When death is near, the main course of action is to fulfil the dying person’s wishes. If the person is dying from an illness, ideally, they will have shared their preferences about how to live and die. Different suggestions could be provided to the dying individual in an attempt to accommodate his or her requests and still provide adequate care. If the dying individual is not able to involve in formulating final plans, you should strive to facilitate their desired preferences. Ideally, the aim will be for the final days to be guided toward maintaining comfort and reaching a natural death.

The Process of Dying & Death

If a person is dying from a chronic illness, he or she may grow weaker and sleep more as each day passes, especially if his pain has been eased.

Closer to the very end of life, his or her breathing becomes slower – sometimes with very long pauses in between breaths. The final outcome of dying is death itself. You will know death has arrived because the person’s chest will not rise and you will not detect any breath. His or her eyes may be glassy and you will not feel the pulse.

The dying process may go through two main stages prior to actual death. The first stage is called the pre-active phase of dying followed by the second stage called the active phase of dying. The duration of pre-active phase of dying may last weeks or even months, while the active phase will be shorter and last only a few days, or, sometimes, a couple of weeks.

Pre-active Phase

• Person speaks of “tying up loose ends” such as finances, wills
• Person spends more time alone and withdraws from social activities
• Person desires to make amends or catch up with family and friends
• Lesser activity, more lethargy or sleep
• Loss of interest in daily activities, eating or drinking
• Increased discomfort, anxiety, agitation, confusion
• Increased difficulty to heal from bruises, infections or wounds
• Person talks about dying or asks questions about death
• Person shows more interest in religious activities e.g. praying, or requests to speak with a religious leader

Active Phase

• Person says that he is going to die soon
• Has problems swallowing or resist consuming food and fluids
• Getting more unresponsive or difficulty speaking
• Personality change
• The hands, feet, arms and legs could be starting to feel very cold.
• However not all the above signs would be apparent and they are merely a guide to what may or often happens

How can you support?

As a family member or friend, you could do the following:

• Ask the person whom he/she would like to see and invite those people. Have a list of people to contact near the time of death.
• Help them to feel comfortable (massage, holdings hands, reading and background music can help decrease a person’s sense of isolation and enhance comfort)
• Standby for physical discomfort (e.g. lip balm to prevent chapped lips)
• Talk with someone you trust about your feelings of potential loss
• Feel free to say good-bye at the time of death

Below are guidelines are for the person who is dying. Ideally, death and dying should be peaceful and healthy for the dying person and the people who love and care about the dying individual.

Specific guidelines for the dying individuals include:

• Don’t be fearful to ask to be alone, time to be by yourself is important
• Be grateful and willing to seek help
• Some people may interact with you differently after knowing that you are dying. Be patient with them as they may slowly adjust to this fact.
• Slow down, and request your family and friends to slow down the pace. Sometimes there may not be a lot of time, but there is sufficient time, except in the most extreme cases, to reflect, plan and carry out the necessary.
• Get someone you trust to help you handle the matters related with your dying and death. Pre-planning will provide your loved ones both assurance that your wishes are being fulfilled and peace of mind from the knowledge that decisions have already been made.
• Ask your health care providers to explain what is being done to you so that you can understand why things are being done and what benefits you can expect.
• If necessary, utilize resources that are available from the community e.g. counselling services.

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Many people have heard of Elisabeth Kubler-Ross’s five stages of grief (denial, anger, bargaining, depression, and acceptance), and they generally find that these stages could reflect their grieving process, at least to a certain extent.

However, there are some people particularly those with an instrumental approach towards grieving may not be able to comprehend their experiences of loss effectively with the five stages of grief. The limitation of the stage model is that it postulates what people who are grieving could be going through but it doesn’t suggest how the sense of loss and grief could be managed at a personal level.

As an alternative, William Worden suggests that there are four tasks one must accomplish in order for the grieving and mourning processes to be completed appropriately, and life equilibrium to be re-established. There is no specific order though there could be some natural sequence in that completion of certain tasks would presuppose completion of the remaining tasks. It may be necessary to revisit specific tasks over time as grief is not linear and likely to be subjective. Additionally, it is challenging to ascertain a timeline for the completion of these four grief tasks. Let us examine these tasks in greater details.

