Cultures have different ways of coping with death.

Grief felt for the loss of loved ones occurs in people of all ages and cultures. Different cultures, however, have different myths and mysteries about death that affect the attitudes, beliefs, and practices of the bereaved.

Individual, personal experiences of grief are similar in different cultures.

The ways in which people of all cultures feel grief personally are similar. This has been found to be true even though different cultures have different mourning ceremonies and traditions to express grief.

Cultural issues that affect people who are dealing with the loss of a loved one include rituals, beliefs, and roles.

Helping family members cope with the death of a loved one includes showing respect for the family's culture and the ways they honor the dead. The following questions may help caregivers learn what is needed by the person's culture:

What are the cultural rituals for coping with dying, the deceased person's body, and honoring the death?

What are the family's beliefs about what happens after death?

What does the family feel is a normal expression of grief and the acceptance of the loss?

What does the family consider the roles of each family member in handling the death?

Are certain types of death less acceptable (for example, suicide), or are certain types of death especially hard for that culture (for example, the death of a child)?

Death, grief, and mourning are normal life events. All cultures have practices that best meet their needs for dealing with death. Caregivers who understand the ways different cultures respond to death can help patients of these cultures work through their own normal grieving process.

The D Vs the D

You have all heard of denial and that in most cases it is not good for your mental health to be adherent. Denial is a defense mechanism designed to help you avoid or process at your own pace new, scary, difficult or overwhelming information about yourself or a certain situation. This can be ok as it serves as a buffer to process these things, as you are able. For instance you may receive a diagnosis of depression or bipolar depression that may feel like too much to think about right then, say nothing about formulate a plan to address it.

This is an example of immediate denial and as stated before that can be ok. Long-term denial of problems that are obvious to others is a different story, and that is the type that usually harms you to some degree. Missing work due to drinking too much, isolating yourself due to depression or fears of going out and making excuses about “just being tired” or “too busy” are examples of this. When combined with behaviors designed to perpetuate the excuses, it becomes a lifestyle before you know it. But not a healthy, fun and creative lifestyle, rather one based in fear and unsuccessful attempts at control. A life that at any moment can spiral out of control.

Dysfunctional families are often seething pits of denial, carrying many generations of emotional baggage forward that goes unaddressed and causes major unhappiness for family members. There may be a sophisticated group of evasive behaviors in place to allow family members not to have to deal with the real problems. You know somewhere inside there is something wrong. It does not have to stay this way, armed with the right tools and the right help you can break free from these unhealthy cycles.

In my previous post on self-soothing, I talk about how to help yourself feel better, calm yourself and become mindful of what is going on with you.  Having these skills in your emotional toolbox can enable you to deal with uncomfortable information about yourself and make headway on seeking the proper help.

A specific skill I discuss is the ability to distract yourself, and I have been frequently asked whether that is just another form of denial. It is not.  Distracting yourself is a deliberate behavior you employ to feel better for the time being. It frees up your mind for a bit and can help break the cycles of rumination that get you nowhere. It allows your brain a breather. It can also allow your whole body a breather as your physiological processes get unbalanced when you are constantly stressed. Your thoughts bring about this stress so allowing your thoughts to wander to something more pleasant is not being in denial, it is helping yourself.

If you are in one bad relationship after another, always choosing the “wrong” person and you don’t stop to take a look at what is going on then you are most likely in denial. There is something going on with you, most likely a self-esteem problem, attachment issue or even unresolved trauma from abuse. Others around you can probably see it and may have mentioned it to you, but you may continue to blame the “wrong” people that you have involved yourself with, seeing it as their problem, not yours. Nevertheless, somewhere down deep you know there is a problem.

If you go to a therapist, receive help and insight into your issues but need a break from processing it all so you go skiing, that is a distraction. If you are given therapeutic homework and it becomes too painful or overwhelming so you turn on the TV, that is also a distraction and that is fine. It does not mean you are going into denial. If however, you put the homework away for good and never go back to the therapist, you probably have retreated into denial.

Having the arsenal of self-soothing techniques available to you is the key to keeping you moving forward through difficult issues in your life. Adding these is a better solution than adding behaviors designed to hide, dodge or isolate yourself and your behaviors. One gives you a quality of life you deserve and create constructively; the other clearly brings more distress, loneliness and negativity.

So if you have a difficult issue to face, bone up on your self-soothing abilities, find things that will distract you in a positive way when called upon, form a social support system and dive in, life is too short to allow dysfunctional issues to get in the way of  the life you want.

In case you may have been taught dysfunctional thought patterns that are keeping you depressed, anxious or unable to break free from problematic behaviors, please visit Dr. Losito at Hand of Compassion for further assistance.

How to Recommend Counseling

We all have experienced stress, anxiety, depression, grief or relationship problems at some point in our lives, right. Many of us have friends or loved ones who are suffering right now and could benefit from therapy. Nevertheless, how do we tell them to go to therapy?

