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Chapter 19. Death and Grieving . Defining Death and Life/Death Issues. Issues in Determining Death . Brain death – a neurological definition of death that states a person is brain dead when all electrical activity of the brain has ceased for a specified period of time.

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Chapter 19 l.jpg

Chapter 19

Death and Grieving

©2008 McGraw-Hill Ryerson Ltd.




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Defining Death and Life/Death Issues

Issues in Determining Death

Brain death – a neurological definition of death that states a person is brain dead when all electrical activity of the brain has ceased for a specified period of time.

©2008 McGraw-Hill Ryerson Ltd.


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Defining Death and Life/Death Issues

Issues in Determining Death

  • The higher portions of the brain die first.

  • The brain’s lower portions monitor vital functions.

  • People whose higher brain areas have died may continue breathing & have a heartbeat.

  • The current definition of brain death (for most physicians) includes the death of both the higher cortical functions & lower brain stem functions.

©2008 McGraw-Hill Ryerson Ltd.


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Defining Death and Life/Death Issues

Decisions Regarding Life, Death, and Health Care

  • Living Wills and DNRs

  • Euthanasia

  • Needed: Better Care for Dying Individuals

©2008 McGraw-Hill Ryerson Ltd.


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Defining Death and Life/Death Issues

Living Will

  • Recognizing that terminally ill patients might prefer to die rather than linger in a painful or vegetative state, an organization called “Choice in Dying” created the Living Will.

  • The Living Will document is designed to be filled in while the individual can still think clearly & expresses their desire that extraordinary medical procedures not be used to sustain life when the medical situation becomes hopeless.

©2008 McGraw-Hill Ryerson Ltd.


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Defining Death and Life/Death Issues

DNRs

  • DNR, or Do Not Resuscitate is an order preventing medical staff within a medical institution to use either specified or all means to prolong a person’s life or to resuscitate the person if their heart stops.

  • DNR can be arranged without a living will.

©2008 McGraw-Hill Ryerson Ltd.


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Defining Death and Life/Death Issues

Euthanasia

  • Euthanasia is the act of painlessly ending the lives of individuals who are suffering from an incurable disease or severe disability.

  • Sometimes referred to as “mercy killing.”

  • Passive euthanasia – occurs when a person is allowed to die by withholding available treatment, such as withdrawing a life-sustaining device.

  • Active euthanasia – occurs when death is deliberately induced, as when a lethal dose of a drug is injected.

©2008 McGraw-Hill Ryerson Ltd.


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Defining Death and Life/Death Issues

Attitudes about Euthanasia

  • Passive euthanasia for terminally ill patients is accepted.

  • Precise boundaries for passive euthanasia & the exact mechanisms by which treatment decisions should be implemented are not entirely agreed upon.

  • Active euthanasia is a crime in most countries & in all U.S. states except Oregon.

  • Walker, Gruman & Blank’s (1999) recent survey of more than 900 physicians found most opposed active euthanasia & believed that adequate pain control eliminated the need for active euthanasia.

©2008 McGraw-Hill Ryerson Ltd.


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Defining Death and Life/Death Issues

Needed: Better Care for Dying Individuals

  • The Canadian Senate report on end-of-life found:

  • Only 1-in-10 Canadians received proper care as they die.

  • Dying individuals often get too little or too much care.

  • Many experience severe pain during their last days.

  • Regulations are needed that allow physicians flexibility in prescribing painkillers for dying patients who need them.

  • Many health-care professionals are not trained to provide adequate end-of-life care.

©2008 McGraw-Hill Ryerson Ltd.


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Defining Death and Life/Death Issues

Palliative Care

  • Palliative care is a humanized program committed to making the end of life as free from pain, anxiety, & depression as possible.

  • Palliative care goals contrast with those of hospitals, which are to cure illness & prolong life.

©2008 McGraw-Hill Ryerson Ltd.



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Death and Socio-historical Cultural Contexts

Changing Historical Circumstances

  • One historical change already presented is the increasing complexity of determining when someone is truly dead.