THE 4 TASKS OF MOURNING

Task 1: Accept the reality of the loss.

While the Kubler-Ross stage model ends with acceptance, Worden believes that accepting the reality of the loss and that the death has indeed occurred, even if it is anticipated, is the foundation of healing. There are a couple of ways to commence this task. Viewing the body of the person silently who died is one way to begin. Participating in rituals such as planning the funeral, preparing the eulogy or tending his or her grave are strategies to begin working on the first task.

Task 2: Process your grief and pain.

Many people have different, and often unique, ways of dealing with their grief. Some need to talk, some would cry, others keep themselves occupied with work or hobby. Some people would cope with the sudden pain of loss by finding a way to memorialize the person who died by suicide e.g. investing in a cause close to the loved one’s heart, finding ways to help other similar group of survivors. It is not inappropriate to process grief by action as long as the focus is to navigate through the pain, not to avoid or hide from it.

Task 3: Adjust to the world without your loved one in it.

To commence on the third task, it requires us to adapt to a novel and frequently much altered world. Importantly, different people would adjust to the new reality in different ways. For example, it could mean removing your loved one’s phone number off or making new lifestyle plans without the deceased. Sometimes this adjustment without your loved one means having to face new financial situations such as having to return to work. Whatever the absence of the deceased means for you, commencing on Task 3 can guide you to explore and become accustomed to your new world.

Task 4: Find a way to maintain a connection to the person who died while embarking on your own life.

In this task many people may find themselves exploring how to remain emotionally connected with the deceased without it preventing them from moving ahead in their own life. Do note it is not about forgetting the deceased rather shifting the attention to find ways to re-connect and enjoy their life while remembering the memories of the deceased. Worden emphasizes that there is no fixed time frame for the completion of this task although it is likely that it would be of over a longer period e.g. months and years instead of days and weeks.

Addressing these 4 Task to adjust and assimilate to grief

In conclusion, Worden believes that while it is essential to address these four tasks to help people adjust and assimilate to their grief appropriately, it is important to note that many people would experience loss or its intensity in their own unique way. Let’s be patient and giving towards people who are grieving in their own way.

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Losing a loved one by suicide is a devastating and traumatic experience. These survivors may feel like their world have fallen apart, and they are left feeling lost, confused and empty. The unexpected nature of the death severely affects them emotionally and survivors always struggle to make sense of the suicide. As a result, they may go through a whirlpool of strong emotions of pain, loss, sadness, anger, panic, guilt, loneliness, and shame. Critically these emotional experiences could have a negative impact in other aspects of their lives e.g. relationships, work, school.

In addition, survivors may be asking themselves these questions:

• Why did this happen? Why didn’t I detect the signs?
• Could I have done something to stop this from happening?
• How can I ever go on living?

Therefore it is important to understand that survivors of suicide deaths desperately need unconditional support and understanding. If a friend or family member has experienced the death of someone they loved from suicide and you are not sure how to go about helping him or her.

The following guidelines could support you to take positive actions.

• Accept The Intensity Of The Grief
• Listen With Your Heart
• Avoid Providing Simplistic Explanation and Clichés
• Respect The Importance To Grieve
• Realize The Uniqueness Of Suicide Grief
• Be Aware Of Special Occasions e.g. Birthdays, Holidays And Anniversaries
• Be Aware Of Support Groups
• Respect Spirituality And Faith
• Work Together As A Team

Accept The Intensity Of The Grief
Do not be surprised by the intensity of their emotions and, sometimes, when they least expect it, they could be overwhelmed by their grief. Understand that survivors may find it hard to deal with complex emotions related with guilt, fear and shame, much beyond the limits experienced in other types of deaths. Be compassionate, empathetic and patient. Allow them the space and time to grieve.

