Chapter 19

1. Chapter 19 Death and Grieving ©2008 McGraw-Hill Ryerson Ltd.

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4. Defining Death and Life/Death Issues Issues in Determining Death Brain death – a neurological definition of death that states a person is brain dead when all electrical activity of the brain has ceased for a specified period of time. ©2008 McGraw-Hill Ryerson Ltd.

5. Defining Death and Life/Death Issues Issues in Determining Death • The higher portions of the brain die first. • The brain’s lower portions monitor vital functions. • People whose higher brain areas have died may continue breathing & have a heartbeat. • The current definition of brain death (for most physicians) includes the death of both the higher cortical functions & lower brain stem functions. ©2008 McGraw-Hill Ryerson Ltd.

6. Defining Death and Life/Death Issues Decisions Regarding Life, Death, and Health Care • Living Wills and DNRs • Euthanasia • Needed: Better Care for Dying Individuals ©2008 McGraw-Hill Ryerson Ltd.

7. Defining Death and Life/Death Issues Living Will • Recognizing that terminally ill patients might prefer to die rather than linger in a painful or vegetative state, an organization called “Choice in Dying” created the Living Will. • The Living Will document is designed to be filled in while the individual can still think clearly & expresses their desire that extraordinary medical procedures not be used to sustain life when the medical situation becomes hopeless. ©2008 McGraw-Hill Ryerson Ltd.

8. Defining Death and Life/Death Issues DNRs • DNR, or Do Not Resuscitate is an order preventing medical staff within a medical institution to use either specified or all means to prolong a person’s life or to resuscitate the person if their heart stops. • DNR can be arranged without a living will. ©2008 McGraw-Hill Ryerson Ltd.

9. Defining Death and Life/Death Issues Euthanasia • Euthanasia is the act of painlessly ending the lives of individuals who are suffering from an incurable disease or severe disability. • Sometimes referred to as “mercy killing.” • Passive euthanasia – occurs when a person is allowed to die by withholding available treatment, such as withdrawing a life-sustaining device. • Active euthanasia – occurs when death is deliberately induced, as when a lethal dose of a drug is injected. ©2008 McGraw-Hill Ryerson Ltd.

10. Defining Death and Life/Death Issues Attitudes about Euthanasia • Passive euthanasia for terminally ill patients is accepted. • Precise boundaries for passive euthanasia & the exact mechanisms by which treatment decisions should be implemented are not entirely agreed upon. • Active euthanasia is a crime in most countries & in all U.S. states except Oregon. • Walker, Gruman & Blank’s (1999) recent survey of more than 900 physicians found most opposed active euthanasia & believed that adequate pain control eliminated the need for active euthanasia. ©2008 McGraw-Hill Ryerson Ltd.

11. Defining Death and Life/Death Issues Needed: Better Care for Dying Individuals • The Canadian Senate report on end-of-life found: • Only 1-in-10 Canadians received proper care as they die. • Dying individuals often get too little or too much care. • Many experience severe pain during their last days. • Regulations are needed that allow physicians flexibility in prescribing painkillers for dying patients who need them. • Many health-care professionals are not trained to provide adequate end-of-life care. ©2008 McGraw-Hill Ryerson Ltd.

12. Defining Death and Life/Death Issues Palliative Care • Palliative care is a humanized program committed to making the end of life as free from pain, anxiety, & depression as possible. • Palliative care goals contrast with those of hospitals, which are to cure illness & prolong life. ©2008 McGraw-Hill Ryerson Ltd.

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14. Death and Socio-historical Cultural Contexts Changing Historical Circumstances • One historical change already presented is the increasing complexity of determining when someone is truly dead. • Another change is the age group death strikes most often—200 years ago it was children, now it is the elderly. • Life expectancy has increased by 50 years since 1900. • In the past, most people died at home. • 80% of all deaths now occur in institutions, minimizing our exposure to death. • Care of the dying has shifted away from families. ©2008 McGraw-Hill Ryerson Ltd.

15. Death and Socio-historical Cultural Contexts Perceptions of Death • In most societies, death is not viewed as the end of existence—though the biological body has died, the spiritual body is believed to live on. • Some cultures: • believe death is caused by magic and demons. • believe death is caused by natural forces. • focus on reincarnation. • view death as punishment, while for others it represents redemption. • fear death, while others embrace it. ©2008 McGraw-Hill Ryerson Ltd.

16. Death and Socio-historical Cultural Contexts Death in Different Cultures • North Americans are death avoiders & death deniers. • People in many countries face death on a daily basis. • In some countries, the presence of dying family members & large funeral attendance are part of everyday cultural reality. • These aspects of life help prepare the young for death & provide them with guidelines on how to die. ©2008 McGraw-Hill Ryerson Ltd.

