Sky Burial

— A unique death ritual

The ancient death ritual called sky burial is still practiced in parts of Upper Mustang, like in Tibet, Bhutan and Mongolia

By Ravi M Singh

The evening in the dining room of the Mystique Hotel, Lo Manthang, buzzed wild—the noise so loud that voices needed raising. Packed almost to the gunwales by trekkers, cyclists, and motor-bikers, the crowd included us too—four cyclists, Khashing, our team leader, Shayeet, Diwas, and this scribe.

The heated room wore a festive ambience; everyone appeared in a back-slapping mood, and so we were—the vibe in the room was almost palpable. It was our last day in Lo Manthang, a 13-day cycling tour we did in 2018.

We were talking with an Australian cyclist group when my eyes clapped on Wangchhen Lowa, better known as Ram Gurung by all in Lo Manthang, sitting before the iron stove sipping Shyu Cha (Tibetan tea made from yak butter, salt, and tea). I brightened up and excused myself from my friends and the Aussies to join him for a chat.

With 20 years at ACAP (Annapurna Conservation Area Project), Wangchhen aka Ram, also co-owner of the hotel, seemed to know what’s what about Mustang and helped me with a wealth of information.

Following an exchange of customary pleasantries and more insight into the walled city of Upper Mustang, its inhabitants, rich culture, religion, and history, the topic, upon my curiosity, diverted to the ancient death ritual called the sky burial, still practiced in Upper Mustang.

With over two decades of experience in conservation, biodiversity, and flora and fauna of the Trans-Himalayan region, Lo Manthang, it was a privilege conversing with him.

Before touching upon the sky-burial issue, he briefed me on the vultures of Upper Mustang, which play a crucial role in the consummation of sky burials. They included especially the Himalayan griffons (Gyps himalayensis) and lammergeiers (Gypaetus barbatus), the bearded vultures.

“In recent years, the number of Himalayan vultures, especially griffons and lammergeiers, the bearded vultures in the Upper Mustang region, has declined disastrously,” said Wangchhen.

The Himalayan griffons survive on carcasses and carrion. They nest in high cliff edges and even deserted sky caves in Mustang—often sighted at Chhuksang, Yara, Ghemi, and other wind-ravaged arid cliffs.

Native to Mustang and other Trans-Himalayan regions like Dolpo, Humla, Jumla, and Manang, these highland carnivores are large birds and weigh from eight to 12 kg with a wingspan of 2.5m to 3m.

The Himalayan lammergeiers, a close cousin to griffons, too, scavenge like the griffons and live on high crags, but weirdly their diet comprises 90 percent bones (the marrow being their favorite). Almost as large as the griffons, if not bigger, they gobble up the shredded bones after the griffons pick them clean.

To honor the dead, funeral ceremonies and death rituals in Nepal vary from one culture to the other. Typically, the deceased body is largely either cremated or buried. In Tibet, singular to their culture, a death ritual commonly performed is a sky burial.

“Going by the legend, the concept of sky burial in Mustang has its roots in Tibetan culture, preserved in Upper Mustang for eons. Widely exercised to date in Tibet, countries like Bhutan and Mongolia, too, follow the ritual,” said Wangchhen.

Some three decades ago, the sky burial ritual ubiquitous in Mustang gradually declined following trappings of haphazard modernization, making inroads into the once pristine area.

“This funeral practice, widely performed in Tiri village in Kagbeni, suddenly ceased; it has been over 10 years since any sky burial took place there, but the ritual continues in a village called Dhamkar in Upper Mustang among the ethnic minorities called the Lowas (Gurungs, Bistas and Biswokarmas),” said Wangchhen. He sounded very convincing, as he has Lowa roots.

When someone from this community dies, a high Lama (priest) scrutinizes the deceased’s zodiac sign, astrologically juxtaposing it against five Tibetan Buddhist elements—the earth, water, fire, air, and the space—and determines the method for the departed’s funeral.

If the high Lamas decide to go for a sky burial, the funeral ceremony begins, accompanied by the beat of drums, cymbals, and dung chen (a Tibetan long-pipe horn). After the rites, the body is handed over to the monks assigned to behead the body, dismember the corpse, and hack it to pieces. The severed head gets buried, and the chopped-up pieces are moved to an elevated site to feed the vultures.

Curiously, the commotion lures vultures from great distances to assemble at the site and swarm at the chopped body tissues, jostling each other to grab their choicest piece. By performing this rite, the sacred vultures, an emanation of wisdom deities, transport the deceased’s soul to heaven—so believe the local folks.

Strange as it may sound, the vultures do not feed on the meat if the deceased were a sinner. The sky burial rite is nothing less than gruesome but a stark reality founded on Tibetan spiritual values.

“Based on Buddhist tenets and values, the philosophy behind the sky burial ritual is insightful and profoundly spiritual. When you die, your spirit leaves your body, leaving behind nothing but a mass of flesh and bones. If your worthless body can serve as a source of sustenance to another living being, it’s good karma to a noble cause,” said Wangchhen Lowa.

A dull boom of a gong, punctuated by the sharp clang of cymbals and the haunting wail of a long pipe horn, sounded from a nearby monastery as Wangchhen Lowa rounded up on the eerie account of Lo Manthang’s sky burial.

