CROSSING THE CREEKBy Michael Holmes, RN

INT&gDlJ·Cl'I~ONThis guide is intended to provide dying people and their caregiver a

general description of what they can expect to encounter. Each one of usdevelops our own personal style of dealing with transitions. We tend tostick withthat style, whatever it might be, when we face the transition wecall death. If we would like to know how you would handle your OWIl death,lookback upon your own life and observe how you have handled all yourother transitions. Unless you decide to change your approach, this is howyou will die. While all transitions have similar key elements, this guidedeals specifically with the transition of dying. Every person does notexperience every sign or symptom described herein, or a person may

. experience a particular signor symptominhis/her unique way.It is well to remember that all transitions entail some disagreeable or

uncomfortable aspects. Dying process is no exception. No reasonableperson expects that life will contain no .discomforts, yet some espouse thenotion that somehow, death will. This is not a reasonable expectation.Dying process has its difficult aspects regardless of one's level ofenlightenmen t.

Modem medicine has demonstrated a remarkable capacity ofmitigating or even eliminating many disagreeable aspects of physical death.At the same time, modem medicine cannot relieve people of theresponsibility of their own lives. We all prepare for our own death by themannerin which we live our lives.

A.PPETITEAppetite Decreases

The patient may stop eating entirely. Progressive loss of appetite isone of the identifying characteristics of dying process and is a mechanism bywhich the-body keeps itself more comfortable. This is often very hard forcaregivers to accept, but listen to what the patient wants and not to what youthink he/she ought to be wanting. Bodies have been going through this forthousands of years and have worked out effective techniques for keepingthemselves comfortable. Pay attentionto what the body is saying it wants ...or does not want.

As physical bodies progress through the dying process, they lose theirability to.digest food effectively. If the patient tries to eat anyway, the foodjust sits there, causing the patient to be bloated, or like he/she has swallowed

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~b?ck.The stomach willlikely rejectteodoutright; i.e, vomit, if the patientmsistson trying to eat after having.losthis/her appetite. .

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FLIJLDINTkKEA dying person win eventually stop wanting to consume fluids as

well, Again; this is ).10W bodies.maiatain.theircomfort, Forcingflaidswhcn.~abo4yd~~~s..not wantfluids.only cau:se,adg~d,.p1isety;People d.o.:,ttotdie .heca~s~.;t~~y.stoReating;they. stop-eati.ngbec,allse.~theYate .dying,. The •onlyreason for an actively dying person toeator drink anything is for pleasure.If it is not pleasurable, there is no value in it. In fact, it is likely to do-harmthan good. . '.

IllJwel~t-t~IOws..:Qt!wnAdecrease .inbowel activity goesalong with loss of appetite,

decreasingphysical activity, and changes in circulation. Most patients aretaking some type of pain medication during their dying process as well, andthese medications slow bowel activity further.

Stool softeners and/or laxativesaregenerally necessary to maintainregular bowel.function.but.it should be kept in mind that "regular" in dyingprocess-may be considerably less.frequentthanitwas while the patient washealthyandactive.

Cessatlen :ofBowelsAs death draws near, total bowel shutdown may he. expected. Trying

to whipthe bowel into action while .the rest of the body is shutting down isnot sensible and attempting to dosomay cause unnecessary sufferingforthepatient.

CIRCULATIONCirculatiQn"Graqil~l.y.]);iminishes

Circulation shuts downprogressivelybybecoming increasinglycentralized. First the outermost circulation diminishes, such asthehandsand feet, .by becoming cool and perhaps even discolored. Then the legs andarms are affected, and so on.

Fevers may come and go. There may be unexplainedsweating,sometimes profuse. There maybe swelling .of the limbs ..and other signs.offluidimbalance .

. Urine output may fall as the kidneys receive less effective circulation.Then again, the urine output may remain surprisingly high even after thepatient has stopped drinking; it just depends on the individual. Fluids shift.from one compartment to another within the body and this can sometimesproduce ,3 surprising amount of urine in the-absence .of any fluid .intake.