Telling someone they need therapy can come off very offensive. Therapy itself is still a sensitive issue to talk about. Suggesting to a loved one or friend they need therapy can make them feel as if they are being criticized.

Six Ways to Recommend Therapy:

​Say something sooner than later – try to prevent a larger issue or a full-blown crisis from arising. Avoid minimizing the issue or hoping the problem will go away on its own.

Normalize therapy – you can disclose how you have benefited from therapy. If you have not gone to therapy yourself, express empathy by saying something like, “I see how stressed you are with everything going on right now and you deserve real support beyond our conversations. Have you thought about seeing a therapist for help?”

Do not judge – admitting you need therapy can be hard on its own. Do not diagnose; leave it to the experts. Say something like, “I notice that you don't seem like yourself. I care about you and think a therapist can help you.”

Be reassuring – let them know therapy does not have to be long term for it to be very effective in resolving their issues. Assure them they can find a compassionate, supportive and objective therapist that will provide the insight and tools to empower them professionally and professionally.

Be resourceful – be prepared to share where they can go to find psychiatrists, psychologists or therapists. Psychology Today, many local hospitals and Community Mental Health Centers provide quality and affordable outpatient counseling services, and if they are employed, ask them to check their insurance card or contact HR to inquire about Employee Assistance Program (EAP) benefits. In addition, many schools and Universities offer free or low-cost services. There are also online therapy options such as Open Path for persons from low-income status. Go to openpathcollective.org/ to learn more.

Be supportive – offer to go with them to their first 12 step-program, therapy session or pay for it. If the situation is very serious, consider an intervention or hiring an interventionist. In case of an emergency, always dial 911 or take them to their local emergency room for an evaluation.

Do not let your loved one or friend suffer in silence. Express to them that therapy is not replacing the relationship. If they decide to not go to therapy, you did your part. If the relationship is becoming harmful to you, reevaluate your boundaries with them. You might want to examine if the relationship is worth continuing. We all can benefit from therapy!

Coping With the Death of a Child in the ED

Health professionals often do not receive formal training in coping with pediatric deaths likely to be encountered in practice. Being unprepared for these intense experiences can negatively affect the health professional and the quality of care provided to survivors. 

After a young patient is pronounced dead in the emergency department (ED), surviving family members are in crisis. ^[5] Survivors can benefit from the engagement of the emergency physician who treated the family member. In addition to making medical decisions during resuscitation, the role of the emergency physician is seen as one of assisting in alleviation of suffering.

A patient's death in the ED, especially the death of a child, is often unexpected. The nature of ED practice is such that the emergency physician often does not have an ongoing professional relationship with the patient's family. Indeed, a patient's death often finds the emergency physician and the patient's family meeting each other for the very first time. This can be a difficult and emotional situation for both physician and family.

In an effort to assist certain care aspects of the child who is pronounced dead in the ED, this article's suggestions are meant only as guidelines to minimize errors. Each patient death is arguably unique. A standard "cookbook" approach by the physician is arguably inappropriate.

Information contained in this article is intended to provide general advice on the subject. As with other aspects of clinical medicine, general advice must be modified according to the individual patient and clinical circumstances. Nothing herein should be applied uncritically to the care of any individual patient or family.

This article is not intended to be encyclopedic. Healthcare professionals can anticipate being students of this topic for their entire professional lives. The author feels this strongly. Accordingly, readers are encouraged to share thoughts and experiences on this subject with the author via email. The opportunity for feedback from readers was a motivation for writing this article. A subject as emotional and potentially controversial as patient death in the ED has many facets. Like pieces of a jigsaw puzzle, each facet contributes to produce a complete clinical picture. Sharing thoughts and experiences is essential to the process of solving the puzzle.

Because a child's death may be viewed as especially tragic, ED personnel may have strong feelings of nonspecific sadness and loss. In the aftermath of a pediatric death, the emergency physician may have feelings that make it difficult to maintain composure. Natural psychological defenses are unconsciously summoned to assist the physician in maintaining composure. A problem may develop if the physician's defenses produce actions that are harmful to survivors of the dead child.

Survivors of a child who has recently died are likely to require emotional support. Every physician cannot be completely supportive of every family member at all times. However, it is reasonable to ask physicians to be aware of their defenses and to avoid actions that interfere with survivors' grief.

"First, do no harm" is a widely known and generally accepted clinical precept. In the care of a patient, the physician should avoid actions that cause harm or produce more harm than good.

Physicians with children may be especially vulnerable to an emotional response to a child's death. If physicians' children are nearly the same age as the deceased patient, physicians may realize suddenly, perhaps for the very first time, the possibility of losing their own children. Physicians with children may also identify with the parents' loss.

