‘The one thing guaranteed in life and yet they won't teach you about it': The case for mandatory grief education in UK schools

Nearly all British children are bereaved of someone close to them by the time they turn 16 and, with the Covid-19 pandemic and world humanitarian crises across the news and social media, they are being exposed to more anxiety about death than ever before. Learners need to be taught about grief and death to prepare them to manage bereavement and support others. As it stands, although teaching resources exist and some curriculum guidance documents mention loss or death, there is no statutory requirement for schools anywhere in the UK to cover grief or bereavement and many pupils have no classes about these difficult topics. This article consolidates the case for grief education in schools. We discuss six key questions to examine evidence that children benefit from talking about grief, death and loss;the current provision for grief education in UK schools;the obstacles to teaching these topics and ways to overcome them;and the potential further implications of a policy change. Following the lead of child bereavement charities, research and new national reports on UK bereavement support, we demonstrate the need for mandatory grief education in all four countries of the UK and offer evidence-based recommendations for its implementation. © 2023, Cruse Bereavement Care. All rights reserved.

Grieving during Covid-19: Exploring the Lived Experiences of People Bereaved during the First Two Waves of the Pandemic

Introduction The COVID-19 pandemic has had a huge impact on all aspects of life. The high number of deaths and bereavements increased demand on already stretched services, whilst the unique circumstances caused by enforced social distancing meant that people bereaved at this time faced many additional challenges and potentially problematic grief trajectories. Aims To explore in depth people's lived experiences of bereavement during the Covid-19 pandemic, their adaptation and coping during this time, and the effect of informal and formal sources of bereavement support . Methods Semi-structured longitudinal telephone interviews were conducted with people bereaved during the first 10 months of the pandemic (March to December 2020), purposively sampled from a cohort of survey participants. Interview transcripts were analysed thematically. Results 24 participants (19 female;5 men) took part in a first interview and 15 in a follow up interview, approximately four months later. Five major themes were identified: End of life experiences;Funerals and memorialisation;Grieving and psychological impacts;Coping and adaptation and Sources of support. Many challenges relating to the pandemic context were identified, including restrictions to end of life and memorialisation arrangements, dealing with personal affairs, and lack of support. Such experiences negatively impacted individual grieving and wellbeing, in particular feelings of isolation and guilt surrounding lack of contact with the deceased. Participants experienced difficulties accessing services, and sometimes received support that was not appropriate for their particular situations and needs. Despite these difficulties, some people demonstrated remarkable resilience, and ability to cope and find meaning. Conclusions People bereaved in the COVID-19 pandemic have navigated grief and bereavement through exceptionally challenging circumstances, often lacking the informal and formal support needed to help them cope. Impact These insights can be used to help improve the care and support provided to bereaved people throughout their bereavement journeys.

Bereavement during the Covid-19 pandemic n the UK: What do we know so far?

The Covid-19 pandemic has been a devastating mass bereavement event, with measures to control the virus leading to unprecedented changes to end-of-life and mourning practices. In this review we consider the research evidence on the experiences of people bereaved during the pandemic. We summarise key findings reported in the first five publications from our UK-based Bereavement during COVID-19 study, drawing comparisons with available evidence from other studies of bereavement during the pandemic. We summarise these findings across three main topics: experiences at the end of life and in early bereavement;coping and informal support during the pandemic;and access to bereavement and mental health services. The synthesis demonstrates the exceptional challenges of pandemic bereavement, including high levels of disruption to end-of-life care, dying and mourning practices as well as to people's social networks and usual coping mechanisms. We identified considerable needs for emotional, therapeutic and informal support among bereaved people, compounded by significant difficulties in receiving and accessing such support. We provide evidence-based recommendations for improving people's experiences of bereavement and access to support at all levels.

