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A Good Death

The Last Dance

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The Last Dance tenth edition

Encountering Death and Dying

L Y N N E A N N D e S P E L D E R Cabrillo College


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Published by McGraw-Hill Education, 2 Penn Plaza, New York, NY 10121. Copyright © 2015 , 2011, and 2009 by Lynne Ann DeSpelder and Albert Lee Strickland. All rights reserved. No part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written consent of McGraw-Hill Education, including, but not limited to, in any network or other electronic storage or transmission, or broadcast for distance learning.

Some ancillaries, including electronic and print components, may not be available to customers outside the United States.

This book is printed on acid-free paper.

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ISBN: 978-0-07-803546-3 MHID: 0-07-803546-5

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Library of Congress Cataloging-in-Publication Data DeSpelder, Lynne Ann, 1944- The last dance : encountering death and dying / Lynne Ann DeSpelder, Cabrillo College, Albert Lee Strickland.—Tenth edition. pages cm ISBN 978-0-07-803546-3 (alk. paper) 1. Death—Psychological aspects—Textbooks. 2. Death–Social aspects—Textbooks. I. Strickland, Albert Lee. II. Title. BF789.D4D53 2014 155.9’37—dc23 2013041273

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In memory of Coleen DeSpelder

who lived with lightness through the shadows of terminal illness

April 2, 1954—May 17, 2001

and to our parents

Bruce Erwin DeSpelder and

Dorothy Roediger DeSpelder

Luther Leander Strickland and

Bertha Wittenburg Strickland

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Brief Contents

Preface xxi Prologue, by David Gordon 1

CHAPTER 1: Attitudes Toward Death: A Climate of Change 5

CHAPTER 2: Learning About Death: Socialization 49

CHAPTER 3: Perspectives on Death: Historical and Cultural 89

CHAPTER 4: Death Systems: Mortality and Society 139

CHAPTER 5: Health Care: Patients, Staff, and Institutions 175

CHAPTER 6: End-of-Life Issues and Decisions 213

CHAPTER 7: Facing Death: Living with Life-Threatening Illness 259

CHAPTER 8: Last Rites: Funerals and Body Disposition 295

CHAPTER 9: Survivors: Understanding the Experience of Loss 341

CHAPTER 10: Death in the Lives of Children and Adolescents 385

CHAPTER 11: Death in the Lives of Adults 417

CHAPTER 12: Suicide 447

CHAPTER 13: Risks, Perils, and Traumatic Death 489

CHAPTER 14: Beyond Death / After Life 531

CHAPTER 15: The Path Ahead: Personal and Social Choices 569

Epilogue, by David Gordon 599 Notes 601 Credits and Sources 671 Name Index 677 Subject Index 693

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Preface xxi Prologue, by David Gordon 1

C H A P T E R 1

Attitudes Toward Death: A Climate of Change 5

Expressions of Attitudes Toward Death 6 Mass Media 6

In the News 6 Entertaining Death 8

Language 10 Music 12 Literature 15 Visual Arts 18 Humor 23

Living with Awareness of Death 25 Contemplating Mortality 26 Dimensions of Thanatology 26 Death Anxiety and Fear of Death 27 Terror Management 29

Studying Death and Dying 31 The Rise of Death Education 31 Pioneers in Death Studies 32

Factors Affecting Familiarity with Death 34 Life Expectancy and Mortality Rates 35 Causes of Death 37 Geographic Mobility and Intergenerational Contact 38 Life-Extending Technologies 40 The Internet and the Digital Age 42

Examining Assumptions 43 Death in a Cosmopolitan Society 44 Exploring Your Own Losses and Attitudes 46

Further Readings 47

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C H A P T E R 2

Learning About Death: Socialization 49

A Child’s Reasoning 50 A Mature Concept of Death 51 Understanding Death Through the Life Course 53

