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Content Overview
Theoretical Perspectives (~12 mins)
Death & Dying: Some relevant definitions
Grief reactions to Dying
Stages of Dying: Kubler Ross - DABDA
A few FYI “practicals”
Q& A (~15 mins)
How do I die, let me count the ways
Necrobiosis. Individual cells die all the time. The cells in your body today weren't there years ago, except your nerve cells. Necrobiosis is the death of cells over the lifespan of an organism. After necrobiosis, a cell is replaced with a new one in a continual process throughout a human's life.
Necrosis. When many cells die at once, it isn't the normal continual necrobiosis of life. Necrosis is the death of an organ or part of an organ. In medicine this is called infarction (yes, that's how it's supposed to be spelled.)
Clinical Death. No breathing, no circulation, and no brain activity characterize clinical death. But that's only half. The other side, the most integral part which separates clinical death from somatic death, is that clinical death begins at the very onset of the symptoms of death, say right after cardiac arrest has cause the heart to stop. It lasts for about four minutes, and it is the interval in which life can be brought back through CPR. After a short few minutes, death is permanent, because the state of the body has gone from clinical death to...
Brain Death. A brain deprived of oxygen survives for 3 to 7 minutes, making it the first organ to die when circulation or respiration ceases or is impeded, whatever the cause of trouble may be. After a few minutes, the brain can't be brought back to life by any means available today. This is brain death, and it's the reason why clinical death, the period in which a person can be resuscitated, is so short. Once the brain goes, the heart doesn't know how to pump and the lungs don't know how to breath.
Somatic death. Eventually an organism ceases to be in the process of dying and proceeds to be dead. Somatic death is the death-- the permanent, irreversible death-- of an organism as a whole. In humans it is usually after brain death, as the other vital organs are unable to function without the brain. With modern technology, though, one can be brain dead but still have circulation and respiration artificially. In such a case one isn't somatically dead because other organs are still alive. Once artificial support is removed somatic death occurs, because the person is then entirely and completely inactive with regard to brain, circulation, and respiration.
Definitions of Types of DeathThere are many types of death, and it's good to know some definitions.
How we interpret the state of death can influence our thoughts, feelings and actions
http://library.thinkquest.org/C0122781/science/semantics.htm
Some DefinitionsGrief, Bereavement, Mourning
Grief1 is defined as the primarily emotional/affective process of reacting to the loss of a loved one through death.
The focus is on the internal, intrapsychic process of the individual.
Grief reactions may include components such as the following:
Numbness and disbelief. Anxiety from the distress of separation. A process of mourning often accompanied by symptoms of depression. Eventual recovery.
Grief reactions can also be viewed as anticipatory, normal, or complicated.
Bereavement2 is defined as the objective situation one faces after having lost an important person via death.
Bereavement is conceptualized as the broadest of the three terms and a statement of the objective reality of a situation of loss via death
1. Jacobs S (1993). Pathologic Grief: Maladaptation to Loss. Washington, DC: American Psychiatric Press.2. Stroebe MS, Hansson RO, Schut H, et al., eds. (2008): Handbook of Bereavement Research and Practice: Advancesin Theory and Intervention. Washington, DC: American Psychological Association.
Mourning1 is defined as the public display of grief. While grief focuses more on the internal or intrapsychic experience of loss, mourning emphasizes the external or public expressions of grief.
Mourning is influenced by one’s beliefs, religious practices, and cultural context.
Grieving
Every person is unique = individual differences in grief experiences
Coping with death ∅ easy process, ∅ dealing with it in cookbook fashion
How we grieve, how we cope, depends on a number of factors, including:
personality
relationship with the person who died
cultural and religious beliefs
coping skills
availability of support systems
socio-economic status
http://www.cancer.gov
Types of Grief Reactions
Anticipatory grief refers to a grief reaction that occurs in anticipation of an impending loss.[8] and is defined as “the total set of cognitive, affective, cultural, and social reactions to expected death felt by the patient and family.”[10]
The term anticipatory grief is most often used when discussing the families of dying persons, although dying individuals themselves can experience anticipatory grief.
