Grief is experienced at an individual level and at a whānau level. It is important that older people have an opportunity to express their feelings at end of life as this helps to prepare them to transition across the ārai (veil).

Whaea Marilyn explained that rongoā (remedy, treatment, solution) is vast and this is important because different people have different needs, for example emotional pain, and these require different healing approaches and solutions:

[Rongoā] it’s not just one thing. It’s not just one thing because everybody’s needs are different. So, whatever you have to offer to soothe that need is rongoā. Doesn’t matter what it is, you know? If the need is physical, then you might have to have a panipani (ointment). Or you might have to have he inu rongoā rākau (herbal medicine). But if the need is, heart, then just kōrero, just crying. Allowing the tears. Sitting with someone and allowing them to cry is a huge rongoā. Some of the old customs are coming back now and some people are frowning at them. A classic example is ‘The puna roimata’ at a tangi. This is such an important part of our healing because once the tears begin, the healing begins.

Kaumātua who are unwell will often try to protect their whānau from seeing them in pain. A trusted health professional can provide valuable support to a kaumātua at end of life by listening to their problems and helping them to process their own emotions.

Matilda (community health care assistant) explained that when she visits whānau who are at the end stage of their life, many of them have sadness and need to talk. Matilda highlighted the importance of listening to whānau and allowing them to speak:

…. yeah listening to them. I can’t offer them [a] magical response and how to fix things but maybe look at how we can. I haven’t had that opportunity to explore how we can do things but always, listening to what they’re having to say. And sometimes they want to say something to you, and it stays with you. Ah, that’s alright.

Listening to whānau helps them to release their sadness said Matilda:

I guess rarurarus [conflicts] with the children and their worries for their children [blocks peace] … They share their sadness… of their families, of their children, and their adult children and yeah… Well I think, I think they’re letting go... For the adult children yeah, to make their crossing over peaceful be straight up... Be pono [truthful] And yeah, that sort of thing…

"Cultural issues can cause a disruption in peoples’ grieving and can complicate the healing process. "

When the person that has died is widely known and loved, their loss can be grieved by family, community and also at a national and international level. People can express grief in many different ways in the same whānau. Grief can be demonstrated through emotional, physical and spiritual expressions including crying, wailing, shouting, anger, sobbing and silence, for example. Many whānau will find comfort in each other’s arms and being together but for others the event can bring up past losses, unhealed wounds, new emotional hurts, regrets, guilt, insecurity and fear. The death can cause distress and the use of alcohol and other substances may seem like a quick method to dull pain can make things worse. Rifts may appear in Māori whānau just as they do in non-Māori families.

Having the right cultural, spiritual and bereavement teams available will enable whānau to express their grief in a safe way. This is crucial to ensure whānau travel through this part of the life cycle with as much mana as possible. Some Māori whānau may experience cross-cultural issues when someone is dying or has died. For example, a Māori kuia (older female kaumātua) married to a Pākehā man, may have lived an urbanised westernised lifestyle since her youth. Now that she is nearing the end of her life, she may wish to continue living out the last of her days privately and independently in her home, with her husband, as they have lived for over fifty years. However, as her death approaches and her whānau (sisters, brothers, nieces and nephews) arrive to care for her, there may a cultural clash.

The visiting family’s collective cultural care values may conflict with her husband’s wish to have his wife at home with him, supported by their adult children and grandchildren, and a community nurse visiting three times a week. Tensions can arise following the kuia’s death when the cultural imperative of the whānau is to take the older woman’s tūpāpaku (body) home to be buried next to her parents and yet, the Pākehā husband (and his deceased wife’s) wishes were to have a small funeral service locally and her body cremated. Cultural issues can cause a disruption in peoples’ grieving and can complicate the healing process. 

The cultural protocols and processes used by whānau manaaki are correct for them. However, the Western health system is bio-medically driven and often fails to provide end of life care that addresses the holistic and integrated needs of whānau. While pastoral care and social services are available, these services are not equally resourced and can be viewed as adjuncts to the core business, which is medical (body/physically focused care). Sometimes a bridge has to be built to help whānau manaaki navigate this new and unfamiliar landscape. The health professional is that bridge. They can support healthy grieving processes at the end of life.

