‘Don’t Let Me Die in Pain,’ My Patient Pleaded

— We must better manage the suffering of patients with a history of substance use disorder

By Ramandeep Kaur, MD

I still recall the look on my patient’s face and her words 2 years later.

“I am done with this life,” she told me. “Don’t let me die in pain,” she added as she folded her hands to physically plead with me.

I simply cannot convey in words how painful it was to witness the agony of this patient.

Here is what happened: My hospital requested a consultation for cancer pain management involving a relatively young patient with metastatic pancreatic cancer. Making matters worse, she was admitted with a severe apparent infection and displayed signs of failure to thrive with anorexia/cachexia. And then there was the pain, which doctors called intractable.

Typically, such pain cannot be cured and is merely managed at best.

My partner physician on the case treated the young patient for several days. There was a documented recommendation of “NO IV OPIOIDS,” citing past medical history of use of injected heroin.

One day, as I entered the patient’s room, I saw that she was fragile, moaning loudly in pain. She was visibly distressed, holding her belly. “I need some pain medicine,” she said immediately.

As I introduced myself and inquired about her pain, she held my hand and said, “Listen, Doc, I have lived in pain my entire life. I beg you, do not let me die in pain.”

Pain is the most prevalent and debilitating symptom in advanced cancer and at the end of life. Opioids are the mainstay treatment for cancer pain treatment. It is challenging when patients with a history of substance use disorder with opioid-type medication get diagnosed with cancer.

According to CDC data, about 107,600 Americans died in 2021 from a drug overdose despite a 44% reduction in prescription opioids from 2011 to 2020.

Since the start of the opioid epidemic, there has been a more significant push by federal agencies like FDA and CDC to decrease opioid prescriptions with no backup options in treating patients’ pain and mental health illnesses like substance use disorder. Abrupt brakes were applied to prescription opioids, forcing patients to resort even more to illegal means of obtaining pain medications on the street.

As expected, physicians and other clinic providers often fear prescribing opioids. This is even more of a reality when patients with a history of substance use are in their last days of life and dying from another disease like terminal cancer, and healthcare workers cite that they are not comfortable prescribing opioids in the current setting.

Synopsi

Substance use disorder is a mental health illness. As of 2015, approximately 10% of U.S. adults had drug use disorder at some point in their lives, and about 4% had met the criteria for drug use disorder in the past year. Additionally, 3.4% of Americans ages 12 and older misuse opioids at least once over a 12-month period. The COVID pandemic added oil on the burning flame of poor mental health.

Given the high prevalence of various types of cancer, many of these patients with a history of substance use disorder may get diagnosed with cancer at some point in their lives. But their mental illness will leave them unqualified to receive pain medications like morphine or buprenorphine to treat severe pain.

Do they deserve to die in pain because they suffered from addiction to illegal substances? People with drug use and mental health issues need the same empathy, compassion, and treatment as any other person.

What Can Be Done?

A multi-disciplinary team approach ensuring close collaboration among palliative and addiction specialists, psychologists, and supportive oncology is the need of the hour. The teams can thoroughly support and evaluate the patient and determine whether prescribing opioids is the most appropriate option. This approach will also help ensure patients aren’t handed-off between various specialties without continuity, leaving them with a sense of abandonment and increasing mistrust between the patient and the medical field.

The palliative subspecialty group is ethically bound to take care of their patients in the last phase of life, relieve their suffering to the best of their ability, and assist with a peaceful transition to the end of life. In my opinion, the presence of inherent empathy and additional training would produce real gems of palliative physicians who can provide comprehensive care to all patients with life-limiting diseases.

We must work with patients on a treatment plan that the provider and patient are comfortable with and maximize the quality of life for the short time the patient has left. The fear of opioid addiction should not cause needless suffering or lead patients to die in pain.

The stigmatization of medically complex patients with mental illness at the hands of the providers is not only unacceptable but morally unethical and reflects discrimination in the medical field. The situation is indescribable when such a patient also suffers from a terminal illness.

Complete Article HERE!

Why Some Referred Patients Never Make It to Hospice

By Jim Parker

Hospice referrals appear to be going up. But many patients who get the referral never receive the care due to low health literacy and social determinant of health factors.

Among patients who received inpatient discharge instructions indicating hospice, nearly 1 in 10 did not enroll within 30 days of leaving the hospital, according to recent research from Trella Health. The company used data from the last quarter of 2020 and the third of 2021.

This trend held despite over all growth in the number of individuals who had received discharge instructions to enter hospice, according to Carter Bakkum, senior data analyst for health care insights at Trella Health.

“When the [hopital] patient is discharged, thosewho have instructions to seek hospice are making up a greater percentage of that pool,” Bakkun told Hospice News. And that means that the the knowledge and awareness of hospice care is growing.”

But there remains a gap in the number of people who receive those instructions and then adhere to them.