Complete Article HERE!

Grief in the Elderly

— When an elderly person loses someone close to them, it can be so heartbreaking that they lose their faith in life. All of a sudden, it feels cold, empty, and completely different. So, what are the characteristics of grief in old age?

By Gorka Jiménez

Grief in the elderly can be especially distressing for them. Indeed, the loss of close family members can be a tremendously painful experience. Unsurprisingly, it reaches the maximum level when an individual loses their partner. In fact, losing a lifetime companion who made them smile and shared their dreams can be heartbreaking.

In addition, the factors surrounding grief in the elderly are aggravated, since this stage of life is already characterized by the loss of social contacts.

“Mourning dares us to love once more.”   -Terry Tempest Williams-

Seniors worried about death in old age
The increase in loneliness and the emotional processes that accompany mourning in old age can constitute a springboard to the suffering of limiting clinical disorders like depression.

Emotional luggage

In old age, people suffer many losses. They can be internal (changes in lifestyle) or external (loss of family, friends, or partner). When an elderly person loses their life partner, they find themselves in a situation where they must deal with both the pain of the loss and the need to have other support figures around them.

Some characteristics of grief in the elderly

All too often, grief in the elderly is accompanied by heartbreaking pain. This is due to the absence of the person who shared their life for so many years. Moreover, they might feel intense helplessness at finding themselves in a different and often cruel world.

Even if they want and try to start a new life, their physical health and external circumstances often constitute powerful barriers that make it impossible for them to do so. This is one of the reasons why we must pay special attention when it comes to providing love, affection, and support to older people who’ve lost their loved ones.

“The loss of relatives s the trigger for 20 percent of the cases of depression in the elderly.” -Emilio Gamo Medina-

In old age, mourning for a friend, family member, or partner is different. These people are aware that their future is shorter than that of younger people. This can reduce the kind of faith and hope that’s intrinsic to grief at other stages of life.

Also, the culture, values, and society in which the elderly were raised are different from those of today. These changes can aggravate their feelings of disconnection from the world. Moreover, the anchors that kept them connected to the present are no longer there. This can trigger a real emotional avalanche that can be tremendously difficult to overcome.

Factors that aid recovery

Older people are often extraordinarily wise. Their experiences, the lessons they’ve learned, and the strategies they’ve developed throughout their lives can help them to face and resolve their difficulties and emerge into a new stage of life. Whether their pain is resolved or complicated will depend on how they deal with it.

Avoid overprotection

Overprotection is never good. In fact, too much attention can cause older people to lose certain skills much sooner.

An overprotected person is isolated from the processes that make us grow as people. Therefore, it’s important to be there for them, but not to do everything for them. They must face the situation themselves. You can help them by letting them know that you’re there for them but you mustn’t restrict them in any way.

“Tearless grief bleeds inwardly.”  -Christian Nevell-


listen to them. They’re building a narrative of the memories they shared with the deceased. It’s important for them. It means they can integrate the loss into their lives.

One way you can help is by paying attention to what they tell you. Even if they repeat themselves. Indeed, listening is part of the grieving process. Two-way listening is important. Try and paraphrase what they’re telling you or stop them to ask about a specific memory. For example, “Grandpa, tell me about that time Grandma did such and such…” can be a tremendously anxiolytic act.

“Honest listening is one of the best medicines we can offer the dying and the bereaved.” -Jean Cameron-

Person holding the hands of an older person
Listening to how they feel is helpful and also a way for them to integrate their loss.

Be with them

Until they reconnect with society and the environment, it’s important to invest your time with them. By this, we mean calling them, inviting them to do activities with you, or simply going to their house and sitting with them.

You may not even have to say anything. The mere act of connecting with them and letting them see that you’re there can be tremendously intimate. In fact, the intimacy that emanates from accompaniment is a powerful tool that reduces the loneliness of loss.

“The only cure for grief is to grieve.”  -Earl Grollman-

When we’re older we become more vulnerable. Losses begin to occur. These are completely natural because they’re produced by the effect of aging or illness. In the face of the death of children, younger siblings, or a spouse, more intense emotions are produced than in other cases, increasing the emotional discomfort they feel.

It’s for this reason that we must provide older people with support in a kinder, more intimate, and closer way. The elderly today built the world in which we now live. We should, therefore, be able to provide them with the necessary support so they can continue to live their lives healthily and with dignity, whenever they have to face a painful loss.

“It is old age, rather than death, that is to be contrasted with life. -Simone de Beauvoir-

Complete Article HERE!

The Various Costs of Dying

— A new report breaks down what it costs to die, giving further reason to make clear final arrangements

By Emma Suttie

As a culture, we don’t like to talk about death. Even though it’s the destination we all share, regardless of our beliefs, most of us prefer not to think about it. Unfortunately, this aversion leaves most of us unprepared for death when it arrives, making things harder for the loved ones left to manage our affairs.

A new report looks at the cost of dying in the United States, from the material costs to the emotional and physical toll it takes on those left behind.

The report was created by Empathy–a company that helps people manage the logistics and emotional hardships associated with death. The company surveyed almost 1,500 people who had experienced the loss of a close family member in the last five years. Their goal was to try to quantify and better understand what they went through.