LEVELS OF GRIEF, SUPPORT NEEDS AND RISK FACTORS AMONG PEOPLE BEREAVED DURING THE COVID-19 PANDEMIC: BASELINE RESULTS FROM A LONGITUDINAL UK ONLINE SURVEY

Background The COVID-19 pandemic has had a detrimental impact on millions of people's experiences of bereavement. Traumatic end-of-life experiences and disruptions to support networks increase chances of poor bereavement outcomes. Aim To examine grief and support needs, and identify associated risk factors. Methods Mixed-methods survey of people bereaved in the UK from March 2020-January 2021, disseminated via media, social media, national associations, community/charitable organisations. Practical and emotional support needs were assessed in 13 domains, and grief intensity using the Adult Attitude to Grief (AAG) scale, which calculates an overall index of vulnerability (IOV) (range 0-36). Results 711 participants, mean age 49.5 (SD 12.9);88.6% female;95.3% white. Mean age of deceased 72.2 (SD 16.1);58% died in hospital;44% from COVID-19. Mean IOV was 20.41 (95% CI = 20.06 to 20.77), i.e. high vulnerability in grief overall. 28.2% exhibited extreme levels of vulnerability (i.e., IOV ≥ 24). In six support domains, all relating to psycho- emotional support, 50% to 60% of respondents reported high/fairly high levels of need. Increased levels of perceived support from health professionals led to significantly (P < 0.001) lower levels of grief and support need (small/medium effect, P < 0.001). Bereaved participants who were socially isolated/lonely experienced higher levels of grief and support needs than those who were not (P < 0.001). Grief and support needs were much higher for close family members compared with other groups (P < 0.05). Levels of grief and support needs were slightly higher for COVID deaths compared with non-COVID (P < 0.01), although this was not significant in a mixed model. Conclusions People bereaved during the pandemic experience high levels of grief and emotional support needs, with social isolation/loneliness and death of a close family member particular risk factors. Healthcare professionals' support is associated with better bereavement experiences.

“Empty and Lost”: The Challenges of Being Bereaved During the COVID-19 Pandemic

Background/aims: The COVID-19 pandemic has resulted in millions of deaths worldwide, whilst also causing severe disruption to end-of-life, grieving and coping processes. We examine bereavement experiences during the pandemic and relate our findings to the constructs of lossoriented and restoration- oriented coping, described in Stroebe and Schut's Dual Process Model (DPM). Methods: Two independent UK-wide surveys were disseminated online, including via social media and community/charitable organizations. They captured adult experiences of bereavement (to all causes of death) from March 2020 to January 2021. Free-text data were analyzed thematically. Results: Free-text comments were provided by 881 participants. Six main themes were identified: troubled and traumatic deaths;disrupted mourning, memorialization and death administration;mass bereavement, media/societal responses and the ongoing threat of the virus;grieving and coping (alone and with others);workplace and employment difficulties;and accessing support via health and social care. Examples of loss-oriented stressors included being unable to visit or say goodbye, the sudden and traumatic nature of many deaths, and restricted funeral and memorialization practices. Reactions included feelings of guilt and anger, and problems accepting the death and starting to grieve. Examples of restoration-oriented stressors and reactions comprised stressful deathrelated administration and severely curtailed social networks, support systems and social/recreational activities, which impacted peoples' ability to cope. Conclusions: These results demonstrate the exceptionally difficult sets of experiences associated with pandemic bereavement, defined by significant disruption to end of life, death and mourning practices, as well as usual coping mechanisms and formal or informal bereavement support. The DPM provides a useful framework for conceptualizing the additional challenges associated with pandemic bereavement and their impact on grieving and mental health.

Good Grief Festival: Evaluation of a UK Public Engagement Initiative on Grief and Bereavement

Background/aims: Good Grief Festival was initially planned as an inclusive face-to-face festival on the topic of grief. Due to COVID-19, the festival was held online over 3 days in October 2020. We aimed to evaluate the festival's reach and impact. Methods: A pre/post evaluation was conducted via online surveys. Prefestival surveys assessed reasons for attending and attitudes to bereavement across 4 items (being scared of saying the wrong thing, avoiding talking to someone bereaved, knowing what to do if someone bereaved was having trouble, knowing what kind of help/support to offer). Postfestival surveys evaluated audience experiences and the 4 attitude items. Results: 8500+ people attended, with most attending 2-5 events. Prefestival survey participants (n=3785) were mostly women (91%) and White (91%). 9% were from Black or minority ethnic communities. 14% were age ≥65 years, 16% age ≤34 years. 44% were members of the public. A third had been bereaved in the last year;6% had never been bereaved. People attended to learn about grief/bereavement (77%), be inspired (52%) and feel part of a community (49%). Post-festival participants (n=685) reported feeling part of a community (68%), learning about grief/bereavement (68%) and being inspired (66%). 89% rated the festival as excellent/very good. 75% agreed that through attending they felt more confident talking about grief. Higher ratings and confidence were associated with attending a greater number of events. Post-festival attitudes were significantly higher across all 4 items (P<0.001). Free-text data showed appreciation e.g., for the online format, connection in the context of lockdown and speakers' ethnic diversity. Suggestions included improving registration, more interactive/arts-based events and reducing the volume of content. Conclusions: Good Grief Festival was successful at reaching a large public audience, with data indicating benefit in terms of engagement, confidence and community-building. The evaluation was critical in shaping future events.

