essay about sudden death

Death Shock: How to Recover When a Loved One Dies Suddenly

5 stages of grief and 5 ways to recover..

Posted March 2, 2020 | Reviewed by Kaja Perina

• Understanding Grief
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It changes you forever. The news arrives, and time stops.

There are few things in life as devastating as the sudden death of a loved one. As your world descends into chaos and you're flooded with despair, you feel like you're trapped in a nightmare and can't wake up:

"How could this happen? It can't be true!"

A sudden death shatters our sense of security

We prefer to believe that our loved ones are safe from harm. We assume that accidents and illnesses will bypass them. So when tragedy strikes suddenly, we go into shock. Our entire being vibrates with a single word: Why?

A sudden death shakes you to the core. You can't turn away from it; you can't reason with it. You know that life will never be the same. (see " How to Recover When Life Crushes You")

Processing death: The five stages of grief

Kubler Ross' identified five stages of grief to provide a framework for the processing of death. Ross spent much of her life working with terminally ill patients. While these stages are not universal, nor do they occur in lockstep, they can be useful in thinking about grief.

1. Denial : You experience shock and disbelief, frequently accompanied by numbness, detachment, or disassociation. You may focus on facts or keep busy, anything to delay experiencing the pain and despair the loss of your loved one has caused you.

2. Anger : Rage emerges in you. You may point your anger at doctors, friends, spouses, siblings, society or even yourself. But when anger is fixated on blame it offers little comfort. As blame subsides, the pain returns. Anger also triggers a crisis of faith, rage at a God that would permit such a horrible thing to happen. You may even feel angry at the deceased for abandoning you.

3. Bargaining: In an attempt to ease the pain of your loss, you try to bargain with it. You may make sudden changes or promises, such as, "I'm going to be a better person." or "I'll honor his or her memory by changing my ways." But such grief-driven promises are hard to keep. Bargaining helps to soften your anger and is your first attempt to come to grips with the loss.

4. Depression : After passing through denial, anger, and bargaining, the painful reality of the situation sinks in. Depression pushes down on you until you collapse under its weight. Everything feels pointless. Exhaustion plagues you. You may fall back on self-destructive habits such as over-eating, sleeping , or isolating. Such patterns existed in your life before the loss and frequently increase during the depression stage.

5. Acceptance.

You begin to accept your new reality. You recognize that, although everything has changed, you must go on living. You start to find moments of inner peace. Perhaps you take comfort in memories, rather than feel depressed or hurt by them. You may dream about your loved one or talk to him or her in your mind. You start to seek new relationships.

The road to recovery from loss

The stages of grief can last months or years. Everyone passes through them differently. To help yourself recover, consider the following suggestions:

1. Seek support: A community of friends and family can be a great comfort after a loss. Accept whatever relief that they can offer and don't be afraid to ask for more.

2. Reach 0ut: Isolation after a loss is common, but too much of it breeds depression. Reach out to others, enroll in a bereavement group, or find a religious community or meditative practice that offers you peace.

3. Maintain self-care : Keep active, explore new habits such as exercise, journaling, or yoga. Find a way to step outside your grief by being more creative, such as taking a class, going to inspiring concerts, or visiting galleries.

4. Find Meaning: There is a beautiful new book written by David Kessler, "Finding Meaning: The Sixth Stage of Grief," In it, he discusses how the loss of his 21-year-old son due to an overdose gave way to depths of grief that he's never known. Books like this can be a great comfort in helping you to realize that you're not alone. They also offer you some tools to help you recover.

5. Start Fresh: At some point, you'll have a choice to make: Do you let grief shrink your life and hold you hostage or do you try to move forward? I had a friend whose son was killed instantly when a car hit him while he was skateboarding. It was so shocking that even now when I think about it, twenty years later, sadness washes over me. My friend emerged from his grief process a changed person. He published a beautiful letter in a local newspaper to his son, celebrating and thanking him for their time together. In the letter, he shared that his son was an organ donor and wrote " His eyes returned sight to someone who couldn't see. His lungs breathe now in another body." It was a beautiful tribute.

When I asked him how he found the strength to go on, he said, "I decided the best way to honor my son, was to live a happy life. I'm sure that's what he would want."

No one fully recovers from the sudden death of a loved one. We all are changed by such losses. But don't give up the battle to go on. A grief that is honored and processed fully frequently gives birth to a greater appreciation and commitment to living.

Sean Grover, L.C.S.W. , is an author and psychotherapist who leads one of the largest group therapy practices in the United States.

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5 moving, beautiful essays about death and dying

by Sarah Kliff

It is never easy to contemplate the end-of-life, whether its own our experience or that of a loved one.

This has made a recent swath of beautiful essays a surprise. In different publications over the past few weeks, I've stumbled upon writers who were contemplating final days. These are, no doubt, hard stories to read. I had to take breaks as I read about Paul Kalanithi's experience facing metastatic lung cancer while parenting a toddler, and was devastated as I followed Liz Lopatto's contemplations on how to give her ailing cat the best death possible. But I also learned so much from reading these essays, too, about what it means to have a good death versus a difficult end from those forced to grapple with the issue. These are four stories that have stood out to me recently, alongside one essay from a few years ago that sticks with me today.

My Own Life | Oliver Sacks

As recently as last month, popular author and neurologist Oliver Sacks was in great health, even swimming a mile every day. Then, everything changed: the 81-year-old was diagnosed with terminal liver cancer. In a beautiful op-ed , published in late February in the New York Times, he describes his state of mind and how he'll face his final moments. What I liked about this essay is how Sacks describes how his world view shifts as he sees his time on earth getting shorter, and how he thinks about the value of his time.

Before I go | Paul Kalanithi

Kalanthi began noticing symptoms — "weight loss, fevers, night sweats, unremitting back pain, cough" — during his sixth year of residency as a neurologist at Stanford. A CT scan revealed metastatic lung cancer. Kalanthi writes about his daughter, Cady and how he "probably won't live long enough for her to have a memory of me." Much of his essay focuses on an interesting discussion of time, how it's become a double-edged sword. Each day, he sees his daughter grow older, a joy. But every day is also one that brings him closer to his likely death from cancer.

As I lay dying | Laurie Becklund

Becklund's essay was published posthumonously after her death on February 8 of this year. One of the unique issues she grapples with is how to discuss her terminal diagnosis with others and the challenge of not becoming defined by a disease. "Who would ever sign another book contract with a dying woman?" she writes. "Or remember Laurie Becklund, valedictorian, Fulbright scholar, former Times staff writer who exposed the Salvadoran death squads and helped The Times win a Pulitzer Prize for coverage of the 1992 L.A. riots? More important, and more honest, who would ever again look at me just as Laurie?"

Everything I know about a good death I learned from my cat | Liz Lopatto

Dorothy Parker was Lopatto's cat, a stray adopted from a local vet. And Dorothy Parker, known mostly as Dottie, died peacefully when she passed away earlier this month. Lopatto's essay is, in part, about what she learned about end-of-life care for humans from her cat. But perhaps more than that, it's also about the limitations of how much her experience caring for a pet can transfer to caring for another person.

Yes, Lopatto's essay is about a cat rather than a human being. No, it does not make it any easier to read. She describes in searing detail about the experience of caring for another being at the end of life. "Dottie used to weigh almost 20 pounds; she now weighs six," Lopatto writes. "My vet is right about Dottie being close to death, that it’s probably a matter of weeks rather than months."

Letting Go | Atul Gawande

"Letting Go" is a beautiful, difficult true story of death. You know from the very first sentence — "Sara Thomas Monopoli was pregnant with her first child when her doctors learned that she was going to die" — that it is going to be tragic. This story has long been one of my favorite pieces of health care journalism because it grapples so starkly with the difficult realities of end-of-life care.

In the story, Monopoli is diagnosed with stage four lung cancer, a surprise for a non-smoking young woman. It's a devastating death sentence: doctors know that lung cancer that advanced is terminal. Gawande knew this too — Monpoli was his patient. But actually discussing this fact with a young patient with a newborn baby seemed impossible.

"Having any sort of discussion where you begin to say, 'look you probably only have a few months to live. How do we make the best of that time without giving up on the options that you have?' That was a conversation I wasn't ready to have," Gawande recounts of the case in a new Frontline documentary .

What's tragic about Monopoli's case was, of course, her death at an early age, in her 30s. But the tragedy that Gawande hones in on — the type of tragedy we talk about much less — is how terribly Monopoli's last days played out.

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Sudden death in young people: heart problems often blamed.

Sudden cardiac death rarely happens in those under age 35. But those at risk can take precautions.

Sudden cardiac death is the swift and not expected ending of all heart activity. Breathing and blood flow stop right away. Within seconds, the person is not conscious and dies.

Sudden cardiac death is different from sudden cardiac arrest (SCA). SCA is the sudden loss of heart activity due to an irregular heart rhythm. Survival is possible with fast, proper medical care.

Sudden cardiac death in seemingly healthy people under age 35 is rare. It is more common in males than in females.

Heart conditions that are not diagnosed such as a genetic heart disease can cause sudden death in teenagers and young adults. A heart condition that is not identified may cause a young person to suddenly die during physical activity, such as competitive sports. But sudden cardiac death can occur without activity.

Most student athletes compete yearly without a heart incident. If you or your child is at risk of sudden cardiac death, talk to your healthcare professional. Ask about steps you can take to lower the risk.

How common is sudden cardiac death in young people?

Most sudden cardiac deaths are in older adults, particularly those with heart disease. Yet sudden cardiac arrest is the leading cause of death in young athletes. Estimates vary, but some reports suggest that about one in 50,000 young athletes to one in 100,000 dies of sudden cardiac death each year.

What can cause sudden cardiac death in young people?

Changes in the heart's electrical signaling often causes sudden cardiac death. A very fast heartbeat causes the lower heart chambers to squeeze fast and in a way that is not coordinated. The heart can't pump blood to the body. This life-threatening type of irregular heartbeat is called ventricular fibrillation.

Anything that strains the heart or damages heart tissue can increase the risk of sudden cardiac death. Some conditions that can lead to sudden cardiac death in young people are:

• Thickened heart muscle, also called hypertrophic cardiomyopathy. This genetic condition is the most common cause of sudden cardiac death in young people. It causes the heart muscle to grow too thick. The thickening makes it hard for the heart to pump blood. This can cause fast heartbeats.
• Long QT syndrome. This heart rhythm condition can cause fast, chaotic heartbeats. It's linked to fainting for no reason and sudden death, especially in young people. If you are born with it, it's called congenital long QT syndrome. If it is caused by a medicine or health condition, it is called acquired long QT syndrome.
• Other heart rhythm conditions. Other irregular heart rhythms can cause sudden cardiac death. These include Brugada syndrome and Wolff-Parkinson-White syndrome.
• Forceful hit to the chest. A blunt chest injury that causes sudden cardiac death is called commotio cordis. Commotio cordis may occur in athletes who are hit hard in the chest by sports equipment or by another player. This condition does not damage the heart muscle. Instead, it changes the heart's electrical signaling. The blow to the chest can trigger ventricular fibrillation. The hit must occur at a specific time in the heart signaling cycle.
• Heart condition present at birth, also called a congenital heart defect. Some people are born with changes in the heart and blood vessels. These changes can reduce blood flow and lead to sudden cardiac death.

How can parents, coaches and others know if a young person is at risk of sudden cardiac death?

Many times, sudden cardiac death occurs without warning. Or warning signs may not be noticed. Ask if a health checkup is needed for anyone who has:

• Fainting, also called syncope. Fainting that cannot be explained and occurs during activity or exercise could mean there is a heart problem.
• Shortness of breath or chest pain. These symptoms could be a sign of a heart problem. But conditions such as asthma also can be the cause. That is why it is important to get a complete health checkup.
• Family history of sudden cardiac death. This family history makes a person more likely to have the same type of heart event. If there is a family history of deaths that cannot be explained, talk with a healthcare professional about screening options.

Can sudden death in young people be prevented?

Sometimes. If you are at high risk of sudden cardiac death, a healthcare professional may tell you not to play competitive sports.

Depending on the underlying condition, medicine or surgery may be recommended to lower the risk of sudden death. For example, a device called an implantable cardioverter-defibrillator (ICD) may be placed in the chest. The device continuously checks the heart's rhythm. If a life-threatening heart rhythm change occurs, the ICD delivers electrical shocks to reset the heart.

Many athletic training centers have a portable device called an automated external defibrillator (AED). An AED is used to treat someone during cardiac arrest. It delivers shocks to reset the heart rhythm. No training is needed to use it. The device tells you what to do. It's programmed to give a shock only when necessary.

Who should be screened for sudden death risk factors?

There's debate in the medical community about screening young athletes in attempt to identify those at high risk of sudden death.

One Italian study found that mandatory heart checks of young people with an electrocardiogram (ECG) leads to lower rates of sudden cardiac death. But some worry this type of screening can suggest something is wrong when there is not a problem. This is called a false-positive result. Another worry is that screening would lead to overdiagnosis of conditions that may never cause harm.

One idea is to give routine ECGs to athletes before they play competitive sports to identify risk and prevent sudden cardiac death. But it's not clear that routine ECGs for athletes can prevent sudden cardiac death. However, such testing might help identify some who are at a higher risk.

If you have a family history or risk factors for conditions that cause sudden cardiac death, screening is typically recommended.

The American Heart Association does not recommend sudden cardiac death screening for young people who are not athletes and who don't have heart disease symptoms.

Should young adults with a heart problem avoid or limit physical activity?

It depends. If you are at risk of sudden cardiac death, talk to your healthcare professional about physical activity. Whether you can safely participate in exercise or sports depends on your specific condition. Do not play full-contact sports if you have a medical device in your chest to find and stop irregular heartbeats. A direct blow to the chest may move the device.

Your health professional can tell you which sports and types of exercise are safe for you or your child.

There is a problem with information submitted for this request. Review/update the information highlighted below and resubmit the form.

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• Podrid PJ. Overview of sudden cardiac arrest and sudden cardiac death. https://www.uptodate.com/contents/search. Accessed Nov. 21, 2023.
• What is cardiac arrest. National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health/cardiac-arrest. Accessed Nov. 29, 2023.
• Couper K, et al. Incidence of sudden cardiac death in the young: A systematic review. BMJ Open. 2020; doi:10.1136/bmjopen-2020-040815.
• Lear A, et al. Incidence of sudden cardiac arrest and death in young athletes and military members: A systematic review and meta-analysis. Journal of Athletic Training. 2021; doi:10.4085/1062-6050-0748.20.
• Tobert KE, et al. Return-to-play for athletes with long QT syndrome or genetic heart diseases predisposing to sudden death. Journal of the American College of Cardiology. 2021; doi:10.1016/j.jacc.2021.04.026.
• Al-Khatib SM, et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2018; doi:10.1161/CIR.0000000000000549.
• Sudden cardiac death in athletes. Merck Manual Professional Version. http://www.merckmanuals.com/professional/cardiovascular-disorders/sports-and-the-heart/sudden-cardiac-death-in-athletes. Accessed Nov. 21, 2023.
• Pelliccia A, et al. Athletes: Overview of sudden cardiac death risk and sport participation. https://www.uptodate.com/contents/search. Accessed Nov. 21, 2023.
• Madias C. Commotio cordis. https://www.uptodate.com/contents/search. Accessed Nov. 21, 2023.
• Defibrillators. National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health-topics/defibrillators. Accessed Nov. 21, 2023.
• Noseworthy PA (expert opinion). Mayo Clinic. April 15, 2022.
• Cardiac arrest: Causes and risk factors. National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health/cardiac-arrest/causes. Accessed Nov. 29, 2023.
• Cardiac arrest: Treatment. National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health/cardiac-arrest/treatment. Accessed Nov. 29, 2023.
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How to Help a Loved One Through Sudden Loss

Here’s how to offer support to someone grieving after an unexpected death.

By Julie Halpert

Listen to This Article

Over the past several years, the husbands of three of my friends died suddenly at the age of 50. These experiences helped educate me on how to be supportive in the face of an unexpected loss. I couldn’t imagine that I would ever be on the receiving end of such support. But that happened when I lost my son, Garrett, to suicide in September 2017.

Since Garrett’s passing, I have been amazed at the generosity of my community. One friend paid to have my home’s gutters cleaned and windows washed. Our family’s veterinarian refused to let us pay for her pet care services for a year. Another friend gave us keys to her lake house to use when we needed to get away. Each spring, we find a hanging plant on our porch from parents of a friend of Garrett’s. As brutally hard as it’s been to walk this new path without my son, these actions have provided a glimmer of positivity amid my despair.

While people have stepped up to help after our loss, such generosity is not always a given in the wake of a sudden death — an outcome that many families are experiencing with the coronavirus pandemic, which has killed more than 800,000 people in the United States alone.

“Many bereaved people experience another secondary loss when friends and family run away after a loss due to their own discomfort,” said Sherry Cormier, a psychologist and certified bereavement trauma specialist. Being present with a friend’s grief in this situation can stir up anxiety about death, she said. “They think, ‘That could happen to me.’”

Unlike a death that occurs in an older person after a long illness, with a sudden loss, “your world is turned completely and totally upside down; you’re in complete chaos,” said Camille Wortman, a professor of social and health psychology at Stony Brook University and author of “Treating Traumatic Bereavement: A Practitioner’s Guide . ”

Outside of the loss itself, one of the most painful experiences for grievers is that their friends and family may not be willing to help them through their grief, Dr. Cormier said. Rather than turning away, you can offer connection. Here are some ways to help a person who has recently experienced a loss.

Take on tasks.

With a sudden loss, the bereaved find themselves immediately inundated with new and mounting responsibilities. Helping ease that burden can be invaluable. Dr. Cormier suggested leading with language like: “I’d love to help. Does anything occur to you that may be useful?” If they don’t provide suggestions, you can be specific: Ask if you can bring dinner, mow the lawn or pick up groceries. You can also provide a welcome distraction, offering to go for a walk with the bereaved or take them out to dinner.

Jerri Vance, who lives in Princeton, W.Va., lost her husband, James, a 52-year-old police officer, to Covid-19 on New Year’s Day of 2021. “He went into the hospital on Dec. 7th and I never saw him again,” she said.

Immediately following her husband’s death, people in her community threw a fund-raiser for medical bills and funeral costs that raised $29,000. Friends and neighbors provided meals for a month and a half. Other friends helped her take down Christmas decorations. The principal of the school where she teaches third grade even showed up to clean her kitchen.

Ms. Vance said she appreciated all the prayers after her husband’s death, but she was most buoyed by those who offered to lighten her load.

Continue reaching out.

A study released in August by the American Psychological Association found that the loss of a loved one in a traumatic event can cause complicated reactions for those left behind, including prolonged grief . Other studies have found that people who have endured a traumatic loss are more likely to experience severe, intense and persistent psychological reactions, such as post-traumatic stress disorder, compared with those who have had an expected loss, according to Kristin Alve Glad, a clinical psychologist and the lead author of the A.P.A. study. In these situations, Dr. Wortman said, the bereaved can struggle for many years or decades.

“Time does not heal all wounds,” Ms. Vance said. “There are times when I feel forgotten. Everybody goes back to their normal lives, and, for us, there’s never going to be a normal life again.”

Dr. Wortman suggested checking in periodically and reaching out during times when those who are grieving may be particularly vulnerable, like a wedding anniversary or major holidays. She has compiled a list of helpful websites and articles that focus on offering support in these situations.

Consider adding simple “thinking of you” messages to your to-do list. Lisa Zaleski, who lives in White Lake, Mich., confronted the unimaginable, first losing her daughter, Sydney, in June 2017 at the age of 23 in a car accident, then her son Robert in December 2019 to suicide when he was 31 years old. After her daughter died, a friend she wasn’t especially close with sent her a text of acknowledgment every day for a year. “It felt like a tremendous amount of support,” she said.

Connect the bereaved with community support.

Nneka Njideka, a licensed clinical social worker in Brooklyn, N.Y., who specializes in grief, explained that those with more resources have “grief privilege.” They may be able to take an extended leave of absence from work and afford a team of professionals to cope with the loss, for example. But she said that isn’t the case for those who are low on resources — and people of color in particular — who, in addition to losing their loved one, may be faced with “living losses,” like unemployment or food insecurity.

Calandrian Simpson Kemp, who is Black and lives in Houston, was working the night shift at a homeless shelter for women in 2013 when she got the call that her only son, George Kemp Jr., had been shot dead at 20 years old. “Everything you envisioned for them has been stolen from you,” she said. It was too much to bear for her husband. When she broke the news to him, “he dropped his keys and never went back to work,” she said. The family, which includes her daughter and stepdaughter, became uninsured as a result. She couldn’t afford mental health care and at one point needed to use a food pantry.

“I felt that bullet was still killing my husband and I, because we lost everything that we had,” she said.

Ms. Njideka said in these types of situations, it’s important to help the bereaved network with the community and build a circle of supportive resources, perhaps to raise funds for bills and therapy. Ms. Simpson Kemp started a program, The Village of Mothers, to assist mothers who lost their children in finding the services they need.

Listen more than you talk.

It’s helpful to just sit with those who are grieving and let them cry, Dr. Cormier said. Allow them to tell you the story of their loss and don’t try to problem solve or give advice. After Ms. Simpson Kemp’s son was killed, a woman from her church offered to drive her to the cemetery and simply sat with her there.

“She would just wait in the back and allow me to be still and silent in that space with George,” Ms. Simpson Kemp said. She “showed me it was OK to slow down and put the pieces together to help make sense of what had just happened.”

Choose your words carefully.

Try to be mindful to avoid minimizing the loss or encouraging a quick recovery, said Roxane Cohen Silver, a professor of psychological science, public health and medicine at the University of California, Irvine. She has developed a list of “don’ts” in the event of a loss, based on her research with hundreds of bereaved people. Never suggest that you know how grievers feel, even if you’ve experienced a similar type of loss; you can’t possibly comprehend the depth of their grief, she said.