The following aspects of anticipatory grief have been identified among survivors:
-depression.
-heightened concern for the dying person.
-rehearsal of the death.
-attempts to adjust to the consequences of the death.
Casarett D, Kutner JS, Abrahm J, et al.: Life after death: a practical approach to grief and bereavement. AnnIntern Med 134 (3): 208-15, 2001.
Normal or Common Grief is marked by a gradual movement toward an acceptance of the loss.
Normal grief usually includes some common emotional reactions that include:
-emotional numbness
-shock, disbelief, and/or denial
-crying; sighing; having dreams, illusions, and even hallucinations of the deceased
-anger
- sadness, despair, insomnia,
-fatigue, guilt, loss of interest, and disorganization in daily routine
Jacobs S: Pathologic Grief: Maladaptation to Loss. Washington, DC: American Psychiatric Press, Inc., 1993.
Patterns of Complicated Grief are described in comparison to normal grief and highlight variations from the normal pattern.
Inhibited or absent grief: A pattern in which persons show little evidence of the expected separation distress, seeking, yearning, or other characteristics of normal grief.
Delayed grief: A pattern in which symptoms of distress, seeking, yearning, etc., occur at a much later time than is typical.
Chronic grief: A pattern emphasizing prolonged duration of grief symptoms.
Distorted grief: A pattern characterized by extremely intense or atypical symptoms.
Bonanno GA, Boerner K: The stage theory of grief. JAMA 297 (24): 2693; author reply 2693-4, 2007.
DABDAElizabeth Kubler-Ross
1. Denial—"I feel fine."; "This can't be happening, not to me."
2. Anger—"Why me? It's not fair!"; "How can this happen to me?"; "Who is to blame?"
3. Bargaining—"Just let me live to see my children graduate."; "I'll do anything for a few more years."; "I will give my life savings if..."
4. Depression—"I'm so sad, why bother with anything?"; "I'm going to die... What's the point?"; "I miss my loved one, why go on?"
5. Acceptance—"It's going to be okay."; "I can't fight it, I may as well prepare for it."In this last stage, the individual begins to come to terms with their mortality or
that of their loved one.
Helping The Client To Let GoThe Five Final Tasks (Ira Byock)
INGREDIENTS
To know that we have said what we needed to say.
• One is our willingness to simply acknowledge that we are dying. Whether very soon or somewhere down the line does not matter. We have a finite amount of time left. Let's use it well by being honest about what is going on. It allows everyone around us to be honest too.
• Two is our openness to talk about dying with our loved ones. Especially with our loved ones. Yes, talk about death. Say what needs to be said. Hear what wants to be said.
• Three is to actually take the time to talk. To make the time to listen. To allow the silences in between. To speak from our hearts. To hear with our hearts. To make room for feelings. All our feelings.
THE FIVE FINAL TASKS
• Will you forgive me? Is there a forgiving that I need from you? Most likely something from a long time ago? Something I have carried with me for so long... Can I actually ask for it?
• I forgive you Am I willing to let go of old wounds and hurts in the face of my dying? Let it just be? Let it rest? And can I say this to you face?
• Thank you What a gift to say thank you one more time. Even if there is neither enough time nor enough words to thank you... for everything.
• I love you This is something we can never say often enough. Never hear often enough. It feels so good to hear and say it, even one more time.
• Good bye Can we actually say it, and mean it? Let it sink in, that this is a final good bye, at least in earthly terms? Feel all its weight? Feel all its finality? Am I ready to say good bye for good?
Byock, Ira (2004). The Four Things That Matter Most: A Book About Living. Free Press.
