Chapter 17: Death, Dying, and Grieving

Kubler-Ross's stages of dying

"On Death and Dying" (1969); over 200 interviews with terminally ill patients *sequence of stages as we face death: 1. denial and isolation 2. anger 3. bargaining 4. depression 5. acceptance

losing a life partner

-3x as many women as men are widowed -often suffer profound grief and endure financial loss, loneliness, increased physical illness, psychological disorders -especially difficult for people who have been happily married for a number of decades -women adjust better than men (have better networks of friends, closer relationships with relatives, experience in taking care of others psychologically) -older widows do better than younger widows because the death is more expected -widowers usually have more money than widows, more likely to remarry -benefits of having social support, engaging in volunteering and helping behavior

psychological death

-absence of self-awareness -severe cognitive impairment -may result form amnesia, dementia, psychosis

adult conception of death

-an understanding that death is final and irreversible -death represents end of life as we know it -all living things must die -while there are many beliefs about afterlife, all are unknown

issues of euthanasia

-legal differences between cessation of treatment and never starting treatment; influence treatment decisions and regimens -may not be consistency in the wishes or in the timing of various family members in the decision making loop; few people face death alone

contexts in which people die

-most people prefer to die at home and hospice care than hospitals or nursing home -many feel they will be a burden at home, that there is limited space there, that dying at home may alter relationships; worry about the availability of emergency medical treatment

cultural variations in the death system

1. ancient Greeks- live a full life and to die with glory; people more conscious of death in times of war, famine, plague 2. Americans- conditioned to live as though they are immortal; tend to be death avoiders 3. Calcutta, Africa's Sahel- death in overdisplay (ex. malnutrition, disease, children not living past age 5) -most societies have philosophical or religious beliefs about death, have a ritual that deals with death -death may be seen as a punishment for one's sins, an act of atonement, a judgement of a just God -most do not view death as the end of existence

forms of mourning

1. cremation- more popular in the Pacific region of the U.S., less in the South; more popular in Canada and most popular in Japan and other Asian countries 2. private funerals- more common in the U.S. vs. public funerals (ex. displaying dead in an open casket) 3. ceremonial meal after a death 4. wearing a black armband one year following a death 5. Amish- community handles virtually all aspects of the funeral, held in a barn or home; calm acceptance of death -high levels of support given to the family a year after the death (ex. visits to the family, special scrapbooks, new work projects started for the widow) 6. Judaism- program of mourning is divided into graduated time periods, each with appropriate practices

childhood conception of death

1. infancy- not even a rudimentary concept of death -can experience loss or separation anxiety from caregiver 2. 3 to 5 years old- little or no idea of what death means; may confuse death with sleep -believe dead can be brought back to life by magic or giving them food/treatment -believe only people who want to die or who are bad/careless actually die 3. middle to late childhood- more realistic perceptions of death -start to recognize death's finality and universality by age 9 -age 7: still see death as unlikely or reversible *should be honest about death with children: -preschoolers: define it in biological and physical terms -young children: reassure them they are loved and will not be adandoned

development of adult conception of death

1. middle adulthood- fear death more than young or older adults do 2. older adulthood- think about death more and talk about it more in conversation than younger or middle adults; have more experience with death -feel less cheated than younger adults who are dying

dimensions of grief

1. pining or yearning for the lost person 2. separation anxiety- pining and preoccupation with thoughts of the person, focuses on places and things associated with the person 3. despair and sadness- sense of hopelessness and defeat, depressive symptoms, apathy, loss of meaning for activities that used to involve the person, growing desolation -pining and protest over the loss diminish over time, but episodes of depression and apathy may remain or increase *grieving process is more like a roller-coaster than an orderly progression of stages -for most people after 6 months, they accept the loss as reality and are more optimistic about the future

"good death"

1. preference for dying process 2. pain-free status 3. emotional well-being (ex. accepting impending death)

evaluation of Kubler-Ross's stages

1. the existence of the five stages has not been demonstrated 2. now know that it is not a universal sequence 3. the stage interpretation neglected the patients' situations (ex. relationship support, specific effects of illness, family obligations, institutional climate in which they were interviewed) -psychologists prefer to describe them as potential reactions to death, not stages 4. interactions that vary by stage 5. useful in any loss situation; can describe others besides the patient 6. role of anticipatory grief work; shows that people who know they are dying often engage in this (ex. spending time together, mending previous wounds)

historical change: death in age groups

1. two hundred years ago- 1/2 children died before age 10; one parent died before children grew up -die at home, cared for by family 2. today- death most often among older adults -die apart from families in hospitals as population is more mobile

euthanasia

a deliberate act that causes death undertaken by one person with the primary intention of ending the life of another person in order to relieve the person's suffering *a form of homicide: even where it is legalized it is legalized homicide -intention is central to the concept -there is no euthanasia unless the death is intentionally caused by what was done or not done

