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Dr. Holly Prigerson Nearly half of all people in the United States who are at the end of their lives receive hospice care, which provides compassionate care to patients with a focus on improving their quality of life. Although hospice does much to ease the physical and emotional burdens imposed on a caregiving spouse when their partner is terminally ill, this type of care could be further strengthened to attend to the psychological needs of family caregivers after their loved ones have died, Weill Cornell Medical College researchers write in a commentary published May 26 in JAMA Internal Medicine.

"The study found that spouses had an overall increase in depressive symptoms after their loved ones died, but that the rate of increase in depressive symptoms was lower for surviving spouses of patients who had used hospice compared to those who had not," said lead author Dr. Holly Prigerson, the Irving Sherwood Wright Professor in Geriatrics at Weill Cornell Medical College. "This suggests that hospice services, which were shown to have only a modest effect on reducing the severity of depressive symptoms, might be improved to reduce depression symptom severity more effectively."

The commentary offers suggestions for ways to improve how hospices treat both patients and their grieving spouses. Recommendations include promoting the patient's psychological acceptance and mental preparation of the caregiver for the patient's impending death; envisioning and planning for life after the spouse is gone to promote psychological adjustment to life as a widowed person; screening caregiving partners for ongoing psychological distress and, if appropriate, making referrals to mental health professionals; proactively finding a financial planner, mechanic, cook or others to fill the practical roles of the deceased family member; and increasing the number and length of hospice bereavement follow-up visits to the living spouse after a partner's death.

Since use of hospice services are on the rise, Dr. Prigerson said, it's of the utmost importance to maximize the benefits that these services bring to terminally ill patients and their family members.

"Most people who die in hospice do so after a serious, chronic illness such as cancer," Dr. Prigerson said. "In those cases, there is an opportunity to plan for the patient's death and the bereavement adjustment of the surviving spouse."

Hospice services can help surviving partners by calmly exploring ahead of time how the impending death of their loved one is likely to affect them emotionally, a process called affective forecasting. Talking about what life after the death of a loved one will look like can help prepare caregivers in advance for that eventuality and combat feelings of being overwhelmed, helplessness and vulnerable, Dr. Prigerson said.

After a patient's death, hospice services should pay closer attention to the mental health needs of the surviving spouse, she contends. Hospices should screen for bereavement-related mental disorders like major depressive disorder, prolonged grief disorder and post-traumatic stress disorder, as well as the not uncommon presence of suicidal thoughts and gestures. Referrals to mental health professionals or other tested interventions would bolster the "anti-depressant" potency of hospice "aftercare," Dr. Prigerson posits. She recommends that the duration and frequency of bereavement follow-up visits be increased to ease the transition to widowhood, and advocates for monthly check-ins and additional sporadic outreach through the phone and social media to help ease feelings of isolation.

With these changes, terminally ill patients will spend the end of their lives comfortable, well-supported and reassured that their spouses will be well cared for and that they will be given the best chance to transition to their new lives that lie ahead.

"There is a public health interest in trying to improve the services hospices provide," Dr. Prigerson said, "both for the patient and for grieving family members."