Here are some interesting findings from the report:

  • 3 million people die in the U.S. every year
  • 68 percent of Americans who are grieving suffer physical symptoms
  • An average of 540 hours of work are spent settling a loved one’s affairs
  • It takes families an average of 12.5 months to resolve all financial matters after the death of a loved one
  • 20 percent of the workforce is grieving a recent loss at any given moment

The Financial Cost

Perhaps the most astonishing figure from the report was that the average direct financial costs related to the death of a loved one can reach $20,000. This includes things like the cost of the funeral and financial and legal matters that must be dealt with when a person dies.

The report found that the average cost of a funeral is $7,848, the cost of financial matters averages $4,384, and legal matters cost an average of $4,967. Using these numbers, it’s easy to see how the cost can easily climb to $20,000 and beyond. And these are only part of the financial costs associated with dying.

Other financial costs the report included in their analysis are those associated with the total funeral costs, like payments to the funeral home ($3,584), the burial plot ($1,841), catering and refreshments ($602), hiring officiants, priests or other clergy ($472), music ($136), and invitations ($111).

How Loss Affects the Mind & Body

There are other, less tangible consequences as well—like grief—which is a highly personal experience that people are grappling with while having to contend with all the tasks associated with the death of someone they love, which only complicates the process further.

The stress and emotional strain associated with a loved one’s death often lead to physical symptoms. The report found that 93 percent of those surveyed suffered from at least one physical or mental symptom after their loss, 83 percent suffered anxiety, with 46 percent suffering for a few months or more. None of this seems surprising, considering that grief can be an overpowering emotion, and after the loss of someone close to us, we have an immediate increase in tasks and responsibilities to manage the affairs of the one we’ve lost.

Other physical and mental symptoms that lasted more than a few months reported in the study were:

  • Memory problems (30 percent)
  • Unusual anger or irritability (30 percent)
  • Weight loss or gain (33 percent)
  • Irregular sleep patterns (38 percent)

And the above numbers increased significantly if the person happened to be the executor of the deceased person’s estate–a job that comes with considerable responsibility and its own unique stresses.

How to Prepare–for Peace of Mind

Although our views about death are highly individual, there are things that we can all do to help prepare for it when the time comes. Preparation can help us relieve some anxiety, think about what we want, as well as think through some of the logistics, which will help others have a clear roadmap of what we desire and how to make it happen.

There are a lot of things to consider when we begin thinking about our own death. And although this can initially seem an anxiety-producing activity, it can actually be very grounding and help give one a sense of peace.

Here are some things to think about, broken into different categories:

If you are diagnosed with an illness and need healthcare, here are some considerations:

  • Do my loved ones fully understand my condition and what to expect?
  • Have I expressed exactly what medical interventions I want and ones I don’t?
  • At what stage do I want to waive further medical interventions or procedures?
  • Do I have a do not resuscitate (DNR) order that would be enacted after certain procedures or surgeries?
  • Have you chosen someone who can make your healthcare decisions when you can no longer make them yourself? Do they know your wishes?
  • If the healthcare system can no longer help with your condition, what would you like to happen? For example, would you like to be at home?

Personal Considerations

  • What are my beliefs about death? Do I need to make peace with any aspect of this process?
  • Are there any family or friends I want to talk to, and share love and gratitude with so they know how I feel about them?
  • Is there anyone I may have had difficulties with and want to make peace with before I die? Perhaps there is someone who may need my forgiveness or a broken relationship I want to repair.
  • Who would you like to leave your personal belongings to? Make notes as to who should have what so you can make sure people get what you want them to have.
  • If you are a single parent with young children, who will care for them after you are gone?
  • If you have pets, who will look after them?
  • Where are all your personal photos/videos? Are they on a computer? If so, does someone else know how to access them?
  • Have you labeled people in your photos? And where do these personal treasures go when you die? Will they go to children or other family? Having personal effects like photos well labeled is important so your family can identify others later on.

Funeral/Memorial/Celebration of Life Planning

  • What would you like to happen to your body after you die? Do you want to be embalmed? Buried? Cremated? Or do you want a green, or natural burial?
  • Do you have a preference for what casket you would like or how you would like to be buried? If you would like to be buried, where will it be?
  • Would you like a burial plot, headstone or grave marker? If cremated, where would you like your ashes scattered, or who would you like to keep them?
  • Do you want a ceremony of some kind? If so, what kind of ceremony would you like, and how would you like people to celebrate you?
  • Would you like flowers, and if so, what type? Or would you like people to donate to a charity you believe in instead?
  • Would you like someone to deliver a eulogy or have several people speak about your life? If so, speak to them ahead of time.
  • Should you pre-pay for funeral/burial/cremation services ahead of time? It can often be less expensive when done in advance.

Legal Considerations

  • Consider writing a will to make your wishes known and have them carried out legally.
  • Do you want someone to be your power of attorney?
  • Make a list of your assets so you can decide who you would like to have them.
  • Organize and store important documents and passwords so they can be easily found and accessed.
  • Talk to your loved ones about your wishes.

If you need a little inspiration, BJ Miller, a practicing hospice and palliative care physician, gives a moving TED talk about what really matters at the end of life.