Other phrases to avoid, according to Dr. Wortman: “You’re so strong,” “You have so much to be thankful for” and “Everything will be OK,” along with religious platitudes like, “It’s part of God’s plan” or “He’s in a better place.”

Ms. Vance said it’s best not to make empty promises. Some of her friends promised her children pedicures and an outing to get ice cream, yet no one followed through. Her kids were hurt. “When you promise something, you’ve got to follow up with it,” she said.

In the case of a death by suicide, it may be even harder to know what to say or how to help, since stigma can be an issue. Doreen Marshall, a psychologist with the American Foundation for Suicide Prevention, said loss survivors often feel an incredible amount of guilt and may assume responsibility for what happened. Dr. Marshall, who lost her fiancé to suicide, said that means friends and loved ones may be even more reluctant to offer support.

As with any other type of sudden loss, focus on providing the type of support that the griever needs, Dr. Marshall said. Avoid asking about the circumstances of the death, she said, but say the loved one’s name, ask about the person’s life and share happy memories that you have.

“We miss our kids like crazy,” said Marny Lombard, when we spoke about her son, Sam, who died by suicide in 2013 at 22 years old. If Sam comes up in conversation, it doesn’t make her more upset. “When you say the name of my child, you bring me momentary joy,” she said.

Audio produced by Kate Winslett .

If you are having thoughts of suicide, in the United States call the National Suicide Prevention Lifeline at 800-273-8255 (TALK) or go to SpeakingOfSuicide.com/resources for a list of additional resources. Go here for resources outside the United States.

Reflections on Death in Philosophical/Existential Context

• Symposium: Reflections Before, During, and Beyond COVID-19
• Published: 27 July 2020
• Volume 57 , pages 402–409, ( 2020 )

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Is death larger than life and does it annihilate life altogether? This is the basic question discussed in this essay, within a philosophical/existential context. The central argument is that the concept of death is problematic and, following Levinas, the author holds that death cannot lead to nothingness. This accords with the teaching of all religious traditions, which hold that there is life beyond death, and Plato’s and Aristotle’s theories about the immortality of the soul. In modernity, since the Enlightenment, God and religion have been placed in the margin or rejected in rational discourse. Consequently, the anthropocentric promethean view of man has been stressed and the reality of the limits placed on humans by death deemphasised or ignored. Yet, death remains at the centre of nature and human life, and its reality and threat become evident in the spread of a single virus. So, death always remains a mystery, relating to life and morality.

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What a piece of work is a man! how noble in reason! how infinite in faculty! In form and moving, how express and admirable! In action, how like an angel! in apprehension, how like a god! the beauty of the world! the paragon of animals! And yet, to me, what is this quintessence of dust? William Shakespeare ( 1890 : 132), Hamlet, Act 2, scene 2, 303–312.

In mid-2019, the death of Sophia Kokosalakis, my niece and Goddaughter, at the age of 46, came like a thunderbolt to strike the whole family. She was a world-famous fashion designer who combined, in a unique way, the beauty and superb aesthetics of ancient and classical Greek sculptures and paintings with fashion production of clothes and jewellery. She took the aesthetics and values of ancient and classical Greek civilization out of the museums to the contemporary art of fashion design. A few months earlier she was full of life, beautiful, active, sociable and altruistic, and highly creative. All that was swept away quickly by an aggressive murderous cancer. The funeral ( κηδεία ) – a magnificent ritual event in the church of Panaghia Eleftherotria in Politeia Athens – accorded with the highly significant moving symbolism of the rite of the Orthodox Church. Her parents, her husband with their 7-year-old daughter, the wider family, relatives and friends, and hundreds of people were present, as well as eminent representatives of the arts. The Greek Prime Minister and other dignitaries sent wreaths and messages of condolences, and flowers were sent from around the world. After the burial in the family grave in the cemetery of Chalandri, some gathered for a memorial meal. This was a high profile, emotional final goodbye to a beloved famous person for her last irreversible Journey.

Sophia’s death was circumscribed by social and religious rituals that help to chart a path through the transition from life to death. Yet, the pain and sorrow for Sophia’s family has been very deep. For her parents, especially, it has been indescribable, indeed, unbearable. The existential reality of death is something different. It raises philosophical questions about what death really means in a human existential context. How do humans cope with it? What light do religious explanations of death shed on the existential experience of death and what do philosophical traditions have to say on this matter?

In broad terms religions see human life as larger than death, so that life’s substance meaning and values for each person are not exhausted with biological termination. Life goes on. For most religions and cultures there is some notion of immortality of the soul and there is highly significant ritual and symbolism for the dead, in all cultures, that relates to their memory and offers some notion of life beyond the grave. In Christianity, for example, life beyond death and the eternity and salvation of the soul constitutes the core of its teaching, immediately related to the incarnation, death, and resurrection of Christ. Theologically, Christ’s death and resurrection, declare the defeat of death by the death and the resurrection of the son of God, who was, both, God and perfectly human (theanthropos). This teaching signifies the triumph of life over death, which also means, eschatologically, the salvation and liberation of humankind from evil and the injustice and imperfection of the world. It refers to another dimension beyond the human condition, a paradisiac state beyond the time/space configuration, a state of immortality, eternity and infinity; it points to the sublimation of nature itself. So, according to Christian faith, the death of a human being is a painful boundary of transition, and there is hope that human life is not perishable at death. There is a paradox here that through death one enters real life in union with God. But this is not knowledge. It is faith and must be understood theologically and eschatologically.

While the deeply faithful, may accept and understand death as passage to their union with God, Sophia’s death shows that, for ordinary people, the fear of death and the desperation caused by the permanent absence of a beloved person is hard to bear – even with the help of strong religious faith. For those with lukewarm religious faith or no faith at all, religious discourse and ritual seems irrelevant or even annoying and irrational. However, nobody escapes the reality of death. It is at the heart of nature and the human condition and it is deeply ingrained in the consciousness of adult human beings. Indeed, of all animals it is only humans who know that they will die and according to Heidegger ( 1967 :274) “death is something distinctively impending”. The fear of death, consciously or subconsciously, is instilled in humans early in life and, as the ancients said, when death is near no one wants to die. ( Ην εγγύς έλθει θάνατος ουδείς βούλεται θνήσκειν. [Aesopus Fables]). In Christianity even Christ, the son of God, prayed to his father to remove the bitter cup of death before his crucifixion (Math. 26, 38–39; Luke, 22, 41–42).

The natural sciences say nothing much about the existential content and conditions of human death beyond the biological laws of human existence and human evolution. According to these laws, all forms of life have a beginning a duration and an end. In any case, from a philosophical point of view, it is considered a category mistake, i.e. epistemologically and methodologically wrong, to apply purely naturalistic categories and quantitative experimental methods for the study, explanation and interpretation of human social phenomena, especially cultural phenomena such as the meaning of human death and religion at large. As no enlightenment on such issues emerges from the natural sciences, maybe insights can be teased out from philosophical anthropological thinking.

Philosophical anthropology is concerned with questions of human nature and life and death in deeper intellectual, philosophical, dramaturgical context. Religion and the sacred are inevitably involved in such discourse. For example, the verses from Shakespeare’s Hamlet about the nature of man, at the preamble of this essay, put the matter in a nutshell. What is this being who acts like an angel, apprehends and creates like a god, and yet, it is limited as the quintessence of dust? It is within this discourse that I seek to draw insights concerning human death. I will argue that, although in formal logical/scientific terms, we do not know and cannot know anything about life after/beyond death, there is, and always has been, a legitimate philosophical discourse about being and the dialectic of life/death. We cannot prove or disprove the existence and content of life beyond death in scientific or logical terms any more than we can prove or disprove the existence of God scientifically. Footnote 1

Such discourse inevitably takes place within the framework of transcendence, and transcendence is present within life and beyond death. Indeed, transcendence is at the core of human consciousness as humans are the only beings (species) who have culture that transcends their biological organism. Footnote 2 According to Martin ( 1980 :4) “the main issue is… man’s ability to transcend and transform his situation”. So human death can be described and understood as a cultural fact immediately related to transcendence, and as a limit to human transcendental ability and potential. But it is important, from an epistemological methodological point of view, not to preconceive this fact in reductionist positivistic or closed ideological terms. It is essential that the discourse about death takes place within an open dialectic, not excluding transcendence and God a priori, stressing the value of life, and understanding the limits of the human potential.

The Problem of Meaning in Human Death

Biologically and medically the meaning and reality of human death, as that of all animals, is clear: the cessation of all the functions and faculties of the organs of the body, especially the heart and the brain. This entails, of course, the cessation of consciousness. Yet, this definition tells us nothing about why only the human species, latecomers in the universe, have always worshiped their gods, buried their dead with elaborate ritual, and held various beliefs about immortality. Harari ( 2017 :428–439) claims that, in the not too distant future, sapiens could aim at, and is likely to achieve, immortality and the status of Homo Deus through biotechnology, information science, artificial intelligence and what he calls the data religion . I shall leave aside what I consider farfetched utopian fictional futurology and reflect a little on the problem of meaning of human death and immortality philosophically.

We are not dealing here with the complex question of biological life. This is the purview of the science of biology and biotechnology within the laws of nature. Rather, we are within the framework of human existence, consciousness and transcendence and the question of being and time in a philosophical sense. According to Heidegger ( 1967 :290) “Death, in the widest sense, is a phenomenon of life. Life must be understood as a kind of Being to which there belongs a Being-in-the-world”. He also argues (bid: 291) that: “The existential interpretation of death takes precedence over any biology and ontology of life. But it is also the foundation for any investigation of death which is biographical or historiological, ethnological or psychological”. So, the focus is sharply on the issue of life/death in the specifically human existential context of being/life/death . Human life is an (the) ultimate value, (people everywhere raise their glass to life and good health), and in the midst of it there is death as an ultimate threatening eliminating force. But is death larger than life, and can death eliminate life altogether? That’s the question. Whereas all beings from plants to animals, including man, are born live and die, in the case of human persons this cycle carries with it deep and wide meaning embodied within specific empirical, historical, cultural phenomena. In this context death, like birth and marriage, is a carrier of specific cultural significance and deeper meaning. It has always been accompanied by what anthropologists refer to as rites of passage, (Van Gennep, 1960 [1909]; Turner, 1967; Garces-Foley, 2006 ). These refer to transition events from one state of life to another. All such acts and rites, and religion generally, should be understood analysed and interpreted within the framework of symbolic language. (Kokosalakis, 2001 , 2020 ). In this sense the meaning of death is open and we get a glimpse of it through symbols.

Death, thus, is an existential tragic/dramatic phenomenon, which has preoccupied philosophy and the arts from the beginning and has been always treated as problematic. According to Heidegger ( 1967 : 295), the human being Dasein (being-there) has not explicit or even theoretical knowledge of death, hence the anxiety in the face of it. Also, Dasein has its death, “not in isolation, but as codetermined by its primordial kind of Being” (ibid: 291). He further argues that in the context of being/time/death, death is understood as being-towards-death ( Sein zum Tode ). Levinas Footnote 3 ( 2000 :8), although indebted to Heidegger, disagrees radically with him on this point because it posits being-towards death ( Sein zum Tode) “as equivalent to being in regard to nothingness”. Leaving aside that, phenomenologically the concept of nothingness itself is problematic (Sartre: 3–67), Levinas ( 2000 :8) asks: “is that which opens with death nothingness or the unknown? Can being at the point of death be reduced to the ontological dilemma of being or nothingness? That is the question that is posed here.” In other words, Levinas considers this issue problematic and wants to keep the question of being/life/death open. Logically and philosophically the concept of nothingness is absolute, definitive and closed whereas the concept of the unknown is open and problematic. In any case both concepts are ultimately based on belief, but nothingness implies knowledge which we cannot have in the context of death.

Levinas (ibid: 8–9) argues that any knowledge we have of death comes to us “second hand” and that “It is in relation with the other that we think of death in its negativity” (emphasis mine). Indeed, the ultimate objective of hate is the death of the other , the annihilation of the hated person. Also death “[is] a departure: it is a decease [deces]”. It is a permanent separation of them from us which is felt and experienced foremost and deeply for the departure of the beloved. This is because death is “A departure towards the unknown, a departure without return, a departure with no forward address”. Thus, the emotion and the sorrow associated with it and the pain and sadness caused to those remaining. Deep-down, existentially and philosophically, death is a mystery. It involves “an ambiguity that perhaps indicates another dimension of meaning than that in which death is thought within the alternative to be/not- to- be. The ambiguity: an enigma” (ibid: 14). Although, as Heidegger ( 1967 :298–311) argues, death is the only absolute certainty we have and it is the origin of certitude itself, I agree with Levinas (ibid: 10–27) that this certitude cannot be forthcoming from the experience of our own death alone, which is impossible anyway. Death entails the cessation of the consciousness of the subject and without consciousness there is no experience. We experience the process of our dying but not our own death itself. So, our experience of death is primarily that of the death of others. It is our observation of the cessation of the movement, of the life of the other .

Furthermore, Levinas (Ibid: 10–13) argues that “it is not certain that death has the meaning of annihilation” because if death is understood as annihilation in time, “Here, we are looking for other dimension of meaning, both for the meaning of time Footnote 4 and for the meaning of death”. Footnote 5 So death is a phenomenon with dimensions of meaning beyond the historical space/time configuration. Levinas dealt with such dimensions extensively not only in his God, Death and Time (2000) but also in his: Totality and Infinity (1969); Otherwise than Being, or Beyond Essence (1991); and, Of God Who comes to mind (1998). So, existentially/phenomenologically such dimensions inevitably involve the concept of transcendence, the divine, and some kind of faith. Indeed, the question of human death has always involved the question of the soul. Humans have been generally understood to be composite beings of body/soul or spirit and the latter has also been associated with transcendence and the divine. In general the body has been understood and experienced as perishable with death, whereas the soul/spirit has been understood (believed) to be indestructible. Thus beyond or surviving after/beyond death. Certainly this has been the assumption and general belief of major religions and cultures, Footnote 6 and philosophy itself, until modernity and up to the eighteenth century.

Ancient and classical Greek philosophy preoccupied itself with the question of the soul. Footnote 7 Homer, both in the Iliad and the Odyssey, has several reference on the soul in hades (the underworld) and Pythagoras of Samos (580–496 b.c.) dealt with immortality and metempsychosis (reincarnation). Footnote 8 In all the tragedies by Sophocles (496–406 b,c,), Aeschylus (523–456 b. c.), and Euripides (480–406 b.c.), death is a central theme but it was Plato Footnote 9 (428?-347 b.c.) and Aristotle Footnote 10 (384–322 b.c.) – widely acknowledged as the greatest philosophers of all times – who wrote specific treatises on the soul. Let us look at their positions very briefly.

Plato on the Soul

Plato was deeply concerned with the nature of the soul and the problem of immortality because such questions were foundational to his theory of the forms (ideas), his understanding of ethics, and his philosophy at large. So, apart from the dialogue Phaedo , in which the soul and its immortality is the central subject, he also referred to it extensively in the Republic , the Symposium and the Apology as well in the dialogues: Timaeus , Gorgias, Phaedrus, Crito, Euthyfron and Laches .

The dialogue Phaedo Footnote 11 is a discussion on the soul and immortality between Socrates (470–399 b.c.) and his interlocutors Cebes and Simias. They were Pythagorians from Thebes, who went to see Socrates in prison just before he was about to be given the hemlock (the liquid poison: means by which the death penalty was carried out at the time in Athens). Phaedo, his disciple, who was also present, is the narrator. The visitors found Socrates very serene and in pleasant mood and wondered how he did not seem to be afraid of death just before his execution. Upon this Socrates replies that it would be unreasonable to be afraid of death since he was about to join company with the Gods (of which he was certain) and, perhaps, with good and beloved departed persons. In any case, he argued, the true philosopher cannot be afraid of death as his whole life, indeed, is a practice and a preparation for it. So for this, and other philosophical reasons, death for Socrates is not to be feared. ( Phaedo; 64a–68b).

Socrates defines death as the separation of the soul from the body (64c), which he describes as prison of the former while joined in life. The body, which is material and prone to earthly materialistic pleasures, is an obstacle for the soul to pursue and acquire true knowledge, virtue, moderation and higher spiritual achievements generally (64d–66e). So, for the true philosopher, whose raison-d’être is to pursue knowledge truth and virtue, the liberation of the soul from bodily things, and death itself when it comes, is welcome because life, for him, was a training for death anyway. For these reasons, Socrates says is “glad to go to hades ” (the underworld) (68b).

Following various questions of Cebes and Simias about the soul, and its surviving death, Socrates proceeds to provide some logical philosophical arguments for its immortality. The main ones only can be mentioned here. In the so called cyclical argument, Socrates holds that the immortality of the soul follows logically from the relation of opposites (binaries) and comparatives: Big, small; good, bad; just, unjust; beautiful, ugly; good, better; bad; worse, etc. As these imply each other so life/death/life are mutually inter-connected, (70e–71d). The second main argument is that of recollection. Socrates holds that learning, in general, is recollection of things and ideas by the soul which always existed and the soul itself pre-existed before it took the human shape. (73a–77a). Socrates also advises Cebes and Simias to look into themselves, into their own psych e and their own consciousness in order to understand what makes them alive and makes them speak and move, and that is proof for the immortality of the soul (78ab). These arguments are disputed and are considered inadequate and anachronistic by many philosophers today (Steadman, 2015 ; Shagulta and Hammad, 2018 ; and others) but the importance of Phaedo lies in the theory of ideas and values and the concept of ethics imbedded in it.

Plato’s theory of forms (ideas) is the basis of philosophical idealism to the present day and also poses the question of the human autonomy and free will. Phaedo attracts the attention of modern and contemporary philosophers from Kant (1724–1804) and Hegel (1770–1831) onwards, because it poses the existential problems of life, death, the soul, consciousness, movement and causality as well as morality, which have preoccupied philosophy and the human sciences diachronically. In this dialogue a central issue is the philosophy of ethics and values at large as related to the problem of death. Aristotle, who was critical of Plato’s idealism, also uses the concept of forms and poses the question of the soul as a substantive first principle of life and movement although he does not deal with death and immortality as Plato does.

Aristotle on the Soul

Aristotle’s conception of the soul is close to contemporary biology and psychology because his whole philosophy is near to modern science. Unlike many scholars, however, who tend to be reductionist, limiting the soul to naturalistic/positivistic explanations, (as Isherwood, 2016 , for instance, does, unlike Charlier, 2018 , who finds relevance in religious and metaphysical connections), Aristotle’s treatment of it, as an essential irreducible principle of life, leaves room for its metaphysical substance and character. So his treatise on the soul , (known now to scholars as De Anima, Shields, 2016 ), is closely related to both his physics and his metaphysics.

Aristotle sees all living beings (plants, animals, humans) as composite and indivisible of body, soul or form (Charlton, 1980 ). The body is material and the soul is immaterial but none can be expressed, comprehended or perceived apart from matter ( ύλη ). Shields ( 2016 ) has described this understanding and use of the concepts of matter and form in Aristotle’s philosophy as hylomorphism [ hyle and morphe, (matter and form)]. The soul ( psyche ) is a principle, arche (αρχή) associated with cause (αιτία) and motion ( kinesis ) but it is inseparable from matter. In plants its basic function and characteristic is nutrition. In animals, in addition to nutrition it has the function and characteristic of sensing. In humans apart from nutrition and sensing, which they share with all animals, in addition it has the unique faculty of noesis and logos. ( De Anima ch. 2). Following this, Heidegger ( 1967 :47) sees humans as: “Dasein, man’s Being is ‘defined’ as the ζωον λόγον έχον – as that living thing whose Being is essentially determined by the potentiality for discourse”. (So, only human beings talk, other beings do not and cannot).

In Chapter Five, Aristotle concentrates on this unique property of the human soul, the logos or nous, known in English as mind . The nous (mind) is both: passive and active. The former, the passive mind, although necessary for noesis and knowledge, is perishable and mortal (φθαρτός). The latter, the poetic mind is higher, it is a principle of causality and creativity, it is energy, aitia . So this, the poetic the creative mind is higher. It is the most important property of the soul and it is immaterial, immortal and eternal. Here Aristotle considers the poetic mind as separate from organic life, as substance entering the human body from outside, as it were. Noetic mind is the divine property in humans and expresses itself in their pursuit to imitate the prime mover, God that is.

So, Aristotle arrives here at the problem of immortality of the soul by another root than Plato but, unlike him, he does not elaborate on the metaphysics of this question beyond the properties of the poetic mind and he focuses on life in the world. King ( 2001 :214) argues that Aristotle is not so much concerned to establish the immortality of the human individual as that of the human species as an eidos. Here, however, I would like to stress that we should not confuse Aristotle’s understanding with contemporary biological theories about the dominance and survival of the human species. But whatever the case may be, both Aristotle’s and Plato’s treatises on the soul continue to be inspiring sources of debate by philosophers and others on these issues to the present day.

Death in Modernity

By modernity here is meant the general changes which occurred in western society and culture with the growth of science and technology and the economy, especially after the Enlightenment, and the French and the Industrial Revolutions, which have their cultural roots in the Renaissance, the Reformation and Protestantism.

It is banal to say that life beyond death does not preoccupy people in modernity as it did before and that, perhaps, now most people do not believe in the immortality of the soul. In what Charles Taylor ( 2007 ) has extensively described as A SECULAR AGE he frames the question of change in religious beliefs in the west as follows: “why was it virtually impossible not to believe in God in, say, 1500 in our western society, while in 2000 many of us find this not only easy, but even inescapable?” (p. 25). The answer to this question is loaded with controversy and is given variously by different scholars. Footnote 13 Taylor (ibid: 65–75, 720–726) shows how and why beliefs have changed radically in modernity. Metaphysical transcendent beliefs on life and death have shrunk into this-worldly secular conceptions in what he calls, “the immanent frame”. As a consequence, transcendence and the sacred were exiled from the world or reduced to “closed world structures”. Footnote 14 In this context many scholars spoke of “the death of God” (ibid: 564–575).

