CHAPTER 19CHAPTER 19

Life’s Final ChapterLife’s Final Chapter

Understanding Death and DyingUnderstanding Death and Dying

Death and Dying• Death

– Cessation of life

• Most widely used criteria for establishing brain death include absence of activity of the cerebral cortex, as shown by a flat EEG recording

• Broader concept of whole brain death includes– death of the brain stem, which is responsible for automatic

functions (person is breathing)– people have been kept “alive” even though they were whole

brain dead by life-support equipment that took over their breathing and circulation

• Death is a legal matter based on a state’s guidelines.

Are There Stages of Dying?

Kübler-Ross hypothesized five stages of dying:

1. Denial – Denial can be flat and absolute, or it can fluctuate.

2. Anger– Denial gives way to anger and resentment toward the young and

healthy, and, sometimes, toward the medical establishment.3. Bargaining

– People may bargain with God to postpone death, promising, for example, to do good deeds if they are given another six months.

4. Depression– With depression comes feelings of grief, loss, and hopelessness.

5. Final acceptance– Inner peace may come, quiet acceptance of the inevitable; this “peace”

is nearly devoid of feeling

Are There Stages of Dying? (cont’d)

• “Death education” – Suggests hospital staff and family members can help support

dying people by • understanding the stages they are going through• not imposing their own expectations on patients• helping patients achieve final acceptance when patients are ready

to do so

• Staff may be imposing Kübler-Ross’s expectations

• Retsinas (1988) notes – Kübler-Ross’s stages are limited to cases where people receive

a diagnosis of a terminal illness.– Retsinas points out most people die because of advanced years

with no specific terminal diagnosis.– Kübler-Ross’s approach may not be much use in helping us

understand their reactions.

Are There Stages of Dying? (cont’d)• Shneidman’s (2008) research shows individuals behave

in dying more or less as they behaved during earlier periods when they experienced stress, failure, and threat.

• Emotional responses and psychological defenses emerge and are observed in every death.

• Key factors that appear to affect the adjustment of the dying individual include– type and extent of organic cerebral impairment– pain and weakness– the time or phase of the person’s life– the person’s philosophy of life (and death)– prior experiences with crises

Where People DieWhere People Die

Where People Die

• Home– Usually with hospice care

• Hospitals– More than half of people in the United States die in

hospitals, and another 1 in 5 die in nursing homes.– Instead of dying in familiar surroundings, comforted

by family and friends, patients in hospitals often face death alone.

– Patients and their families may assume going to the hospital gives them the best chance of averting death.

Hospice Care

Hospice care has the following characteristics: • Offers palliative care

– Control pain and symptoms to enable the patient to live as fully and comfortably as possible

• Treats the person, not the disease– Hospice team addresses the medical, emotional, psychological,

and spiritual needs of patients, family, and friends

• Emphasizes quality rather than length of life

• Considers the entire family to be the unit of care

• Bereavement counseling provided after death

• Help or support is available to the patient and family (24/7)

Supporting a Dying Person • Be there for the person.

– Don’t withhold touching; listen, talk, and share experiences.

• Give the person the opportunity to talk about death and to grieve.– Don’t be afraid to talk about ongoing lives of mutual

acquaintances.

• Be aware of the person’s emotional state on any given day.

• Don’t minimize the person’s emotional pain or need to grieve by changing the subject or refusing to acknowledge it.

• Be sensitive to the person’s feelings, offering consolation and support.

Supporting a Dying Person (cont’d)

• People with cognitive impairment may repeat certain thoughts many times.– Go with it or gently guide the conversation in another direction

now and then– He or she may repeatedly ask whether certain tasks have been

taken care of, and a simple yes may do each time.

Euthanasia: Is There a Right to Die?Euthanasia: Is There a Right to Die?

Euthanasia: Is There a Right to Die?

• Euthanasia– Literally meaning “good death,” derived from the Greek roots eu

(“good”) and thanatos (“death”)– “Mercy killing” is purposeful taking of a person’s life through

gentle or painless means to relieve pain or suffering.

