The ‘death checklist’

— Choosing your agents

OK, maybe the ‘life checklist’ sounds better. Either way, this starts a whole series of reports to get us ready for the end.

By Jason Wheeler

Show of hands: Who is ready to die? OK, that certainly doesn’t sound appealing.

So, as we do a whole series of reports about preparing for future eventualities, we’ll change the original idea from ‘The Death Checklist’ to ‘The Life Checklist’.

That makes sense anyway because preparing your finances for after you die is a part of life. And it’s a critical part for the people you leave behind.

Let’s start with the care you get that may keep you from dying right now.

Texas has long led the nation in the number of people who are uninsured. It’s a good idea to have health insurance in some form. Because if things go really wrong for you health-wise, it gets costly fast. The average hospital bill in Texas went up 38% from 2016 to 2020. The costs can be an onerous burden even if you are covered. But especially if you are not, those bills can quickly diminish the assets you might have been planning to leave behind to loved ones.

Choosing someone to make your health care decisions if you cannot

Regardless of your insurance situation, if you end up needing treatment, it may help you and those who care about you to designate someone now to be your agent with a medical power of attorney.

Some recommendations say if you are married you should fill out one of these forms too, even if the agent you name is your spouse.

In addition to filling out the form, you discuss your medical wishes with your designated medical power of attorney in case something happens to you, and you are unable or incompetent anymore to make your medical wishes known to healthcare providers.

Make sure the person you designate is someone you trust…and that it is someone who makes good decisions under pressure (and may be able to withstand pressure from other family members who might want something for you that goes against your wishes).

In this document you can limit the decisions your agent can make, you can allow it to go on indefinitely or put an expiration date on it, and you can choose alternate agents in case your agent dies or is incapacitated with you. You can also subsequently revoke this document and make a new one if you choose.

Choosing someone to handle your financial affairs if you cannot

If you want to designate the same person or another person to also handle your financial affairs, and make those decisions when you cannot, that’s going to require another document.

Whoever you select to handle your financial affairs if you are unable to, you want to make sure you really trust the person.

If you select this person to have what is called a durable power of attorney, they can make decisions about a lot of different things involving your money. On the form, you can initial the things they can do regarding your money, your possessions, your real estate, investments, social security, retirement, and other things…even your digital assets and content of electronic communications.

You can also limit or extend their powers. And you get to decide when the durable power of attorney begins.

You can also opt for co-agents and decide if they work together or work independently on your behalf. This would be in effect until your death. But you can revoke it, too.

If that seems like too much there are also limited powers of attorney for things like selling an automobile or dealing with your taxes.

You can also read more about powers of attorney here and here.

Complete Article HERE!

5 key things to know when you create a will and make other end-of-life plans

By Sarah O’Brien

  • Planning for who makes decisions and who gets what when you die is “a gift” for your family, says a financial advisor.
  • While many people think estate planning is only for the wealthy, experts say that’s not the case.
  • Here are some key things to think about when you give thought to your own end-of-life plans.

Contemplating your own death may not be on the list of things you’re eager to do.

Yet for your family or other loved ones who would find themselves trying to sort out your affairs while also dealing with the emotional fallout from losing you, your having a so-called estate plan is important, experts say. And this is the case whether you are wealthy or not.

“When you get your things in order, it’s a gift you’re giving your family,” said certified financial planner Lisa Kirchenbauer, founder and president of Omega Wealth Management in Arlington, Virginia.

In simple terms, your estate plan spells out who you want making decisions and who will inherit what you own. “Estate” simply refers to possessions and other assets.

Experts say most estate plans don’t need to be complicated. But to make sure your wishes are carried out, they do need to be done correctly — which may make it worth consulting with a local attorney who specializes in estate planning.

Here are five key things to know if you start thinking about how you’d craft an estate plan.

1. A will may not cover all your bases

A will is a basic part of an estate plan. It lets you identify who you want to receive certain property and allows you to name a guardian for dependent children. If you don’t have a will in place when you die, the courts may decide who gets what or who is appointed guardian.

However, some assets pass outside of the will, including retirement accounts such as 401(k) plans and individual retirement accounts, as well as life insurance policies and annuities. This means the beneficiaries listed on those accounts supersede any instructions in your will.

“If your ex-spouse is listed on the beneficiary designation, your ex-spouse will get the money regardless of what your will says,” said CFP Stephen Maggard, an advisor with Abacus Planning Group in Columbia, South Carolina.

