Death is no stranger to Dr. Tamar Ashkenazi, both personally and professionally. Growing up on the small Kibbutz Beit Hashita in the Gilboa region, she learned as a fourth grader that her cousin was killed in a Jerusalem battle during the Six Day War. She also witnessed from age 17 the funerals of kibbutz members who fell in the Yom Kippur War. Her fiancé Adi died of kidney failure in her arms (a kidney transplant failed) when she was just 22. She lost her grandparents, father and mother to disease.
As a nurse at Sheba Medical Center at Tel Hashomer, she directly encountered death on a regular basis. As an empathic facilitator for bereavement groups and as director of the Israel National Transplant Center, she met death more indirectly. As the Health Ministry official in charge of encouraging and coordinating organ donations for nearly two decades, she has accompanied hundreds of people facing their loved ones’ passing while refusing to lose hope.
Ashkenazi’s main question is: “Is it possible to cope with death?” The answer is a resounding “Yes!” For most people, death is a shocking and unwelcome intruder from whose presence it can take many years to recover, although some never do. To ease their suffering using her experience, Ashkenazi – now a young-looking 61 and mother of two in Ramat Gan – wrote a hefty book in Hebrew and had it translated into English on her practical ideas for coping in the short- and long-term with death.
Titled Mourning, The Day After Loss: Insights and Practical Advice on Coping with Grief
, the interesting and surprisingly easy-to-read volume (310 pages in the English version) should interest doctors, nurses, psychologists, social workers, religious leaders and others who deal with the bereaved – as well as a layman who personally confronts it.
“On the emotional level, death is automatically associated with fear – the fear of death.
Some people feel it more, some less. However, the fear of death is universal and inevitable,” she writes. “We fear our own death and those of the people we love because death is the most significant physical separation there is and the ultimate loss.”
She recounts a traumatizing and life-changing war memory.
“It was frightening; it was dangerous. The sound of sirens tore the sky. I grabbed two babies who were near me and rushed to a shelter nearby. The booms above went on non-stop and the babies’ crying did not cease. At the end of the war we realized that 11 of our kibbutz members had not and would not come back. Our kibbutz is a small community, a few hundred in all. Death touched every house, every family, every person – the social leader, the music teacher, the sports champion, the neighbor’s son and my friend’s brother,” Ashkenazi writes.
“I decided that challenging death was to be my destiny, my profession, my second nature.
Not long afterwards, in 1974, I enrolled in a School of Nursing academic course. My thesis in 1977 dealt with the struggle of cancer sufferers and the corresponding struggle of their families to cope with death.”
SEVEN YEARS ago, she completed her doctoral dissertation on adjusting to loss, from which this book for laymen emerged without academic statistics or arguments to be proved. Every Monday at 6 p.m. for about 18 years, a group of parents who lost their children, spouses, friends, siblings and other loved ones have met to talk about feelings, longings, pain, thoughts and practical matters, to strengthen and advise one another.
Since then she has “accompanied thousands of sick people and their families in their struggle to cope with grief and loss – people wounded in war, people injured in road accidents, people suffering from cancer or from diseases of the lungs or brain, people infected by deadly viruses.”
The original Hebrew version of the book deals specifically with Jewish practices, while the English translation is somewhat broader, mentioning those of Christianity, Islam, Buddhism and other religions. Most of the issues are universal: how to tell relatives – both adults and children, those nearby and abroad – about the death of a loved one.
Related issues include funeral and mourning practices; how to commemorate the deceased; what to do with clothing, jewelry and other possessions; how, if at all, a birthday should be celebrated; how to restart marital relations with the mourner; returning to work; what to tell strangers; what to say in the case of a suicide; the role of an unmarried and even a homosexual partner of the deceased; pupils’ problems with concentrating and returning to studies; coping with guilt and anger; physiological and psychological problems resulting from the loss; coping with religious holidays; the role of prayer; how often to visit the grave; giving birth and raising a new child after losing a child; giving meaning of life; changes in family structure and finances; loneliness; finding a new partner and more.
When Ashkenazi was a child or a teenager, death was wrapped in secrecy.
“No one talked about it with us in school,” she recalled. “We didn’t know what to say or how to deal with our feelings at all, especially toward our homeroom teacher who was now a widow” and a classmate who lost a parent in a road accident.
Ashkenazi’s own grandfather, her mother’s father, died suddenly at the age of 90 on Passover, but her mother didn’t say a word so as not to ruin the holiday for her.
“Today, as a mother, I would not do the same,” she states.
“Back then, the anguish was accompanied by the awareness that it was not acceptable to openly express our thoughts, emotions and fears. Later, I learned that was the way adults thought these things should be handled.