Infancy and Toddlerhood 57 Early Childhood 58 Middle Childhood or School-Age Period 60 Adolescence 62 Emerging Adulthood 64 Early Adulthood 64 Middle Adulthood 65 Later Adulthood 66 The Evolution of a Mature Concept of Death 66

Agents of Socialization 67 Family 68 School and Peers 69 Mass Media and Children’s Literature 72 Religion 76

Teachable Moments 76 The Death of a Companion Animal 78 The Mature Concept of Death Revisited 81 Further Readings 87

C H A P T E R 3

Perspectives on Death: Historical and Cultural 89

Traditional Cultures 92 Origin of Death 92 Names of the Dead 94 Causes of Death 95 Power of the Dead 97

Western Culture 98 The Deathbed Scene 100 Burial Customs 102

Charnel Houses 102 Memorializing the Dead 104

The Dance of Death 104

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Death Masks 106 Invisible Death? 107

Cultural Viewpoints 108 People of Native American Heritage 108 People of African Heritage 112

The LoDagaa of Northern Ghana 114 Traditions Among African Americans 116

People of Hispanic Heritage 117 Attitudes Toward Death in Mexico 118 Día de los Muertos 118

People of Asian Heritage 122 Paper Offerings 127 Ch’ing ming and O-bon Festivals 128

People of Jewish Heritage 129 People of Celtic Heritage 129 People of Arab Heritage 132 People of Oceanian Heritage 132

Mixed Plate: Cultural Diversity in Hawaii 133 Characteristics of Hawaii’s Peoples 133 Death and Local Identity 134

Death in Contemporary Multicultural Societies 136 Further Readings 137

C H A P T E R 4

Death Systems: Mortality and Society 139

Certifi cation of Death 140 The Coroner and the Medical Examiner 141 Autopsies 144 Assessing Homicide 147 Capital Punishment 150 Defi ning Death 151

Conventional Signs of Death and New Technology 153 Conceptual and Empirical Criteria 155 Four Approaches to the Defi nition and Determination of Death 157

Irreversible Loss of Flow of Vital Fluids 157 Irreversible Loss of the Soul from the Body 157 Irreversible Loss of the Capacity for Bodily Integration 159

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Irreversible Loss of the Capacity for Consciousness or Social Interaction 160

The Uniform Determination of Death Act 162

Organ Transplantation and Organ Donation 165 Medical Ethics: A Cross-Cultural Example 170 The Impact of the Death System 172 Further Readings 173

C H A P T E R 5

Health Care: Patients, Staff, and Institutions 175

Modern Health Care 176 Health Care Financing 178 Rationing Scarce Resources 180

The Caregiver-Patient Relationship 181 Disclosing a Life-Threatening Diagnosis 182 Achieving Clear Communication 183 Providing Total Care 185

Care of the Dying 185 Hospice and Palliative Care 187

The Origins of Hospice and Palliative Care 191 Challenges for Hospice and Palliative Care 192 The Future of Hospice and Palliative Care 195

Home Care 196 Social Support 198

Elder Care 199 Trauma and Emergency Care 201 Death Notifi cation 204 Caregiver Stress and Compassion Fatigue 207 A Changing Health Care System 209 Further Readings 210

C H A P T E R 6

End-of-Life Issues and Decisions 213

Principles of Medical Ethics 214 Informed Consent to Treatment 215

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Principles of Informed Consent 215 Preferences Regarding Informed Consent 217

Choosing Death 221 Withholding or Withdrawing Treatment 225 Physician-Assisted Death 226 The Rule of Double Effect 229 Euthanasia 229 Palliative Care and the Right to Die 230 Nutrition and Hydration 231 Seriously Ill Newborns 232

Advance Directives 233 Using Advance Directives 238 Advance Directives and Emergency Care 240

Inheritance: Wills, Probate, and Living Trusts 241 Wills 242

The Formally Executed Will 245 Amending or Revoking a Will 246

Probate 248 The Duties of the Executor or Administrator 248 Laws of Intestate Succession 250