Bodies are composed largely of water. As they move through the dyingprocess and circulation shuts down, there are bound to he effects, which arenoticed by both patient and caregivervRemember that these effects, whileabnormalinahealthy person, maybe quite normal in a dying person. Oneof the most difficult truths for inexperienced caregivers to. accept is this:.inmost cases some degree of dehydration will help to keep the patient morecomfortaole.

RESPIRATORYPulmonary Congestion

Fluids may accumulate in the lungs, but this can be usually avoided iffluids are not forced on patient. .. especially IV fluids.

Patients and their caregivers often express a fear of dehydration, yetsome degree of dehydration is preferable during the dying process because ittends to keep the patient more comfortable. Being fully hydrated whiledying often leads to lung congestion and shortness of breath.

Airway Rattli.ngWhat was once called "the death rattle" is actually an accumulation of

excess fluid and mucous in the upper airway, which "rattles" as the patientbreaths. Certain drugs can be given to help clear up this rattling. However,these drugs may cause discomfort by themselves; things such as excessivelydry skin, mouth and eyes. It is far better to avoid overloading the patientwith fluids in the first place then to be caught up in the hazardous game ofalternately forcing artificial hydration and dehydration.

Ifupper airway rattling does occur, it can be quite loud and disturbingfor caregivers to hear. Fortunately, it is seldom as troublesome for patientsas it is for caregivers. By the time this phenomenon manifests, the patient isusually in a semi-or-full coma and is not really aware of any physicaldiscomfort. Suctioning is seldom recommended because it usually causesmore discomfort than alleviates.

Torelieve the upper airway rattling by suction, it is usually necessaryto do deep suctioning; i.e. suctioning all the way down into the mainbronchus, or windpipe .. It tends to be very traumatic for the patient becauseof the highly sensitive nature of the windpipe. Even after successful deepsuctioning the rattling will likely return within ten to twenty minutesanyway. Since the upper airway rattling is usually more unpleasant forcaregivers than for patients, it may be helpful to remember that the primarygoal is to keep the patient comfortable, not the caregivers.

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BREATH!IN;GPATTERNSAs:the dying processevolvea oertain respiratory patterns mayappear.

One corpmon respiratory pattemiscalh~d;Cheyne.Btokes(pronounced ..'Chain-Stokes). This is aregularly.asregulenypattem, i.e., the patienttakesseveral breaths, then stops, then takes several more breaths, then stops .again,The pauses between breaths can be .quite long; perhaps half to three-quartersof a minute.rsometimeslonger. Family and caregivers often find this veryunnerving, but it seldom is a clear indicator of much, other than that-thepatient is quite ill.

A respiratorypattern, which-sometimes appears-just hours prior toactual death, is a regular, fairly deep.pantingpattern, 'Ihispattem.is.drivenby theautomatic nervous systemaftermuch.of the rest of thebrainhasalready shut down. Caregivers scmetimesrnistakenly think this patternindicates-recovery rather than. approaching death because It is so regular andappears to be effective.

A final or agonal respiratory pattern called "fish out of water".breathing .. This is an .ineffectual.gasping of the mouth with little or no actualintake of air. This occurs very near physical death. The final breaths takenat the moment of death are frequently deep, .cleansing breaths or "sighs".Sometimes there are two or three, sometimes only one .

SLEEPIN·GSleepfIlreamP~ttetns

Sleep or dreaming is very important parts of the dying process .:Patients sometimes complain about howmuch time they spend sleeping andcomment.thatthey feel like they are "wasting'twhat little time. they haveleft. This could not be furtherfromthetruth; Much of thenecessary workof the dyingprocess takes place during a sleep/dream state. This is notwasted time at all, it is vitally important.

The Purpose of SleepThe work of dying process has to do with resolving all the unresolved

issues of one's lifetime. This is a huge job and requires considerable effort.It is very important work because death.is.merely a transition, whichprepares-for the nextphase ofhfe.Itisnot smart to enter the nextphase oflife loaded down with a bunch of unresolved junk from the .last.phase. Thisresolution of work can be broken down into different categories, but sufficeto say, it.is a huge task.

