CHAPTER 17 THE FINAL CHALLENGE: DEATH AND DYING

1. CHAPTER 17THE FINAL CHALLENGE:DEATH AND DYING

2. Learning Objectives • How is death defined? • Why is the definition of death controversial? • How does the social meaning of death vary across groups? • What factors influence life expectancy? • Is it possible to extend life expectancy? • What is the difference between programmed theories of aging and damage theories of aging? Give an example of each.

3. Matters of Life and Death – What Is Death? • A Harvard Medical School committee has defined biological death in terms of brain functioning • Total brain death is an irreversible loss of functioning in the entire brain, both the higher centers of the cerebral cortex that are involved in thought and the lower centers of the brain that control basic life processes such as breathing

4. Matters of Life and Death – What Is Death? • According to the Harvard Medical School definition, to be judged dead, a person must meet the following criteria • Be totally unresponsive to stimuli, including painful ones • Fail to move for 1 hour and fail to breathe for 3 minutes after being removed from a ventilator • Have no reflexes (for example, no eye blink and no constriction of the eye’s pupil in response to light) • Register a flat electroencephalogram, indicating an absence of electrical activity in the cortex of the brain • As an added precaution, the testing procedure is repeated 24 hours later

5. Matters of Life and Death – What Is Death? • The term euthanasia refers to hastening the death of someone suffering from an incurable illness or injury • Euthanasia means “happy” or “good” death • Active euthanasia, also called “mercy killing,” is deliberately and directly causing a person’s death (e.g., by administering a lethal dose of drugs to someone in the late stages of cancer) • Passive euthanasia means allowing a terminally ill person to die of natural causes (e.g., by withholding extraordinary life-saving treatments)

6. Matters of Life and Death – Life and Death Choices • Assisted suicide is another means by which death is hastened • Assisted suicide makes available to a person who wishes to die the means by which she may do so (e.g., writing a prescription for sleeping pills for a person with the knowledge that she likely will take an overdose)

7. Matters of Life and Death – Life and Death Choices • Medical personnel and the general public support passive euthanasia • More than 70% of U.S. adults reportedly support a doctor’s right to end the life of a patient with a terminal illness • African Americans and other minority group members are generally less accepting of actions to hasten death than European Americans

8. Matters of Life and Death – Life and Death Choices • In most U.S. states it is legal to withhold extraordinary life-extending treatments and to terminate life-support activities when that is the wish of the dying person or when the immediate family can show that such action would be consistent with the dying person’s wishes • A living will is a form of advance directive by which people can • State that they do not want extraordinary medical procedures applied to them • Specify who should make decisions on their behalf if they are unable to do so • Direct whether organs should be donated • Provide other instructions for actions to be carried out after death

9. Matters of Life and Death – Life and Death Choices • In 1997, Oregon became the first state to legalize physician-assisted suicide • Terminally ill adults with 6 or fewer months to live can request lethal medication from a physician • Those who have utilized physician-assisted suicide usually had terminal cancer and believed that they faced only hopeless pain and suffering and a loss of dignity with no chance of recovery • Forty states have enacted laws against assisted suicide

10. Matters of Life and Death – Life and Death Choices • Death may be universal, and the tendency to react negatively to loss may be too • However, the experiences of dying individuals and of their survivors are shaped by the historical and cultural contexts in which death occurs • The social meanings attached to death vary widely from historical era to historical era and from culture to culture • Different ethnic and racial groups have different rules for expressing grief and different mourning practices

11. Matters of Life and Death – What Kills Us and When? • In the U.S., life expectancy at birth is almost 78 years • The average number of years a newborn can be expected to live • The life expectancy for white males is almost 76 years • The life expectancy for white females is almost 81 years • The life expectancy for African-American males is 70 years • The life expectancy for African-American females is 77 years