Be aware that many 401(k) plans require your current spouse to be the beneficiary unless they legally agree otherwise.

Regular bank accounts, too, can have beneficiaries listed on a payable-on-death form, which your bank can supply. Same goes for brokerage accounts.

If no beneficiary is listed on these various accounts or the named person has already died (and there is no contingent beneficiary listed), the assets automatically go into probate.

That’s the process by which all of your debt is paid off and the remaining assets that are subject to probate — which includes those that pass through the will — are distributed to heirs. This can last several months to a year or more, depending on state laws and the complexity of your estate.

2. You’ll need to carefully pick your will’s executor, other key roles

When you create a will, you name an executor to carry out your wishes and handle your estate. It can be a big job.

Things such as liquidating or closing accounts, ensuring your assets go to the proper beneficiaries, paying any debts not discharged (i.e., taxes owed) and even selling your home could be among the duties overseen by the executor.

This means that you need to make sure whoever you name is up for the job — and that they are amenable to taking it on.

Additionally, an estate plan should include other end-of-life documents, including a living will. This outlines the health care you want and don’t want if you become unable to communicate those desires yourself.

You also can assign powers of attorney to trusted individuals so they can make decisions on your behalf if you become incapacitated at some point. Often, the person who is given this responsibility for decisions related to your health care is different from whom you would name to handle your financial affairs.

Just be sure to name alternatives.

“It’s super important to have backup people in all roles in the estate plan … in case someone cannot serve,” said CFP Jennifer Bush, a financial planner with MainStreet Financial Planning in San Jose, California.

3. Some assets get a ‘step-up in basis’

If you have assets such as stocks, bonds or real estate (i.e., a house) and are considering gifting them to children or other heirs while you’re alive, it might make more sense to wait.

When these assets are sold, any increase from the so-called cost basis (the value when the asset was acquired) and the sale price is subject to capital gains taxes.

However, upon your death, your heirs who inherit those assets get a “step-up in basis.” In other words, the market value of the asset at your death becomes the cost basis for the heir — which generally means any appreciation prior to that is untaxed. And when the heir sells the asset, any gains (or losses) are based on the new cost basis.

On the other hand, if you were to gift such appreciated assets to heirs before your death, they’d assume your original cost basis — which could translate into an outsized tax bill when the assets are sold.

“We find ourselves often recommending that clients give adult children cash instead,” Maggard said.

4. You may want to consider setting up a trust

If you want your kids to receive money but don’t want to give a young adult — or one prone to poor money management or other concerning behaviors — unfettered access to a sudden windfall, you can consider creating a trust to be the beneficiary of a particular asset.

A trust holds assets on behalf of your beneficiary or beneficiaries, and is a legal entity dictated by the documents creating it.

If you go that route, the assets are left to the trust instead of directly to your heirs. They can only receive money according to how (or when) you’ve stipulated in the trust documents.

5. You’ll need to revisit your estate plan

Anytime you have a major life change — such as birth of a child or divorce — it’s important to review your estate plan.

You’ll want to confirm that your named executor (or trustee, if you set up a trust) is still an appropriate choice. Additionally, check all listed beneficiaries on your financial accounts to make sure no updates are needed.

Additionally, If you move to a new state, be sure to check whether you need to update any part of your plan so it follows that state’s laws.

Complete Article HERE!

Dance Me to the End of Time

— South African film on death is a powerful celebration of life

Activist and theatre director Nancy Diuguid, left, with partner and film-maker Melanie Chait.


In her 2021 documentary Dance Me to the End of Time, South African film-maker and educator Melanie Chait has produced a truly great film. Not only for the breadth of themes it broaches – from cancer to green activism, from lesbian love to arts therapy – but also for the intensity with which she deals with these themes.

One of the hallmarks of a great film is its ability to transport audiences; to hold their undivided attention and evoke deep emotions in them. The documentary does this, as it pieces together four years of home movie footage filmed by Chait.

This very personal, award-winning film chronicles the final years and death of Chait’s life partner, London theatre director Nancy Diuguid. Diuguid died from breast cancer. The film is, of course, more than just about the death of Diuguid. It is also about the triumph of lesbian love in the face of death as well as the ecological and feminist politics of Chait and Diuguid.

In the process it elevates itself above death and disease to become a veritable celebration of life and love. Powerfully original, it is also likely to change the way people think about the food they eat and how it is produced. This is particularly important given the ever increasing prevalence of cancers.

