Hinerman: Death & Dying 1

Describe 4 aspects that comprise cultural sensitivity

-Avoid Stereotyping -Beware of judging the worth of other communities -Understand that culture is not defined simply by ethnicity -Know that there may be more differences WITHIN than BETWEEN cultural groups.

Epidemiologic Transition

-Characterized mainly by a redistribution of deaths from young to old. -With a reduced risk of dying at a young age from infectious disease -People survive into older ages, where they tend to die from degenerative diseases. 1900: 65yo+ = 17% of deaths Today: 65yo+ = 75% of deaths

What are some reasons for initiating End-Of-Life discussions?

-Choices differ based on the information (more information yields more choices) -Could receive undesired treatments (CPR?) -Allows time for healing relationships, completing goals (write poetry?), completing wills, etc. Allows for preparation!

Nonmaleficence

-Do no harm -More accurately be thought of as minimizing harm to as many interested parties as possible. -This can mean a variety of things to different patients -- for some "suffering" is not bad, while for other minimizing suffering can be the primary goal.

Beneficence

-Duty to "do good" -Although, it is often hard to determine what is "good" or "more good" typically dependent upon one's perspective and background.

Justice

-Fairness regarding treatment of others & how goods and services are distributed. -Issues of justice should be at the forefront of health & mental health providers' minds, given the significant issues associated with the cost of care, the vast numbers of individuals who have no or inadequate insurance, and discrimination in service provision.

What are some challenges to hospice care?

-The presence of a primary caregiver who is available 24/7 -Adequate funding -The six-month rule (i.e. life expectancy 6 months or less) -Expanding access to undeserved populations -Excessive bureaucracy leading to routinization of care (from a "good" death to a "peaceful" death?)

Describe school & peers as agents of socialization

-The social world of a child is dramatically broadened during the school years; -playing with children their own age, sports/hobbies - connecting them to a community & a set of social norms. -With a broadening of a child's social network, there is a corresponding increase in possible encounters with death.

Fidelity

-Trust & loyalty in a professional relationship. -Responsibilities to clients/patients take precedence over responsibilities to others & to society -- the professional must act to maintain & enhance the trust of the client/patient.

Managed Death

-We determine WHEN we are going to die based on life extending treatments. -Even when a person's dying has been accepted & further treatments intended to cure have been put aside, there is still a strong desire to manage the situation so that it comes out "right". EX: Ending tx just at the proper moment so that the person is enabled to die a quite or peaceful death.

What are the 5 ethical meta-principles?

-autonomy -nonmaleficence -beneficience -justice -fidelity

What are some agents of socialization?

-family -school & peers -mass media -religion

What are some sources of caregiver stress?

-feelings of inadequacy (what can i say?) -Non-reciprocal giving -Too many demands -Feelings of being devalues (e.g. nurse/patient ratios) -Inability to cure a disease or save a life -Burnout: a rxn to stress in which caregiver moves beyond exhaustion & depressing to being "past caring"

What are the aims of palliative care?

-improve quality of life, for both the patients and the family. -Provides an extra layer of support. -Control pain, relieve suffering, provide care for physical, psychological, spiritual, & existential needs; hep patients achieve a good/peaceful death.

Piaget's: Concrete Operational

7-12 years: Applies logical abilities to understanding concrete ideas; organizes & classifies information; manipulates ideas & experiences symbolically; able to thin backward & forward; notion of reversibility; can think logically about things experienced.

Tamed Death

A phrase coined by Philip Aries to describe an accepting & familiarity attitude toward death associated with earlier historical periods. It corresponds with the technological imperative (ethical ambiguities of EOL care given by radical changes in technology)

Describe religion as an agent of socialization

Religion reflects the efforts of individuals and societies to make sense of the world & human existence. -It is a basis for morality & human relationships. -Religion is concerned with ministering to the dying person, preparing him or her for the world to come, generally being involved w/ his physical needs & psychological feelings at this time, & likewise helping those who are especially close.

The sociological theroy that most resembles the study of the human body is?

The Structural Functionalist Approach -View society as an organic whole, with constituent parts working together to maintain each other & the whole society.

Managed Death

The attempt to control or seek mastery of the threat of death or the circumstances of dying by application of medical technology & by personal & social choices.

Death Anxiety:

The awareness that death is inevitable. -Humans: we are conscious of our death. -Animals: only aware of their present state, and humans are able to think about their future. Think about our future & it's terminal phase.

Technological Imperative

The belief or practice that sophisticated medical technologies should always be used to combat disease with relatively little concern about costs or potentially adverse side effects.

Thanatology

The study of death (the study of death but with life left in). Concerned with questions that are rooted at the center of human experience; unavoidably multidisciplinary.

Causality

There are biological reasons for the occurrence of death.

What does the statement "death involves causality" mean?

There are biological reasons for the occurrence of death.

What are the 4 concepts of a mature concept of death?

Universality Irreversibility Non-functionality Causality

Hospice Care

Unlike hospitals & nursing homes, hospice is not necessarily a place, but a program of caring that is oriented toward the needs of dying patients & their families. -The focus is on comfort rather than cure.

