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19Prenatal Development And

Birth Death, Dying, and

Bereavement

This multimedia product and its contents are protected under copyright law. The following are prohibited by law:• any public performance or display, including transmission of any image over a network;• preparation of any derivative work, including the extraction, in whole or part, of any images;• any rental, lease, or lending of the program.

Copyright © Allyn & Bacon 2006

The Experience of Death

• Death Itself– Clinical death

• The few minutes after the heart stops pumping, breathing stops, and there is no evidence of brain activity but resuscitation is still possible

– Brain death• The person no longer has reflexes or any response to

vigorous external stimuli; the person may still be able to breathe and to survive for some time

– Social death• Deceased person is treated like a corpse by others


Where Death Occurs

• Hospitals in the U.S.• Among old old, death in a nursing home is

common.• Hospice care

– Alternative form of terminal care– Writings of Elizabeth Kubler-Ross emphasized a

“good death” and “death with dignity”– Patient and family have more control over the process– More likely to have the death at home


Hospice care

• Death should be viewed as normal.• Families and the patient should prepare for

death.• The family should be involved in the patient’s

care.• Control of care should be in control of the patient

and the family.• Medical care should be palliative care rather

than curative.


Hospice care

• Home-based programs– One family caregiver – usually the spouse – provides

constant care for the dying person• Supported by specially trained nurses

• Special hospice centers– Small number of patients in the last stages of a

terminal illness

• Hospital-based programs– Provide palliative care and utilize family daily in the

patient’s care


Hospice care

• Hospital-based and home-based hospice care provide similar experiences.– No differences are reported in patients’ pain, length of

survival, or satisfaction with care.– Family members were most satisfied with hospital-

based care.– Home-based care produced a greater sense of

burden.– Additional research shows home-based care provides

better feelings of control for the patient and the family.


Hospice care

• Economic costs of death are reduced by hospice care.

• Home-based care is a tremendous burden on the central caregiver.

• Patients and family worry about pain management in hospice care.

• Hospice care is better for supporting the grief and stress of the caregiver.


The Meaning of Death across the Lifespan

• Children’s and Adolescents’ Understanding of Death– Preschool aged children do not understand

death and believe it can be reversed.

• Some lucky people can avoid death.

• Teaching young children about biological life helps them understand death.


Children’s and Adolescents’ Understanding of Death

• School-aged children– Understand both the permanence and the universality

of death– Children’s specific experiences help with the

understanding of death.

• Adolescents– Understand that death is inevitable– Unrealistic beliefs about personal death contribute to

adolescent suicide.• Sometimes believe that death is a pleasurable experience

– Influenced by personal life experiences


The Meaning of Death for Adults

• Early adulthood– Unique invulnerability – belief that bad things,

including death, happen to others but not themselves– Possess unique characteristics that protect them from

death– Show increased fear of death following open

discussion of the process of dying

– Sudden loss of a loved one tends to shake ideas about death and invulnerability.



• Middle and late adulthood– Death changes the roles and relationships of

everyone else in the family.

– One’s view of time may be shaped by death.

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



• Death as loss– Young adults worry about loss of opportunity

to experience things and about loss of family relationships.

– Older adults worry more about the loss of time to complete inner work.

– Mexican Americans would increase time spent with family or loved ones.


Fear of Death

• Middle-aged adults are most fearful of death.

• Sense of unique invulnerability prevents intense fear of death in young adults.

• Older adults think and talk more about death than anyone else.– Leads to less fear and anxiety– May feel a period of uncertainty rather than fear


Fear of death

• Religious beliefs

– Adults who are religious are less afraid of death.

• View death as a transition from one life to another

• Religion provides adults with death stories that help them cope with their own deaths.

Copyright © Allyn & Bacon 2006Figure 19.1


Fear of Death

• 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.

– Supports Erikson’s theory of ego integrity versus despair


Questions to Ponder

• Your loved one is dying of a terminal illness. Would you use a hospice center? Why or why not?

• If you were told that you had a terminal disease and only 6 months to live, how would you want to spend your time until you died?

• On a scale of 1– 5, with 5 being high, how much do you fear death?


Preparation for Death

• Practical preparations– Purchasing life insurance

– Making a will

– Directives regarding end-of-life care – living will• Directs health care professionals about wishes for feeding tubes, or

invasive measures to prolong life

– Advance funeral planning

• Older adults are more likely to have made these arrangements.


Preparation for Death

• Deeper preparation

– Some process of reminiscence

– Unconscious changes just before death – a terminal drop for psychological health

• Persons become less emotional, introspective, and aggressive and more conventional, dependent and warm


The Process of Dying

• Elisabeth Kubler-Ross’s Stages of Dying• Denial

• Anger

• Bargaining

• Depression

• Acceptance


The Process of Dying

• Criticisms – Methodological problems

• Kubler-Ross did not interview enough people nor did she explain her sample.

