Monica Spinaze

Prospective study of early bereavement on psychological and behavioural cardiac risk factors.

Background: Increasing evidence supports the role of emotional stress in the onset of cardiovascular disease. Although bereavement is a major emotional stress with both acute and more long‐term features, the mechanism of its association with cardiovascular risk is not well understood, in particular because of limited studies of acute bereavement. The aim of the study was to identify psychological and behavioural changes in acute bereavement and potential modifiers of these changes.

Inflammatory and thrombotic changes in early bereavement: a prospective evaluation

Aims: Although there is an increased cardiovascular risk in the immediate weeks following bereavement, the mechanism is not well understood. The aim of this study was to determine whether inflammatory and thrombotic changes were present in acute bereavement. Methods and results: Eighty bereaved spouses or parents were prospectively studied within 2 weeks of bereavement (acute) and at 6 months, and compared to 80 non-bereaved participants. Haemostatic measures were obtained between 8 a.m. and 11 a.m. and processed within 1 h. Compared to non-bereaved participants, those acutely bereaved had a higher neutrophil count (4.34 ± 0.19 vs 3.79 ± 0.15, p = <0.001), von Willebrand factor antigen (132.33 ± 3.6 vs 119.95 ± 3.29, p = 0.02), Factor VIII (1.43 ± 0.06 vs 1.25 ± 0.04, p = 0.02) and platelet/granulocyte aggregates (median 383.0 vs 343.5, p = 0.02). Levels of neutrophils, monocytes, eosinophils, platelet count, platelet/monocyte granulocytes and von Willebrand factor were lower in bereaved at 6 months compared to acutely (all p < 0.05). Conclusion: Acute bereavement is associated with inflammatory and prothrombotic changes that may contribute to the increased cardiovascular risk with bereavement and provide clues for future preventative strategies.

Haemodynamic Changes During Early Bereavement: Potential Contribution To Increased Cardiovascular Risk

BACKGROUND bereavement is associated with increased cardiovascular risk, particularly in surviving spouses and parents, however the mechanism is not well understood due to limited studies. The purpose of this study was to evaluate haemodynamic changes (blood pressure (BP) and heart rate (HR)), that may contribute to increased cardiac risk in early bereavement. METHODS we enrolled 80 bereaved individuals and 80 non-bereaved as a reference group. Twenty-four hour ambulatory blood pressure monitoring was performed within two weeks (acute assessment) and at six months following bereavement. RESULTS compared to the non-bereaved, the acutely bereaved had higher 24-hour systolic BP (mean (SE) 130.3 (1.5) vs 127.5 (1.4)mmHg, p=0.03), higher daytime systolic BP (135.6 (1.5) vs 131.6 (1.4)mmHg, p=0.02) and higher daytime systolic load (median % 39.0 vs 29.3, p=0.02). By six months the BP of the bereaved tended to be lower than acute measures. This difference was significant amongst those not taking BP lowering medications for 24-hour systolic BP (126.5 (2.4) vs 129.7 (2.3)mmHg, p=0.04), daytime systolic BP (129.8 (2.1) vs 133.9 (2.0)mmHg, p=0.01) and daytime diastolic pressure (76.7 (1.0) vs 78.9 (0.9)mmHg, p=0.03). Twenty-four hour heart rate was also higher acutely in the bereaved compared with the reference group (74.0 (1.2) vs 71.7 (0.9) b/min, p=0.02); at six months heart rate in the bereaved had fallen to non-bereaved levels (70.4 (0.09), p=0.02). CONCLUSION early bereavement is associated with increased systolic blood pressure and heart rate. These haemodynamic changes may contribute to a time-limited increase in cardiovascular risk.

Effect of early bereavement on heart rate and heart rate variability.