Mary Te Awhi (hospice kaitakawaenga) explained it is often a listening ear the bereaved whānau really need after someone has died:

I usually, if they are [Māori] whānau that I’ve built quite a [good] relationship with, I will usually see them, either at that [bereavement] time. I’ll go out pay my respects, if they’re still local, go out and pay my respects to the whānau. Might in some cases go to the actual service on the day. And sometimes, in some cases, if I can do neither, I will do a follow up later, a bereavement follow up. And I have been asked at times, to follow up on complex grief… I don’t just turn up on the doorstep. I call first, because I don’t want to give them a shock that I’m turning back up ‘oh, not hospice again’. You know that I’m turning up on the door and usually they’ll say to me ‘yes’. So, I know from the ‘yes’ that they need to talk. And so, I will go out and usually we’ll just sit and relax, and I will just let them talk it through.

Mary Te Awhi said sometimes it’s just about listening to whānau’s stories, burdens and mamae which helps whānau in their grief:

[I say to bereaved whānau]: ‘Don’t apologise for using an expletive. I’m not here to judge you because it may help you to feel a little bit better.’ And sometimes at the end of it I go, ‘How do you feel?’ They said, ‘Oh, I was just so pleased that I could talk to somebody and get it off my shoulders.’ Unburdening. They can’t do it to the whānau because the whānau are grieving. But the whānau were stressed, or there might have been some mamae in the whānau before the death. Often that happens as well… And then I give them an option of me coming back again, in maybe another two- or three-weeks’ time. Would they like another one? And so, if they go, ‘Yes that would be nice.’ I said, ‘But I am going to call first, and if you feel that you’re okay, please don’t accept the visit because you want to make me feel good. This is totally about you and if you feel you’re on a journey to healing, that’s as good as gold,’ I said, ‘but I’m happy to pop in, have a quick cup of tea and go again.’

Adjusting to news of a life-limiting prognosis can cause deep suffering for some kaumātua. Matua Royal explained how it affected him while his wife Betsy was able to highlight that counselling support was helpful:

[Royal] I refused to accept I was ill, and I still went out to try and do things I used to do. It got to the stage where I was getting really frustrated because I couldn’t do it no more… And what made it worse, I felt as though I was getting deprived of what I could do when my own children, plus my wife and my nephew, would do things that I normally do. And I don’t like it. I still find it hard to accept.

Matua Royal found it difficult to come to terms with his diagnosis as he felt very tired all the time, which was frustrating for him, particularly as he was used to being a very active person. He relays this in a conversation with his wife Betsy during their interview:

Betsy: And we’ve also had a counsellor that we’ve kind of needed because-

Royal: I don’t like telling those sort of people my business. I didn’t want to meet him, but he was alright.

Betsy: [Name of counsellor] from [name of service] down there, I just said, ‘We’re doing all the right things, but I think I’m going cuckoo because we can’t get him right.’ He says, ‘Nah, that’s just quite normal.’ Wasn’t just meds eh? It was just sometimes Royal would just say, ‘Look, I’m just so sick about-’ he’d get a bit depressed I believe.

Royal: I was getting depressed because it was such a lovely day, everyone’s outside and I have to have a sleep. That was getting me down. I just, I couldn’t go outside to do anything. I was frustrated… It wasn’t fair… It still isn’t.

Betsy: So, what he [counsellor] suggested [was put into action] … [Royal] got little chairs and cushions and he’d have a little rest as he went around [outside]. Which was something quite new. So, we were still outside, but just do-little bits as opposed to wanting to achieve [big things].

Recommendations

For health and palliative care professionals, we recommend:

  • Using pūrākau (storytelling) to engage people with their own situations; stories are an important vehicle that enable whānau to express themselves when there are difficulties.
  • Encouraging kaumātua and their whānau to discuss any potential issues (such as end of life care preferences and post-death wishes) while the older person is well; any potential cultural issues can be discussed openly with the broader whānau early on.
  • Developing your cultural competencies in supporting whānau to process and manage their grief if this is needed.

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