CHAPTER 19 DEATH AND DYING DYING AND DEATH

CHAPTER 19 DEATH AND DYING

DYING AND DEATH ACROSS THE LIFESPAN

What is death? Although the question seems straightforward, defining the point at which life ceases and death occurs is surprisingly complex • Functional death: is defined by an absence of heartbeat and breathing. Although this definition seems unambiguous, it is not completely straightforward. • Brain death: occurs when all signs of brain activity, as measured by electrical brain waves, have ceased. • Legal death: of death in most localities in the United States relies on the absence of brain functioning, although some laws still include a definition relating to the absence of respiration and heartbeat.

Death across the Life Span: Causes and Reactions • Despite its economic wealth, the United States has a relatively high infant mortality rate • In 48 other countries infants died less often in the first year of birth than in the United States (World Fact Book, 2012) • Infancy and childhood – Miscarriage – Still birth – Sudden infant death – Accidents #1 – Homicides #4

Death across the Life Span: Causes and Reactions Childhood • No concept of death until around the age of 5 • Around the age of 5, better understanding of finality and irreversibility of death • By about age 9, acceptance of universality and finality of death • By middle childhood, understanding of some customs involved with death (e. g. , funerals, cremation, and cemeteries)

Death across the Life Span: Causes and Reactions Adolescence • View of death are often unrealistic • Sense of invincibility • Personal fable • Imaginary audience Terminal Illness • Denial • Depression

Death across the Life Span: Causes and Reactions Young Adulthood • Prime time of life • Death seems unthinkable • Creates feelings of anger and impatience Concerns • Desire to develop intimate relationships and express sexuality • Future planning

Death across the Life Span: Causes and Reactions Middle Adulthood • Life-threatening disease not surprising • Fear of death often greatest Causes • Heart attack or stroke

Death across the Life Span: Causes and Reactions Late adulthood • Realize death is imminent • Face an increasing number of deaths in their environment • Less anxious about dying Causes • Cancer, stroke, and heart disease • Terminal death • a significant drop in performance in cognitive areas such as memory and reading may foreshadow death within the next few years.

Terminal Decline • Suffering • Burden to loved ones • Decrease in value to society

Adding Years

Suicide in Later Life • Rate for men climbs steadily during late adulthood • No age group has a higher rate of suicide than white men over the age of 85 – Severe depression – Some form of dementia – Loss of a spouse

Differing Conceptions of Death Has one person died a better death than the other? • Depends on values related to cultural and subcultural teachings Differing views • Death as punishment • Death as judgment about contributions to society • Death as start of redemption or start of eternal life Religious influence • Christian and Jewish • Sunni Muslim • Druze

CONFRONTING DEATH

Are there steps toward death? Kübler-Ross • Developed a theory of death and dying • Built on extensive interviews with people who were dying • With input from those who cared for them

Kübler-Ross Theory

Evaluating Kübler-Ross’ Theory PROS CONS • One of first people to observe systematically how people approach their own deaths • Increased public awareness and affected practices and policies related to dying • Largely limited to those who are aware that they are dying • Less applicable to people who suffer from diseases in which the prognosis is uncertain • Stage-like increments questioned • Anxiety levels not included • Some people report feelings of yearning rather than anger or depression

Other Theorists Edwin Shneidman • “Themes” in people's reactions to dying that occur—and recur—in any order throughout the dying process –incredulity, a sense of unfairness, fear of pain or even general terror, and fantasies of being rescued Charles Corr • People who are dying face a set of psychological tasks –Tasks include minimizing physical stress, maintaining the richness of life, continuing or deepening their relationships with other people, and fostering hope, often through spiritual searching.

Should people be free to select the nature of their own death?

Choosing the Nature of Death DNR • Issues – Differentiates of “extreme” and “extraordinary” measures from those that are simply routine – Determines of individual's current quality of life and whether it will be improved or diminished by a particular medical intervention – Determines of decision-maker role

Doctors and Decisions • Medical personnel are reluctant to suspend aggressive treatment. • Physicians often claim to be unaware of patients’ wishes • Physicians and other health care providers may be reluctant to act on DNR requests – Trained to save patients – To avoid legal liability issues • Many became physicians in order to SAVE lives

Living Wills To gain more control over decisions regarding the nature of their death, people are increasingly signing living wills • Living will • Health care proxy • Durable power of attorney

Euthanasia and Assisted Suicide Euthanasia • Passive • Voluntary active Assisted suicide • Kevorkian • Issue of “informed consent” • Very ill people make poor decisions • Pain avoidance can lead to wishing for death

What are the arguments? PROS CONS

Pros • Does the right belong solely to an individual, a person's physicians, his or her dependents, the government, or some deity? • In the United States, it is assumed that all have the absolute right to create lives by bringing children into the world, some people argue that we should also have the absolute right to end our lives.