In criticizing postmodern relativism, which brings various vague conceptions of God and transcendence back in play, Gellner ( 1992 :80–83) praises what he calls Enlightenment Rationalist fundamentalism, which “at one fell swoop eliminates the sacred from the world”. Although he acknowledges that Kant, the deepest thinker of the Enlightenment, left morality reason and knowledge outside the purview of the laws of nature, thus leaving the question of transcendence open, he still claims that Enlightenment rationalism is the only positive scientific way to study religious phenomena and death rituals. This position seems to be epistemologically flawed, because it pre-empts what concerns us here, namely, the assumptions of modernity for the nature of man and its implications for the meaning and reality of death.

In rejecting religion and traditional conceptions of death, Enlightenment rationalism put forward an overoptimistic, promethean view of man. What Vereker ( 1967 ) described as the “God of Reason” was the foundation of eighteenth century optimism. The idea was that enlightened rationalism, based on the benevolent orderly laws of nature, would bring about the redeemed society. Enlightened, rational leaders and the gradual disappearance of traditional religious beliefs, obscurantism and superstitions, which were sustained by the ancient regime, would eventually transform society and would abolish all human evil and social and political injustice. Science was supportive of this view because it showed that natural and social phenomena, traditionally attributed to divine agencies and metaphysical forces, have a clear natural causation. These ideas, developed by European philosophers (Voltaire 1694–1778; Rousseau, 1712–1778; Kant, 1724–1804; Hume, 1711–1776; and many others), were foundational to social and political reform, and the basis of the French Revolution (1789–1799). However, the underlying optimism of such philosophical ideas about the benevolence of nature appeared incompatible with natural phenomena such as the great earthquake in Lisbon in 1755, which flattened the city and killed over 100,000 people. Enlightenment rationalism overemphasised a promethean, anthropocentric view of man without God, and ignored the limits of man and the moral and existential significance of death.

In his critique of capitalism, in the nineteenth century, Marx (1818–1883), promoted further the promethean view of man by elevating him as the author of his destiny and banishing God and religion as “the opium of the people”. In his O rigin of the Species (1859), Charles Darwin also showed man’s biological connections with primates, thereby challenging biblical texts about the specific divine origin of the human species. He confirmed human dominance in nature. Important figures in literature, however, such as Dostoevsky (1821–1881) and Tolstoy (1828–1910), pointed out and criticised the conceit and arrogance of an inflated humanism without God, promoted by the promethean man of modernity.

By the end of the twentieth century the triumph of science, biotechnology, information technology, and international capitalist monetary economics, all of them consequences of modernity, had turned the planet into a global village with improved living standards for the majority. Medical science also has doubled average life expectancy from what it was in nineteenth century and information technology has made, almost every adult, owner of a mobile smart phone. Moreover, visiting the moon has inflated man’s sense of mastery over nature, and all these achievements, although embodying Taylor’s ( 1992 ) malaise of modernity at the expense of the environment, have strengthen the promethean view and, somehow, ignored human limits. As a consequence, the reality of death was treated as a kind of taboo, tucked under the carpet.

This seems a paradox because, apart from the normal death of individuals, massive collective deaths, caused by nature and by hate and barbarity from man to man, were present in the twentieth century more than any other in history. The pandemic of Spanish flue 1917–1919 killed 39 million of the world’s population according to estimates by Baro et al. (2020). In the First World War deaths, military and civilians combined, were estimated at 20.5 million (Wikipedia). In the Second World War an estimated total of 70–85 million people perished, (Wikipedia). This did not include estimates of more than seven million people who died in the gulags of Siberia and elsewhere under Stalin. But Auschwitz is indicative of the unlimited limits, which human barbarity and cruelty of man to man, can reach. Bauman ( 1989 :x), an eminent sociologist, saw the Holocaust as a moral horror related to modernity and wrote: “ The Holocaust was born and executed in modern rational society, at the high stage of our civilization and at the peak of human cultural achievement, and for this reason it is a problem of that society, civilization and culture. ”

Questions associated with the mass death are now magnified by the spread of the coronavirus (Covid-19). This has caused global panic and created unpredictability at all levels of society and culture. This sudden global threat of death makes it timely to re-examine our values, our beliefs (secular or religious), and the meaning of life. Max Weber (1948: 182), who died a hundred years ago in the pandemic of great influenza, was sceptical and pessimistic about modernity, and argued that it was leading to a cage with “ specialists without spirit, sensualists without heart; this nullity imagines that it had attained a level of civilization never before achieved. ”

So, what does this examination of philosophical anthropology illuminate in terms of questions of human nature and life and death in deeper intellectual, philosophical, dramaturgical context? Now, we are well into the twenty-first century, and with the revolution in information science, the internet, biotechnology and data religion , the promethean view of man seems to have reached new heights. Yet, massive death, by a single virus this time, threatens again humanity; are there any lessons to be learned? Will this threat, apart from the negativity of death, bring back the wisdom, which T. S. Elliot said we have lost in modern times? Will it show us our limits? Will it reduce our conceit and arrogance? Will it make us more humble, moderate, prudent, and more humane for this and future generations, and for the sake of life in this planet at large? These are the questions arising now amongst many circles, and it is likely that old religious and philosophical ideas about virtuous life and the hope of immortality (eschatologically) may revive again as we are well within late modernity (I do not like the term postmodernity, which has been widely used in sociology since the 1980s).

The central argument of this essay has been that death has always been and remains at the centre of life. Philosophically and existentially the meaning of death is problematic, and the natural sciences cannot produce knowledge on this problem. Religious traditions always beheld the immortality of the soul and so argued great philosophers like Plato and Aristotle. Modernity, since the Enlightenment, rejected such views as anachronistic and advanced an anthropocentric promethean, view of man, at the expense of the sacred and transcendence at large. Instead, within what Taylor (1967: 537–193) has described as the immanent frame, it developed “closed world structures,” which are at the expense of human nature and human freedom. One consequence of this has been massive death during the twentieth century.

Following Levinas ( 2000 ), I argued that death should not be understood to lead to nothingness because nothingness means certitude and positive knowledge, which we cannot have existentially in the case of death. In this sense the reality of death should not be understood to lead to annihilation of life and remains a mystery. Moreover, the presence and the reality of death as a limit and a boundary should serve as educative lesson for both the autonomy and creativity of man and against an overinflated promethean view of her/his nature.

David Martin ( 1980 :16) puts the matter about human and divine autonomy as follows: “Indeed, it is all too easy to phrase the problem so that the autonomy of God and the autonomy of man are rival claimants for what science leaves over”. This concurs with his, ( 1978 :12), understanding of religion, (which I share), as “acceptance of a level of reality beyond the observable world known to science, to which we ascribe meanings and purposes completing and transcending those of the purely human realm”.

We do not know how and when human beings acquired this capacity during the evolutionary process of the species. It characterises however a radical shift from nature to culture as the latter is defined by Clifford Geertz (1973:68): “an ordered system of meanings and symbols …in terms of which individuals define their world, express their feelings and make their judgements”.

For a comprehensive extensive and impressive account and discussion of Levinas’ philosophy and work, and relevant bibliography, see Bergo ( 2019 ).

Perhaps it is worth mentioning here that the meaning of the concept of time, as it was in Cartesian Philosophy and Newtonian physics, has changed radically with Einstein’s theories of relativity and contemporary quantum physics (Heisenberg 1959 ). Heisenberg’s uncertainty principle (Hilgervood and Uffink, 2016 ) is very relevant to non- deterministic conceptions of time/space and scientific and philosophical discourse generally.

Various religions articulate the structure of these meanings in different cultural contexts symbolically and all of them involve the divine and an eschatological metaphysical dimension beyond history, beyond our experience of time and space.

Ancient Egyptian culture is well known for its preoccupation with life after death, the immortality of the soul and the elaborate ritual involved in the mummification of the Pharaohs. See: anen.wikipedia.org/wiki/Ancient_ Egyptian_ funerary_ practices). Also the findings of archaeological excavations of tombs of kings in all ancient cultures constitute invaluable sources of knowledge not only about the meaning of death and the beliefs and rituals associated with it in these cultures but also of life and religion and politics and society at large.

For an extensive account of general theories of the soul in Greek antiquity see: Lorenz ( 2009 ).

For a good account on Pythagoras’ views on the transmigration of the souls see: Huffman ( 2018 ).

For a recent good account on the diachronic importance of Plato’s philosophy see: Kraut ( 2017 ).

For a very extensive analytical account and discussion of Aristotle’s philosophy and work with recent bibliography see: Shields ( 2016 ).

For an overview of Phaedo in English with commentary and the original Greek text see: Steadman ( 2015 ).

See, for instance, Wilson ( 1969 ) and Martin ( 1978 ) for radically different analyses and interpretations of secularization.

Marxism is a good example. God, the sacred and tradition generally are rejected but the proletariat and the Party acquire a sacred significance. The notion of salvation is enclosed as potentiality within history in a closed system of the class struggle. This, however, has direct political consequences because, along with the sacred, democracy is exiled and turned into a totalitarian system. The same is true, of course, at the other end of the spectrum with fascism.

Further Reading

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Kokosalakis, N. Reflections on Death in Philosophical/Existential Context. Soc 57 , 402–409 (2020). https://doi.org/10.1007/s12115-020-00503-5

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The Essay: Sudden death

In films and literature, the act of dying is always accompanied by a summing up, a lesson learnt, a sense of closure. douglas kennedy discovers that, in real life, endings are rarely that neat and tidy, article bookmarked.

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T DAWN in the Daintree, it was hot. By early morning, the mercury was scraping three figures. By midday, the sun was at full wattage. The humidity was inching into sauna-room levels. Any activity involving physical movement was like wading through a vat of goo.

By nightfall, however, a hint of coolness descended upon this corner of Far North Queensland - and you suddenly discovered a renewed capacity for alcohol. Night was the only real time you could drink in the rainforest - something I found out my first day there, when I downed a beer in the absurd hothouse heat of noon and felt as if I had walked straight into a sucker punch.

I was staying in a wilderness lodge situated smack dab in the middle of the Daintree - one of the few extant rainforests still left on the Australian continent. It was located two hours north of the town of Cairns. To get there required negotiating a very bad road which was unsealed for the last 60 miles. A short ride on a barge was also involved - as you had to forge a river, the banks of which were used as sleeping quarters for the local contingent of crocodiles. The further north you travelled into this jungly void, the less sky you saw - as the canopy of the forest was so dense that it closed in over you. As light receded and a nocturnal soundtrack of sinister ornithological cackles broached the silence, you found yourself thinking: this is, verily, a haunted Eden.

The lodge in which I was billeted was located somewhere in the midst of this forest primeval. There was a main lodge building and six simple cabins, all built on stilts, all eco-friendly, all the brainchild of a 60-year-old former property developer from Brisbane I'll call Jack Hamilton (all names in this essay have been changed). Jack was the archetypal Australian bloke, writ large: chummy, beefy, beer-gutted, no hint of reserve. His wife, Joan, was also welcoming - a thin, spindly woman who, five years earlier, had followed her husband into this back-of-beyond hinterland with the idea of creating a wilderness lodge in the middle of nowhere.

And now, the lodge was finally up and running. It was gradually establishing itself as a unique retreat - though, when I was there it was still low season (right after the Daintree's annual bout of monsoons), so the only other guests were a honeymoon couple. They were called Chris and Alice. They were in their mid-20s - a nurse and a podiatrist from Melbourne. They were pleasant - but I didn't try to engage them in too much conversation. They were on a honeymoon, after all.

I was keeping a low profile: bush-walking in the morning, holing up in the relative cool of my cabin after midday to work on a new novel. Around seven at night, I'd stroll over to the main lodge for the first drink of the evening. I'd come equipped with a book to keep myself company. I'd greet the honeymoon couple with a nod. Inevitably, however, they'd call me over after dinner to join them for a beer.

On the night in question, Jack also sat down with us. We downed a couple of bottles of Cooper's Ale, then Jack said: "It's my round," and headed off in the direction of the bar. I turned back to Chris and Alice. We started discussing - I remember this with total precision - the vast number of bones in a human foot (well, Chris was a podiatrist). Then, out of nowhere, came this dull thud, followed by a deeply eerie sound: a strangulated inhalation of breath. It was a loud, startling gasp - like a contorted howl lodged at the back of somebody's throat. Suddenly, I found myself staring at Chris and Alice, wide-eyed. Within a nanosecond, we were all on our feet. Racing over to the bar, we found Jack collapsed behind the counter.

His face was blue, his legs were kicking wildly. He was having a massive heart attack - and we were in the middle of the fucking jungle.

Alice quickly snapped into ER mode. Crouching by Jack's side, she smashed her right fist into the centre of his chest, and started administering CPR. Barking instructions, she ordered her husband to clear Jack's air passage and commence mouth-to-mouth. Then she turned to me.

"Find his wife. Find out if he has any pills or if the lodge has a defibrillator. And find out where the nearest fucking doctor is."

I did as ordered, running into the living quarters at the back of the lodge. I banged on the door. Joan answered it. She went white when I told her that her husband was in the throes of a major heart attack. Instantly she pushed passed me, racing towards the bar. I followed, hearing her scream when she saw her husband, collapsed on the ground. Chris and Alice were still administering CPR, the night silence punctuated by Alice's rapid-fire instructions. Joan became incoherent. I took her by the shoulders and said: "You've got to tell me: where is your defibrillator?"

"What's a defibrillator?" she howled.

"OK, how about pills for his heart condition?"

"I'm the one with the heart condition. Jack's always been fine."

"And your doctor?"

"He's in Port Douglas ... "

Worse and worse. Port Douglas was 100 miles away by unsealed road.

I ran to the reception desk. I picked up the phone. I called the operator and asked to be put through to the local flying doctor service. The guy on call there explained that, as it was night - and as the only local airstrip was a field - landing after dark in this corner of the Daintree was virtually impossible. But he gave me the number of a nearby district nurse. I dialled her frantically. She was a pleasant, laconic woman. Yes, she knew the lodge. Yes, she knew Jack and Joan. Yes, we should keep on administering CPR until she got there - which might take half an hour, as she'd have to ring up the ferryman to get her and her car across that crocodile-infested river.

The moment I hung up the phone, Alice yelled: "Douglas, get over here now. Chris is flagging."

And with good reason - because after five minutes of giving Jack mouth- to-mouth, Chris was winded. So I bent down, pulled open Jack's jaws, and covered his mouth with mine. But before I could exhale, he started to gag. White bile exploded out of his mouth into mine. I spat it out on to the floor, feeling sick. Jack's mouth was now brimming with chalky vomit. His face had turned the colour of a bruised plum, his eyes were as glazed as a lake in winter. People often talk about "a clean heart attack". This was the first one I had ever seen. It was not clean.

I forced open his jaws again. I plunged my finger into his mouth, and frantically began to scrape away the congealing bile. Alice, meanwhile, was still pumping his chest. Suddenly, she stopped. She reached up and touched a pulse-point on his neck. After 10 seconds, she looked at me and quickly shook her head. Then she sat slumped by the body, her face in her hands. Chris put his arms around her. No one said anything. I stood up, and reached for a bottle of Jack Daniel's behind the bar. Unscrewing the top, I used the bourbon as mouthwash, swilling it around my cheeks in an attempt to expunge the foul taste of Jack's bile. I spat two mouthfuls into the sink. Then I tipped the bottle back and drank. I needed alcohol. Badly.

Joan began to shout at us.

"Don't stop! Don't stop! Keep trying. Keep ... "

Alice stood up and held her. Joan let out a wail: a visceral, harrowing, heart-rending wail. I later learnt that she'd met Jack when she was 18. They had been married for 41 years.

I leaned over and handed the bottle of bourbon to Chris. He drank. Alice kept holding Joan. I sat dazed on a barstool, staring blankly into the jungly night. The district nurse eventually arrived with two ambulancemen. She knelt down by Jack's corpse. She looked him over.

"There's nothing you could've done, even if you'd had a defibrillator," she said quietly to me. "He was dead by the time he hit the floor."

Within an hour, the police had arrived. They took statements from each of us. Jack's two sons - both of whom also lived in the Daintree - showed up with their wives. They were men my own age. They looked as I imagined I would look, facing the death of my father.

They were stricken beyond belief. Utterly lost.

Chris and Alice invited me back to their cabin. The bottle of Jack Daniel's accompanied us. We sat there in silence for a very long time. Finally I said: "Quite a honeymoon."

We sat around drinking. Shock began to set in - the sort of shock that renders you numb, devoid of conversation. After half an hour, I excused myself and returned to my cabin. I didn't turn on the lights. I just flopped on to the bed and stared up at the shadowy interplay of the overhead fan. I had around half a litre of Jack Daniel's sluicing around in my bloodstream. I felt completely sober.

I hardly slept that night. At dawn the next morning, I walked back to the main area of the bar. Transportation was arranged for me and the honeymoon couple back to Cairns.

Before we left the lodge, Joan came out to see us. Her eyes were red, her face drained of all colour.

"Thanks for trying," she said quietly, before heading back to her quarters.

We rode in silence down to Cairns. When we arrived, I shook hands with Chris. Alice gave me a fast hug.

"We won't forget the Daintree in a hurry, will we?" she said.

"No," I said. "We won't."

I checked into a hotel. I went down to the pool. I spent an hour swimming laps. Then I changed into shorts and a T-shirt. I walked over to the Esplanade fronting the Pacific. I found a cafe. I ordered a beer. I looked up. After several days in the Daintree, it was good to see the sky again. Especially such a cloudless sky. A breeze blew in off the ocean, tempering the tropical heat. I took a deep breath. The air was sweet, And I found myself thinking: It is good to be here, drinking a beer, staring out at the lapping surf of the Pacific. I finished the beer. I ordered another. The sun was now on my face. I blinked into its incandescent glow. The waiter arrived with my bottle of Cooper's and a fresh glass.

"Beer okay?" he asked.

I looked up at him and smiled.

"This is the best beer I have ever tasted," I said.

He stared back at me, bemused.

"It's just a beer, mate," he said.

I raised my glass and took a sip.

"That's right," I said. "It's just a beer."

This incident took place just over three years ago. But I can still recall every detail of that night with frame-by-frame precision. It was the first time I had seen a man die - and you don't expunge something like that from your brain in a hurry.

But now, whenever I replay the entire dreadful scenario in my head, the most unnerving thing about Jack's death was its banality. One moment he was a sentient being. The next moment he was meat. As he walked to the bar he was a man who - like all of us - carried with him an entire history. Within 60 seconds, that history was over. All his ambitions, all his disappointments, all his pleasures, all his fears - all wiped clean in an instant. And he never saw it coming.

Personally, I hope for this sort of death - sudden and near instantaneous; a form of spontaneous combustion which will whisk me from the temporal to the eternal with the minimum of anguish or pain. Preferably, this abrupt transition should happen in my sleep, when I'm a fully compos mentis 97- year-old. But if it comes before then, let it be over before I know it. I don't want time to get my affairs in order. Or to muse at length about what I have - and haven't - achieved in my life. Or to throw a party and say goodbye. To descend into Mafia parlance, I simply want to be taken out.

Of course, the idea of taking stock or squaring up the accounts before dying inevitably touches an elegiac chord within us all. We all love a good death scene (like Mimi's in La Boheme), just as we all love a good five-handkerchief cancer movie (like Terms of Endearment or the recent One True Thing). Because, of course, in the heightened emotional landscape of a cancer movie, the dying person usually imparts some knowledge, some deep truth, to those he or she is leaving behind. There is a summing up. Familial wounds are healed. Unconditional love is expressed between all protagonists. There is a lot of hugging. There is a lot of growth.

Worst yet, there is closure: that most spurious entry in the psychobabble lexicon. By its very nature, closure implies that profound emotional wounds can be neutralised; that some sense can be made from life's most traumatic experiences. Call me a jaded middle-aged male, but if my 44 years have taught me anything, it's that life is a messy, convoluted business - and one which we never get right (no matter how hard we try). We attempt to know ourselves. We usually end up ceaselessly confused as to why we behave the way we do. We crave love. We mess up love. We struggle for some sense of relevancy to our short time on the planet (and often try to define it through professional accomplishments or material gains). But even success doesn't stop us from having those four-in-the-morning thoughts about the transitory nature of everything.

And lurking behind our every move is the knowledge of our own mortality. It gives life its edgy disquiet, its tenebrous underside. Death is always in attendance - to remind us of our pointlessness, our frantic need for faith, or conviction, or some modus vivendi to get us through the day. Death is the ultimate memorandum that everything is final.

And how we also secretly crave some sort of wisdom, some sort of grand existential insight, as we approach the final curtain. Evelyn Waugh got it so right when he noted (in one of his diaries): "We are American at puberty. We die French."

No wonder, therefore, that popular culture often dresses up the idea of a protracted death in romantic raiments. The wasting-away horrors of cancer, or Aids, or any other terminal nightmare, suddenly seem more palatable when there is a lesson to be garnered from the agony; when the dying person has sage moments of clarity about l'art du vivre. Whereas, of course, the brutal reality of a lengthy terminal illness is usually one of unbearable physical and emotional pain, of dashed hopes and deepest fears, and the gradual dismembering of one's personal dignity. To steal a very French line from a very French writer, Andre Malraux: "Death is not so serious. Pain is."

Perhaps that's the one and only lesson I drew from seeing Jack die.

Though the prospect of dying is a haunting one, the act itself - the passage from being to nothingness - is so damn simple. When life ends, it ends. You're here. You're not here. And the show moves on.

Jack Hamilton's death was fast. Neil Potter's was also fast. It was over in around four minutes. But unlike Jack, Neil knew he was dying for 19 years.

I only met Neil once - on a hot Tuesday afternoon in August 1988. I was travelling through that spiritual junkyard known as the Bible Belt, gathering material for a book that was eventually called In God's Country: an account of a three-month trawl through born-again America. It was the penultimate day of my journey -- and I was spending it in the town of Columbia, South Carolina, in the company of a one-time villain turned evangelist named Zack Leonard. Once upon a time, Zack was considered one of the toughest dudes in the Carolinas: a gent who had spent a total of 27 years in the slammer for a wide variety of offences, including armed robbery, assault with a deadly weapon and homicide.