The art of death

Dance Me to the End of Time has been enjoying a successful festival run after premiering at the Encounters documentary festival in South Africa and has won several international awards.

The documentary fits into a genre of film-making which focuses on disease, dying and death. This genre was popularised in the early 1990s by films which documented the death of people living with AIDS. These are films such as Silverlake Life by US director Tom Joslin and Modesty and Shame by French writer and photographer Hervé Guibert. I argue in an article on this genre that there is something more to such films than just the representation of diseased bodies and slow deaths.

Dance Me to the End of Time shows how two women face the presence and reality of death. Diuguid thinks through how, although she was losing control of her body, she still wanted to be “present in the process of dying”. Chait contends with the idea of losing her loved one. She expresses her helplessness in offering the comfort that her dying lover required:

It felt like I was playing God: deciding what to do, when. Nancy was so unlike the Nancy I had known. I only wished I could do better with the process of knowing how to comfort and help ease her anguish.

Despite the difficult conversations they have about death and the meaning of loneliness, it’s fascinating how the film eloquently demonstrates that even in the face of death, the couple was able to experience happiness. In many instances, Diuguid is filmed swimming in the ocean or dancing with their adopted son, Desmond. This film is a beautiful ode to lesbian love, an elegy of two women loving one another through sickness and health.

Ecological and feminist politics

Chait also weaves into this personal story the important feminist and ecological work that the couple did to expose the health dangers of pesticides. When diagnosed with cancer, Diuguid decided to adopt a holistic, integrated medical approach combining traditional medicine and natural methods.

The story of US scientist and ecologist Rachel Carson is woven into that of Chait and Diuguid. From as far back as the early 1960s, Carson had exposed the health hazards of pesticides, especially DDT, used to spray farm crops. Diuguid grew up on a farm in Kentucky and experienced how small wildlife would be killed days after the spraying of their farm.

A black and white photo of a woman in a collared shirt, smiling.
Rachel Carson.

Diuguid and Carson both died of cancer. By drawing parallels between their lives, the film highlights the politics of what and who is responsible for causing cancer. In its focus on the gruesomeness of the effects on cancer, Dance Me to the End of Time is itself political in dealing with ecological questions and the impact of pesticides.

The film also shows how, when Diuguid was diagnosed, she was able to use the creative arts and her lesbian identity as tools to campaign for justice and to heal others. Through an initiative called VOICES, she used expressive arts to help women and children deal with trauma in the townships of Johannesburg. In addition to the historical trauma of apartheid, townships in South Africa have had to do contend with high levels of intimate forms of violence.

Vulnerability and dignity

A film poster featuring two women, one lying in bed.

Even in chronicling Diuguid’s dying, the film does not rob her of her dignity and humanity.

In fact, the film celebrates her life and her important work in expressive arts therapy.

In its personal and deeply emotional texture, Dance Me to The End of Time offers a sincere depiction of how to face death and more importantly how to live life to its fullest.

Complete Article HERE!

My grandparents donated their bodies to science. I needed to know what happens after

— Jackie Dent’s grandparents’ body donation was hardly discussed until a chance conversation set her on a quest to find out more about the secretive world of dissection

‘I know the enormous contribution that the dissected have made to medicine … We are alive because of them’: Australian journalist and writer Jackie Dent.

By Jackie Dent

Dissection might not be a normal topic to contemplate but when both your paternal grandparents donate their bodies to science it does intermittently cross your mind. My grandmother Ruby’s body went to the University of Queensland in 1969 and my grandfather Julie’s in 1981. Yes, that was his name.

The fact that both my grandparents’ bodies were dissected for science has always lurked within the family. For years, I’ve seen it as a slightly intriguing thing, quietly spectacular. A radical but slightly weird postscript to their ordinary lives. I mean, why would anyone do that?

Over the years, their donation had been very vaguely discussed in the family but not overanalysed. Or analysed at all really. Nobody seemed to wonder much about what had actually happened to Julie and Ruby.

But one hot Sydney summer, everything changed. I was at my parents’ place and their neighbour asked us over for a Christmas drink. As we chatted over sparkling wine, one of the daughters updated us on her new job. She was working at a university and hospital teaching facility and mentioned that some medical students are no longer using full bodies for dissection. She also said that human arms and body parts were being shipped in from the US.

I was stunned. Why aren’t they dissecting full bodies? And why do they have to fly in arms?

She wasn’t sure.

We finished our drinks, said “Happy Christmas” and I went home perplexed.

