CHAPTER NINETEEN DEATH, DYING, AND BEREAVEMENT. Copyright © 2009 Pearson Education Canada 19-2 I. THE EXPERIENCE OF DEATH Most of us use the word death

CHAPTER NINETEEN

DEATH, DYING, AND BEREAVEMENT

Copyright © 2009 Pearson Education Canada 19-2

I. THE EXPERIENCE OF DEATH

Most of us use the word death as if it describes a simple phenomenon

In fact, death is a process as well as a state, and physicians have different labels for different aspects of this process


A. Death ItselfClinical death: a period during which vital signs

are absent but resuscitation is still possible– Presumably, near death experiences occur in this

stateBrain death: absence of vital signs, including

brain activity; resuscitation is no longer possible– The person is considered legally dead

Social death: the point at which family members and medical personnel treat the deceased person as a corpse– Family and friends must begin to deal with the loss


B. Where Death OccursHospitals:

– In Canada, three quarters of deaths occur in hospitals or long term care facilities

Hospice:– A holistic approach to care for the terminally ill that

emphasizes individual and family control of the process of dying

• Death should be viewed as normal, not to be avoided– Palliative care: a form of care for the terminally ill

that focuses on relieving patients’ pain, rather than curing their diseases

• Palliative care programs are offered in home, hospice centres and in hospitals

(continued)


Where Death Occurs (continued)

The Hospice Care philosophy: Death should be viewed as normal The patient and family should be encouraged to prepare for the

death The family should be involved in the patient's care Control over the patient's care should be in the hands of the

patient and the family Care is aimed at satisfying the physical, emotional, spiritual,

and psychosocial needs of a person with a life-threatening or terminal condition and their families

Medical care should be primarily palliative care rather than curative. The emphasis is on controlling pain and maximizing comfort, but not in invasive or life-prolonging measures

(continued)



Selecting Appropriate Care:– Patients and family of terminally ill patients show a

slight preference for hospice care over hospital care

– Hospital and home-based programs show remarkable similarities in patients’ reported pain and satisfaction

– The economic costs of death are reduced by home based hospice care

– Home based hospice care places considerable burden on the central caregiver

(continued)



Caregiver Support:– Care-givers for dying patients have a considerable

burden, including a grief response– Hospice care includes psychological and

educational support– Canada’s Virtual Hospice

• enables health care professionals to interact directly with informal care providers

• provides access to a range of palliative care services

• brings medical expertise to the home and to rural and remote areas of Canada


II. THE MEANING OF DEATH ACROSS THE LIFESPAN

As an adult, you understand that death is irreversible, that it comes to everyone, and that it means a cessation of all function

Children, teenagers, and adults of different ages differ in their understanding of these aspects of death


A. Children's and Adolescents' Understanding of Death Preschool-age children do not understand that:

– death is irreversible– it comes to everyone– it means a cessation of all function

Teaching young children about the nature of biological life helps them understand what causes death and why it is irreversible

At about school age, most children seem to understand both the permanence and universality of death

(continued)


Children's and Adolescents' Understanding of Death (continued)

Adolescents understand the finality of death better than children do, and, in an abstract sense, they understand that death is inevitable

Personal fable: a hypothetical life story created for himself or herself by an adolescent

The personal fable contributes to the frequency of teenagers' potentially fatal risky behaviours and to unrealistic beliefs about personal death that may contribute to adolescent suicide


B. The Meaning of Death for AdultsEarly Adulthood:

– The sudden loss of a loved one appears to shake a young adult's belief in their unique invulnerability and, as a result, is often more traumatic for younger, than for older, adults

– Personal experience changes perception of death• Experience with death (for example in a healthcare

profession) may make it less fearful• Loss of a loved one frequently leads to suicidal thoughts

– The deaths of relatively young public figures challenge young people's beliefs in unique invulnerability

• Young adults look for reasons that death came early to these people, but won’t affect themselves

(continued)


The Meaning of Death for Adults (continued)Middle and Late Adulthood:

– A death changes the roles and relationships of everyone else in a family, as well as the people beyond the family

– Death brings permanent changes in families and social systems

– In middle age, many individuals switch the way they think about time, from "time since birth" to "time until death”

– Those middle-aged and older adults who continue to be preoccupied with the past are more likely to be fearful and anxious about death


C. Fear of Death

Wong suggests that our fear of death stems from six existential uncertainties– The finality of death – The uncertainty of what follows – Annihilation anxiety or fear of non-existence – The ultimate loss – Fear of the pain and loneliness in dying – Fear of failing to complete life work

(continued)


Fear of Death (continued)