During a period of solitary confinement, Zack underwent something of a Pauline conversion, after reading the autobiographical testament of a hood named Nicky Cruz, who changed from being a street-gang heavy to a fully-fledged member of the God Squad. The next morning Zack fell to his knees in this solitary cell. "I pleaded for forgiveness," he told me. "Asked Christ to change my life."

Four years after this "rebirth", he was granted parole - and became an ordained Baptist minister. When I met him in 1988, he was running a prison ministry - a job which sent him constantly to the state penitentiary in Columbia. Every Tuesday, he spent several hours ministering to the men who resided in that ultimate voyage of the damned: death row. And on one such Tuesday he allowed me to accompany him on his rounds.

The Central Correctional Institution at Columbia, South Carolina was a series of low, squat buildings; a grim architectural relic of 19th-century brutalism. After passing through a labyrinth of metal detectors, sliding electric gates and ill-lit corridors, we stopped by a solid iron door fitted with a peephole. Zack rang a bell, an eye appeared at the peephole, the door opened, and an armed guard ushered us into Unit CB2 - death row.

I found myself in a vast, high-vaulted enclosure of cages and steel walkways. There was no air conditioning, no communal fans - so the heat was overpowering. The roof was around 80ft above me, turning this area into the ultimate echo chamber. The place was starved of natural light - it was all harsh fluorescent tubes and naked lightbulbs. There was a non-stop soundtrack of clamorous noise. After five minutes here, silence suddenly struck me as one of the most precious commodities imaginable.

The chapel was a small box of a room at the end of death row. It once served as a solitary confinement cell. Now a sign on its heavy steel door - God Loves Us - marked it out as a place of worship. A guard shouted, "Who's for chapel?" Cell doors opened. The men began to file into this tiny room. Before Zack's "service", I got talking with several of the inmates.

Almost immediately, they each began to tell me their story of the crime that had brought them to this living nightmare, this Ultimate Last Stop. Because, as I discovered, everyone on death row had a story - a story which they had to live with, a story which they constantly replayed in their minds day-in, day-out. And if you were an emissary from normal life, the inmates generally wanted to tell you their story.

Of all the stories I listened to that afternoon, Neil Potter's was the one that stayed with me. He was exactly my age - 33 in 1988 - rail-thin, wearing an American- Indian headband, carrying a notebook. He instantly noticed that I too was carrying a notebook.

"You a writer?" Neil said after Zack introduced us. "Me too. Writing a book about my life. About the way my case was twisted against me ...

"I've been here since '79. I wasn't accused of a killing, though - but of being an accessory to a killing, which down here is the same thing. I was 200ft away when the actual killing took place - when this woman hitchhiker that my cousin and girlfriend and I picked up got stabbed. Wasn't me who did the killing. Was my cousin. He's here too. Course my girlfriend got off. Prosecutor gave her immunity from justice if she'd testify against us. Which, of course, the bitch did.

"Been on the row now for 10 years. Had a retrial and a bunch of appeals, but lost all those. I've been sentenced to death three times now. And you know what really gets me; the state's probably spent millions trying to get me into the electric chair. But, instead of trying to kill me, why didn't they put all that money towards trying to educate me in here?"

It was quite an afternoon. Around four, one of the prison guards informed Zack that we would have to leave now. I shook Neil's hand on my way out, and wished him luck with the book he was writing.

I never was in contact with Zack Leonard or Neil Potter again. The only time I seriously wondered about Neil's fate was sometime in the early Nineties, when I read that the Central Correctional Institution of Columbia had moved into a spanking new modern facility, and that the state of South Carolina had retired the electric chair in favour of lethal injection.

Then, last summer, on a visit back to the States, I sat down for breakfast in a restaurant in downtown Denver and opened that morning's edition of The New York Times. On the back page a headline read something like: South Carolina Executes Convicted Murderer. The five-line story simply stated the facts: "Neil Potter, 43, had been executed the previous night for the 1979 slaying of ... "

The report pointed out that Potter had always maintained his innocence, saying that it was his cousin (executed earlier that year) who did the actual killing. It also noted that, after the lethal poison was administered, Potter was pronounced dead at 6.04pm local time.

I thought back to the previous day. I remembered exactly what I was doing at the moment when that chemical cocktail stopped Neil's heart. I was buying a Lego spaceship for my son Max in some air-conditioned, muzak- ridden shopping mall. I instantly recalled Neil Potter's face in my mind - even though it was 10 years since we had met. Ten years. So much had happened to me during that ten years.

My wife and I had had two children. I had published five books. I'd written far too much journalism. I had travelled a lot. I had moved house twice. I'd entered that long dark corridor called middle-age - and like all newcomers to mid-life, I'd thought a bit about the proverbial downward slope, and the whole business of dying.

Most of the time I simply got on with the business of filling time, as we all do. Because only by filling the time - by crowding our lives with the minutiae of existence - do we keep the reality of our future death at bay.

Whereas, for those 10 years, Neil Potter was confined by a 10ft x 5in cell. Unlike me, he didn't look upon death as a nocturnal terrorist, which one day would hijack him without warning. He had a date.

For 19 years, that date kept changing (thanks to appeals processes). But eventually, the postponements ended. The date was finally kept.

Sitting in that Denver restaurant, staring down at this five-line report of Neil Potter's execution, my mind began to race wildly. I hardly knew the guy - we'd talked for maybe 30 minutes at the most - but I still tried to imagine what his final hours were like. And how he coped during that walk from his holding cell to the death chamber.

At that moment, another image flashed across my brain: that 1996 night in the Daintree ... sitting at a table with Jack and the honeymoon couple ... Jack standing up and saying: "It's my round," then heading off in the direction of the bar.

Two final walks. Two deaths. One anticipated. One not. Of course, Jack knew it was coming. Just as we all do. He just didn't know when. No time for goodbyes, no time for regrets, no extended physical agony, no spiritual grappling with the idea of eternity. The plug was pulled. He was gone. The unexamined life may not be worth living ... but isn't there a lot to be said for the unexamined death? n

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Exertional Heat Stroke and Sudden Death Essay

The main issues/causes of sudden death within this particular condition, what to look out for as an athletic trainer, works cited.

Exertional heat stroke (EHS) is a heat illness that results from either exposure to very high environmental temperature or intense exercise. Although it may not be categorized as the top causes of fatalities among athletes, it is one of the causes of sudden death. I choose to discuss it because of its capacity to cause sudden death. Besides, athletic trainers seem to ignore it, despite its link with several deaths.

Physical injuries that are likely to lead to death such as concussions have been prioritized, with necessary measures being taken to prevent them. Nevertheless, awareness about EHS is not well spread. Scores of athletes have collapsed on the field during practice or matches, particularly in hot and humid weather or when dressed in heavy training gear. EHS is fatal. Therefore, it should be studied in depth, from its causes, symptoms, prevention, and treatment. This would in turn reduce sudden death in sports such as football as noted by Casa et al. (104).

Heat stroke kills within a very short time. When one collapses, it is advisable for the clinician to immerse him or her in ice-cold water. The earlier the immersion takes place, the higher the chances of survival. When immersion is not an option, the patient should be wrapped in cold towels on as much body surface as possible. This plan helps in lessening the body temperature to about 38.9 degrees.

EHS patients may die out of an array of causes. Generally though, deaths result from the shutting down or destruction of vital body organs. When the thermoregulatory system is overwhelmed, there is accumulation of unnecessary heat in the body. The heat leads to the malfunctioning of the Central Nervous System, which is manifested in the symptoms of EHS. If the reduction of body temperature is not done immediately after collapsing, it is less likely for patients to survive, even when they make it to hospital. A delay in the reduction of body temperature increases the severity of damage in the body organs (Casa et al. 104).

According to the National Athletic Trainers’ Association, it is vital for an athletic trainer to recognize the symptoms of EHS (par.1). Some of the indications to watch out for among athletes include diarrhea, muscle cramps, altered consciousness, headache, dizziness, biliousness, confusion,emotional instability, collapse, profuse sweating, weakness, dehydration, irritability, irrational behavior, and rectal temperature above 40 degrees. These symptoms are most likely to occur if it is hot and humid, if the athlete is in poor physical shape, or if the athlete’s is in training equipment for first day. When the symptoms are recognized, the athlete should remove all excess clothing and be immersed in ice water for about 30 minutes.

If such facilities are not available, the athlete should move to a shade, take a cold shower, and cover maximum body area with cold wet towels. Proper breathing and air circulation should be maintained, and emergency services called immediately. Athletic trainers should be well educated on EHS. Therefore, they need to ensure that their practice areas have cooling facilities and water supply in line with EHS policies. They should also program their workout hours to ensure minimum temperature. Trainers have the obligation to ensure that athletes are fully aware of the risks of EHS. Therefore, they should follow all safety guidelines. Heat stroke can be prevented through proper hydration, dressing in light-fitting clothing, practicing in the shade and minimizing warm up time, eating a balanced diet, and getting sufficient sleep. Another means of prevention it is increasing workout time through a slow progress for the athletes.

Casa, Douglas, Kevin Guskiewicz, Scott Anderson, Ronald Courson, Jonathan Heck, Carolyn Jimenez, Brendon McDermott, and Michael Miller. “National Athletic Trainers’ Association Position Statement: Preventing Sudden in Sports.” Journal of Athletic Training 47.1(2012): 96-118. Print.

National Athletic Trainers’ Association. Preventing Sudden Death in Sports: Brief summary of NATA’s Position Statement: Preventing Sudden Death in Sports, 2013. Web.

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IvyPanda. (2020, June 26). Exertional Heat Stroke and Sudden Death. https://ivypanda.com/essays/exertional-heat-stroke-and-sudden-death/

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IvyPanda . (2020) 'Exertional Heat Stroke and Sudden Death'. 26 June.

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1. IvyPanda . "Exertional Heat Stroke and Sudden Death." June 26, 2020. https://ivypanda.com/essays/exertional-heat-stroke-and-sudden-death/.

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Sudden Death

Historical description of sudden unexpected death goes back to Pliny the Elder in the 1st Century AD in his book, Natural History in which he described affluent citizens of Rome dropping dead (Pliny). Lancisi, Roman physician, wrote a classic tome on sudden death at the commission of Pope Clement XI, who had become alarmed at a rash of such deaths in Rome starting in the spring of 1705. The Papal concern was that God had become displeased with the Romans. Lancisi studied the cases, performed autopsies, and analyzed the causes. He failed to exonerate entirely Roman sin and perfidy (Lancisi).

[ The Lancisi Library is housed in the Ospidale Santo Spirito in Rome. That historic hospital also houses, even today, vast wards extending into distant mists pierced by brilliant light shafts from high transoms. An ancient peephole of ill fame can still be found in the eye of a mural figure in the upper reaches, far above the women’s ward, through which it is purported that monks of old satisfied their prurient interest. ]

Lancisi’s theories on the causes of sudden death were traditional, having to do with the prevailing ideas about body humors; he only began to elaborate underlying causes. He, nevertheless, defined sudden and unexpected death and recognized many causes: sudden rupture of the vena cava, aneurysm of the aorta, aneurysm of the heart, specific aortic diseases, and various forms of stroke. And he made the observation that the apparent Roman epidemic had no universal cause; rather he sophisticatedly calculated that it was due in part to the diminution of other causes of death.

Otherwise, he attributed the apparent rash of sudden deaths to intemperance among the population, which he thought accounted for the predominant distribution of cases among men. Lancisi wrote: “… it left the other sex almost untouched, so that until this very day we have scarcely been able to list some few women who did die suddenly.” He attributed the freedom from sudden death in women to their more tempered life: “ … [women] were more continent in regard to food and drink and in their sexual life and had thus far kept themselves happily free from sudden deaths. On the other hand, the uncautious, the voluptuous, and the wine bibbers fell an easy prey to unexpected deaths.”

There was no reference to coronary artery disease, so it is not clear that Lancisi dealt with any coronary cases at all or that his speculations on the causes of the apparent cluster of sudden deaths in Rome have anything to do with the 20th century coronary disease epidemic.

We learned recently from our colleague, Alessandro Menotti of Rome that in the 1980’s another ancient book on sudden death was discovered in Italy, with provenance a century earlier than the famous one of Lancisi. The author was Paolo Grassi, a physician working in the Hospital of Correggio, a small town 20 miles west of Crevalcore, the birthplace of Malpihgi, the anatomist, and coincidentally, the site of a Seven Countries Study cohort.

Grassi’s book was published in Modena in 1612 with the title, “Mortis Repentinae Examen” (Dissertation on Sudden Death), with the exquisite subtitle: “Including a short method allowing those at risk to take some precautions!” The Latin script was discovered by a physician working in the same hospital three centuries after Grassi, then translated into Italian and distributed by an Italian charity promoting CVD prevention. It lacks the anatomical dissections of Lancisi’s book but described angina pectoris followed by sudden death and the accompaniment of specific arrhythmias identifiable in his descriptions of the pulse.

Among the possible causes of sudden death that he considered were, in 1612, sedentariness, excessive eating, eating fatty foods, and excess drinking, all the while recommending moderate wine consumption “for good health and good spirits.” One wonders that Lancini failed to refer to this earlier work. (Henry Blackburn)

White, Paul D. and Boursey, Alfred V, 1971 Translation of De Subitaneis Mortibus (On Sudden Deaths) New York: St. John’s University Press.

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Sheryl Sandberg wrote a beautiful essay about the sudden death of her husband and dealing with grief

Sheryl Sandberg lost her husband, Dave Goldberg, 30 days ago in a tragic treadmill accident while on vacation in Mexico.

In the month since Goldberg's death, Sandberg has learned about love, life, and how to cope with extreme grief. She wrote all these lessons down in a Facebook essay so that others who face tragedy can learn from her experience.

The advice is really good, whether you're experiencing a loss or helping someone else who is. For example, Sheryl says asking her "How are you doing today?" is better than asking "How are you doing?" since the latter suggests ignorance about a great loss, and the former implies knowing it's hard to get through each and every day.

Here's the essay in full :

Today is the end of sheloshim for my beloved husband—the first thirty days. Judaism calls for a period of intense mourning known as shiva that lasts seven days after a loved one is buried. After shiva, most normal activities can be resumed, but it is the end of sheloshim that marks the completion of religious mourning for a spouse.

A childhood friend of mine who is now a rabbi recently told me that the most powerful one-line prayer he has ever read is: "Let me not die while I am still alive." I would have never understood that prayer before losing Dave. Now I do.

I think when tragedy occurs, it presents a choice. You can give in to the void, the emptiness that fills your heart, your lungs, constricts your ability to think or even breathe. Or you can try to find meaning. These past thirty days, I have spent many of my moments lost in that void. And I know that many future moments will be consumed by the vast emptiness as well.

But when I can, I want to choose life and meaning.

And this is why I am writing: to mark the end of sheloshim and to give back some of what others have given to me. While the experience of grief is profoundly personal, the bravery of those who have shared their own experiences has helped pull me through. Some who opened their hearts were my closest friends. Others were total strangers who have shared wisdom and advice publicly. So I am sharing what I have learned in the hope that it helps someone else. In the hope that there can be some meaning from this tragedy.

I have lived thirty years in these thirty days. I am thirty years sadder. I feel like I am thirty years wiser.

I have gained a more profound understanding of what it is to be a mother, both through the depth of the agony I feel when my children scream and cry and from the connection my mother has to my pain. She has tried to fill the empty space in my bed, holding me each night until I cry myself to sleep. She has fought to hold back her own tears to make room for mine. She has explained to me that the anguish I am feeling is both my own and my children's, and I understood that she was right as I saw the pain in her own eyes.

I have learned that I never really knew what to say to others in need. I think I got this all wrong before; I tried to assure people that it would be okay, thinking that hope was the most comforting thing I could offer. A friend of mine with late-stage cancer told me that the worst thing people could say to him was "It is going to be okay." That voice in his head would scream, How do you know it is going to be okay? Do you not understand that I might die? I learned this past month what he was trying to teach me. Real empathy is sometimes not insisting that it will be okay but acknowledging that it is not. When people say to me, "You and your children will find happiness again," my heart tells me, Yes, I believe that, but I know I will never feel pure joy again. Those who have said, "You will find a new normal, but it will never be as good" comfort me more because they know and speak the truth. Even a simple "How are you?"—almost always asked with the best of intentions—is better replaced with "How are you today?" When I am asked "How are you?" I stop myself from shouting, My husband died a month ago, how do you think I am? When I hear "How are you today?" I realize the person knows that the best I can do right now is to get through each day.

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I have learned some practical stuff that matters. Although we now know that Dave died immediately, I didn't know that in the ambulance. The trip to the hospital was unbearably slow. I still hate every car that did not move to the side, every person who cared more about arriving at their destination a few minutes earlier than making room for us to pass. I have noticed this while driving in many countries and cities. Let's all move out of the way. Someone's parent or partner or child might depend on it.

I have learned how ephemeral everything can feel—and maybe everything is. That whatever rug you are standing on can be pulled right out from under you with absolutely no warning. In the last thirty days, I have heard from too many women who lost a spouse and then had multiple rugs pulled out from under them. Some lack support networks and struggle alone as they face emotional distress and financial insecurity. It seems so wrong to me that we abandon these women and their families when they are in greatest need.

I have learned to ask for help—and I have learned how much help I need. Until now, I have been the older sister, the COO, the doer and the planner. I did not plan this, and when it happened, I was not capable of doing much of anything. Those closest to me took over. They planned. They arranged. They told me where to sit and reminded me to eat. They are still doing so much to support me and my children.

I have learned that resilience can be learned. Adam M. Grant taught me that three things are critical to resilience and that I can work on all three. Personalization—realizing it is not my fault. He told me to ban the word "sorry." To tell myself over and over, This is not my fault. Permanence—remembering that I won't feel like this forever. This will get better. Pervasiveness—this does not have to affect every area of my life; the ability to compartmentalize is healthy.

For me, starting the transition back to work has been a savior, a chance to feel useful and connected. But I quickly discovered that even those connections had changed. Many of my co-workers had a look of fear in their eyes as I approached. I knew why—they wanted to help but weren't sure how. Should I mention it? Should I not mention it? If I mention it, what the hell do I say? I realized that to restore that closeness with my colleagues that has always been so important to me, I needed to let them in. And that meant being more open and vulnerable than I ever wanted to be. I told those I work with most closely that they could ask me their honest questions and I would answer. I also said it was okay for them to talk about how they felt. One colleague admitted she'd been driving by my house frequently, not sure if she should come in. Another said he was paralyzed when I was around, worried he might say the wrong thing. Speaking openly replaced the fear of doing and saying the wrong thing. One of my favorite cartoons of all time has an elephant in a room answering the phone, saying, "It's the elephant." Once I addressed the elephant, we were able to kick him out of the room.

At the same time, there are moments when I can't let people in. I went to Portfolio Night at school where kids show their parents around the classroom to look at their work hung on the walls. So many of the parents—all of whom have been so kind—tried to make eye contact or say something they thought would be comforting. I looked down the entire time so no one could catch my eye for fear of breaking down. I hope they understood.

I have learned gratitude. Real gratitude for the things I took for granted before—like life. As heartbroken as I am, I look at my children each day and rejoice that they are alive. I appreciate every smile, every hug. I no longer take each day for granted. When a friend told me that he hates birthdays and so he was not celebrating his, I looked at him and said through tears, "Celebrate your birthday, goddammit. You are lucky to have each one." My next birthday will be depressing as hell, but I am determined to celebrate it in my heart more than I have ever celebrated a birthday before.

I am truly grateful to the many who have offered their sympathy. A colleague told me that his wife, whom I have never met, decided to show her support by going back to school to get her degree—something she had been putting off for years. Yes! When the circumstances allow, I believe as much as ever in leaning in. And so many men—from those I know well to those I will likely never know—are honoring Dave's life by spending more time with their families.

I can't even express the gratitude I feel to my family and friends who have done so much and reassured me that they will continue to be there. In the brutal moments when I am overtaken by the void, when the months and years stretch out in front of me endless and empty, only their faces pull me out of the isolation and fear. My appreciation for them knows no bounds.

I was talking to one of these friends about a father-child activity that Dave is not here to do. We came up with a plan to fill in for Dave. I cried to him, "But I want Dave. I want option A." He put his arm around me and said, "Option A is not available. So let's just kick the shit out of option B."

Dave, to honor your memory and raise your children as they deserve to be raised, I promise to do all I can to kick the shit out of option B. And even though sheloshim has ended, I still mourn for option A. I will always mourn for option A. As Bono sang, "There is no end to grief ... and there is no end to love." I love you, Dave. — with Dave Goldberg.

And here's the Facebook post:

Today is the end of sheloshim for my beloved husband—the first thirty days. Judaism calls for a period of intense... Posted by Sheryl Sandberg on Wednesday, June 3, 2015

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Free Sudden Death: Discussion Essay Example

Type of paper: Essay

Topic: Sociology , Psychology , Health , Workplace , Human Resource Management , Community , Life , Mental Health

Published: 03/17/2020

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It is difficult to cope with life’s challenges right away, especially if a loved one suddenly died. Sudden and tragic deaths give the closest relatives of the deceased a shocking feeling. It is the community mental health centers’ role to serve people feeling feeble after a shocking turn of tragic events. Nobody can escape death, and people are destined to lose someone they cherish very much. Through times of losing someone, it will be difficult to prove that “life goes on.” With the help of mental health centers, they could empower the relatives of the deceased by celebrating life and remembering the good times. It is also the role of community mental health professionals to give sympathy and respect for those caught in the middle of unexpected events. Mental health professionals know what is best for a specific person coping with the loss of special someone. They need to have a high level of patience and understanding, while eventually finding a way to give inspirational counseling. How should government agencies and related higher entities engage communities to offer services at both a micro level? It will be difficult for social workers in small communities to adjust to their job responsibilities, especially if their focus does not lean on people-centric goals. To ensure engagement of social workers tasked for maintaining mental health, consistent encouragement must be existent. Long-term programs through seminars and active participation in efforts relating to character building would be a fresh approach for social workers. Agencies must emphasize importance of giving unconditional help. When social workers show signs of unconditional love, it would seem that social workers do not feel forced when counseling others.