Any number of considerations can play into this, including patients’ choices, family input, cultural belief about the end-of-life, among others. But systemic issues also exist.

One of thos issues is poor health literacy, according to Kenneth Griffith, assistant professor of health policy at Vanderbilt University.

“I have a Ph.D. in health services research, and I still find a lot of medical instructions confusing. So I can only imagine what it’s like for folks who don’t do this kind of work every day,” Griffith told Hospice News. “Some hospitals have have reengineered their discharge processes to help put instructions in lay language, which is especially important for older, disabled adults. But this is definitely still not the norm.”

Health literacy is the degree to which individuals can obtain, process and understand basic health information and services needed to make appropriate health decisions, according to the Institute of Medicine. A health illiterate patient may have a strong overall ability to read or have an advanced education but have a limited understanding of information specific to health care.

This perspective is backed by other research. In general, patients who have poor health literacy are less likely to enter hospice care, a study in the American Journal of Hospice & Palliative Medicine found.

Delays in routine care can also adversely affect referrals and adherence is, often due to a range of unaddressed social determinants of health.

Some patients delay or cancel health care appointments because of insurance status, affordability, transportation difficulties, or a lack of social support, according to Griffith.

“You might want to receive your post-acute care as instructed, but you don’t have anyone to take you to your appointments, Griffith said. “Patients could face a lack of transportation access. Maybe you want to go, but it requires transferring between multiple bus lines. There just might not be a lot of options in your area. Especially if you are you a frail or you are a disabled, that can just be very challenging.”

Health care organizations have taken some strides towards addressing social determinants of health, though that work is not over.

Case in point, the U.S. Centers for Medicare & Medicaid Services (CMS) as of 2020 allows Medicare Advantage plans to cover supplemental non-medical benefits, including transportation and food services and some home modifications, among others.

While offering these benefits is optional for MA plans, a rising number are embracing them. As of 2021, 67% of individual plans offered support related to meals, as well as 69% of special needs plans, according to the Kaiser Family Foundation.

In addition, about 38% of individual plans covered transportation benefits. Among special needs plans the proportion was 87%.

Value-based payment models like Medicare Advantage provide more opportunities to address social determinants amd adherence to discharge instructions that the fee-for-service system, Griffith told Hospice News.

“Our health system doesn’t incentivize the type of care coordination that we might need. That’s the unfortunate nature of having a fee-for-service health system like we do,” Griiffith said. “If you are a health system getting a capitated payment on a patient, you have a much greater incentive to worry about what’s happening after the patient is discharged — especially if you have if you have the financial risk.”

Complete Article HERE!

These Human Composting Facilities Are Open for Business

— to Deceased People Nationwide

A human composting vessel at Recompose’s facility.

By Sophie Hirsh

Human composting, an eco-friendly alternative to traditional burial, has already been made legal in Colorado, Oregon, Vermont, and Washington. Plus, states including California, Illinois, Massachusetts, and New York have introduced legislation to legalize the process. So as the carbon neutral burial process grows in legality across the nation, more and more human composting facilities and funeral homes are springing up.

Thinking about your end of life can be scary — and made even scarier when considering the high environmental impacts of traditional death practices such as burial and cremation.

So if you are interested in learning more about human composting and your body returning to the earth when you leave this planet, keep reading for a look into a few of the innovative funeral homes leading the way in human composting, aka natural organic reduction.

Recompose is leading the way for human composting in the U.S..

human composting facilities

Source: SABEL ROIZEN Recompose’s human composting vessel.

Recompose, which is based in Kent, Wash., is a full-service funeral home that works directly with clients and families for empathetic end-of-life processes. After a client passes away, for 30 days, the Recompose team regularly mixes the body with soil, alfalfa, woodchips, and straw in a Recompose vessel.

Once the body has fully turned into soil, they remove any items that did not break down, such as dental fillings or metal pins and screws, and recycle them; the soil is then moved to a bin for several more weeks to cure and dry. Recompose will then offer some topsoil to the person’s loved ones; otherwise, it will be donated to a conservation partner.

Recompose’s full-service burial (including local transportation of the body, the entire natural organic reduction process, death certificate filing, an online obituary, and more) costs​ $7,000. The company’s services are open to people anywhere; but you’ll be responsible for paying to transport the body to Washington.

Not only was Recompose the first licensed human composting funeral home to open in the U.S., but Recompose and its founder Katrina Spade actually inspired a Washington bill to legalize the process in the state back in 2019. Additionally, the Recompose team is also helping pave the way for other states to legalize human composting, which you can learn more about on the public policy section of Recompose’s website. The company is also planning to open a second location by the end of 2022, in Colorado.

Return Home offers human composting in Washington and nationwide.

 

 
 
 
 
 
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Return Home, which opened in 2021, offers “inclusive, gentle, transparent death care” via its Terramation human composting process. The company’s facility is based in Auburn, Wash., but offers its services to people across all 50 states and Canada.

