PSYCH 223 - CHAPTER 19 - DEATH AND BEREAVEMENT

Clinical Death

vital signs are absent but resuscitation is still possible, near death experiences

Brain Death

Absence of vital signs, resuscitation no longer possible, legally dead

Social Death

Family and medical personnel treat the deceased person as a corpse, family and friends must begin to deal with the loss

Preparation for Death 

• Most agree on the importance of prepping for death: life insurance, will, funeral planning

• Prep is more common as people get older

Advance Directives

• Directions given by a competent individual concerning what, how, and decisions should be made if they become incompetent to make those decisions 

• When patient’s wishes are met, less strain and better quality of life for patients and families

Terminal Decline 

• Process of reminiscence 

• Unconscious changes in the years before death as preparation 

• Closer to death: conventional, docile, dependent, non-introspective 

• Increasing neuroticism and declining conscientiousness

• Sharp decline in life satisfaction 4 years prior to death 

• Gradual but accelerating decline in overall cognitive functioning over the course of roughly six years 

• Sudden steep drop in crystalized intellectual ability, signals that death is imminent

Kubler-Ros 5 Stages of Dying 

1. Denial: hard to believe

2. Anger: life is not fair

3. Bargaining: talking to god, doctors, etc. 

4. Depression

5. Acceptance: depression is necessary for acceptance. Final rest before the long journey

5 Stages of Dying Info

Provides language for those working with dying patients 

Generalizability and cross-cultural relevance is questionable: small sample size 

Stages and order is questioned 

• “Themes” of dying process rather than stages

Tasks of the dying person

• Minimize physical stress

• Maximize psychological security, autonomy and richness of life 

• Sustaining and enhancing significant interpersonal attachments 

• Reaffirming sources of spiritual health and hope 

Responses to Impending Death 

• Women's attitudes three months after diagnosis of breast cancer 

  • Denial 

  • Fighting Spirit

  • Stoic Acceptance 

  • Helplessness

  • Anxious Preoccupation 

• Those with initial reaction of fighting spirit were less likely to die of cancer 

• Impact of psychological self help on survival rates of medically incurable cancer 

  • ⅓ who were the most engaged in self help lived much longer 

End Of Life Care

• Hospital Care: 67% of death in hospitals 

• Hospice Care

  • Holistic approach: individual and family control of the process of dying 

  • Emerged in England in 1960s, and in Canada in mid 1970s

  • Death with dignity: more likely if the dying person remains at home/home like setting surrounded by friends and family

Hospice Care Philosophy 

• Death viewed as normal 

• Patient and family encouraged to prepare for death 

• Family involved in patient care 

• Care is aimed at satisfying physical, emotional, spiritual, psychological needs

• Medical care should be primarily palliative, not curative 

Palliative Care

Relieving patients pain and symptoms

Palliative Care Benefits

Address physical psychological social spiritual and practical issues, and associated expectations, needs, hopes and dears 

Prepare and manage self-determined life closure and the dying process 

Cope with loss and grief 

Curative biomedical care with a wellness, whole person orientation

Caregiver Support 

• Grief response in caregivers 

• Hospice care includes psychosocial and educational support 

• Canadian Virtual Hospice 

  • Direct interaction of health care professionals with informal care providers 

  • Range of palliative hospice care services 

  • Brings medical expertise to the home, rural and remote areas.

Medically Assisted Suicide 

• Medical professional prescribes a self-administered drug to cause death / IV

• “Physician-assisted suicide” / “Physician-assisted death

Eligibility for Medically Assisted Suicide

• Be eligible for federal/provincial healthcare services

• 18+ and mentally competent

• Have grievous and irremediable medical condition or unbearable physical or mental suffering that cannot be relieved 

• Make a quest for MAID without outside pressure/influence (witnessed by 2 people that wouldn’t benefit from death)

• Give informed consent

Grief

Natural response to the loss of someone/something - not always death 

Rituals

• Usually funerals in almost every culture 

• Death ritual is the first of many steps of grieving 

• Provide psychological functions

  • Giving grieving family roles to play

  • Bring family together, strengthen ties, pass the torch 

  • Help survivors understand the meaning of death

  • Transcendent meaning to death in a philosophical/religious context

Age Differences

• Children express grief similar to older people 

• Funerals serve children similarly, and resolve their feelings of grief  within 1 year after loss 

• Knowing a loved one is ill helps coping with the loss in advance 

• Teens are more likely to experience prolonged grief than children or adults - “What if?”