Living Trusts 251

Insurance and Death Benefi ts 253 Considering End-of-Life Issues and Decisions 255 Further Readings 256

C H A P T E R 7

Facing Death: Living with Life-Threatening Illness 259

Personal and Social Meanings of Life-Threatening Illness 261 Coping with Life-Threatening Illness 263

Awareness of Dying 263 Adapting to “Living-Dying” 264 Patterns of Coping 266 Maintaining Coping Potency 269

Treatment Options and Issues 272 Surgery 275 Radiation Therapy 276 Chemotherapy 277 Alternative Therapies 277

The Placebo Effect 280 Unorthodox Treatment 281

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Pain Management 282 The Language of Pain 283 Treating Pain 283

The Dying Trajectory 286 The Social Role of the Dying Patient 289 Being with Someone Who is Dying 292 Further Readings 293

C H A P T E R 8

Last Rites: Funerals and Body Disposition 295

Psychosocial Aspects of Last Rites 298 Announcement of Death 298 Mutual Support 301 Impetus for Coping with Loss 302

Funerals in the United States 303 The Rise of Professional Funeral Services 304 Criticisms of Funeral Practices 306 New and Rediscovered Memorial Choices 309

Selecting Funeral Services 311 Funeral Service Charges 313 Comparing the Costs 314

Professional Services 314 Embalming 315 Caskets 317 Outer Burial Containers 318 Facilities and Vehicles 319 Miscellaneous Charges 319 Direct Cremations and Immediate Burials 319

Funeral and Memorial Societies 321

Body Disposition 321 Burial 324 Cremation 326 Memorialization 328 Laws Regulating Body Disposition 329

New Directions in Funerals and Body Disposition 330 Remembrance Rituals and Linking Objects 333 Making Meaningful Choices 334 Further Readings 339

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C H A P T E R 9

Survivors: Understanding the Experience of Loss 341

Bereavement, Grief, and Mourning 343 Tasks of Mourning 346 Models of Grief 347

Working Through Grief 347 Continuing Bonds with the Deceased 348 Telling the “Story”: Narrative Reconstruction 350 The Dual Process Model of Coping 351 The Two-Track Model of Bereavement 352 Toward an Integrated Model of Grief 353

The Experience of Grief 355 Mental Versus Emotional Responses 355 The Course of Grief 355 The Duration of Grief 358 Complications of Grief 359 The Mortality of Bereavement 362

Variables Infl uencing Grief 364 Survivor’s Model of the World 364

Personality 364 Cultural Context and Social Roles 365 Perceived Relationship with the Deceased 365 Values and Beliefs 367

Coping Patterns and Gender 367 Mode of Death 369

Anticipated Death 370 Sudden Death 371 Suicide 371 Homicide 372 Disaster 372

Multiple Losses and Bereavement Burnout 373 Social Support and Disenfranchised Grief 373 Unfi nished Business 375

Grief Counseling and Grief Therapy 376 Support for the Bereaved 379 Bereavement as an Opportunity for Growth 380 Further Readings 382

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C H A P T E R 1 0

Death in the Lives of Children and Adolescents 385

Experiences with Death 388 Children as Survivors of a Close Death 391

The Bereaved Child’s Experience of Grief 392 The Death of a Parent 393 The Death of a Sibling 395

Children with Life-Threatening Illnesses 399 The Child’s Perception of Serious Illness 400 The Child’s Coping Mechanisms 401 Providing and Organizing Care 402

Pediatric Hospice and Palliative Care 403 Decisions About Medical Treatment 405 Caring for a Seriously Ill Child 406

Support Groups for Children 407 Helping Children Cope with Change and Loss 409

Discussing Death Before a Crisis Occurs 409 Discussions When a Family Member Is Seriously Ill 411 Discussions in the Aftermath of Loss 412

Further Readings 415

C H A P T E R 11

Death in the Lives of Adults 417

Death and the College Student 418 The Death of a Friend 420 The Death of a Parent 420 Parental Bereavement 423