At Return Home, deceased bodies are placed in a vessel. For 30 days, oxygen is flowed through to stimulate microbes in the body, which turns it to soil; then for the following 30 days, the soil rests and stabilizes. During these 60 days, visitors can come visit their deceased loved one in their vessel at Return Home’s facility turning business hours. At the end of the process, the deceased’s family can take the soil, or opt to have it scattered in nature.

Return Home’s full-service process costs $4,950. The company allows people to plan ahead to arrange their eco-friendly burials; it also offers services to those with an immediate need, and keeps its phone lines open 24/7 for this purpose.

Return Home is passionate about legalizing human composting more widely, and the company created the #IdRatherBeCompost campaign to help lead this movement. You can find a letter-writing template on Return Home’s website, which you can use to encourage your elected officials to support legalizing natural organic reduction in your state.

Earth offers natural organic reduction in Washington and Oregon.

“Funeral brand” Earth describes offers burial via a 45-day process called soil transformation. Earth uses its proprietary vessel technology; a balance of carbon, nitrogen, oxygen, and water; materials like mulch, wildflowers, and woodchips; and ideal moisture and temperature levels to create the optimized conditions for microbes and bacteria to break down the body, much like it would in nature.

At the end of the process, the deceased’s family choose to plant or scatter some of the resulting soil; the remaining soil is used for land restoration projects on the company’s conservation site in Washington’s Olympic Peninsula.

Earth has two facilities, located in Portland, Ore. and Auburn, Wash., both of which are powered by renewable electric energy. Currently, the company is only offering its services to those based in the Pacific Northwest (more details can be found here). Even though transporting dead bodies is legal, Earth believes “doing so undermines one of the greatest advantages of soil transformation, which is that the process is carbon neutral.”

Earth’s soil transformation package — which includes funeral services, all paperwork, and more — typically costs between $5,000 and $6,000.

Complete Article HERE!

Sitting shiva and los nueve días

— The parallels between Jewish and Latino Catholic mourning

The Latin American practice of los nueve días is in many ways almost identical to that of shiva.

By Amanda Rozon

When I told my father I’d be writing about the Jewish tradition of sitting shiva, he nodded with a clever smile, as if he was about to let me in on an exclusive piece of information.

“We do that too, you know,” he said. “We” being Dominicans.

As it turns out, Jews aren’t the only group that practices consecutive days of prayer and mourning after a death.

Catholics in many Latin American countries, prominently including Mexico and the Dominican Republic, practice los nueve días or novenario — nine days of mourning, named for nove, the Latin word for nine. It’s a practice in many ways almost identical to that of shiva — the Hebrew word for seven — the Jewish custom of mourning a death communally for seven days.

And like many who follow the traditions of shiva, many who practice novenario have plenty of opinions about how to observe the custom correctly.

My father, for one, holds deep resentments toward those who take los nueve días as an opportunity to party. He would not describe himself as spiritual or religious in any way, but he believes the dead should be respected. And if you show up to a novenario for fun and festivities, in his opinion, then you’d better have just stayed home.

Sharon Rose Goldtzvik, who wrote about shiva for the Forward this year, shared a similar reflection from her mother on sitting shiva. “We are not there for the food. We are not there to catch up with our friends. We are there for a specific purpose: to comfort the mourners,” she wrote.

That last part, my father said, is, in his experience, lost on some.

As Jews do, Catholic Latinos start the mourning process the moment the dead are buried. But when someone is buried varies between the two religions.

Jewish law holds that the dead should be buried no more than 24 hours after death, although today, the strictness with which that mandate is observed varies by denomination. So a shiva might and often does begin shortly after death. But because the Catholic church prefers that the deceased’s body be present for the funeral mass, their burial may take days.

For the nine days that follow that burial, things look very similar to shiva.

Family and loved ones gather at the deceased’s home to offer support, both spiritual and material. The long hours are spent remembering the dead, praying, sharing stories and lamenting the loss.

If the mourners are more well off, you show up empty-handed, bringing only emotional support. If the family has little money to spend on refreshments, everyone pitches in.

Members of Joaquina Chavez’s family in 2018 Puebla, Mexico, holding a final prayer for two deceased relatives.

Joaquina Chavez, who immigrated from Puebla, Mexico, to the United States as a teen in the late 1970s and now lives in Woodside, Queens, New York, says los nueve días is especially precious for Mexicans living away from their home country, since many families transport the deceased back to Mexico to be buried. The long period of communal mourning following that burial gives them an opportunity to come together with family members and friends whom they haven’t seen in years, sometimes decades.

“It’s also a time when people in my town forget about politics and issues and congregate and just pray for the family and the dead together,” she said, speaking in Spanish.

One key difference between shiva and los nueve días: While Jews often literally sit shiva — using low stools or pillows to symbolize feeling low in their grief and to be close to the departed — in a crucial part of the mourning ritual, Latino Catholics walk.

