Is Complicated Grief More Common in Families That Have Lost Someone Through Terminal Illness

Omega (Westport). Writer manuscript; available in PMC 2012 January 24.

Published in final edited form as:

PMCID: PMC3265356

NIHMSID: NIHMS347129

COMPLICATED GRIEF SYMPTOMS IN CAREGIVERS OF PERSONS WITH LUNG CANCER: THE Function OF FAMILY Disharmonize, INTRAPSYCHIC STRAINS, AND HOSPICE UTILIZATION^*

Abstract

Guided by a stress procedure conceptual model, this report examines social and psychological determinants of complicated grief symptoms focusing on family conflict, intrapsychic strains, and the potential moderating upshot of intendance quality and hospice utilization. Relying on data from 152 spouse and adult child lung cancer caregiver survey respondents, drawn from an ancillary report of the Assessment of Cancer Care and SatiSfaction (ACCESS) in Wisconsin, hierarchical multiple regression analysis was used to examine determinants of complicated grief. Later decision-making for contextual factors and time since death, complicated grief symptoms were higher among care-givers with less education, among families with lower prior conflict but higher conflict at the cease-of-life, who had family unit members who had difficulty accepting the illness, and who were caring for patients with greater fright of expiry. Additionally, hospice utilization moderated the result of fear of death on complicated grief. Findings suggest that family conflict, intrapsychic strains, and hospice utilization may aid to explicate the variability plant in complicated grief symptoms amongst bereaved caregivers. Implications for enhancing complicated grief assessment tools and preventative interventions across the continuum of cancer intendance are highlighted.

INTRODUCTION

Every year approximately 160,000 persons, primarily elders, die from lung cancer; the leading cause of cancer mortality in the United States (American Cancer Social club, 2009). Given the rapid deteriorating course of illness, prevalence of uncontrolled symptoms (Griffin, Koch, Nelson, & Cooley, 2007), and stigma associated with lung cancer that is reported past smokers and non-smokers (Chapple, Ziebland, & McPherson, 2004), it is non surprising that these families report high levels of distress during the dying process (Cameron, Franche, Cheung, & Stewart, 2002). Compared to the general population, significant others of lung cancer patients score lower on psychological well-being and feel a decline in family functioning over the course of affliction that continues later the death (Persson, Östlund, Wennman-Larsen, Wengström, & Gustavsson, 2008). Little research has been done on how family unit disharmonize and experiences during treatment and at the end-of-life may influence the bereavement outcomes of family caregivers.

There is tremendous variability in how individuals adapt following the death of a family member; the vast majority of whom are fairly supported, and exercise non benefit from intervention (Jordan & Neimeyer, 2003). Given the high gamble of suicide and other agin mental and physical health outcomes (Latham & Prigerson, 2004), agreement what contributes to complicated grief symptomatology is necessary to identify caregivers at chance and to develop relevant interventions. Preliminary evidence suggests that family disharmonize and intrapsychic strains at the end-of-life that are commonly experienced by family unit members of persons with lung cancer (Cameron et al., 2002), may contribute to bereavement adjustment difficulties (Kramer, Boelk, & Auer, 2006). The purpose of this article was to examine the predictors of complicated grief symptoms focusing on the role of family disharmonize, intrapsychic strains, and the potential moderating effect of care quality and hospice utilization.

Theoretical Framework

Stress process theories have been influential in informing an extensive body of research on the bear upon of family unit caregiving (Kramer & Vitaliano, 1994), and more recently caregiving and bereavement outcomes (Burton, Haley, Pocket-size, Finley, Dillinger-Vasille, & Schonwetter, 2008). Aside from background and contextual considerations, the stress procedure model is made up of 4 principal domains: primary stressors, secondary stressors, moderators, and outcomes (Aneshensel, Pearlin, Mullan, Zarit, & Whitlatch, 1995; Pearlin, Mullan, Semple, & Skaff, 1990).

