Chapter Twelve: Psychological Issues in Advancing and Terminal Illness

1. Chapter Twelve:Psychological Issues in Advancing and Terminal Illness

2. Chapter Outline • Death across the life span • Psychological issues in advancing illness • Are there stages in adjustment to dying? • Psychological management of the terminally ill • Alternatives to hospital care for the terminally ill • Problems of survivors

3. Causes of Death in Infancy and Childhood • Lack of free or low-cost maternal care programs • Congenital abnormalities • Sudden infant death syndrome (SIDS): Condition where an infant stops breathing, which is to occur: • In lower-class urban environments

4. Causes of Death in Infancy and Childhood • If the mother smoked during pregnancy • If baby is put to sleep on its stomach or side • Children under age fifteen • Accidents • Cancer

5. Children’s Understanding of Death Ages up to five • Think of death as a great sleep • Curious about death Ages between five and nine • Idea that death is final develops • No biological understanding of death Ages nine or ten • Moderate understanding of the processes involved in death • Realize that the person who has died will not return

6. Leading Causes of Death in Adolescence and Young Adulthood Unintentional injury Homicide Suicide Cancer Heart disease AIDS

7. Reactions to Young Adult Death • Young adults facing a terminal illness • Feel shock, outrage, and an acute sense of injustice • May face a long and drawn-out period of dying

8. Death in Middle Age • Becomes more realistic since: • It is more common • Chronic health problems leading to death can develop • Premature death: Occurs before the projected age of 78 • Mainly caused by heart attack or stroke

9. Death in Middle Age • Most people prefer a sudden death as: • It facilitates a more graceful departure • Their family does not have to witness their worsening condition • Finances and other resources are not severely taxed • Socioeconomic status is a strong determinant of age of death

10. Death in Old Age • The elderly are more prepared to face death as they have: • Seen friends and relatives die • Thought about their death and made some preparations • Causes • Degenerative diseases • Physical decline that predisposes them to infectious disease or organ failure

11. Death in Old Age • Factors that predict mortality in the elderly • New illnesses and the worsening of preexisting conditions • Poor mental health and reduced satisfaction with life • Women live longer than men

12. Right to Die • The Patient Self-Determination Act - Requires health facilities to have policies concerning patients’ wishes for life-prolonging therapy • Right-to-die movement - Maintains that dying is more a matter of personal choice and personal control

13. Moral and Legal Issues • Euthanasia: Ending the life of a person who is suffering from a painful terminal illness • Living will: Instructions and legal protection for the physician • So that life-prolonging interventions will not be indefinitely undertaken • Does not always ensure patient’s requests are met

14. Psychological and Social Issues Related to Dying Changes in the patient’s self-concept Issues of social interaction Communication issues

15. Issue of Nontraditional Treatment • Reasons for people falling prey to dubious remedies • Hope for a miracle cure • Deteriorating relationship with the formal health care system • Desire for a more humanistic care

16. Stages of Dying • Denial - Patient’s initial reaction on learning of the diagnosis • Defense mechanism by which people avoid the implications of an illness • Anger - Harder response for family and friends to deal with • Patient is not really angry with them but at fate

17. Stages of Dying • Bargaining - Trading good behavior for good health • Depression - Time for anticipatory grief • Patient mourns the prospect of his/her death • Acceptance - A tired, peaceful calm descends • Patients decide to divide up their possessions and say goodbye to friends and family

18. Evaluation of Kübler-Ross’s Theory • Patients do not: • Go through the stages in a predetermined order • Fully acknowledge the importance of anxiety • One of the most common responses

19. Significance of Hospital Staff to the Patient • Provide physical assistance • Help reduce pain • See patients on a regular basis • Are the only source of realistic information • Are privy to the patient’s act of dying

20. Terminal Care • Physical care that is palliative • Palliative care: Designed to make the patient feel comfortable • Curative care: Designed to cure the patient’s disease

21. Risks of Terminal Care for Staff • Staff may burn out from watching patient after patient die • Patients interpret it as abandonment when the physicians spend less time with them • Physicians spend less time with terminally ill patients to dedicate their time for patients who can most profit from it

22. Achieving an Appropriate Death Informed consent Safe conduct Significant survival Anticipatory grief Timely and appropriate death

23. Counseling with the Terminally Ill • Therapy • Short-term • Nature and timing of visits depend on the patient’s desires and energy level • Thanatologists: People who study death and dying • Believe that cognitive-behavioral therapies can be constructively employed with dying patients

24. Management of Terminal Illness in Children • Children infer about their condition by taking cues from: • Their treatments • People around them • Counseling • Helps therapists take cues about what to discuss from the child

25. Management of Terminal Illness in Children • Helps parents to cope with the impending death • Restores balance in a family with other children • Provides supportive mental health services to the parents who experience post-traumatic stress disorder

26. Hospice Care • Provide palliative care and emotional support to dying patients and their family members • Hospice: Place that provided care and comfort for travelers in medieval Europe • Painful or invasive therapies are discontinued • Oriented toward improving a patient’s social support system

27. Home Care • Taking care of the patient at home • Most popular and economically feasible • Provides psychological advantages for the patient • Stressful for the family

28. The Survivor • Grief: Feeling of hollowness marked by: • Preoccupation with the image of the deceased • Expressions of hostility toward others • Guilt over the death • Grief response is more aggravated in: • Men • Caregivers • People whose loss was sudden and unexpected

29. The Survivor • Biggest burden • For women - Financial strain • For men - Strains of managing a household • Death of a sibling raises complications for children • Children should be prepared for the death • Questions should be answered honestly • Information should be provided at the right time

30. Death Education • Developing realistic expectations about: • What modern medicine can achieve • The kind of care the dying want and need • Colleges have developed courses on dying • Volunteer work with dying patients • Potential problem - Unintended encouragement for self-destructive leanings