Brian Nandy Counseling              

DEATH & END-OF-LIFE CARE

Death and dying can be stressful for dying people, their loved ones and care-givers. Psychologists can help. They can assess mood, mental functioning and pain; treat depression, anxiety and other mental health problems; provide end-of-life counseling to the dying and their families; and advocate for good medical care.

As people approach the end of their lives, they and their families commonly face tasks and decisions that include a broad array of choices ranging from simple to extremely complex. They may be practical, psychosocial, spiritual, legal, existential, or medical in nature. For example, dying persons and their families are faced with choices about what kind of caregiver help they want or need and whether to receive care at home or in an institutional treatment setting. Dying persons may have to make choices about the desired degree of family involvement in caregiving and decision-making. They frequently make legal decisions about wills, advanced directives, and durable powers of attorney. They may make choices about how to expend their limited time and energy. Some may want to reflect on the meaning of life, and some may decide to do a final life review or to deal with psychologically unfinished business. Some may want to participate in planning rituals before or after death. In some religious traditions, confession of sins, preparation to "meet one's maker," or asking forgiveness from those who may have been wronged can be part of end-of-life concerns. In other cultural traditions, planning or even discussing death is considered inappropriate, uncaring, and even dangerous, as it is viewed as inviting death (Carrese & Rhodes, 1995).

All end-of-life choices and medical decisions have complex psychosocial components, ramifications, and consequences that have a significant impact on suffering and the quality of living and dying. However, the medical end-of-life decisions are often the most challenging for terminally ill people and those who care about them. Each of these decisions should ideally be considered in terms of the relief of suffering and the values and beliefs of the dying individual and his or her family. In addition, any system of medical care has its own primary values that may or may not coincide with the values of the person. For example, in most Western medical systems the principles of individual autonomy (though not to the exclusion of family members and intimates) and informed consent are primary. In contrast, many cultures eschew the principle of autonomy and the principle of interactive, community decision-making is thought to be the ideal. Therefore, well-intentioned presentations of treatment or care possibilities by health care providers may overlook a particular person's wish not to discuss death.

References

Carrese, J. A., & Rhodes, L. A. (1995). Western bioethics on the Navajo reservation. JAMA, 274, 826-829.

How to support someone who is grieving?

By June Cerza Kolf

1. Let the bereaved person speak about the death. Ask simple questions without probing beyond anything they wish to offer.
2. Do not interrupt to share a similar story.
3. The greatest time of need would be 1-week later, when his family returned to their own home.
4. Make specific dates to meet later, so that they have something to look forward to.
5. When writing sympathy card, if you know anything about the deceased, include a fond memory.
6. Be specific instead of general: Instead of “How are you doing?” ask “ It must be difficult being alone after all these years. How are you getting along so far?”

 Personal Contact:  It is important to make contact as soon as possible when you have heard of a death. Don’t wait. They need support especially when death first occurs. “At first, I felt let down & disappointed in friends and relatives who did not respond at my time of grief.  Hindsight has shown me  that those particular people would not have been able to cope with my sorrow.

Some parents, instead of holding each other up, they pull each other down because they are too weak. So our immediate support is important.

 Offering condolences: There are no pat speeches and no perfect words. Just speak from the heart.

 “I’m so very sorry” is better than clichés. Or you can simply admit and say, “Oh, that wasn’t what I meant to say to you at all. O just feel so awkward and I hurt so much for you.” Honesty is always appreciated.

Loss of a child. “Be grateful for the time you had with little Johnny” Is not a positive statement. It is more appropriate to tell the couple you will miss the joy the child brought and that you heart aches for them. There; no need to feel embarrassed if you cry in their presence. It will only reassure them you truly care.

Violent death [suicide, murder]. Don’t ask Why? As if they knew. The details are not important. Adress the devastation, pain, loss and guilt.

AIDS. Families may feel shunned & privacy intruded. They may feel stigmatized and feel as if an explanation is needed.

Make it clear that the tragedy of the loss is more important than the details of how it happened. Let family know that you u/stand they are experiencing extra pain. Do not ask for details unless the offered. As important as what to say, is what not to say. Studies who that one of the best ways to work thru grief is to talk about it. Grieving people need their friends to listen while they talk away their grief.

Employers and Employees. Frequently co-workers ignore they fact that a death has occurred. Because people are afraid to remind the griever of the death & create discomfort, they don’t mention it. Death is the main thing on the griever’s mind and no one else has to mention it to remind the griever. Not mentioning the death only makes the grieving person feel isolated and abandoned.

These are all normal & natural responses. Their duration is different for everyone.  Don’t predict a time. If someone you love dies, you may not have anger, instead feel relieved. Don’t let anyone create a time frame or fit you into a stage.