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• Volume 30, Issue 2
• “As vast as the world”—reflections on A Very Easy Death by Simone de Beauvoir
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• Correspondence to:
 F Brennan
 Calvary Hospital, Kogarah, Sydney, NSW 2217, Australia; fpbrennanozemail.com.au

In 1964, Simone de Beauvoir, arguably one of the greatest writers of 20th century Europe, published an account of the final 6 weeks of her mother’s life. It is a beautifully written, raw, honest, and powerful evocation of that period from the viewpoint of a relative. Its themes are universal—love, ambivalence in family ties, loss, and bereavement. Given that the events preceded the modern palliative care movement, reflections are made on differences in medical practice since the book’s publication.

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https://doi.org/10.1136/jmh.2004.000163

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A 78 year old woman has two daughters. She has been widowed for 24 years. She begins to complain of anorexia and intermittent abdominal pain. The symptoms abate. One day she collapses at her home. Her left femur is fractured. She is admitted to hospital. The gastrointestinal symptoms return. After a series of investigations, she is discovered to have a sarcoma involving the small intestine. Soon after, she develops, in rapid succession, an acute bowel obstruction, ruptured viscus, and peritonitis. A laparotomy is performed, pus is drained, and the tumour resected. Complications ensue and she dies four weeks after the operation. At no stage is either her diagnosis or prognosis discussed with her. The time is 1963, the place is Paris, and one of her daughters is Simone de Beauvoir.

Simone de Beauvoir was a leading French writer, philosopher, and feminist. She wrote The Second Sex , a classic text of feminist literature and several volumes of autobiography. The autobiographical volumes include Memoirs of a Dutiful Daughter, 1958; The Prime of Life, 1960; Force of Circumstance, 1963 and All Said and Done, 1972. De Beauvoir also wrote fiction (perhaps the best known is The Mandarins , published in 1954) philosophy, travel books, and essays, some of them book length, the best known of which is The Second Sex, 1949. A year after her mother’s death she wrote A Very Easy Death . 1 This book is an extremely personal, indeed intimate account of the death of a woman by her daughter. Madame de Beauvoir was abruptly plunged into a cascade of illness, debility, and finally death and we accompany all parties through the frustrations, false hopes, turmoil, and duplicity of her last weeks. At its heart, the book is about a mother and daughter. But it is also a reflection on suffering, family, faith, and mortality. The insights it gives us as health professionals are fascinating—here we have one of the great minds of 20th Century Europe struggling through, and recording with aching honesty, the terminal phase of her own mother’s life. This paper reflects on the book, but also on medical practice and the changes brought to that practice by the modern palliative care movement.

The book is a narrative and can be read as such. Through that narrative, however, lie several universal themes. They include:

The role of doctors.

Information giving and “betrayal”.

The role of time and change.

Love of life and grief do not respect age.

The power of ritual.

THE DOCTORS

The depictions of doctors in this book are a study in contrasts. When Mme de Beauvoir collapses at home, a doctor in the same set of apartments assists. Her local doctor takes great umbrage that he was not personally called and refuses to see her. A neighbour is appalled: “After the shock and after her night in the hospital, your mother needed comforting by her usual doctor. He wouldn’t listen to a word of it” (De Beauvoir, 1 p 12).

Various hospital doctors are involved with her care and two are described well—Drs P and N. Their styles and capacity for communication are very different. When she develops an acute bowel obstruction, Dr N, who is described as a resuscitation expert, is summoned. When Simone arrives she finds her sister in tears:

“But what’s the good of tormenting her, if she is dying? Let her die in peace”, said Poupette, in tears…Dr N passed by me; I stopped him. White coat, white cap: a young man with an unresponsive face. “Why this tube? Why torture Maman, since there is no hope?” He gave me a withering look. “I am doing what has to be done”. He opened the door. After a moment a nurse told me to come in… “Would you like me to have left that in her stomach?” said N aggressively, showing me the jar full of a yellowish substance. I did not reply. In the corridor he said “At dawn she scarcely had four hours left. I have brought her back to life.” I did not venture to ask him “For what?” (De Beauvoir, 1 pp 27–8)

Later she describes him as “smart, athletic, energetic, infatuated with technique…he had resuscitated Maman with great zeal; but for him she was the subject of an interesting experiment and not a person. He frightened us” (De Beauvoir, 1 p 52). The doing what had to done was coupled with a mechanical, tactless, and detached manner. Late in the illness Simone records:

When she opened her eyes during the day they had an unseeing, glassy look and I thought, “This time it is the end.” She went to sleep again. I asked N, “Is this the end?”“Oh, no!” he said in a half-pitying, half triumphant tone, “she has been revived too well for that!” (De Beauvoir, 1 p 76)

And again later she narrates:

I spent that night beside her. She was as much afraid of the nightmares as she was of pain. When Dr N came she begged, “Let them inject me as often as necessary”…“Ha, ha, you are going to become a real drug-addict!” said N in a bantering tone. “I can supply you with morphia at very interesting rates.” His expression hardened and he said coldly in my direction, “There are two points upon which a self-respecting doctor does not compromise—drugs and abortion” (De Beauvoir, 1 p 79).

It is tempting to view Dr N as a caricature but de Beauvoir does not write in that fashion and otherwise appears to be recording extremely faithfully.

In contrast, Dr P is altogether warmer. Simone states : “I liked Dr P. He did not assume consequential airs; he talked to Maman as though she were a human being and he answered my questions willingly.” 1 When asked, he promised the sisters that their mother would not suffer. Later, after a very poor day of pain they confront him again:

He came and we seized upon him. “You promised she wouldn’t suffer.” “She will not suffer”. He pointed out that if they had wanted to prolong her life at any cost and give her an extra week of martyrdom, another operation would have been necessary, together with transfusions, and resuscitating injections…But this abstention was not enough for us. We asked P, “Will morphia stop the great pains?” “She will be given the doses that are called for.” He had spoken firmly and he gave us confidence. We grew calmer (De Beauvoir, 1 p 82).

“We grew calmer”—would that this were the epitaph of all our careers!

Communication is a crucial part of medical practice. Currently, communication forms part of undergraduate curricula in many countries. One hopes that modern health professionals respond more sensitively to patients and relatives than was the experience of de Beauvoir. Nevertheless, poor, abrupt, and inadequate communication remains an issue. As Lesley Fallowfield, a leading expert in psycho-oncology, states: “many doctors invest considerable energy cultivating a posture of cool detachment on the grounds that it represents the more professional type of response expected of doctors. Unfortunately patients and relatives can view this detached attitude as evasive, cold, and unsympathetic, occurring at just the time that they are in much need of empathy and support.” 2

The other issue pertinent to modern practice is pain and its management. Mme De Beauvoir pleads with the doctor: “Let me be injected as often as necessary”. This entreaty may indeed be a template of the modern approach to analgesia: that pain relief is best provided by regular analgesia with additional (or “breakthrough”) doses when required. In the narrative, the issue of analgesia was further complicated by the fear of addiction. Fear of opioid use continues into the modern era and remains one of the many barriers to adequate analgesia. Concern about opioid addiction, tolerance, and dependence plus unrealistic expectations about precipitating adverse side effects all recur in modern surveys of the attitudes of doctors and nurses to opioids. 3, 4 †

Although certainly not universal, opiophobia is coupled with opioignorance, with survey respondents repeatedly acknowledging that they have received insufficient training in or exposure to pain management. 5

INFORMATION GIVING AND “BETRAYAL”

Throughout the book, Simone is troubled, and often grievously so, by a sense of betrayal of her mother. Firstly, by allowing the operation to occur, and secondly, in being complicit in withholding the diagnosis from her. In the context of the operation, Simone captures perfectly the sense of responsibility relatives feel in these situations, especially when the choices are viewed as extraordinarily bleak:

And that evening too, as I looked at her arm, into which [the intravenous fluid] was flowing a life that was no longer anything but sickness and torment, I asked myself why ?At the nursing home I did not have time to go into it... But when I reached home, all the sadness and horror of these last days dropped upon me with all its weight. And I too had a cancer eating into me—remorse. “Don’t let them operate on her.” And I had not prevented anything. Often, hearing of sick people undergoing a long martyrdom, I had felt indignant at the apathy of their relatives. “For my part, I should kill him.” At the first trial I had given in: beaten by the ethics of society, I had abjured my own. “No,” Sartre said to me. “You were beaten by technique: and that was fatal.” Indeed it was. One is caught up in the wheels and dragged along, powerless in the face of specialists’ diagnoses, their forecasts, their decisions. The patient becomes their property: get him away from them if you can! There were only two things to choose between on that Wednesday—operating or euthanasia. Maman, vigorously resuscitated, and having a strong heart, would have stood out against intestinal stoppage for a long while and she would have lived through hell, for the doctors would have refused euthanasia…A race had begun between death and torture. I asked myself how one manages to go on living when someone you love has called out to you “Have pity on me” in vain (De Beauvoir, 1 pp 56–8).

Neither the diagnosis nor the prognosis is ever discussed with Mme de Beauvoir. It is a duplicity that is initiated by the doctors but thereafter everyone is complicit. For Simone it constitutes a betrayal. After the operation they ask the surgeon: “But what shall we say to Maman when the disease starts again, in another place?” “Don’t worry about that. We shall find something to say. We always do. And the patient always believes it” (De Beauvoir, 1 p 45). Even when her mother asks the question: “Do you think I shall come through?” Simone scolds her (De Beauvoir, 1 p 65) and immediately regrets it:

My unfair harshness wrung my heart. At the time the truth was crushing her and when she needed to escape from it by talking, we were condemning her to silence; we forced her to say nothing about her anxieties and to suppress her doubts: as it had so often happened in her life, she felt both guilty and misunderstood. But we had no choice: hope was her most urgent need (De Beauvoir, 1 p 66).

Even though Simone never betrayed this conspiracy of silence she railed against it and clearly saw what openness could bring and what silence could lead to:

…all this odious deception! Maman thought that we were with her, next to her; but we were already placing ourselves on the far side of her history. An evil all-knowing spirit, I could see behind the scenes, while she was struggling, far, far away, in human loneliness. Her desperate eagerness to get well, her patience, her courage—it was all deceived. She would not be paid for any of her sufferings at all... Despairingly, I suffered a transgression that was mine without my being responsible for it and one that I could never expiate (De Beauvoir, 1 p 58).

This silence is maintained and preserved to such an extent that in the very hour of their mother’s death, Simone’s sister is compelled to respond to an explicit entreaty by her mother:

…she murmured in a rather thick voice, “We must…keep…back…desh.”“We must keep back the desk ?”“No,” said Maman. “Death.” Stressing the word death very strongly. She added, “I don’t want to die”.“But you are better now!” [said Poupette] (De Beauvoir, 1 p 88).

Professional and public attitudes to non-disclosure of diagnosis and collusion between relatives and health professionals have, in many countries, changed significantly since the events narrated in this book. There is clear evidence that most North American and European patients wish to be informed about a diagnosis of cancer, 6– 8 and health professionals have changed their practice to reflect these expectations. There is also, however, significant evidence from other cultures that suggests that non-disclosure and collusion with families are common practice. Some cultures perceive the disclosure as a harmful act, violating the principle of non-maleficence. 9, 10 Brurea et al surveyed palliative care specialists in French speaking Europe, South America (Argentina and Brazil) and Canada. All the clinicians said they would personally like to be told the truth about their own terminal illness. Whereas 93% of Canadians physicians thought the majority of their patients would wish to know, only 26% of European and 18% of South American clinicians thought so. 11 Many Chinese families object to telling the patient a “bad” diagnosis or prognosis and doctors in mainland China often inform the family members instead of the patient. 12, 13

PALLIATIVE CARE

A further dilemma reflected upon in the book is the stark choice de Beauvoir sees confronting her mother, between “operating or euthanasia” and then, postoperatively, “between death and torture”. In retrospect, a third alternative was palliative care. The events of the narrative preceded the modern palliative care movement. Indeed, it was precisely clinical situations such as this narrative reveals, and the recognition of the inadequacy of symptom control and end of life care that motivated the pioneers of that movement. That movement’s founding and primary aim is to care for all people with life threatening illnesses and their families. The most recent definition of palliative care by the World Health Organization includes the objective of “early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual”. Palliative care, as practised today would have been perfect for the situation described: better symptom control, anticipation of worsening symptoms, attention to the psychosocial and spiritual needs of the patient, and assisting the relatives in the vigil leading to the patient’s death. Indeed, this book would provide a useful teaching exercise in palliative care education. Among many questions that the narrative raises, one that could be posed to students would be: how would a modern palliative care service deal with the challenges faced by the patient and her family?

TIME AND CHANGE

Mme de Beauvoir had an unhappy childhood. She brought at least some of that unhappiness into her role as a mother. Simone describes her mother as difficult, possessive, and overbearing. “Her love for us was deep as well as exclusive, and the pain it caused us as we submitted to it was a reflection of her own conflicts…With regard to us, she often displayed a cruel unkindness that was more thoughtless than sadistic: her desire was not to cause us unhappiness but to prove her own power to herself” (De Beauvoir, 1 p 40). Simone pictures her as an unhappy woman who struggled with both her desires and her daughters:

Thinking against oneself often bears fruit; but with my mother it was another question again—she lived against herself. She had appetites in plenty: she spent all her strength in repressing them and she underwent this denial in anger. In her childhood her body, her heart and her mind had been squeezed into an armour of principles and prohibitions. She had been taught to pull the laces hard and tight herself. A full blooded, spirited woman lived on inside her, but a stranger to herself, deformed and mutilated (De Beauvoir, 1 pp 42–3).

However, a strange thing happens. As Simone visits her mother she notices changes in her mother, changes in herself, and finally an outpouring of love and grief that is both powerful and unexpected. For the first period of her illness, Mme de Beauvoir remains difficult and emotionally demanding, but then, vulnerable and recovering, glimpses of another self emerge:

What touched our hearts that day was the way she noticed the slightest agreeable sensation: it was as though, at the age of seventy eight, she were waking afresh to the miracle of living. While the nurse was settling her pillows the metal of a tube touched her thigh—“It’s cool! How pleasant!” She breathed in the smell of eau de Cologne and talcum powder—“How good it smells”…She asked us to raise the curtain that was covering the window and she looked at the golden leaves of the trees. “How lovely. I shouldn’t see that from my flat!” She smiled. And both of us, my sister and I, had the same thought: it was that same smile that had dazzled us when we were little children, the radiant smile of a young woman. Where had it been between then and now? (De Beauvoir, 1 p 50)

The softening continues.

Her illness had quite broken the shell of her prejudices and her pretensions: perhaps because she no longer needed these defences. No question of renunciation or sacrifice any more: her first duty was to get better and so to look after herself; giving herself up to her own wishes and her own pleasures with no holding back, she was at last freed from resentment. Her restored beauty and her recovered smile expressed her inner harmony and, on this deathbed, a kind of happiness (De Beauvoir, 1 p 60).

Finally, after days of sitting with her mother Simone reflects:

I had grown very fond of this dying woman. As we talked in the half darkness I assuaged an old unhappiness; I was renewing the dialogue that had been broken off during my adolescence and that our differences and our likenesses had never allowed us to take up again. And the early tenderness that I thought dead for ever came to life again, since it had become possible for it to slip into simple words and actions (De Beauvoir, 1 p 76).

GRIEF AND LOVE OF LIFE DO NOT NECESSARILY RESPECT AGE

Mme de Beauvoir is 78 years old. Her daughter is content, almost as a reflex, to initially consider this is “of an age to die”. Age, however, is irrelevant. Her mother was aware of this much earlier than her daughter. Simone writes of her mother: “She believed in heaven, but in spite of her age, her feebleness, and her poor health, she clung ferociously to this world, and she had an animal dread of death” (De Beauvoir, 1 p 14).

It was that ferocity that her daughter came to understand. Her mother’s loss she came to see as a form of defeat where time and age were irrelevant. After the funeral she reflects on how empty is the sentiment “they are of an age to die”:

The sadness of the old; their banishment: most of them do not think that this age has yet come for them. I too made use of this cliché, and that when I was referring to my mother. I did not understand that one might sincerely weep for a relative, a grandfather aged seventy or more. If I met a woman of fifty overcome with sadness because she had just lost her mother, I thought her neurotic: we are all mortal; at eighty you are quite old enough to be one of the dead…But it is not true. You do not die from being born, nor from having lived, nor from old age. You die from something . The knowledge that because of her age my mother’s life must soon come to an end did not lessen the horrible surprise: she had sarcoma. Cancer, thrombosis, pneumonia: it is as violent and unforeseen as an engine stopping in the middle of the sky... There is no such thing as a natural death: nothing that happens to a man is ever natural, since his presence calls the world into question. All men must die: but for every man his death is an accident and, even if he knows it and consents to it, an unjustifiable violation (De Beauvoir, 1 pp 105–6).

In one sense, the book is a daily description of a vigil—a 6 weeks long wait by their mother’s bedside. For both Simone and her sister the vigil becomes their reality. As doctors we have all witnessed this aspect of the dying process—the daily visits by relatives and friends, the harried looks as they search for any changes, however small or transient in their loved one, the sleepless nights either at home or next to the patient in the hospital or hospice, the whispered family discussions, the long periods of inactivity, the shared silence. De Beauvoir captures well the heightened sense of reality that comes with the intensity of the wait and also the sense that, throughout this long period, nothing else matters:

The world has shrunk to the size of her room: when I crossed Paris in a taxi I saw nothing more than a stage with extras walking on it. My real life took place at her side, and it had only one aim—protecting her. In the night the slightest sound seemed huge to me—the rustling of Mademoiselle Cournot’s paper, the purring of the electric motor. I walked in stockinged feet in the daytime. The coming and going on the staircase, and overhead, shattered my ears. The din of the wheeled tables that went by on the landing…loaded with clattering metal trays, cans and bowls, seemed to me scandalous” (De Beauvoir, 1 p 76).

Equally, de Beauvoir depicts how her view of her world, even outside the confines of the hospital, has changed irrevocably:

I had the feeling of play acting wherever I went. When I spoke to an old friend …the liveliness of my voice seemed to me phoney: when with perfect truth I observed “That was very good” to the manager of a restaurant, I had the impression of telling a white lie. At other times it was the outside world that seemed to be acting a part. I saw a hotel as a nursing-home; I took the chambermaids for nurses; and the restaurant waitresses too—they were making me follow a course of treatment that consisted of eating. I looked at people with a fresh eye, obsessed by the complicated system of tubes that was concealed under their clothing. Sometimes I myself turned into a lift-and-force pump or into a sequence of pockets and guts (De Beauvoir, 1 pp 74–5).

THE RITUAL OF DEATH

Once their mother had died the shock came in waves, and often unexpectedly, for both of her daughters. Returning to the hospital on the morning after her death they face an empty room. Their world for the past weeks was literally bare:

Once again we climbed the stairs, opened the two doors: the bed was empty…on the whiteness of the sheet there was nothing. Foreseeing is not knowing: the shock was as violent as though we had not expected it at all (De Beauvoir, 1 p 96).

Throughout the book de Beauvoir honestly concedes that a purely material or rationalist approach to the dying and death of her mother neither does nor should apply. Even with the immediate aftermath of her mother’s death, Simone finds regret:

But I did reproach myself for having abandoned her body too soon. She, and my sister too, said “A corpse no longer means anything”. Yet it was her flesh, her bones, and for some time still her face. With my father I had stayed by him until the time he became a mere thing for me: I tamed the transition between presence and the void. With Maman I went away almost immediately after having kissed her, and that was why it seemed to me that it was still her that was lying, all alone, in the cold of the mortuary (De Beauvoir, 1 p 97).

This sense of the unique, the individual, even the sacred extends beyond their mother’s body to simple, even prosaic objects:

As we looked at her straw bag, filled with balls of wool and an unfinished piece of knitting…her scissors, her thimble, emotion rose up and drowned us. Everyone knows the power of things: life solidified in them, more immediately present than in any one of its instants. They lay there on my table, orphaned, useless, waiting to turn into rubbish or to find another identity… (De Beauvoir, 1 p 98).

De Beauvoir concludes that what they face is not rational:

It is useless to try to integrate life and death and to behave rationally in the presence of something that is not rational: each must manage as well as he can in the tumult of his feelings. I can understand all last wishes and the total absence of them: the hugging of the bones or the abandonment of the body of the one you love to the common grave (De Beauvoir, 1 p 98).

Inevitably, de Beauvoir reflects at the end of the book on the events of the prior months. Equally such reflection centres on the rapidity of the disease and her role as her mother’s daughter. There are layers of self reproach and balancing out “respite” and “remorse”:

And is one to be sorry that the doctors brought her back to life and operated, or not? She, who did not want to lose a single day, “won” thirty: they brought her joys; but they also brought her anxiety and suffering. Since she did escape from the martyrdom that I sometimes thought was hanging over her, I cannot decide for her. For my sister, losing Maman the very day she saw her again would have been a shock from which she would scarcely have recovered. And as for me? Those four weeks have left me pictures, nightmares, sadnesses that I should never have known if Maman had died that Wednesday morning. But I cannot measure the disturbance that I should have felt since my sorrow broke out in a way that I had not foreseen (De Beauvoir, 1 pp 93–4).

Illness and death brought to an aching, almost exquisite, focus the importance and the place of her mother. In describing this she eloquently stated the complexity of all close relationships—the uniqueness, the joys, and the regrets:

We did derive an undoubted good from this respite [after the operation]; it saved us, or almost saved us, from remorse. When someone you love dies you pay for the sin of outliving her with a thousand piercing regrets. Her death brings to light her unique quality; she grows as vast as the world that her absence annihilates for her and whose whole existence was caused by her being there; you feel that she should have had more room in your life—all the room, if need be. You snatch yourself away from this wildness: she was only one among many (De Beauvoir, 1 p 94).