Thesleep/dream .state is very useful in accomplishing thesetasksbecause itgets around the limitations of time and space. It is much easierand more effective to review an unresolved episode in one's life (which may

haveoccurredseveral.decades ..pr@vtously) while-in a dream state than it is ina waking state. In a sleep/dreamstate, one can accomplish a virtual return tothe time.and place in question.

Interestingly, the normal sleeping pattern during the dying process isvirtuallyidentical of'newborns; offand on around the clock. There is nonight.or gay for newborns or dying people, just dozing off and ort,dayandnight. Sleeping pills seldom have much effect on this pattern because (iuringthis phaseof life, this pattern in the rrorm.vOn the whole, total sleep timeincreases. This gives the patient time to get his/her work done. Thenatureof that work mayor may not be recalled by the patient while awake. Thentoo, the patient may simply not be willing to share this information; afterall,it may be of private nature.

If this work of resolution is being accomplished, it can generally besurmised-by observing the patient's overall progress; whether the patientseems to be .moving toward a more serene state of mind, or is he/she stuck innegativity.

Even patients who claim not to remember the content of their dreamswill-usually reminisce about their lives. when they are awake, especially .uponfirst.awakening. Virtually everyone who goes through a dyingprocessreminisces. about the important events and people of his/her life.

CONF1JSJ()NC f . .tn· ..- t -t' -O:rlUSlQllt~;lSQrlenalOn

Dying process is a lot of work. Generally speaking, that work isresolutional in nature and accomplishing it involves moving around outsidethe usual constraints of time/space. While this is an extremely useful andeffective technique for resolving one's life issues, it can also be veryconfusing.

Wethink of time as being concrete, predictable and constant. Whenweare .dying, we discover that realityisdifferent than we had previouslysupposed. We begin moving around in-time/space in ways we-neverimagined possible. One might say thatthis takes place "only in the mind"but.then, as a person experiences physical death he/she becomes increasinglyaware of the power and importance of the mind.

Aphoristically, human beings are composed of body) mind and spirit.As --theJ:>oqy-dies, mind.andspiri temergespowerfully.While -thisspeaks _tothemajesty.and wonder of life, it-can be frightening and confusing for theindividual experiencing it directly. It is especially frightening and confusingwhen neither the patient nor caregivers realize it is normal and the caregiverinvariably concludes that the patient is "losing his/her mind". When this

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occurs., ~xiety levels rise ~apidly. It is important to understand that movingaboutlntlme/spaceand being somewhat confused about where oneis.is anatural andnormal aspect of dying process.. Example: A dying man lies sleeping. Heis actively dreaming andreliving an interaction he had with his mother when he was six .yearsof age.He awakens to see this forty-five year old daughter standing at his beside.Do you see how this could be confusing? To be six years old and talking toyour mother one instant, then seventy-four years old and talking to youradult daughter the nextinstant is indeeda.disconcerting and disorientingexperience. Dying people experience this sort of thing all the time. We saythat they are "disoriented". For dyingpeople this is no fantasy, itis real.

Buried- Emonons and ConfusionAnother task in dying process has to dowith the review and resolution

of denied.or buried emotions. Ironically, frank confusion can actu:allybehelpful in accomplishing this task. Most of us bury, hide or ignore a fairamount of unwanted emotion during the course of our lives. Dyingprocessexhumes significant buried emotions and presents them for review prior toour moving on. If the patient attempts to use hislher intellect to block theemergence of these emotions, dying process simply brushes the intellectaside and the patient becomes "confused". Dreams seem to make no sense.While these dreams and/or confused states may seem pointless and arediscomforting to patient and caregiver alike, they elicit certain emotions; thevery ones that were buried and needed to be felt and resolved prior tomoving on.