Inequalities in Access to Bereavement Support Before and During COVID-19: Findings from Voluntary and Community Sector Bereavement Services in the UK

Background/aims: The COVID-19 pandemic has resulted in global mass bereavement;in the UK alone there have been 140,000 deaths to date, with a disproportionate impact on Black, Asian or minoritized ethnic (BME) communities. Voluntary and community sector (VCS) bereavement services including hospices play an important role in bereavement support. We aimed to determine services' perspectives on access to their support. Methods: Cross-sectional online survey of VCS bereavement services in the UK, open March-May 2021, disseminated via national organisations, associations and networks and social media. Results: 147 organisations participated;53% served specific counties or smaller regions;16% were UK-wide. 36% were hospice or palliative care services, 15% national bereavement charities or NGOs;12% local bereavement charities. 67.3% reported there were groups with unmet needs not accessing their services before the pandemic;most frequently reported were people from BME communities (49%), sexual minority groups (26.5%), deprived communities (24.5%) and men (23.8%). 50% of services reported that, in the year before COVID-19, <5% of clients were from BME communities;25% did not collect this data and 25% reported >5% BME clients. Compared with before the pandemic, 3.4% of services were seeing more people from BME groups, 52% were seeing the same proportion, 6.1% were seeing fewer and 38% didn't know/didn't collect this data. Conclusions: For over two thirds of VCS bereavement services in the UK, there are known inequities in who accesses support, with people from BME groups most likely to be recognised as needing support but not Paediatric Palliative Care Commissioners (n=2) Gender Female:Male 2:0 accessing services. During the pandemic, the proportion of BME clients did not increase, despite these communities being disproportionately affected by COVID-19. More attention needs to be paid to assessing and meeting unmet needs for formal bereavement support among disadvantaged groups and routinely collecting client data to help determine and ensure equity. (Table Presented).

The Impact of COVID-19 on the Provision of Voluntary and Community Sector Bereavement Services: A Cross-Sectional Survey from the UK

Background/aims: During the COVID-19 pandemic, voluntary and community sector (VCS) bereavement services including hospices have played a central role in supporting the bereaved. We aimed to describe the impact of the pandemic on these services to inform service development and policy. Methods: Cross-sectional online survey of VCS bereavement services in the UK, open March-May 2021, disseminated via national organisations, associations and networks, and social media. Results: 147 organisations participated;53% were regional, 16% UK-wide. 36% were hospice or palliative care services, 15% national bereavement charities or NGOs;12% local bereavement charities. During the pandemic referrals increased for 46% of organisations and decreased for 35%. 40.3% reported a current waiting list >3 weeks. 78.2% had changed services due to Covid;51.7% introduced new services. There had been a significant reduction in provision of all face-toface support including peer group meetings (50% to 4.1%, OR 0.04), facilitated group meetings (78% to 11%, OR 0.04), 1:1 support (87% to 27%, OR 0.06) and specialist intervention (44% to 16%, OR 0.25). Online and telephone provision saw major increases, particularly online 1:1 support (8.8% to 83%, OR 50.3), facilitated group meetings (4.1% to 56%, OR 30.48) and specialist intervention (3.4% to 36%, OR 16.01). Challenges included staff/volunteers providing support from home (69/64%), emotional impact on staff/volunteers (67/41%), increased pressure on staff due to client volume (41%) and complexity of needs (44%), implementing staff training (60%) and financial challenges (53%). 93% reported positive changes/opportunities during the pandemic, e.g., new coordination initiatives (47%). Conclusions: UK bereavement services rapidly transformed during the pandemic, despite significant challenges. To ensure positive changes and innovations are retained, the experiences and acceptability of new and adapted services among clients and staff require further investigation.