On the first day of mourning, a cross is erected next to an altar in the family home that the family will carry to the deceased’s final resting place on the last day, symbolizing the long journey the departed will take to divinity, and their family’s efforts to help get them there.

An altar decorated with pictures and offerings for the departed that remained erect in Chavez’s home for the nine days following the passing of her sister and brother-in-law.

In the nine days leading up to that final passage, ofrendas, or offerings, are also placed at the base of that altar, to be cleared up when the period ends. These can be small gifts one wishes to send off with the deceased — rosaries in vivid colors, fresh flowers and fruit to brighten up an otherwise dreary occasion.

Finally, for those who practice novenario, the mourning period always ends in a feast. In the Dominican Republic, a cow is traditionally killed to feed a crowd. By this point, word has spread across the town, and all are welcome. Whether you knew the deceased or not, no one is turned away.

Despite my father’s caution against a festive novernario, he was moved to tears describing the scene of those in his small hometown between two mountains, many of whom had little money for food, sitting around a fire pit and eating together — lending strength in numbers to help a family grieve.

In Mexico, the feast is also part of the ritual, although it can look different. In her experience, Chavez said, at gatherings before the final feast, the table is laid with “tostados, tamales, tacos, something small to offer.” But on the last day, she said “we make their” — the departed’s — “favorite meal to share with everyone.” In these last crucial steps, the transfer from the hands of loved ones to the hands of God is marked.

In both mourning traditions, this time of communal mourning can give a grieving family the strength to go back to work and to their daily lives. By leaning on each other, they share the burden of loss so it is not too heavy on any one person, they believe, leaving both the soul of the deceased and the spirit of the living intact.

In sum, it’s a way to tell one another that they’re not alone.

Complete Article HERE!

4 Simple Ways Parents Can Survive The Death Of A Child

By John Cappello

There are many forms of grief that you will face in your life. Some are more difficult to fathom than others. The tough ones like a failed relationship or the loss of a job are rough enough, but there is one loss that is considered the most challenging of all.

The loss of a child.

The loss of a child is not an experience that you expect to endure because it is such an unnatural occurrence. A child is part of your legacy and, to many, becoming a parent is the highest form of achievement that you can accomplish in your life. When a child is lost it affects your very core.

The sense of damage is often unbearable.

To Move Forward, Find A Way To Cope

It does not matter how the child was lost. The hurt of the loss never really goes away. There can be a sense of failure that surrounds this kind of loss and healing from it may simply be impossible.

The solution to moving on from this tragedy is to learn how to cope with it.

1. Face the shock of premature death

Premature death is shocking and keeping it together is not easy. The mental, physical and spiritual pain from the loss of your offspring can create a cycle of other events that can stifle the strongest individuals.

It can create chaos in other areas of your life that had been relatively stable.

A spiral of other unpleasantries can occur if you are not careful. There are no set answers for coping with this problem, but an individual strategy can be created to help.

Since there is no formula for handling this kind of tragedy, you must employ whatever positive behavior you can produce to soothe your pain.

2. Practice the virtue of commitment

The topic of the loss of a child is not easy to discuss but it is necessary because it is a form of grief that is life-altering. Friends or close colleagues are often told to “mind their own business” but this kind of behavior is not helpful to you or them because they are suffering from the same loss.

The others who are hurting may not suffer the same degree of pain, but they are attempting to process the loss as well.

It may sound trite to speak of virtues at this time, but this is a moment when they can matter the most. The virtue of commitment is one of the first that is exhibited by many parents who have lost a child.

This virtue is very important because re-committing yourself to your spouse, significant other, closest family, and friends is essential in the healing process.

You can nurture each other through your pain.

The touch of another loved one — hugging you or holding your hand — is a life link to coping. Re-committing to your spouse or significant other validates the bond that each of you has and the one that was there when you created or adopted your child. Devotion, cuddling, and intimacy allow you some respite and are unique moments that only the two of you can share.

It is your partner who understands your feelings the most and this is not the time to push them away. Your other friends and family are there for you and you are there for them. Ironically, the bond you have with those closest to you becomes stronger during this difficult situation.

This kind of tragedy can bring out problems in a relationship and force those issues to the forefront. 

Many couples separate after a child is lost because other problems that were not pressing are now front and center. It is another heartbreak that results from losing a child, but it may be necessary for an individual to cope if the relationship is not strong enough to survive.

Seeking and giving acknowledgment to others after losing a child is monumental in carrying on. If you do not have anyone to who you can turn at this moment, then seeking help from a therapist or an outreach program is a necessity for your well-being. Emotional support is critical because it is needed at this time.

Some isolation and privacy are expected after your loss but there is a point when isolation becomes negative and accepting the love, support, and nurturing others have for you is a good thing. It will make you feel wanted and that your loss is not discounted in any way. A balance between isolation and socializing with loved ones can prevent negativity.