Here are some resources to help guide you through the process and keep you organized as you go:

Final Thoughts

Although this all might seem a bit daunting initially, you can do what is comfortable and take your time. Choose which tasks are important to you, and work your way through them at your own pace.

Although some people are blessed to know that they are coming to the end of their lives and can prepare, many of us will not know in advance.

Thankfully, we can choose to do any of the things above at any time. Perhaps more important than anything is the way contemplating death can remind us of how precious life is and how important it is to cherish every moment and let the people in our lives know what they really mean to us.

Complete Article HERE!

Rest in … compost?

— These ‘green funerals’ offer an eco-friendly afterlife.

A shrouded mannequin demonstrates the “laying in” ceremony at Recompose, a human composting facility in Seattle. Human composting, water cremation, and green burials are gaining traction as people seek to minimize their environmental impact in death.

Traditional burial and cremation pollute the ground and emit carbon dioxide. People are looking for new options.

By Allie Yang

You may have seen the headlines: Earlier this year, New York State became the sixth in the nation to legalize something called human composting. In 2022, Archbishop Desmond Tutu chose to be cremated not by flame, but by water, in a process called alkaline hydrolysis. In 2019, actor Luke Perry was buried in a “mushroom suit” made of cotton and seeded with mushroom spores. All were part of a push to make the afterlife more eco-friendly.

Death care has remained largely unchanged in the United States ever since embalming and burial became the de facto method as far back as the Civil War, says Caitlin Doughty, mortician and founder of death care advocacy nonprofit Order of the Good Death. Most people don’t even have access to other options: burials and cremation are the only methods that are legal in all 50 states. 

Traditional burial methods harm the planet in various ways. Embalming slows the decay of a person’s body so that it’s presentable at a funeral—but after burial, the chemicals used for embalming leach into the ground. Caskets require enormous amounts of wood and metal, and cemeteries often build concrete vaults in the ground to protect them. Even cremation requires a lot of fuel, and generates millions of tons of carbon dioxide emissions a year.

Now, however, a variety of theoretically more sustainable death care alternatives are increasingly being offered around the country. Here’s what you need to know.

Green or natural burial

Green burials have been used as long as humans have been burying bodies. Both Native American and Jewish communities traditionally use green burials. But in recent generations, they have fallen out of fashion as people opted for more elaborate burials. Green or “simple” burials became more commonly used for the poor and wards of the state.

These are generally defined as burials using materials that are both nontoxic and biodegradable. In a typical green burial, the deceased is dressed in a 100 percent cotton shroud and buried in a plain pine box.

In some cases people choose to “become” a tree in death by having a tree planted over their plot. (However, the tree burial pods that kicked off this trend—in which bodies are wrapped in an egg-shaped pod that supposedly feeds the roots of a young tree—are not available for commercial use and it’s unclear if they are even viable.)

(In these cemeteries, nature also rests in peace.)

Almost every cemetery in the U.S. has an area reserved for green, or “simple” burials, according to Ed Bixby, president of the Green Burial Council (GBC), which helps educate and certify burial grounds meeting sustainability standards. On some burial properties, plots are marked via GPS and a natural stone marker—otherwise, the area is left to grow wild, becoming less like a cemetery and more like a nature preserve full of life.

Most families who choose natural burial also forgo embalming, often seeing the process as overly invasive, when refrigeration alone adequately preserves the body. Others opt for gentler embalming fluids made without formaldehyde, which are becoming increasingly available.

But could these simple burials contribute to the spread of disease or pollution of the land? The data from existing research on traditional cemeteries “doesn’t indicate that bodies are dangerous in and of themselves,” says Lee Webster, director of New Hampshire Funeral Resources and Education and former director of GBC, adding that vaults, chemicals, and non-organic containers used in traditional burial do contribute to pollution. 

Further, the WHO has found “no evidence that corpses pose a risk of epidemic disease—most agents do not survive long in the human body after death.”

Still, it’s unclear if some of the newer variations of green burials are effective. For example, the brand responsible for Luke Perry’s mushroom suit claimed it would neutralize toxins and give nutrients back to the earth. Years earlier, however, the suit’s maker had hired mortician Melissa Unfred to study the suit—Unfred found there was no evidence the suit had any real effect.

Water cremation

One cremation creates an average of 534 pounds of carbon dioxide, one scientist told Nat Geo in 2016. Toxins from embalming fluid and nonorganic implants like pacemakers or tooth fillings also go up in smoke. Water cremation—also known as aquamation or alkaline hydrolysis—produces the same result with significantly less environmental impact and for some, a spiritual benefit.

(Greenhouse gases, explained.)

Native Hawaiians practiced a form of water cremation for thousands of years. They would use heated volcanic water to break down the bodies of their loved ones, says Dean Fisher, water cremation consultant and former director of Mayo Clinic’s donated body program. Then they would bury the remaining bones, where they believed the soul’s spiritual essence was stored.

The tradition has fallen out of practice in recent years—but in July 2022 Hawaii legalized water cremation, putting the tradition back within reach.

Water cremation machines work by pumping a heated alkaline fluid around a body for four to six hours, exponentially accelerating the natural decomposition process. Bodies can be embalmed or unembalmed and dressed in any material that is 100 percent natural. After the body breaks down, only bones and non-organic implants remain. The bones are dried, crushed, and returned to the family.