Primary Stressors

Patient Clinical Care Needs

Primary stressors are the hard circumstances experienced past family care-givers that stalk from the patient'southward care needs (Pearlin et al., 1990). Lung cancer patients have a high prevalence of uncontrolled lamentable physical symptoms; the well-nigh common are pain, shortness of breath, nausea or vomiting, and fatigue (Griffin et al., 2007). These symptoms exacerbate co-occurring psychological symptoms such as patient depression and anxiety (Portenoy, Payne, & Jacobson, 1999), and family distress (McMillan & Minor, 2007). Caregivers experience better bereavement adjustment when these symptoms are minimized and quality of life is enhanced (Grande, Farquhar, & Barclay, 2004).

Secondary Stressors

Part Strains

"Secondary stressors are the means that primary stressors influence and disrupt other areas of the caregiver's life" (Gustavsson & Dal Santo, 2008, p. 292), and are associated with worse bereavement outcomes (Bernard & Guarnaccia, 2003). Pearlin and colleagues (1990) identified family conflict equally a fundamental role strain that may ascend in caregiving families. Based on prior inquiry, suggesting that greater bereavement distress among family caregivers is more likely among families in conflict (Kramer et al., 2006) and who have poorer family performance (Kissane, Bloch, Miach, Smith, Seddon, & Keks, 1997), it is hypothesized that family conflict will be associated with more than complicated grief symptoms.

Intrapsychic Strains

Intrapsychic strains are psychological difficulties occurring within the mind that may exist influenced past primary stressors. Two intrapsychic strains that may be particularly relevant to lung cancer caregivers are difficulty accepting a highly stigmatized illness and the patient's fear of death, that is distressing to witness (Chapple et al., 2004). "Acceptance" has been put along as an essential component of illness aligning, and a growing trunk of literature has focused on the correlates of acceptance among patients with acute and chronic heath weather condition (Stuifbergen, Becker, Blozis, & Beal, 2008). Grieving may be hampered when ane has difficulty accepting illness and related feelings of loss (Prigerson & Maciejewski, 2008). Although an extensive torso of literature has developed investigating the predictors and outcomes of death anxiety amongst elders, the seriously ill and professional person caregivers (Neimeyer, Wittkowski, & Moser, 2004), and personal fright of death as associated with bereavement outcomes (Barr & Cacciatore, 2008), little attention has been given to how the patient'due south fear of death might influence caregiver bereavement. Compared to other cancer patient populations, lung cancer patients exhibit the highest rates of psychological disorders, and existential distress is elevated closer to death (Lichtenthal, Nilsson, Zhang, Trice, Kissane, & Prigerson, 2009). Emotional distress is higher among caregivers of patients perceived to have death feet (Morita, Akechi, Ikenaga, Inoue, Kohara, Matsubara, et al., 2007). It is hypothesized that difficulty accepting the illness and patient fearfulness of death will contribute to complicated grief symptoms.

Moderators

Resources

Resources are the various supports that one has to manage stressful experiences and these are thought to moderate the relationship between stressors and outcomes (Pearlin et al., 1990). Two resources that are peculiarly salient to the needs of lung cancer patients and families are quality of care and hospice utilization. Ameliorate care quality is associated with college quality of life for care-givers of patients with lung cancer (Ryan, Howell, Jones, & Hardy, 2008), and bereaved family unit members who are fairly supported by health intendance providers experience lower levels of psychiatric affliction following hospital deaths (Siegel, Hayes, Vanderwerker, Loseth, & Prigerson, 2008). Back up received prior to decease, is a stronger predictor of bereavement aligning than support received after death (Bass, Bowman, & Noelker, 1991), and perceptions of care quality are associated with better bereavement aligning (Grande et al., 2004).

Hospice programs are specifically designed to provide end-of-life care in order to manage distressing symptoms, maximize patient quality of life, accost needs of family unit, and is touted equally the optimal intendance model for patients with advanced lung cancer (Griffin, Koch, Ackerman, & Cole, 2003). Family members study greater satisfaction with hospice care than care in other settings (Yancey, Greger, & Coburn, 1990), and improved family unit well-existence and functioning (Godkin, Krant, & Doster, 1983–84). Findings regarding hospice utilization and the influence on bereavement outcomes are mixed. Some find utilization to have a positive influence (Christakis & Iwashyna, 2003; Steele, 1990), but others report no human relationship (Grande et al., 2004; Yancey, Greger, & Coburn, 1990). Co-ordinate to the stress process model, we hypothesize that the impact of family disharmonize and intrapsychic strains on complicated grief symptoms will be intensified when resources are depression and macerated when they are plentiful.

