Chapter 17 – Death, Dying, and Grieving (Comprehensive Study Notes)

The Death System: Components & Cultural Variations

• A "death system" = the total network through which a culture organizes, mediates, and gives meaning to death.
  • People – every individual eventually participates.
  • Places/contexts – hospitals, funeral homes, cemeteries, hospices, battlefields, memorials.
  • Times – culturally prescribed occasions for remembrance (e.g., Memorial Day, Día de los Muertos).
  • Objects – clothing, coffins, hearses, skull imagery, photographs, flowers.
  • Symbols & rituals – religious rites, flags at half-mast, black armbands.
• Exposure gap in the U.S.: Many reach adulthood without witnessing an actual death.
  • Most societies maintain spiritual beliefs that life continues; U.S. majority also embraces an after-life perspective.

U.S. Death-Avoidance & Denial Patterns

• Funeral industry “restores” lifelike appearance, glossing over reality.
• Euphemisms ("passed away,” "lost") imply permanence without finality.
• Obsession with youth, cosmetic surgery = cultural fountain-of-youth pursuit.
• Ageism – distancing from older adults to avoid mortality reminders.
• Pleasant‐afterlife narratives reinforce perceived immortality.
• Medical model = emphasis on prolonging biological life rather than easing suffering.

Historical Shifts in Mortality

• 200 years ago ≈ 50\% of children died before 10.
• Today, death predominantly occurs in later adulthood.
• >80\% of U.S. deaths now happen in institutions/hospitals, reducing day-to-day exposure and communal grieving.

Defining Death & Life/Death Issues

• Traditional clinical signs: cessation of breathing, blood pressure, onset of rigor mortis.
• Brain Death (neurological criterion):
  • All electrical activity in entire brain – higher cortex and brain stem – has irreversibly ceased for a specified interval.
  • Persistent vegetative state = higher cortical death while autonomic brain-stem reflexes persist; not considered whole-brain death under current U.S. medical consensus.

Advance Care Planning

• Ongoing process where individuals articulate end-of-life preferences.
• Advance directives (living wills) are legally recognized in all 50 states.
  • Specify use/non-use of life-sustaining treatments when capacity is lost.
  • Must be completed while cognitively intact.

Euthanasia & Assisted Suicide

• Euthanasia – intentional, painless termination for the incurably ill.
  • Passive: allowing death via withdrawal/withholding of treatment (e.g., turning off ventilator).
  • Active: deliberate lethal act (e.g., physician-administered injection).
• Physician-Assisted Suicide (PAS)
  • Legal in 6 countries and 10 U.S. jurisdictions: California, Colorado, Hawaii, Maine, New Jersey, Oregon, Vermont, New Mexico, Washington, Washington DC.
• Supporters: autonomy, dignity, relief of suffering.
• Opponents: moral/religious prohibition, slippery-slope to abuse, equating with murder.
• Reality check: many American deaths remain lonely, prolonged, and painful—fueling “good death” discourse.

Hospice & the "Good Death"

• Goal: maximize quality of remaining life – pain, anxiety, depression minimized.
• Provides palliative care (comfort focused), interdisciplinary teams, family education.
• Majority of U.S. hospice programs are home-based, facilitating familiar environment and family involvement.
• A "good death" often includes: physical comfort, emotional support, acceptance, patient-directed medical decisions.

Developmental Perspective: When & Why People Die

• Annual U.S. deaths ≈ 2 million; \approx\frac{2}{3} are older adults.
• Infancy – Sudden Infant Death Syndrome (SIDS) dominates.
• Childhood – leading causes: accidents, congenital heart disease, cancer, birth defects.
• Adolescence – motor-vehicle accidents, suicide, homicide.
• Young/Middle adulthood – heart disease, cancer.
• Older adulthood – chronic degenerative diseases; long period of progressive incapacity.

Suicide Across the Lifespan

Universal Risk Factors

• Serious physical illness, mental disorders, hopelessness, isolation, academic/occupational failure, bereavement, severe financial stress, substance misuse, prior attempts.

Adolescence & Emerging Adulthood

• Suicide = 2^{nd} leading cause of death.
• Ideation & attempts > completions.
• Gender pattern: females attempt more; males complete more.
• Ethnicity: Native American youth highest rate.
• Depression (hopelessness, low self-esteem, self-blame) most cited proximal condition.
• Cluster/"copycat" suicides raise media-coverage concerns.

