Understanding Death: Exploring Grief, Mourning, and the Stages of Bereavement

1. DEATH IN AMERICA

2. DEATH IS THE FINAL STAGE OF THE LIFE CYCLE... AND IT IS CERTAIN One important and obvious realization when thinking about death is that death is inevitable. The time death will come is uncertain, but that it will arrive is irrefutable. Human bodies cannot withstand all the ravages of accidents, disease, and/or old age. Bodies wear out; people die. Certainty? In this world nothing is certain but death and taxes. Benjamin Franklin

3. Bereavement refers to the state of loss. Griefis a multi-faceted response to loss.Although conventionally focused on the emotional response to loss, it also has physical, cognitive, behavioral, social and philosophical dimensions. GRIEF AND BEREAVEMENT Human beings express a wide variety of grief responses. These are influenced by personality, family, culture, spiritual, and religious beliefs and practices. This lesson focuses on the beliefs, customs, and practices related to death, primarily in mainstream America.

4. Mourning is synonymous with grief over the death of someone. It describes a cultural complex of behaviors in which the bereaved participate or are expected to participate. While customs vary between different cultures and evolve over time, many core behaviors remain constant. MOURNING Using euphemisms, metaphors, and slang terms instead of death and dying terms is sometimes desirable in helping with the healing process. This alternative language can sometimes be amusing and/or “distancing. Pushing up daisies, the big sleep, off to the happy hunting grounds, dead as a mackerel/doornail, going home, shuffling off to Buffalo, bought the farm, cashed in, checked out, croaked, curtains, crossed over, drop dead, departed, dust to dust, eternal rest, expired, give up the ghost, kick the bucket, last breath, the hour has come, the race is run, the days are numbered, on the heavenly shores, passed away, passed on, perished, resting in peace, rubbed out, succumbed, six feet under, terminated, that’s all she wrote, give up the ghost, done in, withered away, etc.

5. LEARNING ABOUT DEATH... It is very difficult for parents to talk to children about death and dying, because it is the ultimate loss of control. Some parents prepare children for death using nature as the tool. Dying leaves in the fall or the death of a pet might introduce the child to death. Parents that allow the child time to experience the loss of a pet, without softening the blow by immediately buying another animal, may be preparing their child for future losses. Be honest. It’s scary to know the truth, but it’s scarier if you don’t know. Parents can’t fix everything. People can’t always be happy. Who Killed Cock Robin is a nursery rhyme beginning: Who killed Cock Robin? I, said the Sparrow, with my bow and arrow, I killed Cock Robin. Technology has brought real and fictional On TV, children see people killed, who then show back up in another episode a day later, creating confusion or an illusion.

6. STAGES OF GRIEF Probably the most well-known theory on the stages of grief might be from Elizabeth Kubler-Ross' 1969 book, "On Death and Dying." Since the time of that publication, today’s psychologists generally agree that those reactions are experienced in response to any “loss”, including the loss of life of a loved one. The 5 stages of grief have been revised to include at least 7 responses: - Shock (or Disbelief)- Denial- Anger- Bargaining- Guilt- Depression- Acceptance

7. STAGE 1: SHOCK -serves to prevent feelings of being overwhelmed, allow time for integration and processing of event at first STAGES OF GRIEF Individual stages are not necessarily experienced in order, or at all. STAGE 2: DENIAL • “no, it can’t be”; “this can’t happen”, “I don’t believe it” STAGE 3: ANGER -against those who caused the death -against the government who didn't do more to protect citizens -against God for allowing it to happen-against the dead for not doing more to save themselves (though it seems irrational)-against self (feelings of guilt)

8. STAGE 4: BARGAINING -“I promise I’ll do better if only…” “Take me instead” STAGES OF GRIEF STAGE 5: GUILT -feelings of survivor guilt: "Why should I still be alive and they’re not?” or “If only I had done more” STAGE 6: DEPRESSION-inability to cope emotionally; physical reactions (nausea, head or stomach aches, nausea, loss of appetite); experienced as intense feelings of loss and sadness that may last weeks, months, or years. STAGE 7: ACCEPTANCE -Finding inner strength through listening to each other, support groups, family; moving toward integration of the experience into one's memory; hope