– Cultural specificity• Cross-cultural studies suggest that cultures vary in

beliefs about what a “good death” is.

– The stage concept• Not all dying patients exhibit all 5 emotions, and

seldom in order.


Alternate Views

• Shneidman– Dying process has many “themes.”

• Terror, uncertainty, rescue fantasizes, incredulity, fear of pain and many more.

• Corr– Coping with death involves taking care of specific

tasks.– For health professionals, thinking in terms of helping

the patient perform tasks is more helpful than themes.


Responses to Impending Death

• Attitudes and behavioral choices can influence the course of a terminal disease.

• Steven Greer– 62 women with breast cancer– Identified 5 groups

• Denial• Fighting spirit• Stoic acceptance• Helplessness/hopelessness• Anxious preoccupation


Responses to Impending Death

• 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.


The Experience of Grieving

• Psychosocial functions of death rituals– Help family members and friends manage grief by giving a

specific set of roles to play• Expected and prohibited behaviors• Role content differs markedly from culture to culture

– Bring family members together like no other occasion• Inspire shared reminiscences and renew family relationships• Can strengthen family ties, and clarify new roles

– Funerals establish shared milestones for families.– Ceremony and ritual can help survivors understand the meaning

of death itself.


The Process of Grieving

• Factors associated with grief– Age of the bereaved

• Children express feelings of grief like teens and adults.– Sadness, crying, loss of appetite, age-appropriate anger

– Resolve their grief within the first year after death

• Teens show prolonged grief responses.– Still feel intense feelings 9 months after a death

– More likely to grieve for celebrities

– More likely to idealize peers’ suicides

– Sign of adolescent’s “what if” thinking about their ability to have prevented the death


Factors associated with grief

• Modes of Death– Widows who have cared for spouses are less likely to show

depression after death.

– Death that has intrinsic meaning reduces grief.

– Sudden and violent deaths evoke more intense grief responses.

– Suicide produces unique responses in survivors.• Family and close friends report feelings of rejection and anger.• Many feel that they should have prevented the suicide.• Bereaved are less likely to discuss the loss.• Loved ones may suffer long-term negative effects.


Widowhood

• Immediate and long term effects on the immune system– Immune system responses were suppressed initially

after death but returned to normal a year later.

• Incidence of depression among widows and widowers rises substantially.– Length of depression may be highly variable.– Mental health history, lack of social support, quality of

relationship with spouse, and economic changes influence the length and quality of depression.



Pathological Grief

• Depression-like symptoms following death of a loved one that last longer than 2 months

• Grief lasting longer than 6 months leads to long-term depression and physical ailments such as cancer and heart disease.

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


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.


Preventing Long-Term Problems

• “Talk-it-out” approach to managing grief can be helpful in preventing grief-related depression.

• Developing a coherent personal narrative of the events surrounding the spouse’s death helps manage grief.

• Participating in support groups helps.

• Appropriate amount of time off from work to grieve is important.


Theoretical Perspectives on Grieving

• Freud– Death of a loved one is an emotional trauma.

• Ego tries to insulate itself from unpleasant emotions by using defense mechanisms.

• Defense mechanisms provide only temporary relief.• To stay healthy, people must eventually examine their

emotions and their source directly.

• The more traumatic a death, the more likely it is to be followed by physical or mental problems.

• Mental illness• Post-traumatic stress disorder


Psychoanalytic Theory

• Grief therapy with children makes use of defense mechanisms.

– Sublimation – expressing their feelings through art

– Identification – watching popular films to discuss young characters’ feelings and compare the characters’ feelings to their own


Bowlby’s Attachment Theory

• Intense grief is likely to occur at the loss of any person to whom one is attached.

• 4 stages of grief– Numbness– Yearning– Disorganization and despair– Reorganization



Alternate Perspectives

• Contrary to psychoanalytic thought– Avoiding expressions of grief neither prolongs

grief nor inevitably leads to mental and physical illness.

– Grieving does not occur in fixed stages as Bowlby proposes.

• Many themes are present at the same time, but one or another may dominate.

• Adults develop different patterns of grieving.


Patterns of Grieving

• Wortman and Silver– Normal

• The person feel great distress immediately following the loss with relatively rapid recovery

– Chronic • The person’s distress continues at a high level for years

– Delayed • The person feels little distress in the first few months but high levels

of distress some months or years later

– Absent• The person feels no notable level of distress either immediately or at

any later time

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