Communication between physicians and surviving spouses following patient deaths

Communication Between Physicians and Surviving Spouses Following Patient Deaths

SUSAN W. TOLLE, MD, PAUL B. BASCOM, BA, DAVID H. HICKAM, MD, MPH, JOHN A. BENSON, JR., MD

The authors e v a l u a t e d the percept ions a n d adjustments of surviving spouses following patient deaths, Of 128 marr ied patients dy ing in a university hospital in 1983, the surviv- ing spouses of 105 (82%) were personally interviewed a yea r after the death . The physicians" perspectives w e r e re- corded through chart review. Half of all spouses h a d had no subsequent contac t with the physicians who h a d cared for the deceased, a n d 55% of spouses still had unanswered questions regarding the d e a t h a yea r later. Survivors of u n e x p e c t e d deaths w e r e f o u n d to be at high risk for poor subsequent adjustment. Spouses with poorer adjustments consulted their o w n physicians m o r e frequently, a n d used more alcohol a n d tranquilizers. The resul ts identify a r e a s where improvement is needed in communication with sur- viving spouses after patients" deaths . Key words- grief; bereavement; dea th ; adjustment, psychological; physi- cian-patient relations; educat ion, medica l ; ethics, m e d i - cal; autopsy; dea th of spouse . J GEN INTERN M~o 1986; 1:309- 314.

SURVIVING SPOUSES have extensive physical and emotional needs . Their morbidity and mortality are increased for a year or longer following the death. Their suffering can be manifest by increased so- matic symptoms, drug and alcohol use, hospitali- zation and death. 1-7 Although few studies have ex- amined the effect iveness of medical interventions with regard to the heal th of survivors, be reavement counsel ing superv ised by psychiatr is ts has been shown to reduce somatic complaints and visits to physicians. ~-10

The primary physic ian is in a unique position to provide support for the newly bereaved. How- ever, the strengths and w e a k n e s s e s of primary physicians' current practices in communicating with be reaved spouses have not been examined.

We conducted an observat ional s tudy of phy- sician communicat ion with surviving spouses a year following in-hospital deaths . We eva lua ted surviving spouses ' percept ions of the circum- s tances surrounding dea th and subsequen t phy- sician contacts. We also a s s e s s e d communicat ion be tween physic ians and spouses by comparing their percept ions of the c i rcumstances of death. We identified survivors' needs for subsequen t contact with physicians, and defined characteris t ics of sur- vivors at increased risk for poor adjustment . Fi-

Received from the Department of Medicine, Oregon Health Sciences University, Portland, Oregon,

Address correspondence and reprint requests to Dr. Tolle: Oregon Health Sciences University, Division of General Internal Medicine L475, 3181 S. W. Sam Jackson Park Road, Portland, OR 97201.

nally, we propose specific guide l ines for more ef- fec t ive c o m m u n i c a t i o n wi th f a m i l i e s fo l lowing patient deaths.

METHODS

We rev iewed all dea ths occurring at the Ore- gon Health Sciences University Hospital from Jan- uary 1 through December 31, 1983. Of the 270 adul ts who died during that year, 137 had a surviving spouse. Medical records for all 137 were rev iewed by one of us (ST) for potential inclusion in the study. Nine pat ients were excluded from the study, six because of the interim dea th of the surviving spouse. Data collected by audi t of each of the 128 remaining charts included: demographic charac- teristics, clinical cause of death, location at the time of death, service of care, number of hospital- izations, au topsy information, and the degree to which death had been expected by the physician.

Each spouse was then mai led a letter explain- ing the s tudy and inviting him or her to part icipate. For those willing to part icipate, phone or in-home interviews were scheduled, and written informed consent was obtained. Of the 128 el igible surviving spouses , 105 (82%) were interviewed. Seventy-two per cent of i n t e r v i e w s w e r e c o n d u c t e d in the spouse ' s home; the remainder were performed by telephone.

Interviews las ted be tween 30 and 150 minutes and were conducted from eight to 19 months after the death (mean = 13 months). They were guided by a f ive-page ques t ionnaire which w a s des igned for use by interviewers with limilted medica l ex- perience. Most of the ques t ions were open-ended, e.g., "To what degree were you expect ing your spouse ' s death?" This s tructured interview format had previously been developed and refined through a pilot s tudy conducted with surviving spouses of pat ients dying in late 1982. The interviewer was unaware of the chart information and had no prior knowledge of the c i rcumstances surrounding any of the pat ient deaths .

