With the trust and understanding built up between general practitioners (GPs) and their patients over years of care, GPs are well-positioned to provide timely bereavement care and support during the end-of-life journey. Find out more about a newly developed resource that aims to support healthcare and community care professionals including GPs in this area – highlighting common care needs and signposting the resources available to address them.
A BROADER UNDERSTANDING OF
BEREAVEMENT CARE
Bereavement care has often been perceived as
receiving psychotherapeutic interventions such as
bereavement counselling or therapy after the death of a loved one. This is not surprising as bereavement
is defined as ‘the objective situation of having lost
someone significant through death’.1
However, the National Institute for Health and Care
Excellence Guidance on Cancer Services (2004)
posited that bereavement care may begin before a death, and is not just about the actual dying phase or time around and after death.
A wide range of bereavement needs
The guidelines also added that bereavement can
give rise to a wide range of needs such as practical,
financial, social, emotional and spiritual.
Therefore, beyond the need for psychotherapeutic
interventions, bereaved persons may also present
with: 2
- Needs for information about loss and grief
- Needs to pursue particular cultural practices
- Needs for additional support to deal with the
emotional and psychological impact of loss by
death
- In a small number of circumstances, specific
needs for mental health service intervention to
cope with a mental health problem related to
loss by death
A broader understanding of bereavement care is
therefore important for community care providers
such as GPs to offer timely and appropriate forms
of psycho-emotional as well as practical support to
patients and their loved ones.
The Role of GPs in Bereavement Care
Primary care (GP clinics and polyclinics) is the
foundation of the healthcare system in Singapore.3
80 per cent of primary care in Singapore is provided
by private medical clinics. In addition, 55 per cent of
chronically ill patients are managed by private GPs,
with polyclinics tending to the remaining 45 per cent.4
What GPs can do
While an informal search of the internet did not
reveal any local papers describing the GP’s provision
of bereavement care in Singapore, international
literature from the United States, United Kingdom
and Australia has posited that GPs are well-positioned
to provide bereavement care and
support to their patients.5-7
It has been proposed that the role of the GP can be
twofold:8-10
-
Supporting bereaved persons, and
- Referring them to additional support services from
mental health professionals when necessary
In the United Kingdom, the average practice has
20 patient deaths per full-time GP each year,
with a proportion of them being newly bereaved
individuals.5 Studies have also documented
increased GP reviews by patients following bereavement due to increased morbidity during this time.11-13
Supporting GPs in providing care
Although GPs and primary care providers may
be suited to provide bereavement support in the
community, few are adequately trained,14-16 and
many are uncertain how to respond after a death
beyond being approachable, accessible and
understanding17-18.
While international literature has continued to focus
on the provision of bereavement care after the death
of an individual, it is important to develop resources
that can offer relevant and useful information
to care providers such as GPs on upstream
bereavement care needs and services.
"As the first line of care in the community,
primary care professionals are often the
first point of contact with patients. They
provide holistic and personalised care
for patients of different age groups."
– Ministry of Health (MOH), 20213
A LOCAL GRIEF AND BEREAVEMENT
RESOURCE
In order to support healthcare and community care
professionals in Singapore in meeting the vast range
of bereavement needs, between 2017 and 2020, the
Grief and Bereavement Community of Practice (GBCoP)
produced an inaugural resource entitled ‘Mapping
of Care Services for the Dying, their Caregiver, and
the Bereaved’.
Resource objectives
This service map was created as an education
and service planning resource for local health and
community care providers to navigate the end-of-life
and bereavement care journey of persons suffering
and dying from serious illnesses.
It can also serve as an information directory for the
general public who may be interested to learn about
services relevant to end-of-life, grief and bereavement
care.
It should be noted that the service map is not meant
to dictate the needs of the dying, their caregivers and
bereaved persons, or to prescribe care interventions
by service providers. Instead, it highlights common
care needs of grieving or bereaved individuals and
signposts available community resources to meet those needs as they arise.
A person-centric approach was adopted in its
development, where the voices of service users
shaped the five major person-centred themes in the
service map (Annex A).
Resource format and structure
In this service map, information is organised and
presented over three demarcated time periods:
Perspectives from both care providers and service
users were consolidated and organised into three key
elements of bereavement care needs and services
across the demarcated time periods (Annex B):
Providers of care:
Who are the ones involved in providing care?
Aspects of care:
What are the different aspects or types of care
needs?
Care tasks: What is the focus of assessment and intervention?
The resource further describes the mainstream
care services within the local landscape, as well as
interventions to address a diverse range of practical,
financial, social, emotional and spiritual needs of the
dying, their caregivers and the bereaved.
Annex C features the elements of care at the 12-month
prognosis period. Brief descriptions of selected care
providers, care services as well as concepts listed in
the service map were added to offer additional useful
information to readers. The numbers annotated beside
these selected items in Annex C allow readers to
locate the corresponding descriptions in the resource.
A sample of the descriptions is shown in Annex D.
Click here to view all four annexes.
CONCLUSION
While GPs have limited time during each consultation
session, the strength of their professional relationships
with and understanding of their patients cannot be understated.