3. Seek perspective

The act of taking care of yourself is paramount with any form of grief but this type of grief is most likely shared by others. You are the most important person who needs the love and nurturing of others at this time, but it is you who must learn to persevere. You may not be used to accepting help, but it may be one of the things that assist you in your self-care.

It is your act of self-love and other virtues that will help you cope. You may never be able to overcome all your grief from your loss but learning to function positively is a necessity. Being magnanimous in this loss and gaining perspective will hopefully come to you at some point. These attributes are essential in keeping a positive outlook on your future.

A sense of guilt and feeling that you did something wrong may surround your loss. Parents who suffer this loss often feel they did not protect their child enough, but this is just a sign of a good parent grieving. Forgiving yourself if you have a sense of failure is a necessity for your ability to cope with this loss.

Your child lives on in the Spirit World and your relationship with them continues in spirit. It is not the situation that is the most desirable, but it is your belief in it that can bring you some peace of mind. A spiritual perspective is necessary during extreme situations because it is a higher power that will give you the fortitude that you need.

Prayer, meditation, and memorializing your child can bring a sense of peace. The ability to find or develop positive skills to manage is essential for coping. Expressing your emotions is healthy but negative actions or approaches will simply create adversity and more difficulties that can damage your life.

4. Know that life is worth living

A loss of a child is devastating but it does not mean that life is not worth living or that you cannot move ahead in the future. It is an unfortunate part of your journey that you cannot ignore. You did not deserve this tragedy, but it occurred, and it has altered your life forever.

Coping with grief is not easy and this type of grief is the most difficult. Re-committing to those who love you and the ones you love is helpful. Seeking professional help and/or support groups is advisable, but it is only you who can determine your path forward. Navigating this uncharted path is an individual one but trying to have a positive perspective is necessary for you to survive.

Your spiritual life is an important ingredient for coping and should be relied upon for perspective.  Memorializing and recalling the joy of having made a child in your life is a good thing. You may never fully recover from your loss but at least you may learn to cope with the tragedy and try to grow from it.

Complete Article HERE!

9 tips to talk to kids about death under any circumstances from natural causes to mass shootings

Children process death in different ways and it’s important to respect their grieving process and let them know you’re there for support.

By

  • When discussing death with kids, experts advise honesty and plain language rather than euphemisms.
  • Aim to tailor the conversation to their age and stick to the facts, avoiding overwhelming details.
  • Kids often need more time to process what happened, so prepare for more conversations later on.

You’ll likely have to tackle the topic of death with your kids at some point, whether that conversation is spurred on by a death in the family, a school shooting in the news, or simple curiosity.

It’s natural to feel a little uneasy approaching this conversation due to your own discomfort and fear around death, or because you’re afraid of upsetting your child, says Reena B. Patel, a licensed educational psychologist and board-certified behavior analyst. Even so, talking to your child about death can help them understand this difficult topic more easily.

What’s more, in the case of publicized tragic events like school shootings, it’s especially important to take the lead in discussing what happened with your child rather than let them find out from the media, says Bethany Cook, a licensed psychologist in private practice.

The news is written and reported in an effort to captivate the viewer, Cook says. In other words, it’s not crafted to your child’s age or level of understanding, and it won’t be able to answer any follow-up questions they have or provide emotional support, she says.

When deciding how to approach the subject of death with a child, Parenting Nerd co-founder Elizabeth Hicks recommends taking their age and emotional maturity into account. If you’re bringing it up because someone your child knows recently died, you should also factor in their relationship with the deceased.

These expert-approved tips can help you talk to your kids about death in a gentle and supportive way.

1. Choose a time and place carefully

Ideally, you want to approach the topic of death in a private and quiet setting, when you and your child have nowhere to be and don’t feel rushed in the conversation.

If your child has a favorite stuffed animal, blanket, or toy they like to carry around or sleep with, you might give it to them to hold for comfort before starting the conversation.

It’s OK to share a loved one’s death with more than one child at the same time if there isn’t a big age difference between them. However, if they aren’t close in age, you may want to have separate conversations so you can tailor your language accordingly.

When sharing the news of a tragic event, such as a school shooting, Cook recommends choosing a private, comfortable space with minimal distractions and presenting the information in chunks.

“The first piece should be geared toward the younger family members,” she says. “Keep it simple, clear, and concise.”

You might start by saying something along the lines of, “Did you hear about something that happened at a school in [XYZ state] today?” If they did, you can ask:

  • “What did you hear?”
  • “How do you feel about it?” “Do you have any questions?”

If they aren’t yet aware, Cook recommends saying something along the lines of, “Someone went into a school with a gun and killed some people.”

Then, give them a chance to ask questions and share their feelings. After you validate those feelings, Cook recommends setting younger children up with an activity, like a movie or engaging toy, in another room so you can continue the conversation with older children.

Adolescents and teens may have more intense emotional reactions to this news, so be prepared to validate their feelings while reassuring them as best as you can that the school staff is trained to keep them safe.