It was the norm. Those were different times, different ways of thinking, different insights.”
Children and even adults were not allowed to cry, say a word, console or hug the bereaved of fallen soldiers during the Yom Kippur War, as the bad news spread by word of mouth, and no confirmation had been received. Today, of course, the situation is different and much more open. Medical students, police officers, social workers and nurses undergo simulations and learn how to bear the bad news.
“I have been on both sides, that of the recipient and that of the bearer of bad news,” Ashkenazi recalls.
EVEN infants from six months to three years will feel something happened, even if they cannot express it. They will sense that something is different.
“Even a small child registers atmosphere and behavior and can differentiate between a high- and low-pitched voice, between normal speech, shouting and crying.” They can feel whether the hands that hold them are tense or relaxed.
“Make an effort to be calm when you hold a child in your arms. Hugs and kisses are important to provide a sense of warmth and security.”
If an illness is prolonged, the family will usually have time to internalize and accept the situation, but sometimes they remain in denial.
There is “anticipatory grief, allowing loved ones to prepare for impending loss. When the death comes suddenly and unexpectedly, the shock leaves people “with the feeling that their world has fallen apart in a flash.”
The author mentions unusual notifications of death, such as that of Princess Diana and the astronauts in the ill-fated Columbia space shuttle.
When children have to be told about the death of a close relative, Ashkenazi advises not delaying or hiding the facts, but they should be delivered according to the child’s age and understanding. One should be very careful so as not to give the child the impression that the loved one will come back. When someone drowns and swallowed water, this should not be described to a young child who might think that drinking water is dangerous.
Youngsters’ reactions should be monitored very carefully. News to adults should also generally not be delayed unless the person suffers from a physical condition that could endanger him or her.
She recalls the tragedy of a 37-year-old Health Ministry employee who was found dead in his car. The unnamed director-general personally asked to be briefed on the family and went to inform his parents gently and sensitively.
Even if the circumstances of death are embarrassing, such as suicide, drug overdose, AIDS or even being found with a prostitute, secrecy is not advised because in today’s world of communications, it will leak out, she advises.
In any case, the person who informs the relatives should give as many details as possible of what happened to the person in the days and hours before the death; this helps them “acknowl - edge the d e a t h and helps restore a sense of control and security.”
THROUGHOUT THE book, Ashkenazi – as head of Israel Transplant – repeatedly recommends organ donation in the event of lower-brain death, noting that it gives the surviving relatives the feeling that the person’s death had some meaning and benefit to others. She notes that the Health Ministry has a memorial page for every organ and tissue donor in Israel and offers help to families that want to build a personalized Web page in the deceased person’s memory. Ashkenazi even discusses whether the donor’s and recipient’s family can or should be in touch as time passes.
The author goes on to explain various funeral, burial and mourning customs in the Jewish and other religious traditions.
She especially praises the Jewish tradition of shiva – the seven days when, with clothing torn as a sign of mourning and sitting on low chairs, the mourners share stories about the deceased, sometimes for the first time. But not everybody mourns the same way, and for some people, visits from friends, strangers and even loved ones is overwhelming.
Ashkenazi even deals with important events for which she suggests shiva may be left, such as a senior brain surgeon who was called to do emergency surgery or even taking an important final exam.
The book discusses the suffering of siblings of any age, as well as parents, spouses, uncles, aunts and children, that result from the death of a loved one and how to cope with it. Signs that the mourners need professional help are also outlined along with details on support groups.
Reactions to loss run the gamut. Some families dispose of the possessions of the deceased, while others want them to be kept and used by descendants. Some prefer to visit the grave every day, while others force themselves to go only once a year. Some want to return to locations where the deceased spent time, while others keep away.
“Do what you feel is right,” Ashkenazi advises.
The book’s chapters end with what the survivors feel a few years or even decades after their loss.
“Nothing keeps me from laughing and being happy, finding interest in new things, loving new people, being enthusiastic, excited and joyful. Nothing is at the expense of departed loved ones. They have no replacement.
They have a special, eternal place in my life and heart,” she declares.
Hundreds of times in the book, Ashkenazi states the situations, views and behaviors of people who have lost their loved ones – their age and their loss, such as “A woman, eight years after the loss of her 15-year-old son…” This gives adequate information to understand the subject, but it might have been preferable to describe – in addition to her own personal experiences – case studies of people, their backgrounds, feelings and thoughts as expressed in her encounters with bereaved. Yet the book stands on its own.
“Months and years after loss, you can look at life differently. Alongside the pain and longing, there is also the good feeling of memories, of the life our loved one had, of experiences and travels over the years, friends and family. You can see what the deceased was blessed with and not just what was lost,” Ashkenazi concludes, offering comfort to her readers.