9. DONATING YOUR BODY TO SCIENCE With 17 people dying every day in the United States for lack of an organ transplant, more and more people are considering the possibility of donating organs - or even their entire bodies - after death. With advances in medical science, it’s now possible to donate: • Organs (before and after death) • Tissue (including skin, bone, corneas, heart valves, blood vessels and tendons) • Bone marrow (before and after death) • Your entire body, for medical research

10. DONATING YOUR BODY TO SCIENCE Under the Uniform Anatomical Gift Act of 1984, it’s illegal to sell or buy- human organs or bodies. Anyone violating this law can be fined and/or sent to jail. Available transplant organs are gifted according to many factors, including: Location of the donor and recipient Severity of illness Physical characteristics like blood type, size, and genetic makeup Factors like wealth or celebrity status are not considered

11. NEBRASKA'S BODY DONATION PROGRAM The whole body donation program for the state of Nebraska is handled by the Nebraska Anatomical Board.Enrollment in the program is required on record before death. Donors may designate the recipient of their choice: University of Nebraska, Creighton University, or Nebraska Anatomical Board-unspecified Many bodies are rejected, including those of minors under 18 years old unless a deed form is co-signed by parents or legal guardian; bodies that have undergone extensive autopsies, trauma, highly contagious disease, excessive obesity, or emaciation; and bodies of persons whose families object. After cadavers are used for at least 2 years, the cremains (cremated remains) can be returned to the family for final disposition, if desired. You can note your desire to be an organ donor on your driver’s license.

12. An autopsy, also known as a post-mortem examination, is a medical procedure that consists of a thorough examination of a corpse to determine the cause and manner of death and to evaluate any disease or injury that may be present. It is usually performed by a specialized medical doctor called a pathologist. AUTOPSY The principal aim of an autopsy is to discover the cause of death, to determine the state of health of the person before he or she died, and whether any medical diagnosis and treatment before death was appropriate.

13. THREE TYPES OF AUTOPSY Forensic Autopsy: Done for legal purposes; takes several days to weeks to complete; no family permission is required; used to determine the cause of death: Natural, Accident, Homicide, Suicide, Undetermined Y-incision for abdominal cavity Clinical Autopsy: Usually performed in hospitals to determine a cause of death for research and study purposes. Permission from legal next of kin is required. Coroner's Autopsy: The county medical examiner/ coroner may require an autopsy for any purpose, including practice, in the state’s interest. No permission of the family is required. Incision from ear to ear on back of scalp; scalp peeled forward over face and skull opened to inspect brain

14. A death certificate is a document issued by a government official such as a registrar of vital statistics, and declares the date, location and cause of a person's death. DEATH CERTIFICATE Before issuing a death certificate, the authorities usually require a certificate from a physician or coroner to validate the cause of death and the identity of the deceased. • Purposes of the certificate: • review the cause of death to determine if foul-play occurred • may also be required in order to arrange a burial/cremation • to prove a person's will • to file a claim on a person's life insurance

15. Embalming is the art and science of temporarily preserving human remains to delay decomposition and make it suitable for display at a funeral if desired. The three goals of embalming are: preservation, sanitization, and presentation (or restoration) of a dead body. Most states require embalming, refrigeration, or burial within 24 hours after death (except for religious objections). EMBALMING After death has been determined by the physician or coroner, it is verified by: 1. rigor mortis – a change in the muscles after death that causes a stiffness in the limbs 2. lividity – a settling of the blood in the lower portion of the body, causing a purplish red discoloration of the skin

16. The mortician (funeral director) or embalmer, following the family’s direction, transports the deceased to the mortuary (funeral home). The identity of the deceased is verified, and the corpse is washed and disinfected with germicidal solutions. The embalmer bends , flexes, and massages the arms and legs to relieve rigor mortis. EMBALMING The human body begins to dehydrate after a person dies. Because the skin is so dry, it "pulls away from nails and hair." This makes it appear as though the nails and hair are growing, but in fact, it's really the opposite. The body is shrinking. Moisturizer can be applied to help with a more natural appearance to the skin.

