Chapter 19

Chapter 19

Death and Dying

Chapter Outline

I. Death and dying across the lifespan.

A. Defining death is a complex decision.

1. FUNCTIONAL DEATH is the absence of a heartbeat and breathing.

a) People can be resuscitated after they have stopped breathing.

b) People can be kept alive by a machine.

2. BRAIN DEATH, where brain activity is measured, has become the medical measure of death.

a) There is still some question about using only brain waves

as the death definition.

b) It emphasizes only biology not the qualities that make people human (thinking, feeling, etc.).

B. Death Across the Life Span: Causes and Reactions

1. Infant and Childhood deaths: the U.S. has a high infant mortality rate.

a) Parents dealing with infant death have a very hard time and depression is a common reaction.

b) Prenatal death (miscarriage) is also difficult, especially since others do not attribute much meaning to a miscarriage so parents feel isolated.

c) In SUDDEN INFANT DEATH SYNDROME (SIDS), a seemingly healthy baby stops breathing and dies.

(1) SIDS usually strikes between 2 and 4 months, suddenly.

(2) There is no known cause for SIDS so parents often feel intense guilt (and acquaintances may be suspicious).

d) Accidents are the most frequent cause of death in childhood but there are a substantial number of homicides (4th leading cause of death between ages 1 and 9).

e) For parents the loss of a child is profound.

2. Children do not have a realistic view of death.

a) Before age 5, children see death as temporary, like sleeping.

b) By age 5 children have begun to accept death as universal and final.

3. Adolescents’ view of death is also unrealistic and often highly romantic.

a) The most frequent cause of adolescent death is accidents.

b) Adolescents tend to feel invulnerable so confronting a terminal illness can be difficult; they often feel angry and cheated.

4. Death in young adulthood is particularly difficult because it is the time in life when people feel most ready to begin their own lives.

a) Young adults facing death have several concerns.

(1) Developing intimate relationships and one’s sexuality.

(2) Future planning (e.g., marry or not? have children?).

b) Like adolescents, young adults are outraged at impending death and may direct anger toward their care providers.

5. Life-threatening disease is the most common cause of death in middle-aged adults.

a) These adults are more aware and accepting of death but also have a lot of fears (more than any other time in lifespan).

b) Most frequent causes are heart attack or stroke -- both of which are sudden.

6. The prevalence of death and losses around older adults makes them less anxious about dying than at any other time of life.

a) Suicide rate increases with age for men.

b) Caucasian men over age 85 have the highest rate of suicide.

c) Impending death is sometimes accompanied by acceleration of declines in cognitive functioning – the terminal decline.

d) A major issue for seniors with a terminal disease is whether their lives still have value and how much of a burden they are.

7. Most people know when they are dying; it is caretakers who tend to have more difficulties communicating about it.

C. Developmental Diversity: Differing Conceptions of Death

1. People’s responses to death take different forms, particularly in different cultures.

a) Some societies view death as a punishment or as a judgment.

b) Others see it as a redemption.

c) Some see death as the start of an eternal life.

d) In some cultures children learn about death at an early age.

D. THANATOLOGISTS, people who study death, suggest that death education be part of everyone’s schooling since we are all affected.

II. Confronting Death

A. Elisabeth Kübler-Ross identified five stages of coping with death.

1. Denial

a) Denial is resisting the whole idea of death (No I’m not or she’s not!).

b) Denial is a form of defense mechanism to allow one to absorb difficult information at one’s own pace.

2. Anger

a) “Why me/her?” “Why not you?”

b) In this stage people may be very difficult to be around.

3. Bargaining

a) At this stage individuals are trying to negotiate their way out of the death.

b) Typically, people try to make deals with God.

c) Sometimes the bargain creates an event or date until which the person can hold on (such as a grandchild's wedding, or a 100th birthday).

4. Depression

a) The individual at this stage is overwhelmed by a deep sense of loss.

b) Reactive depression is a type of depression based on what has already occurred, such as loss of dignity, health, etc.

c) Preparatory depression is the anticipation of future losses, such as the loss of a relationship.

5. Acceptance

a) In this stage individuals near death make peace with death and may want to be left alone.

b) Persons in this stage are often unemotional and uncommunicative.