passive euthanasia

a person is allowed to die by withholding available treatment (ex. withdrawing a life-sustaining device)

bereavement

a state of loss

biological: whole brain death

all electrical activity of the brain has ceased for a specified period of time; death of BOTH the higher cortical functions and lower brain stem functions -total unresponsiveness to stimuli -no spontaneous respiration for one hour -no eye movements, blinking, pupillary reflexes -no postural activity, swallowing, yawning -no motor reflexes -flat EEG for 10 minutes *no change in any measure 24 hours later -must rule out drug overdose, hypothermia, deep coma (some people can be spontaneously resuscitated in these cases)

disenfranchised grief

an individual's grief over a deceased person that is socially a ambiguous loss and can't be openly mourned or supported (ex. relationship that isn't socially recognized like an ex-spouse, a hidden loss like an abortion, when the circumstances of the death are stigmatized like AIDS) -may intensify the person's grief because it must be hidden or repressed for many years, cannot be supported

communicating with a dying person

best for dying individuals to know that they are dying and that significant others know they are dying -allows dying individuals to: 1. close their lives in accord with their own ideas about proper dying 2. may be able to complete some plans and projects, can make arrangements for survivors, can participate in decisions about a funeral or burial 3. have the opportunity to reminisce, converse with others who have been important in their life, end life conscious of what life has been life 4. have more understanding of what is happening with their bodies and what the medical staff is doing to them

death system

composed of people, places or contexts, times, objects, and symbols -serves functions in a culture: issuing warnings and predictions (ex. doctors that communicate with patients and families), preventing death (ex. firefighters), caring for the dying (ex. hospitals), disposing of the dead (ex. cremation), social consolidation after death (coping and adapting by family), making sense of death, and killing (ex. when, how, and for what reasons people in a culture can be killed)

mourning

culturally prescribed way of displaying reactions to death

times

death involves occasions set aside to honor those who have died (ex. Memorial Day, Day of the Dead)

active euthanasia

death is deliberately induced by added treatment (ex. injection of a lethal dose of a drug)

people

death is inevitable, so everyone is involved with death at some point (both the death of others and their own death) -some have a more systematic role (ex. clergy, workers in the funeral industry; life-threatening contexts like firefighters, police)

contexts matter

death may be universal, and the tendency to react negatively to loss may be too, but contexts of age, cause of death, whether it was "expected" or not, other factors influence our reactions -different cultural and ethnic groups and subgroups have different rules for expressing grief, different mourning practices

variations in coping

deaths that are sudden, untimely, violent, or traumatic are likely to have more intense and prolonged effects, make the coping process more difficult -often accompanied by PTSD symptoms such as flashbacks, nightmares, sleep disturbance, problems in concentrating -death of a child is especially devastating and difficult for parents *there is no ideal way to grieve: healthy coping with death involves active mourning across time, flexibility, and appropriateness within cultural context

Parkes/Bowlby attachment model of bereavement

describes four prominent reactions: 1. numbness- in shock (first month) 2. yearning- missing the person -separation anxiety peaks at two months 3. disorganization and despair -peaks at four months (usually time when support dissipates) 4. reorganization

adolescent conception of death

develop more abstract conceptions (ex. describe death in terms of darkness, light, transition, nothingness) and religious and philosophical views about the nature of death/whether there is life after death

removal of life support

disconnecting a patient from external life-prolonging equipment such as a respirator (typically treated as passive euthanasia)

depression

dying person perceives the certainty of his or her death; period of depression or preparatory grief may appear -may become silent, refuse visitors, spend much time crying or grieving; an effort to disconnect the self from love objects -attempts to cheer these people up is discouraged because they need to contemplate impending death

complicated grief/prolonged grief disorder

enduring despair that remains unresolved over an extended period of time; usually has negative consequences for physical and mental health -greatest risk for people who lose someone on whom they were emotionally dependent -more likely when people lose a spouse, lose a loved one unexpectedly, spent time with the person every day in the last week of their life, or have depression

suicide in adolescence

escalates in adolescence and increases further in emerging adulthood -third leading cause of death among 10 to 19 year olds -decline in recent years -more contemplate or attempt it unsuccessfully than actually commit it -varies by gender and ethnicity (most likely = Native American/Alaska Natives both males and females) -teen suicides tend to occur in clusters

loss-oriented stressors

focus on the deceased individual; can include grief work and both positive and negative reappraisal of the loss ex. positive- acknowledging that death brought relief at the end of suffering ex. negative- yearning for the loved one and ruminating about the death