The only byproduct of water cremation is nontoxic, sterile water that can be recycled into the local water supply—270 gallons of it, or slightly less than what the average American household uses in a day. There are no emissions into the ground or air.

But water cremation does have its drawbacks. For one, traditional cremations are more readily available, faster, and usually less expensive. Water cremation also requires energy to heat the water and run the pump, although a Dutch study from 2011 showed that’s only 10 percent of the energy used in flame cremation.

Further, some critics of water cremation argue it is immoral or disrespectful to the deceased, akin to flushing your loved one down the drain. However, advocates counter that water cremation simply accelerates the natural decomposition process and is no different from the blood from routine embalming that also goes through water treatment to be neutralized.

Either way, water cremation appears to be gaining steam in the U.S. It is currently legal in 28 states—and 15 of them approved it within the last decade.

Human composting

Human composting turns bodily remains to soil through a highly controlled process—very different from food composting that can be done in your backyard. In a sealed container, a body is cocooned in a mix of natural materials like wood chips and straw. Over a month or more, the vessel heats up from active microbes that start to break the body down. Fans blow oxygen into the container, which is regularly rotated to reactivate the microbes.

(How composting works.)

After 30 to 50 days, bone and any non-organic matter are taken out. The bones are then ground down and returned to the material. It takes another few weeks to “cure,” as microbes finish their work and the soil dries out. The end result is a cubic yard of compost that families can use or donate to environmental causes.

There are environmental costs to human composting, also called natural organic reduction (NOR). Fuel is needed to transport elements like wood chips, and electricity is used to power air pumps, fans, and the vessel rotation.

“We’re just getting started as a company tightening [those elements] up,” says Katrina Spade, founder of Recompose, the first NOR facility in the country located in Seattle, Washington. Still, she says the company’s own assessment of the process showed just over a metric ton of carbon savings per person over traditional cremation or burial.

Human composting is rare. It’s only legal in six states—most recently in New York in January. But a Massachusetts lawmaker has also proposed a bill to allow human composting, and advocates like Spade believe that a number of states will legalize it in 2023.

But even if you’re not interested in an eco-friendly afterlife, advocates say that these burial alternatives come with another advantage: Families can be more involved in the death care of their loved ones, from bathing and dressing them at home to lowering their body into the grave if they choose a green burial.

“It’s not required. But it’s always encouraged to do what you can, if you wish,” Bixby says, adding that most families embrace being part of the process. “You’ll watch them go through the gamut of emotions… then when they’re done, they’ll have this genuinely serene smile on their face. They found a greater sense of acceptance of that passing through the process.”

Complete Article HERE!

The Stages Of Grief: A Useful Guide, or Misapplied Theory?

— The world’s most popular theory of grief has been heavily criticized. But that doesn’t mean it lacks value.


Humans are burdened with an innate yearning to know. On many levels, this has propelled humanity forward from the birth of civilization, in order to reach new horizons, develop technologies, and find novel solutions to life’s problems. But the yearning to know has one setback: sometimes, we seek the comfort of knowledge to escape the discomfort of uncertainty. And no experience in life is more uncertain than grief.

In the void left by losing someone you love, it’s normal to try and make sense of the pain. Whilst knowledge is never a true escape from matters of the heart — feelings have to be felt — it can offer relief by giving a context for the magnitude of what you feel. The stages of grief is one particular model that articulates the grief process.

This isn’t a prescription or a definitive path, but it does accurately cover universal qualities of grief that the majority of people will experience, to varying degrees. If you’re grieving, or know someone grieving, the grief stages give you a better grasp, to find some order in the chaos, to get a sense of where you are on the journey.

What Are the Stages of Grief?

man looking into horizon

It’s likely you’ve heard of the stages of grief at some point. The theory has become a part of pop psychology and wider culture since its conception in 1969 by Swiss psychiatrist Elisabeth Kübler-Ross in her book, On Death and Dying. Kübler-Ross developed her theory based on terminally ill patients, who were confronted by their impending death. Eventually, the Kübler-Ross model was expanded to other forms of grief.

When considering grief, the most common thing to consider is the death of a loved one, although there are many forms. Disenfranchised grief, for example, covers many facets of grief, from the change in relationship status, the loss of an imagined future due to injury and illness, and more. Although the book contained over 10 stages, the five below are most commonly referenced:

  • Denial: when confronted with a loss that is deeply upsetting, it’s natural to experience the defense mechanism of denial. Rather than “face the facts,” the first stage for many people is to ignore reality, and pretend it isn’t happening, in order to avoid the consequential pain and adjustment.
  • Anger: as people slowly start to adjust to reality, they may transition into anger. With so much emotional pain on the horizon, the temptation is to lash out, to find someone to blame. With terminal patients, this may include blaming healthcare providers or looking for causes. It may also manifest as a sense of existential anger towards life itself.
  • Bargaining: there must be a way out, surely? At this point the solutions-based mind goes on overdrive, attempting to play God by finding ways to “bargain” with reality. This is common after breakups, where someone will start to try and find ways for the relationship to continue, even if clearly not possible. With bereavement, it’s common for people to bargain with “God” in order to bring their loved ones back.
  • Depression: as reality sinks in, all sense of hope and optimism drains from the person. This is different from healthy sadness, a necessary part of the process. Depression is the lack of feeling, a complete withdrawal, from others, from life, from things you once enjoyed.
  • Acceptance: said to be the indication of the “end” of the grief cycle, acceptance is a point of making peace with reality. Anger, bargaining, denial, and depression subside, emotions settle, and the person has a more resourceful and grounded outlook. That includes terminally ill patients, many of whom enter death in a calm state of mind.