Grief, Support Needs and Associated Factors Among People Bereaved During the COVID-19 Pandemic: Baseline Results from a Longitudinal UK Online Survey

Background/aims: The COVID-19 pandemic has had a detrimental impact on millions of people's experiences of bereavement. Traumatic end-of-life experiences and disruptions to support networks increase chances of poor bereavement outcomes. We aimed to examine grief and support needs, and identify associated risk factors. Methods: Mixed-methods survey of people bereaved in the UK from Mar 2020-Jan 2021, disseminated via media, social media, national associations, community/charitable organisations. Practical and emotional support needs were assessed in 13 domains, and grief intensity using the Adult Attitude to Grief (AAG) scale, which calculates an overall index of vulnerability (IOV) (range 0-36). Results: 711 participants, mean age 49.5 (SD 12.9);88.6% female;95.3% white. Mean age of deceased 72.2 (SD 16.1);58% died in hospital;44% from COVID-19. Mean IOV was 20.41 (95% CI = 20.06 to 20.77), i.e., high vulnerability in grief overall. 28.2% exhibited extreme levels of vulnerability (i.e., IOV ≥ 24). In six support domains, all relating to psycho-emotional support, 50% to 60% of respondents reported high/fairly high levels of need. Increased levels of perceived support from health professionals led to significantly (P < 0.001) lower levels of grief and support need (small/medium effect, P < 0.001). Bereaved participants who were socially isolated/lonely experienced higher levels of grief and support needs than those who were not (P < 0.001). Grief and support needs were much higher for close family members compared with other groups (P < 0.05). Levels of grief and support needs were slightly higher for COVID-19 deaths compared with non- COVID-19 (P < 0.01), although this was not significant in a mixed model. Conclusions: People bereaved during the pandemic experience high levels of grief and emotional support needs, with social isolation/loneliness and death of a close family member particular risk factors. Healthcare professionals' support is associated with better bereavement experiences.

Experiences of Bereavement Across the UK, What Are the Challenges and What Might the Future Look Like - Findings From the UK Commission on Bereavement

Background/aims: The increased number of deaths due to the COVID-19 pandemic has left many people bereaved. Working in partnership with a number of UK charities and researchers, the UK Bereavement Commission was established to ensure that the voices of those affected by bereavement are heard and considered in future services and supports for bereaved people across the UK. Aims: To explore experiences of people bereaved in the last 5 years and identify recommendations for policy and practice with the aim of improving the experiences of people affected by bereavement. Methods: Two online surveys were launched in September 2021, one collected individuals' personal experiences of bereavement over the last 5 years while the other captured responses from organisations supporting people affected by bereavement. Both surveys captured qualitative and quantitative data. A lived experience advisory forum was established to ensure the voices of people affected by bereavement were included and considered in the both the formulation of survey questions and the identification of themes and recommendations from data collected. Qualitative data from were analysed using thematic analysis. Descriptive statistics summarised demographic characteristics of respondents, types of support received and satisfaction with support received. Results: Challenges experienced and recommendations for future support were identified by analysing individual and organisational perspectives. Conclusions: Understanding the experiences of bereaved people, from a range of different backgrounds and locations across the UK represents an essential first in ensuring that supports and services for those facing bereavement in the future are informed by people with direct experience of bereavement or of supporting those affected by bereavement. The Commissions plans for ensuring update of identified recommendations will also be discussed.

The Grief and Support Needs of Children and Young People Bereaved During the COVID-19 Pandemic: Parental Views From a UK National Survey

Background/aims: During the COVID-19 pandemic, many children and young people have experienced the death of close family members, whilst also facing unprecedented disruption to their lives. This study aimed to investigate the bereavement experiences and support needs from the perspective of their parents or guardians. Methods: We analysed cross-sectional free-text data from a survey of adults bereaved in the UK during the pandemic. Participants were recruited via media, social media, national associations and community/ charitable organisations. Thematic analysis was conducted on parent/ guardian responses to a question on the bereavement experiences and support needs of their children. Results: Free-text responses from 106 participants were included. Three main themes were identified: the pandemic-related challenges and struggles experienced by children and young people;family support and coping;and support from schools and services. Pandemic specific challenges include the impacts of being separated from the relative prior to their death, isolation from peers and other family members and disruption to daily routines and wider support networks. Examples were given of effective family coping and communication, but also difficulties relating to parental grief and children's existing mental health problems. The important role of schools and bereavement organisations in providing specialist support was demonstrated, but there was evidence of unmet need and lack of access to specialist grief or mental health support. Conclusions: Children and young people have faced additional strains and challenges associated with pandemic bereavement. We recommend initiatives that facilitate open and supportive communication within family and school settings, adequate resourcing of school and community- based specialist services and increased information and signposting to the support that is available.

