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Approaching Death

Approaching Death. Death and Dying. “Immortality” of youth Denial of mortality Anxiety. Death and Dying. Historical and Cultural Views. ability to accept death specific meanings (stop breathing, heartbeat, brain death) individual variation

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Approaching Death

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  1. Approaching Death Death and Dying

  2. “Immortality” of youth Denial of mortality Anxiety Death and Dying

  3. Historical and Cultural Views • ability to accept death • specific meanings (stop breathing, heartbeat, brain death) • individual variation • cultural variation (spiritual, natural, welcome event)

  4. Western history: natural event • 20th Century: withdrawn from daily life experiences • care of dying • Disposition of deceased: dramaturgical (Fulton & Metress, 1995: language of funeral directors) • “interment” vs. burial • “casket” vs. coffin • “remains,” “diseased,” “loved one” vs. corpse, dead body • “lying in repose” vs. dead • “denial” of death, “social”death: avoidance

  5. Cultural denial of death? • Behaviours? Avoidance? • Collectively? • Individually? • Reasons? • Effects of avoidance? • Feelings about death? Regrets? • A “good” death?

  6. Research on Death and Dying • Kubler-Ross (1970) • Openness, disclosure • thanatology: study of death • five emotional stages • Denial, anger, bargaining, depression, acceptance

  7. Inconsistencies in Stages • appearance, reappearance of denial, anger, depression during dying process • age of dying person • young: separation from loved ones • adolescents: focus on quality of present life • effect of condition on appearance social relationships

  8. young adult: rage and depression • end of life at beginning • middle adulthood: concern about obligations, responsibilities • late adulthood: contextual • death of spouse • illness, pain, dependency • acceptance relatively easy

  9. Health Care Policy for the Dying Process • “Medicalization” of death vs. “normative” part of life? • Perspectives, definitions of death? • Death anxiety? • Preparation for death?

  10. Hospice Carevs. “Medicalization” of Death • “good death”: swift, comfortable, dignity, loved ones present • more common prior to extreme medical intervention • alternative to hospital care

  11. London, 1950s: first hospice • Provide medical care, no artificial life support systems to terminally ill • Allow visitors, free movement • Cushion fear, loneliness of impending death

  12. Problems: • Rapid growth: need for well-trained personnel • Legal, ethical questions: premature death? • Potential burn-out of professionals, volunteers (personal involvement, intimacy)

  13. Living Will, Passive Euthanasia • specify how much medical care in terminal illness • inaction (e.g., no respirator) that allows person to die in natural course of illness • ethics: quality of life?

  14. The Right to Die: Assisted Suicide and Active Euthanasia • providing means to person to end life • intentionally terminating life of suffering person • Netherlands: legal euthanasia • North America: Jack Kevorkian • assisted suicide? Value of life? • legal restrictions?

  15. Netherlands • Patient experiencing unbearable pain • Patient conscious • Death request voluntary • Patient must have time to consider alternatives • No other reasonable solutions to problem • Death cannot inflict unnecessary suffering on others • Must be more than one person involved in euthanasia decision • Only doctor can euthanize the patient

  16. Death Anxiety • (Conte, Weiner, & Plutchik, 1982) • Death Anxiety Questionnaire • fear of unknown • fear of suffering • fear of loneliness • fear of personal extinction

  17. nursing home residents, seniors, university students • ages 30 to 80 years • no differences in mean scores (M=8.5) • no correlation with sex, education • separate study: adolescents had higher scores than older participants • emotional stresses • cognitive maturity (meaning of death)

  18. Cicirelli (1999) higher death anxiety in: • Younger • Lower SES • Female • White • External locus of control • Less religiousness

  19. Quality of End of Life • Singer et al. (1999): Canadian sample • Receiving adequate pain and symptom management • Avoiding inappropriate prolongation of dying • Achieving sense of control • Relieving burden • Strengthening relationships with loved ones

  20. Bereavement and Grief • Mourning: expression of grief • Prescribed rituals: funerals • Auger (2000): 4 functions • Provide supportive relationship for bereaved • Reinforce reality of death • Acknowledge open expression of feeling of loss and grief • Mark a fitting conclusion to life of person • Social support • network of familial • small memorial services • failure to express grief: depression

  21. Phases of Mourning (Parkes, 1972) • shock • longing • depression, despair (anger) • recovery (perspective)

  22. Current Perspective (Lund, 1996) • stress with resiliency • adjustment related to self-esteem, coping skills • diversity • between individuals: thoughts, feelings, behaviours • within individuals: simultaneous negative (anger, loneliness) and positive (personal strength) feelings

  23. no stages: • rapidly changing feelings • dealing with personal limits • fatigue, loneliness • learning new skills • new relationships • no specific time markers

  24. Achieving Recovery • cultural facilitation of mourning: • meaningful rituals • emotional support: friends listening • practical help • lengthy process • waves of sorrow: anniversary reactions • healthy response

