Death, Dying, and Bereavement

What is the stigma of hospice?

"We don't focus on the FINALITY OF DEATH; we focus on the practical side of living. Our job is to assist our patients and their families through the physical, emotional, and spiritual challenges of life's final transition."

What 4 things foster dying with dignity?

1) Care, affection and companionship offered to the dying person 2) Allow the dying person to discuss their impending death 3) Education regarding whether to accept or reject treatments 4) Maximize personal control over final phase of life.

What physical changes occur in the day or hours before death?

1. Activity declines (increasingly tired and sleepy, and may be difficult to arouse - LETHARGY) 2. Person moves and communicates less 3. Shows little interest in food, water & surroundings (DYSPHAGIA may also occur) 4. Body temperature, blood pressure & circulation to the limbs fall (hands & feet feel cool) 5. Skin color changes to a duller, grayish hue.

What are the 5 stages of dying?

1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance

What 5 factors reduce death anxiety?

1. Those with deep & consistent faith behaviors 2. Participatory > overcoming perspective (participators less fearful than overcomers) 3. Effective emotional regulation (most older adults cope with anxiety effectively) 4. Symbolic immortality 5. Managed depression

Grief varies from person to person and depends on the situation. 1. We are unable to predict the... 2. There are ___ differences 3. The ______ with the deceased impacts the grieving process 4. The _____ circumstances can impact response

1. Time of grieving 2. Sex differences 3. Relationship with deceased 4. End-of-life circumstances (ex: suicide more impactful than someone who was chronically ill)

➢ State of peace and quiet about the upcoming death ➢ Typically reached in the last weeks or days ➢ Disengagement from all but a few friends and family

Acceptance

This is a written statement of desired medical treatment

Advance Medical Direction

Refers to the gasps and muscle spasms during the first moments in which the regular heartbeat disintegrates.

Agonal phase (of dying)

➢ Prospect of dying before your time ➢ Family and health care workers often targets of this ➢ Need to tolerate and be empathic of this behavior

Anger

What are 4 common goals across all bereavement rituals?

Announcing the death Ensuring social support Celebrating the life of the deceased Conveying a philosophy of life after death

In contrast to accidental or sudden deaths, this acknowledges that the loss was inevitable and emotional preparation can occur.

Anticipatory grieving (for pending deaths)

Development of the Death Concept Death applies only to living things We wouldn't cry over our teddy bear losing its head. Only living things die.

Applicability

This is what makes sense in terms of the individual's pattern of living and values, and at the same time, preserves or restores significant relationships and is as free of suffering as possible. *Maintaining a sense of control *Confronting and preparing for death

Appropriate Death

This is a period of numbness following bad news, "emotional anesthesia"

Avoidance

What are the 3 components of the grief process?

Avoidance Confrontation Restoration

In instances of sudden, unexpected deaths (dependent on situation, ex car accident, suicide, war, etc.), what happens with avoidance and confrontation?

Avoidance: Very pronounced Confrontation: Highly traumatic bc shock and disbelief are extreme

➢ Strike deals for extra time ➢ May be unrealistic and impossible, but some can sustain life & give purpose

Bargaining

Why does death anxiety DECLINE in LA?

Because people go through ego integrity and despair stages *women are more anxious than men!

Experience of losing a loved one by death. It means "to be robbed"

Bereavement

These typically encourage people to draw on their existing social networks, while providing additional social support through group or individual counseling.

Bereavement Interventions

This occurs when a person experiences several deaths at once or in close succession.

Bereavement Overload *Can include a loss of friends, families, or tragedies

Irreversible cessation of all activity in the brain and the brain stem (which controls reflexes), and in most industrialized nations, signifies death (opposed to decades ago when loss of heartbeat and respiration signified it)

Brain death

Multiple losses can deplete what from even well-adjusted people, leaving them overwhelmed, depressed, and vulnerable to PTS symptoms/ complicated grief?

Can deplete coping resources *OLDER ADULTS BETTER EQUIPPED TO HANDLE

Development of the Death Concept Death is caused by breakdown of bodily functioning What is causing it? Brain injury, heart injury, etc. The basic concept of how we develop a concept of death.

Causation

Development of the Death Concept All living functions, cease at death This is where we realize that literally everything goes away once our body goes. Understanding that the body here on earth stops.

Cessation

A short interval follows in which heart-beat, circulation, breathing and brain functioning stop but resuscitation is still possible.