Outcomes

Complicated Grief Symptoms

Salient outcomes of the stress procedure include psychological well-being indicators related to the individual'southward "ability to sustain themselves in their social roles" (Pearlin et al., 1990, p. 590). Complicated grief symptoms interfere with daily life and the fulfillment of social roles (Prigerson, Maciejewski, Reynolds, Bierhals, Newsom, Fasiczka, et al., 1995) and are experienced by ten%–20% of the population (Prigerson & Jacobs, 2001). Although in that location are important features that distinguish information technology from bereavement related depression, feet and Posttraumatic Stress Disorder (PTSD) (Zhang, El-Jawahri, & Prigerson, 2006), one report reports equally many as 75% of complicated grievers also meet criteria for PTSD (Tolstikova, Fleming, & Chartier, 2005). Given that complicated grievers feel intense, persistent emotional and functional impairment (Schulz, Boerner, Shear, Zhang, & Gitlin, 2006), identifying the contributing factors of this particular issue is an important goal of bereavement enquiry.

Groundwork and Context—Control Variables

Pearlin et al. (1990, p. 585) propose that the effects of "ascribed statuses, such as age, gender, ethnicity, along with teaching … and economic attainments are expected to be threaded throughout the entire stress process," influence the main and secondary stressors individuals are exposed to, the resource they accept access to, and the outcomes they experience. As such information technology is important to control for these and other contextual variables. Other contextual variables include advanced intendance planning and the family context. Among several forms of advanced care planning, discussions with significant others is considered an essential component of the planning process (Hammes & Rooney, 1998). Stress and mail-death depression and anxiety among relatives may exist reduced when caregivers know the patient'southward preferences for intendance (Detering, Hancock, Reade, & Silvester, 2010; Tilden, Tolle, Garland, & Nelson, 1995), and bear witness suggests that "end-of-life discussions may have cascading benefits for patients and their caregivers" including amend caregiver bereavement adjustment (Wright, Zhang, Ray, Mack, Trice, Balboni, et al., 2008, p. 1670). Although little attention has been given to the family unit context, college bereavement risk was establish among those with young children at home (Beckwith, Beckwith, Gray, & Micsko, 1990) and a history of conflict was associated with guilt post-obit expiry which negatively effects bereavement adaptation (Mullan, 1992). In addition, a history of conflict is a strong predictor of family conflict at the end-of-life (Kramer, Kavanaugh, Trentham-Dietz, Walsh, & Yonker, 2009), and needs to be taken into consideration in order to empathise how conflict at the end-of-life might influence bereavement outcomes.

This study will place and control for the background and contextual variables that are significantly associated with complicated grief among intendance-givers of deceased lung cancer patients and volition test the post-obit two hypotheses, which were generated from this review of the literature and the stress process model.

Hypothesis one: Afterwards controlling for time since expiry, history of family conflict, and other contextual and primary stressor variables, secondary stressors (i.eastward., family conflict at the finish-of-life, family member difficulty accepting the illness, and patient fright of death) volition significantly predict complicated grief symptoms.

Hypothesis 2: The quality of intendance provided to the patient and family and hospice utilization volition moderate the effect of secondary stressors on complicated grief symptoms.

METHODS

Data Sources

The results reported here are fatigued from an ancillary mail survey of family members of persons who died with lung cancer, drawn from the larger Assessment of Cancer CarE and SatiSfaction (ACCESS) study conducted in the state of Wisconsin. Sampling and survey methods from the ACCESS and ancillary lung cancer family unit study are described in detail past Trentham-Dietz and Walsh (2008) and Kramer et al. (2009) respectively. In cursory, of 358 primary family unit caregivers of persons who died with lung cancer, who were identified in a statewide registry and who had contact information available, 205 (57%) agreed to receive the study questionnaire, and 169 returned surveys (82% of those who received the survey; 47% of total contacted). Consequent with the national profile of informal stop-of-life caregivers (Wolff, Dy, Frick, & Kasper, 2007), the majority, 158 (93%) of respondents were spouses (n = 141) or adult children (n = 17). The analytic sample is confined to 152 of these respondents. These included 148 who answered all of the complicated grief items, and four others who had completed fifty% or more of the items. In these cases we used the person mean substitution method (Downey & King, 1998) found to exist the optimal technique for imputing missing data when half of the items are present (Hawthorne & Elliott, 2005). The time between death and completion of the surveys averaged 19 months (SD = seven.37), and ranged from .9 to 34 months.