Some patients welcome confusion as a means by which they can .expressemotions they were never allowed to express previously. Socialconstraints frequently impinge upon the healthy expression of emotion.Some patients utilize confusion to side step these social constraints .: This isgenerally a subconscious choice.

Confusion can sometimes be just the ticket aperson needs to givethemselves permission to vent and resolve previously forbiddenemotions,

Confusion about ConfusionAnother aspect of dying process-may result fr~mmetabolic

imbalance, neurological damage, and lack of oxygen to the brain or reactionsto medications. In some cases, these kinds of confusion maybe reversible,Determining whethera.particularpatient's "confusion" is normal orabnormal .may require considerable skill and familiarity with the dyingprocess by an experienced professional. Generally speakinghowever, alot

of what.is.interpreted by the less experienced as confusion or hallucination isactuallynonnal and natural, and may even be helpful for the patient.

PAINUtU····· p .. , ,.ZJ,ug 'alU

Patients and their families sometimes utilize pain (unconsciousl.yofcoursejin.avain attempt to stop some of the more frightening aspects of thedying.precess. This is not.done because dying people like pain or becausetheir families don't care. It happens because dying process is not wellunderstood and people 's natural instinct, when faced with something newand frightening, is to opt for that with which they are most familiar. When itcomes right down to it, we are more familiar with pain than we are with thedying process. If for no other reason, this points to why we need to learnmore about the dying process.

Example: Moving about in time (quite normal.during the dyingprocess) can be very confusing and frightening.especially when there is nounderstanding of what is happening. Seeing dead people (very commonamong the dying) may also be frightening and confusing. Pain can allaythese phenomena, to a degree.

The fact that these phenomena tend to occur primarily in a dream statemakes them no less real for the patient. In.fact, dreams tend to becomeincreasingly vivid during the dying.process, Dying people sometimesremark that their dreams seem to be increasingly "real" while theirperceptions of the physical world are growing more "dream-like".

Example: Once, while talking with the gentleman who was very neardeath, Lasked him how he distinguishedbetween the "real world" and this"dreamworld" .He replied that is was very difficult. I asked him whichworld he was feeling any pain. He.thoughtabout it for a couple of seconds,and then replied that he was, in fact, having some physical discomfort. Isuggested that is was a definite clue.

Ifthe patient and family are not aware that these phenomena arenormal, they may blame the medication (s) for causing the "confusion".Next, both patient and caregiver are inclined to either stop the painmedication/ s) entirely. or to severely reduce the dose. This is done with thebest ofintentions but will likely yield a poor result With less painmedication on board, the patient has .more pain. This inhibits sleep.which inturninhibitsdreaming, '..In the short turn, this may seem to be a successfulstrategy: no sleep; no dreams, and no confusion ... justpain. Lots of peopleprefer somedegree of pain over a feeling of confusion and fear.

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Unfo~a~ely,the .addedpainint~r:fe1:es.WithaccQtnplishing thetrue.goalsofthedyingprocess. . .

P,aiit~1tDd"A;tteDitionThedyingprocessis al1about;esC)lving~esolved issues. When the

patient.isexperiencing significant pain, he/she cannot focus attention onresolving.his/her life issues. Pain can.hookone'sauention and stubbornlyhang on. ,In this way, pain subverts the. normal dying process by preventing

.the patient' s .attention .from being focused on relevant issues. Therefore."pain is not-only unpleasant; it interfereswiththetasksofthenorma14yingprocess.. Losing trackof time,.·seeingcde.adpeople,.expenencing increasiJJ;glyvividdrea:ms.and reviewing the .significant,events of one'sJifeare.norilmIaspects oKdying process, which are p~osefu1.

Evenpatients who have no pain (ana therefore take no painmedications) experience the same confusion about time/space, have just asvividdreams, see equally as many "dead-people" and engage mas realistic alife-review as.those who do take pain medications. Pain medications rarelycause .these things to happen

Pain and LingeringWhile pain can be used to mitigate certain phenomena associated with

the nonnaldying process, it ultimately cannot stop that process fromoccurring. Having said that now let me add that pain can actuallybe.used tolive longer; not forever mind you, just a little longer. It is possible for apatient to remain "alive", (or more accurately-to remain within-a physicalbody) aIittle while longer by employing the tactic of focusing his/herattention on physical pain. You are where your attention is.

