Death and the Dying Process Types of Death Basic Statistics Social Aspects of Death Do Not Resuscitate Euthanasia.

Death and the Dying Process

Types of DeathBasic StatisticsSocial Aspects of DeathDo Not ResuscitateEuthanasia

Types of Death

Thanatologists: People who study death and dying.

Two types of death: Functional Death:

Absence of a heart-beat and breathing.

Brain Death: Diagnosis of death based on the cessation of all signs

of brain activity. Measured by electrical brain waves.

Basic Statistics

America has a very high infant mortality rate: Ranks behind 35 other countries Why is this?

Accurate statistics on our part More drug use than almost any other country

In early adulthood the leading cause of death is accidents This is followed by Suicide, Homicide, AIDS, and Cancer

Basic Statistics

Death has changed historically: 200 years ago, 1 out of every 2 children died before age 10,

and one parent usually died before a child grew up Today, death occurs mostly among

the elderly Life expectancy has increased from

47 years for a person born in 1900 to 77 years for a person born today

Over 80% of all U.S. deaths occur in hospitals

Basic Statistics

Causes of death vary across the life span: Prenatal death through miscarriage. Death during birth or shortly afterwards. Accidents or illness cause most childhood deaths. Most adolescent deaths result from suicide, homicide, or motor

vehicle accident. Deaths among young adults

are increasing due to AIDS. Middle-age and older adult

deaths usually result from

chronic diseases.

Social Aspects of Death

Attitudes toward death vary at different points in the life span: Young children use illogical reasoning

to explain death, believing magic or treatment can return life.

Others claim separation anxiety is an indicator of a child’s awareness of separation and loss.

Those in middle and late childhood have more realistic perceptions of death – that it is a finality.


Concerns about death increase as one ages: Awareness usually intensifies in middle age. Older adults are more often preoccupied

by it and want to talk about it more. One’s own death usually seems more

appropriate in old age, possibly a welcomed event, and there is an increased sense of urgency to

attend to unfinished business.


Elisabeth Kubler-Ross Made many observations and interviews with people

who were dying and with those who cared for them. Based on her observations, she suggested that people pass through five basic steps as they move toward death.


1. Denial: People resist the idea that they are going to die. They may argue that their test results have been

mixed up, that an X-ray has been read incorrectly, or that their physician does not know what he or she is talking about.

A patient can flatly reject the diagnosis Sometimes memories of weeks in the hospital are

forgotten.


2. Anger: A dying person may be angry at everyone They may be angry at people who are in good health, their

spouses and other family, those who are caring for them, and their children.

They can lash out at others and get loud. Many become very angry with God. Questions Asked: Why are the bad people not dieing and

why am I? This can lead to the next stage.


3. Bargaining: Dying people try to negotiate their way out of death. They may declare that they will dedicate their lives to the

poor if God saves them. Maybe if they can live just long enough to see a son

married, or a child born, they will willingly accept death. “If you are good, you will be rewarded” The reward for being “good” is to “live”


4. Depression: Realizing that the issue is set in stone and that bargaining will not stop this, they become overwhelmed with a huge sense of loss. Reactive depression: Feelings of sadness are based

on events that have already occurred Loss of dignity that may accompany medical

procedures End of a job Knowledge that one will never return from the hospital.

Preparatory depression: Sadness over future losses. Death will bring an end to their relationships with

others and that they will never see future generations.


5. Acceptance: Final stage of dying is acceptance. Once acceptance has arrived they are fully aware that death

is impending. They will have virtually no feelings, positive or negative,

about the present or future. In essence, they have made peace with themselves and

may wish to be left alone.


Denial and isolation – “It can’t be!” Anger – “Why me?” Bargaining – “Just let me do this first!” Depression – withdrawal, crying,

and grieving Acceptance – a sense of peace comes


The quality of one’s life is linked to how death will be approached: Meaning and purpose bring peaceful acceptance An unfulfilled life brings distress and despair.

Perceived control and denial may be adaptive strategies for remaining alert and cheerful.

Denial insulates and allows one to avoid coping with intense feelings of anger and hurt.

In the U.S., most people die in hospitals (80%), and fewer die in nursing homes or a hospice.