17. Death and Socio-historical Cultural Contexts Evidence of the Denial of Death • The funeral industry glosses over death & fashions lifelike qualities in the dead • Euphemistic language for death is used (passed away). • There is a persistent search for a fountain of youth • Rejection & isolation of the aged, who may remind us of death, is common. • Belief in the concept of a pleasant & rewarding afterlife, suggests that we are immortal • Medical practices emphasis prolonging biological life rather than an emphasizing diminishing human suffering ©2008 McGraw-Hill Ryerson Ltd.

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19. A Developmental Perspective on Death Causes of Death and Expectations about Death • Death can occur at any point in the human life span. • Childhood deaths occur mostly due to accidents or illness. • Adolescent deaths are more likely to occur because of motor vehicle accidents, suicide, & homicide. • Younger adults are more likely to die from accidents. • Older adults are more likely to die from chronic diseases. • Younger adults who are dying feel cheated by death more than do older adults who are dying. ©2008 McGraw-Hill Ryerson Ltd.

20. A Developmental Perspective on Death Attitudes toward Death at Different Points in the Life Span • Childhood • Adolescence • Adulthood ©2008 McGraw-Hill Ryerson Ltd.

21. A Developmental Perspective on Death Childhood • Infants have no concept of death, but once they develop an attachment, they can experience loss, separation & anxiety. • Children 3–5 years old don’t have a true idea of what death really means, often confusing death with sleep. • Young children believe death is reversible & the dead can be brought back to life spontaneously. • Cuddy-Casey & Orvaschel’s (1997) research found children don’t understand death is universal & irreversible until about age 9. ©2008 McGraw-Hill Ryerson Ltd.

22. A Developmental Perspective on Death Explaining Death to Children • Psychologists recommend : • honesty in discussing death with children. • Answering children’s questions about death based on the child’s age & maturity level. • Death can be explained to preschool children in simple physical & biological terms. • Children need reassurance that they are loved & that they will not be abandoned. • Regardless of age, adults should be sensitive & sympathetic, encouraging children to express their own feelings & ideas. ©2008 McGraw-Hill Ryerson Ltd.

23. A Developmental Perspective on Death Adolescence • The prospect of death is so remote for adolescents that it does not have much relevance. • Death may be avoided, glossed over, kidded about, neutralized, & controlled by a cool spectator-like orientation. • Adolescents have more abstract conceptions of death than children do. • Adolescents develop religious & philosophical views about the nature of death & whether there is life after death. • Adolescents are especially likely to think that they are invincible, unique & immune to death. ©2008 McGraw-Hill Ryerson Ltd.

24. A Developmental Perspective on Death Adulthood • There is no evidence that a special orientation towards death develops in early adulthood. • An increase in consciousness about death accompanies individuals’ awareness that they are aging. • Kalish & Reynolds’ (1976) study found adults at midlife fear death more than do young adults or older adults. • Older adults think about death more & talk about it more than in previous adult stages. ©2008 McGraw-Hill Ryerson Ltd.

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26. Facing One’s Own Death Kübler-Ross’s Stages of Dying • Denial and Isolation • Anger • Bargaining • Depression • Acceptance ©2008 McGraw-Hill Ryerson Ltd.

27. Facing One’s Own Death Denial and Isolation • Kübler-Ross (1969) divided the behaviour & thinking of dying persons into 5 stages. • In the first stage, denial & isolation, people refuse to believe that their condition is terminal. • People attempt to convince themselves that lab tests were inaccurate or that the disease will go into remission. • Dying individuals in this stage also seek isolation. ©2008 McGraw-Hill Ryerson Ltd.

28. Facing One’s Own Death Anger • In the 2nd stage of dying, anger, the dying person recognizes that denial can no longer be maintained. • Denial gives way to anger, resentment, rage, & envy. • The dying person’s question is: “Why me?” • The dying person becomes increasingly difficult to care for, as anger may become displaced & projected onto physicians, nurses, family members, & God. • The realization of loss is great & those who represent life are targets of resentment ©2008 McGraw-Hill Ryerson Ltd.

29. Facing One’s Own Death Bargaining • In the 3rd stage of dying, bargaining, Kübler-Ross states that the person develops the hope that death can somehow be postponed or delayed. • Some people enter into a bargaining or negotiation—often with God—as they try to delay their death. • In exchange for a few more days, weeks, or months of life, the person promises to lead a reformed life dedicated to God or to the service of others. ©2008 McGraw-Hill Ryerson Ltd.

30. Facing One’s Own Death Depression • In Kübler-Ross’ 4th stage of dying, depression, the dying person accepts that death is certain. • At this point, a period of depression or preparatory grief may appear. • The dying person may become silent, refuse visitors, & spend time crying or grieving. • Attempts to cheer up the dying person at this stage should be discouraged because the person has a need to contemplate impending death. ©2008 McGraw-Hill Ryerson Ltd.

31. Facing One’s Own Death Acceptance • In the 5th stage of dying, acceptance, the person develops a sense of peace; an acceptance of one’s fate; & in many cases, a desire to be left alone. • Feelings & physical pain may be virtually absent. • Kübler-Ross views this stage as the end of the dying struggle, the final resting stage before death. ©2008 McGraw-Hill Ryerson Ltd.