2. Be honest and concrete

While you might feel tempted to withhold news of a death in an attempt to protect your child, Patel says it’s important to be direct and transparent.

Children often know when you aren’t telling the complete truth. Even if you have good intentions, that dishonesty could erode their trust in you.

You don’t need to share all the details of a person’s death with a younger child, who may not even be able to grasp them. When it comes to older children, though, don’t intentionally leave out key facts — even if the facts are potentially upsetting.

Say a relative died of an accidental drug overdose but the official cause of death was heart failure . Hannah Ly, a child therapist in private practice, advises against saying “They had a heart attack” without mentioning the drug use.

“Leaving out facts could lead to emotional distress when they find out the truth as an adult,” she says.

3. Start small and let them take the lead

In order to avoid overwhelming your child with too much information up front, Patel recommends sharing in doses. Start with simple facts about who died and what death means. Then, allow them to take control of the conversation by giving them an opportunity to ask questions.

For instance, if you tell your child a loved one died due to an illness, like cancer, they might ask why a doctor couldn’t make it better. You can respond matter-of-factly by saying “Doctors can’t always fix everything.” Or, if they don’t ask any questions, that’s OK, too.

Remember, they may need to digest the concept of death in bits and pieces, so just know they might come back to you with more questions on another day. Even if they don’t, you might always follow up yourself in a day or two, after they’ve had some time to process the news.

4. Avoid certain euphemisms

You may feel uncomfortable using the words “death” or “dead,” but Patel advises against using euphemisms to soften the blow. This kind of language can cause misunderstandings and confusion and ultimately do more harm.

For example, if you say the person “went on a long journey,” your child may then be retraumatized when they realize the person will never actually come back. Or, if you say they “went to sleep,” Ly says your child may develop anxiety at bedtime and become afraid they might die in their sleep.

Ly advises focusing on the basic facts of what happened. Say a loved one died naturally due to age. You might explain to a younger child that after many years of life, your body gets so tired that eventually your heart stops beating, your brain stops thinking, and you stop breathing.

5. Allow space for every emotion

Keep in mind that children can experience grief in widely varying ways, just like adults. They may:

  • Express anger, sadness, or confusion
  • Cling closer to you or isolate themselves
  • Need to talk about it a lot to process it, or become quieter and more withdrawn
  • Seem unaffected by the loss

According to Patel, there is no right or wrong way for them to grieve. Ideally, you want your child to understand no emotion is off-limits so they feel safe and supported in expressing themselves however they need to.

Explain that they can come and talk to you any time. When they do share with you, make sure to validate their feelings by saying things like:

  • “It sounds like you’re really upset, and that’s totally normal.”
  • “Of course you’re sad — lots of people feel that way when they have to say goodbye to someone.”

“Let them know it’s OK to cry, and it’s also OK if they need alone time,” Patel says.

If their grief is affecting other areas of their life, such as their performance at school, Ly advises seeking guidance from a mental health professional.

You might start by mentioning the changes you’ve noticed in a curious and non-judgmental way, and asking your child why they think they might be struggling. You can also talk to their teachers to get their perspectives and observations, Cook says.

6. Feel free to express your own grief

You may worry that expressing your own emotions around death will make things worse for your child — but in reality, experts say it’s much better to show your grief than stifle your emotions in an effort to protect them.

You can normalize grief and mourning for your child by openly expressing your emotions, Patel says. It also helps to model healthy coping skills, like journaling, connecting with loved ones, and practicing good self-care.

Children tend to model the behavior they pick up on from the adults in their lives. If they notice you’re comfortable discussing death, and your feelings around it, they’re more likely to do the same.

Conversely, avoiding discussing the death or your feelings about it can send a message that talking about death is somehow bad or harmful. They might then avoid the topic, too — which Ly says may prevent them from fully processing their emotions not only in response to that particular death but others down the road.

7. Keep their age in mind

While it’s important to speak honestly with your child about death, it can be challenging to do so while steering clear of unnecessary details that may traumatize them.

Experts recommend considering your child’s age to find a balance. Here’s how each age group typically perceives and understands death:

Preschool (ages 3-5)

At this age, children may still think of death as temporary or reversible. They may have trouble understanding that when someone dies, they don’t come back. A 2018 study found that media representations of death can often contribute to these unrealistic ideas about death. For instance, an analysis found that 31.6% of the deaths in 57 Disney and Pixar films were portrayed as reversible.

According to Cook, it’s OK if your child isn’t able to grasp the finality of death just yet. You can continue to reinforce the fact that it’s permanent through examples — like how once a tree dies, it doesn’t grow back.

Elementary school (ages 5-9)

At this stage, your child may be coming to grips with the idea that everything and everyone dies eventually, and that death is permanent. They may start expressing concern about their parents or friends dying and begin asking a lot more questions about death in general.

“Magical thinking” at this age can cause them to question whether something they said or did caused the person’s death, or whether they can say or do anything to bring them back.