Death and bereavement due to COVID-19: A discourse analysis of online newspapers with implications for end of life care

Background: The COVID-19 pandemic has been followed intensely by global media. News media create a sense-making narrative, shaping, reflecting and enforcing cultural ideas and experiences. We aimed to explore British newspaper reportage of COVID-related death and bereavement and consider clinical implications. Methods: Discourse analysis of the 7 most-read online UK newspaper articles published during two week-long periods in March-April 2020. 55 articles discussed bereavement after a human death from COVID- 19. Analysis was informed by Terror Management Theory, which describes a psychological conflict arising between the realisation that death is inevitable and largely unpredictable and the human need for self-preservation. Results: We identified 3 main narratives: (1) fear of an uncontrollable, unknown new virus and its consequences;(2) managing uncertainty and fear via prediction of the future and calls for behaviour change;and (3) mourning and loss narratives. Within these narratives, the act of 'saying goodbye' (before, during and after death) was central, represented as inherently important and profoundly disrupted. Bedside access was portrayed as restricted, variable and uncertain, with families begging or bargaining for contact. Video-link goodbyes were described with ambivalence, and patients as 'dying alone' regardless of clinician presence. Funerals were portrayed as travesties and grieving alone as unnatural. Articles focused on what was forbidden and offered little practical guidance about what to do if a loved one became seriously ill or died. Conclusion: Reporting reflected the tension between focusing on existential threat and the need to retreat from or attempt to control that threat. Measures to mitigate the impact of COVID-19 on 'saying goodbye' were presented as insufficient attempts to ameliorate tragic situations. More nuanced and supportive reporting is recommended. Clinicians play an important role in offering alternative narratives.

End of life experiences during the COVID-19 pandemic: Results of a national survey of bereaved people

Background: From March 2020-March 2021 530,000+ people have died from COVID-19 in the EU, and 120,000+ in the UK. In addition, c.4.85 million in the region have died of other causes, leaving c.43.6 million people bereaved at a time of unprecedented social and clinical restrictions. We aimed to inform practice and policy by describing end of life experiences among people bereaved during the pandemic. Methods: National survey of people bereaved in the UK since March 2020, disseminated via media, social media, national associations, community/ charitable organisations. Results: Interim findings from the first 532 participants are reported (full results available by time of conference). 55% of deaths were in hospital;46% were caused by confirmed/suspected COVID-19. Respondents reported high levels of problems specific to the pandemic bereavement context: 56% were unable to visit their loved one prior to death, 59% had limited contact in last days of life, 67% were unable to say goodbye, 67% experienced social isolation and loneliness, 81% had limited contact with other relatives/friends. COVID-19 deaths were associated with higher levels of all these problems compared with other causes of death (all p < 0.05). Experiences of end of life care were variable: 23% were 'never' involved in decisions about their loved one's care, 17% were not at all informed about the approaching death, 36% felt not at all supported by healthcare professionals after the death, 51% were not provided with information about bereavement support. Conclusions: There is evidence of poor end of life care and challenging experiences among people bereaved during the pandemic. To reduce the trauma of negative death experiences, we recommend improved communication by healthcare professionals, with a known point and method of contact, family involvement in decision-making, enabling family visiting as far as possible, and better support after a death, including information about bereavement services.