Childbearing Losses 424 Miscarriage 426 Induced Abortion 426 Stillbirth 428 Neonatal Death 429 Sudden Infant Death Syndrome 430

Grief for “Unlived” Lives 431

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The Death of an Older Child 432 The Death of an Adult Child 433 Coping with Bereavement as a Couple 434 Social Support in Parental Bereavement 435

Spousal Bereavement 436 Factors Infl uencing Spousal Bereavement 436 Social Support for Bereaved Spouses 439

Aging and the Aged 440 Further Readings 445

C H A P T E R 1 2

Suicide 447

Comprehending Suicide 448 Statistical Issues 449 The Psychological Autopsy 451

Explanatory Theories of Suicide 453 The Social Context of Suicide 453

Degree of Social Integration 453 Degree of Social Regulation 455

Psychological Insights About Suicide 456 Toward an Integrated Understanding of Suicide 457

Some Types of Suicide 459 Suicide as Escape 459 Cry for Help 461 Subintentioned and Chronic Suicide 464

Risk Factors Infl uencing Suicide 464 Culture 466 Personality 467 The Individual Situation 468

Life-Span Perspectives on Suicide 471 Childhood 471 Adolescence and Early Adulthood 472 Middle Adulthood 475 Late Adulthood 476

Contemplating Suicide 476 Suicide Notes 479 Suicide Prevention, Intervention, and Postvention 481

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Prevention 482 Intervention 483 Postvention 484

Helping a Person Who Is in Suicidal Crisis 485 Further Readings 487

C H A P T E R 1 3

Risks, Perils, and Traumatic Death 489

Accidents and Injuries 490 Risk Taking 491 Disasters 494

Reducing the Impact of Disasters 498 Coping with the Aftermath of Disaster 499

Violence 501 Random Violence 503 Serial Killers and Mass Murderers 503 Familicide 505 Steps Toward Reducing Violence 506

War 507 Technological Alienation 508 The Conversion of the Warrior 509 Coping with the Aftermath of War 511 Making War, Making Peace 513

Genocide 516 Terrorism 517

September 11, 2001 519 Rescue, Recovery, and Mourning 521 The Mind of the Terrorist 521

Horrendous Death 523 Emerging Infectious Diseases 524

The Response to AIDS 525 Living with AIDS 527 The Threat of Emerging Diseases 527

Traumatic Death 529 Further Readings 529

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C H A P T E R 14

Beyond Death / After Life 531

Traditional Concepts About Life After Death 532 Jewish Beliefs About Death and Resurrection 534 Classical Greek Concepts of Immortality 536 Christian Beliefs About the Afterlife 538 The Afterlife in Islamic Tradition 542 Death and Immortality in Asian Religions 543

Hindu Teachings About Death and Rebirth 544 The Buddhist Understanding of Death 547 After-Death States in Tibetan Buddhism 550

The Consolations of Religion 551 Secular Concepts of Immortality 552 Near-Death Experiences: At the Threshold of Death 554

NDEs: A Composite Picture 555 Dimensions of Near-Death Experiences 556 Interpreting Near-Death Experiences 558

Death Themes in Dreams and Psychedelic Experiences 562 Beliefs About Death: A Wall or a Door? 565 Further Readings 566

C H A P T E R 1 5

The Path Ahead: Personal and Social Choices 569

Exploring Death and Dying 570 Cultural Competence 572 New Directions in Thanatology 574

Gaining a Global Perspective 576 Bridging Research and Practice 580

Creating Compassionate Cities 581 Living with Death and Dying 584

Humanizing Death and Dying 585 Defi ning the Good Death 587

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Death in the Future 591 Postscript and Farewell 596 Further Readings 597

Epilogue, by David Gordon 599

Notes 601

Credits and Sources 671

Name Index 677

Subject Index 693

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In The Last Dance: Encountering Death and Dying, we offer a comprehensive and readable introduction to the study of death and dying, one that highlights the main issues and questions. The study of death—or thanatology, from the Greek thanatos, meaning “death”—is concerned with questions rooted at the core of our experience. Thus, the person who sets out to increase his or her knowledge of death and dying is embarking on an exploration that is partly a journey of personal discovery. This is a journey that has both cognitive (intellectual) and affective (emotional) components. Thus, The Last Dance embodies an approach to the study of death and dying that combines the intellectual and the emotional, the social and the psychological, the experi- ential and the scholarly.