Because a child's death may be viewed as especially tragic, ED personnel may have strong feelings of nonspecific sadness and loss. In the aftermath of a pediatric death, the emergency physician may have feelings that make it difficult to maintain composure. Natural psychological defenses are unconsciously summoned to assist the physician in maintaining composure. A problem may develop if the physician's defenses produce actions that are harmful to survivors of the dead child.

Survivors of a child who has recently died are likely to require emotional support. Every physician cannot be completely supportive of every family member at all times. However, it is reasonable to ask physicians to be aware of their defenses and to avoid actions that interfere with survivors' grief.

"First, do no harm" is a widely known and generally accepted clinical precept. In the care of a patient, the physician should avoid actions that cause harm or produce more harm than good.

Physicians with children may be especially vulnerable to an emotional response to a child's death. If physicians' children are nearly the same age as the deceased patient, physicians may realize suddenly, perhaps for the very first time, the possibility of losing their own children. Physicians with children may also identify with the parents' loss.especially tragic.

Crisis

Crisis involves powerful and often uncontrollable emotions. Individuals in crisis may need assistance in moderating their emotions. Recruiting other family members, clergy, friends, and others to support an individual in crisis is often helpful. The physician should repeatedly recommend specific actions for the safety of the person in crisis (eg, "don't drive home, call a friend or cab").

Because individuals in crisis often behave illogically or have impaired decision-making abilities, responsibilities to dependents may be forgotten. Therefore, it is wise to inquire about other children or elderly family members who may require assistance. These individuals may forget about potentially unsafe conditions at home; inquire about safety items (eg, whether electricity to a stove or water to a bath was been left on). The physician should also ask whether the home was locked prior to coming to the hospital.

Grief

Grief is a natural reaction to the death of a child. The grief process begins with understanding that the child's death is real.

The physician should allow (not force) family members to see or hold their dead child. However, the family should be prepared for what will be seen and possibly misunderstood without prior explanation (eg, endotracheal tubes, chest tubes, other resuscitation equipment) when they enter the resuscitation area. Occasionally, offering the family the opportunity to take with them a memento (eg, a lock of hair) helps.

Suffering is a natural part of grief. The physician should accept a wide range of emotions of families suffering from the loss.

Families often feel guilty. If possible, reassure families that they did not contribute (either by acts of commission or omission) to the child's death. Reassuring families that every care procedure that could have been implemented in the ED was implemented is also important.

What are Advance Directives?

Advance directives center around the principles of your right to die and death with dignity. With an advance directive, you can express how much or how little you want done for you when you are no longer able to make these decisions.

• Advance directives are a way of making your voice heard when you can no longer communicate. They allow you to appoint someone to make your health care decisions for you when you no longer can and to administer or withhold treatment and procedures based on your previously stated wishes. Advance directives are not just for the elderly. All people who desire to direct their medical care in the future should complete an advance directive.
• All 50 states and the District of Columbia have laws regarding advance directives. Authorities also agree that no difference exists between withholding lifesaving treatment and withdrawing life-support treatment. This is especially important in a situation where someone is resuscitated despite his or her wishes because the advance directive could not be found and the person is put on life support. Once the advance directive is shown to health care professionals, life-support measures can be withdrawn according to the advance medical directive.
• An advance directive does not mean "do not treat." This is a common misperception and not correct. Of course, if you want it to mean do not treat, then that is something that your surrogate needs to know.
• Proper execution of an advance directive is a delicate task. A person should discuss this with loved ones and consider personal values and beliefs.

• It is also impossible to think about all the possible medical and social scenarios that may happen in the future during the course of a disease and person's lifetime. Thus, people often change their minds contrary to their living wills while still capable of making their own decisions. Living wills can be modified to reflect any such changes.

Definitions Involved in Advance Directives

Advance directives: An advance directive is a written document or series of forms that must be signed to be binding. The documents indicate an individual's choices about medical treatment.
Two types of advance directives are generally completed: a living will and a medical power of attorney (also referred to as designation of a health care surrogate or health care proxy).

• Living will: This written statement tells health care professionals what type of life-prolonging treatments or procedures to perform if someone has a terminal condition or is in a persistent vegetative state. Living wills should not be confused with a regular will. A living will addresses issues regarding your medical care while you are still living.
• Medical power of attorney (or designation of a health care surrogate): This legal document allows you to select any person to make medical decisions for you if you should become temporarily or even permanently unable to make those decisions for yourself. This person is also referred to as your attorney-in-fact or durable power of attorney for health care. Most people choose a family member, a relative, or a close friend as their surrogate decision maker. It is important that the designated person knows and understands your wishes and preferences and has a written copy of either your living will or medical power of attorney.