  25. Bereavement overload • elderly at risk • several deaths in rapid succession • unable to complete mourning process for one death before another occurs

  26. Anticipatory Grief • expected death • dying person, mourners share affection • helps dull pain of loss • Sudden death (no anticipatory grieving) • Most difficulty in coping • loss of young person vs. at end of long, full life • emotions: guilt, denial, anger, sorrow

  27. Social/Cultural Supports for Grieving? • Similarities, differences, roles?

  28. Finding Comfort • social support: friends listening, sympathizing, not ignoring pain, complex emotions in recovery • recognize bereavement is lengthy process (months, years): sorrow, memory are integral parts of recovery • over time: bereaved should become involved in other activities, but not be expected to forget loved one • successful recovery: deeper appreciation of growth, development of all human relationships

  29. Adult Development from Adolescence to Old Age • Multidimensional, multidirectional change, throughout lifespan

  30. Final Exam • December 12: 2 hours • Chapters 8, 10, 11, 12 (50 Multiple Choice), lecture material (5/7 short answer)

  31. Successful Aging • Survival in late adulthood • Quality of life, satisfaction • Transcend physical limitations • Mental health, optimal adaptation • Positive outlook • Self-understanding • Components • Absence of disease, disability • No risk factors

  32. Maintaining high cognitive and physical function • Active and competent • Engagement with life • Productive activity, involvement with other people

  33. Not avoidance of aging: maintaining adaptability • Consistent with reality of aging: • Successful aging is the norm • “paradox of well-being” (Mroczek & Kolarz, 1998) • 32,000 US adults surveyed • Assumed objective difficulties • Generally fel good about selves and situation • 30-40% over 65 report selves as “very happy”

  34. Positive affect: highest for older reflects personality (extroverts) set point perspective - temperament sets boundaries for levels of well-being throughout life - extroverts: more successful dealings with others - positive interpretations of life events

  35. Successful Aging • Hardiness and thriving (Perls, 1995) • Genetic determiners of “hardiness” in oldest old • Adaptive capacity (ability to overcome disease or injury) • Functional reserve: how much of organ required for adequate performance (determines ability to deal with disease)

  36. Survivability • Beyond age 97, chances of dying at a given age lower than expected • Mortality rate (#deaths/# in age group) • exceeds 1.0 if entire group dies in less than one year • Indicates oldest members of our species tend to be healthier than traditional views of aging would predict • Additional support from medflies • Chance of dying at any age peaks at 50 days (@15%) • If survive to 100 days, chance of dying at any given day @5%

  37. More hardy • Slower rate of progress of symptoms of disease than in less hardy • Threshold for disease lowers more slowly

  38. Symptoms of age-related disease (e.g., Alzheimers) appear later (b vs. a) • Morbidity, mortality, disability compressed into shorter period

  39. Possible explanations for hardiness • Longevity genes: increased resistance against oxygen radicals • Slow rate of damage • Low complement of deleterious genes • E.g., Apolipoprotien E (apo-E) related to risk of Alzheimer's • Gene for protein apo-E less prevalent in oldest-old survivors • 18% of 90-103 year-olds • 25% of under-65 year-olds

  40. Adaptive capacity (ability to cope with and overcome disease or injury) higher in more-hardy • Functional reserve (how much of an organ is required for its adequate performance) higher

  41. Autopsy studies of “healthy” oldest-old brains • No outward signs of disease, but level of neurofibrillary tangles would indicate dementia in younger brain • Excess reserve of brain function compensates for processes damaging the brain

  42. Two Basic Principles of Normal Aging • Variability of aging rates • Longitudinal studies (e.g., Baltimore Study) • Aging rates vary remarkably (60 year olds like 40; some 40 year-olds like 60, physically) • Differences in appearance mirrored on physiological tests • Variability increases as age increases • Individual aging rates vary across years, and across physical systems

  43. Variability of Aging Patterns • Several aging paths: • Cross-sectional research • Some functions decline in a regular way over time • Other functions are stable, unchanged or decline only in terminal phase of life

  44. Physiological loss, but only when an age-related illness is experienced • E.g., heart disease correlated with a decline in heart pumping capacity with age • Without heart disease, pumping capacity as well at age 70 as at age 30

  45. Terminal Loss Pattern • Loss in a normally stable function may be sign of impending death • E.g., immune system: # of lymphocytes (white blood cells) stable normally stale • Decline occurred in minority of Baltimore Study sample • Reported good health; good physical exams • At next follow-up for study – subgroup more likely to have died

  46. Loss occurs, but body compensates for the change • E.g., brain: neural loss but robust individual cell growth (new dendrites, new connections) may help preserve thinking and memory • Physical Aging: not only loss • Stability • Resiliency • Capacity for growth

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