Listen With Your Heart
Be willing to listen is often the best way to offer help to someone who needs to talk. Do not worry about what you need to say or not knowing what to say. Just focus on listening to what they are sharing and feeling their emotions. Let them know you are with them no matter what even if you are unsure of what you can do or say as it is often comforting for them. Take note the survivor may repeat the same story about the death over and over again. Understand this repetition is part of his or her healing process. Simply listen without judgement and understand. And, remember, you don’t have to have the answer.

Avoid Providing Simplistic Explanation and Clichés
Avoid judging or providing simplistic explanations of the suicide. Do not make unpleasant comments about the person who died by suicide like “out of his or her mind”, “mentally sick” or the equivalent as these would only complicate the situation. In addition, words, particularly clichés, are extremely painful for a suicide survivor. Clichés are trite comments often intended to downplay the loss by providing overly simplified solutions to difficult realities. Comments like, “He is in a better place,” “Be strong,” “Time will heal all wounds,” “Think of what you still have (e.g. children)” or “You have to be strong for others” are not constructive. Instead, they hurt even more and make a survivor’s journey through grief more challenging. Suicide survivors need a lot of help in coming to term for understanding of what has happened. In the end, their personal search for meaning and understanding of the death is what is really important.

Respect The Importance To Grieve
Often ignored in their grief are the other family members (e.g. spouses, parents, siblings, relatives, children) related with the person who had died by suicide. Why? Because of the taboo nature of the death, it is sometimes kept a secret. If the death cannot be discussed openly, the grief may be unresolved. You may be the only one willing to be with the survivors and your physical presence and empathetic listening will support the healing process. Allow the survivors to talk, but do it gently. Sometimes you may need to wait and let them know you are ready to listen if, and when, they are ready to share their thoughts and feelings.

Realize The Uniqueness Of Suicide Grief
Remember that no one will respond to the suicide death of someone they loved in exactly the same way. Because the grief experience is unique, be patient. The process of grief takes a longer period, so allow the survivor to manage the grief at his or her own pace. Don’t criticize what is inappropriate behaviour and don’t impose your values.

Be Aware Of Special Occasions e.g. Birthdays, Holidays And Anniversaries
Survivors of suicide may face a more difficult time during special occasions like birthdays, holidays and anniversaries. These events could intensify the absence of the person who has died. Be respectful of their pain as a natural expression of the grief process. Remind yourself to always use the name of the person who has died when communicating with the survivors. Hearing the name can be comforting as it confirms that you have not forgotten this important person who was an important part of their lives.

Be Aware Of Support Groups
Support groups are a good way to help survivors of suicide. In a group, survivors are allowed and encouraged to tell their stories as much, and as often, as they like in a supportive and accepting environment. Do help survivors locate such a group and this practical effort on your part will be appreciated.

Respect Spirituality And Faith
If faith is part of their lives, let them express or utilize it in ways that seem appropriate. If they are angry with their religion e.g. God or equivalent, do not stop them from talking about it. Don’t be a judge, be an empathetic listener. Survivors may also need to understand how religion may have complicated their grief (e.g. believing people who killed themselves will end up in hell). Do not attempt to explain theology, but please listen and learn. Whatever the situation, your desire to listen without judging is the critical helping tool.

Work Together As A Team
Family and friends who experience the death of someone to suicide should not suffer alone in silence. As helpers, you need to work together to provide support and acceptance for survivors who need to grieve in healthy ways.
Finally to experience grief is the result of having loved. Suicide survivors must be given this right. While the above guidelines can be helpful, it is important to realize that supporting a suicide survivor heal will not be an easy task. You may have to give more concern, time and care than you ever knew you had. But this effort will be more than worth it.

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The loss of a child is never easy, simply, parents are commonly accepted not to outlive their children and no parent is prepared for the death of their child.

