Chapter 20: Death, Dying, and Grieving

Brain death

Neurological definition of death which states that a person is brain dead when all electrical activity of the brain has ceased for a specified period of time

Criterion of brain death

A flat EEG (electroencephalogram) reading for a specified period of time

• Higher portions of the brain often die sooner than the lower portions 

• A person may lose consciousness and higher mental function yet still continue to breathe and maintain a heartbeat

Cortical death policy

Functions we associate with being human, such as intelligence and personality, are located in the higher cortical part of the brain

• They believe that when these functions are lost, the “human being” is no longer alive

Advance Care Planning

Advance Care Planning

Living will

Made by the “Choice in Dying” organization

• Since some terminally ill patients might prefer to die rather than linger in a painful or vegetative state

Criticisms O

Advance directive of living will

Must be signed while the individual still is able to think clearly

Physician Orders for Life-Sustaining Treatment (POLST)

Document that is more specific than previous advance directives

• Translates treatment preferences into medical orders (e.g., cardiopulmonary resuscitation, extent of treatment, and artificial nutrition via a tube)

Euthanasia

Easy death or mercy killing

• Act of painlessly ending the lives of individuals who are suffering from an incurable disease or severe disability

Types of euthanasia

• Active

• Passive

Passive euthanasia

Person is allowed to die by withholding available treatment, such as withdrawing a life-sustaining device

Active euthanasia

Death is deliberately induced, as when a lethal dose of a drug is injected

• Physician or a third party administering the lethal medication

Asisted suicide

Patient to self-administer the lethal medication and to determine when and where to do this

Needed: better care for dying individuals

Dying individuals often get too little or too much care

• Many health-care professionals have not been trained to provide adequate end-of-life care or to understand its importance

• Care providers are increasingly interested in helping individuals experience a “good death”

Good death

Involves physical comfort, support from loved ones, acceptance, and appropriate medical care

• Accepting one’s impending death and not feeling like a burden to others

Criticisms of good death

Death itself has shifted from being an event at a single point in time to a process that takes place over years and even decades

Hospice

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

• Treat the dying person’s symptoms, make the individual as comfortable as possible, show interest in the patient and his or her family, and help everyone involved cope with death

Causes of death in prenatal development

Miscarrages or stillbirth

Causes of death in birth

First few days after birth, birth defect or because infants have not developed adequately to sustain life outside the uterus, SIDS

Causes of death in childhood

Occurs most often because of accidents or illness 

• Automobile accident, drowning, poisoning, fire, or a fall from a high place

• Major illnesses that cause death in children are

Major illnesses in childhood

Heart disease, cancer, birth defects

Causes of death in adolescence

Mostly because of motor vehicle accidents (alcohol-related), suicide, homicide

Causes of death in young adults

die from accidents

Causes of death in older adults

Chronic ailments such as heart disease and cancer

• incapacitate before they kill, which produces a course of dying that slowly leads to death

Attitudes toward death in childhood

Conception of death changes as they develop but that even young children begin to develop views of death that are more cognitively advanced than was previously thought

• Vary with the contexts and cultures in which they grow up

attitude toward death 4-5 years old

irreversibility of death and that it involves the cessation of mental and physical functioning

attitude toward death middle to late childhood

Realistic and accurate perceptions of death, such as increasingly viewing its cause as biological in nature

Death of parent

• Child’s school performance and peer relationships often suffer 

• Devastating and result in a hypersensitivity about death, including a fear of losing others close to the individual. In some cases, loss of a sibling can result in similar negative outcomes 

• Relationship quality and cause of death can influence the individual’s trajectory following the death of a person close to them

Explaining death to children

• Honesty is the best strategy in discussing death with children

• Best response to a child’s query about death might depend on the child’s maturity level

Support programs for children

Family Bereavement Program

Attitudes toward death in Adolescence

Deaths of peers, friends, siblings, parents, grandparents, or great-grandparents bring death to the forefront of adolescents’ lives