  • Another change is the age group death strikes most often—200 years ago it was children, now it is the elderly.

  • Life expectancy has increased by 50 years since 1900.

  • In the past, most people died at home.

  • 80% of all deaths now occur in institutions, minimizing our exposure to death.

  • Care of the dying has shifted away from families.

©2008 McGraw-Hill Ryerson Ltd.


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Death and Socio-historical Cultural Contexts

Perceptions of Death

  • In most societies, death is not viewed as the end of existence—though the biological body has died, the spiritual body is believed to live on.

  • Some cultures:

    • believe death is caused by magic and demons.

    • believe death is caused by natural forces.

    • focus on reincarnation.

    • view death as punishment, while for others it represents redemption.

    • fear death, while others embrace it.

©2008 McGraw-Hill Ryerson Ltd.


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Death and Socio-historical Cultural Contexts

Death in Different Cultures

  • North Americans are death avoiders & death deniers.

  • People in many countries face death on a daily basis.

  • In some countries, the presence of dying family members & large funeral attendance are part of everyday cultural reality.

  • These aspects of life help prepare the young for death & provide them with guidelines on how to die.

©2008 McGraw-Hill Ryerson Ltd.


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Death and Socio-historical Cultural Contexts

Evidence of the Denial of Death

  • The funeral industry glosses over death & fashions lifelike qualities in the dead

  • Euphemistic language for death is used (passed away).

  • There is a persistent search for a fountain of youth

  • Rejection & isolation of the aged, who may remind us of death, is common.

  • Belief in the concept of a pleasant & rewarding afterlife, suggests that we are immortal

  • Medical practices emphasis prolonging biological life rather than an emphasizing diminishing human suffering

©2008 McGraw-Hill Ryerson Ltd.



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A Developmental Perspective on Death

Causes of Death and Expectations about Death

  • Death can occur at any point in the human life span.

  • Childhood deaths occur mostly due to accidents or illness.

  • Adolescent deaths are more likely to occur because of motor vehicle accidents, suicide, & homicide.

  • Younger adults are more likely to die from accidents.

  • Older adults are more likely to die from chronic diseases.

  • Younger adults who are dying feel cheated by death more than do older adults who are dying.

©2008 McGraw-Hill Ryerson Ltd.


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A Developmental Perspective on Death

Attitudes toward Death at Different Points in the Life Span

  • Childhood

  • Adolescence

  • Adulthood

©2008 McGraw-Hill Ryerson Ltd.


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A Developmental Perspective on Death

Childhood

  • Infants have no concept of death, but once they develop an attachment, they can experience loss, separation & anxiety.

  • Children 3–5 years old don’t have a true idea of what death really means, often confusing death with sleep.

  • Young children believe death is reversible & the dead can be brought back to life spontaneously.

  • Cuddy-Casey & Orvaschel’s (1997) research found children don’t understand death is universal & irreversible until about age 9.

©2008 McGraw-Hill Ryerson Ltd.


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A Developmental Perspective on Death

Explaining Death to Children

  • Psychologists recommend :

  • honesty in discussing death with children.

  • Answering children’s questions about death based on the child’s age & maturity level.

  • Death can be explained to preschool children in simple physical & biological terms.

  • Children need reassurance that they are loved & that they will not be abandoned.

  • Regardless of age, adults should be sensitive & sympathetic, encouraging children to express their own feelings & ideas.

©2008 McGraw-Hill Ryerson Ltd.


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A Developmental Perspective on Death

Adolescence

  • The prospect of death is so remote for adolescents that it does not have much relevance.

  • Death may be avoided, glossed over, kidded about, neutralized, & controlled by a cool spectator-like orientation.

  • Adolescents have more abstract conceptions of death than children do.

  • Adolescents develop religious & philosophical views about the nature of death & whether there is life after death.

  • Adolescents are especially likely to think that they are invincible, unique & immune to death.

©2008 McGraw-Hill Ryerson Ltd.