Over the ensuing weeks, the conversation at Christmas niggled. Had Australians really stopped donating? But also, come to think of it, what happened to Ruby and Julie all those years ago? Did I really want to know? As a Harvard professor told the 1896 meeting of the Association of American Anatomists: “We know only too well that dissection is an abomination to the popular mind.”

What was I hoping to find out? I maybe wanted to know the gory details of dissection, the slicing and chopping but was nervous as I’m quite squeamish. I wondered what the anatomy lab looked like, who was in the room. I wanted to know if what had happened to their bodies mattered, what it meant to the students. Were they respectful?

Australian journalist and writer Jackie Dent at her home in Sydney, NSW, Australia.
‘I entered a world of embalming fluid recipes, mould on bodies and bandsaws.’

But their bodies went to the university so, so long ago, 50 years. How would I even find the people who were in the room back then? And would they talk? The whole business felt so secretive.

So I began tracking down old surgeons, doctors and technicians who were in the dissecting rooms in the period when my grandparents were there. At first, I thought I would just be dealing with dissection.

No way. That was just the start of it.

There was the possibility that one of my grandparents’ body parts ended up in an anatomical museum. I wasn’t sure if I could handle that. I read an old academic paper penned by an anatomist and surgeon studying the palmaris longus and balked at a photo – was that my grandfather’s hand?

I entered a world of embalming fluid recipes, mould on bodies and bandsaws. Whereas for centuries, embalming methods were kept secret, they are now shared more freely, and sometimes adopted into a dissecting room culture when a new anatomist or technician arrives with a good mix. There are today a plethora of recipes and techniques used to embalm the dead so much so that some say the field is more craft than science. Even in death our bodies are unique – our fat or time of death means we can each react differently to the same chemical formula. I learned from the British anatomist Prof Claire Smith that mould can sometimes form on a donor through a small spore that was already there or through a student or staff member sneezing. When using a bandsaw, human heads are frozen first to get a clean line through the middle of the nose.

By going into the past, I learned about contemporary anatomy. Some students find hands freakier to dissect than faces. While in parts of the world anatomists still use bodies left unclaimed in morgues, there is also a growing “humane” anatomy movement where students meet the families of donors or hold moving ceremonies for the dead when they have finished their dissection course. I delved into the history of body donors, a curious lot who donate for all sorts of reasons, which range from being helpful to avoiding a funeral as they disliked a particular relative. Body donation tends to run in families.

Anatomists once relied on the bodies of people who did not consent to dissection – executed criminals or the vulnerable whose bodies lay unclaimed in asylums, hospitals or poor houses. Thankfully, Australia has long been considered “gold standard”: donors in the labs filled out paperwork and consented to being there. While there are no national figures on numbers of donors, the University of Melbourne, for example, gets about 200 bodies a year, some of which are shared with other institutions. Australians are still donating.

The reason body parts are flown in is fairly straightforward. Sometimes 15 knees are needed for a surgical workshop and it is logistically easier to get them from a US body broker.

After spending time with dead donors at a surgical workshop, watching dissection influencers at work on Instagram, reading evocative dissection notes from 1540 and basically becoming an amateur dissection wonk, I now have a much better sense of “what happened” to my grandparents’ bodies.

The Great Dead Body Teachers by Jackie Dent cover

But I also know the enormous contribution that the dissected have made to medicine for the past 2,000 years or so. We are alive because of them. They should be better known in the history of science as a cohort who created a body of knowledge.

I also view my body differently. We are palaces filled with so many beautiful shapes and curves, all mirrored in nature: the leaf-like lobules in my breast, the atria centralis retinae in the eye is like a crack of lightning in the sky. I now get why some anatomists told me they enjoy dissecting. As the University of New South Wales’ Dr Nalini Pather said: “Some people do needlework, and some people do art. I like to dissect.”

And yet, will I donate my own body? Hmmmm. I’m still young. I’ve got a few years left to decide. For now, my main issue about donating my body? I imagine myself being cold in the dissecting room. I picture myself yearning for a jumper on my torso or a doona over my tattered corpse. Yes, it’s a silly line of thinking as being dead I wouldn’t feel the cold, but there you have it.

Complete Article HERE!

A Good Death: A Father, a Daughter, an End-of-Life Decision

— Jennifer O’Brien’s father broke his hip while contending with advanced congestive heart failure. He declined surgery to fix it, opting for a peaceful death instead. She supported him. The system did not.