Measures

Dependent Variable—Complicated Grief

In 1995 the Inventory of Complicated Grief (ICG) was introduced equally the commencement measure to assess maladaptive grief symptoms (Prigerson et al., 1995), and has since been well validated and widely used. The ICG-revised (ICG-R) is a more than gimmicky version of the ICG further refined past an adept consensus panel (Prigerson & Jacobs, 2001). Using 5-point scales to represent increasing levels of symptom severity respondents rated nine items addressing symptoms of yearning and longing for the deceased, trouble accepting the death, difficulty trusting people, bitterness over the death, inability to move forward, sense of emotional numbness, sense of edginess, feeling the future holds no prospect for fulfillment without the deceased, and feeling life is empty or meaningless without the deceased. This measure is highly correlated with clinical assessments of complicated grief and distinguishes complicated grief from typical grief symptoms in terms of the prediction of morbidity, persistence and intensity (Prigerson & Maciejewski, 2005). A mean score was calculated. Cronbach'southward α was .90.

Primary Stressors

Two measures of patient clinical intendance needs were assessed. An index of iv mutual physical symptoms associated with lung cancer was assessed by asking: "Did your family fellow member accept: a) pain; b) shortness of breath; c) nausea or vomiting; or d) severe tiredness or fatigue during or afterward any of his/her cancer treatments?" Cronbach's α was .66. A psychological symptoms index was assessed by asking "Did your family fellow member experience: a) loss of hope or depression; and/or b) feet during or after any of his/her cancer treatments?" Cronbach's α was .57.

Secondary Stressors

Function strains

A 4-item Family Conflict at the Stop-of Life (FC-EOL) scale was developed for this report, based on findings from a prior qualitative study (Kramer et al., 2006), a literature review, and prior clinical experience. Respondents were asked to apply a v-bespeak scale (1 = non at all to 5 = very much) to answer the following four questions "Every bit you recall most the decisions that your family unit member and the rest of the family faced near the end-of-life, how much did whatever family unit members: Disagree or fence with one another? Feel resentment toward i another? Feel anger toward one another? Insult or yell at ane another?" A hateful score for family disharmonize was calculated. Cronbach's α was .93; detail to total correlations ranged from .72 to .88.

Intrapsychic strains

Family difficulty accepting the illness was assessed with response to the question "How much did whatsoever family members find information technology hard to accept the illness?" using a 5-point continuum to indicate the degree of difficulty (0 = non at all to 4 = very much). Patient fear of death was measured by a 5-bespeak rating of agreement (one = strongly disagree to v = strongly agree) with the statement "After his/her lung cancer diagnosis, my family fellow member was afraid to die."

Moderators—Resources

Patient quality of intendance was assessed using nine items adapted from the Toolkit of Instruments to Measure Stop-of-Life Care (Teno, 2004). Using a 5-betoken response set (0 = non at all to five = very much), respondents rated the extent to which the patient was treated with kindness and respect, and their physical, psychological, spiritual, and informational needs were adequately addressed. Cronbach's α was .86. Family quality of care was assessed using five items adapted from the Toolkit of Instruments (Teno, 2004) to rate family intendance quality. Respondents rated the extent to which the treatment staff included them in decisions, were sensitive to their feelings, paid attending to their wishes for care, and were helpful in explaining the patient's condition, using a 5-point response set up (0 = not at all to 5 = very much). Cronbach's α was .84. Hospice utilization was determined with the question "Was hospice involved in the medical care of your family unit member?" (0 = no; 1 = yes).