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A Developmental Perspective on Death

Adulthood

  • There is no evidence that a special orientation towards death develops in early adulthood.

  • An increase in consciousness about death accompanies individuals’ awareness that they are aging.

  • Kalish & Reynolds’ (1976) study found adults at midlife fear death more than do young adults or older adults.

  • Older adults think about death more & talk about it more than in previous adult stages.

©2008 McGraw-Hill Ryerson Ltd.



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Facing One’s Own Death

Kübler-Ross’s Stages of Dying

  • Denial and Isolation

  • Anger

  • Bargaining

  • Depression

  • Acceptance

©2008 McGraw-Hill Ryerson Ltd.


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Facing One’s Own Death

Denial and Isolation

  • Kübler-Ross (1969) divided the behaviour & thinking of dying persons into 5 stages.

  • In the first stage, denial & isolation, people refuse to believe that their condition is terminal.

  • People attempt to convince themselves that lab tests were inaccurate or that the disease will go into remission.

  • Dying individuals in this stage also seek isolation.

©2008 McGraw-Hill Ryerson Ltd.


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Facing One’s Own Death

Anger

  • In the 2nd stage of dying, anger, the dying person recognizes that denial can no longer be maintained.

  • Denial gives way to anger, resentment, rage, & envy.

  • The dying person’s question is: “Why me?”

  • The dying person becomes increasingly difficult to care for, as anger may become displaced & projected onto physicians, nurses, family members, & God.

  • The realization of loss is great & those who represent life are targets of resentment

©2008 McGraw-Hill Ryerson Ltd.


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Facing One’s Own Death

Bargaining

  • In the 3rd stage of dying, bargaining, Kübler-Ross states that the person develops the hope that death can somehow be postponed or delayed.

  • Some people enter into a bargaining or negotiation—often with God—as they try to delay their death.

  • In exchange for a few more days, weeks, or months of life, the person promises to lead a reformed life dedicated to God or to the service of others.

©2008 McGraw-Hill Ryerson Ltd.


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Facing One’s Own Death

Depression

  • In Kübler-Ross’ 4th stage of dying, depression, the dying person accepts that death is certain.

  • At this point, a period of depression or preparatory grief may appear.

  • The dying person may become silent, refuse visitors, & spend time crying or grieving.

  • Attempts to cheer up the dying person at this stage should be discouraged because the person has a need to contemplate impending death.

©2008 McGraw-Hill Ryerson Ltd.


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Facing One’s Own Death

Acceptance

  • In the 5th stage of dying, acceptance, the person develops a sense of peace; an acceptance of one’s fate; & in many cases, a desire to be left alone.

  • Feelings & physical pain may be virtually absent.

  • Kübler-Ross views this stage as the end of the dying struggle, the final resting stage before death.

©2008 McGraw-Hill Ryerson Ltd.


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Facing One’s Own Death

Criticisms of Kubler-Ross

  • Psychology death expert Robert Kastenbaum refutes the existence of Kübler-Ross’ 5 stage sequence.

  • Research has not demonstrated the process exists.

  • Kastenbaum (2000) believes the stage interpretation neglects the patients’ total life situations, including relationship support, specific effects of illness, family obligations, & the institutional climate in which they were interviewed.

  • Some psychologists prefer to describe the stages as reactions to dying.

©2008 McGraw-Hill Ryerson Ltd.


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Facing One’s Own Death

Contributions of Kubler-Ross

  • Kübler-Ross made the important contribution of calling attention to people attempting to cope with life-threatening illnesses.

  • She did much to encourage needed attention to the quality of life for dying persons & their families.

©2008 McGraw-Hill Ryerson Ltd.


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Facing One’s Own Death

Perceived Control and Denial

  • Perceived control & denial may work together as an adaptive strategy for some older adults facing death.

  • Individuals who believe they can influence & control events, become more alert & cheerful.

  • Denial may be a useful way for some individuals to approach death.

  • Denial protects us from the tortuous feeling that we are going to die.

  • Denial can be maladaptive if it prevents treatment.