The regrets are finally balanced against the closeness, intimacy, and solicitude of the final weeks:

But since you never do all you might for anyone—not even within the arguable limits that you have set yourself—you have plenty of room left for self reproach. With regard to Maman we were all guilty, these last years, of carelessness, omission, and abstention. We felt that we atoned for this by the days that we gave up to her, by the peace that our being there gave her, and by the victories gained over fear and pain. Without our obstinate watchfulness she would have suffered far more (De Beauvoir, 1 p 94).

The book raises many points for reflection. In terms of clinical practice, the themes of adequacy of symptom control, opiophobia, sensitivity and clarity in communication and disclosure versus collusion, remain as relevant today as they did then. Certainly our capacity to meet those challenges has developed significantly. As a piece of literature this book is beautifully written. As an account of one individual’s terminal illness it superbly captures the rhythms of the progression of a disease. As a reflection by a daughter on her mother it is strikingly honest and raw. The illness and death of Mme de Beauvoir brought an extraordinary array of emotions to the surface, for many of which Simone was unprepared. In confronting those, de Beauvoir gives the reader, medical or otherwise, an insight into the universal currents that flow through all our lives both personally and professionally—the sadness of loss, the ambivalence and complexity of children’s relations with their parents, the solace that comes with time and reflection, the uniqueness of all lives, and the sense of violation when that life has ceased. It is that testimony and those insights that make this a document of great richness.

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↵ † For a comprehensive list of the reasons why physicians underprescribe analgesics see A M Martino. 4

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Essay: Sudden death in young athletes

Affiliation.

• 1 Division of Cardiology and Institute of Pathological Anatomy, University of Padova, Via Giustiniani 2, 35121 Padova, Italy. [email protected]
• PMID: 16360752
• DOI: 10.1016/S0140-6736(05)67847-6
• Death, Sudden, Cardiac / epidemiology*
• Death, Sudden, Cardiac / etiology
• Italy / epidemiology
• Sex Distribution
• Sports / statistics & numerical data
• United States / epidemiology

Coping with Grief and Loss

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What is bereavement?

Understanding the grief of losing a loved one, grieving your loss, seek support, celebrate your loved one’s life, take care of yourself, when the pain of bereavement doesn’t ease up, what is complicated grief, finding professional help, bereavement: grieving the loss of a loved one.

Few things compare to the pain of losing someone you love. While there’s no way to avoid intense feelings of grief, there are healthier ways to come to terms with your loss.

Bereavement is the grief and mourning experience following the death of someone important to you. While it’s an inevitable part of life—something that virtually all of us go through at some point—losing someone you love can be one of the most painful experiences you’ll ever have to endure.

Whether it’s a close friend, spouse, partner, parent, child, or other relative, the death of a loved one can feel overwhelming. You may experience waves of intense and very difficult emotions, ranging from profound sadness, emptiness, and despair to shock, numbness, guilt, or regret. You might rage at the circumstances of your loved one’s death—your anger focused on yourself, doctors, other loved ones, or God. You may even find it difficult to accept the person is really gone, or struggle to see how you can ever recover and move on from your loss.

Bereavement isn’t limited to emotional responses, either. Grief at the death of a loved one can also trigger physical reactions, including weight and appetite changes, difficulty sleeping, aches and pains, and an impaired immune system leading to illness and other health problems.

The level of support you have around you, your personality, and your own levels of health and well-being can all play a role in how grief impacts you following bereavement. But no matter how much pain you’re in right now, it’s important to know that there are healthy ways to cope with the anguish and come to terms with your grief. While life may never be quite the same again, in time you can ease your sorrow, start to look to the future with hope and optimism, and eventually move forward with your life.

Grieving the loss of a pet

Bereavement isn’t restricted to the death of a person. For many of us, our pets are also close companions or family members. So, when a pet dies, you can experience similar feelings of grief, pain, and loss. As with grieving for human loved ones, healing from the loss of an animal companion takes time, but there are ways to cope with your grief.

Read: Coping with Losing a Pet .

The intensity of your feelings often depends on the circumstances of your loved one’s death, how much time you spent anticipating their loss, your relationship to them, and your previous experiences of bereavement. Of course, just as no two relationships are the same, no two losses are ever the same, either.

In short, the more significant the person was in your life and the more feelings you had for them—regardless of their relationship to you—the greater the impact their loss is likely to have.

Losing a spouse or partner

In addition to the emotional impact of grief, when you lose a spouse or romantic partner, you often have to deal with the stress of practical considerations such as funeral arrangements and financial issues , too. You may also have to explain your spouse’s death to your children and find a way to comfort them while simultaneously dealing with your own heartache.

Losing a romantic partner also means grieving the loss of your daily lifestyle, the loss of a shared history, and the loss of a future planned together. You may feel alone, despairing, and worried about the future. You could even feel guilty about somehow having failed to protect your partner, or angry at your loved one for leaving you.

Losing a parent

For younger children, losing a mother or father can be one of the most traumatic things that can happen in childhood. The death of the person you relied on, the person who loved you unconditionally, can shake your foundations and leave a huge, frightening void in your world. It’s also common for young children to blame themselves for a parent’s death, prolonging the pain of grief.

Even as an adult child, losing a parent can be extremely distressing. It’s easy to feel lost and for all those old childhood insecurities to suddenly return. You may gain some solace if your parent had a long and fulfilling life, but their death can also cause you to consider your own mortality. If you’ve lost both parents, you’re suddenly part of the older generation, a generation without parents, and you’re left to grieve your youth as well. And if your relationship with your parent wasn’t an easy one, their death can leave you wrestling with a host of conflicting emotions.

Losing a child

The loss of a child is always devastating. You’re not just losing the person they were, you’re also losing the years of promise, hopes, and dreams that lay ahead. The grief can be more intense, the bereavement process harder to navigate, and the trauma more acute .

As a parent, you feel responsible for your child’s health and safety, so the sense of guilt can often be overwhelming. Whether you lost your child in a miscarriage, as an infant, or after they’d grown up and left home, losing a child carries an additional weight of injustice. It feels unnatural for a parent to outlive their child, making it that much harder to find meaning and come to terms with their death.

Losing a child can also put a huge strain your relationship with your spouse or partner and make parenting any surviving children emotionally challenging.

Losing a friend

Close friendships bring joy, understanding, and companionship into our lives. In fact, they’re vital to our health and well-being, so it’s no wonder we can feel their loss so gravely.

When a close friend dies, though, it’s easy to feel marginalized, the closeness of your relationship not given the same significance as a family member or romantic partner. This can lead to what’s called disenfranchised grief , where your loss is devalued or you feel judged or stigmatized for feeling the loss so deeply.

Losing someone to suicide

The shock following a suicide can seem overwhelming. As well as mourning the loss of your loved one, you may also be struggling to come to terms with the nature of their death and the stigma that suicide can still carry.

While you may always be left with some unanswered questions about your loved one’s suicide, there are ways to resolve your grief and even gain some level of acceptance. Read: Suicide Grief.

Whatever your relationship to the person who died, it’s important to remember that we all grieve in different ways. There’s no single way to react. When you lose someone important in your life, it’s okay to feel how you feel. Some people express their pain by crying, others never shed a tear—but that doesn’t mean they feel the loss any less.

Don’t judge yourself, think that you should be behaving in a different way, or try to impose a timetable on your grief. Grieving someone’s death takes time. For some people, that time is measured in weeks or months, for others it’s in years.

Allow yourself to feel . The bereavement and mourning process can trigger many intense and unexpected emotions. But the pain of your grief won’t go away faster if you ignore it. In fact, trying to do so may only make things worse in the long run. To eventually find a way to come to terms with your loss, you’ll need to actively face the pain. As bereavement counselor and writer Earl Grollman put it, “The only cure for grief is to grieve.”

Grief doesn’t always move through stages . You may have read about the different “stages of grief” —usually denial, anger, bargaining, depression, and acceptance. However, many people find that grief following the death of a loved one isn’t nearly that predictable. For some, grief can come in waves or feel more like an emotional rollercoaster. For others, it can move through some stages but not others. Don’t think that you should be feeling a certain way at a certain time.

[Read: Coping with Grief and Loss]

Prepare for painful reminders . Some days the pain of your bereavement may seem more manageable than others. Then a reminder such as a photo, a piece of music, or a simple memory can trigger a wave of painful emotions again. While you can’t plan ahead for such reminders, you can be prepared for an upcoming holiday, anniversary, or birthday that may reignite your grief. Talk to other friends and family ahead of time and agree on the best ways to mark such occasions.

Moving on doesn’t mean forgetting your loved one . Finding a way to continue forward with your life doesn’t mean your pain will end or your loved one will be forgotten. Most of us carry our losses with us throughout life; they become part of who we are. The pain should gradually become easier to bear, but the memories and the love you had for the person will always remain.

Speak to a Licensed Therapist

BetterHelp is an online therapy service that matches you to licensed, accredited therapists who can help with depression, anxiety, relationships, and more. Take the assessment and get matched with a therapist in as little as 48 hours.

When you lose someone you love, it’s normal to want to cut yourself off from others and retreat into your shell. But this is no time to be alone. Even when you don’t feel able to talk about your loss, simply being around other people who care about you can provide comfort and help ease the burden of bereavement.

Reaching out to those who care about you can also be an important first step on the road to healing. While some friends and relatives may be uncomfortable with your grief, plenty of others will be eager to lend support. Talking about your thoughts and feelings won’t make you a burden. Rather, it can help you make sense of your loved one’s death and find ways to honor their memory.

Lean on friends and family . Even those closest to you can struggle to know how to help during a time of bereavement, so don’t hesitate to tell others what you need—whether it’s helping with funeral arrangements or just being around to talk. If you don’t feel you have anyone you can lean on for support at this difficult time, look to widen your social network and build new friendships .

Focus on those who are “good listeners” . When you’re grieving the loss of a close friend or family member, the most important thing is to feel heard by those you confide in. But the raw emotion of your grief can make some people very uncomfortable. That discomfort can cause them to avoid you, say thoughtless or hurtful things, or lose patience when you talk about your loss. Don’t use their actions as a reason to isolate, though. Turn to those who are better able to listen and provide comfort.

Join a bereavement support group . Even when you have support from those closest to you, family and friends may not always know the best ways to help. Sharing your grief with others who have experienced similar losses can help you feel less alone in your pain. By listening to others share their stories, you can also gain valuable coping tips. To find a support group in your area, contact nearby hospitals, funeral homes, or counseling centers, or call a bereavement hotline listed below.

Talk to a bereavement counselor . If you’re struggling to accept your loss or your grief feels overwhelming, try talking to a bereavement or grief therapist —in-person or via video conferencing online. Confiding in a professional can help you work through emotions that may be too difficult to share with family or friends, deal with any unresolved issues from your loved one’s death, and find healthier ways to adapt to life following your loss.

[Read: Online Therapy: Is it Right for You?]

Draw comfort from your religion . If you’re religious, the specific mourning rituals of your faith can provide comfort and draw you together with others to share your grief. Attending religious services, reading spiritual texts, praying, meditating, or talking to a clergy member can also offer great comfort and help you derive meaning from your loved one’s death.

Using social media for grief support

Memorial pages on Facebook and other social media sites have become popular ways to inform a wide audience of a loved one’s passing and to find support. As well as allowing you to impart practical information, such as funeral plans, these pages allow friends and loved ones to post their own tributes or condolences. Reading such messages can often provide comfort for those grieving the loss.

Of course, posting sensitive content on social media has its risks. Memorial pages are often open to anyone. This may encourage people who hardly knew the deceased to post well-meaning but inappropriate comments or advice. Worse, memorial pages can also attract Internet trolls. There have been many well-publicized cases of strangers posting cruel or abusive messages on memorial pages.

[Read: Social Media and Mental Health]

To gain some protection on Facebook, for example, you can opt to create a closed group rather than a public page. This means people have to be approved by a group member before they can access the memorial. It’s also important to remember that while social media can be a useful tool for reaching out to others, it can’t replace the face-to-face support you need at this time.

Rituals such as a funeral or memorial service can fulfill important functions, allowing you to acknowledge and reflect on the person’s passing, remember their life, and say goodbye. In the period after a funeral, however, your grief can often become even more intense. Often, other people may appear to have moved on, while you’re left struggling to make sense of your “new normal”.

Remembering your loved one doesn’t have to end with the funeral, though. Finding ways of celebrating the person you loved can help maintain their memory and provide comfort as you move through the grieving process.

Keep a journal or write a letter to your loved one . Saying the things you never got to say to your loved one in life can provide an important emotional release and help you make sense of what you’re feeling.

Create a memorial . Building a memorial to your loved one, creating a website or blog, or compiling a photo album or scrapbook to highlight the love you shared can help promote healing. Planting flowers or a tree in your loved one’s memory can be particularly rewarding, allowing you to watch something grow and flourish as you tend to it.

Build a legacy . Starting a campaign or fundraiser in your loved one’s name, volunteering for a cause that was important to them, or donating to a charity they supported, for example, can help you find meaning in their loss. It can also add a sense of purpose as you move forward with your own life.

Continue to do things you used to do together . Perhaps you used to go to sports events with your loved one, listen to music, or take long walks together? There’s comfort in routine, so when it’s not too painful, continuing to do these things can be a way to mark your loved one’s life.

Remember your loved one in simple ways . Even simple acts such as lighting a candle, visiting a favorite place, or marking an important date can help the healing process.

When you’re grieving the death of a loved one, it’s easy to neglect your own health and welfare. But the stress, trauma, and intense emotions you’re dealing with at the moment can impact your immune system, affect your diet and sleep, and take a heavy toll on your overall mental and physical health.

Neglecting your well-being may even prolong the grieving process and make you more susceptible to depression or complicated grief. You’ll also find it harder to provide comfort to children or other vulnerable family members who are also grieving. However, there are simple steps you can take to nurture your health at this time.

Manage stress . It’s probably the last thing you feel like doing at the moment, but exercising is a powerful antidote to stress—and can help you sleep better at night. Relaxation techniques such as deep breathing, meditation, and yoga are also effective ways to ease anguish and worry.

Spend time in nature . Immersing yourself in nature and spending time in green spaces can be a calming, soothing experience when you’re grieving. Try gardening, hiking, or walking in a park or woodland.

Pursue interests that enrich your life . Hobbies, sports, and other interests that add meaning and purpose to your life can bring a comforting routine back to your life following the upheaval of bereavement. They can also help connect you with others and nurture your spirit.

Eat and sleep well . Eating a healthy diet and getting enough rest at night can have a huge impact on your ability to cope with grief. If you’re struggling to sleep at this difficult time, there are supplements and sleep aids that may be able to help—just try not to rely on them for too long.

Avoid using alcohol or drugs to cope . While it’s tempting to use substances to help numb your grief and self-medicate your pain, in the long run excessive alcohol and drug use will only hamper your ability to grieve. Try using HelpGuide’s free Emotional Intelligence Toolkit as a healthier way to manage your emotions.

You may never truly get over the death of someone you love. But as time passes, it’s normal for difficult emotions such as sadness or anger to gradually ease as you begin to accept your loss and move forward with your life.

However, if you aren’t feeling better over time, or your pain is getting worse, it may be a sign that your grief has developed into a more serious problem, such as complicated grief or major depression.

Grief vs. depression

Distinguishing between grief and depression isn’t always easy as they share many symptoms, but there are ways to tell the difference:

• Grief can be a roller coaster. It involves a wide variety of emotions and a mix of good and bad days. Even when you’re in the middle of the grieving process, you will still have moments of pleasure or happiness.
• With depression , on the other hand, the feelings of emptiness and despair are constant.

[Read: Depression Symptoms and Warning Signs]

Other symptoms that suggest depression, not just grief, include:

• Intense, pervasive sense of guilt.
• Thoughts of suicide or a preoccupation with dying.
• Feelings of hopelessness or worthlessness.
• Slow speech and body movements.
• Inability to function at home, work, or school.
• Seeing or hearing things that aren’t there.

While the sadness of losing someone you love never goes away completely, it shouldn’t remain center stage. If the pain of the loss is so constant and severe that it keeps you from resuming your life, you may be suffering from a condition known as complicated grief or persistent complex bereavement disorder .

Complicated grief is like being stuck in an intense state of mourning. You may have trouble accepting the death long after it has occurred or be so preoccupied with the person who died that it disrupts your daily routine and undermines your other relationships.

Symptoms of complicated grief include:

• Intense longing and yearning for your deceased loved one.
• Intrusive thoughts or images of the person.
• Denial of the death or sense of disbelief.
• Imagining that your loved one is alive.
• Searching for the deceased in familiar places.
• Avoiding things that remind you of your loved one.
• Extreme anger or bitterness over your loss.
• Feeling that life is empty or meaningless.

Complicated grief and trauma

If your loved one’s death was sudden, violent, or otherwise extremely stressful or disturbing, complicated grief can manifest as psychological trauma or PTSD.

Being traumatized from the loss of a loved one can leave you feeling helpless and struggling with upsetting emotions, memories, and anxiety that won’t go away. But with the right guidance, you can make healing changes and move on with your life.

If you’re experiencing symptoms of complicated grief, trauma, or clinical depression, talk to a mental health professional right away. Left untreated, these conditions can lead to significant emotional damage, life-threatening health problems, and even suicide. But treatment can help you get better.

[Read: Finding a Therapist Who can Help You Heal]

Contact a bereavement counselor or therapist if you:

• Feel like life isn’t worth living.
• Wish you had died with your loved one.
• Blame yourself for the loss or for failing to prevent it.
• Feel numb and disconnected for more than a few weeks.
• Are having difficulty trusting others since your loss.
• Are unable to perform your normal daily activities.

Crisis Call Center  at 775-784-8090

Cruse Bereavement Care  at 0808 808 1677

GriefLine  at (03) 9935 7400

Other support

Find a GriefShare group meeting near you  – Worldwide directory of support groups for people grieving the death of a family member or friend. (GriefShare)

Find Support  – Directory of programs and support groups in the U.S. for children experiencing grief and loss. (National Alliance for Grieving Children)

Chapter Locator  for finding help for grieving the loss of a child in the U.S. and  International Support  for finding help in other countries. (The Compassionate Friends)

If you're feeling suicidal…

Seek help immediately. Please read  Suicide Help , talk to someone you trust, or call a suicide helpline:

• In the U.S., call 1-800-273-8255.
• In the UK, call 08457 90 90 90.
• In Australia, call 13 11 14.
• Or visit  IASP  to find a helpline in your country.

More Information

• Grief and Loss - A guide to preparing for and mourning the death of a loved one. (Harvard Medical School Special Health Report)
• Death and Grief - Article for teens on how to cope with grief and loss. (TeensHealth)
• Grief: Coping with Reminders after a Loss - Tips for coping with the grief that can resurface even years after you’ve lost a loved one. (Mayo Clinic)
• Life after Loss: Dealing with Grief - Guide to coping with grief and loss. (University of Texas Counseling and Mental Health Center)
• Bereavement - Symptoms, causes, and treatment. (Psychology Today)
• Bereavement and Grief - Mourning the loss of a loved one. (Mental Health America)
• Understanding Grief - Articles to help you cope with the grieving process. (Cruse Bereavement Care)
• Depressive Disorders. (2013). In Diagnostic and Statistical Manual of Mental Disorders . American Psychiatric Association. Link
• Zisook, S., & Shear, K. (2009). Grief and bereavement: What psychiatrists need to know. World Psychiatry, 8 (2), 67–74. Link
• Stroebe, M., Schut, H., & Stroebe, W. (2007). Health outcomes of bereavement. The Lancet, 370 (9603), 1960–1973. Link
• Simon, N. M., Wall, M. M., Keshaviah, A., Dryman, M. T., LeBlanc, N. J., & Shear, M. K. (2011). Informing the symptom profile of complicated grief. Depression and Anxiety, 28 (2), 118–126. Link
• Simon, N. M. (2013). Treating Complicated Grief. JAMA, 310 (4), 416–423. Link
• Corr, C. A. (1999). Enhancing the Concept of Disenfranchised Grief. OMEGA – Journal of Death and Dying, 38 (1), 1–20. Link
• Johansson, A. K., & Grimby, A. (2012). Anticipatory grief among close relatives of patients in hospice and palliative wards. The American Journal of Hospice & Palliative Care, 29 (2), 134–138. Link

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Institute of Medicine (US) Committee on Palliative and End-of-Life Care for Children and Their Families; Field MJ, Behrman RE, editors. When Children Die: Improving Palliative and End-of-Life Care for Children and Their Families. Washington (DC): National Academies Press (US); 2003.

When Children Die: Improving Palliative and End-of-Life Care for Children and Their Families.

• Hardcopy Version at National Academies Press

APPENDIX E BEREAVEMENT EXPERIENCES AFTER THE DEATH OF A CHILD

Grace H. Christ, D.S.W., * George Bonanno, Ph.D., * Ruth Malkinson, Ph.D., † and Simon Rubin, Ph.D. ‡

• INTRODUCTION

The death of a child of any age is a profound, difficult, and painful experience. While bereavement is stressful whenever it occurs, studies continue to provide evidence that the greatest stress, and often the most enduring one, occurs for parents who experience the death of a child [ 1 – 6 ]. Individuals and families have many capabilities and abilities that allow them to respond to interpersonal loss and to emerge from the experience changed but not broken. The few studies that have compared responses to different types of losses have found that the loss of a child is followed by a more intense grief than the death of a spouse or a parent [ 5 ]. This conclusion must be considered cautiously, however, since these studies have typically confounded sample differences in age and degree of forewarning [ 7 ]. Forewarning is important because according to the Centers for Disease Control and Prevention [ 8 ], about half of child deaths occur during infancy, most with limited preparation time. Unintended injuries are the leading cause of death in children age 1 to 14 and account for more than half of all deaths among young people 15 to 19 years of age. In addition, while the overall death rate for children aged 14 and younger has declined substantially since the 1950s childhood homicide rates have tripled and suicide rates have quadrupled [ 9 ]. Recent findings suggest that parents of children who die from any cause are more likely to suffer symptoms of traumatic stress and experience more severe problems with emotional dysregulation than occurs with the death of a spouse [ 10 ].