Extending the dying process by focusing on pain is somethingthatoccasionally occurs to dying people who havean inordinate fearofdeath,These people may prefer higher levels of pain to death and many actuallyfocus on their physical pain so as to squeeze every last minute out.of theirphysical existence. .

Some dying people conclude that if remaining physical meansexperiencing significant pain, "The heck with it, I'm out of here!"

The wishes of the individual play a huge role in determining whichway theygo; into the nonphysical realm or to stay in the physical realm.

AddictionSome people-fear becoming addicted to their pain medications.

Addiction is extremely rare when narcotics are used to control real pain (orother noxious symptoms such as.shortnessof breath or excessive anxiety).

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Recreationaluse of drugs can easily lead to addiction, but very few dyingpeopleusedrugs for recreational purposes, Addiction in the terminally ill isbasically anon-issue.

Menta,IClo.udingSomepeople are reluctantto take medications because they feelthat it

clouds their mind. Remember, pain clouds the mind; too. It can be verydifficult to think clearly when experiencing significant pain .. Some timesone has to choose between thelesser.of'twodevils. Wouldyou rather haveyour thoughts clouded by pain or from taking a narcotic to block the pain?Most people do not labor long in contemplating this dilemma beforechoosing the pain-free approach. However, in certain situations .a personmightelectto experience a higher level of pain for a short period of time inorder to-participate more fully in aparticular activity.

LOSS 'OF EN:ER.GY"I Feel So Weak"

A universal symptom among dying people is a feeling of losingenergy. Some people have pain and some not. Some people have nauseaand some.not. Some people areconfused.and.others not. But everyonecomplainsof feelingaIoss of energy. Itis not possible toovercome thissense ofl() sing energy by taking vitamins or any other medication. In short;feeling the-loss of energy while dying is unavoidable.

Maintaining a physical body requires .an enormous degree of focusedenergy, which can only be kept up for a limited period of time. Beingphysical-at allis miraculous, but sooner or later it must fade away; Asenergy is required to maintain a physical-body fades, the dying personinevitably feels as though he/she is losing energy. There are no health foods;no vitamins, no IV's, no pills and no secret techniques that can change this.That isjust.the way it is, and that is why the one universal symptom amongthe dying is a feeling of losing energy,

FiEARA UniversalEmotien

Everyone had some fear of death, There are no exceptions. Thedegree of fear an individual feels about his or her own death may varyconsiderablyfromperson to person. People who arenot currently facingdeath.are.often inclined toclaim they have no fear. Some dyingpeopleclaim to have no fear of death, but frankly, I have neverseen a person facingdeath who acted unafraid.

The one situation which I had hoped would prove to be an exceptionto this rule (that the dying process always involves some degree of fear)

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wouldbethose cases when thedying.perso~had.alt:eady died; Le. had aprevious near death experience. I was.disappointed to discover that" this didnot bear out. True, 'these people bave.lessfear. and a-much better ,,' ,"underst;:uaumgofwhat the dying:pro(;ess:is~ll about.butJt does.not.exeraptthem from the rigors of an in-depth life-review.

Acce.p.tblg"QurEJilotions.'When a dying person accepts that he/shemay experiencesome fear,

then that fear ,can be handled much more .easily . Allowing oneself tofeel.thefearand.thenseeking the support of friends and loved ones is themosteffective way to handle the feat of death. .

The entire dying process does not involve feat. Fear is -onlyone.partof the overall process. That part, howeveralways shows up sooner.or later.If we burden ourselves with the unrealisticexpectation that we will.not beafraid of our own death, we put ourselvesin an impossible position.Denying our fearonly makes thatfear:worse. ,

The fear of death .istOll;gh:et.1:-011g1lto 'manage Without lettingirrun ,rampantby attempting to ignore its presence. When we deny our feat it onlycrops .up in some other guise (such as a more acute perception of physicalpain, or an inexplicable sense or foreboding and anxiety.) Deceivingourselves about our feelings will not make feelings go away, it only.makesthem more.unmanageable.