Fear of Death Across Adulthood:– For young adults, the sense of unique invulnerability

probably prevents intense fears of death– Middle-aged adults are most fearful of death– In middle-age, a belief in one's own immortality

begins to break down, resulting in increasing anxiety about the end of life

– By late life, the inevitability of death has been accepted, and anxieties are focussed on how death will actually come about

– Older adults are more likely to fear the period of uncertainty before death than they are to fear death itself

(continued)



Religious Beliefs:– Both those who are deeply religious and those who

are totally irreligious report less fear of death– The most fearful may be those who are uncertain

about or uncommitted to any religious or philosophical tradition

– Religious beliefs may moderate fears of death • Death is seen as a transition from one form of life to

another• The belief that God exists increases with age

– Ley and van Bommel: the spiritual search for meaning in our lives is often intensified by the reality of death: an important aspect in palliative care

(continued)


Prevalence of Beliefs in God



Personal Worth:– Adults who have accomplished goals or believe

they have become the person they set out to be have less fear of death

– Belief that life has purpose or meaning reduces the fear of death

– Fear of death may be an aspect of the despair described in Ericson’s theory of ego integrity versus despair


D. Preparation for DeathPractical preparation may include obtaining life

insurance or making a will, preparations that are more common as people move toward late adulthood and more accepting of the inevitability of death

At a somewhat deeper level, adults may prepare for death through some process of reminiscence

Deeper still, there may be unconscious changes that occur in the years just before death that we might think of as a type of preparation

(continued)


Preparation for Death (continued)

The physical and mental changes associated with the concept of terminal drop may be accompanied by terminal psychological changes as well

Lieberman et al showed that people near to death became less emotional, introspective, and aggressive or assertive, and more conventional, docile, dependent, and warm– People with these personality traits didn’t

die sooner; rather, these qualities became accentuated in those close to death


III. THE PROCESS OF DYING

In the 1960s, Kübler-Ross formulated a model that asserted that those who are dying go through a series of psychological stages

In addition, research suggests that individual differences affect the process of dying in important ways


A. Kübler-Ross's Stages of DyingDenial: Many people confronted with a terminal diagnosis react

with some form of denial, a psychological defence that may be useful in the early hours and days after such a diagnosis

Anger: Anger often expresses itself in thoughts that life is not fair, but may also be expressed toward God, or toward doctors, nurses, or family members

Bargaining: The patient in stage 3 tries to make "deals" with doctors, nurses, family, or God

Depression: When bargaining fails as a result of declining physical status, the patient becomes depressed and sinks into long-lasting depression

Acceptance: Kübler-Ross views this depression as a necessary preparation for the final step of acceptance since a person must grieve for all that will be lost with death. When such grieving is finally done, the individual is ready to die


B. Criticisms & Alternative Views

Methodological problems:– Kübler-Ross's observations might be correct only

for a small subset of dying individualsCultural Specificity:

– Cultures vary considerably in what they believe to be a “good death”

– Exhibitions of denial, anger and bargaining may seem to indicate a lack of faith in religious people who are dying, so may be actively avoided

(continued)


Criticisms & Alternative Views (continued)

The Stage Concept– Many clinicians and researchers have found that

not all dying patients exhibit these five emotions, let alone in a specific order

– Schneiderman suggests themes to the dying process, rather than stages

– Corr suggests 4 tasks for the dying person• Health professionals may be able to help the dying

person achieve these tasks


C. Responses to Impending DeathDo specific emotional responses to impending

death have any effect on the physical process of dying?

Greer classified women's attitudes three months after they were diagnosed with breast cancer:– Denial (positive avoidance)– Fighting spirit– Stoic acceptance (fatalism)– Helplessness/hopelessness– Anxious preoccupation

Those whose initial reaction was either denial or fighting spirit were less likely to die of cancer

(continued)


15 Year Outcomes Among Cancer Patients


Responses to Impending Death (continued)

The message may be:– Those who struggle the most, who fight the hardest,

who express their anger and hostility openly and who find some sources of joy in their lives, live longer

Difficult patients who question and challenge those around them last longer

This may be appropriate for cancer-like illnesses, but not others, such as heart disease

People with good social support systems tend to survive longer


IV. THE EXPERIENCE OF GRIEVING

In virtually every culture, the immediate response to a death is some kind of funeral ritual

A death ritual, however, is only the first step in the process of grieving (the emotional response to a death) that may take months or years to complete


A. Psychosocial Functions of Death RitualsFunerals, wakes, and other death rituals provide

several psychological functions:– They help family members manage their grief by giving

them a specific set of roles to play, providing shape to the first hours and days

