➣ Unique Needs at the End of Life

by Deborah Grassman


Many people do not realize that military service influences soldiers in ways that can sometimes complicate peaceful dying, even though their death may not occur until many years after they leave military service. Deborah was the first person to identify the influence that the military sometimes exerts on dying Veterans. Peace at Last: Stories of Hope and Healing for Veterans and Their Families was subsequently published and is now a recognized authority on how the military impacts veterans and their families as they experience the dying process.

These influences include:

  • The value of stoicism so earnestly and necessarily indoctrinated in young soldiers might interfere with peaceful deaths for all veterans, depending on the degree to which stoicism permeated their later lives;
  • Veterans who served in dangerous duty assignments might have their deaths complicated by traumatic memories or paralyzing guilt, depending on the extent to which they were able to integrate and heal traumatic or guilt-inducing memories;
  • There is a high incidence of alcohol abuse or other “flight”-type behaviors used either to avoid confronting locked-up feelings or to numb traumatic memories. These factors might contribute to “unfinished business” as veterans face the end of their lives;
  • Veterans often acquire wisdom because they have reckoned with trauma, stoicism, and addictions. Understanding these three elements helps access their wisdom and has been referred to as “post-traumatic growth.”
  • Veterans and their families have unique bereavement needs to consider when providing care.


When people learn that I work with dying veterans, they will often say, “I can’t imagine working in hospice.” To help you imagine my everyday world, let me tell you the stories of the nine patients on the Hospice and Palliative Care unit at the time of this writing. Then, you can understand the context from which my lessons are derived. You will also understand the privilege that it is to care for veterans. Military experiences changed them in fundamental ways that shape, mold, destroy, and redeem the rest of their lives. Many are able to confront their sufferings successfully. In one aspect of their lives or another, they have been able to redeem portions of their suffering so that it can be used for healing as they face the end of their lives. You will notice that in many ways, they die the same way civilians do. You will also notice that they experience some unique distinctions.

Mark is dying of liver failure from alcohol abuse, his skin yellow as a low-glowing lamp. He came to the Hospice and Palliative Care unit semi-comatose; we won’t get to know him except through his brother’s eyes. I comment on his brother’s devotion. The brother responds, “I look at Mark and know why I’m in Alcoholic’s Anonymous.” I behold one brother willingly serving the suffering of the other.

Donnie is 50 years old and has lung cancer. He’s been a quadriplegic since he was 27 when an automobile accident derailed his career as a professional football player. “I spent three years in despair. Then I found God and salvation,” he tells me. He says he is thankful for his suffering: “I never would have found Jesus if the accident hadn’t happened.” Twenty-three years of redeemed suffering is a story worth beholding.

In the next room, an embittered, lonely man sits sullenly. Alcohol has estranged Zachary from his family. At 82, he’s angry at his body for failing him. He’s been afraid of death since he was 10 years old when a neighbor died falling through a skylight. Bitterly, he tells me, “My only solace is in knowing that someday all the rest of you are going to be in this bed too.” A gathering of team members provided a turning point as Zachary experiences the concern of the four staff members who were willing to love him. “Why aren’t we talking about my breathing, and the 16 pills I’m taking?” he asks us. “Because you are more than just your breathing, and we are more than just pill-givers,” I reply, leaning in and daring to touch him tenderly. A tear forms; his features soften for the first time. “I can’t argue with that,” he says quietly. I can’t tell you the ending of his story, but once the crack starts hope emerges.

In the room next to Zachary is Marvin. He was a photographer to a general in World War II. He has been a physician, sailboat racer, and builder of piers, driveways, and roofs “made with my own hands.” Marvin’s wife and four children sit at his bedside supporting his journey into the next world and supporting one other. Near death, he says little except the Lord’s Prayer. There’s no need for us to intervene. We just get out of the way and behold a life well lived.

In the adjoining bed is Jim, a Vietnam War veteran who has lived a colorful life. He’s intermittently confused; sometimes he’s argumentative. He has no family; a few close friends are his source of comfort. His first days on the unit were filled with agitation. He was convinced the Vietcong had put a bomb in the stereo. Nurse Suzanne responded creatively. She called the security officer and said, “I want you to inspect the stereo and declare it bomb-proof. Tell the patient you’re pulling guard so you’ve got his back and the perimeter is safe. Let him know that another guard will be on patrol when you leave duty.” The police officer responded convincingly, and Jim’s agitation subsided.

Then there’s Bruce, a 67-year-old man who came for pain control. He hadn’t wanted to come to our Hospice unit because, he said, “I’m afraid I’ll never get out.” His early days of anxiety and impatience were manifested with frequent summons on the call light. Probably because he realizes he’s in a safe, loving environment his spirit is now emerging bright and full. He simply needed a little time and a little love to know that he need not fear. He has grown closer to his family as he approaches death and tells us, “I wouldn’t trade these last few weeks in my life for anything.”

Bruce’s roommate, Richard, suffers respiratory distress from a tumor encroaching on his breathing tube. He awaits his daughter’s arrival from Indiana tomorrow. He says his suffering will be redeemed when he can rejoin his wife who died two years ago. “That will be a happy day,” Richard says with tears. We share his anticipated joy.