The Magic.efHumaaContactOne of the most.effecti ve salves for the fear of dying is the presence

.of other.human beings. ,It is not necessary what a personmay say or do, buttheir very presence makes the difference. We often feel at a lossfor wordswhen faced ..with tragedy..but sometimes sayingnothingat all has-the-besteffect. There is something truly magical-about one human being simply"being there" for .anothervN everunderestimate the power of your being.

SEEIN-G,P.E,QPLE,.~Q-;BAVE~GONEBEFQimSeeiJ)g:~theother'Siue

Nearly everyone has heard of dying people seeing or talking to peoplewho are already dead. ''This is so COIl11nonas to be expected at somepoint.invirtually everyone's dying process. Whether we can explain itor not isirrelevant. It happens, and it happensconsistently. 'It is not the.prerogativeof peoplewho are not dying yet to pass judgment on the validity of theexperiences reported by people who are dying.

When dying people report seeingdead people; then the restof ushadbetter pay attention. Sometimes dying people are reluctant to speak.of theirperception because they are afraid of being labeled "crazy". It can be

enormous relief for-them to discover that they are normal and that thosearound them accept their perceptions. I have often had experience of sayingto a dying person, "So ... have you seen your mother yet?" Then have themturn tomein astonishment and reply, "How did you know?" .

What dying people are experiencing is quite normal and really verywondrousfrom a spiritual point of view

SYM3D,OL,OGYDescribing .theIadescrfbable

As people approach death, theybegin spendingmore time "on theotherside, Sudden unexpected death is tragic because it bypasses normaldyingprocesses.

The.normal dyingprocessispurposeful; it enables the dying person toapproach-his/her transition at his or her own pace. As the dying processevolves, the person experiencing it moves back and forth between beingfully awakeand.alertasleep and dreaming, and perhaps semi-conscious, oreven unconscious, The patient may become increasingly withdrawn, ormore accurately, "internally focused". When notawakeand conscious.theyare frequently restless; moving their -fingers, hands, arms and legs aboutaimless, or "picking at the air". It is also common to hear them moaning,mumbling or even crying out. All of this is indicative of how hard they areworking as they process all the unresolved issues of their lifetime.

Somepeople maintain aremarkably high degree of wakingconsciousness throughout their entiredyingprocesss approaching their actualcrossingwide-awake. This is rare, butcan.bequiteastounding and upliftingfor everyone involved. Typically, these.peoplesuddenlysee something(which-we, the "living" cannot see). Their faces light up, they throw theirarms forward in a gesture of joyous longing, and then they leave (that is,they "die"). As a person moves through the dying process, their statements(if they can be understood) may become increasingly symbolic in nature.This is because what they are experiencing and perceiving has less and lessto do with the physical world. _

Our language is based upon our familiarity with the-physical world.Describing.anon-physical world.inphysicalworld terms is difficult. Sincedying people have no words for.whatthey perceive, they tend to speak of itin symbolic terms.

SYIl1b~oUC-La.pgJl~geSymbolic language may be uniquetothe individual. When people get

close to crossing over, they begin to conceptualize how they win get there.Some people talk about catching a train.others.mumble about having

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After that, there is no more choice in that.matter and the person is basicallyevicted. Some dying people want to move on without completing theirtaska.whileothers completetheirtasks.but.decide to wait.

GIU\EFTll:e.··Pr~ocess

Grief, like life and death, isa process. Everyone experiences grief,including' caregivers and professionals. Grief runs a general course, but isnot necessarily linear. In other words,aperson can be in the acceptancestage.one.day and jump hack .into.anger .the next. In fact, people tend to hoparound from one stage to another quite frequently.

