EPILOGUE DEATH AND DYING Historical and Cultural Contexts

EPILOGUE DEATH AND DYING

Historical and Cultural Contexts of Death and Dying • Morality rates, in developed countries, began to decline in 20 th century. • Leading causes of death shifted from acute, infectious disease to chronic, degenerative disease • Medical advances in end-of-life health care • Process of death and dying examined from a Western societal perspective

Figure EP. 1: Death Rates by Age in the United States, 2006

Defining Death • At one time death happened quickly, as there were no life-support medical advances • Persistent vegetative state – Higher cortical functioning has ceased while brain stem functioning • Brain death – All signs of brain activity have ceased for a specific period of time

Choices and Decisions at the End of Life • Determining Medical Care at the End of Life: Advanced Directives – Advance directives, a legal documents specifying the lifesustaining medical treatments people wish to receive, gives some personal control over decisions at end of life. – Living will provides directions about life-sustaining treatments the person does or does not want – Durable power of attorney authorizes a specific person to make health care decisions – Few Americans have these documents, partly due to misconceptions about the documents or discomfort with death

Figure EP. 2: A Sample Living Will

Choices and Decisions at the End of Life • Determining the Timing of Death: The Rights to Die – Desire to have control over timing of death often arises when a terminally ill patient’s pain and suffering can not be alleviated – Passive euthanasia – withholding treatment that would prolong life – Active euthanasia – actions that deliberately induce death – Physician-assisted dying – legal in several European countries and several states in the United States

Table EP. 1

The Experience of Dying • Kubler-Ross identified five stages experienced by dying persons – – – Denial Anger Bargaining Depression Acceptance • Experience of dying is affected by characteristics of the illness and the individual

Caring for Dying Persons • Although Americans prefer to die at home only 25% will do so • When needs of dying patients and their families are met, they are more likely to consider the death a “good death. ”

Caring for Dying Persons in Hospitals • 50 % of Americans die in hospitals and 25 % in nursing home • Hospitals are not equipped to meet the needs of dying individuals and family members – Staff experience demands on their time and need to maintain emotional distance – Patient pain may not be adequately managed

Caring for the Dying in Hospice Programs • Palliative care – designed to improve quality of life for patients with life threatening illnesses – Hospice care – care for terminally ill with less than 6 months to live • Emphasizes managing pain, showing respect for patient needs, supporting family members, and helping the patient prepare for impending death • Studies support distinct benefits for patients • Barriers to adequate end of life care, particularly for ethnic minorities

Video: Death and Dying

Losing a Loved One • Bereavement – objective experience of having lost a loved one • Grief – painful emotional responses to loss of a loved one – Can vary over time and from one person to the next – Can be difficult for some to overcome, particularly if the death is unexpected

Adjusting to the Loss of a Loved One • Dual process model of coping with bereavement – Coping with their feelings of loss – Coping with the changed realties of daily lives • Mourning – manner in which a person expresses grief – Shaped by cultural practices – Includes rituals, manner of dress, memorial events – Designed to facilitate transition to a new identity

Helping the Bereaved • It is helpful to show interest in bereaved person’s experiences and feelings. • Bereaved children have special needs. – By age 9 or 10 most children realize that death is permanent state – Children have less well-developed coping skills – May experience feelings of guilt or responsibility