Family coping and bereavement outcome

The Effects of Bereavement Time on the Relationship Between Coping Strategies and Psychological Distress

The purpose of this study was to investigate the relationship between bereaved individuals' coping patterns, mental health, and time post-loss. A questionnaire using the Coping with Bereavement Scale (CBS) and the Kessler Psychological Distress Scale (K6) was completed by 173 family members of individuals who died from cancer between August 2013 and March 2016. Confirmatory factor analysis revealed a three-factor solution for the CBS comprised of "life orientation," "avoidance," and "retaining ties" with the deceased. Scores on retaining ties were significantly but weakly correlated with K6 scores; however, the intensity of this relationship increased with more time post-bereavement, and individuals who retained strong ties with the deceased for two years or more demonstrated poorer mental health. Although retaining ties with the deceased might be an adaptive psychological process following bereavement, in this study, long-term persistence with that coping strategy was associated with greater overall psychological distress. Further research is needed to identify optimal coping methods to address evolving needs during the bereavement process.

Traumatised, angry, abandoned but some empowered: a national survey of experiences of family caregivers bereaved by motor neurone disease

Background

There are few illnesses as disruptive as motor neurone disease, a fatal neurodegenerative condition, where diagnosis introduces a clinical narrative of inevitable decline through progressive immobilisation into death. Recent evidence suggests that bereaved motor neurone disease family caregivers are more likely to be at moderate or high risk of complicated grief.

Methods

Qualitative data from an anonymous national survey of bereaved motor neurone disease caregivers (n = 393) was examined through thematic analysis to explore the experiences of people who are at low, moderate, and high risk of complicated grief. Up to 40% responded to three open-ended questions: How caregivers viewed their coping strategies; the advice they had for others and what had been positive about their experience.

Results

Ten themes informed the narratives of illness and loss. All three groups shared similar experiences but differed in their capacity to address them. The low-risk group seemed to recognise the uncertainty of life and that meaning needed to be created by them. For the moderate-risk group, while motor neurone disease was a major disruption, they could with support, regroup and plan in different ways. The high-risk group did not have many resources, external or internal. They felt let down when professionals did not have answers and could not see or did not know how to change their ways of responding to this unwanted situation.

Conclusion

The differences in these three profiles and their narratives of loss should alert health and community service providers to identify and address the caregivers' support needs early and throughout the caregiving journey. Motor Neurone Disease Associations are involved throughout the illness journey and need to invest in a continuum of care incorporating end-of-life care and bereavement support. Community grief literacy and enhancement of social networks are keys to improved support from families and friends that can enable the focus to be on feelings of empowerment rather than abandonment.

'Saying goodbye' during the COVID-19 pandemic: A document analysis of online newspapers with implications for end of life care

BACKGROUND

News media create a sense-making narrative, shaping, reflecting and enforcing cultural ideas and experiences. Reportage of COVID-related death and bereavement illuminates public perceptions of, and responses to, the COVID-19 pandemic.

AIM

We aimed to explore British newspaper representations of 'saying goodbye' before and after a COVID-related death and consider clinical implications.

DESIGN

Document analysis of UK online newspaper articles published during 2 week-long periods in March-April 2020.

DATA SOURCES

The seven most-read online newspapers were searched: The Guardian, The Daily Mail, The Telegraph, The Mirror, The Sun, The Times and The Metro. Fifty-five articles discussed bereavement after a human death from COVID-19, published during 18/03-24/03/2020 (the UK's transition into lockdown) or 08/04-14/04/2020 (the UK peak of the pandemic's first wave).

RESULTS

The act of 'saying goodbye' (before, during and after death) was central to media representations of COVID bereavement, represented as inherently important and profoundly disrupted. Bedside access was portrayed as restricted, variable and uncertain, with families begging or bargaining for contact. Video-link goodbyes were described with ambivalence. Patients were portrayed as 'dying alone' regardless of clinician presence. Funerals were portrayed as travesties and grieving alone as unnatural. Articles focused on what was forbidden and offered little practical guidance.

CONCLUSION

Newspapers portrayed COVID-19 as disruptive to rituals of 'saying goodbye' before, during and after death. Adaptations were presented as insufficient attempts to ameliorate tragic situations. More nuanced and supportive reporting is recommended. Clinicians and other professionals supporting the bereaved can play an important role in offering alternative narratives.