Ben has a history of drug use and actively continues with alcohol abuse. He identifies himself as a loner who has witnessed much violence. “My family doesn’t care about me,” he told me. We’ve had some difficult sessions confronting his suffering. He’s going to be discharged next week. I don’t know what’s going to happen with him. What I can tell you is that his brow unfurls after prayer, he plans to go to Alcoholic Anonymous meetings, and he wants to reach out to a faith community. Seeds planted and good intentions, however, are still not enough to withstand the ravages of alcohol. Ben’s redemption awaits a courageous decision that only he can make every day for the rest of his life.

The last patient, Edwin, has severe chronic respiratory disease and is ready to die but he worries about his wife of 54 years. His needs are increasing rapidly but he doesn’t acknowledge them because he doesn’t want to worry her. “I can’t hold on much longer though,” Edwin says while making plans to hold on for his wife’s sake. We talk about the advantage of letting go so he can prepare himself and his wife for his death; we talk about the damage his denial is causing them both. Edwin cries as his grieving begins. Stories of sacrifice in the name of love are always worth beholding.

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Family Care

➣ Creative Cocooning: A Caregiver’s Journey

by Patricia McGuire

You may have heard that death is like the birth of the butterfly. What a peaceful thought that is. It brings images of delicate, colorfully-winged, creatures flitting from flower to flower. What it does not even hint at is the dramatic process of “cocooning” that happens between caterpillarness and butterflydom. More importantly we don’t get sick alone (if we are lucky). We will need a caregiver. Most of us know little about cocooning or caregiving. The furry little caterpillar pictured above looks so cute and harmless. And it is…until it begins to transform into a cocoon. Notice that as it spins its cocoon, it entangles those around it. Using the cocoon as a metaphor for the end of life and death processes can be very instructive. Transformation from “well and healthy,” to death is the most profound change we experience in life. (See “Cocooning” under topics for more information.) Not only that, but the caregiver can get so consumed with caregiving that they might lose their own sense of self, becoming immobilized in the cocoon (see picture below).


The average life expectancy twenty or thirty years ago was much shorter than it is today and many people died suddenly and unexpectedly. Today just 15% of us will die quickly. Medical advances allows the other 85% to spend longer and longer time in transition and caring for those in transition.

So let’s consider that we are all a bunch of caterpillars. 15% of us will emerge from our caterpillars suddenly and unexpectedly and be released to our new lives as butterflies. That may seem a lovely thought, but what about the other 85%? Some will have short illnesses, some will have a couple of years of decline, and still others will enter the place between “life as we knew it” and “living loss.” For example, consider Carol and Bob. They met when they were quite young, married, raised a family and had a good life together for many years. Then Bob got Alzheimer’s disease and the next fifteen years of their lives was filled with chronic sorrow and living loss. Carol told me, “He would get so agitated and yell at me to get out of the house.” Bob didn’t recognize Carol as his wife anymore. Thinking that she was an intruder in the house, Carol would have to go out the front door, change clothes, and “come home” through the front door. She would then be accepted as his wife once more, and Bob would tell her about “the strange woman” who had been there. Imagine the chronic sorrow of lengthy cocooning!

I made the furry caterpillar you see in the picture above. When I showed it to Carol, she became animated, excitedly taking it from my hands and wrapping it around her neck like a shawl. “This is exactly what taking care of Bob has been like!” she exclaimed. The following week, Carol returned with a treasure she wanted to share with me: a hand-made book about her cocooning process. The book was beautifully illustrated with her artful drawings. I was so impressed that when she finished reading it to me, I declared that I would dub my furry frined “Bob” in honor of her and her husband.

Here is Carol’s eloquent version of her cocooning journey:

The Journey

I was a bush, bright and green
Covered with shimmering leaves upon which butterflies did preen.

Then one day along came this funny, furry little thing,
That climbed right up on a branch of mine!

Oh, Caterpillar, Caterpillar so furry and cute,
All dressed up in your Caterpillar suit.

I loved you true and you loved me too.
We used to laugh and play and throw away each day.

He took a bite here, and a little crunch there,
But I had so many leaves, I really didn’t care.

Caterpillar, you munch and crunch on me all through the day and night.
My life has become an agonizing fight.

Our memories fly away like dead leaves before autumn’s cold breeze
One by one my leaves do fall, one by one, you devour them all.

Like stiff-legged mice, across the frozen pond they fly.
Searching for comfort…they hopelessly try.

In your mindless advance,
You crunch and munch, as onward you prance.

Oh, Caterpillar, Caterpillar can’t you see,
You’re draining the life out of me?

Stripping away my last shred of dignity,
Only death can set me free.

Illness often precipitates the cocooning process. One woman who had been debilitated by Lymes Disease and was no longer able to practice her profession described the cocooning process beautifully when she told me, “I’m in a place between ‘I don’t fit like everyone else’ and ‘those in the main stream who can’t understand the life I live’.” She went on to say, “A friend asks me to lunch, and I really want to go. I say ‘Yes’ because I know going to lunch will allow me to feel normal for a little while… but if I’m having a bad day that day and can’t go…people don’t get it when I cancel at the last moment. They don’t invite me again.”