Supporting the bereaved following mass bereavement events: A systematic review of disaster response interventions with lessons for covid-19

Background: The COVID-19 pandemic represents a global mass bereavement event, on a scale seldom witnessed. National health and social care systems are challenged with supporting large numbers of bereaved people whilst also negotiating the ongoing restrictions to provide this support safely. This review aimed to synthesise the evidence regarding system-level responses to mass bereavement events, including natural and human-made disasters, to inform service provision and policy during the pandemic. Methods: A rapid systematic review was conducted in April 2020, with narrative synthesis of results. MEDLINE, Global Health, PsycINFO and Scopus databases were searched for studies published between 2000 and 2020, reporting evidence on system-level responses to mass bereavement events in OECD countries (plus Singapore, China and Taiwan). Citation and reference tracking was conducted and study quality assessed. Results: Six studies were included, reporting on system responses to man-made disasters (e.g. terror attacks in the US and Norway), as well as natural disasters (e.g. Hurricane Katrina and the South-East Asian Tsunami). Despite differences across disaster types, common approaches were identified and positive impacts were reported across a range of individual and group-based support interventions. Key features of service delivery included: a proactive outreach approach, centrally organised but locally delivered interventions, event-specific professional competencies and an emphasis on psycho-educational content. However, study quality was generally low and reliant on data from retrospective evaluation designs. Conclusion: Co-ordinated responses to bereavement support which include the features we identified are required to meet the needs of bereaved people during and beyond the pandemic. Rigorous primary studies investigating the experiences of the bereaved and the services that support them are essential to inform current and future disaster response efforts.

The support needs and experiences of people bereaved in the uk during the COVID-19 pandemic: Baseline results from a mixed-methods longitudinal survey

Background: COVID-19 presents a mass bereavement event, causing over 120,000 deaths in the UK. Unprecedented infection control restrictions also mean that all people bereaved at this time experience high level disruption to end of life, mourning, grief and coping experiences. This study aims to investigate the grief experiences, support needs and use of bereavement support by people bereaved during the pandemic. Methods: A mixed method online survey of adults bereaved in UK since March 2020, disseminated via media, social media, national associations and community and charitable organisations. Grief was measured using the Adult Attitude to Grief Scale. Results: Interim findings from the first 532 participants are reported (full baseline results available by time of conference).46% of deaths were confirmed/suspected COVID-19 and 55% of deaths were in hospital. Over half of participants demonstrated 'severe' (28%) or 'high' (24%) levels of vulnerability in grief, as well as high/fairly high needs for support in six psycho-emotional domains (51- 62%). 21% of those with 'severe' vulnerability were accessing individual counselling support, compared with 23% overall. 59% of respondents had not tried to access support from bereavement services;of those who tried, 56% experienced difficulties. Barriers included long waiting lists, feeling uncomfortable asking for help, and lack of appropriate support/knowledge of how to access help. 41% also experienced difficulties getting support from family and friends, reporting issues such as a lack of understanding and struggling without in-person contact. Conclusions: Results suggest unmet needs for support and problems getting support from friends/family and bereavement services. We recommend increased public information about bereavement support options, increased provision of and investment in bereavement services and flexible 'support bubble' arrangements for those bereaved during 'lockdown' conditions.

How do funeral practices impact bereaved relatives' mental health, grief and Bereavement? A mixed methods review with implications for COVID-19

Background: Funerals are a fundamental component of cultural and religious mourning systems that facilitate the offering of support to the bereaved. Those who are bereaved during the COVID-19 pandemic are subject to restrictions on funeral sizes and practices. It is possible that being unable to participate in funerals, rituals, and ceremonies will have a detrimental effect on the bereaved, affecting their mental health and ability to cope with or process their grief. Aim: To synthesize evidence on the impact of funeral practices on bereaved friends and relatives' mental health and experience of bereavement, and consider implications for the COVID-19 pandemic. Methods: We conducted a rapid systematic review according to PRISMA guidelines, synthesising the quantitative and qualitative evidence regarding the effect of funeral practices on bereaved relatives' mental health and bereavement outcomes. Searches of MEDLINE, PsycINFO, KSR Evidence, and COVID-related resources were conducted on 24/4/2020. Results: 805 records were screened;17 studies of variable quality were included. Current evidence regarding the effect of funeral practices on bereaved relatives' mental health and bereavement outcomes is inconclusive. Five observational studies found benefits from funeral participation while six did not. However, qualitative research provides additional insight: the benefit of after-death rituals including funerals depends on the ability of the bereaved to shape those rituals and say goodbye in a way which is meaningful for them, and on whether the funeral demonstrates social support for the bereaved. Discussion: Our findings suggest that restrictions to funeral practices do not necessarily entail poor outcomes or experiences for bereaved people. As well as access to bereavement support and sign-posting to specialist services, palliative care and bereavement teams should provide locally-relevant information regarding the creation of meaningful, culturally appropriate funerals.