The Ending (13)
Definition (#f7aeae)
Important (#edcae9)
Extra (#fffe9d)
Death System and Cultural Variations:
People: Everyone is involved with death, either their own death or the death of others.
Places/contexts: Hospitals, funeral homes, cemeteries, battlefields, and memorials.
Times: Death involves times or occasions and anniversary of disasters. Ex: tsunami in Acheh, Indonesia 2004.
Objects: Many objects in a culture are associated with death, including caskets and clothes in specific colours.
Symbols: Such as a skull and crossbones, last rites in the Catholic religion and various religious ceremonies.
Most societies throughout history have had philosophical or religious beliefs about death, and most societies have a ritual that deals with death.
For some, death means loneliness; for others, death is a quest for happiness. For still others, death represents redemption, a relief from the trials and tribulations of the earthly world.
In most societies, death is not viewed as the end of existence - after the biological body has died, the spiritual body is believed to live on.
Defining Death and Life/Death Issues:
Issues in determining death:
The definition of brain death currently followed by most physicians includes the death of both the higher cortical functions and the lower brain stem functions.
Decision regarding life, death and healthcare:
Advance care planning: Process of patients thinking about and communicating their preferences about end-of-life care.
1 study found that advance care planning decreased life-sustaining treatment, increased hospice use, and decreased hospital use.
A study of older adults found that advance care planning was associated with improved quality of care at the end of life, including less in-hospital death and greater use of hospice care.
Euthanasia:
The act of painlessly ending the lives of individuals who are suffering from an incurable disease or severe disability.
Sometimes euthanasia is called “mercy killing.” Involves the physician or a third party administering the lethal medication. Legal in some countries.
Passive euthanasia: Person is allowed to die by withholding available treatment, such as withdrawing a life-sustaining device.
Active euthanasia: Occurs when death is deliberately induced, as when a lethal dose of a drug is injected.
Assisted suicide: Requires the patient to self-administer the lethal medication and to determine when and where to do this, whereas active euthanasia involves the physician or a third party administering the lethal medication. Legal in some countries.
Physician-assisted suicide:
Process in which physicians provide dying patients with a fatal dose of medication that the patient self-administers.
Most people favour having a choice regarding assisted suicide if they should ever be diagnosed with a terminal disease. However, many oppose it on moral and religious grounds.
5 criteria must be met:
The patient’s condition is intolerable with no hope for improvement.
No relief is available.
The patient is competent.
The patient makes a request repeatedly over time.
2 physicians review the case and agree with the patient’s request.
Social death:
When others begin to dehumanize and withdraw from someone who is terminally ill or has been diagnosed with a terminal illness.
Dehumanization includes ignoring them, talking about them if they were not present, making decisions without consulting them first, and forcing unwanted procedures.
Why do other withdraw:
Friends and family members, healthcare professionals withdraw to protect themselves against feeling inadequate or from having to face the reality of death.
People in nursing homes may live as socially dead for years with no one visiting or calling.
Why would younger or healthier people dehumanize:
Dehumanisation is a way for people to put a distance between themselves and the unwell ones.
Keeps the well person from thinking of themselves as becoming ill or in need of assistance.
The repeated experience of loss that paid caregivers experience when working with terminally ill and older people requires a distance which protects against continual grief and sadness, and possibly even burnout.
Better care for dying individuals:
Dying individuals often get too little or too much care.
3 frequent themes described in articles on a good death:
Preference for dying process
Pain-free status
Emotional well-being
Hospice: Program committed to making the end of life as free from pain, anxiety, and depression as possible. Traditionally, a hospital’s goals have been to cure illness and prolong life.
Palliative care: Type of hospice that involve reducing pain and suffering and helping individuals die with dignity.
Death Process:
Weeks before passing:
Increase in the need for sleep.
Increased weakness.
Incontinence of bladder and/or bowel.
Restlessness or disorientation.
Increased need for assistance with care.
Days before passing:
Decreased level of consciousness.
Pauses in breathing.
Decreased blood pressure.
Decreased urine volume and urine colour darkens.
Murmuring to people others cannot see.
Reaching in air or picking at covers.
Need for assistance with all care.
Days to hours before passing:
Decreased level of consciousness or comatose-like state.
Inability to swallow.
Pauses in breathing become longer.
Shallow breaths and weak or absent pulse.
Knees, feet, and/or hands becoming cold, discolouring to purplish hue.
Noisy breathing due to relaxed throat muscles, often called a “death rattle”.
Skin colouring becoming pale, waxen.
Causes of Death:
Suicide:
Suicide rates have risen for all racial and ethnic groups and increased in every state, except for Nevada which was already high.
Suicide rate for the most rural counties is higher than the most urban counties.
Males have consistently demonstrated higher rates of suicide, experiencing higher rates of substance use disorders, do not seek out mental health treatment, and use more lethal means.
Females are now closing the suicide gap, responding to the stress in their lives through self-harm, substance abuse, and risk-taking behaviours.