How Long Do the Stages Last?

Grief is unique to each individual. Returning to the yearning to know, when experiencing grief, it can be tempting to want a timeline. In some way, this can become a part of the bargaining process — “I can handle this pain, as long as I know it’ll stop.” The path is different for everyone, as is the amount of time each stage lasts. In the words of Kübler-Ross:

“The reality is that you will grieve forever. You will not ‘get over’ the loss of a loved one; you will learn to live with it. You will heal and you will rebuild yourself around the loss you have suffered. You will be whole again but you will never be the same. Nor should you be the same nor would you want to.” — Kübler-Ross

There’s a reason the final stage is acceptance. That includes accepting the way life has changed since the loss and the ways in which you adjust, and live, even if that grief stays with you, in its own way. But this is a utopia, a place to reach where everything will be okay, or something to attain to “complete” grief. It doesn’t work that way. And that’s a good thing. It means the people you love will stay with you, and your heart will grow through heartbreak.

Do the Stages of Grief Happen in Order?

man walking up steps

If there’s no possible timeline, what about an order? In 2004, a year after Kübler-Ross had died, On Grief and Grieving was released, co-authored by David Kessler. The book updated and adapted the model, whilst addressing common misconceptions about the theory, which had expanded beyond its original conception. Kessler notes that the stages were “never meant to help tuck messy emotions into neat packages,” and that “there is not a typical response to loss as there is no typical loss.” He adds:

“They are tools to help us frame and identify what we may be feeling. But they are not stops on some linear timeline in grief. Not everyone goes through all of them or in a prescribed order. Our hope is that with these stages comes the knowledge of grief ‘s terrain, making us better equipped to cope with life and loss. At times, people in grief will often report more stages. Just remember your grief is as unique as you are.” — David Kessler

So, the stages themselves are fluid and don’t have a timeline. By now you might be getting a sense of the model’s flaws, and you’re not alone. Despite its popularity, many people have criticized Kübler-Ross’ model, for a number of different reasons.

Criticisms of the Stages of Grief

McGill University presents a thorough overview of the lack of evidence-based support for the grief stages. Multiple studies have found that there doesn’t appear to be a “normal” range of grief, questioning the validity of the model itself. In the article, It’s Time to Let The Five Stages of Grief Die, Ada McVean B.Sc. argues that “Kübler-Ross saw many patients and gathered many anecdotes, and then used them to create a scientific model that simply is not based on good evidence.”

A big criticism is the data upon which the framework was built, developed from case studies of people approaching death. Kübler-Ross’ intention was to cultivate more care and compassion for terminally ill patients, who she viewed as being overlooked and neglected. To some extent, it’s unfair to apportion blame to her, but instead to question how widely adapted the model has become, especially considering many alternatives exist.

And here’s the biggest issue: when a model such as the stages of grief becomes commonly known, it can lead people into a comparison trap. Rather than attempt to understand their unique, personal experience, they begin to relate their experiences to the model, seeing how well they “fit” with normal grieving, which can create additional shame or guilt, especially for those who experience a prolonged grieving process. How, then, do you relate to the stages of grief? Are they useful? Or is it time to find a different model?

How to Apply the Stages of Grief

woman reading

The stages of grief were designed to better support people facing their own death. Over the decades since, it has expanded to apply to all forms of grief, has become hugely popular despite its flaws, and remains misunderstood. Can a model be valid if it’s acknowledged that the stages are loose and flexible and that everyone’s journey is unique?

Above all else, the stages of grief are valid as a reminder. They’re a reminder that part of being human, and going through loss, is unique. But they’re also a reminder that this uniqueness is universal. All of us experience our blend of denial, anger, bargaining, depression, acceptance. No matter where we’re at in our own path of healing, there is cause for compassion and kindness, to meet yourself where you’re at, and to avoid judgment.

The stages of grief offer reassurance; many have tread the path before and felt pain difficult to feel, believing they’d be consumed, but made it through. Others have found gentle acceptance of a fate impossible to escape. All of this is a reminder that grief is a journey, not something to resolve, not something to fix, something hard to describe, something only understood by being present to it. It comes in many flavors, and all are “normal.”

There are no models to live up to, no right way to grieve. If you’re hurt now, know that things will get better, and trust in your heart’s ability to heal. If you know someone hurting, support them as best you can, be empathetic and forgiving, know that the journey is wild and unpredictable but also teaching, an opportunity to open the heart if allowed to do so, to accept the bitter beauty of the impermanent nature of life, and the pain of losing something once loved, but knowing love and loss is the better option, always.

Complete Article HERE!

How hospice helps patients and families navigate end-of-life care

— Former president Jimmy Carter’s wish to enter hospice care has raised awareness about how families cope with the dying process

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The decision by former president Jimmy Carter to stop medical intervention and spend his remaining time at home with his family has brought new attention to hospice care.