We-grieve each and every loss and disappointment that we experiencein everyday life. The intensity of the grief depends upon the intensity of theloss, but-we generally are not aware of our grief until it becomes intense.When grief does become intense, it may seem overwhelming, and we fearthat we will never be free of it again. The intensity of our grief will ebb andflow.but.itis a part of who and what weare. Notonly do we grieve ourlosses.afterthey occur; we grieve our losses before they occur in anticipationof their occurrence .

.ACCEPT ANCE ..SHO;CK-H,OPE-IJ:ENIAL-SADNESSC@NFIISl-ON-RELIEF-BARGMNIN~DEP~SSION-ANGER

FEAR & 'DLAM' ING- :.: _--~~,-_'.:_",",..'U<...J· ._ -~.'. ".. :: ;, "'_~: ..

We can.expect to go through at least some of these stages with everyloss, but if the loss is severe we may go through virtually all of them ..

Some of the emotions associated.with normal grief are surprising. Forexample.Jt is common to feel anger toward the person who has died. It isalsocommon to feel relief that they have died. These emotions may beconfusing for friends and relatives of the deceased; they may be unexpected,do not always seem to make sense and may trigger feelings of guilt. Still,they are common and normal in ·most cases.

Anticipating a feeling,and feeling a feeling are two different things.Some.of'theemotions of grief are more difficult to deal with than others.Anger..for. example.imay be difficult for some people to acknowledge withinthemselves. It may also be difficult to accept in others. It may help toremember that the emotion being expressed is just a part of the grievingprocess.randthat it is betterto get the emotion out than to hold it inside.Sadness-is another difficult emotion. It is not uncommon for concernedfamily members to request a sedative (usually for someone other thanhimselfor herself) when sadness becomes intense and tears are flowingfreely. Actually, weeping is healthy when intense loss is experienced,even

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for men ...Buryinga11emotionmetely~l;lY-~its expression and is: likely to.cause protracted Or complicatedgrief'witli.more harmful) long-term .consequences. If a person threatens .harm tohim/herself or to others inresponse.to their grief, .1henhe/she.dqes:ne~dprofessional assistance,Barring:tlf(lt, the frank expression.of'grief.isa .good thing and should heencouraged. the healthiestfanriUesiare.the-onestnatencourage:its .expression or emotion. The emotionally supportive family encourages itsmembers to. recognize and communicate their individual feelings. Thisallows everyone within that family to resolve his/her grief and moveon inlife. .

Child~~{laa4.G,riefChildrenshould alsobe -inCiuQecimid.encouraged to participate .in .

expressions of grief and loss. They should.not be forced toparticipate.buttheyshould.beallowed to participate if they desire. Grieving is a.partof .everyday life andtherefore,go.od grieving skills shouldbe taught-to childrenby the ..adults-in their .lives, For chikirentoJeam.good.grieving skillscfhey .must.beable.to see-good .grieYingskills;,.beirig>ptacti~ed:aroi.U1dfuem..Excludingchildren from loss deprives them.of the opportunity to learn howto deal with loss.Children.should not be banished from seeing death or dying people. Theirimaginations can and will create far worse images than reality could ever

. produces.Reality may be tough to deal with atrimes-but-theimagination.canbe a lot worse.

-How Long·n.()es,ItTake?There is no time limit on grief. How long it takes to grieve a loss can

vary greatly and depends on a wide variety of factors, not the least of whichare: the severity of the loss; thesupport.available to the individual

.:experiencing the loss; ~d"his/herwjllatworkjngthrOll:gh.the,griefp~Qcess.Strictly .speaking, one never "gets .ovet';'aserilJUs loss. One leamstocope,one learnstointegrate that lossintolarger meaning, but one does not forget.

SharlagLossHuman beings are innately social and need to share at least some of

their feelingsinorder to process them.effectively .. Spending -timealone.isimportant after experiencing a loss; but itmay be just as important to grievewith someone as well. The need to recall the stories of our losses is .important It is a normal and effective way of processing grief. Hospicesprovide grief counselors.