Females who identify pain, depression, and anxiety are especially at risk in middle age.
Death can occur during prenatal development through miscarriages or stillborn births and it can happen during birth process or first days/weeks after birth.
Childhood: Death occurs most often because of accidents or illness. Accidental death in childhood can be the consequence of events such as an automobile accident, drowning, poisoning, fire, or a fall from a high place.
Major illnesses that cause death in children are heart disease, cancer, and birth defects.
Adolescence: Death is more likely to occur because of motor vehicle accidents, suicide, and homicide.
Older adults: More likely to die from chronic ailments such as heart disease and cancer.
Attitudes toward death at different points in the lifespan:
Childhood:
Young children (4-5 years) understand the irreversibility of death and that it involves the cessation of mental and physical functioning
Around 9, children view death as universal and irreversible.
Death can be explained to preschool children in simple physical and biological terms. Children need more than elaborate explanations of death is reassurance that they are loved and will not be abandoned.
Adults should be sensitive and sympathetic, encouraging them to express their own feelings and ideas.
Support programs for parentally bereaved children and their caregivers can be beneficial.
Adolescence:
Death regarded as remote and may be avoided, glossed over, or kidded about
Death of friends, siblings, parents, or grandparents bring death to the forefront of adolescents’ lives
With formal operational thinking, adolescents can now think abstractly about death, philosophize about it, and ponder their own lack of existence.
The personal fable of adolescence causes them to feel immune to the death and result to them engaging in drugs, unsafe sex and reckless driving.
Early adulthood:
Their overall lower rate of death is a significant factor in their lower rates of death anxiety.
Individuals in early adulthood typically expect a long life ahead of them, and consequently do not think about, nor worry about death.
Middle adulthood:
Those in middle adulthood report more fear of death than those in either early and late adulthood.
Study of young adults and middle-aged adults found that women had more difficulty than men in adjusting to the death of a parent and also that women had a more intense grief response to a parent’s death.
Middle adults often provide assistance for both their children and parents, and they feel anxiety about leaving them to care for themselves.
Late adulthood:
Those in late adulthood have lower fears of death than other adults.
Older adults think about death more and talk about it more in conversation with others than do middle aged and young adults.
They also have more direct experience with death as their friends and relatives become ill and die.
They have less anxiety because they have already experienced the death of loved ones and have become accustomed to the likelihood of death.
Theories:
Kubler-Ross’ stages of dying:
Denial & isolation:
Dying person denies that they are really going to die.
Denial is usually only a temporary defense.
Eventually replaced with increased awareness when the person is confronted with such matters as financial considerations, unfinished business, and worry about the well-being of surviving family members.
Anger:
Dying person recognizes that denial can no longer be maintained. Denial often gives way to anger, resentment, rage, and envy.
Dying person’s question becomes “Why me?”
The person becomes increasingly difficult to care for as anger may become displaced and projected onto physicians, nurses, family members.
Bargaining:
Person develops the hope that death can somehow be postponed or delayed.
Psychologically, the person is saying, “Yes, me, but ..”
Depression:
The dying person comes to accept the certainty of death. At this point, a period of depression or preparatory grief may appear.
The dying person may become silent, refuse visitors, and spend much of the time crying or grieving.
Acceptance:
The person develops a sense of peace, an acceptance of his or her fate, and in many cases, a desire to be left alone.
Criticisms:
The existence of the five-stage sequence has not been demonstrated by either Kübler-Ross or independent research.
The five-stage interpretation neglected the patients’ situations, including relationship support, specific effects of illness, family obligations, and institutional climate.
Because of the criticisms of Kübler-Ross’ stages, some psychologists prefer to describe them not as stages but as potential reactions to dying.
The extent to which people have found meaning and purpose in their lives is linked with how they approach death.
Facing death:
When individuals are led to believe they can influence and control events, they may become more alert and cheerful.
Giving nursing home residents options for control improved their attitudes and increased their longevity.
Denial can be used to avoid the destructive impact of shock by delaying the necessity of dealing with one’s death.
Denial can insulate the individual from having to cope with intense feelings of anger and hurt; however, if denial keeps us from undergoing a life-saving operation, it clearly is maladaptive.
Context in which people die:
An increasing number of people choose to die in the humane atmosphere of a hospice.
Most individuals say they would rather die at home but many feel that they will be a burden at home, that space is inadequate there, and that dying at home may alter relationships.
Death anxiety:
Feeling of anxiety or fear of death and dying.
Terror management theory addresses the issue of why people engage in certain behaviours to achieve particular psychological states based on their deeply rooted concerns about mortality.
Ensuring the continuation of one’s life is the primary motive underlying behaviour and that all other motives can be traced to this basic one.
It also explains how health conditions affect how we think about death.
Older adults present an existential threat for the younger and middle-aged adults because they remind us all that death is inescapable.
Dealing with death anxiety:
Write your own obituary and to plan your own death and funeral services.
Ask yourself: “What circumstances would help make my death acceptable?” “Is death the sort of thing that could happen to me right now?”
