Chapter Twelve: Psychological Issues in Advancing and Terminal Illness

1. Chapter Twelve:Psychological Issues in Advancing and Terminal Illness

2. Chapter Outline • Death across the life span • Psychological issues in advancing illness • Are there stages in adjustment to dying? • Psychological management of the terminally ill • Alternatives to hospital care for the terminally ill • Problems of survivors

3. Causes of Death in Infancy and Childhood • US: one of worst infant mortality rates • Lack of free or low-cost maternal care programs: Pre-ACA • Distinctions in class and race • Congenital abnormalities • Sudden infant death syndrome (SIDS): Condition where an infant stops breathing, which is to occur: • In lower-class urban environments

4. Causes of Death in Infancy and Childhood Sudden infant death syndrome (SIDS): Condition where an infant stops breathing, which is to occur: • In low-SES urban environments • smoking during pregnancy • baby is put to sleep on its stomach or side Children under age fifteen • Accidents • Cancer

5. Children’s Understanding of Death Ages up to four: Preoperational • Think of death as a great sleep • Curious about death • Idea that death is reversible • No biological understanding of death; cause? Ages between four and seven: Ages nine to ten: Concrete Operational • Curious about causes of death • Realize that the person who has died will not return

6. Leading Causes of Death in Adolescence and Young Adulthood Unintentional injury Homicide Suicide Cancer Heart disease AIDS

7. Reactions to Young Adult Death • Young adults facing a terminal illness • Feel shock, outrage, and an acute sense of injustice • Formal Operations Stage: abstract ideas of fairness, justice • May face a long and drawn-out period of dying

8. Death in Middle Age • Becomes more realistic since: • It is more common • Chronic health problems leading to death can develop • Premature death: Occurs before the projected age of 78 • Mainly caused by heart attack or stroke

9. Death in Middle Age • Most people prefer a sudden death as: • Their family does not have to witness their worsening condition • Finances and other resources are not severely taxed • Socioeconomic status is a strong determinant of age of death: poor die younger

10. Death in Old Age • The elderly are more prepared to face death as they have: • Seen friends and relatives die • Thought about their death and made some preparations • Causes • Degenerative diseases – Chronic Illnesses • Physical decline that predisposes them to infectious disease or organ failure

11. Death in Old Age • Factors that predict mortality in the elderly • New illnesses • Worsening of preexisting conditions • Poor mental health and reduced satisfaction with life • Women live longer than men

12. Right to Die • The Patient Self-Determination Act - Requires health facilities to have policies concerning patients’ wishes for life-prolonging therapy • “DNR” do resuscitate order • Life sustaining interventions stopped • Living will: give physicians legal protections • Right-to-die movement - dying is a matter of personal choice and personal control; Physician Assisted Suicide

13. Psychological and Social Issues Related to Dying Changes in the patient’s self-concept Issues of social interaction Communication issues

14. Kubler-Ross Stages of Dying • Denial - Patient’s initial reaction on learning of the diagnosis • Defense mechanism by which people avoid the implications of an illness • Anger - Harder response for family and friends to deal with • Patient is not really angry with them but at fate

15. Stages of Dying • Bargaining - Trading good behavior for good health • Depression - Time for anticipatory grief • Patient mourns the prospect of his/her death • Acceptance - A tired, peaceful calm descends • Patients decide to divide up their possessions and say goodbye to friends and family

16. Evaluation of Kübler-Ross’s Theory • Patients do not: • Go through the stages in a predetermined order • Fully acknowledge the importance of anxiety • One of the most common responses

17. Significance of Hospital Staff to the Patient • Provide physical assistance • Help reduce pain • See patients on a regular basis • Are the only source of realistic information • Are privy to the patient’s act of dying

18. Terminal Care • Physical care that is palliative • Palliative care: Designed to make the patient feel comfortable; dying does not need to mean suffering • Hospice Care: focus on comfort, relationships, in process of dying; palliative care, no curative care • Curative care: Designed to cure the patient’s disease

19. Risks of Terminal Care for Staff • Staff may burn out from watching patient after patient die • Patients interpret it as abandonment when the physicians spend less time with them • Physicians spend less time with terminally ill patients to dedicate their time for patients who can most profit from it

20. Management of Terminal Illness in Children • Children infer about their condition by taking cues from: • Their treatments • People around them; parents/doctors • Counseling • Helps families cope with anxiety and grief and help give direction to how to take care of ill child. • Address parents PTSD

21. Home Care • Taking care of the patient at home • Most popular and economically feasible • Provides psychological advantages for the patient • Stressful for the family

22. The Survivor • Grief: Feeling of hollowness marked by: • Preoccupation with the image of the deceased • Expressions of hostility toward others • Guilt over the death • Grief response is more aggravated in: • Men • Caregivers • People whose loss was sudden and unexpected

23. The Survivor • Biggest burden • For women - Financial strain • For men - Strains of managing a household • Death of a sibling raises complications for children • Children should be prepared for the death • Questions should be answered honestly • Information should be provided at the right time