6. Criticisms of Kübler-Ross’s model

a) The theory does not apply to people who are not sure they are going to die -- when the prognosis is ambiguous.

b) The stages are not universal, nor do people go through them in progression.

c) Anxiety, especially about pain, is omitted in her stages and this is an important concern for cancer patients.

d) There are still a lot of differences in peoples’ reactions to death related to family, culture, finances, personality, etc.

e) However, Elisabeth Kübler-Ross is still influential and is credited with being the first person to bring the phenomenon of death into public awareness.

B. Choosing the Nature of Death: Is DNR the Way to Go?

1. The letters "DNR" (do not resuscitate) mean that medical personnel should not go to extraordinary or extreme efforts to save the terminally ill patient.

a) The terms "extraordinary" or "extreme" are difficult to define.

b) No one likes to make this decision.

c) It is sometimes difficult to get medical personnel to follow these directives.

2. LIVING WILLS, legal documents designating what medical treatments people want or do not want if they cannot express their wishes, are a method of letting people gain control over their deaths.

a) Often comas are not covered, since they may be considered "non-terminal."

b) Some living wills specify a health-care proxy to act as a person's representative in making health-care decisions.

3. Assisted suicide is a death in which a person provides the means for

a terminally ill patient to commit suicide.

a) Dr. Jack Kevorkian is best known for this role and has been prosecuted in the U.S.

b) Laws are more accepting in other countries (e.g., Netherlands).

c) Assisted suicide is one form of EUTHANASIA, the practice of assisting terminally ill people to die more quickly.

(1) Passive euthanasia involves removing respirators or other medical equipment that may be sustaining life.

(2) Voluntary active euthanasia is where caregivers or medical staff act to end a person’s life before death would normally occur.

(3) No one knows how widespread euthanasia is.

(4) Euthanasia is high controversial since it centers on decisions about who should control life.

C. Caring for the Terminally Ill: The Place of Death

1. For the terminally ill, hospitals may not be the best places to die.

2. Hospitals are impersonal, expensive, and designed to make people better and many people die alone.

3. In HOME CARE, an alternative to the hospital, people stay in their homes and receive comfort and treatment from their families and visiting medical staff.

a) Many people prefer to die in familiar surroundings with the people and things they have loved around them.

b) Home care can be very difficult for the family.

4. HOSPICE CARE, care provided for the dying in institutions devoted to those who are terminally ill.

a) The term "hospice" comes from the Middle Ages where hospices were places that provided comfort and hospitality to travelers.

b) The focus of hospice care is not to try and cure the patient, but to make their final days pleasant, meaningful, and pain-free.

c) Some hospice workers allow the terminally ill to live at home.

d) Research shows that hospice patients seem to be more satisfied with their care than hospital patients.

III. Grief and Bereavement

A. Mourning, funerals, and forms of last rites.

1. Funerals are a big business.

2. Death represents an important passage for the individual and the society, so the associated rite is important.

3. Funerals are also recognition of everyone’s ultimate mortality and an acceptance of the cycle of life.

a) Western funeral rituals typically include:

(1) Preparation of the body

(2) A religious ritual

(3) A eulogy

(4) A procession

(5) A wake or Shiva

(6) Military funerals include firing weapons and a flag on the coffin

b) Funeral patterns are differ in different cultures but all have the same function: to mark the endpoint of the life of the person who has died and the starting point for the survivors, from which they can resume their lives.

B. Bereavement and Grief: Adjusting to the Death of a Loved One

1. BEREAVEMENT is the acknowledgment of the objective fact that one has experienced a death.

2. GRIEF is the emotional response to that loss.

3. There are some general stages people go through in adjusting to loss.

a) Shock, denial, and numbness allows a person to function in coping with death (funeral, etc.) without being overwhelmed.

b) In the second stage, people begin to confront the death and fully realize the extent of their loss.

(1) They fully experience their grief and yearn for the individual.

(2) Eventually the person moves through the pain and depression to a realistic review of the relationship and start to let go.

c) Finally, people reach an accommodation stage where they pick up the pieces of their lives and move on.

d) Differentiating unhealthy grief from healthy grief is difficult and many of the common assumptions are wrong.

(1) There is no timetable; many people take longer than 1 year.

(2) Not everyone experiences deep depression.

(3) People who do not show deep, initial grief do not necessarily have problems later.