View on death of Adolescence 

• Abstract conceptions of death than children do

• Develop religious and philosophical views about the nature of death and whether there is life after death

Factors to help adolescents adjust with death of parent for adolescence

Family support, religion, meaning- making coping, exercising, and journal writing

Attitudes toward death in Adulthood

Women had more difficulty than men in adjusting death of parents

Awareness of death in adulthood

Increases with age

• Becoming more prominent in middle adulthood, when individuals realize their time is limited

• Middle-aged adults fear death more than younger or older adults

• Older adults think and talk about death more often due to increased exposure to the deaths of friends and relatives

Old age

One’s own death may take on an appropriateness it lacked in earlier years

• They usually do not have children who need to be guided to maturity

• Their spouses are more likely to be dead

• Less likely to have work-related projects that require completion

• Death may be less emotionally painful to them than to young or middle-aged adults

Kübler ross

We are all born to die, and our lives prepare us for that finality

• Dealing with our own death usually becomes the focal point in our life only when we are nearing death, but we live with an awareness of death throughout our lives

Five stages of Küblr ross

1. Denial and isolation

2. Anger

3. Bargaining

4. Depression

5. Acceptance

Denial and Isolation

First stage of dying

• Person denies that death is going to take place

• Common reaction to a diagnosis of terminal illness

• Temporary defense but replaced with increased awareness when the person is confronted with financial considerations, unfinished business, and worry about the well-being of surviving family members

Anger

Second stage of dying 

• Person becomes increasingly difficult to care for as anger may become displaced and projected onto physicians, nurses, family members, and even God

• The realization of loss is great, and those who symbolize life, energy, and competent functioning are especially salient targets of the dying person’s resentment and jealousy

Bargaining

Third stage of dying

• A person develops the hope that death can somehow be postponed or delayed

• Some persons enter into a bargaining or negotiation as they try to delay their death

Depression

Fourth stage of dying

• Person comes to accept the certainty of death

• Preparatory grief may appear

• Dying persons may become silent, refuse visitors, and spend much of their time crying or grieving

• This behavior is normal and is an effort to disconnect the self from love objects

Acceptance

Fifth stage of dying

• Person develops a sense of peace, an acceptance of his or her fate and a desire to be left alone

• Physical pain may be virtually absent

• End of the dying struggle, the final resting stage before death

Evaluation of ross stages of dying

• Existence not been demonstrated by either Kübler-Ross or independent research

• Neglected to consider variations in patients’ situations, including degrees of relationship support, specific effects of illness, family obligations, and the institutional climate in which they were interviewed

• Some say that they are not stages but potential reactions to dying

People vary in how they face death

• Some resist it until the end, while others find peace through acceptance

• Struggling or denying death can make dying harder, though for some, avoidance may be adaptive

• Finding meaning and purpose in life shapes one’s approach to death

• Spirituality helps protect against depression, and meaning-focused coping improves quality of life for many terminally ill patients

Perceived control and denial

Perceived control may work as an adaptive strategy for some older adults who face death

• Become more alert and cheerful if they believe they can influence events

• Denial is a temporarily protect individuals from the shock of facing death, helping them manage overwhelming emotions

When is denial maladaptive

• If it prevents necessary treatment or decision-making

• Value depends on how it affects coping and well-being

Context in which people die

39% of older adults die at home, 33% in hospitals, and 28% in nursing or hospice facilities

• Most prefer to die at home or in hospice for a more humane setting

• Hospitals provide medical staff and life-prolonging technology but may lack emotional comfort

• Some avoid dying at home due to fear of burdening family, limited space, or inadequate care

Communicating with a dying person

Open awareness helps dying individuals face death on their own terms

Advantages of open awareness

• Allows completion of plans, arrangements, and farewells

• Enables meaningful conversations and closure with loved ones

• Increases understanding of their condition and medical care

Conversations

• Conversation should not focus on mental pathology or preparation for death but should focus on strengths of the individual and preparation for the remainder of life