By Jennifer A. O’Brien, MSOD

“Your dad declined the surgery to repair his hip fracture,” the anesthesiologist blurted incredulously over the phone. “Okay. I guess there’s no surgery then,” I responded. “Well, here, talk to the orthopedic surgeon,” he protested. I shrugged and said, “Okay” to no one as the anesthesiologist handed the phone to the orthopedic surgeon. The surgeon came on: “Your dad declined the surgery!” he exclaimed. “I heard,” I said. “I mean, your father said ‘No!’” I could visualize the surgeon’s wide eyes.

My dad was 85 years old with advanced congestive heart failure and severe lung disease. He had fallen two days before and sustained a neck of femur (NOF) fracture, also known as a hip fracture. I had been very involved in my dad’s healthcare for several years. His mind was sharp.

Several years before that, he had signed a do not resuscitate (DNR) order, a legal document saying that in the event of a cardiac arrest he did not want to be resuscitated, as well as a do not intubate (DNI) order, a legal document stating he did not want to be intubated in an emergent situation in which he was unable to breathe. Because “Do not ____” instructs clinicians to hold something back, these code status documents may also be referred to as an instruction to “allow natural death.”

The orthopedic surgeon was unconvinced, however, and pressed on. “He declined the surgery!” “Yes, I heard. My dad is crystal clear cognitively and entirely capable of making this decision, so I guess you can take the rest of the night off,” I told him. The surgeon chuckled and mumbled, “I wish.” At this point, he seemed to realize that while he may have to work into the night, it would not include operating on Jim O’Brien. We said our goodbyes and hung up.

About 30 minutes later, I called my dad and told him that while I would have supported his decision either way, I felt he had made a good choice.

My dad’s congestive heart failure had reached the final stage. He barely had the strength to stand and ambulate enough for trips to the bathroom. A sudden cardiac arrest was distinctly possible, if not likely. His advanced lung disease meant that for the last two years, his ability to breathe had been entirely dependent on a bilevel positive airway pressure, or “BiPAP,” ventilator.

By “entirely dependent,” I mean he could not exist, for even a few minutes, without a large face mask that covered his nose and mouth while forcing oxygen into his lungs. He could eat for a few minutes at a time but had to have a nasal cannula in order to breathe.

He was likely to die soon, and a major surgery now might well have ruined any chance he had of a peaceful, comfortable end of life.

The reactions of the two physicians who called made me realize that our case was unusual, both because of my dad’s decision against surgery and my unequivocal support of his decision. I got the impression most family members would have responded, “Oh no, let me talk to him.” They would have then called and said, “Daddy, if you don’t have this surgery you are going to die!”

But here’s the thing, he was going to die.

And while our deaths may not be as imminent as his was, so am I and so are you going to die. At the end of life comes death. At the end of a long life, with or without comorbidities, an NOF fracture may indeed be the onset of that final phase of life.

My late husband, a surgeon for 30-plus years and then a retrained, board-certified palliative medicine physician for another 10 years, named this final phase of life “Precious Time.”

He always said it with the emphasis on the first word, Precious Time. Precious Time is when death is likely, if not imminent. Precious Time is a type of time, the period of life that comes at the end. Not everyone has Precious Time; a sudden death does not allow for Precious Time.

Knowing that a loved one is into Precious Time allows for saying what needs to be said and doing what needs to be done, such as: I love yous, apologies, and reconciliations. Precious Time allows you to keep to yourself and not say what you might later regret. In recognizing that we are into Precious Time, we can minimize or eliminate the subsequent I-thought-we-had-more-time regrets and focus on the love, the honor, and the bereavement rather than a vague or acute befuddled remorse because we just didn’t want to talk about end of life.

Even with surgery to repair the hip fracture, there is a 27 percent 12-month mortality rate among 65-plus-year-olds. That is, there is a 27 percent chance that an otherwise healthy 65-year-old will not survive more than a year post NOF fracture. Add more years and comorbidities, and that mortality rate only increases. In other words, an NOF fracture, with or without surgery, is often the beginning of the end.

Another statistic is that 80 percent of people want to die at home rather than in a hospital or facility, “hooked up to a bunch of machines,” yet only about 20 percent do.

If we put these statistics together and add our just-fix-it culture, which has us operating now and asking questions later, I submit that a patient having to remain intubated postoperatively or never recovering is not the way we make the most of that Precious Time and not the way that most people want to spend their last days, weeks, or months.