Groundwork and Context

Demographic characteristics included sociodemographic variables such every bit age (continuous variable that was dichotomized; 0 = under 65; 1 = 65 or over), gender (0 = male; 1 = female person), race (0 = Not-Hispanic White; one = Black), income (iv income categories included less than $12,000, $15,000–$29,999, $30,000–$49,999, and $50,000+), education (two categories that include high schoolhouse or less, and some college or advanced caste), and relationship to the deceased (0 = developed child; i = spouse). Intendance preferences specified was ascertained by asking: "Did your family member take specific wishes or plans well-nigh the types of medical treatment he/she wanted while dying?" (0 = no; 1 = aye). Regarding family context we assessed presence of children in the home (0 = no; 1 = aye), and history of family disharmonize prior to affliction with a two-item scale developed past (first author). Respondents were asked "Prior to [the decedent'due south] affliction, how much did any of your family members: 'have serious arguments with one some other;' and 'insult or yell at ane another'?" Response categories range from 0 = non at all to 4 = very much. Cronbach'south α was .94.

Analytic Plan

Details regarding strategies for treatment missing data are reported elsewhere (Kramer et al., 2009). The analysis has iv parts. Starting time, nosotros present descriptive statistics and the results of the two-tailed t tests and F tests comparison the means for complicated grief on all values of the categorical background and contextual variables. 2nd, nosotros present the descriptives and bivariate correlations for the analytic variables. Third, to test the get-go hypothesis, we used hierarchical multiple regression assay to control for the time since death, contextual variables, and primary stressors. Given the limited sample size and the number of independent variables, aside from time since decease and history of family conflict, only the variables that were significantly correlated with complicated grief were chosen for the analysis to allow for a more parsimonious model. Omitted contextual variables were analyzed as covariates in an exploratory regression analysis, and their presence did not alter appreciably the relationships between disharmonize, intra-psychic strains, and complicated grief. Finally, to examination hypothesis 2 and examine the extent to which resources would have a stress-buffering upshot, interaction terms were computed by multiplying each of the selected secondary stressor variables past each of the three resources variables, which were centered before forming the multiplicative terms (Jaccard, Turrisi, & Wan, 1990). Carve up regression analyses were run to identify any pregnant interactions. One interaction was a significant predictor of complicated grief and as such, the regression analysis included 2 additional blocks to command for resources and this interaction effect respectively. The more conservative 2-tailed tests of significance were used to interpret the results.

RESULTS

Sample Characteristics and Contextual Correlates of Complicated Grief

Sample characteristics and complicated grief ways for categorical background and contextual variables are described in Table 1. The majority of respondents were female, Non-Hispanic White, spouses, with less than a college instruction. The sample fell fairly evenly into the under and over age 65 groupings. Consequent with the national profile of terminate-of-life caregivers, the mean age was 63 for family members (Wolff et al., 2007), and 66 for patients (SD = 8.82; range = 43–80), indicating that this was primarily an older sample. Less than half of the patients had expressed specific wishes for end-of-life intendance (39%) and the majority (68%) received hospice care. Complicated grief symptom were greater among those who were younger (t = 2.96, p ≤ .01), less educated (t = 2.65, p ≤ .01), and who had more than children in the home (t = 2.49, p ≤ .01). No differences were constitute past gender, race, income, or relationship, and grief was college among those caring for patients who had expressed their end-of-life care wishes (t = 2.52, p ≤ .01).

Table one

Sample Characteristics and Complicated Grief Means for Categorical Groundwork and Contextual Variables (N = 152)

	N	%	Complicated grief a
			Mean	SD
Historic period
Less than 65(b=1)	74	(49.0)	2.59	(.97)**
65+(b=ii)	78	(51.0)	2.19	(.69)
Gender
Male	31	(20.4)	2.35	(.84)
Female	121	(79.half-dozen)	2.39	(.87)
Race
Non-Hispanic White(b=2)	148	(97.4)	two.37	(.86)
Black	4	(2.6)	ii.83	(.71)
Income
Less than $15,000	17	(11.2)	2.23	(.81)
$15,000 to $29,999	32	(21.i)	two.28	(.81)
$30,000 to $49,999	56	(36.8)	2.45	(.88)
$50,000+	36	(23.seven)	ii.50	(.92)
Missing	11	(vii.2)
Education
High school grad or less(b=3)	94	(61.8)	2.53	(.93)**
Some college or advanced caste	58	(38.2)	2.15	(.68)
Relationship to patient
Spouse	136	(89.5)	two.twoscore	(.85)
Adult kid	sixteen	(10.5)	2.22	(.98)
Expressed end-of-life care wishes
Care preferences specified
No(b=four)	95	(61.3)	2.24	(.44)
Yeah	threescore	(38.vii)	2.60	(1.01)**
Family context
Presence of children in home
No(b=four)	142	(93.4)	2.31	(.82)
Yep	10	(half-dozen.6)	iii.nineteen	(.95)**

