Death, Dying, and Bereavement

1. Death, Dying, and Bereavement PS277 – Lecture 19 – Chapter 13

2. Literary Commentary on the Great Mystery: Shakespeare vs. Dylan Thomas • Julius Caesar: “Of all the wonders that I have yet heard, It seems to me most strange that men should fear; • Seeing that death, a necessary end, • Will come when it comes.” • Dylan Thomas: “Do not go gentle into that good night. Old age should burn and rave at close of day; rage, rage against the dying of the light.”

3. Outline • Euthanasia and Death • Cultural and Historical Context of Death • Experiencing Death Personally • Dying as a Process • Death Anxiety • Grieving: Process and Causes

4. Medical - Legal Definitions of Death • Modern medical definitions focus on concept of “brain death” • Strong definition = absence of both cortical and brain stem functions and reflexes, total unconsciousness • Other conditions which might produce this state must be ruled out • Inability to live on own, without use of supportive technology for cardiovascular function

5. Various States of Awareness after Injury and Their Relations

6. Euthanasia Issues: Ending Life • Active vs. PassiveEuthanasia – actively inducing death vs. withholding treatment. More of an issue as life sustaining technology has developed to more sophisticated levels • Terri Schiavo case (March, 2005) – withholding of nourishment from a woman in persistent vegetative state for 15 years – US Supreme Court upheld husband’s right to have feeding tube removed • Legal issues – some countries and jurisdictions allow active euthanasia under medical supervision (e.g., the Netherlands) • Canadians can leave a DNR document to prevent use of extraordinary measures, but active euthanasia is illegal – Sue Rodriguez case, ALS • Hitler’s “euthanasia” programs for undesirable persons!

7. Historical Context of Death and Dying • Death occurs primarily away from home and from our everyday life • 60 years ago, fewer than 50% of all deaths occurred at hospital, now over 80% do • Philippe Aries, a French historian, notes how much this has led to the “hiding” of death: “Our senses can no longer tolerate the sights and smells that in the early 19th century were part of daily life, along with suffering and illness. The physiological effects have passed from daily life to the aseptic world of hygiene, medicine and morality…The hospital has become the place of solitary death.”

8. My Grandparents • Both died at home in 1958 • Very quickly and within two weeks of one another

9. Some Issues for Person and Society of Our Modern Technological Context • Personal: Dying alone more common today • Personal: Dying with little dignity or control • Society: Avoidance of contemplation of death and dying • Society: Difficulty in accepting death as a natural process

10. Sherwin Nuland: How We Die

11. Immediate Causes and Experience of Death • Nuland’s 23 cases of autopsy of people in 80’s & 90’s: 7 heart attacks, 4 strokes, 3 pneumonias, 5 “severe infections”, 4 advanced cancers – these are the most common ends • All of these 23 cases had serious atherosclerosis diseases of heart or brain associated with aging, plus many other incidental diseases – “wear and tear” for every one of them • Lack of oxygen is most direct cause of death, however • Sequence of death: shock due to oxygen loss to organs, agonal moments (gasping, etc.), clinical death, irretrievable mortality • Common for the brain to secrete endorphins during these final moments, makes people more tranquil than we might expect

12. Famous African Explorer, David Livingstone’s Lion Attack – 1844, Age 30 • Later description of the attack, which almost killed him: • “Growling horribly close to my ear, he shook me as a dog does a rat. The shock produced a stupor similar to that which seems to be felt by a mouse after the first shake of the cat. It caused a sort of dreaminess, in which there was no sense of pain nor feeling of terror, though quite conscious of all that was happening. The shake annihilated fear, and allowed no sense of horror in looking round at the beast. This peculiar state is probably produced in all animals killed by carnivores; and if so, is a merciful provision by our benevolent Creator for lessening the pain of death.”

13. Kubler-Ross: Stages of Death and Dying

14. Stages of Dying and the Process Itself • Kubler-Ross’s 5 stages: • Shock and Denial • Anger (“Why me?”) • Bargaining • Depression, sadness • Acceptance/accommodation • Not likely that these represent stages or that everyone experiences all of them • Cultural variations may shape these, etc.

15. Fear of Death and Some of Its Correlates • What do you fear most about death? • Generally, people fear most the process of dying and the unknown • Religiosity can be an important factor in moderating fear of unknown • Previous experience with death of a loved one can affect • Feelings of purpose and accomplishment can help lower fear

16. Age Differences in Fear of Death

17. Coping with the Fear and Avoidance of Death • Exercises: Doing a personal obituary • Decide on final scenarios – end state care, hospice care, funeral choices, burial or cremation, etc. • Thich Nhat Han: Contemplating being dead: Buddhist meditation exercises – imaging yourself as a corpse and meditating on what will happen to it…not fun, but important to integrating one’s death and life with equanimity?

18. My Parents

19. My Father’s Death • Non-Hodgkin’s lymphoma – cancer of the blood • Recurrence led to very low red blood counts and heavy stress on heart, many other health problems w/ treatment • Last 2 years – in and out of hospital many times • Hospice care at home, but limited time permitted in US • Several times convinced he was dying, angina symptoms • End: had a fall, high fever, etc. – had to go to hospital • Last phase was short, massive pneumonia - led to death in a few days • Very clear that wanted to die • Able to say good-bye to family + strong religious beliefs • Last evening- not completely lucid, but very gentle ending • Funeral was a positive process, community celebration of his life

20. Bereavement and Grief • Grief work: Freud’s theory of the need to “work through” attachment to lost person and resolve negative emotions over time, important to talk through the loss • Recent research questions – those who do more early “grief work” actually seem to have more problems later on • Wortman & Silver found much variability in grieving, not the case that failure to grieve necessarily means problems – several patterns are normal • typical (high initial, fairly quick recovery) = 35% • chronic (high over several years) = 30%-35% • delayed (low then increases) = 5% • absent (person shows and feels little distress at all) = 25%

21. Loss of Parents • Loss of parents is the most expectable bereavement, but still very difficult • Has much symbolic meaning about one’s generational place • Context is everything – my father’s parents and his grief

22. Darwin’s Father Robert • Darwin’s father, Robert, died in 1848, age 82, of heart failure • Darwin’s illness during these months was much worse, he visited often but could not attend funeral • Darwin had a very difficult relationship as child, but was closer to father as adult

23. Loss of a Spouse • Disrupts immune function, strong rise in depression for some time, 1-2 years as typical for older adult spouses • Quality of bond, social support available, other factors can moderate these effects – Emma Darwin • Seems to be worse in some ways for men, who may have less social support, harder time talking about this

24. Losing a Child • Seems most “unnatural,” probably hardest to fully resolve • Historical Context: Many parents in past generations lost children to illness, etc. Some people have suggested that attachments to infants were less – these claims are strongly disputed, certainly grief occurred nonetheless • My cousin’s daughters - sudden, shocking, more difficult to handle immediately, some research suggests stronger health effects for sudden deaths • Overall, grieving is highly individual, variable, personal – takes time

25. Darwin’s First Daughter, Annie • Parents’ favourite, died at age 10 in 1851 of TB • Darwin did not attend this funeral either, overcome with grief • Lost what little faith he had left at this point, though his wife continued to believe • Annie’s box