And, having now lost every member of my family, including my husband, I can say from experience that when surviving loved ones are able to recognize and face that they are into Precious Time, they are likely to have an easier transition to grief and loss.

Fortunately for my father and me, my late husband taught me well. After my dad’s decision to forgo the surgery, I got in the car and drove across the country. In his hospital room, we talked about the fact that he was dying, and that the most comfortable way for that to happen was to convert his inpatient status to hospice, remove the BiPAP after a sedative, and he would sleep into an entirely natural death.

My dad and I spent our Precious Time together. We said our goodbyes as the medication took effect. I told him I loved him because I know that hearing is the last sense to go. I stayed with him until he took his last breath and then made the disposition arrangements we had discussed years prior. It was a beautiful, peaceful death at 85 years old, one week post NOF fracture.

In the three years since I had allowed the art journal I kept during the 22 months I cared for my husband, and about 18 months after his death, to be published as the book The Hospice Doctor’s Widow: A Journal, I have spoken on what I call the Triad of Certainty:

  1. At the end of life comes death.
  2. There are no do-overs in end of life.
  3. Changed forever, surviving loved ones remain and remember.

There is absolutely no one who will not die at the end of life — no one. Some of us don’t get married, don’t have children, but all of us die. And if we are lucky enough to love others, there is a good chance that one or more of them will die before us and their death will have an impact on us for the rest of our lives.

I am not saying that if you or your elder loved one sustains a NOF fracture, they should forgo the surgery. I am saying that protocol for an NOF fracture in a patient older than 65 should call for a pause rather than an unquestioned trip to the OR.

And that pause should include a consultation with a family practitioner, gerontologist, palliative care team, medical ethicist, social worker, end-of-life doula or whoever can facilitate a meaningful conversation, or more likely a series of conversations. These conversations should assist the patient and family in recognizing Precious Time, establishing the goals of care, and having a say in designing their end-of-life experience (even if it ends up being years hence).

Complete Article HERE!

Making Meaning of Life When They Say “You Are Dying”

— What we know about suffering at the end of life is that it is most frequently a result of a psychological condition known as demoralization. It is defined by hopelessness, helplessness, and isolation. It is not physical pain people suffer from, rather, in the end, we most frequently suffer from existential pain. Demoralization is existential pain.


  • Finding meaning is essential to a good death experience.
  • There are a variety of ways to counter demoralization.
  • Early referral to hospice increases guidance to remoralization.
  • Finding meaning at the end of life is heavy lifting but worth the work.

Responding to a terminal diagnosis

Demoralization is a normal response to being told you have a terminal condition. You are suddenly acutely aware of your own mortality. You know you may not be there for a wedding, the birth of a grandchild, or a myriad of many other milestones. People realize the large sum in their savings does not affect the inevitable. One may wonder if that number will be enough to cover their daughter’s college tuition. Meaning is often measured by achievement, and now you have limited time to meet the goals you have planned or time to set new goals.

A typical death and outliers

While many still believe that death is a painful process, the fact is that most deaths are uneventful. There are times when people die in pain, but this is typically a result of a patient being treated by a non-pain or palliative care specialist. Unfortunately, such patients are often referred to hospice or palliative care too late when there is not enough time to manage patients symptoms. It is existential suffering that is more common at the end of life.

The importance of hospice

Early referral to hospice will not only help to assure a peaceful and painless death. It will also help to reverse demoralization. Hospice offers an interdisciplinary team that consists of a registered nurse, chaplain, social worker, home health aide, and a physician as the core team. It also consists of ancillary team members, which may include art and music therapists. Some hospices even offer massage or Reiki therapy. These all work together to increase meaning.

Hospice is adept at helping patients to find meaning in their lives as the end comes near. When meaning occurs, it is beautiful. This is known as remoralization. There was a case of remoralization that took place over ten years ago with a young woman who was only 22 years old, very angry, and dying. Her process of remoralization was a stellar example of how this is possible.

Ways to find meaning in life before it ends

There are several ways that individuals and clinicians work to find meaning. This section illustrates various means to work towards finding meaning at the end-of-life.

“Go Wish”: an educational game

During resident education, a game called Go Wish has been used. It is a card game that depicts possible goals on the face of each card that the participant prioritizes. The deck includes such goals as “I don’t want to die in pain,” “I don’t want to be a burden to my family,” “I want to feel close to God,” or “I want to be clean”. The surprising result of this game is that rarely are the things the clinician believes should be important coincides with what the clinician values as they step out of their role and examine what they would want for themselves at the end of life.

