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Ernest H. Rosenbaum, MD, Isadora R. Rosenbaum, MA and Sabrina Selim, MD
- 1. Engage in conversations about what should happen after death. Prepare an ethical will; leave instructions for what kind of funeral you want -- for example, who should officiate and whether should be private. Such information can relieve the guilt that survivors often feel during the crisis that occurs after a loved one's death, when decisions must be made while grief clouds the mind. It can also prevent unnecessary expense, since many people do not wish to be remembered in a more elaborate way, with a special public memorial, can make this clear.
2. Use a memorial service to try to consolidate the survivor's feelings about the person who has died. This formal means of expressing feelings can initiate and accelerate grieving. Often survivors talk about their feelings and express their love at such a service, which can be a positive, reaffirming experience.
3. During the mourning period, make use of visits from family and friends. Most religions go through rituals and periods of observance that aid in the grieving process. For example, a wake -- a party to celebrate a person's life -- is a Christian custom. In Judaism during a week of intense mourning (called Shiva, seven), mirrors are covered, the immediate family sits on the floor or lower than visitors, and meals are provided by friends and family. After this week, the family gradually progresses back towards the living. The setting of the headstone, approximately 11 months later, is supposed to end the period of mourning so that life can go on.
Emotional counseling and support from clergy, family and friends is more available during the first week or two. As time goes on, friends and family return to their homes and their lives. Calls and letters come less frequently, and the grieving person is gradually left more alone to face the finality of the loss. Periodic letters and telephone calls give continued support but in reality, the grieving person has to take over, regain control of his or her destiny and resume taking care of self, family and friends. Life will go on at its own pace.
We often tell people that this is the time when they need courage and fortitude, and that in part, they could take such strength from their lost relative or friend, who exemplified strength in going through the illness. The survivors now need to emulate that person, calling on a similar strength to continue living in a way that honors the person's memory.
If grief persists without abating over 6 to 12 months, becoming the dominant force in the survivor's life, spiritual or psychological support becomes essential in order to help the bereaved return to an active productive life. There is a need for a purpose in life and for setting new goals.
Most terminally ill patients have already thought about these concerns, and the questions they are asked may come as no surprise. Giving the person the chance to express him/herself, especially in the presence of loved ones, can be a very positive aspect of the coping process.
There are clearly many things on a person's mind during life's final episode. Expressing these concerns can be a effective part of palliative care, improving the quality of the remaining time. It also provides a unique opportunity to help family members bond in a way that fosters both current and future faith and hope, enhancing their courage and giving them strength to face the future.
Love and care begin early in life, and there needs to be some level of satisfaction before death. How a person dies also makes a difference, because survivors will remember many events from the final days, hours and minutes.
Compassion shown by the medical team, clergy, psychologists and social workers can reduce the chance that grieving survivors will feel angry that not everything possible was done. There are always questions along the lines of whether a person could have lived longer had the medical team only kept him or her on the respirator or the feeling this death is not fair.
Feelings that my life is now ruined and now I have to fend for myself are normal and natural, but can often be lessened through appropriate guidance during the final episode in life. Attacking the psychosocial as well as the medical issues can reduce or eliminate many of the emotional crises common to grieving.
In facing your own death by taking steps, you may help your survivors live better and lessen their grief of loss. Not everyone can provide this type of help, though. In part, our resistance to doing so may relate to Freud's suggestion that the unconscious mind does not recognize it's own death, and regards itself as immortal... It is indeed impossible to imagine our own death; and whenever we attempt to do so, we can perceive that we are, in fact, still present as spectators.
Often, even near death people act in an unknowing way. A sudden death, which denies the dying person a chance to express helplessness, abandonment or fear of death, presents a more difficult situation. The difficulty, in part relates to one's ego when the final event is taking place.
In the hospital, the approach of death is often denied until the time it occurs. Media revelations of magical cures and new treatments give false hope. Elizabeth Kubler-Ross reports that only 2 percent of dying patients reject the chance to discuss their dying, but many staff members become so emotionally upset that they cannot help in helping a dying patient share the experience with staff, family or friends. Such discussions are usually less upsetting to the dying person that to those around him or her. The fear of death can provoke withdrawal, depression or a heroic transcendence into a more giving and gracious attitude. The dying person can provide a touchstone for the survivors and future generations by reflecting on the meaning of life and by giving hope that his or her spirit and thoughts will continue.
The care of the dying provokes a pervasive fear in many people -- that they themselves will die and be extinct, helpless, abandoned, lose their self-esteem. People who wallow and struggle in their own mortality during the final episode of the dying process may be detaching themselves from reality. This is one of the normal mechanisms of escape, but such repression of death and anxieties about the future, although normal, can affect not only how the dying person copes but how the survivors cope.
This leads to what has been termed appropriate grief, where the mourning resolves around recognizing and integrating each person's feeling of live or hate for the person they are mourning. Our attitudes toward life and death play a role not only in how we live and how we die but also in how we grieve. The process of death and grieving is thus different for each person. Preparing for death through physical means (such as preparing for funerals, buying plots and deciding on code status) and through emotional means (such as making an ethical will) can alter the grieving process.
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