Life-prolonging treatments: These are procedures that are not expected to cure your terminal condition. They generally are used to sustain life. Examples of life prolonging treatments include mechanical ventilator (breathing machine), kidney dialysis, and cardiopulmonary resuscitation (CPR).
Terminal condition: A terminal condition is an incurable (without cure) condition that is in its terminal stages.
Persistent vegetative state: This permanent coma or state of being unconscious is caused by injury, disease, or illness. No reasonable expectation of recovery exists.
Do not resuscitate (DNR): This document tells health care professionals and emergency personnel that if your heart stops beating (cardiac arrest) or if you stop breathing (respiratory arrest) that they are not to attempt to revive you by utilizing CPR, chest compressions, intubation, or shocking the heart.
Artificial nutrition and hydration: This procedure is the administration of nutrition and fluids through IV lines and feeding tubes. IV (intravenous) hydration is a common proactice in the hospital by which fluids are delivered into veins. Tube feeding introduces liquid food through a nasal or oral tube into the stomach. Sometimes intravenous (IV) antibiotics are also included in this category. The POLST form (Physician Orders for Life-Sustaining Treatment) addresses the patient's preferences regarding artificial hydration and nutrition. This form can be signed by the patient or their decision maker and the treating physician.

Anticipatory Grief

What is Anticipatory Grief?

Patients and families facing terminal illness usually begin the grieving process prior to the actual loss. This is called “anticipatory grief.” Although it may be uncomfortable, anticipatory grief is sometimes helpful and may result in fewer grief complications later. Each person will experience grief in his or her own unique way. The same is true with anticipatory grief. It is a natural process that helps individuals prepare for emotional and physical closure. It is also a time when both patient and family prepare for change.

Things to Consider

Emotional and physical symptoms associated with grief may also be associated with anticipatory grieving. You may experience some of the following:

• Loss of appetite
• Tension and irritability
• Fatigue and insomnia
• Tearfulness
• Restlessness
• Indecision about what to do
• Guilt or anger
• Mood changes over small things, crying unexpectedly

Frequently, there may be a desire on the part of the patient to put his or her “affairs in order,” so that their wishes will be honored. This is sometimes referred to as completing “unfinished business.”
Often, there is a concern on the part of the patient about how loved ones will cope after the loss. The patient may wish to ensure that loved ones obtain practical life skills during this time, such as learning to balance the checkbook or learning how to cook.
The patient may also express the need to emotionally withdraw from others. Caregivers may observe “distancing” behavior, such as the patient becoming less conversational, losing interest in activities that once held meaning, and refusing to allow close friends and family to visit.

What to Do

• Reach out to persons and groups that can offer you support and help.
• Seek help through counseling with a therapist, minister, priest or rabbi.
• Remind yourself that everyone needs adequate time to grieve.
• Utilize any spiritual beliefs that bring you comfort or relief.
• Express yourself through art, poetry, music, journaling, or gardening.
• Engage in life review through photographs, music, conversation and writing.
• Identify issues and concerns, which are important to address prior to the loss.
• Talk about your feelings.
• Address legal/financial/funeral issues as appropriate.
• Discuss future plans as appropriate.
• Identify whether or not your expectations are realistic. 

Even though the loved one you've been caring for is still alive, you may have already started feeling the weight and pain of their loss.
While some people might think of this as a type of depression, it's really a distinct form of grieving. And it's also a natural, expected response to caring for someone with a long-term or incurable illness.
This kind of grief can hurt as much as what you feel when a loved one dies. Sometimes, it may make the loss after death easier, but not always.
It's real. You can't ignore it and hope to just power through. So allow yourself to process the grief and appreciate the time you have left.
What Is Anticipatory Grief?
Unlike the grief and mourning that happen after someone has passed away, this "anticipatory grief" begins before the person has died. But the emotions can be similar.
When someone has a disease, injury, or condition that permanently changes their personality, like Alzheimer's, the grief may come as it sinks in that your loved one, as you knew them, will be "gone" even before they're gone.
You might have anxiety, dread, or sadness as you wait for their passing.
You could also feel a sense of loss and longing for your independence and freedom as your own life changes because much of your time and energy is now going to someone who needs you. And that can also lead to guilt.
Anger, bitterness, even resentment are common feelings, too, as you're forced to come to terms with the fact that you can't change the outcome.It's important to remember that all of these feelings are normal in such a difficult situation. And often, primary caregivers -- those whose take on the daily responsibility for someone's well-being  -- feel a piece of this loss each day, more deeply and in a way that others in their lives probably don't.
Be Honest About Your Feelings Whether it's a support group, a counselor, a good friend, or within the privacy of a journal, sharing what you're going through can ease those moments when you're sad, powerless, and tired. Your loved one may be dealing with their own grief, and you might find comfort together.
It's OK to cry or admit that you're angry or frustrated. These are helpful ways to keep pent up emotions from turning into resentment toward the person you care for or from taking a toll on your health.