12. Caption: Life expectancy at birth for the world and major areas 1950-2050

13. Matters of Life and Death – What Kills Us and When? • Death rates change over the lifespan • Infants are vulnerable, with the U.S. infant mortality rate standing at fewer than 7 out of 1,000 live births • We have a relatively small chance of dying during childhood and adolescence • Death rates climb steeply and steadily throughout adulthood

14. Matters of Life and Death – What Kills Us and When? • The causes of death change over the lifespan • Infant deaths are mainly associated with birth complications and congenital abnormalities • Preschool and school-age children’s deaths are caused by unintentional injuries or accidents (especially car accidents but also poisonings, falls, fires, and drownings) • The leading killers of adolescents are accidents (especially car accidents), homicides, and suicides

15. Matters of Life and Death – What Kills Us and When? • The causes of death change over the lifespan (continued) • Young adults die from accidents, and cancers and heart diseases also begin to take a toll • Among the 45-to-64 age group, cancers are the leading cause of death, followed by heart disease • Among adults 65 and older, heart diseases are the leading cause (more than a third of all deaths) followed by cancers and cerebrovascular diseases (strokes)

17. Matters of Life and Death – Theories of Aging • Theories to explain why we age and die fall into two categories • Programmed theories • Emphasize the systematic genetic control of aging • Damage theories of aging • Emphasize the processes that that cause errors in cells to accumulate and organ systems to deteriorate

18. Matters of Life and Death – Theories of Aging • Each species has its own characteristic maximum lifespan, or a limit on the number of years that a member of the species lives • For humans, the longest documented and verified life was 122 years • An individual’s genetic makeup combined with environmental factors will influence how rapidly he ages and how long he lives compared with other humans • A fairly good way to estimate how long you will live is to average the longevity of your parents and grandparents

19. Matters of Life and Death – Theories of Aging • Researchers have identified specific genes that may be implicated in the basic aging process • Many of these genes regulate cell division and become less active with age in normal adults • These genes are inactive in children who have progeria, a premature aging disorder caused by a spontaneous (rather than inherited) mutation in a single gene • Babies with progeria appear normal at first but age prematurely and die on average just as they are entering their teens, often of heart disease or stroke

20. Matters of Life and Death – Theories of Aging • Biological researchers suggest that humans are programmed with an “aging clock” in every cell of our bodies • Hayflick (1976, 1994) discovered that cells from human embryos could divide only a certain number of times (50 times, plus or minus 10) • This limit is referred to as the Hayflick limit • Hayflick also demonstrated that cells taken from human adults divide even fewer times, presumably because they have already used up some of their capacity for reproducing themselves • The maximum lifespan of a species is related to the Hayflick limit for that species

21. Matters of Life and Death – Theories of Aging • The mechanism of the cellular aging clock (as suggested by the Hayflick limit on cell division) is believed to be telomeres, the stretches of DNA that form the tips of chromosomes and that shorten with every cell division • The progressive shortening of telomeres eventually makes cells unable to replicate and causes them to malfunction and die • Thus, telomere length is a yardstick of biological aging • Chronic stress is implicated in the rate at which telomeres shorten • Chronic stress is linked to shorter than normal white blood cell telomeres, which in turn are associated with heightened risk for cardiovascular disease and death • Lack of exercise, smoking, obesity, and low socioeconomic status are also associated with short telomeres

22. Matters of Life and Death – Theories of Aging • Other programmed theories of aging focus on genetically programmed changes in the neuroendocrine system and the immune system • Possibly the hypothalamus serves as an aging clock, systematically altering levels of hormones and brain chemicals in later life so that we die • Perhaps aging is related to genetically governed changes in the immune system, associated with the shortening of the telomeres of its cells • These changes could decrease the immune system’s ability to defend against potentially life-threatening foreign agents such as infections, cause it to mistake normal cells for invaders (as in autoimmune diseases), and make it contribute to inflammation and disease