We need to remember that the lifespan of your child does not and should not determine the intensity of your loss. The death of a child, young or older, changes every aspect of family life. Parents often have to face an enormous sense of emptiness like a missing ‘limb’ in their lives when it happened. When the deceased child is an adolescent or adult, parents may perceive that they lose a close friend and an irreplaceable source of practical and emotional support. If it is their only child, their identity as parents or potentially as grandparents would be severely affected. In addition to grieving the child’s death, parents may also need to cope with the pain and loss of the hopes and aspirations they had for their child.

Signs and symptoms of common grief reactions

The signs and symptoms of grief following the child’s death, though similar to those after other losses, are often more intense and of longer duration. These are the likely grief reactions:

• Overwhelming despair and sadness, such that facing daily tasks can seem difficult
• Intense shock, disbelief, confusion, and even denial
• Intense anger and feelings of bitterness and unfairness at a life left unfulfilled
• Extreme guilt – you may think that you are a failure because you could not save your child and dwell on what you could have done differently
• Feeling that life is meaningless and wishing to be to join your child to be released from the pain or guilt
• Fear or dread of being alone and overprotecting your other children
• Feelings of resentment toward parents with children who are still around
• Doubting or loss of spiritual or religious faith/beliefs
• Dreaming or having nightmares about your child, or feeling your child’s presence nearby
• Feeling intense isolation, emptiness and loneliness, even when with other people. You may feel that the intensity of your grief separates you from others and that no one will understand how you feel

Therefore when a child dies, some parents will have an especially difficult time. For this group of parents, even over a period of time, dealing with the intense grief and loss appropriately is challenging. And they feel it is almost impossible to return to their normal life. Some parents may even think about harming themselves as a way to relieve or escape from the pain. Even for parents with this complex form of grief, however, there can be a way forward. If you believe you may be one of these parents, talk with a professional who can help you, such as a doctor, psychologist or a counsellor.

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When we lose someone through death, it is common for grief, sadness, anger or anxiety to appear sometimes. While these mood issues might seem like depression, the experience of grief is quite different. Grief is precipitated by distress over the loss of another e.g. death. Generally people could go through grief while maintaining their daily routine in their personal life e.g. family, relationships, work, school, without severe disruptions.

Generally speaking, someone who is depressed would:

• Have persistent low mood over a prolonged period of time
• Experience a loss of interest in their usual pleasurable activities or even basic activities like showering or dressing
• Have sleep issues e.g. insomnia
• Have a change in appetite e.g. loss of appetite
• Have lowered self-worth, pessimism or feelings of hopelessness
• Experience a change in energy level e.g. fatigue
• Face difficulty in concentration or decision-making
• Physically slow down (walk and talk slower) OR become more agitated and unable to sit still
• Have thoughts of harming themselves

How to tell if someone else has depression

We may believe we understand someone well doesn’t always mean we will be able to identify accurately when they have experienced some behavioral and emotional changes. Sudden changes especially prominent ones are likely to be noticeable but if the changes are gradual and slow, it is likely that these subtle changes could be missed. Additionally, even the familiar people we know (including our loved ones) will not overtly reveal their depressive thoughts and emotions.

Importantly, a portion of people experiencing grief could develop depression subsequently, but it is usually weeks or months later. The helpful approach is to be mindful that depression is not uncommon and to be aware of the common characteristics of depression.

Finally if you are concerned that someone you know could be depressed, it is critical to discuss with them about it and/or suggest that they seek some help from a mental health professional.

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Well, do not feel alone as Insomnia is actually quite a common problem suffered by working adults. In fact, it has been reported that nearly one-third of the adult population in the US suffer from sleep problems. Insomnia is a significant health issue because of its high prevalence and its implication with work absenteeism, impairment of quality of life, and increased medical and societal costs.

Here are 10 simple steps to help you to sleep better!

10 ways to tackle insomia

If your Insomnia still persists and it starts to affect your daily life e.g. work, please seek professional or medical attention promptly. If your company has an Employee Assistance Programme, consider seeking Telephonic Consultation as another efficient option to get help. For a couple of brief Telephonic Consultations, a customized plan of recommendations could be attained for you to make some lifestyle modification and improve your sleep.

Written by our Principal Psychologist, Gerald Boh Boon Tiong

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