Sadness, despair and anger when a patient dies alone from COVID-19: A thematic content analysis of Twitter data from bereaved family members and friends

BACKGROUND

To inform clinical practice and policy, it is essential to understand the lived experience of health and social care policies, including restricted visitation policies towards the end of life.

AIM

To explore the views and experiences of Twitter social media users who reported that a relative, friend or acquaintance died of COVID-19 without a family member/friend present.

DESIGN

Qualitative content analysis of English-language tweets.

DATA SOURCES

Twitter data collected 7-20th April 2020. A bespoke software system harvested selected publicly-available tweets from the Twitter application programming interface. After filtering we hand-screened tweets to include only those referring to a relative, friend or acquaintance who died alone of COVID-19. Data were analysed using thematic content analysis.

RESULTS

9328 tweets were hand-screened; 196 were included. Twitter users expressed sadness, despair, hopelessness and anger about their experience and loss. Saying goodbye via video-conferencing technology was viewed ambivalently. Clinicians' presence during a death was little consolation. Anger, frustration and blame were directed at governments' inaction/policies or the public. The sadness of not being able to say goodbye as wished was compounded by lack of social support and disrupted after-death rituals. Users expressed a sense of political neglect/mistreatment alongside calls for action. They also used the platform to reinforce public health messages, express condolences and pay tribute.

CONCLUSION

Twitter was used for collective mourning and support and to promote public health messaging. End-of-life care providers should facilitate and optimise contact with loved ones, even when strict visitation policies are necessary, and provide proactive bereavement support.

How do Funeral Practices Impact Bereaved Relatives' Mental Health, Grief and Bereavement? A Mixed Methods Review with Implications for COVID-19

Those who are bereaved during the current COVID-19 pandemic are subject to restrictions on funeral sizes and practices. We conducted a rapid review synthesising the quantitative and qualitative evidence regarding the effect of funeral practices on bereaved relatives’ mental health and bereavement outcomes. Searches of MEDLINE, PsycINFO, KSR Evidence, and COVID-related resources were conducted. 805 records were screened; 17 studies of variable quality were included. Current evidence regarding the effect of funeral practices on bereaved relatives’ mental health and bereavement outcomes is inconclusive. Five observational studies found benefits from funeral participation while six did not. However, qualitative research provides additional insight: the benefit of after-death rituals including funerals depends on the ability of the bereaved to shape those rituals and say goodbye in a way which is meaningful for them. Findings highlight the important role of funeral officiants during the pandemic. Research is needed to better understand the experiences and sequalae of grief and bereavement during COVID-19.

Hospice Bereavement Service Delivery to Family Members and Friends With Bereavement-Related Mental Health Symptoms

OBJECTIVES:

A sizable minority of those who lose a loved one in hospice will experience symptoms of bereavement-related mental health disorders. Though hospices offer services to bereaved informal caregivers (family members or friends) of patients, little is known about services offered or interest in them. Therefore, we sought to assess services offered by hospice staff and interest expressed by bereaved informal caregivers with symptoms of depression, anxiety, or complicated grief (CG).

METHODS:

De-identified electronic bereavement care charts of 3561 informal caregivers who lost someone in a large urban metropolitan hospice from October 1, 2015, to June 30, 2016, were reviewed.

RESULTS:

Of bereaved informal caregivers in the sample, 9.4% (n = 333) were positive for symptoms of depression, anxiety, or CG. The symptom-positive family members/friends were more likely than other family members/friends to be offered mailings, one-to-one counseling, telephone calls, and reference material. However, interest in most services by symptom-positive caregivers was low, with only 6% interested in one-to-one counseling and 7% interested in outside referral.

DISCUSSION:

The findings suggest that hospices offer a range of services to family members or friends with symptoms of anxiety, depression, and CG, but that there can be a gap between what is offered and in the interest levels of the bereaved. Engagement with symptomatic family members and friends could be enhanced in future work.

