Chapter 19:

Death, Dying, and Bereavement

In This Chapter

The Experience of Death Death Itself

Characteristics Clinical death

Brain death

Social death

The Experience of Death Where Death Occurs

Hospitals in the U.S. (45%) Decedent’s home (25%) Long-term Care (22%) Hospice (14%) Other (6%)

The Experience of DeathHospice Care

Philosophy Death viewed as normal Families and the patient encouraged to

prepare for death Family are involved in patient’s care Control of care is in the hands of the patient

and family Medical care is palliative rather than curative

Hospice CareTypes of Hospice Care

Home-based programs Hospital-based programs Special hospice centers Hospice

HospiceHospital-based and Home-based Care

Comparison

Hospital-Based Care Home-Based Care

Patient Pain Same Same

Length of Survival Same Same

Patient Satisfaction with Care

Same Same

Family Satisfaction with Care

Higher Lower

Family Sense of Burden Higher Lower

Let’s take a minute to review some of these comparisons.

Dying, Death, and BereavementHospice Care

Hospice Care

Pros Reduced cost of death Less burden on central caregiver

Cons Increased family worry about pain

management

Developmental Understanding of Death

The Meaning of Death for Adults Death as Loss: Age

Age differences

Young adults: Loss of opportunity to experience things; loss of family relationships

Older adults: Loss of time to complete inner work

The Meaning of Death for Adults Death as Loss: Ethnic Differences

Ethnic differences

Mexican Americans: Increase time spent with family or loved ones

White and African-Americans: Would not change their lifestyle

See Table 19.2 for responses to hypothetical impending death

Stop and Think!

At what age do you think people are most fearful of

death?

What prompted your answer?

Fear of Death

Middle-aged adults most fearful of death

Sense of unique invulnerability prevents intense fear of death in young adults

Older adults think and talk more about death than anyone else

Fear of Death Religious beliefs

Religious beliefs and fear of death Very religious adults less afraid of death Those totally irreligious may also fear

death less

Figure 19.1 Age, Ethnicity and Fear of Death

Fear of DeathPersonal Worth

Fear of death reduced Adults accomplish goals or believe they

have become the person they set out to be Belief that life has purpose or meaning

How is this related to Erikson’s stage of integrity versus despair?

Your loved one is dying of a terminal illness. Would you use a hospice center? Why or why not?

If you were told that you had a terminal disease and only 6 months to live, how would you want to spend your time until you died?

On a scale of 1– 5, with 5 being high, how much do you fear death?

Questions To PonderQuestions To PonderQuestions To PonderQuestions To Ponder

The Process of DyingPreparation for Death

Kinds of preparations Practical preparations Deeper preparations Older adults more likely to have made

these arrangements

The Process of DyingPreparation for Death

Final preparations Unconscious changes just before death Terminal drop for psychological health

Theoretical Perspectives on Dying Elisabeth Kubler-Ross’s Stages of Dying

Theoretical Perspectives on Dying Criticisms of Kubler-Ross’s Theory

Methodological problems

Cultural specificity

Stage concept unsupported

Theoretical Perspectives on Dying Alternate Views

Two additional views

Shneidman: Dying process has many “themes”

Corr: Coping with death involves taking care of specific tasks

Theoretical Perspectives on Dying Responses to Impending Death

Greer: Attitudes and behavioral choices can influence course of terminal disease

Five groups/stages Denial (positive avoidance) Fighting spirit Stoic acceptance Helplessness/hopelessness Anxious preoccupation

Theoretical Perspectives on Dying Responses to Impending Death

Greer concluded that the message may be:

“Those who struggle the most, fight the hardest, express their anger and hostility openly, and who find some sources of joy in their lives live longer.”

Theoretical Perspectives on DyingPsychoanalytic Theory

Traumatic death often followed by physical or mental problems

Grief therapy with children makes use of defense mechanisms (sublimation, identification)

Theoretical Perspectives on Grieving

Freud: Death of a loved one is an emotional trauma

Ego tries to insulate itself from unpleasant emotions through defense mechanisms such as denial

BUT Defense mechanisms provide only temporary

relief

How do people grieve in healthy ways?

Theoretical Perspectives on Grieving Attachment Theory

Bowlby Intense grief likely to occur at loss of any

attachment figure

Quality of attachment related to grief

Theoretical Perspectives on Grieving Attachment Theory

Bowlby: Four stages of grief

Theoretical Perspectives on Grieving Attachment Theory

Sanders five stages of grief comparable to Bowlby: Shock Awareness Conservation/withdrawal Healing Renewal

Theoretical Perspectives on Grieving Attachment Theory

Revisionist Views Avoiding expressions of grief neither

prolongs grief nor inevitably creates mental health problems

Grieving does not occur in fixed stages Many themes present simultaneously but

one or another may dominate at one point in time

Adults develop different patterns of grieving

Figure 19.2 Jacobs’s Model of Grieving

Theoretical Perspectives on Grieving Patterns of Grieving

Wortman and Silver Normal Chronic Delayed Absent

Theoretical Perspectives on Grieving Dual-Process Model

Alternates between:

Theoretical Perspectives on Grieving The Experience of Grieving: Death Rituals

Psychosocial functions of death rituals such as funerals

Help family and friends manage grief by giving a specific set of roles

Bring family members together in unique ways

Establish shared milestones for families

Theoretical Perspectives on Grieving The Process of Grieving

Factors Associated with Grief: Age of the Bereaved

Children express feelings of grief like teens and adults

Teens often show prolonged grief responses

Theoretical Perspectives on Grieving Factors Associated with Grief

Modes of Death and Grief Caregiver widows may show depression. Death with intrinsic meaning reduces grief. Sudden and violent deaths evoke more

intense grief. Suicide produces unique responses in

survivors.

Theoretical Perspectives on Grieving Widowhood and Effects of Grief

Immediate and long term effects on the immune system

Incidence of depression among widows and widowers rises substantially

Theoretical Perspectives on Grieving Pathological Grief

Depression-like symptoms lasting longer than 2 months

Grief lasting longer than 6 months can lead to long-term depression and physical ailments

Problems may continue for up to 2 years after death of loved one

BUT cultural practices may mimic pathological grief

Theoretical Perspectives on Grieving Sex Differences

Spouse death more negative for men than for women.

Risk of death higher in men immediately after a spouse’s death.

Widowers withdraw in multiple ways. Alcohol use may influence depression. Social relationships remain important for

both sexes.

Theoretical Perspectives on Grieving Preventing Long-Term Problems

“Talk-it-out” approach to managing grief can help prevent grief-related depression.

Developing coherent personal narrative of events surrounding spouse’s death helps manage grief.

Participating in support groups helps.

Appropriate amount of time off from work to grieve is important.