Cons • Practice is morally wrong. • Prematurely ending someone's life, no matter how willing that person may be, is the equivalent of murder. • Physicians are often inaccurate in predicting how long a person's life will last. • Emotional state of the patient may be unstable.

How Long Do “Terminal” Patients Really Live? According to the large SUPPORT study, a significant percentage of a group of 3, 693 patients given no more than a 50 percent chance of living for six months survived well beyond that period. Why do you think this happened? (Source: Based on Lynn et al. , 1997. )

Caring for the Terminally Ill Place of Death • Home care • Hospice care • Hospital care

GRIEF AND BEREAVEMENT

Mourning and Funerals: Final Rites Costs • Average funeral and burial costs $7, 000 • Survivors are susceptible to suggestions to “provide the best” for deceased • Determined by social norms and customs

Cultural Differences in Grieving Western societal rituals (some variations) • Body preparation • Celebration of a religious rite • Military customs • Other customs – like Masons, or family, or personal wishes

Cultural Differences in Grieving Non-Western rituals different from Western • Examples: – Shave heads, let hair and beard grow – Noisy celebration and silence – High emotional display of emotion and no display of emotion

Feldman concludes that all funerals basically serve the same underlying function. They serve as a way to mark the endpoint for the life of the person who has died—and provide a formal forum for the feelings of the survivors, a place where they can come together and share their grief and comfort one another.

Bereavement and Grief: Adjusting to the Death of a Loved One

What is the difference? • Bereavement is acknowledgment of the objective fact that one has experienced a death • Grief is the emotional response to one's loss.

Grieving in the Western World • 1 st stage: grief typically entails shock, numbness, disbelief, or outright denial • 2 nd stage: people begin to confront the death and realize extent of their loss • 3 rd stage: people reach accommodation stage • Most people emerge from the grieving process and live new lives, independent from the person who has died. Form new relationships, and some even find that coping with the death has helped them to grow as individuals. They become more self-reliant and more appreciative of life. •

Death of Long-term Spouse Death of spouse • Strength of relationship with can have effect on grieving process • Almost always traumatic experience that is usually followed by intense grief and anguish

Close Marriages • Almost half of those who reported having satisfying marriages were able to get past their grief within six months of the death of their spouses • • People who enjoy close and happy marriages tend to have strong interpersonal skills on which to rely during their time of loss. They may be better equipped to call upon friends, family, and even a professional counselor if necessary to assist them through their grieving period.

Close Marriages • Surviving spouses who enjoyed a close marriage are more likely to have settled lingering issues and to have talked through what would happen after either of them died; they therefore are more likely to feel secure in knowing what their departed would have wanted for them in widowhood. • Finally, spouses who have a close and secure relationship may simply have a better opportunity to say their final goodbyes as one of the partners’ heath fails.

Strained marriages • Surviving partners of strained marriages might feel more sadness over never having achieved a desired level of closeness, or they might regret not having an opportunity to resolve lingering conflicts, or they might feel guilty about not working harder to make their marriage better when they had the chance. • Slower recovery • Increased possibility of permanent personality and relationship changes

When Grief Goes Awry • No particular timetable for grieving • For some people (but not all) grieving may take considerably longer than a year • Only 15 to 30 percent of people show relatively deep depression following loss of loved one • Those who show most intense distress immediately after a death are most apt to have adjustment difficulties and health problems later on

Consequences of Grief and Bereavement Negative • Widowed people are particularly at risk of death • More negative consequences if person is already insecure, anxious, or fearful, overly dependent, or lacking in social support • Sudden death Positive • Remarriage lowers risk of death for survivors, especially for widowers

Survivor Risks • risk of death is as much as seven times higher than normal in the first year after the death of a spouse. • At particular risk are men and younger women • Those highly dependent on the person who died, and who therefore feel more vulnerable without them, are apt to suffer more after the death, as are those who spend a great deal of time reflecting on a loved one's death and their feelings of grief. • Those lacking social support from family, friends, or a connection to some other group, religious or otherwise, are more likely to experience feelings of loneliness, and therefore are more at risk. • Those unable to make sense of the death or find meaning in it show less overall adjustment.

How Helpful Is Grief Counseling? Effectiveness and the necessity of grief counseling services has recently been called into question • Meta-analysis of more than 60 studies of therapeutic interventions for bereaved people concluded that these grief counseling did not help significantly more than the mere passage of time • There are many variations on how people react to the death of a loved one, friend, or acquaintance • Care should be taken about applying preconceptions about the course of grief as people cope with death

Helping a Child Cope with Grief • Be honest • Encourage expressions of grief • Reassure children that they are not to blame for the death (But be careful NOT to introduce idea!) • Understand children's grief may surface in unanticipated ways • Children may respond to books for young persons about death