Grief on the CCFP exam

Approach

• Name the feelings ahead of time: sadness, yearning for the person, anger, guilt and numbness.
• Warn about body symptoms too: poor sleep, tiredness, low appetite, aches and an upset stomach.
• Say there is no set end date. Grief usually eases over months, and waves can come back at birthdays, holidays and anniversaries.
• Infants grieve too. After losing someone who cared for them, expect crying, clinging, poor sleep and poor feeding.
• For a young child, keep routines steady. Add new separations, such as starting daycare, slowly while the child settles.
• Say when to come back: grief that stops daily life, hopelessness, thoughts of death, or heavier drinking.

Approach

• Ask every grieving patient about low mood, loss of interest, hopelessness and thoughts of suicide. Grief does not rule out depression.
• Ask how the evenings go. Alcohol, cannabis, sleeping pills or someone else's pills are common ways to cope.
• If suicidal thoughts come up, ask about a plan and the means at hand. Lock up or remove medicines at home.
• Ask about alcohol before any sleeping pill. A sedative on top of heavy drinking is dangerous.
• For mild low mood, at any age, start with support, talking therapy and lifestyle steps. Do not routinely start an antidepressant first.
• In older adults, a benzodiazepine or other sleeping pill is not the first choice for poor sleep. It raises the risk of falls and fractures.
• Refer for grief-focused therapy or mental health care when grief stays intense and disabling, or depression, suicide risk or a drinking problem is found.

Approach

• Ask what this loss means to this patient: who died, how, what they were to each other, and what else is going on.
• Ask how the person died. A sudden or violent death, or a death by suicide, makes grief harder to settle.
• Ask about culture and faith: the rituals, who mourns how, and what the family expects of the patient.
• Tell children the truth in plain words: the person died and will not come back. Let them join rituals if they want to.
• Children often grieve in bursts, and may grieve again as they reach a new stage of development.
• Keep school, routines and friends going. Keep reminders of the person, and let the child choose some.
• Older adults may face many losses at once: a spouse, health, a home, independence. Ask about each one.

Approach

• Ask: “Have you lost anyone or anything important lately?” Then ask what time of year past losses happened.
• Ask about a pet that died, a lost job or retirement, a breakup, a move, or leaving family behind in another country.
• Ask about losses others may not see: a miscarriage, infertility, a new diagnosis, a lost role, a child leaving home.
• Check the calendar. Symptoms near an anniversary, a birthday or a holiday can be grief coming back.
• Allow grief others may not recognise, such as for an ex-partner, a friend, or a pet.
• Treat the loss as real. Brushing off a pet or a job ends the conversation.

Approach

• When several symptoms start at once, ask what happened just before they began.
• Ask about deaths, separations and other losses in any unexplained case, at any age, infants included.
• In a child, pains that keep to school mornings, with a normal exam and steady weight, point to distress. Ask about loss before tests.
• New or heavier drinking, drug use, falling marks or trouble at work: ask about recent losses.
• Symptoms that do not respond to sound treatment: ask about loss before more tests or drugs.
• Still examine, and watch for red flags such as fever, vomiting, diarrhea or blood in the stool. Grief can sit beside disease.
• Once you find grief, screen for depression, suicidal thoughts and drinking, as in any grieving patient.