This is true for caregivers as well. Caregiving can be very lonely because most often it is done in isolation. When you are tangled in a cocoon, you are not free to pick up and go on a whim. You also may find yourself cancelling plans at the last minute when your loved one is “not having a good day.” Your friends may be concerned for you, but they go on with their lives.

Many people are frightened by the cocoons of people with disabilities. One woman told me, “If I was bitten by a shark, I might not be so scary because people don’t think a shark will ever bit them as long as they stay out of the ocean. But, I have a disease and if that could happen to me, it could happen to you too. That’s why people are afraid of me.”

Albert Schweitzer said, “Depersonalization is worse than death.” A man told me, “Smiling for the chronically ill is what they do instead of crying.” A caregiver may notice that when you take your loved one out in a wheelchair that the people around you speak to you rather than your loved one: ”I feel invisible,” wheelchair-bound people have told me. Make a point of including them in the conversation. Modeling comfort with those who are cocooning may reduce their sense of isolation.

Consider the following for peace-making and tool building:


Feelings: Anger, hope, fear, guilt, jealousy, helplessness, sadness. When a loved one is ill, we are forced into strange and unfamiliar situations. This threatens our security and may cause many emotions. Having a safe place and understanding people to talk with about these emotions is very important. A community of supportive people can keep you from losing “you” in the caregiving process. Then, you will have a “you” to grow into your changed life. Supportive people can “cocoon” YOU. Afterall, a cocoon is a safe place for dramatic change.

Self-care: If you don’t take care of yourself, you will not be able to care for anyone else. Physical exercise, eating healthy food, drinking plenty of fluids, maintaining adequate rest, seeking medical care for your own health issues, and having sources of fun are all important self-care needs to build into your daily routine. Find people to talk with. Set realistic goals and arrange time for yourself. When someone says, “What can I do to help?”, tell them to sit with your loved one so you can have some respite to take care of your own needs. Don’t let your pride interfere with receiving help and support.

Advocating for your loved one: When your loved one has unmet needs, speak up. Let the doctors and health care professionals know. The caregiver knows the patient better than anyone else. Your voice is important for the healthcare team to hear. The healthcare team relies on you to make your loved one’s needs known. You may have to speak your need repeatedly to numerous people. Until the need is met or you understand why it is not, keep asking until you are satisfied.

Communicating with medical staff: Frequently families say, “I don’t know what is going on with________”. You have a right to understand what is happening. You can schedule an appointment with the doctor. Write your questions down to help you remember. If you don’t understand what the physician tells you, ask for clarification.

Advance directives: These documents explain to the medical staff what medical care or treatments the patient wants if they are no longer able to make decisions for themselves. Do you have advance directives complete for yourself and your loved one? If not, we can help you complete one.

Health care surrogate: This is a trusted person appointed by the patient to make decisions for them in the event that they cannot make them for themselves. Because someone told you that they want you to make decisions for them, does not necessarily mean that legally the medical staff will be able to follow your directives. This must be written and witnessed to make it legal. Without such documentation, the legal next of kin is responsible to make decisions. Health Care Surrogate is no longer valid once the patient has died and in no way affects the patient’s last will and testament.

Legal next of kin (NOK): Legally, next of kin does not necessarily mean the person closest to the patient. We refer to the person who is close to the patients and not legally the NOK as the next of heart (NOH). The NOH has no legal rights. Unless you are related by marriage or blood, you are not the legal next of kin. An estranged wife who hasn’t seen the patient in twenty years could be legally the NOK. An estranged son or daughter who never remembers meeting the patient may be the legal NOK. If the patient wants you to be the one acting for him/her, this must be done legally.

Wills: A will is a legally binding document which one completes prior to death to direct the distribution of one’s earthly possessions after death. A person must be of “sound mind” to create a will, so it is important to complete before mental deterioration starts. This can be done with a lawyer, by completing a standard will available in office supply stores, or by simply writing out your wishes. This must be notarized and witnessed to be legal. In the will, a personal representative/executor is named. This person insures that the wishes in the will are completed. If no will is left, the legal NOK will assume this responsibility. Many people make their wishes for funerals, burial, etc. known in their will.

Durable power of attorney (DPOA): This is a legal document, which allows a designated person to act on behalf of another. If you are unable to act in your own behalf, you may designate a trusted person to take care of your personal business, banking, bill paying, etc. DPOA ceases upon the patient’s death.

Details office: This office at the Veteran’s Administration handles the care of the patient’s bodily remains after death. When someone is getting close to the end of life, it is helpful to visit the details office before he/she dies. There, you will get information about what parts of the final arrangements are your responsibilities and which are the VA’s. They can also provide information about funeral homes and types of burial. You might be surprised at how much better you will feel after this is accomplished.

Autopsy: An autopsy can be done at the request of the family. This may be helpful in determining the cause of death, assist with research, or identify genetic risks for other family members. Limited autopsies can also be specified, if you prefer. Limited autopsies only examine the part of the body suspected of causing the death. You can also specify that certain body parts (such as the brain) not be examined.