• Communication should be directed toward internal growth

Dimensions of grieving

• Grief

• Pinning or yearning

• Separation anxiety

• Despair and sadness

• Grief process

• Long term grief

Grief

Emotional numbness, disbelief, separation anxiety, despair, sadness, and loneliness that accompany the loss of someone we love

• Not a simple emotional state but rather a complex, evolving process with multiple dimensions

Pinning or yearning

Effects an intermittent, recurrent wish or need to recover the lost person

Separation anxiety

Focuses on places and things associated with the deceased, as well as crying or sighing

Despair and sadness

Sense of hopelessness and defeat, depressive symptoms, apathy, loss of meaning for activities that used to involve the person who is gone, and growing desolation

Griefing process

Roller-coaster ride than an orderly progression of stages with clear-cut time frames

• Rapidly changing emotions, meeting the challenges of learning new skills, detecting personal weaknesses and limitations, creating new patterns of behavior, and forming new friendships and relationships

• Manageable over time, with fewer abrupt highs and lows

Long term grief

Masked and can predispose individuals to become depressed and even suicidal

Concepts under long term grief

• Prolonged grief disorder

• Disenfranchised grief

Prolonged grief disorder

Feelings of despair remain unresolved over an extended period of time; Negative consequences for physical and mental health

Disenfranchised grief

Individual’s grief over a deceased person that is a socially ambiguous loss and can’t be openly mourned or supported (e.g., relationship that isn’t socially recognized such as an ex-spouse)

Dual process model of coping with bereavement

• Loss oriented stressors

• Restoration oriented stressors

Loss oriented stressors

Focus on the deceased individual and can include grief work and both positive and negative reappraisals of the loss

• Positive reappraisal: acknowledging that death brought relief at the end of suffering

• Negative reappraisal: involve yearning for the loved one and ruminating about the death

Restoration oriented stressors

Secondary stressors that emerge as indirect outcomes of bereavement 

• They can include a changing identity (e.g. from “wife” to “widow”)

Effective coping with loss and engaging in restoration

Take place concurrently

• Person coping with death might be involved in grief group therapy while settling the affairs of the loved one

Original model of coping with bereavement

Focus on the bereaved individual

Revised model of coping with bereavement

Recognizes that many people do not grieve in isolation

• Most do so with immediate family members and relatives who also are bereaved by the loss

Coping and type of death

Deaths that are sudden, untimely, violent, or traumatic are likely to have more intense and prolonged effects on surviving individuals

• Death of child= depressive

PTSD

Intrusive thoughts, flashbacks, nightmares, sleep disturbance, problems in concentrating, and other difficulties

Cultural diversity in healthy grieving

Some approaches to grieving emphasize the importance of breaking bonds with the deceased and returning to autonomous lifestyles

• People who persist in holding on to the deceased are believed to be in need of therapy 

• But people grieve in a variety of ways: there is no one correct, ideal way to grieve

Forms of mourning

• Funeral

• Culture activities after death

• Amish

• Judaism

Funeral

One decision facing the bereaved is what to do with the body

• Provides a form of closure to the relationship with the deceased, especially when there is an open casket

Culture activities after death

• Ceremonial meal 

• Black armband is worn by bereaved family members for one year

Amish

Christian group, family oriented society where family and community support are essential for survival 

• The funeral service is held in a barn in the warmer months and in a house during colder months

• Calm acceptance of death, influenced by a deep religious faith

• Following the funeral, a high level of support is given to the bereaved family for at least a year

• Visits to the family, special scrapbooks and handmade items for family members, new work projects started for the widow, and quilting days that combine fellowship and productivity are among the supports given to the bereaved family

Judaism

Program of mourning is divided into graduated time periods

1. Aninut

2. Alevut (Shivah and Sheloshim)

Aninut

period between death and burial

Avelut

Next two periods

• Shivah

• Sheloshim

Shivah

period of seven days, which commences with the burial

Sheloshim

30-day period following the burial, including shivah

• After sheloshim, the mourning process is considered over for all but one’s parent