The burden of psychosocial morbidity related to cancer: patient and family issues

With cancer incidence increasing over time, attention to the burden of related psychiatric and psychosocial consequences of the disease and treatment is a major topic for both cancer patients and their caregivers. Among cancer patients, psychiatric (e.g. adjustment, anxiety, depressive disorders) and neuropsychiatric disorders (e.g. cognitive disorders secondary to treatment, delirium) have been shown to affect an average of 30-35% patients, with differences according to stage and type of cancer. Also other psychosocial syndromes (e.g. demoralization, health anxiety, irritable mood) not taken into account in usual nosological systems should be considered for their impact on the patient's quality-of-life. Also, it has been repeatedly reported that psychological distress reverberates substantially throughout the nuclear family, and that a family approach is necessary in cancer care, with the caregiver-patient dyad as a unit to be the focus and direction of assessment and intervention. In this review the most significant psychosocial disorders causing burden for cancer patients and their caregivers are examined, and the main methods of assessment for more proper referral and treatment are summarized.

An Integrative Model of Personality, Coping and Appraisal for the Prediction of Grief Involvement in Adults

This Study Contrasts Two Opposing Conceptualizations Of Personality's Effect Upon Grief: A Traditional Ego Psychology (Risk Factor) View And Lazarus And Folkman's Contextual Coping Model. The Eysenck Personality Questionnaire, the Coping Inventory for Stressful Situations, and the Revised Grief Experience Inventory were administered to 101 bereaved adults. Predictor variables included neuroticism, extraversion, threat appraisal, emotion-oriented coping, task/problem-oriented coping, and avoidance coping. Significant predictive effects for emotion oriented coping, task/problem oriented coping, and grief-related variables were found. Results support contextual coping theory, indicating that immediate coping processes may be better predictors of grief involvement than longstanding personality traits. Clinical implications are discussed.

Describing and understanding depression in spouses of cancer patients in palliative phase

BACKGROUND

The cancer patient's relatives and family constitute one of the patient's main sources of support throughout the disease. In recent years, several studies have emphasized the psychological vulnerability of spouses-caregivers with a high proportion suffering from anxiety and depression symptoms. The literature underlines several factors of detrimental outcomes but critical aspects of the spousal relationship as attachment were neglected.

OBJECTIVES

This study aims at (1) describing depressive symptoms and depression among spouses who care for palliative cancer patients and (2) highlighting important factors explaining these symptoms.

METHODS

We surveyed 60 spouses 1-6 months before the patient's death, (38 men, mean age: 62 years).

RESULTS

We found a high frequency of depression symptoms (25%) in the sample. Higher depression scores were associated to insecure-anxious attachment style, more frequent venting of emotion and disengagement through substance use.

CONCLUSION

Despite limitations, this description of caregivers' emotional adjustment in the palliative phase is unique. Future support programs could use the present information by focusing on emotional venting and avoidance. It also underlines the benefits for caregivers to develop organizational skills thanks to services that will lessen tasks or care responsibilities.

Inter-rater reliability of the Bereavement Risk Assessment Tool

Objective:

The Bereavement Risk Assessment Tool (BRAT) was designed to consistently communicate information affecting bereavement outcomes; to predict the risk for difficult or complicated bereavement based on information obtained before the death; to consider resiliency as well as risk; and to assist in the efficacy and consistency of bereavement service allocation. Following initial development of the BRAT's 40 items and its clinical use, this study set out to test the BRAT for inter-rater reliability along with some basic validity measures.

Method:

Case studies were designed based on actual patients and families from a hospice palliative care program. Bereavement professionals were recruited via the internet. Thirty-six participants assessed BRAT items in 10 cases and then estimated one of 5 levels of risk for each case. These were compared with an expert group's assignment of risk.

Results:

Inter-rater reliability for the 5-level risk scores yielded a Fleiss’ kappa of 0.37 and an intra-class correlation (ICC) of 0.68 (95% CI 0.5-0.9). By collapsing scores into low and high risk groups, a kappa of 0.63 and an ICC of 0.66 (95% CI 0.5-0.9) was obtained. Participant-estimated risk scores yielded a kappa of 0.24. Although opinion varied on the tool's length, participants indicated it was well organized and easy to use with potential in assessment and allocation of bereavement services. Limitations of the study include a small sample size and the use of case studies. Limitations of the tool include the subjectivity of some items and ambiguousness of unchecked items.

Significance of results:

The collapsed BRAT risk levels show moderately good inter-rater reliability over clinical judgement alone. This study provides introductory evidence of a tool that can be used both prior to and following a death and, in conjunction with professional judgment, can assess the likelihood of bereavement complications.