Organ donation: Discussing organ donation with your loved one prior to death can help you to know their wishes about donating organs. Even if the patient requests organ donation, the legal NOK will have the final say about donating organs after the death because all patient rights cease upon death.

Florida Department of Veterans’ Affairs: Many questions arise about eligibility for benefits when a veteran is sick. There are Veteran’s Service Officers can help you with these concerns.

Children and grandchildren: Community hospices have special camps and programs to assist with children’s grief. Ask for a referral. Schools can arrange for grief support for your child through their guidance department.

Consider the following websites to help:
The National Family Caregivers Association and the National Alliance for Caregiving or

“Caregiving is one way for humans to learn about humanity. It is not only about simply doing for others. It is also about self-acceptance and honest intentions.”
-Daniel Warner


➣ Good Grief: Those Who Grieve Well, Heal Well

by Deborah Grassman

Life is dramatically altered as people learn how to live in the world without their loved one in it. During the period after a death, little peace can be found initially.

The following letter is written by a woman who had avoided grief with the many deaths she had experienced. As a result, she became overwhelmed when her husband died. Luckily, she was amenable to learning how to grieve so that she could be transformed, finding peace. Here is the letter that she wrote describing the healing process:

Dear Grief,
How many times you have come with your black shroud wrapping your darkness around me. But I would only let your blackness be seen for a little while because as I looked into the eyes of others, I saw their pain so I quickly folded you and hid you within myself. As life went along, you came to me with each loss, but I always was quick to fold your black shroud and hide you away – thinking I was protecting those who could see your dark arms folding in around me.Then, I lost my husband, my dear love. You descended upon me, but I didn’t resist you this time. I let you wrap me in your black shrouded arms. As my tears flowed non-stop from my eyes and my spirit, it was as though you were inviting me on a journey with you, with places to stop along the way. I allowed you to take control, and like a little train, our journey began.The first stop was guilt. Could I have done more? Did I do enough? Did I give enough? I wish I had held my tongue. Could I have shown more understanding? This was a hard stop, but I let myself stay here long enough to examine these doubts. By doing that, I came to the satisfaction that I could have done no more than I could at the time with the strength I had. I had done the best I could with the circumstances I was dealing with.
The next stop the little train made was anger. Why was I so angry? Why wouldn’t people stop acting as if I had not experienced a great loss? Why was I being urged to get on with my life? Couldn’t they see I was locked into a place that had not been my choosing? As I lingered at this stop, I came to realize that FORGIVENESS made it possible for me to get back on that little train and continue my journey.Next we stopped at loneliness. It was difficult to see how I might get past this stop. It felt like I had been thrown off a mountain and I was left trying to crawl back up in total darkness having only jagged edges to hold onto. I let myself feel all the deep emotions of loneliness and with time, I decided to get back on the little train.The next stop surprised me with pleasantness. I started feeling the sun and its warmth. I saw blue sky and noticed the colors of flowers, birds, and leaves. They had been lost to me during my journey of grief. I reflected back on the other stops and realized that having let myself get off at each stop, I no longer felt lost any more.But there was another stop. This was the stop of New Life…a new way to live in the world without my loved one in it. I really hadn’t thought it possible. If anyone would have told me that I could now be so vitally alive without him, I never would have believed them. But my journey of grief had yielded many lessons. Lessons like: not to take life or people for granted, to give love freely and unconditionally, deciding to forgive, taking steps to heal anger, and living each day so that it has worth and meaning.

So, Grief, I no longer fear you. I no longer feel I should hide you. You are my friend who leads me through my pain so that I can make the necessary and healing stops along the way to that place where new life is possible.



➣ Spiritual Care: The Paradoxical Dimension

by Deborah Grassman


Peace that lies beyond human understanding is derived from the spiritual dimension. This dimension creates energy — that spark of life that powers the soul. During times of trouble or sorrow, people often contemplate deeper and more serious issues of the soul; they may even encounter despair. This time of darkness can be beneficial because it cultivates humility; humility accesses the soul. In the soul’s dimension, lies pervasive peace where energy beyond the material world is generated.

A word that might capture the spirit of energy is “vitality.” When I stop denying feelings and instead open up to them, I experience vitality; I become more alive. When I reckon with hardships rather than cope with them, I become vitally alive; my soul is engaged. This soul is important because it’s the most authentic and enduring part of me.

The National Consensus Project Guidelines for spiritual practice defines spirituality as “the aspect of humanity that refers to the way individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred.” Teilhard de Chardin offers yet another perspective: “We are all spiritual beings here for a human experience.” These definitions capture the nature of our soulful beingness where energy and vitality are generated.

