Chapter 16: Understanding Death, Dying, and Bereavement

1. Chapter 16:Understanding Death, Dying, and Bereavement

2. Understanding Death, Dying, and Bereavement • Chapter Objectives • To understand the role of mortality in shaping psychosocial development • To define the biological state of death • To describe factors associated with the process of dying and the modern ideal of a good death • To describe death-related rituals and their functions • To analyze factors that affect grief and bereavement

3. Understanding Death, Dying, and Bereavement • Thanatology is the field of science that addresses dying and death, as well as the psychological mechanisms of coping with them

4. Understanding Death, Dying, and Bereavement • Mortality And Psychosocial Development • In infancy, as one achieves a balance between trust and mistrust, an outlook of hopefulness emerges • This outlook shapes one’s orientation toward risk, toward transitions, and ultimately, toward death • If one has lived a life of hopefulness about the future, this same orientation is likely to extend toward one’s beliefs about death, a sense that whatever follows the death of the physical body is going to be good

5. Understanding Death, Dying, and Bereavement • Mortality And Psychosocial Development (cont.) • In the resolution of the crisis of identity versus role confusion one confronts the need to impose a sense of meaning on one’s life • The crisis of generativity versus stagnation brings the issue of mortality even more to center stage • Developing a point of view about death is a major developmental task during later adulthood • Finally, the crisis of immortality versus extinction brings the confidence of continuity

6. Understanding Death, Dying, and Bereavement • Mortality And Psychosocial Development (cont.) • Over time, direct personal experiences with dying and death have changed • Beginning with the works of Elizabeth Kübler-Ross, the needs of the dying person were given a voice

7. Understanding Death, Dying, and Bereavement • Definitions Of Death • The definition of death has changed • Used for 100s of years, the criteria for death were lack of a heartbeat and lack of respiration called cardiopulmonary death

8. Understanding Death, Dying, and Bereavement • Definitions Of Death (cont.) • In 1981, the President’s Commission for the Ethical Study of Problems in Medicine and Biomedical and Behavioral Research identified eight criteria for determination of whole-brain death • No spontaneous movement in response to any stimuli • No spontaneous respirations for at least one hour • Total lack of responsiveness to even the most painful stimuli • No eye movements, blinking, or pupil responses

9. Understanding Death, Dying, and Bereavement • Definitions Of Death (cont.) • In 1981, the President’s Commission for the Ethical Study of Problems in Medicine and Biomedical and Behavioral Research identified eight criteria for determination of whole-brain death (cont.) • No postural activity, swallowing, yawning, or vocalizing • No motor reflexes • A flat electroencephalogram (EEG) for at least ten minutes • No change in any of these criteria when they are tested again 24 hours later

10. Understanding Death, Dying, and Bereavement • Definitions Of Death (cont.) • In addition to these eight criteria, certain other conditions such as deep coma have to be ruled out • There are two areas in the brain that control different types of life functions: the brainstem controls heartbeat and respiration; and the cortex controls sensory integration and cognitive function • It is possible for a person’s brainstem functions to continue even when there is no cortical functioning, called a persistent vegetative state

11. Understanding Death, Dying, and Bereavement • Definitions Of Death (cont.) • Because there are a variety of technologies that can extend life when a person is no longer able to communicate his or her preferences, it is recommended that adults prepare some form of advance directive such as a durable power of attorney or a living will

12. Understanding Death, Dying, and Bereavement • The Process Of Dying • People can experience death in many different ways • A dying trajectory is the time during which the person’s health goes from good to death • Certain illnesses such as some cancers or AIDS result in a gradual decline. Under these conditions, people have more time to acknowledge their death and to plan for it

13. Understanding Death, Dying, and Bereavement • The Process Of Dying (cont.) • Some people experience unpredictable, sudden death in the midst of a healthy life as in an automobile accident, by homicide, or a heart attack. This trajectory does not allow the person to confront the reality of death

14. Understanding Death, Dying, and Bereavement • The Process Of Dying (cont.) • For some, death involves an ambiguous decline in which periods of illness may alternate with periods of remission such as in the case of leukemia or muscular dystrophy. For these people, there is a complex process of learning to live with a terminal disease in which there may be periods of health as well as periods of decline

15. Understanding Death, Dying, and Bereavement • Case Study: Too Late To Die Young • Thought Questions • What are the challenges of facing an ambiguous trajectory? For the dying person? For close relatives? • What are some of the possible reasons for Harriet’s depression at age 30? • According to psychosocial theory, what are some of the life themes that Harriet is facing at age 4? At age 30? • How might her psychosocial development be affected by her illness at age 4 and age 30? By her sense of herself as someone who is dying?

16. Understanding Death, Dying, and Bereavement • Case Study: Too Late To Die Young (cont.) • Thought Questions (cont.) • What are some of Harriet’s coping strengths? Weaknesses? • If you were Harriet’s parents, what would you do to try to prepare Harriet for her life? For her death?