Tabular array 2 presents the means and standard deviations of the analytic variables as well as the zero-order correlations amongst them. Complicated grief symptoms were not correlated with a history of family disharmonize, but were significantly correlated with physical (r = .28, p ≤ .001) and psychological symptoms of the patient (r = .34, p ≤ .001).

Table 2

Correlations and Descriptives for Analytic Variables

Variables	1	2	iii	four	5	vi	7	viii	9	10	11	12	thirteen	14
1 Complicated grief	—
ii Caregiver historic period	−.23**	—
3 Caregiver education	−.21**	−.02	—
iv Care preferences specified	.20**	−.xviii*	−.02	—
5 Presence of children in home	.25**	−.22**	.12	.06	—
6 History of family conflict	.10	−.13	.01	.09	.22**	—
7 Patient concrete symptoms	.28***	−.26***	.16*	.16*	.26***	.26***	—
viii Patient psych symptoms	.34***	−.38***	.x	.14	.24**	.32***	.51***	—
ix Family disharmonize at terminate-of-life	.27***	−.19*	.08	.21**	.23**	.62***	.23**	.31***	—
10 Difficulty accepting illness	.42***	−.08	−.09	.03	.21**	.15	.16*	.fourteen†	.20	—
11 Patient fearfulness of expiry	.17*	−.07	−.02	−.12	.02	−.10	.xv†	.30***	.01	.02	—
12 Patient quality of care	−.30***	.10	−.06	−.08	−.21**	−.16*	−.34***	−.35***	−.xix*	−.04	−.10	—
thirteen Family unit quality of care	−.25**	.03	−.08	−.09	−.15†	−.17*	−.28***	−.20*	−.10	−.07	−.05	.72***	—
14 Hospice utilization	.08	−.12	−.xiv†	−.xvi*	.02	.01	.07	.11	.03	−.02	−.06	.00	−.02	—
G	2.39	.51	.38	.39	.07	.36	2.1	.86	.38	two.12	2.72	28.86	15.22	.67
SD	.86	.50	.49	.49	.25	.71	1.35	.81	.76	1.35	1.17	seven.06	5.00	.47
Range	i–4.6	0–1	0–ane	0–1	0–1	0–four	0–4	0–2	0–four	0–4	i–v	0–36	0–20	0–1

Secondary Stressors and Complicated Grief: Hypothesis 1

We hypothesized that later on controlling for time since death and a history of family conflict, and other contextual and primary stressor variables, that higher levels of family conflict at the end-of-life, family member difficulty accepting the affliction and patient fear of expiry will contribute to complicated grief symptoms. Table three presents the results of the regression analysis for complicated grief. Every bit shown in Step three, after decision-making for contextual and primary stressor variables, secondary stressors uniquely explained 15% of the variance in complicated grief symptoms, the most of import two existence family conflict at the cease-of-life (b = .23, p ≤ .01) and family member difficulty accepting the affliction (b = .34, p ≤ .001).

Table 3

Hierarchical Regression Analysis for Complicated Grief Symptoms

Variables	Betas
	Stride 1	Step 2	Step 3	Step iv	Pace 5
Background and Context
Time since decease	.01	.03	−.03	−.03	−.03
Caregiver age	−.14†	−.05	−.04	−.06	−.04
Caregiver education	−.24**	−.28***	−.25***	−.25***	−.25***
Care preferences specified	.16*	.xiii†	.12†	.12†	.xiii†
Presence of children in domicile	.23*	.nineteen*	.11†	.10	.ten
History of family unit conflict	.01	−.08	−.26**	−.24**	−.21*
Chief Stressors
Patient physical symptoms		.16†	.13	.08	.09
Patient psychological symptoms		.22*	.16†	.12	.15†
Secondary Stressors
Family conflict at end-of-life			.23**	.22**	.21*
Family member difficulty accepting disease			.33***	.33***	.33***
Patient fear of death			.10	.10	.15*
Resources
Patient quality of care				−.12	−.xi
Family unit quality of intendance				−.ten	−.08
Hospice utilization				.01	.02
Interaction-Moderating Procedure
Patient fear of death × hospice utilization					−.16*
Full R 2	.17	.25	.40	.43	.45
R 2 change	.17	.08	.xv	.03	.02
F for R 2 change	5.03***	seven.twenty**	10.75***	ii.58†	4.lxxx*