Getting over | Getting complete

Misinformation: you can “never get over” the death of a child. “Not forgetting” becomes incorrectly entangled with the idea of “not getting over”.  Ask yourself; “When you remember pleasant memories, does your heart feel broken?” No. Instead of saying “my heart is permanently broken”, use instead “sometimes when I am reminded of her struggles and her death, my heart feels broken. Other times remembering her wonderful qualities, I feel happy and pleased to share my memories about her.”

Grievers are willing to talk about the circumstances of the loss and to review the relationship they had. Grief Recovery can happen immediately. The accuracy of our memories is heightened about the loss. Tragic circumstances creates social isolation [AIDS, suicide, murder] – the feeling of the unfairness of it all. So quickly move to consider 2 large truths:

1. Would you love your loved one any less if s/he died some other way?
2. What is left emotionally unfinished for you as a result of this death?

Closure is another unhelpful and inaccurate word. Lawsuits may complete a crime but does not being emotional completeness.

 Guilt implies “intent to harm”. Since you had no intention to harm, and having the devastation of the death, you don’t need to add hurt with an incorrect word hat distorts your feelings. In some instances, people have does things with intent to harm, in that case, an apology helps to remove any obstacle to completion.

 Survivor reminds people to revisit the circumstances about the loss. It becomes an identity. Do not use that word. Segregating the grievers by type f loss adds to that isolation. Meeting together with others who have had a similar experience is comforting.

We are ill prepared to deal with loss.

We are always thought to learn to acquire things to make life successful and happy. We are even advised not to learn about dealing with loss, not to talk about it. “What is done is done. You have to move on. Don’t burden others with your feelings.”  The crucial step is to develop some helpful habits for dealing with grief. To develop a new habit:

1. must become aware of the need to develop a new habit.
2. learn the component parts/ skills necessary to build the habit. This means identifying the ideas that don’t work & replacing them with ideas that work.
3. MUST practice the new ideas to turn them into habits.

 Misinformation about dealing with loss:

1. Don’t feel bad. “If you’re gonna cry, go to your room” aka “Don’t cry” “there are plenty of fish in the sea.”
2. Replace the loss. “Let’s go shopping”, “I’ll get you a new dog.”
3. Grieve alone. “Give her some space.” “He needs to be alone”.
4. Just give it time aka “time heals all pain”.  If you have a flat tire, would you just stare at it and wait for air to somehow get back into the tire? Time itself does not heal; it is what you do within time that’ll help complete the pain.
5. Be strong for others.
6. Keep busy

 Grieves have been taught to isolate themselves. Participation is part of the solution. Participate is your own recovery.  The accumulation of unhelpful reactions add up to a loss of trust.

Others are Ill Prepared to Help Us Deal with Loss.

 People don’t know what to say. “I know how you feel.” This is delivered with great compassion & with intent to soothe. Most people report that they are anything but soothed by that comment. All relationships are unique, no exceptions! A similar loss is an intellectual fact. It is not emotionally helpful. The great majority of well-meaning people around us do not have successful grief recovery experiences to share. Therefore they unwittingly encourage us to act recovered.

 People are afraid of our feelings. Society teaches us that having sad, painful or negative feelings & showing them are somehow not appropriate. “Get a hold of yourself” “You can’t fall apart”.

 People try to change the subject. The implication is that if your loved one is no longer suffering, then you shouldn’t either.

 People intellectualize. Since we rely on our minds everyday, we’ve got more practice with it. Grief is an emotional response to loss. The cause of the loss itself is intellectual, but the reaction to it is emotional. That’s because death of a loved one is not an everyday occurrence. Reliance on intellect is at the expense of feelings. Comments that are not helpful: “Be grateful you had him for along time”, “He’s in a better place”, “She led a full life”, “God won’t give you more than you can handle”.

 People don’t hear us. A teenager had a birthday party and her 3 best friends in the last minute cancelled. She was sad and her mom said “Don’t feel bad, there are lots of other nice people here to enjoy.” Instead she should have said “Ouch, you must feel so disappointed.” Grieving people want and need to be heard, not fixed.

 People don’t want to talk about death. “What happened to daddy? God has called him to heaven.” The next several years, the child is upset and confused by God. It is better to tell the truth. “Your daddy died. And now we believe that after he dies, we went to be with God.” Avoid metaphors with children. Developing minds can’t match reality with metaphors.

 People want us to keep the faith. Anger will pass if we’re allowed to express the feeling. We have to be allowed to tell someone that we’re angry with God and not be judged for it.  If not, this anger may persist and block spiritual growth.