17. Understanding Death, Dying, and Bereavement • The Good Death • The Hospice Education Institute (2001) offers the following goals for high quality end-of-life care: • Promote relief from pain • Integrate the psychological and spiritual aspects of patient care • Offer a support system to help patients live as actively as possible until death • Help the family cope during the patient’s illness and their own bereavement

18. Understanding Death, Dying, and Bereavement • The Good Death (cont.) • Spouse was at peace with the idea of dying • Spouse was aware of impending death • Respondent and spouse discussed the death • Respondent was with spouse at the moment of death • The spouse led a full life • The spouse was not in pain • The spouse did not receive negligent care

19. Understanding Death, Dying, and Bereavement • Hospice Care • Hospice is an integrated system of medicine, nursing, counseling, and spiritual care for the dying person and family • Its goal is to achieve the highest possible quality of life for the dying person and the family, alleviating physical and emotional pain to the degree possible, while supporting family strengths to cope with the process of dying, loss of the loved one, and long-term bereavement

20. Understanding Death, Dying, and Bereavement • Hospice Care (cont.) • Hospice care differs from traditional hospital care in that the focus is on enhancing quality of life for the dying person and his or her loved ones rather than treating the disease or intervening to delay the end of life

21. Understanding Death, Dying, and Bereavement • Hospice Care (cont.) • Clear guidelines have been established for the range and quality of services hospices must offer in order to received Medicare reimbursements, and an increasing range of educational and training programs have emerged to provide professional interdisciplinary training for those working in hospice and end-of-life care settings

22. Understanding Death, Dying, and Bereavement • Euthanasia • Euthanasia is the practice of ending someone’s life for reasons of mercy • Passive euthanasia refers to withholding treatment or removing life-sustaining nourishment and breathing aids • Active euthanasia are activities designed to end a person’s life • Mercy killing involves taking a person’s life

23. Understanding Death, Dying, and Bereavement • Euthanasia (cont.) • Physician-assisted suicide involves either the administration of a lethal dose of some medication by a physician or arranging for a terminally ill patient to administer his or her own lethal dose of medication using a suicide machine

24. Understanding Death, Dying, and Bereavement • Ethical Issues at the End of Life • End of life decisions are not only relevant for the elderly; they may be addressed when parents decide to limit treatment for a terminally ill child; when family members decide to remove life support for an adult who is in a vegetative state, or when a person seeks assisted suicide in order to avoid the inevitability of decline into an immobile or helpless state

25. Understanding Death, Dying, and Bereavement • Ethical Issues at the End of Life (cont.) • The matter is made even more complex as decisions about ending life conflict with the commitment of the medical profession to prolong life • As a result of many new technologies, medications, and genetic interventions, there are ongoing innovations that may be effective in slowing the progression of a disease or sustaining life even if the condition cannot be cured

26. Understanding Death, Dying, and Bereavement • Ethical Issues at the End of Life (cont.) • Most people agree that when a dying person who is in extreme pain asks a doctor to end his or her life that request should be honored • Despite public opinion supporting measures to actively end life, these measures are illegal in the United States, with the exception of Oregon, and continue to be a topic of ethical controversy

27. Understanding Death, Dying, and Bereavement • Ethical Issues at the End of Life (cont.) • Some opponents argue that legalizing assisted suicide might put unnecessary pressure on the elderly to end their lives rather than be a burden to their families or to use precious financial resources for end-of-life care.

28. Understanding Death, Dying, and Bereavement • Death-Related Rituals • The American culture’s rituals surrounding death of a loved on permit adults to cope with death-related anxiety • The elaborate arrangements for a burial service allow adults to work through the reality of their own death by focusing on aspects of it over which they can exercise some control • To appreciate how people cope with death, it is helpful to consider the cultural rituals that have emerged for structuring the response to death

29. Understanding Death, Dying, and Bereavement • Death-Related Rituals (cont.) • Care of the Body • Most funeral preparations include specific practices for caring for the corpse and cultures have different practices concerning how quickly the body is to be disposed of after death • Care of the Spirit • Most cultures believe that there is a spiritual component of a person’s being that is not destroyed as the body decomposes or burns • Certain funeral practices are designed to help the spirit make a transition to whatever existence the culture believes take place after death

30. Understanding Death, Dying, and Bereavement • Death-Related Rituals (cont.) • Care of the Surviving Family, Friends, and Community • Death rituals are important for helping the people who remain to cope with their grief and to reorient their lives in a world without the person who died • These rituals allow society to elaborate the meaning of death and to decrease the ambiguity surrounding death • In the United States, people typically have a will, which is read to the heirs; a ritual that provides for the distribution of resources and assets according to the deceased person’s wishes