Mode of Death 

• Widows who cared for spouses during a period of illness are less likely to become depressed after death 

• A death with intrinsic meaning provides a sense of a purposeful death (dying in a heroic way)

• Sudden and violent deaths evoke more grief

Suicide Responses Among Survivors

• Feelings of rejection and anger

• Feel they could’ve done something to prevent it 

• Less likely to discuss the loss

• More likely to experience long-term effects 

Widowhood and Physical Health 

• Immune system functions suppressed immediately after death 

• Return to normal by a year after

• Immune dysfunction can last beyond signs of grief

Widowhood and Mental Health 

• Within 1 year: incidence of depression increases 

• Mental health history impacts duration

Prolonged Grief

• 2+ months, prolonged grief disorder 

• 6+ months: long-term depression, decreased quality of life, physical ailments 

• Cultural grief behaviour

Suicide Prevention of long term-problems 

• Talk about it 

• Developing a coherent personal narrative of the events 

• Support groups 

• Interventions that work promote a sense of mastery and social support 

• Appropriate amoutnof time off work 

The Widowhood Effect 

• Rise in mortality following the death of a spouse 

• Risk: 30-90% during the first three months 

• Sudden loss of whatever social and emotional buffering effects that marriage provides

Life Course Approach 

• Young adults: cheated by death 

• Middle aged adults: confront mortality, measure time as until death 

• Older adults: more accepting

Death Anxiety

apprehensive, uneasy, or nervous feeling brought on by the awareness of death

Fear of Death - Paul Wong

1. Finality of death 

2. Uncertainty of what follows 

3. Annihilation of anxiety or fear of non-existence

4. Ultimate loss 

5. Fear of the pain and loneliness in dying 

6. Fear of failing to complete life work

Young Adults

 sense of unique invulnerability prevents intense fear of death

Middle Age

most fearful of death, belief in one's own mortality breaks down, increasing anxiety

Late Life

 inevitability of death is accepted, anxieties focused on how death will come about. More likely to fear the period of uncertainty before death, than death itself.

Religious and Spiritual Beliefs 

• Those who are very religious and not religious at all report less fear of death 

• Most fearful: those uncertain 

• Religion may moderate fears of death 

  • Seen as a transition from one form of life to another 

  • Belief that god exists increases with age, but belief in life after death decreases

Lev and Van Bommel

spiritual search for meaning in our lives is intensified by the reality of death 

Death stories that teach life is a part of a larger, multigenerational story. Losses to contributions 

Indigenous: Death is faced and accepted with composure

Personal Worth

• Less fear if: they have accomplished their goals and believe life has a purpose 

• Aspect of the despair in ego integrity vs. despair

Children 

• Adults understand death is irreversible, comes to everyone, cessation of all function 

• Teaching young children about the nature of biological life helps them understand (age 7 understand)

Adolescents

• Understand the nature of death 

• Unrealistic beliefs about personal death contribute to ado suicide 

• Ado’s ideas about death are affected by their personal experiences

Early Adulthood

• Unique invulnerability: bad things only happen to others 

• Sudden loss of a loved one shakes the belief, more in younger than older 

• Death of relatively young public figured challenge young people's belief

Middle and Late Adulthood 

• Death changes the roles and relationships of everyone in the family 

• Bring permanent changes in families and social systems 

• “Time since birth” to “Time until death” 

• Those preocupied with past more likely to be fearful

Death as Loss

• Most pervasive meaning of death 

• Young adults: concerned about the loss of opportunity to experience, and loss of family relationships 

• Older adults: worry about loss of time to complete inner work