The interview addressed four major areas. First, quest ions were a sked about the spouse ' s percep- tions of the medical c i rcumstances of the dea th (duration of illness, the degree to which dea th w as expected, the cause of death, the method of noti- fication of the death, and the family's response to each method). Second, there were ques t ions about

309

310 Tolle et aL, COMMUNICATION WITH BEREAVED SPOUSES

the nature of subsequent communicat ions with physicians, as well as the family's response to each contact (cards, phone calls, follow-up appoint- ments, and autopsy information). Third, we asked about the persist ing unmet needs of survivors (per- sisting unanswered quest ions about the death). Fourth, we assessed the spouse's adjustment a year after the death.

The interviewer a s sessed the spouse's read- justment following the death according to the cri- teria proposed by Brown and Stoudemire." Ad- justment was classified as "good" when spouses reached the resolution phase, having recognized that they had grieved, they were able to return to work, regain an interest in activities, and seek the companionship of others. The adjustment of those spouses who remained preoccupied with the de- ceased was classified as "poor." At the time of the interview, these spouses continued to have anger, sadness, insomnia, anorexia, weakness , fatigue, guilt, thoughts of the dead, and introversion, and had not regained interest in activities. Adjustment was des igna ted as "fair" when a mixture of preoc- cupation with the death and features of resolution were identified.

We assessed the reliability of the first inter- viewer. A second interviewer eva lua ted the ad- justment of a stratified sample of 35 spouses three months af ter the first in te rv iew. In te robserver agreement, measured by the kappa statistic, was 0.42; this compares well with levels of agreement found in other medical settings. ~ Each discrepant classification was reviewed, and both interview- ers' justifications were evalulated. Differences were attributed to documented changes in adjustment during the three months between interviews in all but one case. This case was reclassified from poor to fair; all others were ana lyzed according to the classification given by the first interviewer.

The chi-square statistic was used to assess the significance of differences in quest ionnaire re- sponses between groups of respondents. The kappa statistic was used to assess agreement between the spouse and the physician with regard to au- topsy status, cause of death, and the degree to which d e a t h was expec ted . S tepwise logis t ic regression was used to measure the degrees to which different clinical at tr ibutes were independ- ent predictors of surviving spouse adjustment.

RESULTS

For the 105 adul ts who died, the mean (+- SD) age was 62.2 ( ± 13.7) years. Fifty-five per cent were male, 93% were white, approximately a third were Protestant, and a third had no religious preference. The deceased had been married to the surviving spouse an average of 33.7 (± 15.1) years at the time

of death. Forty per cent of the dea ths occurred dur- ing the patient 's first hospital izat ion at the univer- sity hospital. The majority of dea ths (62%) occurred in patients cared for on the internal medical serv- ice; 35% were on surgical services, and only 3% were under the care of other services (family prac- tice and ob-gyn). The causes of dea th included neo- plasms in 37% and cardiac d i sease in 31%. These dea ths occurred primarily on the hospital wards (42%) and in the intensive care units (44%); only 9% occurred in the emergency room and 4% in the op- erat ing room. The dea th of one patient, an outpa- tient with terminal cancer, took place in the ra- diology department.

Physician-Spouse Perceptions of the Medical Circumstances of Death We found good agreement be tween physicians

and surviving spouses on the cause of death. There was complete agreement on the major cause of death for 89% of pat ients and part ial agreement for the other 11%. Those with part ial agreement usu- al ly knew death had been caused by cancer but did not know the tumor type. Even though survivors were in agreement on the major cause of death, 20 spouses still felt that their knowledge of the cause of death was incomplete, and expressed anxiety about their lack of information. Most spouses had copies of the death certificate. A few spouses were upset by or d i sagreed with the wording used in describing the cause of death.

P h y s i c i a n s a n d s p o u s e s g e n e r a l l y a g r e e d (kappa 0.54) on whether the dea th was expected. For 83 (79%) of the deaths, there was agreement on whether death was expected or unexpected. In 11 instances the family was expecting the death and the physicians were not. All of these pat ients had had substant ia l prior i l lnesses but were new to our hospital and had died shortly after their arrival. In another 11 instances the doctors were expecting the death and the family was not. In most of these instances, a major sudden event had occurred just prior to the hospital ization (e.g., head trauma, massive myocardial infarction). The pat ients ' poor prognoses had been evident to physic ians imme- diately but survivors had needed more time to ac- cept the death.