Early bereavement is associated with increased cardiovascular events. The mechanism, however, has not been well studied. We assessed whether bereavement is associated with an increased heart rate (HR) and decreased heart rate variability that might contribute to increased cardiovascular risk. A total of 78 bereaved spouses and parents (55 women and 23 men; aged 34 to 87 years, mean 65) were studied with 24-hour Holter monitoring within 2 weeks of bereavement (acute) and at 6 months. Their findings were compared to those from a nonbereaved reference group (52 women and 27 men) aged 33 to 91 years (mean 63.6). All participants were in sinus rhythm. We assessed the mean HR, atrial and ventricular arrhythmias, and both time and frequency domain heart rate variability measures. Acute bereavement was associated with increased 24-hour HR (mean ± SE, 75.1 ± 1.1 vs 70.7 ± 1.0; p = 0.004) and reduced heart rate variability, as indicated by lower standard deviation of the NN intervals index (median 45.4 vs 49.9, p = 0.017), total power (7.78 ± 0.10 vs 8.02 ± 0.09, p = 0.03), very low frequency (7.23 ± 0.09 vs 7.44, p = 0.046) and low frequency (5.76 ± 0.12 vs 6.16 ± 0.09, p = 0.01). At 6 months, the bereaved had a significantly lower HR (p = 0.001) and increased standard deviation of the NN intervals index (p = 0.02), square root of the mean square of differences of successive intervals (p = 0.045), number of interval differences of successive NN intervals >50 ms divided by the number of NN intervals (p = 0.039), low-frequency power (p = 0.02), and high frequency (p = 0.002) compared to the initial acute levels. In conclusion, the present study, the first to report 24-hour HR monitoring in the early weeks of bereavement, has demonstrated increased HR and altered autonomic function that might contribute to the increased cardiovascular events in early bereavement.

The nature of death, coping response and intensity of bereavement following death in the critical care environment

INTRODUCTION Bereavement, defined as the situation of having recently lost a significant other, is recognised as one of lifes greatest stressors and may lead to decrements in health status, psychological morbidity and excess risk of mortality. AIM The aim of this study was firstly to describe the relationships between the nature of death and bereavement intensity following death in the adult critical care environment and secondly to examine the modifying effects of coping responses on intensity of bereavement reaction. METHOD Prospective evaluation of the impact of the nature of death and coping responses on bereavement intensity. 78 participants completed a nature of death questionnaire within 2 weeks of bereavement and at 3 and 6 months completed the Core Bereavement Items Questionnaire (CBI-17) and Brief COPE Inventory. RESULTS At 6 months, univariate variables significantly associated with bereavement intensity were: being unprepared for the death (p<0.001), a drawn out death (p<0.001), a violent death (p=0.007) and if the deceased appeared to suffer more than expected (p=0.03). Multivariate analysis revealed being unprepared for the death appears to account for these relationships. Regarding coping, there were significant increases from 3 to 6 months in both acceptance scales (p=0.01) and planning (p=0.02) on The Brief COPE Inventory. Greater use of emotional support (p=0.02), self-blame (0.003) and denial (p<0.001) were multivariate variables associated with higher bereavement intensity at 6 months. CONCLUSION The results from this evaluation provide insight into the impact of bereavement after death in the critical care environment and inform potential preventative approaches at the time of death to reduce bereavement intensity.

Effect of a patient-directed discharge letter on patient understanding of their hospitalisation

Poor patient understanding of their diagnosis and treatment plan can adversely impact clinical outcome following hospital discharge. Discharge summaries are primarily written for the doctor rather than the patient. We determined patient understanding of the reasons for hospitalisation, in‐hospital tests, treatments and post–discharge recommendations, and whether a brief patient‐directed discharge letter (PADDLE) delivered during a brief discussion prior to discharge would improve understanding.

The complexities of recruiting bereaved family members into a research study in the critical care environment: a discussion paper.