You can reassure them the person’s death was not their fault without dismissing their feelings.

Middle childhood (ages 9-12)

Once they reach this age range, kids often start to acknowledge that death applies to them, too, so they may have more philosophical questions about life and death. They might be more inclined to dig into “why” death happens, especially when it comes to tragic events like murder and suicide.

Certain events can threaten their sense of safety in the world, which makes it important to reassure them you’ll always do your best to keep them safe. It can also help to offer them plenty of choices in everyday life so they can maintain a sense of control in an unpredictable world. For example, you might:

  • Give them three options for how they’d like to spend their Saturday afternoon.
  • Let them pick between a few different outfits for school.
  • Encourage them to select which book they’d like to read at bedtime.

You can also offer multiple options for how to commemorate the deceased person so they can say goodbye in the way they’d like to.

Teens (ages 13-18)

At this point, your child likely has a strong understanding of what death means, so you can focus your conversations around empathizing with and validating their feelings — which may range from sadness or fear to anger and numbness.

Cook advises continually checking in with them to remind them that you’re there to listen, without pressuring them to talk if they don’t want to.

“Follow their lead,” Ly says. “Normalizing the grieving process and giving them space is important.”

If your teen is unwilling to share their feelings with you, but you sense they may need some emotional support, Ly suggests offering to help them connect with a counselor.

8. Shape the conversation according to how the person died

How a person died will play a part in:

  • What you tell your child
  • How much you should share
  • The way you choose to discuss the topic

A sudden death

For example, if a person died suddenly due to a heart attack or car accident, Patel says your child may be in shock and have a lot of questions since they didn’t have the chance to say goodbye.

A natural death

A death due to age can lead to a larger discussion about the circle of life, Patel says. She says you can feel free to use metaphors in nature to help young children understand death — like pointing out how a flower starts as a seed, gets bigger and bigger until it stops growing, starts wilting, and eventually stops living.

Once your child begins to recognize that all plants and animals die, too, they may have an easier time transferring this understanding to people.

A death due to illness

On the other hand, if the person died due to an illness, whether Alzheimer’s or COVID-19, you might explain they had a disease that makes your body stop working as it should. Ly says you can use similar wording to simplify death related to mental health conditions, too.

A death due to suicide

When telling a child about a death by suicide, it helps to answer questions honestly but focus more on your child’s feelings, rather than the details.

It’s essential to:

  • Offer reassurance that nothing your child did or said caused the loved one’s death
  • Stick to the facts
  • Encourage questions
  • Prepare to have multiple conversations about suicide — not just in the days after you share the news, but in the weeks and months to come

If a relative who had depression died by suicide, you might tell a young child, “Their depression made them so sad they didn’t want to feel anything anymore, and so they decided to stop their body from working.”

You could also emphasize to older children that depression is a mental health condition, not a choice or personal failing.

For more guidance on talking about suicide with children and teens, visit the American Foundation for Suicide Prevention.

A violent death

If you find yourself needing to explain a murder, school shooting, or other violent death, keep it simple and only use language they’d understand. For instance, if they ask why the shooting happened, you might say, “People who are hurt and angry sometimes hurt other people.”

9. Other helpful strategies

Death can bring up a lot of feelings like fear, uncertainty, and vulnerability for your child. Some strategies experts recommend for comforting them include:

Make a memory box

Patel advises helping your child to put together a bereavement box filled with special tokens that remind them of the person who died.

This activity can promote positive memories about the person and help them process their grief at the same time. On days when they’re thinking about the deceased person, they can pull out their memory box to help them cope.

Items to add might include:

  • Photographs
  • Cards written by that person
  • A sample of their cologne or perfume
  • Personal items of theirs like jewelry or a passport
  • Keepsakes like tickets from travel or events your child attended with the person

Write a goodbye letter

If your child feels sad they never got to say goodbye, Hicks says you can encourage them to write a letter to the deceased. You can tell your child the letter offers the space to say anything they wish they got to say. If they’re not sure how to begin, ask them how that person made them feel, or what they loved most about them.

Another option, according to Hicks, is to give your child a journal and let them know it’s their safe, private space to share whatever they’re feeling.

Keep up routines

Since the unpredictability of death can disrupt a child’s sense of security, it’s a good idea to maintain as much structure and consistency in their life as possible.

Try to keep up with routines when it comes to schoolwork, meal times, play, and other activities.

Lean on other resources when needed

You can find many books about death specifically geared toward children in your bookstore or local library. Some of these may help fill in the gaps you find most challenging to explain.

Ly recommends reading “The Invisible String” and “When Dinosaurs Die” to check whether either option might help you explain loss to your child.

The National Association for the Education of Young Children has also compiled a list of additional books and other helpful resources. Find that here.

Consider professional support

In some cases, your child may benefit from talking with a therapist about their grief.