©2008 McGraw-Hill Ryerson Ltd.


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Facing One’s Own Death

The Contexts in Which People Die

  • For dying individuals, the context in which they die is important.

  • 75% of Canadians die in hospitals or long-term care facilities.

  • Hospitals offer important advantages in that professional staff members are readily available, & the medical technology may prolong life.

  • Kalish & Reynolds (1976) identified most individuals say they would rather die at home.

©2008 McGraw-Hill Ryerson Ltd.



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Coping with the Death of Someone Else

Communicating with a Dying Person

  • Most psychologists believe that it is best for dying individuals to know that they are dying, & that significant others know they are dying.

  • Dying individuals can thus close their lives in accord with their own idea of proper dying.

  • They can complete plans and projects.

  • They can make arrangements for survivors.

  • They can participate in decisions about a funeral.

  • They will have the opportunity to reminisce.

©2008 McGraw-Hill Ryerson Ltd.


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Coping with the Death of Someone Else

Grieving

  • Dimensions of Grieving

  • Cultural Diversity in Healthy Grieving

©2008 McGraw-Hill Ryerson Ltd.


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Coping with the Death of Someone Else

Dimensions of Grieving

  • Emotional numbness, disbelief, separation anxiety, despair, sadness, & loneliness accompany the loss of someone we love.

©2008 McGraw-Hill Ryerson Ltd.


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Coping with the Death of Someone Else

Dimensions of Grieving

  • Pining or yearning reflects a recurrent need to recover the lost loved one.

  • Separation anxiety includes pining but also focuses on places & things associated with the deceased, as well as crying.

  • Numbness, disbelief, & outbursts of panic are typical immediate reactions.

  • Despair, sadness, & hopelessness are part of grief.

©2008 McGraw-Hill Ryerson Ltd.


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Coping with the Death of Someone Else

Cultural Diversity in Healthy Grieving

  • In contrast to Western beliefs, maintenance of ties with the deceased is accepted & sustained in the religious rituals of Japan.

  • In the Arizona Hopi, the deceased are forgotten as quickly as possible & life is carried on as usual.

  • In Egypt, the bereaved are encouraged to dwell at length on their grief.

  • In Bali, the bereaved are encouraged to laugh & be joyful, rather than be sad.

  • Diverse grieving patterns are culturally embedded.

©2008 McGraw-Hill Ryerson Ltd.


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Coping with the Death of Someone Else

Making Sense of the World

  • A beneficial aspect of grieving is that it stimulates many individuals to make sense of their world.

  • A common occurrence is to go over again & again all of the events that led up to the death.

  • When death is caused by an accident or disaster, the effort to make sense of it is pursued more vigorously.

  • The bereaved want to put the death in a perspective they can understand—divine intervention, a logical sequence of cause & effect, etc.

©2008 McGraw-Hill Ryerson Ltd.


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Coping with the Death of Someone Else

Losing a Life Partner

  • Those left behind after the death of an intimate partner suffer profound grief & often endure financial loss, loneliness, increased physical & psychological problems.

©2008 McGraw-Hill Ryerson Ltd.


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Coping with the Death of Someone Else

Losing a Life Partner

  • Those left behind after the death of an intimate partner suffer profound grief & often endure financial loss, loneliness, increased physical illness, & psychological disorders.

  • The bereaved are also at increased risk for many health problems, including death.

  • Optimal adjustment after a death depends on several factors.

  • Women do better than men in our society, due to their networks of friends & close relationships.

©2008 McGraw-Hill Ryerson Ltd.


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Coping with the Death of Someone Else

Forms of Mourning and the Funeral

  • Mourning varies cross-culturally.

  • Funeral rituals are an important aspect of mourning in many cultures.

  • One consideration is what to do with the body.

  • Approximately 80% of corpses are buried.

  • Studies showed that bereaved individuals who were religious derived more psychological benefits from a funeral, participated more actively in rituals, & adjusted more positively to the loss.

©2008 McGraw-Hill Ryerson Ltd.