17. EMBALMING The process of closing the mouth, eyes, shaving, etc is collectively known as setting the features. The eyes are closed and kept closed with an eye cap under the lid that keeps them shut and in the proper expression, or with adhesive. The mouth may be closed via suturing, using an adhesive, wire, or other specialized device. Care is taken to make the expression look as relaxed and natural as possible. Ideally, a recent photograph of the deceased while still living is used as a guide. An embalmer has passed a National Board Examination and Licensing procedure, and has completed a study in anatomy, chemistry, and mortuary science. Immediate family members only have rights to view or assist with body preparation.

18. EMBALMING The actual embalming process usually involves four parts: 1. Arterial embalming - draining blood and displacing it with chemicals (using the gravity of a slanted table and a pump) 2. Cavity embalming – suctioning internal fluids from a small abdominal incision, puncturing hollow organs, and filling the cavities with chemicals 3. Hypodermic embalming – injecting embalming chemicals under the skin 4. Surface embalming – supplements other methods and includes the restoration of injured body parts with modeling wax

19. Embalming chemicals are a variety of preservatives, sanitizing, and disinfectant agents and additives used to temporarily prevent decomposition and restore a natural appearance for viewing a body after death. Typical embalming fluid contains a mixture of formaldehyde, methanol, ethanol, and other solvents. The fluids are or can be colored to restore a more life-like appearance. EMBALMING While embalmers hope to create a somewhat life-like appearance of the corpse, the goal is not to truly make the person appear alive. This would prolong “denial”. Family and friends may view the body and remark “he doesn’t look natural”. No, the corpse does not look natural. The person is no longer alive.

20. After embalming, the body may once again be washed and dried. Moisturizing creams may be applied, as well as lightly-fragranced powders. The body is dressed. Wax may be used to repair damaged areas of the body. RESTORATIVE ART The family usually selects the clothes for the deceased. Makeup is used on both men and women, designed to add depth and dimension to a person's features that the lack of blood circulation has removed. The embalmer may fix the hair and add makeup, or trained cosmetologists may be hired for this purpose. Once again, a recent photo of the deceased may be helpful. Using the exact makeup, nail polish, and hair style of the deceased prior to death might be possible.

21. Cremation is the practice of disposing of a human corpse by burning. A body to be cremated is first placed in a container for cremation, (regular casket, a simple corrugated cardboard box, a plain wooden box, or a special liner from a rented casket, and then placed in the crematorium/crematory. CREMATION The chamber where the body is placed is called the retort, which incinerates the body at 1400 – 2100 °F. During the process, flesh, organs, and other soft tissue is vaporized and oxidized due to the heat, and gases are discharged through the exhaust system. The entire process usually takes about two hours. Larger bone pieces are put into a machine, grinding them into finer fragments resembling wood-ash in appearance.

22. CREMATION Cremated remains are returned to the funeral home/ next of kin in a plastic container in a cardboard box or velvet sack, along with an official cremation certificate. Some families bury cremains, while others keep them in their homes. There are environmental concerns with spreading the cremains elsewhere. How about setting them aloft in a helium balloon, or shoot them up in fireworks, or have them made into a manmade diamond, added to a manmade coral reef, or carry them in a locket? A columbarium is a special wall or entombment facility with small niches for “cremains”. Some people prefer cremation to slow decomposition of the body. Some prefer it because of cost, simplicity, and environmental concerns.

23. FUNERAL DIRECTING... A funeral director may or may not be a qualified embalmer. The funeral director, or mortician, runs the mortuary business. They manage and maintain the funeral home (mortuary). They counsel and work together directly with the families or next of kin in regard to the conduct of the funeral service and disposition of the deceased.