Role of Palliative Care in Adolescent and Young Adult Oncology

Adolescents and young adults (AYAs) with cancer are a heterogeneous group. Nevertheless, there are sufficient unifying characteristics to form a distinct clinical entity. Management of this special group requires a broad-based interdisciplinary clinical team, which should include palliative care (PC), psychology, social work, oncology, and nursing representatives. The function of PC is to provide impeccable pain and other symptom control and to coordinate care as the disease progresses. Features unique to AYAs with cancer include the psychosocial developmental phases, a young person facing death, grief, and bereavement. Pharmacologic and medical interventions by PC in AYAs are broadly similar to adults. Developing trust and being flexible are key skills that PC must use with AYAs. There is a paucity of high-quality controlled studies in the PC literature in general and AYA-PC in particular. Therefore, the methodology of this article is largely based on the narrative and clinical experience. The experience is based on clinicians' work with AYAs with cancer in Israel and Australia. Clinical lessons will be drawn by comparing and contrasting the cultures. Nevertheless, most PC clinical interventions, both pharmacologic and psychosocial, are derived from literature where there is a good evidence base. Future development of PC within AYAs should be coordinated at a national level via appropriate palliative and oncology professional organizations.

What makes grief difficult? Perspectives from bereaved family caregivers and healthcare providers of advanced cancer patients

Objective:

Family members who take on the role of caregiving for someone who is dying begin bereavement after being emotionally and physically taxed by the caregiving experience. The course of bereavement is influenced by a number of factors, including health problems, financial concerns, social support, and family relationships. This paper reports on findings from a secondary analysis of qualitative data from a study examining family caregiver coping in end-of-life cancer care, to describe, from the perspectives of bereaved family caregivers, their perspectives on what made their grief difficult.

Method:

Qualitative data from three focus groups with family caregivers (n = 19) and two focus groups with health professionals (n = 14) were subjected to interpretive thematic analysis.

Results:

Our finding suggest three broad areas that make family caregivers' grief difficult: (1) dealing with occurrences in everyday life; (2) dealing with challenges specific to the caregiving situation; and (3) dealing with the healthcare system.

Significance of results:

The findings provide an important beginning point in understanding the types of issues that seem to make grief difficult for family caregivers of cancer patients at the end of life and can help professional groups to understand what is needed by family caregivers in terms of support and delivery of services.

Bereavement needs assessment in specialist palliative care: a review of the literature

Bereavement needs assessment for specialist palliative care services has been highlighted as important by NICE guidance on palliative care for adults with cancer. Identifying and implementing appropriate bereavement measurement tools has remained a challenge. This paper identifies and reviews bereavement measurement tools to determine their suitability for use within bereavement services and hospice settings. Cochrane, MEDLINE, PsycINFO and CINAHL, electronic databases were searched, yielding 486 papers. From fifty-nine full text papers appraised, 10 measurement tools were analysed in detail. Some tools had been tested on specific populations which limited transferability to specialist palliative care settings; some lacked adequate theoretical links and were not effective in discriminating between normal and complicated grief reactions; and some lacked clear evidence of validity or reliability. Based on these criteria, conclusions are drawn about the suitability of particular tools for UK bereavement services and hospice settings where intervention is delivered by both trained professionals and volunteers.

Factors associated with psychological distress and grief resolution in surviving spouses of patients with advanced gastrointestinal cancer

GOALS OF WORK

Patients with advanced gastrointestinal cancer often have a short survival time. This means that spouses only have a short time to adjust to the approaching death. The aim was to explore whether psychological distress at diagnosis, the course of the illness (anti-tumour treatment, respite period and survival time), the spouses' experience of the care and of losing a loved one were related to distress and grief resolution after the patient had deceased.

MATERIALS AND METHODS

Twenty-one spouses were followed prospectively from the patient's diagnosis of advanced gastrointestinal cancer to 6 months after the patient death. Spouses' experiences were measured with an interview, psychological distress with the Hospital Anxiety and Depression Scale and grief resolution with the Grief Resolution Index.

MAIN RESULTS

The spouses' anxiety at the time of diagnosis was related to their anxiety and grief resolution at follow-up. Two additional factors were associated with higher levels of anxiety at follow-up; the patient having received anti-tumour treatment and the spouse having experienced stress as a caregiver.

CONCLUSIONS

The study indicates that anti-tumour treatment, though it has the potential to prolong life, does not positively influence spouses' psychological distress and bereavement after the death of the patient.