It’s easy to confuse religion and spirituality. Sometimes I conceptualize that their relationship is like trees and forests. Religion is the trees of beliefs that we create to understand the spiritual forest of our existence. We all live our religion (the values and beliefs that underlie our actions); even atheists live out their “religion.” Beliefs, however, sometime interfere with understanding existence because “we can’t see the forest for the trees.” Many people discount the value of religion because of this distortion of perspective. Yet, forests can’t exist without trees; and the quality of the forest is dependent on each tree’s contribution. Forests and trees are not mutually exclusive; in fact, they might be mutually inclusive. I learned this from a rabbi on National Public Radio. He was on a panel of religious leaders of different faiths discussing religion and spirituality. All of them agreed that not all spirituality is religious. Almost all panelists agreed that all religions are spiritual. A rabbi disagreed. He said that any religion that teaches exclusivity is not spiritual because spirituality is based on humility not arrogance. I liked his distinction.

As death approaches, people start contemplating deeper issues. Their perspectives shift, and frequently they undertake a spiritual quest.

“Tell me how you are doing spiritually,” I’ll say to a patient.

Often the response is, “Oh, I don’t go to church.”

“Sounds like you’re not a religious person, but I’m wondering if spirituality has any meaning to you,” I’ll reply. “Do you receive strength or comfort from a source of energy or power beyond your own?”

Many will say they believe in God; others talk about nature or their family; some say spirituality has no relevance in their lives. I distinguish between religion and spirituality because I want patients to know I have no interest in trying to convert them to a religion, impose my personal beliefs, or urge them toward any specific beliefs at all. My attitude is important because many patients have had experiences where others had an agenda to change or impose religious ideas; sometimes this kind of imposition was done in a manner that did not respect the patient’s personal beliefs or his or her need to doubt and question.

I usually try to provide nonreligious spiritual care. It takes time to assess a person’s beliefs, time I don’t usually have. Also, there are many different faiths, even divisions within the same faith. It requires time to discern the particular meaning of a patient’s religion. Instead, I provide open-ended “generic” spirituality so the patient can infuse his own personal meanings. I let the patient lead and I follow. I’m secure enough in my own religion that I don’t worry about differing beliefs sabotaging my own. Neither do I think it’s my business to convince them of my beliefs. Sometimes, we explore spiritual ideas together. I proceed cautiously though, always mindful that the patient could be vulnerable to my authority as the healthcare provider. I’m also aware that I might unconsciously want him to think like me.

I’ve learned a lot by watching other people provide religious and spiritual care. Shaku, one of the nurses on our Hospice unit, is Hindu, a religion not shared by many of our patients. She has learned prayers and practices of other religions so she can respond to patients’ varying needs. It’s not unusual to hear her reciting the Lord’s Prayer or the rosary with patients. Patients frequently tell me what a comfort Shaku is to them. (Contact Shaku at

I had an encounter with a nursing assistant who reminded me of Shaku when I, myself, was a patient. I had abdominal surgery and afterwards a small artery began bleeding. I lost many pints of blood, and all my clotting factors were consumed. I not only needed several blood transfusions but a second surgery to control the bleeding. I was left weak and debilitated. I also had severe diarrhea. Too weak to quickly get to the bathroom, I was incontinent. Embarrassedly, I activated my call light. When the nursing assistant came to the room, I told her apologetically about the mess awaiting her under the sheets.

“Oh, that’s okay. That’s why I’m here,” she said cheerfully. “You don’t worry about a thing. Your job is to just let me help you.”

Long after she left, I thought about this woman who made me feel like there was nothing more she wanted than to have the opportunity to clean up my stinky mess. She gave me graciousness, and that was a gift of the spirit that remains with me to this day. “God” was never mentioned, but she helped me realize that tenderly emptying a bedpan for a patient is one of the most spiritual things I can do.

This nursing assistant’s act made me reflect on an adage that sometimes circulates in healthcare circles: “Nursing assistants aspire to be nurses; nurses aspire to be physicians; and physicians aspire to be God.” I sometimes ask myself, “To what role in a hospital does God aspire?” I wonder if the answer is that God aspires to be a patient whose suffering is redeemed through the love of a compassionate care provider like that nursing assistant who knows how to empty bedpans spiritually.


1-Day Workshop: Soul Restoration: Revitalizing the Weary, Wary Heart

Caregiving, whether personal or professional, takes a toll! Caregivers encounter emotional pain on a regular basis. Understandably, we often disconnect from the pain. By disconnecting from the part of self carrying the pain, we unwittingly contribute to the loss of energy, emptiness, and compassion fatigue that can ensue. This 4-8 hour ceremonial workshop provides a restorative experience of self by re-owning and re-homing parts of self that may still be carrying unmourned grief.

1-Day Workshop: Forgiveness & Healing.

Would you like to recover the energy of pieces of self you may have knowingly or unknowingly lost through: self-disregard, heartache, neglect, abuse, trauma, death, or war so you can inhabit yourself more completely? Deborah Grassman joins forces with Dr. Abi Katz to provide an unforgettable day. to schedule them to come to your event.


