Chapter 26: Death, Bereavement, and Affirmation of Life

How Death Has Changed in the Past 100 Years

• Death occurs later in life.
• The process of dying takes longer.
• Death often occurs in hospitals or institutions.
• The primary causes of death have shifted.
• What happens after death is often uncertain or unclear in contemporary society.

Cultures, Epochs, and Death

• Ancient societies shared common themes regarding death:
  • Actions during life influenced destiny after death.
  • Belief in an afterlife was prevalent.
  • Mourners performed specific prayers and offerings to prevent the deceased's spirit from causing harm.
• Contemporary Beliefs
  • Each faith has distinct rituals and practices surrounding death.
  • Death customs sustain communities and families.
  • Religious practices change with historical conditions.
  • Death always inspires strong emotions.

Understanding Death Throughout the Life Span

• Death in Childhood:
  • Children's understanding of death is often impulsive.
  • Fatally ill children fear abandonment; physical presence and care are crucial.
  • Older children seek factual information and exhibit less anxiety about death.
• Adolescence and Emerging Adulthood:
  • Teenagers may appear fearless of death, engaging in risky behaviors.
  • Risk-taking may be a way to control anxiety about death.
  • Terror Management Theory (TMT): People adopt cultural values and moral principles to cope with their fear of death.
• Death in Adulthood:
  • Attitudes toward death shift when adults take on work and family responsibilities.
  • Many adults adopt precautionary behaviors.
  • Death anxiety typically increases from the teens to the 20s, then gradually decreases.
  • Terminally ill adults aged 25 to 65 often worry about leaving unfinished tasks or family members behind.
• Death in Late Adulthood:
  • Death anxiety decreases, and hope increases.
  • Acceptance of mortality and altruistic concern for others are signs of mental health.
  • Many older adults accept death and make plans for it.
  • Family becomes more significant as death approaches.
  • Acceptance of death doesn't mean giving up on life.

Turning to Family as Death Approaches

• Both young and old cancer patients preferred spending time with family over unfamiliar individuals.

Near-Death Experiences

• An episode where a person nearly dies, survives, and reports leaving their body, moving toward a bright light, and feeling peace and joy.
• Often include religious elements.
• Result in a worldview emphasizing:
  • Limitations of social status.
  • Insignificance of material possessions.
  • Narrowness of self-centeredness.

Choices in Dying

• Good Death: A peaceful, quick, painless death after a long life, surrounded by family and friends, in familiar surroundings.
• People in all religious and cultural contexts hope for a good death.

A Good Death

• Modern medicine can lead to well-intentioned medicalization, which may not always result in a good death when a cure is impossible
• Honest Conversation:
  • Kübler-Ross identified emotions experienced by dying people and their loved ones.
  • Maslow's hierarchy of needs provides another framework for understanding the stages of dying.

Attending to the Needs of the Dying

• Kübler-Ross's Five Stages of Grief:
  • Denial
  • Anger
  • Bargaining
  • Depression
  • Acceptance
• Maslow's Hierarchy of Needs:
  • Physiological needs
  • Safety
  • Love and acceptance
  • Respect
  • Self-actualization
  • Self-transcendence

Hospice

• Hospice: An institution or program providing palliative care to terminally ill patients.
• Hospice caregivers focus on pain relief and comfort, avoiding measures that delay death.
• Two key principles of hospice care:
  • Respect for patient autonomy and decisions.
  • Counseling for family and friends before and after death, along with guidance on providing care.

Not With Family

• Most people prefer to die at home but often die in institutions.

Barriers to Entering Hospice Care

• Patients must be terminally ill with a prognosis of six months or less to live.
• Patients and caregivers must accept the reality of death.
• Hospice care can be costly.
• Availability of hospice care varies.

Palliative Medicine

• Palliative Care: Care focused on providing physical and emotional comfort rather than curing the illness and support and guidance to his or her family.
• Double Effect: An ethical dilemma where an action has both a positive effect (relieving pain) and a negative effect (hastening death).

Ethical Issues

• Deciding when death occurs is complicated by life-support measures.
• Treatments and interventions can postpone or prevent death.
• Religious advisors, doctors, lawyers, and family members may disagree on the definition of death.
• Historic evidence of death
  • No heartbeat or respiration
• Modern evidence of death
  • Brain death
  • Locked-in syndrome
  • Coma
  • Vegetative state
• Lack of professional or international agreement on the definition of death.

Euthanasia

• Passive Euthanasia: Allowing a seriously ill person to die naturally by withholding medical intervention.
  • DNR (Do Not Resuscitate) Order: A written order from a physician (sometimes initiated by a patient’s advance directive or by a health care proxy's request) that no attempt should be made to revive a patient during cardiac or respiratory arrest
• Active Euthanasia: Taking direct action to end another person's life to alleviate suffering.
  • Legal in some countries (Netherlands, Belgium, Luxembourg, Switzerland) but illegal in most others.
  • Some physicians condone active euthanasia under specific conditions:
    • Unrelievable suffering
    • Incurable illness
    • Patient's desire to die

Physician-Assisted Suicide

• Physician-Assisted Suicide: Providing the means for someone to end their own life.
  • Concerns exist about the potential for abuse and a slippery slope toward killing vulnerable individuals.
• International physician-assisted suicide
  • The Netherlands has permitted active euthanasia and physician-assisted suicide since 1980; extended in 2002.
  • First, try to make suffering bearable
  • Criticized for paying too little attention to patient’s psychological state
• U.S. physician-assisted suicide
  • Death with dignity physician-assisted suicide in Oregon, Washington, Vermont, and California

Oregon Residents’ Reasons for Requesting Physician Assistance in Dying, 2015

• Less able to enjoy life: 91%
• Loss of autonomy: 92%
• Loss of dignity: 67%
• Burden on others: 54%
• Loss of control over body: 37%
• Pain: 26%
• Financial implications of treatment: 5%

Advance Directives

• An individual's instructions for end-of-life medical care, written before such care is needed
• Living Will: A document outlining desired medical interventions if one becomes incapable of expressing wishes.
• Health Care Proxy: A designated person to make medical decisions if one becomes incapacitated.

Affirmation of Life

• Bereavement: The sense of loss following a death.
• Grief: The intense sorrow felt at the death of another.
• Mourning: Culturally prescribed ceremonies and behaviors for expressing bereavement.

Complicated Grief

• Absent Grief: Cutting oneself off from community and customs, leading to social isolation.
• Disenfranchised Grief: Grief that is not publicly acknowledged or supported.
• Incomplete Grief: Grief process interrupted by circumstances.

Mourning

• Public and ritualistic expression of bereavement, honoring the dead.

How Mourning Helps

• Provides familial support.
• Facilitates the transition from grief to reaffirmation.
• Channels and contains private grief.

Placing Blame

• A common impulse after death for survivors.
• Can be directed at the deceased, oneself, or others.
• May be irrational.

Placing Blame and Seeking Meaning

• Often involves preserving memories.
• Support groups offer understanding and help.
• Organizations and charities may emerge from loss.

Diversity of Reactions

• Reactions to death are varied.
• Responsiveness to the needs of grieving individuals is essential.
• Childhood reaction patterns can influence grief.
• Reaffirmation doesn't mean forgetting; continuing bonds endure.