The degree to which dea th was expected was affected by the medical setting. The spouse and physician were more likely to expect the death when the decedent had had a longer period of i l lness before dea th (p <0.001). Patient age did not cor- relate with the durat ion of il lness prior to death, nor with whether dea th was expected or unex- pected. Among patients with cancer, physic ians and spouses were more likely to expect the death than in those with heart d i sease or other i l lnesses (p <0.0001).

JOURNAL OF GENERAL INTERNAL MEDICINE, Volume 1 (Sep/Oct), 1986 311

Spouses reported many reasons for expecting the death. The most common reason was "the way he/she looked," reported by 86% of spouses who expected the death. Seventy-one per cent s tated the doctor had told them to expect the death, and 33% had been told to expect death by their dying spouse. When death was expected, the family was more likely to be at the bedside, and the patient often remained on the general hospital ward. Unex- pected dea ths occurred with greater frequency in the intensive care units, emergency room, and op- erating room, and spouses were less frequently at the bedside when dea th occurred.

Survivors were informed of the death by var- ious persons. Half of the spouses were notified by physicians, 22% by nurses, and the remainder by non-medical persons (family members, friends, and the family minister). Survivors had no objections to having been notified by someone other than a physician when contact with the physician was avai lable subsequently. However, spouses often expressed a desire for privacy and support when they were informed of the death. A majority of spouses (81%) preferred to have friends or family with them at the time of notification. Only 19% wished to have been alone. Being with their spouse at the time of dea th was important to most survi- vors. Many survivors who were not with their spouse expressed the strong wish to have been at the bed- side at the time of death.

Subsequent Communication with the Deceased's Physician

Spouses expressed a need for improved com- municat ion with physicians regarding the post- mortem examinat ion. Sixty-eight spouses reported having been offered the opportunity for a post- mor tem e x a m i n a t i o n . Twen ty - seven of t he se spouses s tated they had denied the request for an autopsy, for a variety of reasons, such as concerns about disf igurement and feeling the cause of death was a l ready known. Several spouses stated, "he had a l ready suffered enough." Even though agree- ment between survivors and physicians regarding whether an autopsy had been performed was sta- tistically good (kappa 0.76), in 12 instances spouses were incorrect in reporting whether an autopsy had been done. Six spouses thought an autopsy had been done when it had not. Despite having given consent, six others were unaware that an autopsy had been performed.

Autopsies were performed on 41 of the 105 pa- tients. Over half of the spouses (51%) stated they had never received any report of the autopsy find- ings. A year after the death, 25 (61%) of the spouses still wanted a further explanat ion of the autopsy findings. However, 26 (63%) felt the autopsy had

TABLE 1 Physician-Spouse Communication after a Patient's Death

No physician contact

Physician contact* Physician sent a card Physician called spouse Spouse called physician Office appointment Physician attended the funeral Other contact with physicians at

University Hospital Contact with physicians not affiliated

with University Hospital

53 (50%)

52 (50%) 13 (12%) 9 (9%) 6 (6%) 7 (7%) 0 ( 0 % ) 6 (6%)

15 (14%)

* Multiple responses included.

been beneficial, if not for themselves, then for oth- ers.

Physicians infrequently approached families about anatomical donation. Only 15% of spouses reported having been asked for an ana tomica l do- nation. Of the 105 deceased patients, only 17 had made an anatomical donation, and a third of the families reported that they had ini t iated these do- nations.

Spouses reported limited contact with physi- cians after the death to address quest ions or to receive support following their loved one's death. Fifty per cent of spouses had had no subsequent p h y s i c i a n contac t r e g a r d i n g the dea th . Those spouses who did communicate with physic ians had a variety of interactions (Table 1). There were 43 spouses who specifically s ta ted a desire for further contact with the physician, and 72% of these had had no follow-up communicat ion in any form.

Survivors expressed an unmet need for an- swers to persisting questions. Fifty-five per cent of spouses still had at least one unanswered question a year following the death (Table 2). Although many had questions regarding the findings or interpre- tation of the autopsy, when quest ions regarding the autopsy were excluded, 51% still had at least one specific quest ion regarding the death. Of the 20 spouses request ing clarification of the cause of death, most were confused about the immedia te cause of death but knew the major under lying di- agnosis. Thirty per cent had some quest ion re- garding the medical care given prior to death, in- c lud ing ques t i ons abou t exces s ive care (prolongation of life and suffering) or fai lure to di- agnose the condition which ul t imately led to death. Spouses occasionally b lamed themselves, ques- tioning whether they might have done something to have prevented the death.