The title The Last Dance relates to a book written by Carlos Castaneda about the warriors of the Yaqui Indian tribe in Central America. Because a warrior can die on any day, the warrior makes a dance of power in the face of death. Castaneda says that, to truly live, we must keep death over our left shoulder. In other words, death is part of life and, because we can die at any time, we should be dancing through life.

The painting on the cover, The Dance of Life, by Norwegian artist Edvard Munch, evokes thoughts of the inexorable, compelling cycle of life. It depicts a festival dance on the Asgaardstrand beach on a midsummer night. An indifferent moon sheds light on the water while the dancers dance a roundel, a ring dance. One woman is entering the dance, another is leaving. There is youth, innocent new life, and age.

We are sometimes asked how we came to write a college textbook on death and dying. Lynne says, “It’s as simple as the realization that students hated buying the many books needed for studying all of the topics important to learning about death and dying. And I hated having to assign all those books. One day at the start of a new semester, after getting the usual com- plaints from students, I whined to Al, ‘Why isn’t there just one book that a student could pick up and put under his or her arm that would cover all of these topics?’ Al’s response was, ‘Well, why don’t we write one?’”

So, some years ago, after fi ve years dedicated to research and writing, The Last Dance: Encountering Death and Dying was born. Each subsequent edition refl ects the changes and transformations that have occurred in the fi eld of

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death studies. This book provides a solid grounding in theory and research as well as in methods for applying what is learned to readers’ own circum- stances, both personal and professional. It encourages a constructive process of self-discovery. The Last Dance is not an indoctrination to any particular point of view but, rather, an introduction to diverse points of view. The values of compassion, listening, and tolerance for the views of others are empha- sized. Readers may form their own opinions, but when they do we hope it is only after considering other possibilities in a spirit of open-mindedness. Unbiased investigation leads to choices that might otherwise be neglected or overlooked.

While retaining the popular features of earlier editions, this new edition of The Last Dance refl ects the ongoing evolution of death studies. Although people sometimes think, “What changes about death?” the truth revealed in these pages is that much has changed in recent decades and continues to change in the present. Because of this fact, every chapter has been revised to integrate the latest research, practices, and ideas and to enhance clarity of presentation.

Throughout the text, we give attention to the ways cultural and ethnic viewpoints shape our relationship with death, and there is specifi c discus- sion of the viewpoints and traditions associated with people of African heri- tage, Hispanic heritage, Native American heritage, Jewish heritage, Celtic heritage, Arab heritage, Oceanian heritage, and Asian heritage, including the diverse cultures of Southeast Asia as well as the cultures of India, China, Taiwan, Japan, Korea, and the Philippines. In the pages of The Last Dance, you will also fi nd coverage of

• Ongoing developments in care of the seriously ill and dying, especially as they pertain to hospice and palliative care

• Death through the life course, from infancy through later adulthood, including a new section on death and the college student

• New directions in mortuary services, including personalized funerals, “green burials,” and innovative options for body disposition and memorialization

• A changing health care system and its impact on dying and death • How the Internet is infl uencing our relationship to death, dying, and

bereavement in the digital age • Insights about grief gained through an appreciation of the dual process

and two-track models of coping with bereavement, as well as other models that can aid in understanding bereavement, grief, and mourning, includ- ing discussion of working through grief, maintaining continuing bonds with the deceased, and “telling the story” or narrative approaches to coping with grief

• How achieving the “Care-Full Society” and striving toward the creation of “compassionate cities” could improve and enhance our encounters with death

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In addition, this edition contains new and updated material on physician- assisted suicide, remembrance rituals and linking objects, grief counseling and grief therapy, horrendous death, the placebo effect, familicide, and the death of a companion animal.