Adulthood & Aging

• Adult suicide trend is rising.
• Females ≈ 3\times more attempts; males ≈ 4\times more completions.
• Highest-risk profile: older male, widowed, living alone, declining health, perceives self as burden.
• Protective resources: strong family/friend network, emotional regulation, religious engagement.

Intervention Guidelines (Figure Highlights)

• DO: ask directly, assess plan/lethality, stay present, listen, mobilize professional help.
• DON’T: dismiss hints, refuse discussion, use humor/disgust, offer platitudes, abandon post-crisis.

Facing One’s Own Death

Shifting Temporal Values

• Inquiry: “How would you spend your last 6 months?”
  • Young adults – travel, goals, achievements.
  • Older adults – inner pursuits (meditation, reflection).
• Desire for autonomy in end-of-life decisions; urge to "finish business."

Kübler-Ross Reactions (Not universal stages)

1. Denial & Isolation
2. Anger
3. Bargaining
4. Depression
5. Acceptance

• Empirical critique: reactions vary in order, intensity, repetition; context matters.

Perceived Control & Denial

• Belief in extending life enhances alertness/cheerfulness.
• Denial can buffer overwhelming emotion OR hinder beneficial treatment.

Contexts of Dying

• U.S. place-of-death distribution: >50\% hospitals; nearly 20\% nursing homes.
  • Pros: immediate professional care, advanced technology.
  • Cons: institutional impersonal setting; many prefer home.
• Home death obstacles: caregiver burden, limited space, emergency-care access.

Communication With the Dying

• Most psychologists advocate full disclosure when cognitively possible.
• Benefits of open awareness:
  • Plan closure on personal terms.
  • Settle affairs, funeral preferences.
  • Reminisce and say farewells.
  • Understand procedures, choose among treatments.

Grief: Processes & Variations

• Grief = complex of numbness, disbelief, yearning, despair, sadness, loneliness.
• Pining/separation anxiety – recurring urge to reunite or revisit meaningful places.

Typical (Uncomplicated) Grief

• 80\%{-}90\% of survivors adapt; by 6 months reality is accepted, future orientation resumes.

Complicated/Prolonged Grief

• 7\%{-}10\% remain stuck in chronic despair >6 months.
• Risk magnified when the deceased was primary attachment/dependency figure.

Disenfranchised Grief

• Loss that society doesn’t openly acknowledge (secret relationship, abortion, stigmatized death).
• Griever lacks social support; grief may be hidden, resurfacing later.

Dual-Process Model (Stroebe & Schut)

• Loss-oriented stressors – focus directly on grief work, memories, appraisal.
• Restoration-oriented stressors – secondary tasks (finances, roles, identity changes).
• Healthy coping oscillates between the two over time.

Traumatic Loss & PTSD

• Sudden/violent deaths intensify and prolong grief; intrusive memories, sleep and concentration issues typical.
• No single "correct" grieving path; cultural norms shape appropriateness.

Meaning-Making

• Narratives and sense-making dialogues help integrate the loss, especially when death is accidental or disastrous.

Losing a Life Partner

• Consequences: profound sorrow, financial strain, loneliness, physical health decline, depression.
• Coping avenues:
  • Enhanced religious/spiritual engagement.
  • Deriving meaning or legacy from partner’s life.
• Gender differences:
  • Women usually adjust better — larger friend networks, closer kin ties, psychological self-reliance.
  • Older widows fare better than younger widows due to expectation and life-course timing.
  • Widowers often retain greater financial assets and are more likely to remarry.
• Facilitators of well-being: religious faith, volunteering, social support (e.g., Widow-to-Widow program).

Forms of Mourning & Cultural Diversity

• 53.1\% of U.S. deaths ( 2018 ) followed by cremation — shift toward private funerals + later memorials.
• Funeral industry critique: necessary closure vs. profit motive, embalming called grotesque.
• Global mourning practices vary widely (e.g., Tibetan sky burial, Jewish shiva, New Orleans jazz funerals).

Key Take-Home Review Questions

• Describe a death system and outline its historical/cultural context.
• Explain criteria for determining death; evaluate ethical/legal controversies of euthanasia and PAS.
• Identify leading causes of death and suicide across developmental stages.
• Summarize psychological reactions to one’s own impending death and typical settings in which people die.
• Detail grief processes, complications, cultural expressions, and evidence-based coping strategies.