Spouses' Emotional Adjustment

Spouse adjustment was ranked as good, fair or poor. Sixty per cent of the spouses were clas-

312 Tolle et aL. COMMUNICATION WITH BEREAVED SPOUSES

TABLE 2

Survivors' Questions Regarding the Death

Type of question*

Cause of death,

Criticisms of medical care Excessive care Other complaints about care

Preventability 18 (17")

Inheritability 1 ( 1 )

Other$ 22 (21)

TOTAL SPOUSES WITH AN UNANSWERED QUESTION 58 (55)

* Multiple responses included. UsualLy regarding the immediate cause of death. "Other" were often personal questions (e.g., "Was he in pain?"

or "Did he know I was there?").

Number (%)

20 (19)

31 (29) 12 (1196) 19 (18%)

sifted as "good," 30% as "fair," and 10% as "poor." Neither age nor gender correlated with subsequent spouse adjustment.

Spouses with poorer adjustments reported in- creased personal use of drugs and alcohol follow- ing their loved one's death. Twenty-four spouses (23%) found alcohol helpful following the death. A majority of these users were men who reported al- cohol was helpful for a l leviat ing loneliness and for facili tating sleep following the death. Alcohol use was greatest in younger surviving spouses, and two spouses reported they had been in motor ve- hicle accidents while intoxicated since the death. Most who used alcohol with increased frequency had done so for a short period of time following the death and had resumed their normal drinking pat- terns at the time of the interview.

Forty-four spouses (42%) used drugs other than alcohol to help cope with the death. The use of tranquilizers and other drugs was unaffected by the spouse's age and gender. These drugs came from a variety of sources. Nineteen spouses got them from their own doctors, 17 from the doctor caring for their deceased spouse (often also their physician), and eight were taking drugs that had not been prescribed for them (the deceased 's med- ications or street drugs). Most used tranquilizers and other drugs for a limited period following the death. Only 13 (12%) were still taking tranquilizers at the time of the interview.

Most surviving spouses had sought the care of a physician. Eighty-eight per cent of all spouses in our study had had at least one physician visit, and 34% said they had visited a physic ian more fre- quently since their spouse's death. These office vis- its were primarily for the evaluat ion of somatic complaints rather than to address their grief. Sur- viving spouses with poorer adjustment had visited their own physicians more frequently during their bereavement (p = 0.05). These spouses more often

s tated a desire for further contact with the physi- cian(s) who had cared for the deceased (p = 0.006).

Characterist ics of each dea th set t ing were ex- amined for associat ion with subsequent spouse ad- justment. One strong predictor of adjus tment was the degree to which the spouse had expected the death. When spouses regarded the dea th as a sur- prise, their subsequent adjus tments tended to be poorer (Table 3). Also, cause of dea th of the de- ceased was correlated with subsequent adjust- ment. Adjustment was better in survivors of spouses dying of cancer than in those with other causes of death. However, the associat ion of cancer dea ths with better adjustment may be expla ined by the fact that most of the spouses were expecting these deaths. All but two of the cancer dea ths were ex- pected by their survivors.

Several additional factors were associated with poor adjustment. Survivors of dea ths in the emer- gency room were less well adjus ted than survivors of deaths occurring after admiss ion to the hospital . In those dea ths associa ted with a short prior ill- ness, adjustment was poorer than in those asso- ciated with es tabl ished il lnesses. Nevertheless, deaths occurring in the emergency room or after a short prior il lness usual ly were unexpected by the spouse.

We performed a s tepwise logistic regression to examine whether durat ion of illness, location of death, and degree of expectat ion of dea th were independent predictors of spouse adjustment . In this analysis , degree of expectat ion of dea th was the only significant (p <0.05) predictor of adjust- ment.

DISCUSSION

Our study has provided insights into the extent to which primary physic ians communicate with families following a pat ient 's death. We identified some unmet needs. When the deceased ' s i l lness was prolonged and death was expected, survivors had less need for subsequent phys ic ian contact, and most had a good adjus tment a year after the death. When the deceased ' s i l lness was short or the dea th was unexpected, survivors had a greater number of persist ing quest ions and their adjust- ment tended to be poorer.