Moderators of Complicated Grief Symptoms: Hypothesis 2

We hypothesized that the quality of care provided to the patient and family and hospice utilization will buffer the effect of secondary stressors on complicated grief symptoms. Every bit shown in the terminal model of Table 3, internet of the other predictors, an interaction between patient fear of decease and hospice care utilization significantly predicted complicated grief symptoms (b = −.xvi, p ≤ .05). We graphed this interaction using the estimated regression coefficients for combinations of low and high patient fear of death by hospice or no hospice status; all other variables evaluated at their hateful (see Figure i for a portrayal of this interaction effect). Patient fear of decease contributed to complicated grief when hospice care was not utilized, and supports the stress-buffering hypothesis.

Interaction between patient fear of decease and hospice utilization on complicated grief.

The regression equation explained 45% of the total variance in complicated grief symptoms. In the final model, in addition to the moderator variable (i.e., patient fear of decease past hospice utilization), significantly more complicated grief symptoms were institute among caregivers without college education (b = −.25, p ≤ .001), who were caring for patients who had specified their stop-of-life care preferences (b = .xiii, p ≤ .x), and had more than psychological symptoms (b = .15, p ≤ .10), and fear of dying (b = .15, p ≤ .05), who had family members who expressed difficulty accepting the illness (b = .33, p ≤ .001), and who had low levels of a history of family disharmonize (b = −.21, p ≤ .05), but higher levels of family conflict near the end-of-life (b = .21, p ≤ .05).

DISCUSSION

The most compelling findings from this written report business organisation the importance of secondary stressors in predicting complicated grief symptoms and hospice utilization in moderating the stress process. Secondary stressors uniquely explained fifteen% of the variance in complicated grief symptoms and both family disharmonize and the ii intrapsychic strains were pregnant predictors in the final model. Kissane and colleagues (Kissane & Bloch, 2002; Kissane, McKenzie, Bloch, Moskowitz, McKenzie, & O'Neill, 2006) take well documented a relationship between "maladaptive family functioning" and bereavement outcomes. Our results advise that although not very common, as evidenced by the strong correlation between prior conflict and conflict at the end-of-life (i.e., r = .62), that families with lower levels of prior conflict and higher levels of conflict associated with difficult decisions at the end-of-life may be at most risk. Developing and testing interventions to meet the needs of families at risk of experiencing conflict at the end-of-life (run into Kramer et al., 2009), to better back up families during critical junctures in decision making, and in the aftermath of unresolved conflict across the continuum of cancer care are important goals for futurity research and practice.

National guidelines and preferred practices for palliative care have been established that emphasize the importance of assessing and treating social and psychological responses to illness that often contribute to patient and family suffering (Hultman, Keene-Reder, & Dahlin, 2008). Our findings advise that assessment and treatment of these needs should not be relegated to palliative care only. Family unit difficulty accepting illness and patient fear of death both represent psychological needs that may be present very soon after the diagnosis. Oncologists, family physicians, and other interdisciplinary care providers demand to be mindful of the intrapsychic strains that are stimulated by a lung cancer diagnosis and consider psychotherapeutic interventions or referrals to address them. Cognitive-existential group therapy has been used successfully to address expiry anxiety among cancer patients (Kissane et al., 1997). Similar models might exist employed to support lung cancer patients and family unit members to address fearfulness of death and difficulty accepting the illness.