The Opus Peace Prayer

Cultivate in me, Oh God, the willingness to re-own and re-home scattered pieces of myself so that I might be restored to Your wholeness. Grow in me the honesty, courage, and humility to release my fears of who I am and who I am not. Fuel me with your Grace. Amen

More Information

Quality of Life Meetings



➣ Dying Healed: A Shared Quest to Wholeness

by Deborah Grassman

The time surrounding death is fraught with fear and uncertainty. Few of us have developed an “exit strategy” for the end of our lives. Yet, exit strategies are essential if we want to die healed. We wouldn’t even consider leaving on a trans-continental adventure without seeking a map, guide, and advice. Yet, we often embark on our inevitable trip into the mystery of death all the while denying that we’re even leaving. We seldom stop to ask ourselves: “Could there be some advantages to preparing for the trip we’re destined to take? Would facing death rather than running from it reveal any secrets about living more fully?”

Not preparing for death has practical consequences: we might receive treatments we don’t want or need. Our family may be placed in the uncomfortable position of advocating on our behalf. This happened to Sheila Lozier, a hospice colleague of mine, when her father was dying of cancer. The following poem was written on a napkin in an airport as she was returning from her father’s funeral in Nebraska. She had just been through the unfortunate experience of having to advocate for his peaceful dying by preventing Tube Feedings from being initiated. Her poem helps families understand their role in helping loved ones die healed:

DEATH is Like the Birth of a Butterfly…


We walk along life’s path feeling the warmth
from the sunshine on our faces and
eating the leaves of life to fuel our bodies.

Then one day,
without warning,
our body is invaded
by sickness or by time itself.
A change begins to happen.

Slowly the foods that gave us great joy
lose their interest.
Friends and family can’t understand.
They insist we are starving to death.
The journey becomes more difficult for a time.

Now, eating is done to please others.
It’s ironic that in the end,
the very ones who love us the most,
make our lives more difficult by not understanding. Nevertheless, little by little we stop eating.
Meats, then vegetables, then
anything which requires energy to chew.

Finally all our palate wants
are the sweets of the earth:
puddings, ice cream and juices.
As our energy wanes,
we embark on a new phase of the journey-
the caterpillar stage.

In this slowing down and shutting down process,
the body does not require the fuel it once did.
Like a caterpillar, the body is drawing inward
as if spinning a cocoon,
waiting silently for the dawn of a new existence.

Slowly the muffled cries from the outside world
grow further and further away.
One day a miracle happens.
The broken and damaged shell that once housed
the spirit during its journey here on earth,
begins to break away.
First the hands and feet become cold.
Breathing slows down until it is no longer needed.

Now, as in the birth of the butterfly,
a new energy emerges that is headed
on a wonderful journey on a different dimension.

Perhaps if you listen very quietly
you will hear the gentle beating
of wings as they catch the wind
on their final journey to touch the face of God.



Aging & Transitions

Aging: Redeeming the Destiny We Were Born to Fulfill

by Deborah Grassman

“It takes a lot of courage to grow old,” my 90-year-old mother said the last few decades of her life. “Aging is not for sissies,” I’ve heard others say. Indeed, it is so. Rather than cultivating courage, however, we often resist aging, even deny its personal existence. Could it be possible that aging might have something that we need? What are we missing by not valuing aging? Are we too arrogant or too controlling to think that aging might have something to teach us? Why would we want to be anything other than who we are (which includes the age that we are)?

Conceptually, I describe aging as a Soul → to Sole → to Soul journey. Our soul is born into this world to embark upon what psychologists call an “individuation process” that manifests as the unique individual that we are. As we age, we complete the tasks of individuation, we start letting go of our sole self and gradually start opening up to our soul self.

The Soul-Sole-Soul process is described much more scientifically in healthcare literature, most notably by Erikson. Most healthcare professionals have studied Erik Erikson’s developmental tasks for aging. He says that there are maturational crises or critical decision points that require attention and mastery in order for successful aging to occur. They are:

  • 0-18 months: Trust vs. Mistrust
  • 18 months-3 years: Autonomy vs. Shame
  • 3-5 years of age: Initiative vs. Guilt
  • 6-12 years old: Industry vs. Inferiority
  • 12-18 years old: Identity vs. Role confusion
  • 18-35 years old: Intimacy/solidarity vs. Isolation
  • Middle age: 35-55: Generativity vs. Self absorption or Stagnation
  • Older age:55+: Ego Integrity vs. Despair


It is the last two categories (middle and older ages) that are surrounded with fear and ignorance. Healthcare providers working in pediatrics are well versed in the first five categories. Programs designed for toddlers are vastly different than those designed for school-age children. But something happens after adulthood is reached. The developmental tasks seem to fade from healthcare providers’ practices. At best, the general principles of Erikson are known by clinicians, but most geriatric programs evidently don’t take the principles seriously because the concepts are often ignored. For example, Erikson writes about the value of helping elderly people face the fear of death so that they can gain “ego integrity.” Contemplating death and “the meaning of life” can bring fuel for the soul, expanding consciousness as elderly people face numerous challenges in their lives. Yet, geriatric centers and healthcare facilities seldom have classes on aging and dying; instead, classes focus on fitness, clubs, games, and interests from the past. These are important activities, but the topic of aging and death is also important. Yet, it is seldom broached, much less discussed and contemplated. Personally, I think we miss a lot when this “let’s don’t talk about dying” approach is taken, and in some ways, it’s even more than that. To not have programs that integrate death contemplation and exit strategies could be considered a form of abandonment since research and developmental models (like Erikson’s) demonstrate the value.

