder bereaved person. The spouse was the most frequentprincipal family caregiver in the 40 hospices studied by Mor etal. 6 . About two-thirds of the spouses taking responsibility for carewere people above the age of 55 and it was not unusual for thecaregiver to be over 75. The elderly caregiver seldom developednew physical problems over the course of the spouse’s final illness,but there was a tendency to ignore his/her existing conditions.During the first months of bereavement, the survivor’s health wassometimes impaired by exacerbation of previous illnesses andimpairments. It would be helpful, then, to encourage the spouseand other elderly family members and friends to look after theirown health during the pre-bereavement period, and to see thathealth status is carefully assessed afterward. Symptoms that mightappear to be part of an anxious depression syndrome could berelated to physical health problems that have not received theattention they deserved.example, the difference between death at home and in a hospitalsetting. A terminally ill woman was being looked after at home byher elderly mother, with support from a local hospice service. Themother had accepted her daughter’s wish to be allowed to die athome without intubation and other futile procedures. But whenthe daughter appeared to be actively dying, the mother panickedand called not the hospice but a visiting nursing service. Now, as asurvivor, the old woman is haunted by memories of her suctioned,intubated and drugged daughter accusing her with her eyes 7 .Inamore frequent scenario, an elderly person will call for assistancefrom paramedics when his/her spouse appears to have died. Butwhen the paramedic team arrives, the caller may have secondthoughts about seeing the spouse’s body subjected to resuscitationprocedures. Some bereaved elderly persons remain troubled notby the fact of the death itself, but by unanswered questions aboutwhether or not they did the right thing at the right time.Knowing only that the death took place in a hospital does nottell us whether supportive nurses encouraged a woman to be withher husband right through to the end and to have time with himafterward—or whether she was made to feel unwelcome andhustled away. Perhaps, again, she had not been notified until sometime after the death. The particularities of the final scene caneither provide an acceptable conclusion to the story of a marriageor friendship, or torment the survivor with resentment, self-doubtand other disturbing thoughts.The psychiatrist often has the opportunity to increase thesensitivity of physicians, nurses, and other caregivers in theircommunication patterns around the time of death. Survivors mayhold on to a word or a gesture, either as a cherished or aninfuriating/depressing memory. Often one can be helpful simplyby validating the survivor-to-be’s feelings and giving him/her theopportunity to clarify his/her own thoughts by active listening.The generational difference between the bereaved person and thepsychiatrist can be a source of misunderstanding. A widow, forexample, may first respond according to the models of grief thatwere prevalent in her youth. It may take patience and encouragementto help her discover, express and cope with her own feelings.It is also helpful to be aware of ethnic differences in expectationsfor behavior around the time of death. Caregivers whose owntradition involves subdued behavior and restraint of emotionsmay not be prepared for families in which intense expressions ofgrief are expected, even required.4. Who Else Was There and What Else Was Happening?Explored diligently, this line of inquiry may reveal significantsources of concern or potential strength that bear on adjustmentto the loss. ‘‘Well, Frank’s brother had come to live with us again.And he was drinking again. I could have killed him’’; ‘‘The peoplefrom the church were over all the time. They really cared. We wereso far from the rest of the family, but they were just like family tous . . .’’; ‘‘I couldn’t get anything from the doctor—what wasreally going on with George, what else I could do. I felt like tellinghim, ‘I’m old—not stupid!’, but you don’t do that, do you?’’.Some of the problems that beset the survivors after the death maybe the continuation or outcome of difficulties that occurredearlier. Strained interpersonal relationships and unansweredquestions create more of a burden for some survivors than thedeath itself.AT THE TIME OF DEATHLearning what happened around the time of death can help usunderstand the bereaved elder’s state of mind. Consider, forEARLY PHASES OF BEREAVEMENTThe idea that there are fixed ‘‘stages’’ of either dying or grief hasattracted more believers than it deserves. One can select and forceobservations to fit stage theories, but to what purpose? Individualresponses to grief deviate markedly from the models: this is evenmore common in old age, where uniqueness has been deeplyengraved and polished to a high gloss.It does make sense, though, to differentiate between responsesto earlier and later periods subsequent to bereavement. Indicatorsof a potentially intense, disabling and protracted reaction oftenappear within a short time. Parke and Weiss 8 found that thosewho had the most difficult time coping with the spouse’s deathtended to smoke and drink more heavily, use tranquilizers andexpress depressive mood (e.g. ‘‘Life is a strain for me . . . I wonderwhether anything is worthwhile any more’’). These and otherinvestigators have found that the way the survivor responds to theloss within the first few months provides a fairly reliable forecastof what kind of adjustment will be made over a longer period oftime. The obvious lesson here is that early-appearing indicators,such as loss of appetite, withdrawal from friends and activities,sleep disturbances and escape into alcohol and drugs (including