32. Facing One’s Own Death Criticisms of Kubler-Ross • Psychology death expert Robert Kastenbaum refutes the existence of Kübler-Ross’ 5 stage sequence. • Research has not demonstrated the process exists. • Kastenbaum (2000) believes the stage interpretation neglects the patients’ total life situations, including relationship support, specific effects of illness, family obligations, & the institutional climate in which they were interviewed. • Some psychologists prefer to describe the stages as reactions to dying. ©2008 McGraw-Hill Ryerson Ltd.

33. Facing One’s Own Death Contributions of Kubler-Ross • Kübler-Ross made the important contribution of calling attention to people attempting to cope with life-threatening illnesses. • She did much to encourage needed attention to the quality of life for dying persons & their families. ©2008 McGraw-Hill Ryerson Ltd.

34. Facing One’s Own Death Perceived Control and Denial • Perceived control & denial may work together as an adaptive strategy for some older adults facing death. • Individuals who believe they can influence & control events, become more alert & cheerful. • Denial may be a useful way for some individuals to approach death. • Denial protects us from the tortuous feeling that we are going to die. • Denial can be maladaptive if it prevents treatment. ©2008 McGraw-Hill Ryerson Ltd.

35. Facing One’s Own Death The Contexts in Which People Die • For dying individuals, the context in which they die is important. • 75% of Canadians die in hospitals or long-term care facilities. • Hospitals offer important advantages in that professional staff members are readily available, & the medical technology may prolong life. • Kalish & Reynolds (1976) identified most individuals say they would rather die at home. ©2008 McGraw-Hill Ryerson Ltd.

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37. Coping with the Death of Someone Else Communicating with a Dying Person • Most psychologists believe that it is best for dying individuals to know that they are dying, & that significant others know they are dying. • Dying individuals can thus close their lives in accord with their own idea of proper dying. • They can complete plans and projects. • They can make arrangements for survivors. • They can participate in decisions about a funeral. • They will have the opportunity to reminisce. ©2008 McGraw-Hill Ryerson Ltd.

38. Coping with the Death of Someone Else Grieving • Dimensions of Grieving • Cultural Diversity in Healthy Grieving ©2008 McGraw-Hill Ryerson Ltd.

39. Coping with the Death of Someone Else Dimensions of Grieving • Emotional numbness, disbelief, separation anxiety, despair, sadness, & loneliness accompany the loss of someone we love. ©2008 McGraw-Hill Ryerson Ltd.

40. Coping with the Death of Someone Else Dimensions of Grieving • Pining or yearning reflects a recurrent need to recover the lost loved one. • Separation anxiety includes pining but also focuses on places & things associated with the deceased, as well as crying. • Numbness, disbelief, & outbursts of panic are typical immediate reactions. • Despair, sadness, & hopelessness are part of grief. ©2008 McGraw-Hill Ryerson Ltd.

41. Coping with the Death of Someone Else Cultural Diversity in Healthy Grieving • In contrast to Western beliefs, maintenance of ties with the deceased is accepted & sustained in the religious rituals of Japan. • In the Arizona Hopi, the deceased are forgotten as quickly as possible & life is carried on as usual. • In Egypt, the bereaved are encouraged to dwell at length on their grief. • In Bali, the bereaved are encouraged to laugh & be joyful, rather than be sad. • Diverse grieving patterns are culturally embedded. ©2008 McGraw-Hill Ryerson Ltd.

42. Coping with the Death of Someone Else Making Sense of the World • A beneficial aspect of grieving is that it stimulates many individuals to make sense of their world. • A common occurrence is to go over again & again all of the events that led up to the death. • When death is caused by an accident or disaster, the effort to make sense of it is pursued more vigorously. • The bereaved want to put the death in a perspective they can understand—divine intervention, a logical sequence of cause & effect, etc. ©2008 McGraw-Hill Ryerson Ltd.

43. Coping with the Death of Someone Else Losing a Life Partner • Those left behind after the death of an intimate partner suffer profound grief & often endure financial loss, loneliness, increased physical & psychological problems. ©2008 McGraw-Hill Ryerson Ltd.

44. Coping with the Death of Someone Else Losing a Life Partner • Those left behind after the death of an intimate partner suffer profound grief & often endure financial loss, loneliness, increased physical illness, & psychological disorders. • The bereaved are also at increased risk for many health problems, including death. • Optimal adjustment after a death depends on several factors. • Women do better than men in our society, due to their networks of friends & close relationships. ©2008 McGraw-Hill Ryerson Ltd.

45. Coping with the Death of Someone Else Forms of Mourning and the Funeral • Mourning varies cross-culturally. • Funeral rituals are an important aspect of mourning in many cultures. • One consideration is what to do with the body. • Approximately 80% of corpses are buried. • Studies showed that bereaved individuals who were religious derived more psychological benefits from a funeral, participated more actively in rituals, & adjusted more positively to the loss. ©2008 McGraw-Hill Ryerson Ltd.