Most death education programs combine factual information about death with issues aimed at reducing anxiety and fear to increase sensitivity to others’ feelings.
Research shows participating in experiential workshops about death significantly lowers death anxiety in younger, middle-aged, and older adults and raises awareness about the importance of advance directives.
Coping With Death of Someone Else:
Communicating with dying people:
Psychologists argue that it’s best for dying individuals to know that they are dying so they can interact and communicate with their caretakers on the basis of this mutual knowledge.
Advantages:
Dying individuals can close their lives in accord with their own ideas.
They may be able to complete some plans and projects, to make arrangements for survivors, and to participate in decisions about a funeral and burial
Dying individuals have the opportunity to reminisce and to converse with people who have been important to them
Individuals who know they are dying have more understanding of what is happening within their bodies and what the medical staff is doing for them.
The conversation should not focus on mental pathology or preparation for death but on the strengths of the individual and preparation for the remainder of life.
Grief process:
The grieving process is often described as reflecting many themes and issues people confront that may be expressed through rituals, both in-person and digital.
When someone close to us dies, we must reorganize our lives, establish new patterns of behaviour, and redefine relationships with family and friends.
Unlike bereavement, grief is a process that involves choices in coping, from confronting the reality and emotions to using religion to ease one’s pain.
Grief is an active process when a person must do several things:
Acknowledge the reality of the loss
Work through the emotional turmoil
Adjust to the environment where the deceased is absent.
Loosen ties to the deceased
Dimensions of grieving:
Grief: Emotional numbness, disbelief, separation anxiety, despair, sadness, and loneliness that accompany the loss of someone we love.
Grief is a complex, evolving process with multiple dimensions.
Grief may also involve despair and sadness, a 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.
The sense of separation anxiety and loss may continue to the end of one’s life, but most of us emerge from grief’s tears, turning our attention once again to productive tasks and regaining a more positive view of life.
Anticipatory grief:
Experienced during the period before an expected death occurs that supposedly serves to buffer the impact of the loss when it does come and to facilitate recovery.
A death after a long-term, painful illness may bring family members a sense of relief that the suffering is over, and the exhausting process of caring for someone who is ill is also completed.
Prolonged or complicated grief:
Grief that involves enduring despair and remains unresolved over an extended period of time; and usually has negative consequences for physical and mental health.
Includes atypical grief reactions after losing loved ones.
Symptoms include: Feelings of disbelief, a preoccupation with the dead loved one, distressful memories, feeling unable to move on with one’s life, and a yearning for the deceased.
Disenfranchised grief:
Describes an individual’s grief over a deceased person that is a socially ambiguous loss and can’t be openly mourned or supported.
Ex: A relationship that isn’t socially recognized such as an ex-spouse, a hidden loss such as an abortion, and circumstances of the death that are stigmatized like AIDS.
Disenfranchised grief may intensify an individual’s grief because the feelings cannot be publicly acknowledged. This type of grief may be hidden or repressed for many years, only to be reawakened by later deaths
Grief reactions:
Typical grief reactions involve mental, physical, social and/or emotional responses that include feelings of numbness, anger, guilt, anxiety, sadness and despair.
The immune systems of individuals grieving is suppressed and their healthy cells behave more sluggishly, resulting in greater susceptibility to illnesses.
However, the intensity and duration of typical grief symptoms do not match those usually seen in severe grief reactions, and symptoms typically diminish within 6-10 weeks.
Dual-Process Model:
Loss-oriented stressors:
Focus on the deceased individual and can include grief work and both positive and negative reappraisals of the loss.
A positive reappraisal of the loss might include acknowledging that death brought relief at the end of suffering.
A negative reappraisal might involve yearning for the loved one and ruminating about the death.
Restoration-oriented stressors:
Involve the secondary stressors that emerge as indirect outcomes of bereavement.
They can include a changing identity (such as from “wife” to “widow”) and mastering skills (such as dealing with finances).
Effective coping with bereavement often involves an oscillation between coping with loss and coping with restoration.
Earlier models often emphasized a sequence of coping with loss through such strategies as grief work as an initial phase, followed by restoration efforts.
Oscillation might occur in the short term during a particular day as well as across weeks, months, and even years.
Making sense of the world:
Grieving stimulates individuals to try to make sense of their world.
A reliving of the events leading to the death is common.
When a death is caused by an accident or a disaster, the effort to make sense of it is often pursued more vigorously.
Losing a life partner:
The death of an intimate partner brings profound grief.
Widows outnumber widowers because women live longer than men.
Widowed women are probably the poorest group in America.
Many widows are lonely and benefit considerably from social support.
Forms of mourning:
Funerals are an important aspect of mourning.
Cultures vary in how they practice mourning.
In some cultures, a ceremonial meal is shared after a death, while in others a black armband is worn by bereaved family members for one year following a death.
4 tasks of mourning:
Acceptance that the loss has occurred.
Working through the pain of grief.
Adjusting to life without the deceased.
Starting a new life while still maintaining a connection with the deceased.