Case Scenario

A 42-year-old woman has been my patient for 17 years. She has always been upbeat and cheerful until recently, when her 16-year-old son was killed in a car wreck. I saw her three weeks later, and she wept throughout the visit. After a six-week trial of antidepressants, she is no better. What can physicians do to comfort grieving parents?

Commentary

The death of a child is the most devastating loss any parent can face. If physicians can help even a little, we will have done something of lasting value. Most of the things we can do may seem small to us, but are appreciated by the parents.

When you first talk with a bereaved parent, it is best to simply say that you are sorry for his or her loss. Nothing we say can remedy the situation, and platitudes and cliches are seldom helpful. You should refer to the deceased by name, and not as “your child.” You should also avoid using phrases such as “closure,” “getting over it,” “moving on,” and “turning loose.” These phrases imply forgetting, and parents never want to forget their child.

It is important for physicians to be familiar with the grieving process in bereaved parents.^1,2 Healing varies from person to person, but the average time to fully adapt to the death of a child is three to four years.³ This may be considerably longer if the child's death was unexpected or violent. Parents may feel pressured by their friends, family, employers, and physician to hurry up and get well. Although parents may adapt to life without their child, they will never be the same again.

The death of a child puts a strain on the entire family unit. Marital stresses are considerable, but, contrary to popular lore, the divorce rate among bereaved parents is actually less than that of the general population.⁴ It is important to recognize that men and women grieve differently,⁵ and this difference may exacerbate marital problems. Women tend to grieve by talking, sharing, and crying. They are usually receptive to seeking the help of physicians and support groups. Men are more reticent about grieving openly. They tend to maintain a more stoic approach, often choosing to cope by involving themselves in solitary projects or work. Mothers and fathers both find it difficult to continue parenting their other children while mourning the death of a child. As a result, siblings often feel neglected. Teen Grief Relief: Parenting with Understanding, Support and Guidance is an excellent information source for parents of surviving siblings.⁶

Physicians can also help grieving parents by offering simple reassurance that their emotions are normal. If the parents are established patients, it is appropriate to attend the child's funeral, if possible. Sending a personal note is also appreciated. Parents often cite notes from physicians, nurses, and office staff as being extremely meaningful. You should record the child's birthday and the day he or she died in the parents' charts. When you see the parents in the future, you can mention their child by name at the end of the visit. This and a brief reminiscence show that their child is not forgotten.

Perhaps the most helpful thing you can do is listen. Parents need to talk. They need to tell their stories over and over. Friends, coworkers, and many family members may find it difficult to listen after a while, and repetitions can be emotionally draining. For this reason, physicians should be familiar with local support resources. A grief counselor who specializes in parental grief can be invaluable. Two well-known support groups are The Compassionate Friends (http://www.compassionatefriends.org) and Bereaved Parents of the USA (http://www.bereavedparentsusa.org). These organizations have more than 700 support groups nationwide where family members can share with others in the same circumstances. The Compassionate Friends Web site has a wealth of information, sources of literature, and online support groups and chat rooms for parents and siblings.

Statements such as “I don't care if I live or die” are common and should be explored, but almost never indicate suicidal intent. The fact that grieving parents are sad and often tearful does not necessarily mean that they have a major depressive disorder (MDD). The primary symptoms of MDD in bereaved parents are morbid preoccupation with worthlessness and psychomotor retardation that last longer than two months, as well as suicidal ideation. Anyone with these symptoms should be screened for MDD.

There are no controlled studies comparing parental bereavement-related depression, which typically does not respond to antidepressants, with MDD, which often does respond to antidepressants. The results of a major study of widows and widowers showed that after the death of a loved one, MDD can be expected in 13 percent of those who have never had major depression, 30 percent of those who have had one episode of major depression, and 43 percent of those who have had two or more episodes.⁷ Although many parents do not require antidepressant medication, if it is unclear whether the patient is experiencing normal grieving or MDD, a trial of an anti-depressant is a reasonable approach. Either way, improvement may take a long time.

In this scenario, reassure your patient that she is grieving normally and that you will work with her for as long as she wants. It is appropriate to see her at two- to four-week intervals. Encourage her to attend support group meetings and to take her spouse, if possible. Referral to a grief counselor might also be useful. Finally, be alert for illnesses brought on by prolonged, severe stress.