Clinical death

This is severe, prolonged, distress that lasts for years. It impairs physical & mental health

Complicated grief

This is when... ➢ One confronts the reality of death & emotions ➢ Grief is the most intense ➢ Self-destructive behaviors may occur ➢ Allows mourner to work through the pain

Confrontation

Where is there controversy today in the definition of death?

Controversy lies in having life vs. having quality of life

Besides the 3 phases of death that we will cover, what 2 things happen during dying?

Culmination of lifespan development Loss of O2 to organs/brain

What variations to customs occur after death during bereavement rituals?

Cultural, spiritual, religious, and individual variations.

This is fear and apprehension of death.

Death anxiety

Many people desire to die with ____. quick, agony-free end during sleep or a clearminded final few moments in which they can say farewell & review their lives.

Death with DIGNITY

➢Initially disregards seriousness ➢ Self-protective ➢ Most people move in and out of this stage. ➢ Family members should accept this as a coping strategy ➢ However, don't prolong this stage by distorting the truth

Denial

➢ Realization that the other stages have not changed the prospect of dying ➢ Many negative experiences associated with dying lead to this (pain, decreased mental state, loss of personal control) ➢ Compassionate medical & psychological treatment aimed to alleviate this

Depression

1/3 of hospital treatment programs don't have what? What can this lead to?

Don't have end of life programs. This can lead to depersonalizing hospital conditions at the end of life.

This states that effective coping requires people to oscillate between dealing with the emotional consequences of loss & attending to life changes which when handled successfully have restorative or healing effects.

Dual-Process Model of Coping

➢ This authorizes appointment of another person to make health care decisions on one's behalf ➢ More common ➢ Allows non-legally married partners health care surrogacy ➢ Can appoint health-care proxies

Durable power of attorney for health care

Ending the life of a person suffering from an incurable condition

Euthanasia

What reduces the fear of death? (religion, spirituality, etc)

FIRMNESS IN BELIEFS (well developed personal philosophies) and CONSISTENCY BETWEEN BELIEFS AND PRACTICES (rather than religiousness itself)

This is a feeling that comes along with bereavement, and is a feeling of intense physical and psychological distress.

Grief

This is the preferable place to die; however, only 1/4 experience this kind of death. Caregivers are critical in these situations, which places high demands on caregiving.

Home death

Comprehensive Support Services for terminally ill people & their families focusing on quality of life

Hospice

This death can take place in many forms, and most deaths in the US take place here.

Hospital deaths

What cultural and spiritual variations exist in defining death? *brain death particularly

In Japan and China, doctors rely on the traditional criteria for death - absence of heartbeat & respiration (this hinders organ transplant, as previously explained) Japan: brain death standard ONLY used when the dying person is a potential organ donor. China: brain death is NOT legally recognized.

Development of the Death Concept All things will eventually die We might not be as heartbroken here. We understand that death is a part of life. This also includes objects (worrying about teddy bears and GI joes - stuff breaking etc)

Inevitability

Doctors ends a suffering person's life without the patient's permission *Administering a lethal injection/dose without the patient's permission/a medical waiver.

Involuntary active

This theory recognizes the psychological needs of the dying patients

Kubler-Ross stages of dying (1969)

People specify the treatment they do or do not want in case of a terminal illness, coma, or other near-death situation Helps ensure personal control but does not guarantee it

Living Will

What is the largest reason given by Oregon patients for requesting medical aid-in-dying?

Losing autonomy

Doctor helps a suffering patient take their own life, but final act is completed by the patient. *People who do this need to have a secondary opinion: must show that they are emotionally stable (not suffering from depression etc.)

Medical Aid-in-Dying (Assisted Suicide)

The individual passes into permanent death.

Mortality

When is anticipatory grief most often used?

Most often used when discussing the families of dying persons, although dying individuals themselves can experience anticipatory grief.

This is the culturally specified expression of the bereaved person's thoughts and feelings.

Mourning

The is the course of illness & its symptoms that affect the dying person's reactions.

Nature of the disease

This kind of death can be more personalized than in hospital deaths, but advocating from family might be necessary.

Nursing home deaths

What is brain death important for?

Organ donation: few organs can be salvaged from bodies without artificially maintaining vital signs.

In this perspective, death is seen as imposed on people, as defeat or failure, and as robbing them of opportunities to achieve their goals.