Research on the effects of stressful events on human health and wellbeing has progressed in recent years. One such stress, bereavement, is considered one of lifes greatest stresses, requiring significant readjustment. The Cardiovascular Risk in Bereavement study (CARBER) investigated in detail cardiovascular risk factors during the first weeks following the death of a partner or adult child in the critical care environment. The purpose of this paper is to explore the once held perception that the bereaved population should not be involved in research, using an actual illustrative project. The paper specifically focuses on the challenges regarding acceptability and feasibility of recruitment of recently bereaved individuals from the critical care environment. The question of whether bereaved individuals have capacity to consent to involvement in research immediately after loss is considered. The appropriateness of asking newly bereaved individuals to participate in research immediately after the death of their relative is also discussed. The work of the research team demonstrates that early recruitment of bereaved family members into a research project is feasible and acceptable to participants, especially when a multidisciplinary collaborative approach is employed and a personal mode of recruitment used.

Therapy for Triggered Acute Risk Prevention in Subjects at Increased Cardiovascular Risk

Heavy physical exertion, emotional stress, heavy meals, and respiratory infection transiently increase the risk of myocardial infarction, sudden cardiac death, and stroke; however, it remains uncertain how to use this information for disease prevention. We determined whether it was feasible for those with either risk factors for cardiovascular disease (CVD) or known CVD to take targeted medication for the hazard duration of the triggering activity to reduce their risk. After a run-in of 1 month, 20 subjects (12 women and 8 men) aged 68.6 years (range 58 to 83) recorded for 2 months all episodes of physical and emotional stress, heavy meal consumption, and respiratory infection. For each episode, the subjects were instructed to take either aspirin 100 mg and propranolol 10 mg (for physical exertion and emotional stress) or aspirin 100 mg alone (for respiratory infection and heavy meal consumption) and to record their adherence. Adherence with taking the appropriate medication was 86% according to the diary entries, with 15 of 20 subjects (75%) achieving ≥80% adherence. Propranolol taken before exertion reduced the peak heart rate compared with similar exercise during the run-in period (118 ± 21 vs 132 ± 16 beats/min, p = 0.016). Most subjects (85%) reported that it was feasible to continue taking the medication in this manner. In conclusion, it is feasible for those with increased CVD risk to identify potential triggers of acute CVD and to take targeted therapy at the time of these triggers.

Response to “Who cares how we care?”

We welcome the comments regarding our manuscript reportng the impact of events at the time of death, coping response and ereavement outcomes for family members after death in critical are and the recent special issue of Australian Critical Care – Volme 28, No. 2.1 In their letter, the author highlights the potential ensions that nurses may experience working in fast paced, highly echnical, and ethically raw environments in regards to end of life are, particularly in relation to care of family members at the time f impending death of their loved one and the challenges posed by family member wishing to remain at his daughter’s bedside. Any strategy to facilitate a more natural grief response should e at the core of expert nursing care. Presence at the time of death ould appear critical in promoting acceptance of the death of loved one, but also needs to be facilitated by staff promoting nderstanding of events.2 Inadequate information and not being repared for the death of a loved one was associated with higher rief intensity at both three and six months in our study1 and is n indicator for potential complicated grief.3 Facilitating undertanding, by allowing Presence and giving explanation of events o relatives is well within the scope of intensive care nurses and hould be seen as therapeutic. Our study findings suggest that nurses should be aware that elatives may have had complex relationships with their loved ne, or their death may be occurring after complex situations. or example, feelings of self-blame were reported by many paricipants in our study and associated with higher bereavement ntensity.1 Self-blame has been reported to be present in up to 0% of end of life scenarios, and the act of apologising before the eath can result in significantly better psychological recovery for he relative,4 an act that can feasibly be facilitated at the bedide prior to death. Prohibiting relatives from time at the bedside nd limiting opportunities like this prior to a loved one’s death ould almost be seen as inhumane and certainly not within nursing hilosophy. In the letter to the editor, the author identifies the most imporant consideration for all concerned when determining priorities f care in end of life scenarios, asking just who will remember the hift in question most, the patient’s relative or the nurse? I doubt any health professionals would dispute the correct answer here.