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for patients and their families suffering from post-intensive care syndrome. If you need a guide to intensive care, . Here is also a webpage for

Advance directives are documents that provide healthcare professionals or family with choices regarding a person’s care should they become unable to communicate those wishes. Below are two well-known documents used to develop advance directives.

Five wishes link:

Respecting choices link:

Taking time to yourself to feel of sense of calm will help during these difficult times. Be kind to yourself.

What's your grief website:

Coping with Grief and Loss_HelpGuide.org
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What are the stages of grief? How to process and deal with grief or loss

Includes commentary from Dr. Keeley:

• What is grief? Grief is a strong emotion that comes out of a serious loss, usually through death. Grief is exhibited in physical, mental, emotional, and spiritual ways that vary in degrees of intensity and length of time. Grief is a personal journey that varies in behaviors and length of time that is often directed by cultural, religious, and family expectations. There is not a right or wrong path through the grief journey. There are three categories of grief that include: anticipatory, post-death, and disenfranchised:
   
  • Anticipatory grief by both patients and family members begins with a terminal diagnosis of an illness (or in our current circumstances, when our loved one is diagnosed with COVID-19, admitted to an ICU, and put on a ventilator because of the high risk of death) because of the expected loss that will accompany the death. Layers of loss include what is anticipated (loss of the family role enacted by the terminally ill, loss of relationships, and loss of tangible benefits achieved by these relationships). Anticipatory grief is characterized by disorientation and suffering by both the patient and family member, but it is also often accompanied by increased feelings of attachment, closeness, tenderness, and a desire to be with the terminally ill during the time that is left.
  • Post-death grief is normal and to be expected. Post-death grief will vary in intensity and length of time. Post-death grief is divided into two sub-categories: non-complicated and complicated grief (also known as persistent grief). Non-complicated grief varies according to each person and can involve a wide variety of physical (e.g., shortness of breath, heart palpitations, gastrointestinal problems, physical numbness, dizziness, headaches, nausea, etc.), emotional (e.g., crying, fatigue, depression, loss of sexual desire, lack of appetite, sleep issues, etc.), cognitive (e.g., short-term memory loss, disorganized thinking, hallucinations, preoccupation with the deceased, etc.), and spiritual (e.g., enhanced faith and connection with religion or conflicts with faith) changes (Strada, 2017). Complicated grief occurs in approximately fifteen to twenty-five percent of people; bereaved individuals experience psychiatric symptoms and maladaptive reactions that continue to cause extreme, persistent, and disabling impairment long after the death.  Complicated grief may also be a result of multiple, unprocessed, previous deaths, especially if the deaths come within short time frame.  
  • Disenfranchised grief is when grief is not recognized or supported by friends, family members, communities, or social norms; individuals feel marginalized and their grief feels disqualified. Situations that often unfairly trigger disenfranchised grief may include death by suicide, death by stigmatized illnesses (i.e., AIDS in the 1980s), death of "adjacent" people, death of a family member in prison, death of an ex-spouse, or even death of a pet. People in these situations may not have the needed social support to help them move through the grieving process. 
  • New strategies are needed to replace passive coping strategies during the mourning process by providing opportunities for self-transformation and personal growth, resilience, and renewal and/or revision of relationships during the grieving process. There is also a need for greater understanding regarding responses to the grieving process influenced by culture, gender, spirituality, and level of cognitive development (e.g., age and education). 

• We think about grief with death, but when else might people grieve?

  Any major loss can trigger grief, including overwhelming losses such as those currently experienced worldwide as a result of the COVID-19 pandemic. Other reasons why people may grieve include death of a beloved pet, a terminal diagnosis, divorce; and even career loss (which may negatively impact identity).

• How can grief be differentiated from worry or stress?

  Worry usually results from situations or events for which people have no control and can be inflamed because of people's fears. Stress is the physiological reaction to grief that leads to elevated blood pressure and heart rate, as well as an increase in cortisol, the primary stress hormone. Cortisol increases sugars (glucose) in the bloodstream, enhances the brain's use of glucose, and increases the availability of substances that repair tissues. Stress and cortisol increases comprise a psychological reaction that can cause difficulty focusing, problem solving, and managing emotions. 

• Stages of Grief: Dr. Elizabeth Kubler-Ross (1969/1997) 5 Stages of Grief: Denial, Anger, Bargaining, Depression, and Acceptance

  • Many people do experience all of these stages.
  • They are not necessarily linear (so do not look at them as stage 1(denial), then onto stage 2 (anger), etc.
  • They can come in any order; they can be experienced more than once (think cycles) and are best dealt with each time that they are experienced.
  • In addition, various individuals in a family may experience these stages in different orders but occurring simultaneously (which can cause familial conflict).
  • The 5 Stages of Grief are a useful framework for everyone who is trying to understand the complexity of grief; they help people realize that they are not alone and that we all experience complicated emotions and intellectual reactions that will come in waves and varying degrees of intensity.

   

• Sixth Stage of Grief: Daniel Kessler (2019): Finding Meaning

  • See
  • “Finding meaning” highlights the importance of seeing the potential for growth and healing through the pain that is experienced through grief.
  • “Finding meaning” through the loss is a very empowering, positive, and important stage.
  • Highlighting this stage reveals the necessity for looking for the light in the midst of the dark that shrouds death and covers us in a dark veil of grief.

   

• What strategies can you use to help during the grieving process?

  • It is important to acknowledge the grief.
  • Be willing to acknowledge that your grief journey is unique to you (and that others may judge you if you are doing it differently than they would).
  • Find people with whom you can communicate and who will listen to you (e.g., friends, families, church support groups). Seek out people who accept where you are in the grieving process at that point in time.
  • You may want/need to seek out professional help (psychiatrists, psychologists, counselors, clergy trained in grief, support groups, etc.)
  • Pay attention to the physical, emotional, and mental demands of grief and to find ways to process/deal with each of these aspects of grief (i.e., meditation, prayer, exercise, humor therapy, journaling, support groups, etc.).

   

• How long does the grieving process usually last?

  There is no exact timeline, but the grieving process depends on a wide variety of factors:

  • What factors might cause the length of the grieving process to differ? Suddenness of the death, personality, resources, types of and amounts of support, cultural/religious/family norms, age of the person experiencing the loss may all be contributing factors.
  • What can make grieving easier or harder? The ease or difficulty of the grieving process may be affected by individual circumstances, including love and support of family and friends, communication styles, faith in an afterlife, the passage of time, and personal resiliency.  

   

• Communication is vitally important when dealing with grief.  You can provide comfort to someone who is grieving a loss by engaging in the following:

  • Verbal messages such as “I am here for you if you want someone to talk with” or “I can’t possibly understand what you are going through, but I am hoping to understand it better with your help, if you are willing to share with me.”
  • Nonverbal actions such as hugs, a comforting touch, appropriate eye contact, and/or a card or letter
  • Acts of service such as making a meal or performing a duty to help during this time of grief (i.e. mowing the lawn, cleaning the house, doing laundry, etc.)
  • Acts of kindness such as listening and showing empathy, compassion, patience, the willingness to be present to help the person as they walk their personal grief journey.

• What should I avoid doing if I am trying to help someone grieving?

  • Avoid judging the person as they walk their personal grief journey.
  • Remember what works (or has worked) for you may not work for them; the length of time that they are dealing with their grief may differ from yours—there is NOT a right or wrong timeline.