Patients are familiar with and comfortable speaking
to their GPs, and may be more willing to disclose
stressors, losses and illness within the family, as well
as existing coping strategies or the lack thereof.
They may also be more receptive to the advice
and recommendations offered by their GPs such as
seeking specialist and/or professional services when
needed. Furthermore, GPs may be better positioned
to collaborate with other community partners to offer
timely support and follow-up for patients, considering
their proximity in the community.
It is the hope of the GBCoP that the service map can be
a useful resource to both health and community care
providers, to signpost the range of instrumental and
practical support services that can be made available
to their patients, clients and caregivers across the
illness trajectory. We also hope that it can function
as a springboard to generate interest and future
opportunities to build local death and grief literacy.
REFERENCES
Stroebe, M. S., Hansson, R. O., Schut, H., & Stroebe, W. (Eds.). (2008). Handbook of bereavement research and practice: Advances in theory and intervention. American Psychological Association.
National Institute for Health and Care Excellence (2004). Improving Supportive and Palliative Care for Adults with Cancer – Cancer Service Guideline [CSG4]. Retrieved on 20 April 2022 from https://www.nice.org.uk/guidance/csg4/resources/improving-supportive-and-palliative-care-for-adults-with-cancer-pdf-773375005
Ministry of Health (2021). Primary Healthcare Services. Retrieved on 29 April 2022 from https://www.moh.gov.sg/home/our-healthcare-system/healthcare-services-and-facilities/primary-healthcare-services
Khoo HS, Lim YW, Vrijhoef HJM. Primary healthcare system and practice characteristics in Singapore. Asia Pacific Family Medicine, 2014, 13:8
Nagraj S, Barclay S. Bereavement care in primary care: a systematic literature review and narrative synthesis. British Journal of General Practice, 2011, 61:e42–e48.
Ghesquiere AR, Patel SR, Kaplan DB, Bruce ML. Primary care providers’ bereavement care practices: recommendations for research directions, International Journal of Geriatric Psychiatry, 2014 December; 29(12): 1221-1229
O’Connor M, Breen LJ. General Practitioners’ experiences of bereavement care and their educational support needs: a qualitative study. BMC Medical Education 2014 14:59.
McGrath P, Holewa H, McNaught M. Surviving spousal bereavement: insights for GPs. Australian Family Physician 2010, 39:780–783.
Lobb EA, Clayton JM, Price MA. Suffering, loss and grief in palliative care. Australia Family Physician 2006, 35:772–775. 7.
Nagraj S, Barclay S. Bereavement and coping with loss. InnovAiT 2009, 2:613–618.
Bergman E, Haley WE. Depressive symptoms, social network, and bereavement service utilization and preferences among spouses of former hospice patients. Journal of Palliative Medicine. 2009; 12:170–176
Buckley T, Sunari D, Marshall A, Bartrop R, McKinley S, Tofler G. Physiological correlates of bereavement and the impact of bereavement interventions. Dialogues in Clinical Neuroscience, 2012, 14:129–139.
King M, Vasanthan M, Petersen I, Jones L, Marston L, Nazareth I. Mortality and medical care after bereavement: a general practice cohort study. PLOS One. 2013; 8:e5256
Low J, Cloherty M, Barclay S, et al. A UK-wide postal survey to evaluate palliative care education amongst general practice Registrars. Journal of Palliative Medicine, 2006; 20(4): 463–469. 11.
Barclay S, Todd C, Grande G, Lipscombe J. How common is medical training in palliative care? A postal survey of general practitioners. British Journal of General Practice, 1997; 47(425): 800–804. 12.
Barclay S, Wyatt P, Shore S, et al. Caring for the dying: how well prepared are general practitioners? A questionnaire study in Wales. Journal of Palliative Medicine, 2003; 17(1): 27–39.
Charlton R, Dolman E. Bereavement: a protocol for primary care. British Journal of General Practice, 1995; 45(397): 427–430. 6.
Mazza D. Bereavement in adult life. GPs should be accessible, not intrusive. BMJ 1998; 317(7157): 538–539 9.
Mr Andy Sim is part of Singapore General Hospital’s Internal Medicine Supportive and
Palliative Care Service and the Isolation Intensive Care Unit supportive care team.
He holds a Master of Social Work degree from New York University (NYU) and is a Leadership
Fellow of the Zelda Foster Studies Program in Palliative and End-of-Life Care, NYU.
He is also a Fellow in Thanatology of the Association for Death Education and Counselling.
Mr Sim was a core group member of the Grief and Bereavement Community of Practice
and co-edited the 'Mapping of Care Services for the Dying, their Caregiver, and the
Bereaved' resource.
GPs can call the SingHealth Duke-NUS Supportive & Palliative Care Centre for appointments at the following hotlines:
Singapore General Hospital: 6326 6060
Changi General Hospital: 6788 3003
Sengkang General Hospital 6930 6000
KK Women’s and Children’s Hospital: 6692 2984
National Cancer Centre Singapore 6436 8288
National Heart Centre Singapore 6704 2222
National Neuroscience Institute 6330 6363