Specialized palliative care services are associated with improved short- and long-term caregiver outcomes

GOALS OF WORK

The goal of this study was to evaluate, at a population level, the association between specialized palliative care services (SPCS) and short- and long-term caregiver outcomes.

PATIENTS AND METHODS

The Health Omnibus Survey, a face-to-face survey conducted annually in South Australia since 1991, collects health-related data from a rigorously derived, representative sample of 4,400 households. This study included piloted questions in the 2001, 2002, and 2003 Health Omnibus Survey on the impact of SPCS. Sample size was 9,088 individuals. "Unmet needs," a short-term outcome relevant to the caregiving period during a life-limiting illness, were tallied. "Moving on," a long-term caregiver-defined outcome reflecting the caregiver's adaptation and return to a new equilibrium after the death, was assessed with and without SPCS.

RESULTS

Thirty-seven percent (3,341) indicated that someone close to them had died of a terminal illness in the preceding 5 years, of whom 949 (29%) reported that they provided care. SPCS were involved in caring for 60% of deceased patients. Day-to-day caregivers indicated fewer unmet needs when SPCS were involved (p = 0.0028). More caregivers were able to "move on" with their lives when SPCS were involved than when SPCS were not involved (86 vs 77%, p = 0.0016); this effect was greatest in the first 2 years after the loved one's death.

CONCLUSION

At a population level, SPCS were associated with meaningful improvements in short-term ("unmet needs") and long-term ("moving on") caregiver-defined outcomes.

Grief support provided to caregivers of palliative care patients in Spain

Grief support for relatives of patients in palliative care is recognized as a fundamental practice within palliative medicine. The aim of this research was to determine the nature and extent of grief support programs offered to relatives of patients in palliative care in Spain. A postal survey was carried out among members of the Spanish Society of Palliative Care. The members' names were obtained through the Society's 2000 Directory, which lists 160 different teams, of which 50% answered a questionnaire made up of 34 questions, some open-ended and others multiple choice. Results show that 88.6% of the services include grief support, that mainly emotional and one-to-one care is provided (92.4 and 89.9%, respectively), and that the number of psychologists and social workers in each team is limited. The risk factors most commonly taken into account by professionals are: absence of family support (36.92%) and the bereaved's case history (21.54%); while the most widely used diagnostic criteria for complicated bereavement are blame and depression (12.5 and 11.36%). In conclusion, it can be seen that bereavement services are not completely consolidated in Spain and there is a need for a greater variety of intervention strategies.

Building a new world: habits and practices of healing following the death of a child

The goal of this interpretive phenomenological study is to describe and understand significant habits and practices developed by families bereaved from the sudden and unexpected loss of their children. Data were primarily collected through the interviewing of 15 family members in seven families. At least four interviews were conducted with each family. Family members were interviewed both together and separately. The analysis of the data illuminated the development of significant and meaningful family practices. These practices acknowledged the death of the children, integrated their loss into the everyday lives of these families, allowed for continuing connection, and were of utter importance as they contributed to family healing.

Does ethnicity matter? Bereavement outcomes in two ethnic groups living in the United Kingdom

Background: Sociologists, anthropologists, and psychologists agree that grief is a universal phenomenon. Reactions to it are, however, socially constructed and patterned.

Objective: To compare the outcomes of bereavement among family or close friends of deceased first-generation black Caribbean and white native-born patients living in the United Kingdom.

Design: Comparative cross-sectional questionnaire survey in three inner London health authorities administered 10 months after the patient's death.

Participants: Family and close friends of 50 deceased first-generation black Caribbean and 50 native-born white patients with advanced disease.

Main outcome measures: 28-item General Health Questionnaire (GHQ-28), Core Bereavement Items scale, a 17-item measure of grief.

Results: The intensity of grief, measured using the Core Bereavement Items was similar between the two groups. Seventy-two respondents had visited their family doctor subsequent to bereavement, and of these, black Caribbean respondents reported more psychological problems. Depression and anxiety measured by the GHQ-28 were significantly higher among black Caribbean respondents (28.00 vs. 21.2) (t-test = −2.28,p= 0.025). Multiple regression analysis revealed this difference was best accounted for by bereavement concerns such as legal and housing problems.

Conclusions: This study has observed higher psychological morbidity among the bereaved Caribbean individuals. Family doctors are a source of support for three-quarters of respondents, and they may need to focus on the needs of black and minority ethnic minorities.