Hospice care is a form of medical care given at the end of life, when medical interventions to prolong life are stopped, and the focus shifts to supportive care and helping both patients and their family members cope with the dying process.

By entering hospice, Carter has taken on “one of the most serious decisions anybody can make in their life,” said William Dombi, president of the National Association for Home Care & Hospice. “I think it’s a good thing that people are gaining awareness of hospice through this. Every generation needs to learn about what hospice is, how valuable it is and that it’s an option — a great option — that is available to them.”

We answered common questions about hospice and end-of-life care.

What happens when you go into hospice?

Hospice describes a specific type of supportive care for people near the end of life. A defining principle of hospice care is that it does not include medical interventions focused on curative treatments or prolonging life. Patients may decide to enter hospice care because they have run out of realistic treatment options, or they may decide that want to focus on quality of life and no longer want invasive medical treatments.<

“You need to get good medical care for the stage of illness you’re in,” said Leslie Blackhall, a physician and section head of palliative care at University of Virginia Medical Center. Hospice care doesn’t shorten life, “it’s just a more appropriate form of care,” she said.

Some people who need extensive care may spend their final days in a nursing home or assisted-living facility. But many people “entering hospice” simply go home to be with their families. A patient’s hospice care plan may include a team of nurses and home caregivers, therapists, social workers and religious advisers, Dombi said. The plan likely will include medical equipment, such as a home hospital bed, as well as medications to ease pain, anxiety and ensure comfort.

Most insurance plans cover the costs of hospice care. For those who don’t have insurance, many hospices will provide free care and, state Medicaid systems also may assist with the cost, said Phil Santa-Emma, medical director of hospice and palliative care services at Mount Carmel Health System.

How long do people live in hospice care?

Hospice is set up for patients who are expected to have less than six months to live. But there’s no way to accurately predict how long the dying process may take.

“A significant number of people live less than 15 days and a significant number more than a year,” Dombi said.

Even among very sick patients in intensive care units, doctors’ predictions of the timing of death are only accurate around 20 percent of the time.

“So many people are under the misconception that hospice means I’m dying right now,” Santa-Emma said. “We have to reframe that. Hospice is going to help me live the very best I can, and even though I have the terminal illness, I know I’m mortal, and I know I’m going to pass away. But between now and then, how do I live the best that I can?”

What happens if you live longer than expected?

Sometimes people in hospice care exceed doctor’s predictions for how long they might live. When this happens, the hospice provider will require the patient to be assessed every few months to decide whether the patient remains terminally ill, said Santa-Emma. If patients are stable and the disease is no longer showing signs of progression, “then you graduate from hospice,” he said.

Patients who continue to meet the criteria for hospice are allowed to continue the supportive care.

Margaret Drickamer, the associate medical director of inpatient hospice care at UNC School of Medicine, said it can be upsetting for family members and patients who have prepared for death, only to be told the patient has hit a plateau and is being discharged from hospice care.

“I have the unhappy job of saying this person isn’t dying fast enough,” Drickamer said. “It’s very hard on the families.”

What are the four levels of care for hospice?

Routine care, which is the predominant form of hospice care, is provided in the home — or wherever the patient lives. Several times a week, hospice nurses visit to assess the patient and provide medical services, and an aide visits to help the patients with personal needs such as bathing. Social workers and a chaplain or other spiritual adviser visit as needed.

General in-patient care is for patients whose symptoms are rapidly changing and can no longer be managed at home. These patients are admitted into a facility such a hospital or hospice facility to receive around-the-clock care.

Respite care is to give caregivers a break. The patient is admitted to a hospital or skilled nursing facility for a short period of time so family members and friends can take time for self-care.

Continuous care is for patients who are actively dying and need eight hours or more of continuous care from nurses and aides. Hospice sends a medical professional to the home to provide that care.

What’s the difference between hospice and palliative care?

Hospice care and palliative have a lot in common, but they are also very different.

Palliative care primarily focuses on managing pain and symptoms to ensure a chronically ill patient has a good quality of life. Some patients in palliative care may still be pursuing treatments to cure serious illness or slow decline.

A cancer patient, for instance, may still be receiving chemotherapy or radiation treatments to slow the progression of the disease, but also be given palliative care, such as medications to focus on pain and symptom relief, special equipment to make life at home easier and mental health support.

“When they refer to palliative care, we are primarily on symptom management,” said Jennifer A. Winegarden, a senior associate consultant for hospice and palliative care at Mayo Clinic Health System. “The focus is to truly palliate. That’s the definition – to relieve suffering.”

Someone can be on palliative care for years before they’re transferred to a form of hospice care.

Hospice is the final stage of palliative care in which the person has decided not to seek curative treatment, but is still given a wide range of supportive care for both patients and families.<

When should someone seek hospice care?

The answer depends primarily on the patient’s wishes, but can be influenced by their age, quality of life, prospects for future treatments, input from family members and the advice of doctors. Someone in their 40s with a young family, for instance, may be willing to continue invasive medical treatments longer than someone twice that age.

Drickamer said the answer boils down to this: How do I want to spend the time I have left?

Doctors may suggest hospice care for patients who are frequently returning to the hospital, sleeping more than 12 hours a day, eating less or losing weight or speaking only a few words a day, Winegarden said.