24. FUNERAL DIRECTING... In the 1800s the local funeral director, once known as an undertaker, typically operated a furniture store and built caskets too. Today, the manufacture and sale of coffins, caskets, and urns is a separate industry. COFFIN – 8 sides Full couch – lid is one piece Casket – 6 sides

25. FUNERAL DIRECTING... Receptacles for burial can be purchased or rented (used for viewing only or a funeral service prior to cremation or body donation). The cost of the receptacle is usually the most expensive portion of the total funeral cost. Considerations in Purchasing a Casket Lumber or metal costs: Bronze, copper, stainless steel (in various gauges or thicknesses, and wood (mahogany, walnut, cherry, maple, oak, ash, poplar, pine, and wood veneers). Thickness and type of metal or wood Exterior shell design Corner design Finish: brushed, glossy, satin finishes Interiors: velvets, crepes, satins Hardware such as bed frame, raising, lowering, and tilting mechanisms, locks Gasket seals Jewish Orthodox requirements (must be fully biodegradeable and have holes drilled in the bottom to hasten decomposition)

26. The National Funeral Directors Association estimates the average cost of a funeral in the United States as of July 2004, is $6,500, not including burial cost. Social Security allows a benefit of $250. FUNERAL DIRECTING... The cost of the funeral is dependent upon the services used and the merchandise selected. There are three places where expenses are incurred: 1. Professional Services (embalming, printing obituaries, the hearse) 2. Merchandise selected (casket, vault, urn) 3. Cash Advance Items. Cash advance items are items that the funeral director pays for on a family's behalf, that are not directly their services.  These items include clergy honorarium, music honorarium, grave opening, flowers, lunch, and monument work

27. Pre-planned and pre-paid funerals do 3 things: 1. Locks in pre-inflationary prices 2. Removes the burden of funeral planning for relatives at a time when their judgment may be impaired 3. The funeral preferences of the deceased can be carried out without question FUNERAL DIRECTING... Families that feel any sense of guilt about the death tend to be emotionally over-loaded and make decisions about funeral costs that they really can’t afford.

28. THE FUNERAL Prior to many funerals, a “viewing” or “visitation” is held. Family and friends use this ritual with an “open casket” to realize the death and deal with grief. During the viewing, pink-colored lighting is sometimes used near the body to lend a warmer tone to the deceased's complexion. A “closed casket” may be desired (lid is closed), especially if the body was damaged.

29. THE FUNERAL For Irish descendants or others, a “wake” usually lasts 3 full days. On the day after the wake the funeral takes place. Family members and friends will ensure that there is always someone awake with the body, traditionally saying prayers. Some cultures and religions consider the sending of flowers, embalming, or viewing of the body as disrespectful. A funeral may take place at either a funeral home or church, usually 3-5 days after the death of the deceased. During the funeral and at the burial service, the casket may be covered with a large arrangement of flowers, called a casket spray.

30. Funeral services may be conducted by the funeral director or clergy. They may include prayers, readings from the Bible or other sacred texts; hymns sung by the attendees or a hired vocalist; and words of comfort by the clergy. A funeral service provides a place for family and friends to gather for support and to reminisce; an opportunity to celebrate the life and accomplishments of a loved one; a chance to say goodbye; and the focal point from which the healing process can begin. THE FUNERAL If the decedent served in a branch of the Armed forces, the casket may be covered with a national flag; however nothing should cover the national flag. Use of the flag for funerals is governed by law.

31. THE FUNERAL The funeral identifies that a person's life has been lived, not that a death has occurred. It is also important to notify the community that this person has died. There are people beyond the immediate family who have the right to grieve a death. A eulogy is a speech or writing in tribute to a person or people who have recently died. Eulogies should not be confused with elegies, which are poems written in tribute to the dead; nor with obituaries, which are published biographies recounting the lives of those who have recently died; nor with obsequies, which refer generally to the rituals surrounding funerals.

32. THE FUNERAL In the United States, black is generally considered the color of mourning. At a time like this, it is considered improper by some to draw attention to yourself by wearing bright colors. In some Asian cultures, white is the color of mourning. White flowers from the lily family are traditional flowers for funerals. Memorial gifts are sometimes given to the family. These might include food or flowers, or money. Money may aid the family or be designated by the family for a special cause. Example: Memorial money given at the funeral of a person who suffered from Alzheimer’s Disease prior to death might be designated for research for a cure for Alzheimer’s; money given to the family of a deceased young father might be designated for his children’s college education.

