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Let's Face It

A conversation about death, dying, and grief
With Mark Grimm, LCSW

iStock 000005094274SmallMark Grimm, LCSW, works with older adults and their loved ones who are facing death, dying, and grief every day. It’s a special gift and his area of expertise. We recently sat down with Mark to talk about these difficult subjects.

People don’t really want to talk about death. How do you approach it?

The first thing is that I try to help people get over what I call “the denial of death.” We’re all mortal and we’re all going to die sometime. And when we’re unwilling to accept that, we do a great disservice to ourselves and those around us. Americans, culturally speaking, are afraid of death. We haven’t embraced that fact that death is a normal part of life. We’re born, we live, and we die.

People need to become aware of their own attitudes about death and about their expectations and wishes. These will vary depending on the person’s culture, background, and religious beliefs, and it’s important to be sensitive to them.

How has evolving technology and medical science affected the way we die?

One of the things that can get in people’s way is this concept of “the perfect death.” They think they’re going to die peacefully in their sleep or “have the big one”—a heart attack that will kill them instantly. But what we need to keep in mind is that very few people die this way anymore. Because of medical science and all of the treatments and interventions we have, most people experience a slow, incremental dying process. And I think we need to get our heads around the fact that that’s probably what’s going to happen to most of us.

You have to think about, at what point do you feel that life is no longer worth living?  There comes a point where people have no quality of life. It just becomes this long, drawn out, excruciating series of illnesses, in and out of the hospital. With all of the technology out there, it’s almost as if there’s this imperative that we have to use it. But the real answer is, no, you don’t have to use it. You have the right to opt out.

So, it’s important for the people around you to be aware of your wishes in that regard.

Yes. What it comes down to is that it’s important to have “The Talk.” Frequently. With all of your family members. The talk about what you’re thinking about life and death, and under what circumstances you do or don’t want to be around. Now, this can be uncomfortable and painful. What happens in a lot of families is that the seniors are rebuffed in their attempts to open up such a conversation with, “Oh, mom, don’t talk that way,” or “Oh, dad, you’re going to get better.” The kids shut it down because they don’t want to face it. As a result, they do a great disservice not only to their parent, but to the entire family. We must be willing to have these kinds of discussions.

This can actually be a very calming, reassuring conversation for those who are facing their own impending death. They want to sit down and talk about it.

How do you suggest people sort through the issues with their loved ones?

I always urge people to get ahold of The Five Wishes document to use as a tool and guideline for discussions with the family. This is a simple workbook that asks the critical questions you need to think about (available through ). True, this can be painful—I won’t deny that. But you’re going to be a lot better off summoning up the courage to have the discussion than if you choose to be an ostrich and bury your head in the sand. Take control of this! You have the power and the right to make your own designations. If you wait too long, choices will be made for you by other people, by default. Your family members will be put in a difficult position where they have to make crucial choices for you. And, if they don’t know what your wishes are, then they may do something that’s totally contrary to your values and desires.

I also recommend that people make (and document) a decision about a medical durable power of attorney—so that you have someone you know you can trust to act in your best interest. You want to designate somebody who will be calm and objective during difficult circumstances; someone who is willing and able to shoulder the responsibility. Otherwise, you have a recipe for disaster. Conflicts arise in the family and everyone gets caught up in that power struggle. “Should we put a tube in,” or “should we do this surgery or that surgery?” As a result, no one is really present dealing with the emotional aspects of the dying process and the grieving process is negative or delayed for everyone.

What about hospice?

Most people wait way too long to call hospice—if they use it at all, they come in at the 11th hour. Hospice can provide invaluable service for a long time before the eventual death by maintaining comfort, providing pain management and family support. They help to ensure that your quality of life is at the highest level that it can be in end of life times. I always encourage people to take advantage of hospice early. It’s a fallacy that hospice means it’s over for you—that’s totally incorrect!

What, exactly, is grief? And how can we learn to cope with it?

There are a lot of misconceptions about grief and grieving. Patients are often referred to me for “depression” and, after a talk with them, it’s obvious that they’re not depressed—they’re just grieving. I define grief as a normal, natural collection of very intense emotional reactions that we all go through at various times in our lives: sadness, anger, fear, guilt. The process allows us to let go of our attachments to people, places, and things. I think this definition helps to normalize what people are going through.

There are two kinds of grief: the first kind is what we call “normal survivor grief,” which occurs when there is a sudden, unexpected death. It typically lasts about 25 months—you go past the anniversary of the loss a couple of times. There will always be an empty place in your heart for the person who died, and you will never get over it. But you do learn how to live with it.

That is not the kind of grief that typically happens with older adults. Instead, it’s what we call “anticipatory grief.” At some point, people begin to realize that the beginning of the end is upon them. They realize that they’re entering the final phase of life, they’re not getting any better; rather, it’s just one illness, one hospital stay, one rehab visit after another. It begins to dawn on them that, “wow, this is the final chapter of my life.” And so they begin the process of anticipatory grief, feeling sad and anxious. Lots of feelings from the past get stirred up and old family conflicts from over the years can get activated. All of this emotional and psychological turmoil gets stirred up. This process can go on for years and years. It can be like a series of deaths, dying a little piece here and a little piece over there. And it affects the person as well as their loved ones and caregivers.

At some point in this kind of drawn out grieving process, people can become emotionally and psychologically exhausted, and then it can slip over into a true clinical depression. If that happens, psychotherapy, counseling, and medications might be necessary.

What’s really behind the fear of death?

There are a whole lot of worse things in this life than death! The truth is that most older adults are not afraid of death. What they’re afraid of is what happens between now and then. Am I going to be totally dependent? Am I going to be in excruciating pain? Am I going to be out of it? Am I going to die alone? People have all of these worries and issues, and so death, as the final act, is actually a relief.

And the best thing to do in the meanwhile is to talk about it!


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