Evaluation of the Bereavement Risk Index (BRI): a community hospice care protocol

AIM

to test the validity, reliability and feasibility of using a modified version of Parkes' (1993) Bereavement Risk Index (BRI) and bereavement support protocol in an Australian home hospice care setting. In addition, the study aimed to explore what types of family members are most likely to experience a more difficult grief reaction.

DESIGN

a prospective, descriptive study was used. One hundred and fifty bereaved family members participated. Bereaved family members were classified as high, medium or low risk and received a structured bereavement support protocol based on their level of risk as measured by the BRI.

FINDINGS

results indicated that a shorter 4-item version of the BRI was more internally consistent than the longer version and demonstrated good predictive validity when correlated with outcome measures at 3 months following the patient's death.

CONCLUSION

the modified 4-item BRI demonstrated acceptable reliability and validity and was brief and simple to use. Nurses were able to use the instrument with minimal training and were able to adhere to a matched bereavement support protocol.

Grief and bereavement

Bereavement support is an integral part of palliative care. Grieving after loss is a normal process; however, some grief reactions become complicated and may seriously compromise the health of an individual. Routine bereavement care helps identify people at risk of complicated grieving. The burden of grief can last for years, sometimes indefinitely. People caring for the bereaved need to pay special attention to cultural differences, the burden of caring for dying children, and the special support needs of bereaved children and adolescents. Excellent resources to assist in grief management, including the expertise of palliative care teams, are readily available.

Evidence-based protocol. Family bereavement support before and after the death of a nursing home resident

Front-line caregivers in nursing homes frequently provide bereavement support to family members before and after the death of a nursing home resident. Use of the evidence-based guideline "Family Bereavement Support Before and After the Death of a Nursing Home Resident" (Davidson, 2002) can reduce uncertainty and increase the confidence of staff providing before and after death care to families, and can ensure all families receive consistent bereavement support.

Family distress in palliative medicine: a pilot study of the family APGAR scale

The family is essential to patients with advanced cancer. Family and caregiver distress, however, can impair optimal care and support of the patient. A five-item questionnaire, the Family APGAR Scale, was evaluated to determine family functioning levels of selected patients. The APGAR Scale has five components for measuring family functioning: Adaptation, Partnership, Growth, Affection, and Resolve. Fifty consecutive patients admitted to a palliative medicine inpatient unit were reviewed for a pilot study. Eligibility requirements included admission to the unit for the first time, and the ability to speak English and give informed consent. Fifteen patients and 11 primary caregivers participated. Despite the small sample, some significant family functioning issues were identifed. Completing the study later with a larger sample will provide information that will help the multidisciplinary team better meet the needs of both patient and family.

[Depression in the elderly and the role of family dynamics]

OBJECTIVE

The objective was to find the relationship between the lived experience within the family and depression in the elderly.

DESIGN

The study had a crossover and descriptive design.

SETTING

Carranque and Campanillas Health Districts, Málaga.

PATIENTS

The target population was the over 65's. The sample consisted of 97 people attended at 2 health centres, one rural and one urban.

MEASUREMENTS AND MAIN RESULTS

The main study variable was the results on the Yesavage Geriatric Depression Scale (GDS), which were contrasted through multiple linear regression with the variables of age, sex, marital status, tobacco dependency, number of people living together, presence of the children in the home (concretely, daughters), family income, ownership of the home, social support network, and Apgar Family II. The results showed that the GDS correlated only with the results of the Apgar Family II (p = 0.00003).

CONCLUSIONS

When tackling the depression of elderly people in primary care, it is absolutely vital to look at the family context, as this is a factor strongly linked to the depression.

Analysis of content regarding death and bereavement in nursing texts

Information contained in textbooks provides the foundation for undergraduate education and entry into clinical practice. Inadequate knowledge of health care professionals in end of life (EOL) has been documented and efforts are in progress to improve this care. This paper reports on a project to strengthen nursing education in EOL care. One of the three project goals was the evaluation of EOL content in 50 nursing textbooks. This paper reports findings in two of the nine areas of the analysis framework which are Death and Bereavement. Findings indicate significant deficiencies in the content within these texts. Improvement in text content will require collaboration of palliative care professionals and textbook publishers and can result in increased ability of nurses to improve EOL care.