epilogue: death and dying

In all religions and cultures, death is regarded as a(n):

passage not an endpoint

Active euthanasia

- Situation in which someone takes action to bring about another person's death, with the intention of ending that person's suffering. - Legal under some circumstances in the Netherlands, Belgium, Luxembourg, and Switzerland, but it is illegal (yet rarely prosecuted) in most other nations.

Most bereaved people recover within a year.

A feeling of having an ongoing bond with the deceased is no longer thought to be pathological.

Controversial ethical issues

Acceptance varies markedly by culture, religion, education, and local values

_____ is the medical order that would precede _____.

DNR; passive euthanasia

Contemporary religions: Examples

Hinduism Islam Buddhism Native Americans North American Christians

Ancient times

Neanderthals Egyptians Greeks

Health care proxy

Person chosen by another person to make medical decisions if the first person becomes unable to do so.

Normal grief

Powerful sorrow that an individual feels at a profound loss, especially when a loved one dies Criteria changed with DSM-5

Bereavement

Sense of loss following a death

DNR (Do not resuscitate)

Written order from a physician (sometimes initiated by a patient's advance directive or by a health care proxy's request) that no attempt should be made to revive a patient if he or she suffers cardiac or respiratory arrest

According to Kübler-Ross, the fifth and final stage of dying is:

acceptance

Which statement does NOT describe one of the changes that has occurred surrounding death in the past 100 years?

death is more spiritually accepted

Compared to their ancestors and those in developing nations, people in developed nations are less likely to:

have watched someone die

Elisabeth Kübler-Ross

identified emotions and stages experienced by dying people

Many who experienced the tragedy of the 9/11 terrorist attacks were not able to fully grieve the loss of loved ones because of the immediate security threat related to the attack. What kind of grief would those individuals have experienced?

incomplete grief

Typically, young children who have a fatal illness fear death mainly because it means that:

they may be abandoned

filtered reactions of death

- Cultural prisms - Historical changes - Regional variations - Age of dying and bereaved - Hope remains constant

Changes in Death in the Past Century:

- Death occurs later - Dying takes longer - Death often occurs in hospitals - The causes of death have changed

Consistent themes in known ancient societies

- Life actions affect destiny after death - Afterlife was assumed - Particular prayers and offerings engaged to prevent haunting from spirit of dead

death in adolecence

- Teens have little fear of death. - Adolescents often predict that they will die at an early age and their developmental tendency toward risk-taking can be deadly. - Romanticizing death makes young people vulnerable to cluster suicides, foolish dares, fatal gang fights, and drunk driving

death in adulthood

- W age, responsibility for work, and family, death is avoided or at least postponed (quit taking addictive drugs, start wearing seat belts, and adopt other precautions) - Terminally ill adults worry about leaving something undone or leaving family members—especially children—alone. - Older adults typically accept death

Physician-Assisted Death with Dignity: OR, VT, WA, CA, MA Dying person must:

- adult - Request lethal drugs twice orally and once in writing. - Allow fifteen days elapse between first request and prescription. - Obtain confirmation from two physicians of terminal illness, less than six months to live, and competence - Record-keeping and annual reporting

Near-Death Experience

- episode in which a person comes close to dying but survives and reports having left his or her body and having moved toward a bright white light while feeling peacefulness and joy - experiences often include religious elements. - Survivors may adopt a more spiritual, less materialistic view of life. - To some, near-death experiences prove that there is a heaven, but scientists are more skeptical

understanding death in childhood

- have a different perspective of death - Older children use more concrete operational cognition; they seek specific facts and become less anxious about death and dying

Good death

- peaceful, quick, and painless - occurs after a long life, in the company of family and friends, and in familiar surroundings. - People in all religious and cultural contexts hope for good death

Stages of Dying: Kübler-Ross

1. Denial "I am not really dying." 2. Anger "I blame my doctors, or my family, or God for my death." 3. Bargaining "I will be good from now on if I can live." 4. Depression "I don't care about anything; nothing matters anymore." 5. Acceptance "I accept my death as part of life."

Stage Model Based on Maslow's Hierarchy of Needs

1. Physiological needs (freedom from pain) 2. Safety (no abandonment) 3. Love and acceptance (from close family and friends) 4. Respect (from caregivers) 5. Self-actualization (spiritual transcendence)

The "Right to Die": Slippery slope

A given action will start a chain of events that will culminate in an undesirable outcome.

Not with Family

Almost everyone prefers to die at home, yet most people die in an institution, surrounded by medical personnel and high-tech equipment, not by the soft voices and gentle touch of loved ones

opiods double effect

An ethical situation in which an action has both a positive effect, which is intended, and a negative effect, which is foreseen but not intended

Palliative care

Care designed not to treat an illness but to provide physical and emotional comfort to the patient and support and guidance to his or her family.