A small 2013 study examined children and adolescents with prolonged grief disorder, a condition marked by feelings of intense longing and intrusive thoughts about a deceased loved one six months or more after their death.

Researchers found that children who received nine sessions of cognitive-behavioral therapy, a common form of talk therapy, experienced a reduction in symptoms of grief, depression, and post-traumatic stress disorder.

Patel, Ly, and Hicks say a child may be finding it difficult to cope if they have:

  • Trouble falling or staying asleep
  • Increased nightmares
  • Changes in appetite
  • Less interest in their favorite activities, including socializing with friends
  • Persistent worrying about death, especially pertaining to parents and caregivers
  • Frequent angry outbursts or temper tantrums

If you notice these behaviors — or any others that seem to affect your child’s health and well-being — your child may need additional support to begin healing.

A good next step involves connecting with your child’s teacher or guidance counselor for more support. You can also reach out to a therapist or counselor or ask your child’s pediatrician if they can recommend one.

Insider’s takeaway

As a general rule, death is best explained to children in a simple and straightforward way, without misleading euphemisms. Always offer the opportunity for your child to ask questions, and make it a point to validate any feelings they share.

You don’t need to hide your own grief — in fact, expressing it openly tells your child two important things: Their feelings are natural, and it’s OK to express those emotions openly.

Just know talking to your child about death won’t be a one-and-done conversation. You can share information in smaller doses to avoid overwhelming them, but you’ll also want to let them know your door is always open, so to speak, so they can come to you with any questions or fears.

Complete Article HERE!

‘I’m a Death Doula, and This Is the Most Common Regret I Hear From People Nearing End of Life’

By Jessica Estrada

Death is inevitable but reaching the end of our lives without any regrets is something we have some control over. The key is making the necessary shifts now so that when our time is up, we can go knowing we made the best of it. Learning the top regrets people have when they’re dying can help us understand what specific changes we should make. To help with this, we turned to Maryanne O’Hara, an end-of-life doula and author of Little Matches: A Memoir of Finding Light in the Dark.

In case you’re not familiar, an end-of-life doula, also referred to as a death doula, provides emotional, spiritual, practical, and physical (though not medical) support for people living with a terminal illness and their loved ones. Some things they can support with include sitting vigil, running errands, doing household chores, and helping with funeral arrangements. Death doulas essentially help people navigate the pain that comes with death and loss and are often the ones who are there when the dying are reflecting on their life.

Below, O’Hara shares the most-common regrets she hears from clients and the big, universal realization they have at the end.

According to O’Hara, the most-common regret she hears from people nearing the end of their life boils down to a single, overarching regret: “We always think we have more time,” she says.

In other words, people get caught up in the day-to-day things of life that they put off doing the things that are truly meaningful to them. “When you take the future for granted, it’s easy to lose sight of larger questions of meaning and purpose and respond to what’s demanding your attention in the moment,” O’Hara says.

For instance, O’Hara remembers a woman she worked with while volunteering at a hospital who received a terminal diagnosis. The woman’s biggest regret was not enjoying life’s little pleasures instead of focusing on daily stresses and chores and using those things as an excuse to not take better care of herself and spend more quality time with loved ones. “The woman said: ‘If I could go back and relive it all, knowing just how quickly it was going to pass, I would savor it all more. I would savor every delicious bit.’ She emphasized the word savor,” O’Hara says.

Another example O’Hara recalls is one client who regretted not spending time with his son. “There was one man, he hadn’t been very talkative, but I saw him after his team had given him some tough news, and he started asking me about my life, whether I was happy, what I did with my days,” O’Hara says. “Then he said: ‘You know that old Cat Stevens song about the dad who doesn’t have time for his son and then he grows up, and the son doesn’t have time for him?’ He was teary and trying not to be, and he pointed at himself as if to say that says it all.”

The most-common realization from people nearing the end of their life

Beyond the things they regret not doing, people nearing the end of their life also have one common realization: Love is all that truly matters, O’Hara says. People often wish they had realized this sooner and lived their life knowing it.

O’Hara recalls one client saying to her: “You have to tell the people you love that you love them. It can be hard, and you might say to yourself, ‘oh, she knows,’ but people need to hear it.” Similarly, she shares about a man nearing the end of his life who berated himself for not reconciling with his mother and telling her how much he loved her before she passed.

This sentiment of love being all that matters rings true for O’Hara in particular who lost her daughter. “We didn’t know it was going to be the last thing she ever said to me, but in the ICU, as I was trying so very hard to be strong for her, she said, ‘It’s okay to cry, mummy,’” O’Hara recalls. “She began crying, too, and she said, ‘I love you so much. I’ve never loved anyone as much as you.’ That’s the most cherished, painful memory of my life. Ask anyone who’s ever sat vigil beside a loved one in an ICU. It’s a heightened time of connectedness when everything else falls away, and for me, nothing ever mattered or will matter as much as the eternal love I have for my child and the love she had for me.”

Complete Article HERE!