Chapter 13 Dying and Bereavement

Chapter 13 Dying and Bereavement Sociocultural Definitions of Death Sociocultural definitions of death vary greatly around the world customs surrounding death also vary

In Western culture, several meanings have developed

Legal and Medical Definitions of Death Clinical death : Lack of heart beat and respiration Has been used for centuries as the criteria for death

Brain death: Includes eight specific criteria, all of which must be met

The most widely used definition in the United States and other industrialized countries

Persistent vegetative state When brain-stem functioning continues after cortical functioning stops

Ethical Issues Bioethics Examines the interaction between human values and technological advances The most important bioethical issue is euthanasia

Euthanasia: The practice of ending life for reasons of mercy

Two types of euthanasia are distinguished Active euthanasia--- Deliberately ending someone’s life through some sort of intervention or action Passive euthanasia ---Ending someone’s life by withholding treatment

Living will and durable power of attorney Personal preferences for medical intervention The purpose of both is to make one’s wishes about the use of life support known in the event one is unconscious or otherwise incapable of expressing them

These can also serve as the basis for Do Not Resuscitate (DNR) medical order which is used when cardiopulmonary resuscitation is needed

The Price of Life-Sustaining Care A growing debate concerns the costs for keeping someone alive through technology and includes financial, personal, and moral costs

The most obvious are financial costs which are usually staggering

Personal emotional costs are often underestimated, but can be devastating and long-lasting Thinking About Death: Personal Aspects A life course approach to dying Young adults report a sense of being cheated by death Middle-aged adults begin to confront their own mortality and undergo a change in their sense of time lived and time until death Older adults are more accepting of death

Dealing with One’s Own Death Kübler-Ross’s includes five stages: Denial ---the first reaction is likely to be shock and disbelief Denial is a normal part of getting ready to die

Anger---at some point people express anger as hostility, resentment, frustration, and envy

Bargaining--in the bargaining phase people look for a way out or a person sets a timetable

Depression--when one can no longer deny the illness feelings of depression become common

Acceptance--In the acceptance stage, the person accepts the inevitability of death and often seems detached from the world and at peace

It is important to note that some people do not progress through all of these stages, and some people move through them at different rates People may be in more than one stage at a time and do not necessarily go through them in order

A Contextual Theory of Dying Emphasizes the tasks and issues that a dying person must face A contextual theory would be able to incorporate differences in reasons people die and the places that people die

Corr identified four dimension of tasks that must be faced Bodily needs, psychological security, interpersonal attachments, and spiritual energy and hope Death Anxiety Death anxiety is essentially universal in Western culture However, defining and measuring it is difficult

Several components have been identified, including

Interruption of goals Negative impact on survivors These components can be expressed at public, private, and unconscious levels

Death anxiety is demonstrated in many different ways Less common ways to express death anxiety

Learning To Deal With Death Anxiety Several ways to deal with anxiety exist: Living life to the fullest Personal reflection Death Education

End-of-Life Issues: Creating a Final Scenario End-of-life issues Managing the final aspects of life After-death disposition of the body and memorial services Distribution of assets

Final Scenario: Making choices about what people do and do not want done A crucial aspect of the final scenario is the process of separation from family and friends Bringing closure to relationships

End-of-Life Issues: The Hospice Option Hospice: An approach to assisting dying people that emphasizes pain management (palliative care) and death with dignity Hospice care emphasizes quality of life rather than quantity of life The goal is a de-emphasis on the prolongation of death for terminally ill patients Both inpatient and outpatient hospices exist The role of the staff is to be with patients, not to do things for patients

Research shows that hospice patients have better psychological status than hospital patients the patients tend to be more mobile, less anxious, and depressed family members tend to stay more involved in the care of hospice patients

How Do People Decide To Explore The Hospice Option? Kastenbaum lists six key considerations: Is the person completely informed about he nature and prognosis of his or her condition? What options are available at this point in the progress of the person’s disease? What are the person’s expectations, fears, and hopes? How well do the people in the person’s social network communicate with each other? Are family members available to participated actively in terminal care? Is a high-quality hospice care program available?

adults can not benefit from hospice care unless: Family reluctance to face the reality of terminal illness and participate in the decision- making process is changed Physicians reluctance to approve hospice care for patients until the very end is changed

Survivors: The Grieving Process Bereavement is the state or condition caused by loss through death Grief--the sorrow, hurt, anger, guilt, confusion, or other feelings that arise after a loss Mourning--The way we express or grief Mourning is heavily influenced by cultural norms Society assigns different values on the death of people of different ages For example, the older the person is at death the less tragic it is perceived to be

The social view of the degree to which a death is considered tragic is an important aspect of the dying process

Experiencing Grief Grief is an active process in which a person: must 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

How these are accomplished is an individual matter The amount of time to deal with death is highly individual Most agree at least 1 year is necessary

Expected Versus Unexpected Death Grief is equally intense in both expected and unexpected death May begin before the actual death when the patient has a terminal illness Unexpected death often is called high-anxiety death Expected death is often called low-anxiety death Because deaths are usually less mysterious than unexpected deaths

Normal Grief Reactions Normal feelings include: Sorrow Sadness Denial and disbelief Guilt Religious feelings

Grief work: The psychological side of coming to terms with bereavement Anniversary reaction: Grief that often returns around the anniversary of the death

Effects of normal grief on adults’ health In general, experiencing the death of a loved one does not directly influence physical health Middle-aged adults have the most difficulty dealing with grief People who have a hard time coping tend to have low self-esteem before losing a loved one Abnormal Grief Reactions Abnormal grief usually involves excessive guilt and self-blame

Older adults who are still having difficulty coping longer than two years after the death: Tended to have lower self-esteem prior to bereavement Were more confused Had a greater desire to die themselves Cried more Were less able to keep busy right after the death

Types of Loss and Grief Society makes judgements about how much grief one should have after different types of loses arbitrary time limits on the grieving process

Death of one’s parent The death of a parent serves to remind people of their own mortality and deprives them of a very important person in their lives Death of one’s child The death of a child, including miscarriage and perinatal death, is thought to be the most traumatic type of loss

Death of one’s spouse Death of a spouse is a great loss of a lover and companion Widowhood is more depressing for men than women Bereaved spouses tend to have positive bias about their marriage

Comparing Types of Loss In general, bereaved parents are the most depressed and have more grief reactions in general The intensity of depression in a bereaved person after a loss is related to the perceived importance of the relationship with the deceased person Survivors are more often and more seriously depressed after the death of someone particularly important to them