Mourning

Ceremonies and behaviors that a religion or culture prescribes for people to employ in expressing their bereavement after a death Mourning customs designed to move grief from loss toward reaffirmation

Placing blame

Common impulse after death for the survivors (e.g., for medical measures not taken, laws not enforced, unhealthy habits not changed) Bereaved sometimes blame the dead person, sometimes themselves, and sometimes distant others. Nations may blame one another for public tragedies. Blame is not necessarily rational.

Ethical issues: Deciding when death occurs

Death does not necessarily occur when vital organs stop

Advance directive

Document that contains an individual's instructions for end-of-life medical care, written before such care is needed

Living will

Document that indicates what kinds of medical intervention an individual wants or does not want if he or she becomes incapable of expressing those wishes.

Contemporary religions

Each faith displays diversity in death practices.

Two principles for hospice care

Each patient's autonomy and decisions are respected. Family members and friends are counseled before the death, shown how to provide care, and helped after the death.

What is unbearable suffering?

Fatigue, pain, decline, negative feelings, loss of self, fear of future suffering, dependency, loss of autonomy, being worn out, being a burden, loneliness, loss of all that makes life worth living, hopelessness, pointlessness, and being tired of living a life of unbearable suffering

When modern medicine makes a good death

For most, death occurs at end of a long life. Illness often treated effectively. Death at young age is often quick.

Physician-assisted suicide

Form of active euthanasia in which a doctor provides the means for someone to end his or her own life.

Evidence of death controversy

Harvard physicians (late 1970s): Cessations of brain waves - AAN (2008): No spontaneous breathing; no eye response to stimuli

The "Right to Die": Slippery slope relating to death

Hastening death when terminally ill people request may cause a society to slide into killing sick people who are not ready to die—especially the old and the poor

Barriers to Entering Hospice Care

Hospice patients must be terminally ill. Patients and caregivers must accept death. Hospice care is costly. Availability varies. Ethnic differences influence usage

Locked-in syndrome

Inability to move, except for the eyes, but brain waves still apparent. Person is not dead

Hospice

Involves institution or program in which terminally ill patients receive palliative care.

Bad death

Lacks these six characteristics (of a good death) and is dreaded, particularly by elderly

Honest conversations

Most dying people want to spend time w loved ones and to talk honestly with medical and religious professionals. Is unethical to withhold information if the patient asks for it, although some people do not want the whole truth. Hospital personnel need to respond to each dying person as an individual, not merely as someone who must understand that death is near

Which of the following does research show is the MOST common reaction to the death of a spouse?

Most people are resilient and about as happy and productive as they were before the death six months later

Seeking meaning

Often starts w preserving memories (e.g., displaying photographs, telling anecdotes) Support groups offer help when friends are unlikely to understand (e.g., groups for parents of murdered children). Organizations devoted to causes such as fighting cancer and banning handguns often find supporters among people who have lost a loved one to that particular circumstance.  Close family members may start a charity.

Personality has a major affect on grief and mourning

Only about 10 to 15% exhibit extreme or complicated grief.

Reactions to death are varied

Other people need to be especially responsive to whatever needs a grieving person may have. Grief is less likely to destroy survivors when markers or rituals are observed

General trends

Past marriages idealized Thoughts of dead spouse gradually decrease

When modern medicine makes a bad death.

People may submit to surgery and drugs that prolong pain and confusion, especially when cure is not possible. Hospital restrictions may make dying in peace more difficult.

Brain death

Prolonged cessation of all brain activity with complete absence of voluntary movements; no spontaneous breathing; no response to pain, noise, and other stimuli. Cessation of brain waves; EEG is flat

Hospice caregivers

Provide skilled treatment to relieve pain and discomfort Measures to delay death are avoided. Focus is to make dying easier.

Four types of responses (from longitudinal research)

Resilient (66%) Depressed (15%) Less depressed after death than before (10%) Slow to recover/complicated grief (9%)

allowing death: Passive euthanasia

Situation in which a seriously ill person is allowed to die naturally, through the cessation of medical intervention.

Disenfranchised grief

Situation in which certain people, although they are bereaved, are prevented from mourning publicly by cultural customs or social restrictions.

Incomplete grief

Situation in which circumstances, such as a police investigation or an autopsy, interfere with the process of grieving. Grief process may be incomplete if mourning is cut short or if other people are distracted from their role in recovery

Absent grief

Situation in which overly private people cut themselves off from the community and customs that allow and expect grief; can lead to social isolation.

Coma

State of deep unconsciousness from which the person cannot be aroused. Some people awaken spontaneously from a coma; others enter a vegetative state; the person is not dead

Vegetative state

State of deep unconsciousness in which all cognitive functions are absent, although eyes may open, sounds may be emitted, and breathing may continue; person is not yet dead.  Can be transient, persistent, or permanent.  No one has ever recovered after two years; most who recover (about 15 percent) improve within three weeks.  After time has elapsed, the person may, effectively, be dead.