Effective communicat ion with survivors at the time of death is often compromised by the period of shock, numbness and denial immedia te ly after a spouse's death, n Even when death is expected, there is usual ly a brief period of shock. When death is sudden, unexpected or follows a short prior ill- ness, the shock may be greater, with survivors hav- ing more difficulty unders tand ing and remember- ing conversations at this time. Unfortunately, it is during this period of distress that physic ians usu-

JOURNAL OF GENERAL INTERNAL MEDICINE, Volume I (Sep/Oct), 1986 313

ally explain the immedia te cause of death and re- quest permission for postmortem examinat ion. It is not surprising that in six instances in this s tudy the spouses had s igned the au topsy permit but did not remember having done so. Most survivors' post- death communicat ion with the primary physic ian was limited to this period of emotional distress.

The period of shock and denial lasts from a few hours to a few weeks and gives way to preoc- cupation with the deceased . With rumination on the death and the deceased, questions become clear in the survivor's mind. However, opportunit ies to have these issues add res sed by the primary pro- viders are limited. One year after the death, 55% of spouses had unanswered ques t ions regarding the death (Table 2). Many of these ques t ions could have been answered by physic ians who had cared for the deceased . However, 50% of spouses had had no follow-up contact with any physic ian regarding the death. Despite a desire for information, only 9% of all surviving spouses had contacted the phy- sician of the deceased . Spouses tended to feel they no longer were enti t led to the doctor's time after their spouse had died. Survivors often indicated a strong desire for a card or phone call from the doc- tor but felt they had no right to expect it. Those spouses who had received any form of subsequen t communicat ion with physic ians were often deeply grateful. Those who had received a card usual ly saved it, showing it with appreciat ion during the interview.

Only 36% of surviving spouses of our inpatient deaths had had some form of subsequen t contact with physic ians at our hospital (Table 1). These results may be affected by referral and training features of a universi ty hospi tal setting. To deter- mine how well the results of our s tudy general ize to other practice sett ings, in a separa te s tudy we surveyed the managemen t of pat ient dea ths by community physicians. Less than a third of com- munity physic ians init iated follow-up communi- cation with survivors. ~3 Of 132 community physi- c ians who reported their usua l practice following a patient 's death, nine send a card, 23 call the family, and none a t tend the funeral. This rate of subsequen t family contact is similar to the findings of the present s tudy of physic ians affiliated with our universi ty hospital . Thus, it appea r s that a ma- jority of pr imary physic ians both in the community and at our universi ty hospi tal do not routinely in- itiate subsequen t contact with survivors.

Does this lack of subsequen t contact adverse ly affect the adjus tment of survivors? Our results do not a l low us to demonst ra te cause and effect. Sur- vivors with poor subsequen t adjus tment perceived an unmet need to communicate with the primary physician. Our s tudy did not measure whether the

TABLE 3

Survivors' Emotional Adjustments

Significance Spouses with of

a Good Difference Adjustment (Chi-square)

Death not expected by spouse 36

Death expected by spouse 69

14 (39°,6)

49 (71%) p = 0.002

primary physic ians had a t tempted to meet the spouses ' needs. Most of these poorly ad jus ted sur- vivors were at high risk of poor outcome, having s p o u s e s who h a d d ied s u d d e n or u n e x p e c t e d deaths. A spouse ' s support system, prior s t resses , and coping skills have been well documented to affect subsequen t adjustment . Spouses who lack social support are at high risk of poor subsequen t adjustment. 14-~7 Pre-bereavement s tressors affect adjustment, and those concurrently coping with other life crises are a lso at high risk.14, ~s Our s tudy did not eva lua te the role of these predictors.

High-r isk su rv ivors h a v e p r e v i o u s l y b e e n shown to benefit from b e r e a v e m e n t interventions. Bereavement counsel ing has been shown to im- prove the subsequen t ad jus tment and dec rease the morbidity of survivors, s~° Rates of drug and alcohol use, ~8 somatic complaints , 8, ~0 and phys ic ian visits ~° have been reduced. While it is p robab le that be- reavement interventions by pr imary phys ic ians are effective, all previous s tudies of be reavemen t in- tervention have been conducted by psychiatr is ts without involvement of the phys ic ians who had cared for the deceased . Bereavement interventions by primary physic ians are p robab ly at least as ef- fective, because of their prior re lat ionship with the family.