I cite my mother’s experience living in an Adult Living Facility (ALF). The ALF staff took good care of Mom. She was bathed twice a week, had numerous activities to choose from, and ate good food in a beautiful dining room. She seldom complained about the many ills she had but rather focused on the gratitude she felt for her many blessings. Over the last six months of her life, I noted that she was sleeping more, losing interest in participating in activities, eating poorly, incontinent, and losing weight. She was treated for depression with no change; I surmised that she probably had a cancer, which later turned out to be the case. The ALF staff had a different idea. They called her doctor and got an order for physical therapy.

“I don’t want to go,” Mom told me.

“It’s your life Mom. If you don’t want to go, tell them ‘no’.” Mom worried about staff getting mad at her if she didn’t go and so she went.

One day, I entered Mom’s room unbeknownst to her or the Physical Therapist. I stood at the doorway witnessing their conversation.

“I’m too tired to go,” Mom complained to him.

“You’re not going to get stronger if you don’t get out of that bed,” the therapist said nicely.

“But I don’t care if I get stronger. I just want to sleep,” Mom argued.

“You can sleep after you do your exercises,” he countered.

I intervened to protect my mother’s interests. “It’s okay,” I told the therapist. “Mom is nearing the end of her life. She doesn’t need therapy. If she wants to sleep, let her sleep. We’re in a mode now of just respecting what she wants.” Then I turned to Mom, “Mom, you don’t have to do anything that you don’t want to do.”

“I keep telling them that, but they don’t listen,” she said.

Her therapy didn’t stop until I called Medicare myself and told them not to pay for it.

I don’t want to imply that the staff were insensitive or incompetent. Their intentions were good. They typify the current geriatric culture with its exclusive focus on rehab and activities. Every staff member is schooled in Erik Erikson’s developmental theory, yet these principles are usually ignored. It seems odd that helping people confront death and reckon with its unseemly ramifications is commonly excluded within geriatric communities. Rather than having programs that help people reckon with their approaching death, the focus is on distracting them from death, pretending that death isn’t happening. For example, I always enjoyed sitting on the front porch in the rocking chairs with the residents. It was also a good source of information.

“You remember Florence?” Mom asked me. Yes, I had spoken with her many times in the hallways and dining room. “She went to the hospital and never came back. I asked what happened to her and the nurse said they’re not allowed to talk to us about other patients. We didn’t find out that she died until we saw her obituary in the paper.”

I could only sigh with my mother at the disrespect that she felt — not only for Florence, but for her own needs to know, honor, and grieve.

Another resident sitting nearby chimed in: “When you die, there’s no public acknowledgment,” he said mater-of-factly. “We’ve been living together and helping each other for years, and one of us dies, and everything goes on as if nothing happened.”

Even the deterioration of aging is squelched. One resident told me how anytime they try to talk about how bad they feel or how hard it is to get through the day, that the staff try to cheer them up and talk them out of their difficulties. “They don’t want to hear us complain.”

I’m thankful that Mom and I had many talks about her death on that porch. She told me about a few things she wanted to do before she died, and we were able to accomplish those. We planned her funeral and I reassured her that her body would be flown back to Indiana and buried with my father. However, even these meaningful conversations were discouraged. Overhearing us, a nurse said, “Don’t be talking like that. You’re going to live another 10 years.”

“Oh, I hope not!” Mom laughed. “Ninety years is long enough!”


Opus Peace focuses on aging and transitions – not by fearing or denying it. We also don’t take the other extreme: ie. Looking at aging and dying by only focusing on the positive virtues of aging. Rather, Opus Peace seeks to cultivate honesty, humility, and courage to navigate the later years because these years can be difficult! Let’s look at middle age first.

Middle Age invites us to summon the courage to stop clinging to who we were and open up to who we are. Then, we no longer cling to fame or fortune or the appearance of youth. We are transformed by relinquishing the old ego attachments and affirming our deepening descent into the mystery. We move from sole to soul and gain our freedom. This is not an easy process. It is normal to feel distress as we age with the undoing of all we have labored to secure. That’s why aging is not for SISSIES!

There is a saying in Hospice: “Those who grieve well, heal well.” This is a paradoxical truth that initially seems counterintuitive. But, grief is the normal, natural emotion that accompanies loss and change. Grief allows us to let go so we can move forward rather than “stagnate” as Erikson called it. So grief is not a destructive process as many think. In fact, it’s just the opposite: it’s a creative process that allows us to be re-formed and opened to something new that will better fit the changing circumstances. So, healthy aging during the middle years usually involves getting honest with the losses we are experiencing and allowing ourselves to humbly grieve the changes so we can open up to who we are becoming rather than clinging to who we used to be.