Determining and clarifying values is a step towards finding meaning at the end of life. The game was actually designed to be used by patients and families to make sure that the patient’s wishes are understood by the family or proxy. This game was studied, and it was found that frequently there is a vast difference between what the patient would like and what the family believes the patient would like. This game is available online as a card deck or can be played online.

Dignity therapy and life review

Another, more in-depth way to find meaning at the end of one’s life is through processes known as dignity therapy or a life review. The intervention involves storytelling, reminiscing, and highlighting milestones from one’s past. It has been reported by patients that these interventions decrease depression, increase quality of life, and increase a sense of dignity. This is accomplished with the help of someone on the interdisciplinary team and is recorded digitally or in print. The patient is given the document to do what they please.

Building a legacy

Should someone give this document to a loved one, it would then be considered a part of something known as life review. Legacy building is not just telling someone your life’s story. It may be finding meaningful photos and organizing them, so future generations know who their ancestors are and not lose sight of their histories. It could be making a recording of a song that your mother sang to you as a baby so that it can be played to your grandchild. It could be a letter written for your young son to read on his wedding day. Whilst this can be sad, it is also a work of beauty and great joy can be the end result.

Working towards reconciliation

Probably the most difficult is to make meaning through reconciliation and redemption. Not all family relationships are ideal, for that matter, there is no perfect family relationship. In hospice, it is often said that “hospice puts the fun in dysfunction.” We all know that over the years when you are close to someone, there will be a history of slights, moments of anger, and some disappointments. This is true in some relationships, more than others. How do we mend these fences when we are so close to death, and we thought we would always have more time? Ira Byock wrote a book called The Four Things That Matter Most. In it, he says that there are four things everyone should say to those they love before they die. Those four things are: “please forgive me, I forgive you, thank you, and I love you.”

These are difficult tasks, but at the risk of sounding like an old timer, anything worth accomplishing isn’t easy. We don’t grow in times of comfort. We grow during times of adversity. There will surely be tears, but there will be tears in any case when someone dies. This is hard work, however, meaning at the end will help the dying and the bereaved. It not only brings meaning to the dying but helps to ease the pain of those left behind as they grieve.

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Why, when and how to talk with grieving clients about sex

By Kailey Bradley and Victoria Kress

Grief is an experience that everyone navigates at different points in their lives. For the past three years, the COVID-19 pandemic has impacted peoples’ lives in myriad ways and left many experiencing significant grief.

Loss can also deeply affect one’s sexuality, a concept referred to as sexual bereavement. Any form of loss, not just the loss of a sexual partner, can alter one’s sexual desire. As noted in Alice Radosh and Linda Simkin’s 2016 article published in Reproductive Health Matters, both sexuality and grief are stigmatized, which creates a double-barreled taboo. This double stigma can result in someone not feeling comfortable or confident addressing the topic.

When working with clients who have experienced loss, counselors must consider the interplay between grief and sexuality. There are few spaces where clients can address their grief and even fewer safe spaces where they can discuss their sexuality, so it is important that counselors consider how they can approach this subject with clients. This article discusses why this topic is important and when and how counselors can address the intersection of grief and sexuality with clients.

Why is this topic important?

Radosh and Simkin noted that some bereaved clients want to discuss how their sexuality has changed as a result of grief, yet they are often hesitant to do so. Clients may perceive that sexuality and grief cannot coexist. If this is the case, then they may feel shame if they have sexual feelings while grieving. Clients may also believe it is inappropriate to admit that they miss intimacy or that their sexual desire has changed. Other clients may perceive sexuality as distant and remote — something that may never again feel accessible.

The complexities of this topic, combined with counselors’ and clients’ personal discomfort, may cause counselors to avoid addressing it. This discomfort can arise because counselors are uncertain about how to broach the topic, counselors are uncomfortable with the topic of sexuality in general or the client is hesitant to bring the topic up. Although we do not know a lot about how various aspects of sexuality are affected after a loss, it is clear this is an issue that people experience as part of their normal development and growth, so counselors must be prepared to address this topic.

When to address this topic?

Although there is no right time to address this topic, counselors can introduce conversations related to the topic early in the counseling process. They could include questions about how grief has impacted the client’s sexuality on the intake form and then use the information the client provided to gently broach the topic during the first session. Counselors may also need to go slow and consider if it makes sense to bring up the topic during one of the initial sessions. For example, it may not be a good idea to discuss it in the first session if the client has a lot of shame around the topic of sexuality. In this situation, clinicians need to establish therapeutic trust and rapport before mentioning the topic. This approach will help clients feel safe enough to share their experiences.