In recent years, our society has at tached greater importance to physicians ' skills and sensit ivit ies in effectively meet ing the needs of the terminally ill. Perhaps, in part, this expla ins the better ad- justment of survivors after expec ted dea ths from prolonged i l lnesses. Our results sugges t a need for subsequen t physic ian contact with survivors fol- lowing a pat ient 's death. Sugges t ions for increased sensit ivity and at tention to detai l in informing the family that the pat ient has d ied have been pro- posed. ~9. 2o Famil ies usual ly prefer to be notified as a group and care should be exerc ised in assur ing the family privacy to grieve. Physic ians should consider personal ly a t tending the funeral. 2~

P h y s i c i a n s s h o u l d con tac t su rv ivo r s in the weeks following death, providing an opportunity to clarify u n a n s w e r e d quest ions . Also, an expla- nation of the au topsy findings should be routinely given. Survivors need comfort and educat ion about

314 Tolle et aL, COMMUNICATION WITH BEREAVED SPOUSES

the normal grieving process. In some instances the patient's physician may work through the spouse's physician in providing bereavement support.

Features of the death setting can be used to predict a group of survivors at increased risk for poor adjustment. Survivors of sudden, unexpected, or emergency room deaths are at high risk for poor adjustment. These groups may require more vig- orous intervention. Survivors of sudden or unex- pected deaths should be routinely contacted in the weeks fol lowing death. Emergency rooms should develop protocols to aid survivors during their acute grief and to ensure subsequent follow-up. Referral to support groups has been found to improve ad- justment, and psychiatric referral is occasionally necessary.

The authors thank Marjorie E. Willis for her assistance with family interviews, Mark Hofmann and Louise Pinamonti for preparation of the manuscript, and Donna Kling Knudson for her review of the manuscript.

REFERENCES

1. Clayton PJ. Mortality and morbidity in the first year of widowhood. Arch Gen Psychiat 1974;30:747-50

2. Parkes CM, Brown RJ. Health after bereavement: a controlled study of young Boston widows and widowers. Psychosom Med 1972;34: 449-61

3. Clayton PJ. The effect of living alone on bereavement symptoms. Am J Psychiat 1975;132:133-7

4. Helsing K J, Szklo M. Mortality after bereavemenL Epidemiol Rev 1981;114:41-52

5. Parkes CM. Effects of bereavement on physical and mental health: a study of the medical records of widows. Br Med J 1964;2:274~9

6. Blankfield A. Grief and alcohol. Am J Drug Alcohol Abuse 1982- 1983;9(4) :435-46

7. Zisook S, Shuchter SR. Time course of spousal bereavement. Gen Hosp Psychiat 1985;7:95-1 O0

8. Vachon ML. Bereavement programmes and interventions in palliative care. Prog Clin Biol Res 1983;132E:451-61

9. Parkes CM. Bereavement counseling: does i t work? Br Med J 1980;281:3-6

10. Raphael B. Preventive intervention with the recently bereaved. Arch Gen Psychiat 1977;34:1450-4

11. Brown JT, Stoudemire GA. Normal and pathologic grief. JAMA 1983;250-378-82

12. Koran LM. The reliability of clinical methods, data and judgments. Part 2. N Engl J Med 1975;293:695-701

13. Tolle SW, Elliot DL, Hick, am DH. Physician attitudes and practices at the time of patient death. Arch Intern Med 1984;144:2389-91

14. Maddison D, Walker WL. Factors affecting the outcome of conjugal bereavement. Br J Psychiat 1967;113:1057-67

15. Vachon ML, Rogers J, Lyall WA, Lancee W J, Sheldon AR, Freeman SJ. Predictors and correlates of adaptation to conjugal bereavement. Am J Psychiat 1982;139:998-1002

16. Bornstein PE, Clayton P J, Halikas JA, Maurice WL, Robin E. The depres- sion of widowhood after thirteen months. Br J Psychiat 1973;122: 561-6

17. Lazare A. Unresolved grief. In: Lazare A, ed. Outpatient psychiatry diagnosis and treatment. Baltimore: Williams & Wilkins, 1979;498- 512

18. Gerber 1, Weiner A, Battin D, Arkin A. Brief therapy to the aged be- reaved. In: Schoenberg B, Berger I, eds.: Bereavement: its psychological aspects. New York, Columbia University Press, 1975;310-13

19. Creek LV. How to tell the family that the patient has died. Postgrad Meal 1980;68:207-9

20. Tolle SW, Girard DE. The physician's role in the events surrounding patient death. Arch Intern Med 1983;143:1447-9

21. Irvine P. The attending at the funeral. N Engl J Med 1985;312: 1704-5