Older age (55+ according to Erikson) means that the horizon is no longer obscure. Bodily reminders start creeping in to remind us of our destiny. Ultimately, INTEGRITY means getting honest about the reality of approaching death. No matter how much we medically advance technologically, death is still a mystery and good travelers are able to open up to the uncertainty of it with a growing wisdom that the world is broad and doesn’t revolve around us. We start accepting death as the completion of life. Despair, on the other hand, is more narrowly focused around fear of the past (“Was the trip here on Earth worth it?” or “I wish I would have done ______ {regret}) or the future (“What is going to happen to my loved ones after I go” or “I don’t want to let go of what I know to go into the uncertainty of the “great beyond.”) Narrow focus can also be disguised as rather arrogantly denying existing fears or covering them over by pretending that there’s no uncertainty in death. Running or hiding from our fear of death can lead to despair. I have seen it many times in the 10,000 people that I’ve been with as they’ve faced death. At the same time, I will tell you that most of these people were able to reckon with their fears by allowing death to humble them. As one patient told me: “Now, while I’m dying, is no time to be lying to myself.” I applauded his wisdom. And in the space of just a few short days, he mounted the courage to open up to the peace that awaited him beyond his fears.

Carl Jung said that the pain we feel is with those who “content themselves with inadequate or wrong answers to the questions of life.” Aging wisely means asking ourselves tough questions that require non-superficial answers. If we’re honest with ourselves, we discover that much of our thinking and frustration centers on clinging to who we used to be. The questions we ask ourselves are:

  • Which facelift surgeon should I use?
  • How many pounds can I bench press?
  • How can I maintain power and authority?
  • What love-object do I need to find?
  • How can I stay fixated on what I used to be?


Jung would want us to ask questions that can only be answered beyond our ego-self:

  • What HONESTLY empowers me (job, status, muscles, boobs, trophy wife, etc.)?
  • What happens when erotic success or social status no longer count?
  • Why am I ashamed of the age I am, realizing that it is part of who I am?
  • Why have I let commercials brainwash and control how I feel about myself?
  • Am I willing to regain my NOW life (which includes the age I am NOW)?


The truth is we have allowed modern advertising to dictate who we are rather than allowing our own imprinted destiny to unfold with grace and dignity. Viktor Frankl puts it this way: “Today’s society is characterized by achievement orientation, and consequently it adores people who are successful and happy and, in particular, it adores the young.”

We allow money and temporary materialism to take us away from the eternal. This leads to ignoring our soul. We cover it up so we can “Buy our product so you don’t have to be you.” This is an archetypal form of prostitution: we sell our current-aged self and buy a younger version of ourselves, losing ourselves in the process. When we stop being unfaithful to ourselves, then we can allow the natural urge to age unfold. This produces luminosity and liberation.

If aging is so fearful that we have to deny it, then it has a lot of power over us. Paradoxically, we then miss the very gift that aging brings; we are robbed of our own Self. In our western culture, the premise is that materialism, narcissism, hedonism will make us happy, yet, it leads to emotional/spiritual bankruptcy. In a society that is afraid of loss, aging and death will appear as the enemy to be conquered. Aging is viewed as a poison that we’re forced to drink. The question then becomes: Is it possible that if aging is a poison, that it might be a healing poison?

In my Aging workshops, I often have participants meet their Interior Elder. I even have their Elder write them a letter. Here’s the letter my Elder wrote me:

Dear Deborah,

I first met you 61 years ago. I was so far away that you could barely see me, yet I was in every beat of that tiny little heart that so bravely decided to come into this world to meet me.

You are no longer so far away. As I have called your name with the lub-dub of each heart beat, you have drawn closer. You sit at my knees now. I long to gaze fully into your eyes, but sometimes you turn your gaze away from my loving arms that await your return to my bosom – a buxom bosom that yearns to hold you and suckle you with breasts filled with the milk of life.

Each day, you are looking more and more like me. You don’t like that do you? You are ashamed of me. You didn’t think I knew that did you? Well, I do, and it hurts each time you hide me or curse me when you look in the mirror or groan with the ache in your bones. Deborah, I am the destiny you were born to fulfill. Do not be afraid of me. Do not be ashamed of me. Every time you say you are “lucky” that you don’t have gray hair, you are turning me away. Whether you know it or not, you need me, and when I come to the hairs of your very head, I hope you won’t cover me up or color me away, but that you will REJOICE and wear me proudly. If you will do that, I can hold you even more tenderly than I already am. I notice that you are wearing makeup now. You didn’t used to do that you know. Why are you doing it now? What is it going to take to make you realize that appearances aren’t important? Yes, you do have wrinkles. This should be no surprise to you. Yet, you act surprised to see them each and every day. When you pull the loose skin up from the sides of your face to erase the grooves I’ve so lovingly placed there, you make me feel very sad. Not for me, but for you. You see, Deborah, you lose your power when you do that. Yes. You are running away from the very thing that gives you strength and wisdom.

Deborah, it was I who carried you through treacherous days. It was I who suckled you at my breast during the night and gave you dreams to guide your way back home. Deborah, it was I who stood strong by your heart to assure that it would not become crusted over with bitterness.

You are about to launch Opus Peace to help bring peace to the Soul of this broken world. Deborah, I have a secret to tell you about that. You are not going to be its CEO… I AM! So, call on me when you are scared, weary, or feint of heart.

Welcome home! It’s about time that you finally acknowledged me as your roommate.

With love,

Your Soul’s Crone