Overcoming perspective

This type of care relieves pain and other symptoms (nausea, breathing difficulties, insomnia, and depression) rather than prolonging life *Prevention of further injuries or pain *Symptom control, QOL, and preparation for death Care of clients with a terminal illness, and established medical specialty that meets the needs of people with illnesses that cannot be cured

Palliative care

In this perspective, death and dying are viewed as natural and life-promoting, as fulfillment of life goals, and as a time to share one's experiences with others.

Participatory perspective

Withholding or withdrawing life sustaining treatment by allowing the patient to die naturally ex: removing food tube/O2 *legally it is not suicide (although some cultures oppose)

Passive Euthanasia

Development of the Death Concept Once a living thing dies, it cannot be brought back to life. This is what we learn as children (ex: when a goldfish dies and you have to learn that it can't be brought back)

Permanence

Brain stem (autonomic movements such as breathing & processing food) continues to register electrical activity. but cerebral cortex no longer active/ registers electrical activity.

Persistent Vegetative State

Understanding the way individuals view stressful life events & have coped with them in the past helps us appreciate the way they manage the dying process. What is this in reference to?

Personality and coping style

Rather than phases, the grief process is best conceived as a set of tasks to take in order to recover & return to a fulfilling life. What does this create in the individual?

Resilience

This involves recognizing the new role without the loved one.

Restoration

Among Westerners, what is more important in limiting death anxiety?

Spirituality - or a sense of life's meaning - seems more important than religious commitment.

What does spirituality reduce the fear of? It also lessens what?

Spirituality reduces FEAR OF DEATH & also lessens END OF LIFE DESPAIR. *It is very important to understand how different religions view death/dying as well as practices when preparing one for death.

This is the belief that one will continue to live on through one's children or through one's work or personal influence

Symbolic immortality

This is the irreversible cessation of all vital functions especially as indicated by permanent stoppage of the heart, respiration, and brain activity

The end of life

Describe the stages in in kubler-ross theory.

Theory of 5 typical responses (stages) of dying. Stages are more like a COPING STRATEGY than a stage, which allows one to call on in the time of threat of dying. The person may stop at any stage or move back and forth between stages. Family members/ clinicians should understand the stages. These stages allow the dying to have "unfinished needs" that they want to address

Doctors act directly, at a patient's request to end life. "mercy killing" *There is no legal right to this except for the patient's. The patient can or cannot be suffering from something severe.

Voluntary Active

This death issue involves dealing with relationship and role issues. Most older adults fare well, while younger adults display more negative consequences.

Widowhood

It is important to understand that a decision not to receive "aggressive medical treatment" is not the same as what?

Withholding all medical care *cancer patients may not want to go through chemo, but this isn't the same as withholding all care

What are some difficult situations/deaths to deal with?

⎻ Young child (most difficult for adults) ⎻ Teenagers losing friends ( more likely for depression & acting out) ⎻ Traumatic events

What approaches does Hospice use to achieve the dying persons' needs, and so that family members can prepare for death in ways that are satisfying for them?

➢ Interdisciplinary team approach ➢ Help people to adapt to life-threatening diseases ➢ Palliative (comfort care) ➢ Maintain a holistic approach ➢ Address physical, emotional, social & spiritual needs ➢ Patient & family are viewed as a unit of care ➢ Provide 24 hours a day, 7 day a week care ➢ Promote a therapeutic setting for patient and their caregivers ➢ Including bereavement services in the year after death

Helping family members cope with the pending death of a loved one includes what 3 things?

➢ encouragement to commemorate the life and the death ➢ respect for cultural heritage ➢ Having a trusting relationship

What are 4 aspects of anticipatory grief?

➢Depression ➢Heightened concern for the dying person ➢Rehearsal of the death ➢Attempts to adjust to the consequences of the death

Bereavement interventions encourage coping strategies. What are 4 of these?

➢Give permission to feel the loss ➢Be realistic about the grieving process ➢Remember your loved one ➢When ready, invest in new activities & relationships

What are the criticisms of Kubler-Ross Theory?

➢Professionals take too literally & "push" through stages ➢No evidence for universal, linear sequence ➢Limited in the "responses" ➢Can lead to easily dismissing a legitimate complaint or concern if not careful ➢A single strategy, such as acceptance, is not best for every dying patient

What family implications can arise, and why would caregivers be important in these situations?

➢Unfortunately, not everyone who is dying has a family wishing they wouldn't go. ➢You and other care givers may be the their only contacts