The study of death is unavoidably multidisciplinary. Accordingly, con- tributions from medicine, the humanities, and the social sciences are all found here in their relevant contexts. Throughout the book, principles and concepts are made meaningful by use of examples and anecdotes. Boxed material, photographs, and other illustrative materials expand upon and provide counterpoint to the textual presentation. Specialized terms, when needed, are clearly defi ned. Accompanying this edition is a companion Online Learning Center, , designed to pro- mote mastery of the material covered in the text itself. We urge readers to make use of these features.

Chapter-by-Chapter Tour Before you begin using The Last Dance, please join us for a quick tour through the text.

• In Chapter 1, we look at expressions of attitudes toward death in mass media, language, music, literature, and the visual arts. We ask what it means to live with an awareness of death, and we explore death anxiety, or fear of death. We conclude by examining the reasons people tend to be unfamiliar with death in modern, cosmopolitan societies.

• In Chapter 2, we investigate how we learn about death throughout the life course.

• In Chapter 3, we explore historical and cultural factors that shape atti- tudes and practices relative to dying and death.

• Chapter 4 shows how public policy affects our dealings with dying and death by means of a society’s “death systems.” Certifi cation of death, the role of coroners and medical examiners, the functions of autopsies, procedures for legally defi ning and making a determination of death, medicolegal views of homicide and capital punishment, and rules regard- ing organ donation and transplantation are important aspects of the death system. An instructive cross-cultural example describing how Japan has dealt with ethical, moral, and legal questions involving brain death and organ transplantation wraps up this discussion.

• Care of dying persons is the primary focus of Chapter 5. Topics include health care fi nancing; rationing of health resources; the relationship between caregivers and the patient; hospice, palliative care, and home care; elder care; trauma and emergency care; death notifi cation proce- dures; and caregiver stress and compassion fatigue.

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• Chapter 6 deals with a variety of issues and decisions that pertain to the end of life. Some of these issues and decisions become important in the context of diagnosis and treatment—for example, informed con- sent. Others come to the fore when individuals face a more immediate prospect of dying. These include choices about withholding or with- drawing life-sustaining medical treatment, physician-assisted death, and euthanasia, as well as issues involving artifi cial nutrition and hydration. Also discussed is the rule of double effect, which may be invoked when a medical intervention that is intended to relieve suffering leads to death. Some issues regarding the end of life can be dealt with before the crisis of a life-limiting illness—for example, making a will, setting up a living trust, obtaining life insurance, and completing advance directives to express wishes about medical treatment in the event one becomes inca- pacitated.

• Chapter 7, with its focus on how people live with a life-threatening illness, gives attention to the psychological and social meanings associated with such illnesses and offers insight about the ways individuals and families cope with “living-dying,” from the time of initial diagnosis to the fi nal stages of the dying trajectory. Discussion includes treatment options and issues, as well as pain management and complementary therapies. The chapter concludes with sections on the social role of the dying patient and advice about being with someone who is dying.

• The ceremonies and rituals enacted by individuals and social groups after a death form the content of Chapter 8. Death rites and customs create opportunities for expressing grief and integrating loss. This chapter exam- ines the nature and function of last rites, with particular attention to the history of mortuary services in the United States. Information about the options for funeral services and body disposition, as well as a discussion about making meaningful choices, completes the chapter.

• Chapter 9 is devoted to helping readers gain a comprehensive under- standing of bereavement, grief, and mourning. A number of important models of grief are discussed, with the recognition that any notion that “one size fi ts all” is likely to be inadequate. An understanding of the ways people experience and express grief, and of the variables that infl uence grief, demonstrates that there are many ways to cope with grief and to provide support to the bereaved. The concluding section shows that, despite loss, bereavement can present opportunities for growth.

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