33. The memorial service is a service given for the deceased without the body present. This may take place before or after a burial, donation of the body to science, cremation (sometimes the cremains are present), or burial at sea. Typically these services take place at the funeral home and may include prayers, poems, or songs to remember the deceased. Pictures of the deceased are usually placed at the altar where the body would normally be to pay respects by. A memorial service is appropriate when bodies cannot be recovered and identified after mass tragedies or war-time. THE FUNERAL Funerals and memorial services are in memory of the dead…but they are FOR the living.

34. Burial, also called interment, is the act of placing a body into the ground. After death, a corpse will start to decay and emit unpleasant odors due to gases released by bacterial decomposition. Burial prevents the living from having to see and smell the decomposing corpse. INTERMENT Jewelry may be removed just prior to the casket being closed for the final time. This discourages the idea of “grave robbing” for artifacts. In many religious traditions, the “pall” or body-in-a-casket is carried by 6-8 relatives such as cousins, nephews, grandchildren or friends of the decedent called pallbearers.

35. INTERMENT A burial service may be conducted immediately following the funeral, beginning with a procession. The large car transporting the pall, the hearse, is followed by the immediate family and then the other attendees, and travels to the burial site. In some military funerals, a caisson (wagon carrying artillery ammunition) may be used to transport the casket.

36. A unique funeral tradition in the United States is the New Orleans Jazz Funeral arising from African-American spiritual and French musical traditions. A typical jazz funeral begins with a march by the family, friends, and a jazz band from the home or funeral to the cemetery, while a band plays somber dirges. Once the final ceremony has taken place, the solemn music is replaced by loud, upbeat music and dancing. The New Orleans dance known as the “second line" is where celebrants do a dance-march, while raising the hats and umbrellas and waving handkerchiefs above the head that are no longer being used to wipe away tears. INTERMENT

37. A cemetery is a place in which dead bodies and cremains are buried. The term cemetery, from the Greek meaning “sleeping place”, implies that the land is specifically designated as a burying ground. INTERMENT Some Christians wish to be buried in “consecrated ground," usually a cemetery in or near the church…hence the word churchyard or graveyard. Graves near the Gulf of Mexico are above-ground due to the high water tables.

38. INTERMENT Body positioning Burials may be placed in a number of different positions. Christian burials are made extended, lying flat with arms and legs straight, or with the arms folded upon the chest, and with the eyes and mouth closed. Other practices place the body on its side in a flexed position with the legs folded up to the chest. Warriors in some ancient societies were buried in an upright position. In Islam, the head is pointed toward and the face is turned toward Mecca, the holiest city in Islam. Casket Orientation: Historically, Christian burials were made supine east-west, with the head at the western end of the grave…to view the coming of Christ on Judgment Day.

39. A growing trend in the U.S. is a natural burial, used in protecting and restoring the natural environment. With a natural burial, the body is returned to nature in a biodegradable coffin or shroud (winding, sheet-like burial garment). Native vegetation or “memorial trees” are often planted over or near the grave in place of a conventional cemetery monument. The resulting green space establishes a living memorial and forms a protected wildlife preserve. INTERMENT Natural burial grounds are also known as woodland cemeteries, eco-cemeteries, memorial nature preserves, or “green” burial grounds. A “potter’s field” is a county- owned piece of land for burying the unknown and indigent.

40. A burial vault is a protective outer container for a casket. One of those or a simpler concrete container called a graveliner may be required by some cemeteries to keep the ground from settling and preserve the beauty and ease the maintenance of the memorial park or cemetery. INTERMENT While basic concrete offers no protection from outside elements, the reinforced vault has a synthetic material or metal applied to the concrete to improve the integrity and strength. Stainless steel, bronze, and copper are common metals for these.

41. INTERMENT If the decedent served in a branch of the Armed Forces, military rites are often provided at the burial service by representatives of the Armed Forces or Veterans organizations such as the American Legion. Military rites include a gun salute, the playing of Taps (Army bugle call at the end of the day), and the presentation of the folded casket flag to the surviving widow or family member. The military also provides a monument to mark the grave if desired.

42. Others in uniform, such as firefighters and police officers are honored with special funeral rites. INTERMENT At a police officer's or firefighter's funeral, the bagpipes are often played. A foot procession of department members in full dress uniforms follow fire trucks bearing the caskets of fallen firefighters. The fire trucks pass under an arch of the raised aerial ladders and suspended flags.