making sense of the world

grief stimulates people to try to make sense of their world and finding a meaning in the death -includes sense making (ex. seeking biomedical explanations of the death, revisiting one's role and decisions, assigning blame), benefit finding (ex. finding ways to help others), continuing bonds (ex. reminiscing about the person, sharing pictures), identity reconstruction (ex. changes in a parent's sense of self)

places or contexts

include hospitals, funeral homes, cemeteries, hospices, memorials

symbols

includes a skull and crossbones, last rites in Catholicism, etc. that are connected to death

objects

includes caskets, various colored objects like clothes, armbands, hearses ex. U.S. = black; China = white

adult suicide

increasing rates among U.S. adults -- now surpasses the deaths from car accidents -males more likely to commit suicide, females are more likely to attempt it -older adults most likely to commit it when they are males who live alone, has lost his spouse, and is experiencing poor health

social death

individual or group refuses to recognize a person as among the living ex. shunning by the Amish

sudden infant death syndrome (SIDS)

infants stop breathing (usually during the night) and die without apparent cause -leading cause of infant death in the U.S.

biological: higher brain death

lack of cortical activity; persistent vegetative state -higher portions of brain often die sooner than the lower portions -lower portions control heartbeat and respiration; people whose higher portions have died may continue to breathe and have a heartbeat

living will

legal document that reflects the patient's advance care planning

living-dying

life is complicated, and so death; often seen as a continuum in current understandings of the lifespan

perceived control and denial

may work as an adaptive strategy for some older adults as they face death -when individuals are led to believe they can influence or control events, they may become more alert and cheerful (ex. giving nursing home residents options for control) -denial can be adaptive or maladaptive; can avoid the impact of shock by delaying the necessity of dealing with one's death, but can prevent some people from receiving life-saving treatments

prenatal/birth death

miscarriages, stillborn births, death within a few deaths after birth due to a birth defect or underdevelopment, SIDS

adulthood death

more likely to die from chronic diseases (ex. heart disease, cancer) -tend to incapacitate before they kill (slow course of dying)

childhood death

most often due to accidents or illness (ex. car accident, drowning, poisoning, falls; heart disease, cancer, birth defects)

adolescent death

most often due to car accidents, suicide, and homicide -car accidents usually alcohol-related

biological: clinical death

no heartbeat, no respiration

acceptance

person develops a sense of peace and acceptance of one's fate; often develops a desire to be left alone -feelings and physical pain may be virtually absent; a final resting stage before death

hospice

program committed to making the end of life as free from pain, anxiety, and depression as possible; emphasizes palliative care -many are home-based

assisted suicide

providing means for a patient to end own life through administration of an added treatment or condition (such as an overdose) -technically not active euthanasia because administered by the patient -laws in relatively rapid transition; currently legal in DC and 7 states

palliative care

reducing pain and suffering and helping individuals die with dignity

thanatology

scientific study of death; a "natural" part of the lifespan and can occur at any point within it

factors of suicide

serious physical illnesses, mental disorders, feelings of hopelessness, social isolation, failure in school and work, loss of loved ones, serious financial difficulties, drug use, a prior attempt -males more likely to commit it than females for all age groups

advance directive

states preferences such as whether life-sustaining procedures should or should not be used to prolong the life of an individual when death is imminent (ex. living will) -must be signed while the individual can still think clearly

anger

the dying person recognizes that denial can no longer be maintained; often gives way to anger, resentment, rage, envy (ex. "Why me?") -anger can be displaced and projected onto health care professionals, God, those who embody life

grief

the emotional numbness, disbelief, separation anxiety, despair, sadness, and loneliness that accompany the loss of someone we love -a complex, evolving process with multiple dimensions

bioethics

the interface between human values and technological abilities in health and life sciences

denial and isolation

the person denies that death is really going to take place (ex. "No, it can't be me"); only a temporary defense

bargaining

the person develops the hope that death can somehow be postponed or delayed; some enter into negotiating with God (ex. person promises to lead a reformed life dedicated to serving others in exchange for more months of life)

advance care planning

the process of patients thinking about and communicating their preferences about end-of-life care (ex. people in coma: not clear what their wishes are about termination of treatment) -decreases life-sustaining treatment, increased hospice use, decreased hospital use

restoration-oriented stressors

the secondary stressors that emerge as indirect outcomes of bereavement; can include a changing identity (ex. wife to widow) and mastering skills (ex. dealing with finances)

dual-process model of coping with bereavement

two main dimensions: 1. loss-oriented stressors 2. restoration-oriented stressors -effective coping involves an oscillation between coping with loss and coping with restoration; can be carried out concurrently -person may be involved in grief group therapy while settling the affairs of the loved one

voluntary euthanasia

when a person has requested for it for him/herself

involuntary euthanasia

when it is carried out despite an expressed wish to the contrary

non-voluntary euthanasia

when there has been no request or consent