Integrating the loss of a child into the life narrative, making sense and new meanings of such a wrenching event, presents a challenge to parents and family [ 11 ]. Although once common, deaths of children between the ages of 1 and 14 now account for less than 5 percent of all deaths in the United States; about 57,428 infants, children, and adolescents died in 1996. In contrast to the past when families might have had several children die, death in childhood is now rare. Children are expected to live to adulthood. Conflicting with current life-cycle expectations, the death of a child may be experienced as the death of the parents' future dreams as well as creating a profound change in their present roles and functioning. Increases in the incidence of suicide and homicide in adolescents and random acts of violence in our society have increased the risk of traumatic stress responses for bereaved family members.

Medical advances have prolonged the dying process for children as well as adults, making terminal illness in children longer and more complex, often requiring parents to make difficult decisions about end-of-life care. Preliminary research evidence suggests that family bereavement may be adversely affected by the inability to reduce suffering during the child's dying process [ 12 ].

This appendix reviews the unique features of the parent role; the importance of the parents' continuing memory of the child; the impact of variations in atypical, unresolved, and catastrophic deaths; and the special features of parents' loss of an infant, a school age child, and an adolescent, and the impact of a child's death on siblings and other family members. Also reviewed are interventions and research directions.

• BEREAVEMENT, MOURNING, GRIEF, AND COMPLICATED GRIEF

Bereavement is a broad term that encompasses the entire experience of family members and friends in the anticipation, death, and subsequent adjustment to living following the death of a loved one [ 13 ]. It is widely recognized as a complex and dynamic process that does not necessarily proceed in an orderly, linear fashion [ 14 , 15 ]. Rather, individuals have concurrent and overlapping reactions that may recur at any time during the family's bereavement process. Bereavement includes the internal adaptation of individual family members; their mourning processes, expressions, and experiences of grief; and changes in their external living arrangements, relationships, and circumstances.

Grief is a term that refers to the more specific, complex set of cognitive, emotional, and social difficulties that follow the death of a loved one [ 16 ]. Individuals vary enormously in the type of grief they experience, its intensity, its duration, and their way of expressing it. Mourning is often defined as either the individual's internal process of adaptation to the loss of a loved one or as the socially prescribed modes of responding to loss, including its external expression in behaviors such as rituals and memorials. Taken together, the grief and mourning processes are understood to be a normal and universal part of the natural healing process that enables individuals, families, and communities to live with the reality of loss while going on with living [ 17 , 18 ].

Complicated grief in adults refers to bereavement accompanied by symptoms of separation distress and trauma [ 19 ]. It is defined as occurring following a death that would not objectively be considered “traumatic” (i.e., not resulting from an unanticipated, horrifying event) and requires that the person experience (1) extreme levels of three of the four “separation distress” symptoms (intrusive thoughts about the deceased, yearning for the deceased, searching for the deceased, and excessive loneliness since the death), as well as (2) extreme levels of four of the eight “traumatic distress” symptoms (purposelessness about the future; numbness, detachment, or absence of emotional responsiveness; difficulty believing or acknowledging the death; feeling that life is empty or meaningless; feeling that part of oneself has died; shattered world view; assuming symptoms of harmful behaviors of the deceased person; excessive irritability, bitterness, or anger related to the death). These symptoms must have lasted at least six months and led to significant functional impairment. Because parents of children who die are at greater risk for traumatic stress symptoms and emotional dysregulation, they are at greater risk of complicated grief [ 10 ].

Siblings of children who die have also been found to be at greater risk for externalizing and internalizing problems when compared to norms and controls [ 20 - 23 ] within 2 years of the death. Complicated bereavement has been less clearly defined for children but is also thought to include symptoms of PTSD, other psychological characteristics associated with this disorder, and grief. The Expanded Grief Screening Inventory is a 20-item measure developed to assess complicated bereavement in children and adolescents. Factor analysis indicates three independent factors including positive reminiscing, intrusion of PTSD on the grieving process, and existential loss [ 24 - 27 ]. This measure has shown strong psychometric properties and is currently being used to follow the clinical course of such complicated bereavement in children.

• THE PARENT ROLE AND LOSS OF A CHILD

The process of conceiving, giving birth, and raising offspring is shared by virtually all living animals. The human experience of this process, however, adds many elements of psychological, social, and meaning construction. At various stages in the life cycle, men and women relate to child-conceiving and child-rearing roles as central to their existence. Of the bonds formed within the family, the parent–child bond is not only particularly strong, it is also integral to the identity of many parents and children [ 4 ]. Much has been written about the significance of the parent–child attachment bond as a major organizer of the individual parent's positive sense of self and significant relationships with others [ 17 ].

Parents of children and adolescents who die are found to suffer a broad range of difficult mental and physical symptoms. As with many losses, depressed feelings are accompanied by intense feelings of sadness, despair, helplessness, loneliness, abandonment, and a wish to die [ 28 ]. Parents often experience physical symptoms such as insomnia or loss of appetite as well as confusion, inability to concentrate, and obsessive thinking [ 17 ]. Extreme feelings of vulnerability, anxiety, panic, and hyper-vigilance can also accompany the sadness and despair.

Grieving parents evidence anger as part of the normal reaction to the loss of their child [ 17 , 29 – 33 ]. This may be expressed as intense rage or as chronic irritation and frustration. It may be directed at the spouse, at other family members, at the professional staff, at God, at fate, or even at the dead child. Anger may also be directed at the self, creating feelings of self-hatred, shame and worthlessness [ 28 , 34 - 36 ].

Children take on great symbolic importance in terms of parents' generativity [ 37 ] and hope for the future. All parents have dreams about their children's futures; when a child dies the dreams may die too. This death of future seems integral to the intensity of many parents' responses. Three central themes in parents' experience when a child dies include (1) the loss of sense of personal competence and power, (2) the loss of a part of the self [ 38 , 39 ], and (3) the loss of a valued other person whose unique characteristics were part of the family system. While guilt and self-blame are common in bereavement, they are especially pronounced following the death of a child. The parent's role competence as the child's caregiver, protector, and mentor is severely threatened by untimely death.

Parents assert that their grief continues throughout their lives, often saying, “It gets different, it doesn't get better.” Words such as “closure” can be deeply offensive. The few studies that have followed parents for years after the child's death support the concept of their preoccupation with the loss of children across the life cycle [ 4 , 40 – 42 ]. Klass [ 39 ] refers to the “amputation metaphor”: the vivid sense of a permanent loss of a part of oneself that may be adapted to, but will not grow back. Freud's letter to a friend about the loss of his eldest daughter describes this eloquently:

For years I was prepared for the loss of my sons (in war); and now comes that of my daughter. Since I am profoundly irreligious there is no one I can accuse, and I know there is nowhere to which any complaint could be addressed. “The unvarying circle of a soldier's duties” and the “sweet habit of existence” will see to it that things go on as before. Quite deep down I can trace the feelings of a deep narcissistic hurt that is not to be healed [ 43 , p.20].

Parents resist the idea that they will recover from their child's death. Rather than “recovery” or “resolution,” which suggest a return to pre-loss functioning, “reconciliation,” and “reconstitution” have been used to describe the post-death period because these terms more adequately reflect the profound changes that take place when a child dies. They express the reality that even the successful mourning process results in a transformation in the person consequent to the death of a loved one [ 44 ]. Despite traditional assumptions that all bereaved individuals must mourn, prospective studies have shown that considerable numbers of bereaved individuals evidence no overt signs of grieving or of the reconstitutive processes associated with grieving (for a review see [ 1 ]). The question these findings raise is to what extent this type of resilient pattern may also be found among those mourning the death of a child [ 27 ].

• CONTINUING BONDS: THE TWO-TRACK MODEL OF BEREAVEMENT

There is little doubt that most persons respond with emotional and physiological distress following loss. Equally apparent is the fact that the bereavement response is predominantly one of readjusting and recalibrating the often covert psychological attachment to, and preoccupation with, the person now deceased. However, most studies have assumed that a reduction of symptoms defines “recovery” and constitutes a successful bereavement outcome. The parent's continuing investment in the relationship with the deceased has often been neglected. In a recent study of parents of infants who died of SIDS (sudden infant death syndrome), the phenomena associated with the bereavement response had a very different time frame and trajectory when the continuing investment in the relationship with the deceased was assessed [ 4 ].

The Two-Track Model of Bereavement [ 41 , 42 ] combines the perspective of both the symptomatic bio-psychosocial response to bereavement and the relationship with the deceased. The bereavement response is understood to unfold along two multidimensional axes or tracks that are generally significant to understanding human adaptation to life demands. The first track focuses on how people function generally, and in the case of loss, it focuses on how functioning is affected following death. The second track focuses on how people are involved in maintaining and changing their relationships with significant others. In the case of bereavement, this relational track focuses on the bereaved parent's emotions, memories, and mental representations as they relate specifically to the deceased. Thus, the human bereavement response is not only triggered by the death of a significant person, but also initiates a degree of a continuing, albeit quite varied and modified, relationship to that person across the life cycle.

The implications of the Two-Track Model of Bereavement are relevant to theory, research, social support, and clinical and counseling interventions. It is important to consider not only the degree of overt function and dysfunction following loss, but also the ways in which memories and thoughts about the deceased are discussed, thought about, and serve an active role in the emotional and mental life of the bereaved. This ongoing connection is most vividly and consistently reported, indeed insisted on, by many bereaved parents in relation to the death of a child.

The two-track model proposes 10 domains for assessment on each of these axes following loss. On Track I, the individual's functioning is assessed in relation to (1) degree of anxiety and depressive responses and triggers of such responses; (2) other affective responses such as guilt and helplessness; (3) somatic concerns and dysregulation; (4) psychiatric symptoms including orientation and mental status, PTSD (post traumatic stress disorder) in both full-blown and partial forms, and suicidal ideation; (5) self-esteem; (6) the individual's ability to work or perform major life tasks; (7) the management of family relationships, including the relationship to spouse or partner, to other children, and to the extended family; (8) the nature and degree of involvement in interpersonal relationships outside the family; (9) the meaning framework or structure in which the bereaved is embedded and its current power; and (10) the degree to which the bereaved is able to invest emotional energy in life tasks and the type of life tasks that are engaged.

On Track II, the nature of the relationship to the deceased is assessed on 10 other dimensions. These include (1) the degree of preoccupation with memories and thoughts of the deceased; (2) the extent to which the description of the deceased is characterized by an inability or unwillingness to express the personal feelings brought about by the death; (3) the degree of idealization of the deceased; (4) the report of psychological conflict or contradictions in the relationship; (5) the degree and type of positive affect and emotion; (6) the degree and type of negative emotion toward the deceased; (7) the degree of closeness or distance from the relationship and experience of the deceased; (8) the affective experience when discussing the deceased (e.g., a parent who might say, “I always feel guilty thinking about how my son died”); (9) the presence of previously described grief phases of shock, seeking reminders of the deceased, disorganization, and restoration of a coherent life flow; and (10) the manner in which the deceased is memorialized both publicly and within the family. The individual with complicated grief is at greater risk for a variety of psychopathologies and physical illnesses.

• ANTICIPATED, SUDDEN, TRAUMATIC, AND CATASTROPHIC DEATHS

The particular circumstances of the death (i.e., whether it was an anticipated death from illness, a sudden death, the result of a natural disaster or a terrorist attack that affects an entire community) also shapes families' bereavement reactions and service needs. When a child's illness is long, arduous, and filled with chronic crises, parents may develop unusual coping skills to sustain themselves and their family over many months and years or they may become worn down and depleted emotionally and financially by the entire process. Therefore interventions that provide practical and emotional support, skills training, and respite throughout the often long and crisis-filled period of the child's illness may aid families' bereavement. Psychological processes that parents have described as helpful include working through the need to assign blame for the disease including self-blame, becoming well informed about the disease and treatment, developing a more realistic assessment of the medical care system and an ability to communicate with professionals, becoming the child's advocate, and focusing on immediate treatment successes while maintaining a long-range perspective.

When the child's death can be anticipated, evidence suggests that effective management of the terminal illness period may also benefit the family's bereavement. In Wolfe's study [ 12 ], parents who were informed in a timely way that their child's illness had become terminal, that death was now inevitable, were able to make decisions that lessened their child's experience of pain and suffering. Compared to parents who were informed later, parents informed closer to the time the physician documented the terminal nature of the illness were able to reflect on the death with greater feeling of their own effectiveness in providing their child a peaceful death. With the longer terminal illness period made possible by medical advances, it is important for physicians to recognize and inform families when there is no realistic possibility of significant extension of life so that they can make informed decisions about palliative care or other concurrent model of care rather than curative treatments. Wolfe also found that families may be helped during this highly stressful period by mental health interventions.

Trauma theories and grief theories developed in separate literatures, and only recently has research begun to integrate the findings, concepts, and responses related to these overlapping but distinct conditions [ 45 – 48 ]. There is some evidence to suggest that those bereaved by traumatic deaths may benefit from initial interventions focused on reducing terror, fear, and anxiety about the circumstances of the death—that is, by interventions similar to those typically used for PTSD. Grief therapies have also been found effective in situations of complicated grief, of which traumatic grief is one example [ 47 ]. A failure to address the intertwining of these symptoms of trauma and loss early in their bereavement may compromise the individual's capacity to experience optimal recovery. For example, cognitive behavioral interventions suggested for trauma symptoms in a treatment manual by one research team include stress inoculation therapy, gradual exposure, and cognitive processing. Stress inoculation involves such techniques as feeling identification, relaxation techniques, deep breathing, progressive muscle relaxation, thought stopping, cognitive coping skills, enhancing the individual's sense of safety, psycho-education, and understanding the connection between thoughts, feelings, and behaviors [ 48 ]. Gradual exposure aims to separate overwhelming negative emotions such as terror, horror, extreme helplessness or rage from thoughts, reminders, or discussions of the death of the loved one. Cognitive processing aims to identify, correct, and challenge thoughts about the death that are unhelpful or inaccurate (for example “my dad must have suffered terrible pain during the explosion in the WTC”). In contrast, bereavement interventions focus on understanding the mourning process including feelings of loss and anticipation of reminders; resolving ambivalent feelings about the deceased, preserving positive memories of the deceased, accepting that the relationship is one of memory and recommitting to present relationships [ 48 ]. Nader describes convincingly how trauma prevents reminiscence necessary to grieve by evoking feelings of terror [ 25 , 49 ]. Conversely, grief can also act as a traumatic reminder to the individual who may be experiencing a sub-clinical response to trauma or meet criteria for a formal diagnosis of PTSD, increasing anxiety in either situation. Those bereaved by deaths seen as nontraumatic are more apt to focus on their relationship to the deceased as an important feature of the experience of loss [ 44 , 50 ]. Many aspects of parental grief reactions in response to the death of a child have been viewed as overlapping with traumatic symptoms, and indeed even parents whose children have cancer have been assessed to experience high levels of traumatic stress [ 51 ].

While the added stresses on families' bereavement related to violent and intentional death have been documented, bereavement interventions or follow-up care have only recently been offered in emergency room settings in a systematic way. Even when offered, families affected by homicide have seldom participated in follow-up bereavement services [ 52 , 53 ]. Management of the final moments of an intentional or unintentional sudden death of a child continues to challenge professionals. Trauma research consistently supports the benefit of early intervention with traumatized individuals or families close to the time of the death in order to prevent later adverse reactions [ 54 ]. However, which interventions are most effective in which situations continues to be debated and awaits further research. For example, a summary of studies of critical stress debriefing in a 2001 review of the effectiveness of psychological debriefing concludes that though debriefing holds potential as a screening procedure, it does not prevent psychiatric disorders or mitigate the effects of traumatic stress. Still, people generally find the intervention of debriefing helpful in the process of recovery [ 55 ].

Catastrophic events such as the Oklahoma City bombing and the New York City World Trade Center attacks are very public with broad media coverage. They involve large numbers of deaths and unusual situations that present unique coping challenges during bereavement. Each catastrophic event has important commonalities with other catastrophes, but also important differences. It is these similarities and differences that need to be identified and studied in order to sharpen the ability not only to treat grief reactions, but also to prevent the development of PTSD as well as other forms of complicated bereavement

The World Trade Center attacks involved an attack from an outside hostile enemy that mobilized patriotism and national anger and gave rise to an ongoing war on terrorists throughout the world. Victims, especially firemen, policemen, and rescue workers were hailed as heroes in a war, killed in the act of protecting or saving others. Victims were mostly adults. Particular stresses for survivors include the ongoing search for bodies or body parts and the many continuing reminders related to the ensuing war as well as the many public memorials. For some, finding no remains hinders progress with the mourning process. Early reminders included frequently announced threats of other impending terrorist attacks and other purported enemy acts, such as sending anthrax in letters. The war itself constitutes a reminder interspersed with media reports of investigations about “what went wrong” that permitted the attack and the deaths of thousands.

• POSITIVE AND NEGATIVE IMPACT OF A CHILD'S DEATH ON SELF, MARITAL RELATIONSHIP, AND FAMILY

Bereaved parents report a number of potentially positive as well as negative reverberations as a consequence of adjusting to loss. Bereaved individuals discuss their experience of having changed as a result of the loss, of learning to value anew what is really important to them, and of reviewing priorities. Some relationships with families and friends are strengthened, others are found wanting. Perhaps the most important relationship affected by child loss is that of the parents.

The majority of studies on this issue have focused on divorce as an indicator of stress upon the parents. However, there is a great deal of variability across studies regarding the divorce rates following a child's death. A recent review of these studies concluded that some writers give overly high estimates of divorce for which there is no empirical support [ 32 ]. On the other hand a substantial minority of couples do seem to experience severe marital distress. Bohannon [ 33 ], for example, conducted a longitudinal study of couples' grief responses and marital functioning. In her study, about 30 percent of husbands and wives reported having more negative feelings toward their spouse since the death; 19 percent of husbands and 14 percent of wives felt their marriages had deteriorated since the death. About the same proportion had considered divorce after the death of their child. A major difficulty in doing such research is that the frequency of divorce in the U.S. population is about 50 percent. Separating the “real” contribution of the death of a child from other causes of marital strife in bereaved families is a difficult research challenge.

To address this issue Compassionate Friends, a self-help organization for bereaved parents, recently completed a survey of 14,852 parents who had lost a child. When a Child Dies: a Survey of Bereaved Parents, was conducted by NFO in 1999 and published on the Web site of compassionate friends” ( www.doorsofhope.com/grieving-healing/compassionate friends.htm ). Its concern was how troubled newly bereaved parents frequently feel when they read or hear about high divorce rates among couples following the death of a child (80-90 percent by some estimates). The survey found that of those who completed it 72 percent of parents who were married at the time of their child's death are still married to the same person. The remaining 28 percent included 16 percent in which one spouse had died, and only 12 percent of marriages had ended in divorce. While acknowledging the potential bias in its sample, the conclusion was that the divorce rate among bereaved parents was substantially lower than is often cited.

Most studies of parent divorce after the death of a child are limited by methodological problems including the lack of a control group, selection bias, and high attrition rates. The highest estimates of divorce seem overstated. Indeed some studies have found that as many as 25 percent of couples experience increased closeness in their marriage [ 2 , 33 ]. As Rando suggests [ 56 ] bereaved couples need to be informed that grief is a very individualized process experienced differently by each partner and reassured that relationships can and do survive after a child's death.

A number of studies have investigated the marital relationship and tried to identify gender differences that may account for conflict and distancing between couples. These and other common problems between parents after the death of a child include the following:

Conflict and anger, at times directly or indirectly blaming the spouse for the death, [ 34 , 56 ] are frequently described as a way of dealing with painful feelings.

Breakdown in communication, such as avoidance of all discussion of the death or misunderstandings about it, is often associated with marital distress.

Discordant coping is related to differences in grief expression between men and women. Women tend to use more emotional expression as they process discussions to cope with the stress, while men try to control their emotions and cope with them alone, engaging in solution-focused discussions and activities.

Incongruent grieving in which father and mother react to the infant or child death with different levels of intensity and for different periods of time—women typically grieve more intensely and for longer periods of time than do their spouses [ 13 ]. One study reported continued marital distress from such variations in grief as long as two to four years after the child's death supporting the enduring nature of such stresses [ 57 ].

Low intimacy in which the combination of incongruent grieving, discordant coping, communication breakdowns, and other misunderstandings, as well as different needs for sexual intimacy are thought to contribute to a low sense of intimacy between parents [ 58 , 59 ]. Lower levels of intimacy and support from one's partner are associated with greater incidence, intensity, and duration of grief symptoms for both men and women [ 14 , 38 , 60 - 62 ].

• IMPACT OF THE LOSS ON SIBLINGS AND OTHER FAMILY MEMBERS

The death of a child may be one of the most difficult and profound experiences for surviving siblings, grandparents and other family members as well as parents. In the case of an illness such as childhood cancer, the death may have been preceded by months or years of stressful treatments in which family attention and resources were focused on the ill child. In 1981, the title of an article on sibling loss, “Siblings: The Forgotten Grievers” [ 63 ], reflected the lack of attention in practice and research to sibling bereavement. Over the past two decades, clinical and research attention to sibling loss, although relatively new, has increased significantly [ 64 ]. This development occurred in response to a growing awareness that earlier beliefs of children's inability to grieve were incorrect. In addition, qualitative studies and personal narratives documented the intensity of sibling grief and sometimes lifelong negative consequences of failure to recognize and support siblings in their grief.