– They bring family members together; they can strengthen family ties, clarify the new lines of influence or authority within a family, and pass on the flame in some way to the next generation

– They may help survivors understand the meaning of death itself, in part by emphasizing the meaning of the life of the person who has died

– They may give some transcendent meaning to death itself by placing it in some philosophical or religious context


B. The Process of GrievingAge of the Bereaved:

– Children express feeling of grief very much the way teens and adults do—through sad facial expressions, crying, loss of appetite, and age-appropriate displays of anger

– Funerals seem to serve the same adaptive function for children as for adults, and most children resolve their feeling of grief within the first year after the loss

– Knowing that a loved one is ill and in danger helps children cope with the loss in advance, just as it does for those who are older

– Teens may be more likely to experience prolonged grief than children or adults

(continued)


The Process of Grieving (continued)

Mode of Death:– Widows who have cared for spouses during a period of

illness prior to death are less likely to become depressed after the death

– A death that has intrinsic meaning provides the bereaved with a sense that the death has not been without purpose

– Sudden and violent deaths evoke more intense grief responses

– Suicide produces unique responses among survivors:• They experience feelings of rejection and anger• They may feel that they could have done something to

prevent the suicide• They are less likely to discuss the loss• Suicide survivors may be more likely to experience long-term

negative effects


C. WidowhoodWidowhood and Physical Health:

– Immune system functions are suppressed somewhat immediately after the death

– Most return to normal by a year after the death– The immune dysfunction can last beyond obvious

signs of griefWidowhood and Mental Health:

– In the year following bereavement, the incidence of depression among widows and widowers rises substantially, while rates of death and disease rise only slightly

(continued)


Widowhood (continued)

Pathological Grief:– Grief symptoms for more than two months

following the loss of a loved one may indicate pathological grief

– Grief lasting longer than 6 months can lead to long-term depression and physical ailments such as cancer and heart disease

– Problems may continue for up to 2 years after the death of the loved one

– Cultural grief behaviour must be taken into account

(continued)



Sex differences:Death of a spouse is more negative for men than

for women– Risk of death from natural causes or suicide is

higher in men immediately after the death of spouse

• Widowers withdraw from social activities• Widowers find it difficult to return to earlier levels of

emotional functioning• Alcohol use may play a role in higher levels of

depression(continued)



Preventing Long-Term Problems:– The "talk-it-out" approach to managing grief can

be helpful in preventing grief-related depression– Participating in support groups helps– Developing a coherent personal narrative of the

events surrounding the spouse’s death helps manage grief

– Appropriate amount of time off from work to grieve is important

• Returning to work too soon can contribute to illness and depression


Policy Question:Do People Have a Right to Die?

Most medical ethicists distinguish between two forms of euthanasia (also known as “mercy killing”)– Passive euthanasia: the withholding of life

supporting interventions– Active euthanasia (also called assisted suicide):

hastening death by active means

(continued)


Policy Question (continued)

Living Wills:– Most people agree that individuals should be able

to determine the degree to which life-support technology will be used to delay their own deaths

– All Canadian provinces except New Brunswick have legislation that recognizes the directives expressed in living wills

– Living wills usually contain two elements:• A proxy directive (who will act for you if you can not

act for yourself)• An instruction directive (choices you have made

about end-of-life care)

(continued)



Assisted Suicide:– A 1997 Ipsos-Reid poll found that three-quarters

(76%) of Canadians surveyed support the notion of the patient’s “right to die” and 21% were opposed

– Euthanasia and assisted suicide are still illegal in Canada. Doctors also have a legal obligation to prevent patients from harming themselves in a case where there is a risk of suicide

– The only place in the world where assisted suicide is fully and explicitly legal is in the Netherlands

(continued)


Policy Question (continued)Opponents of assisted suicide consider it to be an

immoral act, similar to suicide– The ‘slippery slope’ argument states that it is difficult to

set limits on the process• If assisted suicide were considered to be moral, the infirm

or severely disabled might be encouraged to end their lives– Van Bommel argues that if all dying patients’ needs were

met, assisted suicide would be unnecessary– Those who decline medical treatment are not necessarily

interested in hastening death– Terminally ill patients’ depression may play a role in their

decision to request assisted suicide

(continued)



Advocates of assisted suicide note that current medical technology can keep people alive long past the point where natural death would have occurred

Advocates say patients who are not able to carry out their own suicide require (and should have) the help of a physician

Is assisted suicide equivalent to death with dignity?

Documents

CHAPTER NINETEEN DEATH, DYING, AND BEREAVEMENT. Copyright © 2009 Pearson Education Canada 19-2 I. THE EXPERIENCE OF DEATH Most of us use the word death