Although no directly bivariate relationship was found betwixt hospice utilization and complicated grief, hospice enrollment did serve to buffer the consequence of patient fear of death and the outcome. The decedent's fear of death, as reported past the survivor, did not lead to complicated grief when hospice was used, simply did accept a negative issue on bereavement outcomes for those not enrolled. Hospice professionals are found to take less death anxiety and more expiry related feel than other health care professionals (Carr & Merriman, 1995–1996), and may take greater competency to address fright of decease among patients. Of course this is an empirical question, but may help to explain our findings. Hospice intendance is recommended as the optimal care model of patients with advanced lung cancer (Griffin et al., 2003), but is typically underutilized by lung cancer patients (McCarthy, Burns, Davis, & Phillips, 2003). In add-on to encouraging efforts to promote timely hospice referral, other initiatives to increment the cognition, skills, and competencies of oncology and other health care providers for routinely assessing and treating patient fear of death may help foreclose complicated bereavement.

Non surprisingly, bivariate analysis revealed strong relationships between lower quality of care of the patient and family and college levels of complicated grief. Given the documented concerns regarding care quality for lung cancer patients and their families (Krishnasamy, Wilkie, & Haviland, 2001), this is an important finding. The human relationship between intendance quality and complicated grief was no longer statistically significant in the multivariate model when contextual and stressor variables were included and care quality did not moderate the result of stressors on grief. Routine care may not sufficiently address the distinctive issues associated with secondary stressors. More intensive and targeted interventions to meet these distinctive needs may be required.

Several limitations should be acknowledged when interpreting these results. The cantankerous-sectional pattern and reliance on retrospective reports of intendance and conflict at the terminate-of-life are of import limitations. Current affective states may affect retrospective appraisals of subjective measures. Prospective studies are necessary to evaluate the direction of relationships and capture experiences as they occur, simply practice present upstanding and methodological challenges of their ain (Casarett, Knebel, & Helmers, 2003). Although the interaction between hospice utilization and patient fear of death was interpretable, it may exist a chance finding given the multiple exploratory tests used to evaluate possible interaction effects. Other studies are needed to test for replication. Some of our measures are limited such as the clinical intendance needs of the patient that measured the number of symptoms rather than symptom severity that may underestimate the relationship between symptoms and complicated grief. In add-on, we did not collect any data on the end-of-life care treatment preferences that were expressed by patients or the extent to which they were carried out, which seriously limits our ability to interpret the unanticipated positive correlation between care preferences specified and grief symptoms. It is possible that the patient's expressed end-of-life care wishes were not fulfilled or were a source of disagreement among family members. Finally, the nonrepresentative nature of the sample, seriously limits the generalizability of written report findings. Although the ACCESS report sought a representative statewide sample and over sampled by race, less than half of the eligible families completed the survey, and the sample was primarily older White female spouses. In improver, the hospice utilization rate of our sample is higher than that of lung cancer Medicare beneficiaries (i.due east., 68% compared to 27%; McCarthy et al., 2003), and the overall rates of family conflict were fairly modest (Kramer et al., 2009).

Despite its limitations, this study was guided by a theoretical framework to provide a more comprehensive agreement of the complex determinants of the bereavement process with attention to domains not previously considered in research. Results provide substantial support documenting a relationship between family conflict, intrapsychic strains and complicated grief, and a moderating influence of hospice utilization. Risk assessment tools used to place persons at take chances for complicated grief (Melliar-Smith, 2002) could be expanded to include assessment of patient symptoms, intrapsychic strains, prior and end-of-life conflict, and caregiver education. Future research to replicate these findings and to illuminate agreement of the primary and secondary stressors and resources that might influence the bereavement process, as well as development and testing of interventions to accost these are warranted.

Acknowledgments

The authors gratefully acknowledge the bereaved family members for their participation in this written report, and the contributions of our colleagues who participated in the pattern of the Access survey.

Footnotes

^*This study used information from the Cess of Cancer Care and SatiSfaction (Admission), survey, a project of the Wisconsin Comprehensive Cancer Control Programme. Funding for the WI CCC Program is provided by The Centers for Disease Control & Prevention, The Wisconsin Department of Wellness Services, The Wisconsin Partnership Fund for a Healthy Future, and the UW-Paul P. Carbone Comprehensive Cancer Heart. This commodity was prepared with back up from the National Institute of Mental Health (T32 MH65185 to Jan. Greenberg).

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3265356/