Retrospective qualitative studies suggest that surviving siblings may have feelings of isolation and social withdrawal at home and with peers [ 23 , 65 , 66 ]. They have reported feeling different from peers as a result of their experiences and typical peer activities (e.g., interests in fashion, sports) may seem less important after the death. Parents and teachers reported that siblings have significantly lower social competence and higher social withdrawal scores on standardized measures within two years of the death [ 20 , 21 ]. Siblings themselves describe feeling guilty, anxious, and depressed and parents have noted problems with sleeping, nightmares, anxiety and post-traumatic stress symptoms [ 22 , 23 , 67 , 68 ].

Explanations for siblings' distress have focused on the parents' preoccupations with the child who has died and distraction with their own grief causing the neglect of the siblings. Bereaved parents have reported high levels of parenting stress as they are confronted with many new daily responsibilities. Siblings describe a lack of communication, decreased availability and support from parents [ 23 ]. Some have suggested bereaved parents may also become closer to and overprotective of surviving children [ 69 ].

As understanding of children's capacity to grieve has grown [ 44 , 70 ] attention has turned to studying the variations in their grief experiences. Research has focused on the development of a measurement tool for assessing sibling bereavement, studied effects of sibling death on younger children and adolescents, identified longer term outcomes of sibling bereavement, and documented the natural history of sibling bereavement [ 3 , 65 , 71 , 72 ]. Practice guidelines for interventions with bereaved siblings have also been developed [ 73 ].

Few interventions of bereaved siblings have been systematically studied in relation to their effectiveness [ 74 ]. However, Davies, in her overview of the literature, suggests a number of principles that have emerged that may inform the structure of interventions and provide helpful thematic foci with the individual child and adolescent [ 64 ]. The following principles expand on Davies' discussion.

Children of all ages can benefit from validation of the normalcy and appropriateness of a broad range of grief reactions to the death of a sibling. Recognition of their unique relationship to the sibling and their individual responses to the loss of that relationship within their personal and familial situation is fundamental to intervention with bereaved siblings.

Context is important and includes taking account of the timing and specific circumstances of the death, the ethnicity and culture of the family. Siblings are likely to benefit from being included in interventions earlier in the trajectory of the sibling's death and continuing follow up contact over a longer period of time than generally occurs. Children facing the impending death of a parent experience greater anxiety and depression than they do immediately after the death occurs [ 44 ]. This finding suggests that the terminal illness period offers the opportunity for family members to prepare for a loss and provides the possibility of preventive intervention. Similarly, facing the death of a sibling gives an opportunity to provide information, education, emotional support, and preparatory actions that can mitigate the adverse consequences of the death. Knowledge of longer term effects of sibling and parent death is limited, therefore interventions need to provide for monitoring of children's and families' functioning over time in order to identify later effects and infuse timely services.

The details of the specific circumstances of the death, (e.g., anticipated, sudden, catastrophic) affect how siblings and family members experience the loss. They may confront more or less traumatic stress, greater or less avoidance of reminders and thoughts about whether the death could have been prevented, and more or less hopefulness about the consequences of the death on the family and their future opportunities in life.

The importance of the family's ethnicity and traditional way of coping with stresses including death is important in intervening effectively with a broad range of diverse family cultures. For example the level of openness in communication of facts and feelings about the loss with both adults and children, the expectations of the length and quality of the grief process, the use of particular rituals and symbolic processes, and decision making patterns can vary enormously and should inform intervention approaches.

Developmental attributes are likely to influence how siblings experience and express their loss. For example, young children are more likely to harbor unrealistic fears of their own vulnerability to the illness, injuries, or condition their sibling experienced. Adolescents are more vulnerable to depression in response to the parents' grief and subsequent withdrawal from them as the adolescent goes through normal separation from the family. Knowledge of these differences in cognitive, emotional, and social/ ecological capacities should be integrated into intervention approaches and thematic foci.

A family and interpersonal focus is essential, whether the primary target of the intervention is the parent or the child. The parents' management of their own grief and construction of the meaning of the loss has an enormous impact on surviving children. The degree to which they blame the surviving children, are able or unable to re-establish a positive relationship to the siblings, to engage in the siblings' growth and view their progress and development as uniquely important as the lost future of the child who died has an impact on the stress of the situation for siblings. Facilitating communication and understanding between parents and their children about these often unacknowledged dilemmas and management of family communication during terminal illness and after death is an important component of intervention efforts. Similarly the parents' own positive mental health and ability to fulfill important life goals going forward contributes to a stronger support system for surviving siblings.

Empowering a broad range of support systems is also an essential part of an intervention. As children develop, they are affected by an increasing number of social, service, and political systems: e.g. extended family and friends, teachers, coaches, peers, health and mental health professionals, religious groups and institutions, community services, and national and international policies and structures [ 75 ]. Influencing these systems through education, dissemination of information, consultation, and support can significantly expand the help available to siblings and other family members.

Qualitative analyses of sibling experiences highlight the following themes as a focus for interventions with siblings.

Loss of affection, attention, continuity, and stability within the family due to parental distress and preoccupation with their own bereavement. This can include multiple separations and lack of attention from parents during the ill sibling's terminal illness or unavailability due to parents' traumatic stress responses after the sibling dies. Stresses on the marriage after the death of a child affect the siblings as well.

A lack of social validation of siblings' grief experiences. This can be due to lack of understanding of children's grief, underestimation of the importance of the sibling relationship, or fear and lack of knowledge about how to respond to the grief of another child by peers and adults. A student bitterly reported a teacher's question, “Why are you upset, he was only your step-brother?” “But he lived with me all my life,” she said to herself. Siblings experience a high level of social constraint in response to their grief.

Perceptions of not being good enough to fill the void in the parents' affection. Parents' intense preoccupation with the dead child is interpreted as a lack of love of the surviving sibling—“the wrong child died.” The sibling feels devalued, alienated, and isolated from both family and peers.

Davies summaries these themes from the sibling's perspective [ 64 ] (pp. 211-216):

“I hurt inside” requires comfort, consolation, and validation of the child's unique experience of the loss. This is a particularly challenging task for grieving parents and may be assisted by the use of peer support groups.

“I don't understand” requires explanation and interpretation provided at a level appropriate to the child's cognitive developmental level. Concerns about the child's own safety and well being in addition to other facts about the situation should not be overlooked. Resources available to parents and professionals include books that focus on helping children with a broad range of grief reactions and types of losses [ 76 - 78 ].

“I don't belong” requires including and involving the child before the death occurs in the case of anticipated loss, during the death and burial rituals, and in the post-death bereavement process. Research continues to support the helpfulness of children's and adolescents' involvement in these processes when they are given adequate preparation for their particular role.

“I'm not enough” requires continued reassurance and validation of the unique worth of each child. This response is somewhat unique to sibling loss compared to other types of losses and has at times powerfully affected siblings' adaptation.

• IMPACT OF THE DEATH OF INFANTS, OLDER CHILDREN, AND ADOLESCENTS

Infant Death

The deaths of infants, either through miscarriage, stillbirth, newborn death, or SIDS, were until recently regarded even by most professionals as “nonevents” or “non-deaths” affecting unnamed “non-persons” [ 79 ]. Greater awareness of the importance of validation and recognition of the significance of the loss of infants to parents has resulted in the development of programs to guide parents in their expression of grief and to encourage them to engage in rituals from their particular religious, cultural, or ethnic background. While there are common issues in bereavement for all infants, each of these circumstances of infant death brings its unique stresses related to the way in which it occurs as well as to the individual parent(s) [ 80 ].

Stillbirths. A stillbirth turns an anticipated joyful event into tragedy. Stillbirth can assume two forms. The more common occurs when the baby was viable and then dies during labor or delivery. In the second type the fetus dies in utero and the mother is forewarned of the death days or even weeks before the delivery. Particularly difficult and stressful for the mother is carrying a dead fetus when movement has ceased. Parents often describe these situations as the simultaneous birth and death of the child.

Perinatal Deaths. With the dramatic increase in the survival of low birth weight babies, the death of a very tiny, sick, or deformed newborn is no longer always expected. Parents' hopes may be buoyed with the suggestion of each additional medical procedures, and the added time that the child lives increases their attachment. The advent of new technologies and surgical procedures that might prolong survival but at a price of pain, discomfort, or survival with gross disfigurement or retardation presents new problems to both parent and physicians. A not-uncommon situation occurs when careful diagnostic assessments and open discussions between physician and family have led to a decision not to perform a life-saving operation, with a change of mind by the parent following delivery when the full-blown symptoms of a lifelong disability are only minimally apparent. This situation may engage them in complex legal and ethical issues that intensify the emotional difficulties parents have in dealing with their loss.

Sudden Infant Death Syndrome. SIDS deaths declined by 46 percent from 1983-1996 due to successful education and broadly disseminated ad campaigns. SIDS usually occurs within the first year of life and is the most common form of death after the neonatal period. The particular stress of this type of death relates to the ambiguity about its cause that leads parents to struggle with guilt and whether the death could have been prevented. Family and friends often do not know how to respond and therefore withdraw, inadvertently creating a “conspiracy of silence.” Here, health care personnel can make a contribution by providing information about the nature of SIDS that helps reduce ambiguity about the cause of the death.

Grief Reactions to Infant Death

A very common grief reaction after perinatal or SIDS death of an infant is intense preoccupation with thoughts and images of the dead baby. According to several studies, between 65 and 95 percent of mothers and 51 and 85 percent of fathers report problems with preoccupation or irrational thoughts about their dead baby during the acute phase [ 81 , 82 ]. Many parents report a sense of the baby's presence—of hearing their dead baby cry—and some mothers say they feel fetal movements for months after the delivery. Others report illusions or hallucinations that their baby is still alive. This can be disconcerting to parents and family members; however it is reported in studies of many bereaved parents. Like many other traumatic events, the death of an infant challenges parents' assumptions about their own and their families' safety in the world. Anger and irritability about the injustice and unfairness of losing their child are common grief responses and may be directed toward health care professionals, their spouse, God, or fate. Alternatively, these may be emotions directed inward toward themselves resulting in lowered self-esteem, self-blame, and depression. Parents also experience intense anger and jealousy toward other parents who have living babies.

In general, parents of infants who have died from whatever causes share the experience that their friends and family do not know their infant, that they may not recognize or empathize with the full extent of their loss [ 83 ]. Many parents of infants who die report being particularly stressed by people who avoid any discussion of the loss or offer clichés or dismissing statements such as “you can have another child”. The advice to have a new child as a way of bypassing or avoiding the pain of loss for the particular child who died remains controversial because findings from research are contradictory [ 4 ]. Friends as well as other family members may be impatient about the “slow” rate of parents' recovery from the loss. As in most forms of bereavement, depressive feelings are often present following this type of loss. In fact, bereaved parents have been found to experience elevated symptoms of depression more than two years following perinatal death of their child [ 57 , 84 ].

Almost all parents search persistently for explanations of the cause of the death following perinatal or SIDS death. Studies suggest that most families believe that it is highly important for them to understand the cause of their baby's perinatal death. Often there is no definite answer or explanation, which they find frustrating. Of interest in one study was the tendency of parents to blame the mother for the baby's death (26 percent of mothers and 13 percent of fathers), despite explanations by their physician to the contrary.

Across studies, mothers consistently report more intense and prolonged grief reactions than fathers except for the area of denial where fathers report greater denial in the immediate aftermath [ 84 ]. These differences are reported to cause additional stress and strain on the marriage relationship and to reduce the support available from the intimacy it could provide. A range of theories are suggested to explain differences that could be the subject of future research such as the differences in the bond formed between mothers and fathers and the developing infant [ 2 , 85 – 87 ]; general gender differences in reaction to stress; and differences in gender-role socialization involving emotional expressiveness and willingness to acknowledge and report emotions [ 58 , 61 , 88 – 90 ].

Deaths of Children and Adolescents

Deaths are less common among older children than among infants, with accidents, especially among adolescents, the most frequent cause. Cancer is the leading illness cause of death in children and adolescents. Parents who experience the death of an older child usually have many of the feelings already discussed in relation to infants. However, more is known about the grief of parents of children who die of an illness than about the grief of parents whose children die suddenly by accidents, homicide, suicide, natural, or man-made disasters [ 91 ]. One reason for this greater knowledge may be that parents already connected to the health system during their child's illness are more likely to participate in bereavement services after the death as well as having access to services during terminal illness [ 12 ]. Retaining parents in need of assistance who have experienced sudden death in formal longer-term bereavement services remains a challenge [ 92 ]. At the same time, the existence of self-help organizations focusing on child loss, such as Compassionate Friends, provides alternative avenues for bereaved parents to receive support; yet such organizations serve only 25 percent of bereaved parents. These organizations have been the focus of significant studies on the services they provide to parents [ 38 ].

Families' avoidance of formal and informal support services is thought to reflect, in part, avoidance of traumatic reminders. However, the lack of participation in interventions may also reflect inappropriate treatment models that fail to respond to the needs of families who have experienced the sudden death of a loved one [ 93 ]. An example of this problem was reported by the William Wendt Center in Washington, D.C., a program developed to provide trauma and bereavement services to families at the time of identification of the body of a loved one who died suddenly from accident, homicide, or suicide [ 94 ]. This innovative service established a site in the coroner's office where providers can immediately meet with families upon identification of the body. The center soon discovered that in addition to trauma and grief counseling, case management services were needed to help families with the consequences of such losses (e.g. loss of housing, dramatic loss of income, unsafe living environments, and the loss of support networks) [ 94 ]. Longer term follow-up of families affected by such traumatic deaths remains a challenge. With parents of older children, as with parents of infants, the intense nature of their response to the death of their child is thought to be related to multiple factors:

the love for the unique child who has died;

the special intimacy and strength of the parent–child bond, unlike most other relationships [ 17 , 28 ];

the connection with the parent's hopes and dreams for the future and even immortality [ 17 , 94 , 95 ];

the challenge to parental identity as competent protector, provider, nurturer;

the social stigma associated with child death [ 96 , 97 ];

the isolation and loss of social support that often follows such stigmatized deaths; and

the existential crisis of finding meaning in life without parenting this child.

• INTERVENTION APPROACHES

It is important to keep in mind that there are numerous individual, familial, and cultural differences that make responding appropriately to another person's grief anything but a formula. The United States, as most Western countries, has a variety of cultural, religious, and ethnic variations that mediate and modulate the experience of grief and mourning [ 98 ]. There is mounting evidence that forms of support that leave room for the bereaved to discuss their thoughts, feelings, and experiences are often seen as the preferred mode of response to bereavement [ 19 , 99 , 100 ]. This is in contrast to approaches that emphasize a more active approach to the bereaved, one that confronts them with models of the “appropriate ways” in which to grieve and expects linear progress along some stage model of grief. It is sometimes surprising to laypersons and professionals alike the degree to which people are willing to educate others about their culture, share elements of their experience, and feel benefited by the experience. What is needed in the listener is an ability to listen with a degree of empathy and patience.

Evidence suggests that parents of newborns, children and adolescents who die benefit from a range of early intervention services [ 62 , 101 , 102 ], yet bereavement programs connected with medical care are only beginning to develop. A small percentage of parents who experience child loss contact self-help organizations. Child death is infrequent in the United States and many parents feel stigmatized by their situation, become isolated, and find outreach difficult. This small number of parents who engage in support programs or participate in research on bereavement following the death of a child has limited knowledge development and innovation. Newer intervention models and interventions described below are promising as they are located at times and in places that are more accessible to parents and they focus on the broad range of needs of parents, siblings, and extended family after a child's death. While additional research is needed to clarify post-bereavement outcomes both short and long term, existing knowledge suggests the following interventions. Those specific to families of newborns who die might include:

help parents accept the reality of their loss by gently encouraging them to see, hold, and name their dead baby and to hold and then participate in memorial services;

help parents retain important mementos such as photographs and locks of hair, hand and footprints, tangible reminders and “evidence” of the child's presence such as bedding and clothing; and

connect families to other parents who have experienced this loss, to self-help organizations, or to professional counseling or services that address this issue.

Interventions for families of children and adolescents might include:

accept a broad range of grief reactions without becoming judgmental or withdrawing—this may include parent's anger, blame, humor, and inability to grieve;

provide information in multiple formats (e.g., written, audio/visual, public meeting, broader media programs, Internet based) about the bereavement process including gender differences, expected problems, needs of siblings and extended family, and available services;

include information on both trauma and grief responses of children and adults in all education efforts. This is especially important with children as so many children's deaths occur from accidents;

create opportunities for families to meet other families facing similar situations that can make the experience less lonely as well as provide a perspective on the loss process. This includes connecting parents to self-help groups, especially those that include siblings and extended family services;

make available professional bereavement follow-up counseling for grieving family members, including individual, family, and/or group;

create a range of intervention models that address the bereavement process and are accessible to families in time and location. For example services should not be limited to once-a-week psychotherapy for one hour, to a time limited series of meetings, but models may also include less frequent, more intensive meetings offered over a longer period of time. Interventions should also be provided at places convenient to families both geographically (e.g., at home or within local communities) and/or in relation to where the child's terminal condition is treated. Intervention models should address the broad range of families' needs including financial and practical needs;

bereavement interventions should begin before the loss when it can be anticipated in order to take advantage of the opportunity for preparation and prevention of later adverse reactions;

create models of follow-up care that provide ongoing access and increase knowledge of longer term outcomes;

provide family focused interventions that assist parents in connecting or reconnecting with their existing families, friends, and networks of support as a means of re-establishing coherence and meaning as they go forward; and

provide specific services and outreach for neglected sub-groups of parents and family members: e.g., parents who have lost an only child, parents who have lost multiple children, parents whose child died from accident, suicide or homicide, grandparents of children who die.

Interventions for surviving children and adolescents have been addressed in the section on siblings. Suggested models and approaches from the existing literature include the following:

provide information in multiple formats (e.g., written, audio/visual, Internet based, group meeting and larger event) for children and adolescents about the nature of grief following the death of a sibling and ways to cope with it;

provide information/consultation about ways to help bereaved siblings to parents, extended family, teachers, coaches, religious and social service organizations, hospitals and health care services, emergency services, mental health providers and the media. In this way the knowledge base and social and cultural context in which siblings experience their grief is improved. Information should include the emerging knowledge about the intertwining of trauma and grief, ways to recognize these symptoms and ways to manage them;

provide opportunities to receive mementos of the child who died and to participate in memorial services;

provide access of bereaved siblings to other bereaved children or adolescents who can share their experiences and reduce isolation. Since sibling death is infrequent in the United States, where possible, integrate children and adolescents who have experienced sibling death into existing bereavement groups and services that include children who have experienced loss from the death of a parent or peer or through divorce. Consider the use of the Internet and teleconferencing as additional ways to form sibling groups and facilitate communication; and

increase knowledge of, and provide for the special needs of particular sub-groups of bereaved siblings: those whose sibling died of homicide, suicide, accident or terrorist attack.

Newer intervention approaches have included:

Interventions that focus on developing ongoing networks of support within specific geographic, ethnic, or religious communities;

Interventions located within service organizations that treat the child's terminal condition and can direct parents early in the bereavement process to appropriate services—e.g., hospitals, emergency services, the coroner's offices, and schools;

Interventions that utilize intensive camp/retreat experiences or 1 day work shops with follow-up services in the community;

Combinations of professional and self-help leadership in groups; and

Novel uses of the Internet and technology to provide group information and on-line discussion groups. A recent qualitative analysis of an online perinatal bereavement group, not professionally led, identified themes of interpersonal connection, memorializing the child who died, and validation of the parent's unique grief experiences. Such technologies can provide important opportunities for access to social support and education.

• RESEARCH IN BEREAVEMENT

New intervention models have been developed for specific bereavement situations, some beginning during the terminal illness period [ 103 , 104 ]. Evidence suggests that this time period offers an important opportunity for preparation and prevention of unnecessary bereavement distress after the death of a child as well as the death of a parent [ 12 ]. Other variables that continue to be the focus of research include the role of symptoms of traumatic stress, particular types of child deaths such as suicide, homicide, and deaths from AIDS, gender differences in coping, marital distress and divorce, depressive symptoms, verbal disclosure, emotional expression in the face of social constraints, and the role and function of ongoing memories of and connection to the child who died [ 4 , 105 ]. Additional research questions include the following:

What are relevant bereavement outcomes for sibling, parents, and the family as a whole?

What prevention opportunities occur during the child's terminal illness?

What are the range of psychological symptoms including traumatic stress experienced by parents and siblings during a child's terminal illness and after a child's death and are they responsive to medical and psychosocial interventions?

Do current criteria for complicated grief in adults apply to bereaved parents?

Do symptoms and behaviors suggested for complicated or traumatic grief in children differentiate the grief experience of siblings?

Most studies of parents' grief for a child who dies have relatively short-term outcome evaluations. Longer term prospective research could improve our understanding of delayed and complicated grief and associated risk and protective factors that occur over time.

How is child and adolescent functioning after the death of a sibling affected by family functioning and social support?

What are the range of risk and protective factors that affect different outcomes such as the parent's decision making about the child's terminal treatment, timely information, and the use of psychosocial support services?

How do health professionals differ in their responses to parents during the child's terminal illness from their responses to parents whose children are not terminally ill?

Does professional training and skill development in working with bereaved parents and siblings affect outcomes of the experience?

Can studies move beyond outcomes such as grief symptoms, depression, and social support to include broader variables of self-esteem, personal growth, and flexibility [ 4 , 105 ]?

What are the barriers to recruitment of research samples in this area and how can they overcome?

Columbia University, School of Social Work.

School of Social Work Tel Aviv University, Israeli Center for REBT.

Professor of Psychology, Clinical Psychology Program, University of Haifa, Israel.

• Cite this Page Institute of Medicine (US) Committee on Palliative and End-of-Life Care for Children and Their Families; Field MJ, Behrman RE, editors. When Children Die: Improving Palliative and End-of-Life Care for Children and Their Families. Washington (DC): National Academies Press (US); 2003. APPENDIX E, BEREAVEMENT EXPERIENCES AFTER THE DEATH OF A CHILD.
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