Women feel the loss of a life partner more than men because They live longer than men A widowed man is more likely to remarry They usually marry older men

Cross-culturally, many widows fall into poverty after the loss of a life partner

Impact on one’s physical and psychological health is linked to how long one grieves and remains widowed

Do Not Resuscitate Written order from a doctor that resuscitation should not be attempted if a

person suffers cardiac or respiratory arrest.

Sometimes known as a no-code order.

Such an order may be instituted on the basis of an advance directive from a person.

Or from someone entitled to make decisions on their behalf, such as a health care proxy.

In some jurisdictions, such orders can also be instituted on the basis of a physician's own initiative, usually when resuscitation would not alter the ultimate outcome of a disease.

DNR is more commonly done when a person who has an inevitably fatal illness wishes to have a more natural death without painful or invasive medical procedures.

DNR order came into being in the U.S. in the 1960s when defibrillation allowed the reversal of cardiac arrest, but this may prolong the life of the patient for only a short time.

Euthanasia

Defined: The practice of assisting people who are terminally ill to die more quickly.

There are three types of euthanasia:

1. Passive Euthanasia Withholding common treatments (Antibiotics, drugs, or surgery) or giving a

medication (Morphine) to relieve pain, knowing that it may also result in death. Passive euthanasia is currently the most accepted form as it is currently

common practice in most hospitals.

2. Non-aggressive Euthanasia: The practice of withdrawing life support Quite controversial

3. Aggressive Euthanasia: Using lethal substances or force to kill Extremely controversial

Physician-Assisted Suicide: Term for aggressive voluntary euthanasia.

Death and Grieving

The Death System and Cultural Contexts

Defining Death and Life/Death Issues

A Developmental Perspective on Death

Facing One’s Own Death

Coping with the Death of Someone Else

Death in Different Cultures

Perceptions of death vary; reflect diverse values and philosophies

Individuals more conscious of death in times and places of war, poverty, disease.

Most societies have Philosophical or religious beliefs about death Rituals that deal with death View that death does not end existence

Death and Cultural Contexts

U.S. Denial and Avoidance of Death

Funeral industry emphasizes lifelike qualities

Euphemisms — softening language for death

Persistent search for “fountain of youth”

Rejection and isolation of aged

Concept of pleasant and rewarding afterlife

Medical emphasis — prolonging life, not easing suffering


Changing Historical Circumstance

Death becoming increasingly complex

When to determine death has occurred

Life expectancy has increased

Most die apart from families

Care for dying shifted away from family

Minimized exposure to death and its pain


Issues in Determining Death

Brain death — neurological definition of death

All electrical activity of brain has ceased for a specified period of time

Flat EEG recording

Some medical experts argue criteria for death should include only higher cortical functioning


Decisions Regarding Life, Death, and Health Care

Natural Death Act and Advance Directive

Expresses person’s desires regarding extraordinary medical procedures that might be used to sustain life when medical situation becomes hopeless


Euthanasia

Painlessly ending lives of persons suffering from incurable diseases or severe disabilities

Passive euthanasia — withholding of available treatments, allowing the person to die

Active euthanasia — death induced deliberately, as by injecting a lethal dose of drug

Publicized controversy: assisted suicide


Needed: Better Care for Dying Individuals

Death in U.S.: often lonely, prolonged, painful

Plan for your death

Make a living will

Give someone power of attorney

Give your doctor specific instructions

Discuss desires with family and doctor

Check insurance plan coverage


Needed: Better Care for Dying Individuals

Hospice — humanized program committed to making the end of life as free from pain, anxiety, and depression as possible

Palliative care — reducing pain and suffering and helping individuals die with dignity


Causes of Death

Death can occur at any point in human life span

Prenatal — miscarriage, stillborn

Childhood — accidents or illness

Adolescence — motor vehicle accidents, suicide,

and homicide

Older adults — chronic diseases

A Developmental Perspective of Death

Death and Children

Honesty may be best way to discuss death with children

Explained in simple physical or biological terms to preschool children

Be sensitive and sympathetic, encouraging feelings and questions

Not unusual for terminally ill children to distance themselves in final stages, may be a result of depression


Attitudes Toward Death at Different Points in the Life Span

Childhood

Adolescence

Adulthood

Infant has no concept of death; perceptions of death develop in middle/late childhood; even very young children concerned about separation and loss