43. A mausoleum is a free-standing building constructed as a monument enclosing the burial chamber of a deceased person or persons. A mausoleum may be temporarily locked or permanently sealed; it encloses a burial chamber either wholly above ground or within a burial vault below the superstructure. INTERMENT The pyramids of ancient Egypt are also types of tomb, each housing one or more mummies. A mummy is a corpse whose skin and dried flesh have been preserved by exposure to chemicals, extreme cold, very low humidity, or airlessness. They are wrapped in a shroud and buried with possessions.

44. Crypts are stone or brick-lined underground spaces or 'burial' chambers for the interment of a dead body or bodies. They often have vaulted ceilings and stone slab entrances. They are often privately owned and used for specific family or other groups. INTERMENT They are often found beneath public religious buildings, in cemeteries, beneath mausolea, or in churchyards. The poet Edgar Allen Poe wrote of crypts. Catacombs are a network of underground burial galleries, such as caves, grottos, or subterranean places.

45. Burial at sea means the deliberate disposal of a corpse into the ocean, weighted to make sure it sinks. Two reasons for burial at sea are if the deceased died while at sea and it is impractical to return the remains to shore, or if the deceased died on land but a burial at sea is requested for private or cultural reasons. INTERMENT Legally, a Captain can bury remains at sea, provided that environmental regulations and dumping laws are satisfied. In the United States, ashes have to be scattered at least 3 miles from shore; bodies can be given to the sea if the location is at least 600 feet (200 m) deep. Special regulations may also apply to the urns and coffins

46. Mass burial is the practice of burying multiple bodies in one location. This may be the only practical means of dealing with an overwhelming number of human remains, such as those resulting from a natural disaster, an act of terrorism, an epidemic, or an accident. INTERMENT • Some married couples, family members, or groups of people may wish to be buried in the same plot. Two reasons for this: • 1. cost-effective and • saves space in cemeteries Coffins can be buried standing on end, with several coffins in one plot. Caskets may also be interred one above another. The first casket is buried deeper than the traditional 6 feet, and the second casket is buried on top with only a thin layer of dirt in-between.

47. In many traditions, a meal or other gathering follows the burial service, either at the decedent's home, fellowship hall at their place of worship, or other off-site location. This provides a time to reminisce and grieve and provide comfort. AFTER INTERMENT

48. AFTER INTERMENT A headstone, gravestone, tombstone, or monument is a marker used to identify the resting place of the deceased. They can also offer genealogical information. Materials commonly found in cemeteries are: aluminum, bronze, granite, marble, field stones, and zinc. Each material has features and benefits that are unique to the properties of the metal or stonework being considered. Those of Jewish faith visiting graves might leave a small stone at the graveside. This shows that someone has visited, represents permanence, and is a way of ‘tending the grave’.

49. Poor John Gray, here he lies,No one laughs, and no one cries,Where he's gone, and how he fares,No one knows, and no one cares. AFTER INTERMENT An epitaph is text honoring the deceased, most commonly inscribed on a tombstone or plaque. Quoth the Raven,"Nevermore." The Best is yet to come. Mine today, yours tomorrow Stranger by the roadside, do not smileWhen you see this grave, though it is only a dog's,My master wept when I died, and his own handLaid me in earth and wrote these lines on my tomb. Here Lies Lester Moore,Four Slugs From A .44,No Les, No More Rest in Peace. That's all folks! Step softly, a dream lies buried here. I told you I was ill. Never Born, Never Died—Only visited this planet Earth between December 11, 1931 and January 19, 1990. He beat her 189 times. She only got flowers once.

50. Suicide is the act of intentionally taking one's own life. SUICIDE Views on suicide have been largely shaped by cultural views on existential themes such as religion, honor, and the meaning of life. Most religions consider suicide a dishonorable or sinful act; some societies consider it a crime. In some Asian cultures it has been considered an honorable way to atone for past mistakes or an acceptable military strategy. Assisted suicide, euthanasia, is a controversial ethical issue related to people who are terminally ill, in extreme pain, and/or have minimal quality of life through illness. Self-sacrifice for others is not usually considered suicide. The predominant view in modern medicine is of suicide as a mental health concern.