Autonomy

self-determination. Providing informed consent & decision making competence.

Approximately how much has the average life expectancy int he US increased since 1900?

1900's: 47yo 2012: 77yo

What percentage of the gross domestic product of the US in 2000 was spent on health care?

13% of the gross domestic product

What are the characteristics of the concept of 'invisible death'?

-Human beings seek to manage death in ways appropriate for their cultural & historical circumstances. -Current practices compared to earlier suggest dying & death are in many respects less visible, less part of our common experience. -Care of the dying & the dead is now the domain of hired professionals. -The role of family & friends as witnesses to a loved one's dying has diminished. -Funerals & memorials are shorter, more discreet, & private.

What are the urgent clinical indications for discussing End-Of-Life Care?

-Imminent death -Talk about wanting to die -Inquiries into hospice & palliative care -Recently hospitalized for severe progressive illness -Severe suffering & poor prognosis

Hospital health care focuses primarily on which aspect of the patient's well-being?

-In the past, hospitals were devoted mainly to acute intensive care of a limited duration. -Now, they offer an integrated system of health care services providing education, outpatient therapy, and (in some cases) palliative care. -Aggressive medical techniques are used to diagnose symptoms, provide tx, & sustain life. -The singular focus of hospitals on acute care appears to be evolving toward a more integrated approach in which outpatient & extended care, as well as home & hospice care, play important roles. -Hospitals are changing from "monolithic" centers, focused on acute care, to broader institutions that offer a "portfolio" of healthcare services.

Dance Macabre

-Influenced by mass plague deaths -Reflected inevitability & impartiality of death -Emphasized uncertainties of human mortality -Images & icons remain today

Describe the major factors affecting our familiarity with death in the contemporary US.

-Life expectancy & mortality rates (median death age: 1912 = 47yo; 2012 = 77yo) -Causes of death (Early 1900's: acute infectious disease w/ sudden onset & death soon following - e.g. diptheria; Today: chronic illness typically following a slow progressive course lasting wee,s months, or years - e.g. cancer) -Geographic mobility: people are less likely to be present at the deaths of relatives or friends, resulting in the loss of shared death rituals. Each year 1/6 of americans move. -Displacement of death from the home: 1900's: 80% of deaths occurred at home; today: 80% of deaths occur in institutional settings -Life-extending technologies: life extending? or death prolonging?

Childhood experiences with death are most likely related to:

-Life experiences--particularly those that involve an encounter with death or other significant loss--are powerful in shaping a person's attitudes & beliefs about death. -When such experiences occur in early childhood, a person may become fully aware of the impact only in adulthood.

According to the text, what percentage of Americans are affiliated with a religious tradition?

-More than 90% are affiliated w/ a religious tradition.

What are the features & goals of hospice care?

-Provide relief form pain & suffering -Promote an aura of peacefulness & acceptance of dying -Treat patient & family as the unit of care -Provide access to comprehensive services -Designated for those in the final stages of a terminal illness who agree to forgo medical interventions intended to extend life.

List topics that should be included in end-of-life discussions

-Relative emphasis on life prolongation -Relative emphasis on quality of life -Advance directives (living will, health care proxy) -DNR orders, mechanical ventilation, feeding tube, antibiotics, hemodialysis -Palliative care (pain mgmt; psychological, spiritual, & existential suffering; unfinished business.

In many traditional societies, death is believes to occur because ____? (more than one answer)

-Some evil influence? Possibly shaped by magic? -Supernatural causes -Psychosocial -Traditional societies typically embrace an ecological orientation: they look at the possible role of such phenomena as the wind or mood, heredity, & behavioral excesses, such as not getting enough sleep. -A variety of socioeconomic & psychosocial causes -Natural & supernatural causes

Traditional societies tend to view disease & death as ________? (more than one answer)

-Something is "out of balance" -Public, not private events -Death happened because of god, or their god is mad. Death didn't happen for medical reasons. -To restore a sense of security & proper order, sacrifices are offered to purify & protect the community from further calamity.

What are the 5 major social institutions delineated by sociologists?

-The economy -The educational system -The family -The political system -Religion

Describe family as an agent of socialization

-the family is the foundational social institution in all societies, although the definition of family varies from place to place and time to time. -beliefs & values of parents are transmitted to their children.

What are the stages of intolerance?

1. Deregation: dismissing views other than your own 2. Assimilation: converting others to your view (missionary activity) 3. Accommodation: taking others' views & customs, change most things about them, but preserve something minimal (food, clothing) 4. Annihilation: remove threat to your view.

Describe the ways in which religion functions in societies

1. Religion is a unifier, the social glue that binds a group together by giving it a common set of values. 2. Religion provides answers to the "big questions" about human existence & purpose - outlines the kind of life people are expected to lead, & explains what happens to them after they die. 3. Religion often provides a foundation for the norms & laws of society. 4. Religion is a source of emotional & psychological support to people, especially at time of crisis.

