Bereavement The interest in palliative care, or counseling for bereavement comes to different people in different ways, and one doctor came into it through home care as long ago as 1975. The doctor had just finished working as a house staff in the University of California in San Francisco. Then he got a job at Massachusetts General Hospital as a physician. The doctor was placed at Chelsea Memorial health Center. This was a neighborhood health center in a poor multi-ethnic community, yet not a great distance away from MGH. The doctor had come to replace a person who had come from Britain for a working experience of a year in United States and had gone to the houses of a few elderly patients. In the beginning itself, it was suggested to the doctor by the senior that he visit two patients who were being cared by relatives at home. This was the first visit to any patient's home by the doctor but it became a practice. The doctor was then supported by a multi-disciplinary team at MGH about the patients that the doctor visited at home. This team included doctors, nurses, a social worker, a geriatric outreach worker, a nutritionist and a medical librarian. (Pioneer Programs in Palliative Care: Nine Case Studies)

The group met regularly to discuss about complications of geriatric cases, and this led them to focus on home care cases. The other doctors may not then have viewed the visits of this doctor to the homes of patients as normal, but they all appreciated the intimacies that had been highlighted by the home visits and even came out with certain details that they had also found out from home visits. This was not unusual as many families at Chelsea and similar communities were accustomed to treating sick relatives at home, and some persons even had an idea that they will be cared at home by the relatives till the end of their days. This experience had also come to the doctor and the first two patients that he had met were old and demented, and the care was being given by the wife in one case and by the son in another case. The doctor was able to learn a lot about the care of elderly from colleagues and these were nurses and social cases generally. This led to talks about giving care for elderly from the seniors and this led to finding out of the intellectual challenges of the job. That led to the question of training others for this important task.

Ultimately this led to the formation of a group around 1978 and the doctor was asked to join the group. The inspiration behind the group was the work of Cicely Saunders, who had started St. Christopher's Hospice in London, and that had led to the first hospice in Massachusetts. At that time, there was a lot of teaching on this subject about terminal care as also conferences at Hospice of New Haven, the National Hospice Organization and Balfour Mount. Ultimately the doctor turned his attention to practicing and teaching about care for patients nearing the end of life, and the management of the pain and concerned symptoms by the people who took care of them. This was when the doctor wanted to set up a palliative care unit even at Massachusetts General Hospital. That never happened, but the doctor became an authority on the subject -- J. Andrew Billings. (Pioneer Programs in Palliative Care: Nine Case Studies)

This has now become much more professional and the service for the help of the patients and the other persons connected with them has become available. There is an organization called the Loss Counseling Center which has a setting where all people feel it in order to ask questions about their own feelings. They can also get support at all levels for their needs and to even explore other issues and their own internal feelings as much as they are capable of. The experience of loss is very intimate and no experience can be considered to be out of the line. The experience of loss can come in many different ways like separation, divorce, death of parent or spouse or friend, loss of a pet, miscarriage or loss of a child through natal or infant or child deaths, loss of a job, retirement, relocation, career changes, life changing or threatening health problems, preparation for death either one's own or others who are related, infertility, or even a loss of body part through hysterectomy or mastectomy. This organization provides services in the Washington Metropolitan area on a weekly basis. Even when the people come from other areas the services...

There are also other forms like discussions on topics of loss, or workshops and seminars. (Services: The Loss Counseling center of Washington)
The development of studying the losses due to bereavement and supporting people who have suffered on this account is now common and has spread to even relatively less common places. Bloomington School district also has an Institute for Therapy and Behavior Change situated at the institute and it attends all difficulties like a mental health agency. It provides individual, group, couple and family therapy for all troubles like adolescent or youth counseling, anger management, bereavement and grief counseling, and cultural transition. (Bloomington School District) Thus it is clear that while the problem is being recognized, yet the treatment is combined with a lot of other psychological problems.

The other area that this is seen together with is the psychological help that is required by people approaching the end of their lives. Beth Israel Hospital is one such organization as it was committed to improving the care of seniors. Their understanding of the need for care in this area came when the results of the 1995 study had come in and shown that there were a lot of defects within the care of patients who had life threatening diseases. The survey results were combined with Picker Institute documents and that showed the main area of defects were in patient centered care. When the study was completed, there was already a great part of a palliative care program ready, and that included a 15 bed inpatient hospice unit which had started off at Deaconess Hospital in early 1996. This was attached to Beth Israel Hospital and the unit where the largest amount of pain relief was carried out. The effort to bring about the system was warmly supported by the leaders and they encouraged the efforts to build a total program. Staff also warmly welcomed them. (Pioneer Programs in Palliative Care: Nine Case Studies)

There were other difficulties in development. Organizational stress started, major changes were then in institutional leadership, and the financial position was bad. All this compelled that priority be given to financially stabilizing the organization. While all this was happening, all the concerned organizations as also some others were clubbed together in Care Group. This was a health care delivery system and gave new opportunities for planning of the exercise and providing the palliative care facilities to all patients in the inpatient and outpatient sectors. This was followed by support from the Faculty Scholars Program on Death in America and this gave the project support for another two years in 1999. This gave rise to a full scale palliative program and the operating budget supported for the appointment of a full time nurse and 4 physicians on a full time equivalent basis. The development of the system also led to careful documentation and evaluation of what was being provided to the patients. The finances were also stabilized up to 2001. (Pioneer Programs in Palliative Care: Nine Case Studies)

It is clear that the need for a system of this type is being recognized by most hospitals, and action is taking place. At the same time, funds seem to be a major criterion, as the Jewish Family Service Association was compelled to withdraw Kesher, which was a program meant for the help of the Orthodox community. The meaning of Kesher in Hebrew is connection and was started by Mt. Sinai Health Care Foundation with a grant of $200,000 in 1999. The program could be continued in 2001 as there was a further grant of $100,000. The program was expected to extend the counseling programs to the community. The confidential services of the group included help through support groups, counseling for bereavement, employment, parenting and marital difficulties, abuse and personal crisis, education, financial assistance, as also home management and assistance for childcare. The program was being administered by a board of rabbis. (Finances force JFSA to scale back Kesher)

Sometimes it is needed that a study be made of the quality of service as seen by the patients. This was done in St. Clair Hospital in May 2002, when a letter of request was sent to a random sample of family members and others who died there during December 2001 to February 2002. The total number of…