SPIRITUALITY can help
A study of 160 people with less than three months to live showed that those who felt they understood their purpose in life or found special meaning, faced less fear and despair in the final weeks of their lives than those who had not.
In this and similar studies, spirituality helped dying individuals deal with the depression stage more aggressively than those who were not spiritual.
Santrock, J.W. (2007). A Topical Approach to Life-Span Development. New York: McGraw-Hill.
Palliative Performance Scale (PPS)Palliative Performance Scale (PPS) : This is a clinical assessment instrument developed at the Victoria Hospice that is used to assess the functional status of palliative care patients and to communicate their status among care provider team members.
http://web.his.uvic.ca/Research/NET/tools/PrognosticTools/PalliativePerformanceScale/index.php
PPS v2.0 Instrument
Click here to download a PDF copy of PPS version 2.
PPSLevel
AmbulationActivity & Evidence of
DiseaseSelf-Care Intake
ConsciousLevel
100% Full Normal activity & workNo evidence of disease
Full Normal Full
90% Full Normal activity & workSome evidence of disease
Full Normal Full
80% Full Normal activity with EffortSome evidence of disease
Full Normal orreduced
Full
70% Reduced Unable Normal Job/WorkSignificant Disease
Full Normal orreduced
Full
60% Reduced Unable hobby/house workSignificant disease
Considerable assistancenecessary
Normal orreduced
Fullor Confusion
50% Mainly Sit/Lie Unable to do any workExtensive disease
Considerable assistancerequired
Normal orreduced
Fullor Confusion
40% Mainly in Bed Unable to do most activityExtensive disease
Mainly assistance Normal orreduced
Full or Drowsy+/- Confusion
30% Totally BedBound
Unable to do any activityExtensive disease
Total Care Normal orreduced
Full or Drowsy+/- Confusion
20% Totally BedBound
Unable to do any activityExtensive disease
Total Care Minimal tosips
Full or Drowsy+/- Confusion
10% Totally BedBound
Unable to do any activityExtensive disease
Total Care Mouth careonly
Drowsy orComa
+/- Confusion
0% Death
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Dying in ActionA LESSON WE CAN ALL LEARN SOMETHING FROM
ReferencesBecker, E. (1963). Denial of Death. Free Press, New York.
Byock, Ira (2004). The Four Things That Matter Most: A Book About Living. Free Press, New York.
Byock, Ira (1998). Dying Well. Riverhead Press, New York.
Ferris FD, Balfour HM, Bowen K, Farley J, Hardwick M, Lamontagne C, Lundy M, Syme A, West P. A (2002). Model to Guide Hospice Palliative Care. Ottawa, ON: Canadian Hospice Palliative Care Association.
Kastenbaum, R.J. (1997). Death, Society and Human Experience. Allyn & Bacon,, New York.
Kramp. E.T., & Kramp, D.H. Living with the end in mind. (1998). Three Rivers Press, New York.
Kübler-Ross, E. (1969) On Death and Dying. Routledge.
Kübler-Ross, E. (2005) On Grief and Grieving: Finding the Meaning of Grief Through the Five Stages of Loss. Simon & Schuster Ltd.
Lanza, R & Berman, B. (2010). How Life and Consciousness are the Keys to Understanding the True Nature of the Universe. BenBella Books.
Leary, T. (1997). Design for Dying. Harper-Collins, San-Francisco.
Rosenberg, L. (2000). Living in the Light of Dying. Shambhala Publications, Boston, MA.
Stroebe MS, Hansson RO, Stroebe W, et al., eds. (2001): Handbook of Bereavement Research: Consequences, Coping, and Care. Washington, DC: American Psychological Association.
Taylor, T. (2002). The Buried Soul: How Humans Invented Death. Beacon Press, Boston.
Similar to PPS instrument, you can find other Prognostic Instrument Links @ http://web.his.uvic.ca/Research/NET/tools/PrognosticTools/OtherPrognosticInstrumentLinks.php
Questions & Answers
