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A. The Grief and Separation Process

In the 1800's and early 1900's death was very much a part of life. Families witnessed the death of a loved one and the preparation of the burial. Then, in the middle 1900's when a

family member became ill the family member went into the hospital. If the person died it was

very common to "protect" the children and shelter them from the grieving process. Today, we are returning to allowing all family members to share the grieving process. Today, we

have hospice and people have the right to choose to die at home or in the surroundings they choose.

Stages of Grief

Individuals do not necessarily go through all these stages in order and they may repeat stages. The grief process is unique to the individual.

1. Shock: There is disbelief that the loss has occurred.

2. Denial: Denial is a temporary buffer after unexpected news. The person refuses to

accept the loss has occurred. Denial is encouraged by silence.

3. Anger: Anger may be directed toward the loss, the person lost, or even a deity. Families

have a hard time with anger because the anger is displaced in all directions.

4. Bargaining: "Let's make a deal". The person attempts to reconcile the loss by making

deals with other people, sometimes also with a deity. 5. Depression: Anger is turned inward.

6. Guilt: Guilt is marked by statements of "If only I had done / been. . . . " It usually comes

from things one cannot change.

7. Acceptance: Living in the present is possible. Acceptance and hope mean that the

person understands that life will never be the same but it will go on with meaning and hope.


Death comes in its own time and in its own way. Death is unique to each individual.

One to three months prior to death

Withdrawal - This is the beginning of withdrawing from the outside world and focusing inward. The person's world becomes smaller, possibly involving only closest friends and

immediate family. With withdrawal you will see the person possibly taking more naps,

staying in bed all day, and more time sleeping becomes the norm. Verbal

communication decreases and touch and wordlessness take on more meaning.

Food - We eat to live. When a body is preparing to die, it is perfectly natural that eating should stop. This is one of the hardest concepts for a family to accept. It's okay not to eat.

The person dying will notice a decrease in eating. Liquids are preferred to solids. Meats

are the first to go, followed by vegetables and other hard to digest foods. Cravings will come and go.

One to two weeks prior to death

Disorientation - The person is sleeping most of the time now and cannot seem to keep

his or her eyes open but can be awakened from the sleep. Confusion can take place

when you talk to the person, and the person may start talking about previous events and people who have already died. The focus is transition from this world to the next.

Physical changes:

Blood pressure often lowers; pulse beat becomes erratic, either increasing or


Skin color changes.

Breathing changes; it has an erratic rhythm, either increasing or decreasing.

One to two days, to hours prior to death

A burst of energy may be present.

Breathing patterns become slower and irregular, sometimes stopping for 10 to 45


Congestion may be audible.

Eyes may be open or semi-open and have a glassy haze.

Hands and feet become purplish and parts of the body become blotchy. The person becomes non-responsive.


Consumer and Family

Individuals are unique in their display of emotions. The fact that some people do not display what others think is "normal" does not mean that they are not grieving.

Some differences in grieving:

Some people are quite vocal; some are quiet.

Some are accepting; some are in denial or shock.

Some people weep; some are very stoic (emotionless). Some people are angry; some may appear happy.

The Direct Care Worker

It is only natural that the DCW and the person being cared for build a rapport. When that

person dies, the DCW may grieve as though the person was a family member. If this is the case the DCW may want to use the coping strategies in the next section.


This exercise will help you understand the dynamics of a family dealing with a loss, whether it is through death of a loved one, disability, or any other major change.

Envision a child's mobile. Imagine on the mobile are five family figures: Mom, Dad,

Sister, Brother, and Grandmother. The family is in balance until a family diagnosis takes place.

Let's say the brother has just been in an accident and has sustained a spinal cord injury. Remove the brother from the imaginary mobile and what happens? The mobile becomes

out of balance and for the mobile of the family to get in balance again, everyone needs to negotiate their position to get the family in balance.

This is the best scenario. Often what happens is the sister is going through her own

crisis from just being a teenager. Dad might not be able to deal with the added changes

and starts drinking. Grandma is in her own world. Sometimes, the whole family mobile is trying to be balanced by one person.


Part of healthy grieving is to allow yourself to grieve not doing so can cause

emotional and/or physical problems later on. Take care of yourself by:

Talking Use your social support system, or talk to clergy person or a counselor.

Writing Take up journaling, even writing letters to the deceased person about things you wished you would have said.

Reminiscing Remember the good times. Plant a garden in the person's honor, or support causes the person was involved in.

Getting enough sleep, exercising, and eating healthy Keep your body healthy. Do

no turn to alcohol or drugs to "numb the pain" this usually makes the situation worse. Planning ahead Realize that anniversaries, holidays and special days will be difficult at first. Plan to spend time with a valued social support.

Don't be reluctant to ask for help Help is out there, just ask. (See "Resources.")

Consumers and Family: DCWs need to be aware of the needs of the people they are

assisting. If you think a consumer is not grieving in a healthy way, talk to your supervisor. He/she may be able to arrange agency or community resources.

Direct Care Worker: As previously mentioned people grieve differently so allow

yourself to grieve in your own way. You may need to talk to a valued social

support. You may need to have some relaxation time. Try to be good to yourself

and seek out the help that you need. Your supervisor may be very helpful in arranging agency or community resources to assist you.


Cultural and family differences will influence the death and dying process. DCWs need to be aware of the various beliefs and practices of the people for whom they are providing care.

But as you can see below, the cultural differences are so varied that it is difficult to become culturally competent in all areas. Ask your supervisor to give you direction on how to handle the individual needs.

Some religions or cultures

Discourage or forbid embalming and autopsy.

will not allow non-family to touch the body.

do not want the body to be touched shortly after death.

cover the mirrors in the home after a family member dies. remove water from the room after family member dies.

First Name

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Grief & End of life

Which of the following is not one of the key steps in the grief process?

How many stages of grief are there?

At what point in the dying process does disorientation take place?

Death is unique to each individual.

It’s O.K. if the client who is dying refuses to eat.