Erik Erikson's Identify vs. Role Confusion

11-18: who am i? -Death might threaten achievement, bring to surface unresolved issues, insist a person to grow (recognize morality)

Piaget's: Formal Operational

12+ years: Resons logically about abstract ideas & experiences -can think hypothetically about things never experienced -deductive & inductive reasoning -complexity of knowledge -many answers to questions; interest in ethics, politics, social sciences.

Piaget's: Preoperational

2-7 years: Development of symbolic thinking & language to understand the world. -(2-4 years): Preconceptual subperiod: sense of magical omnipotence; self as center of world; egocentric thought; all natural objects have feelings & intention. -(4-6 years): Prelogical subperiod: beginning problem solving; seeing is believing; trial & error; understanding of other points of view; more socialized speech; gradual decentering of self & discovery of correct relationships.

Erik Erikson's Initiative vs. Guilt

3-5: Looking for approval -Death: child will feel guilty, like they had something to do with it.

What are some barriers to physicians have "bad news" conversations with their patients?

5 reasons physicians don't want to talk about it: 1. Do not want to inflict pain bc it destroys hope 2. Think patient will get depressed 3. Hospice/Palliative care used to hasten death **INACCURATE!! 4. It's not culturally appropriate (don't know how to talk to them about it) 5. Prognosis unknown

Erik Erikson's Industry vs. Inferiority

5-11: Recognition/encouragement -Death: less encouragements/support because of 1 less parent.

Origines & Causes of Death in Early & Traditional Societies

Acute infectious disease -- sudden onset and imminent death. -Thought to have happened because of God, with not necessarily having medical reasons.

Universality

All living things eventually die. Death is all-inclusive, inevitable, & unavoidable (although unpredictable with respect to its exact timing).

Piaget's: Sensorimotor

Birth - 2 years: Focused on senses & motor abilities; learns objects exist even when not observable (object permanence) and begins to remember & imagine ideas & experiences (mental representation)

Erik Erikson's Trust vs. Mistrust

Birth - 2: Child developing sense of self, seeking routine, predictability. -Death causes unpredictability

According to the text, what is the leading cause of death in the US today?

Chronic illness (health disease)

Institutional Denial

Death avoidance. -Seeking to control death with the seemingly limitless possibilities of medical technology. -Medical professionals witness pt death, and do not take time to process emotions or discuss amongst each other.

Nonfunctionality

Death involves the cessation of all physiological functioning, or signs of life.

Irreversibility

Death is final. -Organisms that die cannot be made alive again.

Irreversibility:

Death is final. Organisms that die cannot be made alive again.

What is the approximate death rate per 1000 in the US today?

Deaths per year, per 1000 1912 = 17/1000 2012 = 8.7/1000

DRG's

Diagnosis Related Groups: Involve a predetermined schedule of fees for reimbursement to health care providers -A predictive model where the insurance company will predict how much to spend.

What comprises a Mature Concept of Death?

It is not a single, unidimensional concept but is, rather, made up of several relatively distinct subconcepts -- that unfold throughout the life span. -The core concepts are enriched by questions, doubts, exceptions, conditions, etc. -"either/or" logic is eventually replaced by more sophisticated "fuzzy" concepts. -Allows for elaboration about the meaning of death -Values other cultural contexts & expressions -Avoids ethnocentrism

Ethnocentrism

Making judgments about others based solely on one's own cultural assumptions & biases

Institutional Death

No processing of death in institutional settings -Social institutionalized avoidance of death related thoughts & emotions.

Teachable moments

Opportunities of situations for learning about death during unplanned or unexpected occurrences (e.g. observing a dead animal in the road)

Mean World Syndrome

Portrayals of Violence: -Lessens sensitivity to real violence & its victims -Increases unwarranted fears of becoming a victim -Contributes to aggressive behavior -Conveys heightened sense of danger, insecurity, & mistrust -Contributes to irrational dread of dying

QALYs

Quality Adjusted Life Year: A measure of disease burden, including both the quality & the quantity of life lived. It is used in assessing the value for money of a medical intervention. -The QALY model requires utility independent, risk neutral, and constant proportional tradeoff behavior.

Erik Erikson's Autonomy vs. Shame

Roughly 1-3years -As the toddler explores the environment & develops greater independence, there are clashes between what the child wants to do and what others want the child to do. -Exercising independence while also experiencing some degree of shame and doubt is hallmark of this stage. •(2 - 3) - Letting go, holding on -Death can cause a regression like clinging, crying, demanding

Palliative care

Specialized medical care for people with serious illnesses. Focused on providing patients with relief from the symptoms, pain, & stress of serious illness -- whatever the diagnosis. -Active total care of patients whose disease is unresponsive to curative treatment.

In which country was the most influential modern hospice established?

St. Christopher's Hospice in Sydnham, England

Describe mass media as an agent of socialization

TV, movies, radio, newpapers, magazines, books, videos, records -- these media have a powerful socializing influence. -Media messages relay cultural attitudes toward death to children -Many classic fairytales & lullabies depict death, near deaths, or the threat of death.