Friday, February 23, 2007

"Good Grief" - JAMA and Newsweek; Time Magazine brings the Pain;

JAMA published an excellent, ground-breaking study in to the actual testing of the stage theory of grief (apparently this is a full-text free article) this week. You may have seen this brought up in some of the media outlets over the past few days, but we here at Pallimed will break down the study for you in ways those health care reporters cannot.

Maciejeski, Zhang, Block, and Prigerson followed 233 bereaved people up to 24 months post-death of their loved ones. They were interviewed in 3 different periods after their loss (1-6, 6-12, and 12-24 mos). The stages of grief assessed were a combination of Kubler-Ross' (Denial, Anger, Bargaining, Depression, and Acceptance) and Bowlby & Parkes' (Shock-Numbness, Yearning-Searching, Disorganization-Despair, and Reorganization) stages of grief. The study stages were as follows:

Disbelief -> Yearning -> Anger -> Depression -> Acceptance

Now it should be said these items do not have to happen in any particular order, nor does any one stage have to be completed before the other can begin. In fact what is great about this study is that it demonstrated that these various stages do have peaks, and do largely overlap each other. I wish I could post the figure that demonstrates this, but JAMA has some strict terms of use. The article is free so go get it. The graphs would be very helpful in any talk on grief and bereavement. The discussion is very well formed in this article and should be a must read for any SW or counselor dealing with the bereaved or soon to be bereaved.

The ones sentence that really makes the study is this one:

Within each period, acceptance is greater than disbelief, yearning, anger, and
depression; yearning is greater than disbelief, anger and depression; and
depression is greater than anger.

It does give support to the resilience of the human spirit in times of great adversity. I hope to see more studies on grief based off of this one. Maybe ones that track people closer to the time of loss? In this study the mean time to first interview was 6.3 months post-loss. Hopefully with active bereavement groups in hospices this could be started a little earlier. The authors do comment on the difficulty in obtaining IRB for bereavement studies out of fear of causing harm in discussing loss.

It should also be noted that this study excluded those who met criteria for complicated grief and the the majority of participants were white (97%), females (71%) over 65 (54%) who lost their spouse (84%). So your mileage may vary with your population that you see. Obviously A 24yo Laotian father who loses his son may not have the same sort of grief. Which brings up the point to study the stage theory of grief in vastly different populations to see if it is the humanity that gives us a commonality or if our cultures really separate our emotional experiences.

(Thanks to Scott L. for the heads-up)

2) Coming home from the AAHPM, I had a layover in Denver and got to read a whole Newsweek. (Man it has been a long time since I have done that.) The My Turn piece (not yet avail online) was written by a father who lost his son 13 years ago and is still distressed over the junk mail he receives for his son. Graduation pictures, military recruitment ads, etc. I thought it was bad when my dog got a credit card application (Spot Sinclair, c'mon?!), but this has too be very difficult as Gary Weiner writes very well in his editorial. I have already written a letter to the editors to bring light on the UK solution with the bereavement register that we posted here on Pallimed. Do you think the Bereavement Register would work here in the US? Or would direct mailers oppose it fiercely, and funeral home directors balk at more data collection? It might save a lot of heartache...

3) Time magazine has an opinion piece by Scott Haig [link fixed 2/25] (an emergency room doctor I presume, although his credentials are not listed) about the value of the human mind in assessing other people’s pain. The discuss the poor efficacy of the Visual Analog Scale in the ED comparing a stoic man who denies pain to a recent female MVA patient who seems to be embellishing her pain in the desire to get Percocet.

While I agree that the VAS can be of limited usefulness and that patients sometimes rebel against it, or become confused by it, we should not abandon the VAS. It remains a critical tool for assessing impact of therapies in reducing a patient’s pain. All of us have different thresholds for pain and to imagine that we can walk in another shoes and feel their pain is ludicrous. I gave a talk a few months ago about assessing pain, and I asked the audience to assess my pain by looking at me. They all said 'Zero.' Well I rated my pain at a 6 because I just played hockey last night and my back was killing me from a accidental body check in my no-check league (Honestly, I did not see the guy coming. I didn't mean to knock him over.)

The professional skill comes in taking the VAS applying it to the clinical situation and using it as part of a comprehensive examination. Never should a policy say, "for pain of X give a morphine dose of Y." That makes our professional skills take a back seat. So while the general point of the article (our minds are still useful in medicine) was good, I think the gist is that 'people may deceive' and 'the VAS is worthless.' It all depends on how you use the tools provided.

PS for those of you wanting the talks at the AAHPM , check out Rollin' Recordings for the MP3's they have there. I got to talk to Lou at the meeting and he is a great guy. And you can listen to the talks in your car.

-CTS

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