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Acute And Chronic Loss
Ernest H. Rosenbaum, MD, Isadora R. Rosenbaum, MA and Sabrina Selim, MD

The way a person dies can affect how that person's survivors grieve. There is a major difference between grieving an acute loss (a sudden death) and grieving a chronic loss (a death that is expected).

Grief is more acute with a sudden death -- for example, an auto accident or from a an unexpected post surgical complication. An unexpected death allows no time for planning. On the other hand, when a person has a chronic illness such as cancer, kidney failure or heart disease, people know that death is coming. One is often given support from friends, family and clergy about what to expect where death is concerned.

When someone we care about is dying we often feel anticipatory grief. We may begin to fear the loss and may go through phases of depression, anger or just difficulty coping with the situation, knowing that death is near.

This is a time for compassion, where people often put their trust and faith in their belief system or religion. Visits from family, friends and the clergy to offer compassion and support during a chronic illness can prepare the family for death. The family of a patient who enters a hospice program also have time and built-in support; after death, they can get additional counseling.

There is a feeling of sorrow throughout this chronic process; on behalf of the patient who is suffering, we may often wish for mercy -- that the process would end. This sometimes leads to feelings of guilt. Accepting that the shortening of life is not fair results in anger when the impending death occurs.

There are great vicissitudes or changes during the course of illness. With a sudden, unexpected death, there is no time for preparation; suddenly, one experiences a grievous loss. The death of a loved one in war might be expected, yet people on the home front constantly pray and do many acts, often of kindness, aimed psychologically at helping prevent that death. When the dreaded telegram arrives, it is such a crushing blow and shock that totally alters the recovery process. When shootings or assaults result in a sudden death, survivors may suffer for years. Recovering from acute death is often difficult and slow.

People try to keep hope alive through the realization that life continues during the many crises one undergoes during a chronic illness -- and also preparing for the eventual death. In Planning for Your Future by Getting Your Affairs in Order we describe many ways to prepare for death; we also provide forms and sample documents; such as wills and funeral instructions. Having such documents in place can avert suffering and pain, and help family and friends honor the patient's wishes.

We also discuss ethical wills in which people transmit their thoughts either verbally or with an audio or video recording. An ethical will communicates a person's thoughts, love and philosophy to survivors, providing a chance to say goodbye and to leave a legacy of encouragement and support, as well as to give instructions on how the estate and possessions should be distributed.

Frequently we have participated in conversations where a dying person tries to alleviate feelings of guilt in his or her partner by advising the loved one to become romantically involved again if the opportunity presents itself. We believe grieving can be shortened and eased when survivors receive explicit permission to continue living, and strong advice that although memories of the deceased will always be alive, life must go on.

The ethical will is a great avenue for recording such thoughts. When curing or controlling a person's cancer is no longer possible or practical, an ethical will can provide the patient with a continuing sense of hope that although he or she will not live longer, he or she will live better. Peace of mind comes with having shared important events in our life and with knowing that we will live what remains of our life without pain or suffering.

The ethical will also allows people to acknowledge that their life has been successful: for example, having raised a family, or leaving a moral or financial inheritance that reflects their values. This often gives a sense not only of the value of life but also of continuing hope for the future -- that family and friends will continue to grow, mature and emulate the moral standards and patterns we set. This hope can comfort a dying person, strengthen his or her beliefs and faith, and provide a sense of inner peace despite the most stressful circumstances.

In ethical wills, patients often express hopes that my family will be all right when I am gone. Some hope for some extra time that has meaning; others for a peaceful death that will not traumatize their family. Those whose religious faith includes a belief in life after death hope that at some time in the future, they'll be reunited with their loved ones.

Patients have expressed such feelings as I hope I die peacefully and painlessly, and that my memory will linger and I hope that my life has had meaning that will give strength to my survivors, and that I have served others in a way that has enhanced my feelings of what I term a successful and happy life. Such expressions not only give solace, and comfort to the family but are very helpful to remember in the grieving process to come.

Those who have had angry relationships or discord within their family may try to mend their fences, so that when does occur, they will have achieved better peace of mind for themselves and their family. People who have not talked to a relative or friend for years -- angry because of an incident that occurred a long time ago -- have called or met with the other person so that they could make peace. Others have sought forgiveness for deeds they have come to regret. Reaching out in this way can be very helpful for the survivors, softening the grieving process.

Expressions of what a dying person perceives as the meaning of his or her life can also be a touchstone for survivors. Though patients may see no hope for themselves, they may hope that recalling the events that made their lives meaningful will provide for their survivors with hope for the future. Often during such a period, religion can play a role through the belief in God who has shown them a path of righteousness and a way of life. They know that when God takes them, their family will be comforted by the faith that although their body is no longer present. their spirit will continue and will be remembered.

Some have remarked that their illness has renewed religious feelings, giving them reassurance. This can improve the quality of life for whatever time remains, and can transmit strength to the survivors. The patient and the survivors have put their faith in God's hands for comfort, and know that is not up to them alone.

We have often heard people say -- after either going through a final confession or receiving the sacraments -- that they are now at peace and are no longer worried. Receiving absolution helps not only the dying but also the survivors to continue their anticipatory and subsequent grieving process. This often requires an acknowledgement that the dying no longer have control over their life or the disease, and that even though they will not attain remission, they are now ready to continue living as best they can.

Those who do not have strong religious convictions can experience similar peace by reaffirming their faith in humanity.

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