On Death and Dying

Written by Dr. Prathap Addageethala 




Just being thankful for what I got.

My absence from social media activities has been noticeably lengthy, at least it felt like it, but behind it lies  a sad reason. One week ago today, we laid to rest my grandmother, whom we affectionately called "Nainamma" (Dad's Mother). Being halfway across the globe, language barriers, and her inability to pen letters were all factors in not having an exceptionally close relationship with her. I was able to visit her a few days before she died, and although she did not have the cognitive ability to recognize me, I felt that spiritually she had realized that her eldest son's eldest son had come to visit. It made my heart glad to have been able to feed her a tiny bit as she lay there breathing heavily, and to have seen someone I know had so much love for me in their last stages. But still, last Wednesday, seeing someone so closely related after having taken their final breath was a shock to my system.

I was very young when my mother's father passed away; I was lucky to have had the opportunity to see him in his final stages. My Dad's sister eventually succumbed to a vicious stomach cancer some years later. Even then, I didn't feel the sting of the loss. I never met my paternal grandfather who left us when my Dad was still a boy.

As an aware adult, this was the first loss of a family member with whom I had a connection or bond. Nainamma was in poor health for the last several years. The most recent trauma was a slip and fall, where she suffered a broken tibia. Being from a rural area in South India, and having exceedingly problematic vitals, the local medical specialists sent her home having not been able to treat her adequately. Again, even though the loss was expected, it was a surreal experience. Hearing the news last Tuesday, I felt unable to concentrate, and an immediate need to be by myself. I took the afternoon off to reflect, and prepared to go to the funeral the next day.

It occurred to me later that I was grieving. From an excerpt of a book entitled "Handbook of bereavement research and practice: Advances in theory and intervention," endorsed by the American Psychological Association grief is defined as "the usual reaction to bereavement [i.e. intense distress]... as a primarily emotional (affective) reaction to the loss of a loved one through death." That was where I was - although it may not have been intense - I was definitely distressed.

I looked at it a little closer and I realized that there are more folds to this particular dough. When applied to a loss - as in death - this strict and austere definition applies. What if you've just lost something of significance? Indeed a definition with a larger breadth and scope is much simpler: grief is a response to having lost something of personal significance. For perspective, it's perfectly normal that people "grieve" over a stain on a favourite sweater, others a scratch on their car, or a misplaced swanky hat. Others may grieve over a lost job, a missed opportunity, or the end of a relationship over divorce. Certainly the diagnosis of serious health conditions qualify here as well. The underlying aspect of grieving is that something had a value for the grieving person, and now that something is gone, or unalterably changed. The difference lies in the level or volume of the grieving response.

Since 1969, from her book On Death and Dying, the gold standard in evaluating grief has been Kubler-Ross' "Stages of Grief." While there have never been definitive studies regarding this model until recent times, this has been widely accepted in medical and psychological circles, commonly being taught in medical curricula. The stages are a progression, as one learns to cope with and "get over" their grief. Again, this model is typically applied to death of a loved one. The model also acknowledges that it is an incomplete list of all possible emotions experienced, and that it does not always apply to each and everybody. The final provision also states that the stages can be experienced in any order, but the following order of the stages are most common:

*it should be noted that ranking severity of grief can be a very personal thing, allowing for differences among individuals

• Denial - where the grieving person ignores the reality of the situation, or imagines a more "false, preferable reality"
• Anger - this is commonly witnessed as a "lashing out" by the grieving person to those close to him or her. The moot nature of denial sinks in, and is replaced by a deep-seated frustration which needs to be transferred to the nearest personal lightning rod.
• Bargaining - depending on the severity of loss, this stage can be looked at with "let's make a deal" lenses. In less severe cases, a bargain can be struck by making a compromise (instead of buying x, I'll replace [lost item]). Other times, bargaining manifests as a swap, usually in stark change in behaviour in return for an extended life or a return to health.
• Depression - this topic could fill every health related blog from now until the end of times. Common signs of depression in response to loss are despondence, low affect, loss or gain of appetite, and lack of concentration.
• Acceptance - there still may be strong emotions surrounding the loss, but there is an overall stabilizing of the affect. A person comes to terms with the loss, and returns to a calmer, more rational state. Integrating new information into old beliefs has almost completely occurred by this stage.

This model does not come without it's share of critics. As mentioned earlier, many academics have outright shunned this model, referring to grief being an unimportant and somewhat contrived emotional defect. Some have taken a more rational and conventional approach, offering constructive changes to the model. A study from The British Journal of Psychiatry (2008) by Prigerson and Maciejewski seemed to offer the most fair and sensible explanations:

• proposed 4 states of grief that co-exist as a psychological construct, rather than individual, ascending stages of grief
• indicators of grief include anger, sadness, yearning and disbelief 
• anger, sadness, disbelief decreased over a period of two years (acute bereavement period); peaking at 6 months
• the feeling of yearning, or intense longing was consistent (read: did not decrease) over the same time period
• acceptance increases with relation to decrease in grief indicators
• "At its core, grief may be the state of emotional unrest and frustration associated with wanting what one cannot have"

In my next article, I'll address some strategies when coping with loss, grief, and the frustration or stress involved in the process. These helpful hints will come in handy for anyone going through a loss, however minor or traumatic.

Support from family can be extremely important in progressing through grief.

The states of my grieving felt like they were actualized in a day. My anger manifested towards people who I perceived as being disrespectful during the last rites. My sadness was directed towards my Dad, who seemed utterly alone, and to my grandmother who had a very tough older life. My disbelief suspended when I saw her lifeless body on the dais, adorned with garlands. The yearning I felt was to have been more involved with my granny while she was alive; just a need to have told her that even though she was suffering, I was still there for her.

In my case, I found peace through realization that Nainamma was no longer suffering through her array of illnesses. The spiritual connection we shared prior to her death was an actual palpable thing, I could feel her grow more calm when I went and spoke to her, whether she recognized me or not. I was surrounded by family, people who have been supportive influences in our lives from the very beginning. I had shed a few tears, and ultimately it helped the overwhelming feeling of being at the centre of something so sad. There were cousins, uncles, aunts, and well wishers, all braving the ridiculous village heat, came from hours away, started journeys in the early mornings, and navigated with me through confusing customs. I was lucky to have a support system like that, and I recognize not everybody can be so fortunate. A sincere, heartfelt thank you to all who have stood by our family in our time of mourning. Your sympathies and condolences have moved mountains.

- Dr. P