23. Matters of Life and Death – Theories of Aging • Damage theories generally propose that death is caused by wear and tear, an accumulation of haphazard or random damage to cells and organs over time • Free radicals (toxic and chemically unstable byproducts of metabolism) damage cells and compromise their functioning • Free radicals are produced when oxygen reacts with certain molecules in the cells • There is an extra, or “free,” electron that reacts with other molecules in the body to produce substances that damage normal cells, including their DNA • Over time, the genetic code contained in the DNA of more and more cells becomes scrambled, and the body’s mechanisms for repairing such genetic damage simply cannot keep up with the chaos • More cells then function improperly or cease to function, and the organism eventually dies

24. Matters of Life and Death – Theories of Aging • “Age spots” on the skin of older people are a visible sign of the damage free radicals can cause • Free radicals have also been implicated in some of the major diseases that become more common with age, most notably, cardiovascular diseases, cancer, and Alzheimer’s disease • The most concerning effect of free radicals is damage to DNA because the result is more defective cells replicating themselves

25. Matters of Life and Death – Theories of Aging • Research on the basic causes of aging and death may lead to methods for increasing longevity • Stem cell researchers may discover ways to replace aging cells or modify aging processes • Researchers have also established that the enzyme telomerase can be used to prevent the telomeres from shortening and thus keep cells replicating and working longer • However, telomerase treatments could go awry if they also make cancerous cells multiply more rapidly

26. Matters of Life and Death – Theories of Aging • Research on the basic causes of aging and death may lead to methods for increasing longevity (continued) • Some researchers are focusing on preventing the damage caused by free radicals • Antioxidants such as vitamins E and C (or foods high in them such as raisins, spinach, and blueberries) may increase longevity by inhibiting free radical activity and in turn helping prevent age-related diseases

27. Matters of Life and Death – Theories of Aging • Research on the basic causes of aging and death may lead to methods for increasing longevity (continued) • At present, the most successful life-extension technique is caloric restriction, ahighly nutritious but severely restricted diet representing a 30-40% or more cut in normal total caloric intake • Laboratory studies involving rats and primates suggest that caloric restriction extends both the average longevity and the maximum lifespan of a species and that it delays or slows the progression of many age-related diseases • Caloric restriction reduces the number of free radicals and other toxic products of metabolism

28. Learning Objectives • What are Kübler-Ross’s stages of dying? • How valid and useful is the theory? • What is the Parkes/Bowlby attachment model of bereavement? • Is there evidence to support this model? • What is the dual-process model of bereavement? • Is there evidence to support this model?

29. The Experience of Death – Perspectives on Dying • Psychiatrist Elizabeth Kübler-Ross (1969, 1974) interviewed terminally ill patients and identified a common set of emotional responses to the knowledge that one has a serious, and probably fatal, illness • Kübler-Ross’s “stages of dying” called attention to the emotional needs and reactions of dying people

30. The Experience of Death – Perspectives on Dying • Kübler-Ross’s “stages of dying” are as follows • Denial and isolation • Anger • Bargaining • Depression • Acceptance

31. The Experience of Death – Perspectives on Dying • Kübler-Ross’s theory has been criticized • Dying is not stagelike • The nature and course of an illness affects reactions to it • Individuals differ widely in their emotional responses to dying • Personality traits, coping styles, and social competencies vary and influence the experience of dying

32. The Experience of Death – Perspectives on Bereavement • Responses to the death of a loved one may be differentiated • Bereavement is a state of loss • Griefis an emotional response to loss • Mourningis a culturally prescribed way of displaying reactions to death

33. The Experience of Death – Perspectives on Bereavement • Relatives and friends also experience painful emotions before the death • They may experience anticipatory grief, grieving before death occurs for what is happening and for what lies ahead • Anticipatory grief can lessen later distress and improve outcomes of bereavement if it involves accepting the coming loss • However, no amount of preparation and anticipatory grief can entirely eliminate the need to grieve after the death occurs