“The biggest issue is that people associate hospice with giving up, and I disagree,” Winegarden said. She said some of her patients have told her they haven’t “lived this well for years.” Hospice care is about bringing patients the greatest support and comfort with “the time they have left,” she said.

It takes courage for anyone to shift gears and focus on pain management and care instead of preventing or treating a chronic condition, Drickamer said. That’s why President Carter’s example is so important, she added.

“He’s gotten to a stage where he wants comfort and dignity,” she said. “He’s demonstrating to people how to do that.”

Complete Article HERE!

What it means to enter hospice care as Jimmy Carter elects to stop medical treatment

— The Carter Center said he wants to spend his remaining time at home with family.

Former U.S. President Jimmy Carter reacts as his wife Rosalynn Carter speaks during a reception to celebrate their 75th wedding anniversary in Plains, Georgia, July 10, 2021.

By Mary Kekatos

Over the weekend, former President Jimmy Carter entered home hospice care, the Carter Center announced.

The center said in a statement that the oldest living president, who is 98 years old, had elected “to spend his remaining time at home with his family and receive hospice care instead of additional medical intervention” after several hospital stays.

“He has the full support of his family and his medical team. The Carter family asks for privacy during this time and is grateful for the concern shown by his many admirers,” the statement read.

Experts explained to ABC News what it means to enter hospice care and what it may entail:

What is hospice care?

Hospice care is a type of end-of-life care meant to maximize the comfort and quality of life of a terminal patient.

“Typically, hospice care requires a referral from a physician who agreed that hospice care is appropriate for the patient and so we certified that the patient’s life expectancy is six months or less, based on our best knowledge and data we have if the disease runs its expected course,” said Dr. Jay Bhatt, an internist and geriatrician in Chicago and an ABC News contributor.

Bhatt said a patient suffering from several conditions can enter hospice including cancer, dementia, kidney failure, recurrent infection and more.

“Entering hospice means your caregivers are focused on managing your symptoms…and it’s oriented around alleviating suffering, during that projected time of life,” he said.

Several needs are addressed when a patient is in hospice care including physical, psychological, social, and spiritual, according to the National Association of Home Care and Hospice.

Hospice care may be misconstrued as a process used to accelerate the worsening of someone’s condition so that they may pass, but that is not the case, Bhatt said.

“This is not intended to speed up the dying process or reduce their time that they may have,” he said. “It really is focused on addressing physical health, managing their symptoms that create suffering, [and] their emotional and spiritual health.”

What is included in hospice care?

Hospice care can include a broad set of services including physician care; nursing care; a home health aide; social work services; physical, occupational, and speech therapy; and bereavement services for the patient’s family, according to the NAHCH.

These services can help manage medication for pain or other conditions, supply emotional support for mental health needs and therapy for mobility that help alleviate suffering, Bhatt said.

“Hospice care at home relies primarily on the family or personally paid caregivers to provide that day-to-day care,” he said. “But you can have a nurse or physician on call 24 hours a day to help with medications for pain or trouble breathing [or] other symptoms.”

If symptoms become too difficult to manage, a person can receive inpatient hospice care at a facility.

While hospice care may be covered by employer-provided insurance or private insurance, it began being covered by Medicare in 1983.

According to the NAHCH, more than 1.6 million Medicare beneficiaries received hospice services in 2019 with Medicare expense totaling about $20.9 billion.

Qualifying for hospice care

Experts told ABC News that it’s a complex process filled with hours of discussion before a patient can receive hospice care.

PHOTO: FILE - Former U.S. President Jimmy Carter smiles during a book signing event in Midtown Manhattan, March 26, 2018 in New York City.
Former U.S. President Jimmy Carter smiles during a book signing event in Midtown Manhattan, March 26, 2018 in New York City.

A hospice physician and a regular physician, if the patient has one, have to certify that a patient is terminally ill. The patient has to accept the care as opposed to care to cure their illness, and the patient has to sign a statement choosing hospice care.

“Clearly, the recognition is that Jimmy Carter lived an incredible life; we should all be so lucky to live a life that is so full, rich and rewarding,” said Dr. John Brownstein, an epidemiologist and chief innovation officer at Boston Children’s Hospital, and an ABC News contributor. “At the end of the day, it’s about patient-centered decisions and their wishes and in this particular case, I’m sure there’s been a lot of consultation with medical teams, and family.”

He continued, “These things are are complicated, you know, long conversations that require many layers of discussion within that, you know, reaching out very quick decisions that are, they’re done without, you know, without the guidance of the whole care team and family.”

How is it different from palliative care?

While hospice care and palliative care are often used interchangeably, they’re not the same, experts said.

Both are about offering compassionate comfort care, but patients in palliative care might have their symptoms treated as well as receiving treatment with the intent of curing their illness.

Additionally, while hospice care requires physicians to sign off, palliative care can begin whenever the physician and patient decide and at any stage or illness — and the illness is not required to be terminal.

“Hospice care is really focused highly on the comfort of that patient,” Brownstein said. “So, comfort care without any sort of intention for cure, whereas palliative care is broader ’cause it’s comfort care, but it could have some component of curative intent.”

Complete Article HERE!