Develop more abstract concepts of death; common to think they are immune to death

Middle-aged adults fear death more than young adults or older adults; older adults think about death more


Suicide


Serious physical illness

Feelings of disparity, isolation, failure, loss

Serious financial problems

Drug use or prior suicide attempts

Antidepressant links

– Cultural and gender differences exist

– Rare in childhood, risk increase in adolescence

– Most adolescent attempts fail

– Linked to genetic and situational factors

– Gay or lesbian links not clear

Risk factors

Suicide in U.S.Adolescence

3rd leading cause of death in ages10-19

19% of high school students seriously considered or tried suicide in last 12 mos

Adulthood and Aging

Suicide rates increase in adulthood

Older adults use more lethal ways, are more successful

Racial and gender differences exist



Most dying individuals want to make decisions regarding their life and death

Complete unfinished business

Resolve problems and conflicts

Put their affairs in order


Kubler-Ross’ Stages of Dying

Denial and isolation

Anger

Bargaining

Denies s/he is going to die

Denial gives way to anger, resentment, rage, and envy

Develops hope that death can somehow be postponed

Depression

Acceptance

Comes to accept the certainty of her or his death

Develops sense of peace and may desire to be left alone


Perceived Control and Denial

When individuals believe they can influence and control events, they may become more alert and cheerful

Denial can be adaptive or maladaptive


The Contexts in Which People Die

Context of dying is important for most Most would rather die at home but worry over

Burden at home

Limited space

May alter relationships

Competency and availability of emergency medical treatment


Communicating with the Dying Person

Establish your presence

Eliminate distraction

Limit visit time

Don’t insist on acceptance

Allow expressions of guilt or anger

Discuss alternatives, unfinished business

Ask if there is anyone s/he would like to see

Encourage the dying individual to reminisce

Talk with the individual when s/he wishes to talk

Express your regard


Grieving Grief: emotional numbness; a complex

emotional state of… Disbelief Separation anxiety Despair Sadness Loneliness

Complicated grief

Disenfranchised grief


Model of Grieving

Dual-process model for effective coping Loss-oriented stressors

Restoration-oriented stressors

Coping and type of death Sudden or violent deaths have more

intense and prolonged effects

Many such deaths accompanied by PTSD

Cultural Diversity in Healthy Grieving

Persistent holding on to deceased may be therapeutic Hopi of Arizona forget quickly Egyptians dwell on grief Netherlands: integrate loss into their lives

Healthy coping involves Growth Flexibility Appropriateness within the cultural context

Making Sense of the World

Grieving stimulates many to try to make sense of their world — positive themes linked to hopeful future and better adjustment

Effort to make sense of it pursued more vigorously when caused by an accident or disaster


Losing a Life Partner Those left behind after the death of an

intimate partner suffer profound grief and often endure

Financial loss

Loneliness linked to poverty and education

Increased physical illness

Psychological disorders, including depression


Adjustment to Widowhood

Women live longer Widowed men more likely to remarry Measures of older women’s health

Physical and mental health Health behaviors and outcomes

Overall, women adjust better than men Older widows do better than younger

widows Support programs aid adjustment


Forms of Mourning

Approximately 80 percent of corpses are disposed of by burial, the remaining 20 percent by cremation

Funeral industry is source of controversy

Funeral is important aspect of mourning in many cultures

Cultures vary in how they practice mourning


The Amish, Traditional Judaism, and Mourning

Amish

Conservative group; family-oriented society

Live same unhurried pace as ancestors

Time of death met with calm acceptance

Neighbors notify community; funeral at

home

High level of support to family for one year


The Amish, Traditional Judaism, and Mourning

Traditional Judaism Mourning in graduated time periods; each

with appropriate practices

1st period: Aninut — between death and burial

2nd period: Avelut period — mourning proper Shivah period — 7-day begins at burial Sheloshim period — 30-day period after burial

Mourning over for all but parents who mourn another 11 months


Death and the Dying Process Types of Death Basic Statistics Social Aspects of Death Do Not Resuscitate Euthanasia.

Documents

brain death

death increase

functional death

prenatal death

diagnosis of death

leading cause of death

realistic perceptions

social aspects of death3