This guideline addresses the needs of adult patients with incurable cancer or advanced disease (but can be useful for adults dying of any cause), as well as the needs of their caregivers or family, including children. Information and tools are provided to improve a primary care provider's comfort and skills in dealing with this type of loss.- Everyone grieves losses, but it is important to recognize especially vulnerable groups such as the elderly, children, the socially isolated, the mentally ill, the disenfranchised, and culturally diverse groups such as new immigrants and the indigenous community. - It is not necessary to alter normal grieving, but it is helpful to provide a listening ear, to be supportive, and to provide information. - Distinguish grief from depression and treat grief-related major depression once you are confident it is pathological. - In the case of Prolonged Grief Disorder (complicated grief), assess and take note of any risk factors or concerns. - Primary care providers play a key role in the continued monitoring of patients' grief responses and may refer the patient to grief counselling and treatment options.Grief and bereavement are distinguished from each other, although bereavement includes many aspects of grief. Grief: An expected response to loss.Response to anticipated losses.The state where, following death, the family creates meaning and sense out of the new reality of life without their loved one/person who died.Occurs when there is a debilitating intensity or duration of "normal" grief responses that adversely affect the ability to cope with normal life events. 1,2 # Background
Grief and bereavement services should be available to all patients and families based on assessed needs. Family physicians often feel unprepared and uncomfortable about knowing how to support those going through intense grief. They may both mourn the death of their patient and the patient's death may also trigger their own past grief. Physicians who find themselves significantly impacted by a patient's death should consider contacting the Physician Health Program. Refer to Associated Document: Resource Guide for Patients and Caregivers.
} Assessment of Grief
- Consider using the Adult Attitudes to Grief Scale 3 (Appendix A: Adult Attitudes to Grief Scale -Patient Handout, Practitioner Score Sheet, and Protocol for Use). The Adult Attitudes to Grief Scale is a brief, self-reported, evidence-based, practical tool. The questions are designed to promote an understanding of the patient's grief and vulnerability by identifying grief reactions (controlled or overwhelmed) and coping responses (vulnerable or resilient). By scoring responses to the Adult Attitudes to Grief Scale, practitioners can assess levels of vulnerability, and need for support. A score higher than 23 suggests severe vulnerability and a need for specialized grief support services. - Be aware of the potential desire for hastened death. If present, assess for suicide risk.
- Focus on personal strengths and coping mechanisms: what has worked in the past? - Protective factors / resiliency for a patient or caregiver:
- Has an internalized belief in his / her own ability to cope effectively. o Perceives the need for AND is willing to access social support.
- Is predisposed to a high level of optimism / positive state of mind. o Has spiritual / religious beliefs that assist in coping with the death.
All of us grieve differently due to age, gender, personal, religious, and cultural differences. Enquire regarding cultural and individual preferences (refer to Appendix B: Cultural Diversity and Individual Preferences) and be aware of age differences (refer to Appendix C: Children and Death).
} Management of Grief

# Non-pharmacological management
The relationship between the physician and the patient is one of the most potent therapeutic tools for assisting patients who are dealing with grief. Reassurance about the normal pattern of grief and a commitment to supporting the patient in an ongoing way is the mainstay of care. It may involve scheduled follow-up visits as necessary. Within that context, the following aspects of management should be considered (refer to Table 1).
- Refer to patient handout: Appendix D: The Grief Journey.

# Pharmacological management
In general, there is a limited place for pharmacological management in normal grief. The physician must be alert to the possibility of underlying disease and incipient pathologic grief and treat accordingly, but it is unwise to interrupt the normal constituents of grief such as depressed mood, anxiety, insomnia and anger.

# Other support
Bereavement includes the period of adjustment following a person's death and it encompasses many elements of grief, including prolonged grief disorder (complicated grief). Anticipate / screen for prolonged grief disorder (complicated grief) reactions and also consider using Appendix E: Bereavement Risk Assessment Tool to assess risk.

# Risk factors for Prolonged Grief Disorder (complicated grief) 4 :
- co-morbidities: mental illness; cognitive impairment; substance abuse;
- concurrent stressors: significant other with life-threatening illness;
- circumstances around the death: perceived as preventable, sudden, unexpected, violent, traumatic or untimely; suicide;found/saw/identified the body; issues with death notification; - lack of supports: social isolation, disenfranchised grief; cultural or language barriers; relationships: anger, ambivalence, resentment, attachment insecurity; high marital dependency; - low social support; and - being a spouse or parent of the deceased.  - Personally contact the bereaved person / family.

# Assessment of bereavement (Refer to
- Acknowledge the death and reactions including feelings such as guilt, relief, or shock.
- Ascertain and address immediate concerns about care, the death, or the funeral.
- Arrange for follow-up contact.

# After death
Self-management - Provide information about grief, i.e., what to expect and what is helpful (refer to Appendix D: The Grief Journey (Patient Handout). - Provide information about local resources (e.g., bereavement groups, spiritual / religious supports, grief counsellors) and online resources (refer to Associated Document: Resource Guide for Patients and Caregivers). - Share Appendix J: Be Gentle with Yourself (Patient Handout). Ongoing care contact - Within 2 weeks, acknowledge, or contact family.
- Contact again at 1-2 months, 6 months, and 11-12 months (anniversary of the death). - Recognize that holidays, birthdays, and wedding anniversaries are tough.
- Be aware that the second year can also be difficult.

# Pharmacological management
85% of grief in bereavement is normal grief, not requiring pharmacological management. 6,7  - Assess in the context of the person's life, personality, culture, and the nature of the illness/death. - Refer to a bereavement counsellor, psychologist, or psychiatrist who will provide targeted psychotherapy, Complicated Grief Treatment, in addition to possible pharmacologic management.
These references were chosen to be helpful and do not form an exhaustive list:
- Cairns M,