34. The Experience of Death – Perspectives on Bereavement • The Parkes/Bowlby attachment model of bereavement describes four predominant reactions to loss • Numbness • A sense of unreality and disbelief • Yearning • Severe pangs of grief, feelings of panic, bouts of uncontrolled weeping, physical pain • Disorganization and despair • Depression, despair, and apathy predominate. • Reorganization • Feel ready for new activities. • Identity is revised

35. The Experience of Death – Perspectives on Bereavement • The process of grieving normally takes a year or more for widows and widowers but can take much longer

36. Caption: Peak times for different grief reactions in the Parkes-Bowlby phase model of grief in a sample of adults whose loved ones died of natural causes

38. The Experience of Death – Perspectives on Bereavement • Stroebe and Schut (1999) have suggested a dual-process model of bereavement in which the bereaved move between coping with the emotional blow of the loss and coping with the practical challenges of living, revising their identities, and reorganizing their lives • Loss-oriented coping involves dealing with one’s emotions and reconciling oneself to the loss • Restoration-oriented coping is focused on managing daily living and mastering new roles and challenges

39. The Experience of Death – Perspectives on Bereavement • Stroebe and Schut (1999) have suggested a dual-process model of bereavement (continued) • Both processes in the dual-process model can involve positive and negative emotions (happy memories, painful memories) • Over time, the emphasis shifts from loss-oriented to restoration-oriented coping • As less time and energy need to be devoted to coping with grief, the balance of positive and negative emotions shifts in a positive direction

40. Caption: The dual-process model of coping and bereavement

41. Learning Objective • What is the infant’s understanding of separation and death?

42. The Infant • Infants lack the concept of death as permanent separation or loss and lack the cognitive capacity to interpret what has happened • However, infants develop an understanding of concepts that pave the way for an understanding of death • Possibly, infants first form a global category of things that are “all gone” and later divide it into subcategories, one of which is “dead”

43. The Infant • Attachment theory provides a means for understanding infants’ reactions to loss of an attachment figure • Infants first engage in vigorous protest, yearning and searching for the loved one and expressing outrage when they fail • When an infant has not succeeded in finding the loved one, he begins to despair, displaying depression-like symptoms • The baby loses hope, ends the search, and becomes apathetic and sad • Grief may be reflected in a poor appetite, a change in sleeping patterns, excessive clinginess, or regression to less mature behavior

44. The Infant • Attachment theory provides a means for understanding infants’ reactions to loss of an attachment figure (continued) • Then the bereaved infant enters a detachment phase, in which he takes renewed interest in toys and companions and may begin to seek new relationships • Infants will recover from the loss of an attachment figure most completely if they can rely on an existing attachment figure (for example, the surviving parent) or have the opportunity to attach themselves to someone new

45. Learning Objectives • How do children’s conception of death compare to a “mature” understanding of death? • What factors might influence a child’s understanding of death? • What is a dying child’s understanding of death? • How do dying children cope with the prospect of their own death? How do children grieve?

47. The Child – Grasping the Concept of Death • Children between age 3 and age 5 have limited understanding of death, especially its universality • They may believed the dead live under altered circumstances and retain some capacities (experience hunger, continue to love) • They may see death as reversible (as sleep, as a trip, or something that can be remedied with medical care) • They may think death is caused by an external agent

48. The Child – Grasping the Concept of Death • Most children between age 5 and 7 understand that death is characterized by finality (cessation of life functions), irreversibility, and universality • By age 10, children understand the biological causality of death • The hardest concept of death for children to grasp

49. The Child – Grasping the Concept of Death • Children’s concepts of death are influenced by the cultural context in which they live, their life experiences, and the specific cultural and religious beliefs to which they are exposed • A mature understanding of death is correlated with IQ

50. The Child – Grasping the Concept of Death • To help children understand death, experts suggest that parents • Avoid the use of euphemisms to explain death (“asleep” or “gone away”) • Give simple, honest answers to children’s questions • Take advantage of opportunities (such as death of a pet) to teach children about death and express their emotions