Counselors can also ask clients to describe the various realms in their lives that have been affected by loss and grief, and they can mention sexuality as one possible area. And throughout the counseling process, clinicians can validate and normalize their clients’ experiences regarding grief and sexuality.

Because clients will move at their own pace and some may want to revisit the topic throughout counseling, regular check-ins with clients can be helpful. Counselors can encourage clients to engage in these difficult conversations by asking them to create “permission slips” to attend to forgotten or challenging dimensions of grief. Clinicians can give clients a scrap piece of paper and ask them to write out an area in their lives that is affected by grief that they find difficult to discuss. Another option is for counselors to write down overlooked topics related to grief and sexuality — such as dating, desire and arousal, physical changes, ways to talk about grief with a partner — on a sheet of paper and then ask clients to choose a topic from the list they want to discuss.

How can counselors help clients?

There is limited research on how to support clients’ sexuality in the context of grief. Formal interventions, however, may not be as important as the compassionate environment and empathic presence a counselor provides. Empathic presence can help clients introduce difficult conversations at their own pace and on their own terms.

Psychoeducation can also play an important role in counseling this population. For example, counselors can share that for some clients, sexual desire and arousal increase after a loss while others have the opposite experience. Providing education around the different reactions people have to grief can validate clients’ experiences and help them connect with the ways they may be experiencing grief. Counselors can also teach clients that grief is not just relegated to the cognitive or emotional domain; our bodies carry and process grief as well, and in this way, our bodies grieve. Providing this education to clients may allow them to feel relief that their somatic reactions surrounding sexuality after a loss are valid.

Another area of psychoeducation that could be valuable to clients is the identification of their grieving styles. The Grief Pattern Inventory is a tool that can help clients gain insight into how they are approaching the grief process. (For more, see Kenneth Doka and Terry Martin’s Men Don’t Cry, Women Do: Transcending Gender Stereotypes of Grief.) Understanding how a person is grieving can help the client and counselor gain valuable insight into the client’s grief process. Intuitive grief is an emotional style of grief in which emotional expression is valued, whereas instrumental grief is a cognitive style of grief in which problem-solving is valued. According to Doka and Martin, a client who identifies as having an intuitive style of grief will prefer a space to emotionally express the wide range of feelings that emerge when considering the intersection of sexuality and grief. In contrast, a client who identifies with an instrumental style of grief may prefer using specific techniques to reengage with their sexuality because they may view the changes in their sexuality after a loss as a problem to be solved. Counselors can introduce this concept to clients and invite them to consider how their grieving style may be affecting how they approach their sexuality after loss.

Finally, creative interventions can be a powerful way to help clients navigate these issues. Counselors can invite clients to write themselves a permission slip to engage with their sexuality in whatever way feels appropriate to them. For example, they might write, “I give myself permission to lean into the feelings that arise when I consider how my sexuality has changed in the following ways.” Clinicians can also encourage clients to create a grief playlist in which they share songs that help describe or capture the feelings surrounding the areas of their life that are affected by grief (including sexuality). Clients could share their grief playlists with their partners and identify how their grief experience is similar or different. Overall, outward expression of loss can help validate the complexity of feelings that arise when navigating this double-barreled taboo.

Addressing personal biases

When working with this population, it is important to be mindful of biases that both the client and counselor may have about grief and sexuality. Some common biases include the assumption that sexual desire disappears after a loss, sexuality is not appropriate to discuss after a loss or having sexual desire after a loss is wrong. To address these biases, counselors can use reflective questions and journaling prompts that ask individuals to reflect on what they have been taught culturally about grief etiquette, sexuality and scripts surrounding what is normal after grief. Again, some might feel judgmental of a griever whose sexual desire and/or arousal has increased after a death. However, addressing our own biases will help create a hospitable environment where a client is met with nonjudgment.


Counselors play an important role in empowering clients who are grieving. Even though we live in a grief-avoidant culture where we shy away from pain, counselors can create a refuge of hospitality where we can openly acknowledge what is uncomfortable. It is in our power and our scope of practice to gently remind clients that it is OK to talk about the intersection of grief and sexuality and to meet our clients with compassionate curiosity and encourage them to grant themselves permission and space to grieve and embrace their sexuality after loss in whatever way makes sense to them.

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