31. Understanding Death, Dying, and Bereavement • Grief and Bereavement • Grief is the cognitive and emotional reactions that follow the death of a loved one • Grief can vary in duration and intensity, and it can fade and reappear at unexpected moments • Bereavement is the long-term process of adjustment to the death of a loved one and is more all-encompassing than grief • In the face of bereavement, there is a need to work through the reality of the loss as well as the feelings that accompany it

32. Understanding Death, Dying, and Bereavement • Grief and Bereavement (cont.) • The depression and confusion accompanying grieving may decrease the survivors’ sensitivity to their own physical health and pose risks to their mental health as well • Among people who have lost a spouse, intense depression is more likely to be experienced by those who described their marriage as positive and vital

33. Understanding Death, Dying, and Bereavement • Grief Work • In the face of bereavement, there is a need to work through the reality of the loss as well as the feelings that accompany it • Lindemann’s 3 Phases of Grief Reaction: • The person must achieve “emancipation from bondage to the deceased” • The person must make an adjustment to all the aspects of the environment from which the deceased is missing • The person must begin to form new relationships—what we have called redirecting energy to new roles

34. Understanding Death, Dying, and Bereavement • Grief Work (cont.) • Questions have been raised about how universally applicable Lindemann’s idea of grief work really is. In some cultures, intense emotional expressions of grief are considered inappropriate • The context of death and its meaning for those who mourn suggests a more individualized view of the adaptive process of bereavement

35. Understanding Death, Dying, and Bereavement • Five Patterns of Bereavement Among Widows • The common grief pattern • These people had low levels of depression before the spouse dies. They experienced an increase in depression six months after the loss. They returned to the same low level of depression after 18 months characterized them before the loss • The resilient pattern • People in this group had low levels of depression before the death of the spouse and continued to have low levels after the death of the spouse

36. Understanding Death, Dying, and Bereavement • Five Patterns of Bereavement Among Widows (cont.) • Chronic grief pattern • These people had low pre-loss depression but showed increased grief responses at 6 months and 18 months after the loss • Chronic depression pattern • These people had high levels of depression before the loss and depression continued at high levels at 6 and 18 months • Depressed-improved pattern • These people had elevated levels of depression before the loss, but lower depression scores at 6 and 18 months after the loss

37. Understanding Death, Dying, and Bereavement • Factors that Affect the Distress of Survivors • Bereavement may be more difficult for those who lose a loved one in a sudden death • Bereavement may be difficult if the dying person is unable to receive effective pain control in their last days of life

38. Understanding Death, Dying, and Bereavement • Factors that Affect the Distress of Survivors (cont.) • Ambiguous loss is another especially difficult challenge for loved ones • A person is missing and may be dead, as in soldiers who are missing in action or people who may have died in a disaster, but there are no physical remains • A person is physically present but unable to participate in any meaningful way in family interactions, as when a person is in a coma or in late stages of Alzheimer’s disease

39. Understanding Death, Dying, and Bereavement • Factors that Affect the Distress of Survivors (cont.) • Religiosity leads to lower levels of anxiety and anger for the survivors and may provide them with an analysis of the meaning of the death of their loved one • Finally, bereavement may be difficult if the survivor has experienced many positive benefits of caregiving, including feelings of being needed, important, and effective as they addressed the needs of an ailing spouse

40. Understanding Death, Dying, and Bereavement • Factors that Affect the Distress of Survivors (cont.) • Unacknowledged and Stigmatized Loss • The bereavement process is influenced by a society’s interpretation of who the legitimate mourners are and who has experienced a legitimate death

41. Understanding Death, Dying, and Bereavement • Factors that Affect the Distress of Survivors (cont.) • Stigmatized deaths are those in which people attribute the death to an immoral, illegal, or evil cause • Death by suicide is an example of a stigmatized death in which survivors may feel guilty about not having been able to prevent the death and anger at that person for killing themselves • AIDS is another example of a stigmatized loss

42. Understanding Death, Dying, and Bereavement • Psychosocial Growth Through Bereavement • Bereavement brings new opportunities for psychosocial growth • The intense experiences of sadness and emptiness are universal human emotions. Even though they are unpleasant, the emotions associated with grief connect people to their essential human nature • Grief stimuli leads to greater levels of understanding of oneself and others • When a person who is close dies, it stimulates reflection about that relationship

43. Understanding Death, Dying, and Bereavement • Psychosocial Growth Through Bereavement (cont.) • The death of a loved one may stimulate the process of life review by causing you to think about the meaning of your own life • The loss of someone whose presence serves to help you define your identity will require a redefinition of your identity • When a person you admire dies, it often promotes new levels of identification with the deceased

44. Understanding Death, Dying, and Bereavement • Psychosocial Growth Through Bereavement (cont.) • Introjection is different from identification, in that the person feels that the lost person is in them Introjection allows the bereaved person to keep the dead person alive and to preserve their relationship • The depth of emotion created by the death of someone close helps a person understand the value of their own life and the emotions that significant others will experience when they die