Bereavement Risk Assessment

This questionnaire can be used to help highlight those relatives who are at high risk of an abnormal bereavement reaction.   A score higher than 18 is of HIGH risk.  When trying to complete this questionnaire, please try not to lose the narrative of what the person you are talking to is telling you.   Please click on this link if you would like to see more Notes for Doctors and Nurses Making Telephone Calls to Bereaved Relatives.

1. Person’s relationship to the patient: 7. is the main carer inclined to consume alcohol or drugs (incl. tranquillisers, antideps etc)
Widow
Widower
5
5
None or a little
Moderately
0
2
Partner 5 Heavily 5
Child under 15
Dependent adult child
Parents of adult child
5
3
5
Alcoholic or Drug addict 10

2.

8
.

Available support. Does the main 
carer lack a caring family or does their family/friends inhibit the expression of grief?
Has the patient got children living at home?
Aged    0-5 5 Some 2
Aged    6-12 2 Much 5
Aged    13-16 4

3.
9. Is the main carer facing a concurrent life crisis eg other losses, moving house, financial difficulties, redundancy etc?

Major
Minor
5
3

 

Is the main carer unusually dependent? Dependant clinging, insecure or sensitive to separation?
Some
Much
3
5
4. Unusually angry or bitter? 10. Is the main carer suffering from:
Some 3 Minor nervous problems 5
Much 5 Major nervous problems
Minor heart disease
10
5

5.

Unusually self reproachful or guilty?

Major heart disease or stroke
Threat of suicide in the past
Serious risk of/or attempted suicide in the past
10
5
10
Some
Much
3
5

6.

Is the family unable to share feelings or reluctant to face patient’s illness?

11. Is the main carer in need of bereavement support’?
Some 2 Probably 5
Much 5 Definitely 10

 

Total        ______                    Low Risk/High Risk

 (if score is above 18 – at High Risk)