• Active euthanasia– A lethal treatment (usually a drug) is administered to cause a

quick and painless death; usually a spouse or family member administers it.

• Voluntary active euthanasia– Euthanasia is carried out with the patient’s consent; illegal

throughout most of the U.S.

Euthanasia: Is There a Right to Die? (cont’d)

• Physician-assisted suicide– Physicians assist patients with terminal or incapacitating

illnesses who wish to die by providing them with lethal doses of drugs or by sometimes administering the drugs when patients have been too ill to administer them themselves.

• Best-known cases of physician-assisted suicides – Dr. Jack Kevorkian, a retired pathologist dubbed “Dr. Death” by

the press for assisting in more than 35 patient suicides

Euthanasia: Is There a Right to Die? (cont’d)

• Involuntary active euthanasia– A person causes the death of a person without the person’s

informed consent– Involves patients who are comatose or otherwise incapacitated,

and whose guardians believe they would have wanted to die if they had retained the capacity to make the decision

– Considered homicide in the eyes of the law

• Terminal sedation– Practice of relieving distress in a terminally ill patient in the last

hours or days of his or her life by means of a continuous intravenous infusion of a sedative drug

– Some debate whether or not it hastens death

Fig. 19-4, p. 397

Passive Euthanasia

• Passive euthanasia– Actions that hasten death by means of withholding potentially

life-saving treatments, such as failing to resuscitate a terminally ill patient who stops breathing, or withdrawing medicine, food, or life-support equipment

• One form of passive euthanasia that is legal throughout the United States and Canada is the withholding or withdrawing of life-sustaining equipment or techniques in terminally ill people who clearly specified their wishes.

The Living Will

• Living will– Specifies the conditions under which the person desires to have

life-sustaining treatment withdrawn or withheld– Must be drafted in accordance with state laws– Identifies next of kin to carry out orders– Many advance directives are still ignored– Cruzan and Schiavo cases have helped to set precedence

Lifespan Perspectives on DeathLifespan Perspectives on Death

Lifespan Perspectives on Death

• Younger children lack cognitive ability to understand the permanent nature of death.– Increase knowledge of death as understanding of biology of

human body is increased

• Children display different behaviors when handling the loss of a loved one.– Some children revert back to younger or needier behaviors– Some are angry

• Most children are taught some concept of an afterlife.

Lifespan Perspectives on Death (cont’d)

• Be honest with children when discussing a person dying. – Follow their cues as to whether or not they can handle attending

the funeral

• Provide them another type of closure that may be more emotionally appropriate.– Let them share their feelings openly

• Help child to maintain bond with deceased person while maintaining current activities and building new relationships.

Adolescents

• Adolescents know that when life functions come to an end in a particular body, they cannot be restored.– May still construct magical, spiritual, or pseudoscientific theories

as to how some form of life or thought might survive

• Speak of death in terms of concepts such as light, darkness, transition, and nothingness

• More exposed to death among older family members and even among fellow adolescents than young children– More likely than young children to attend funerals

• Continue to engage in riskier behavior than adults but not in highly risky behaviors

Adults

• Death is not frequent among young adults in developed nations.– Not much thought given to it

• Disease main reason for death in middle and late adulthood; accidental death increases as we age

• Ego transcendence, or concern for the well-being of humankind in general, enables some people to begin to face death with an inner calm.– Continuing with physical, leisure, and informal social activities

are all associated with greater life satisfaction among older, retired people.

– There is no single workable formula for coping with physical decline and the approach of death.

Coping with DeathCoping with Death

What to Do When Someone Dies

• Call 911, the family doctor, or the police– A doctor is needed to complete the death certificate and

indicate the cause of death.– A coroner or medical examiner may need to determine the

cause of death if unknown reason

• A funeral director may be contacted to remove the body from the home or the hospital and arrangements for burial, cremation, or placement in a mausoleum will be made.

• If death occurs unexpectedly or foul play is suspected, an autopsy may be performed to determine the cause and circumstances of death.– Sometimes an autopsy may be performed with the family’s

consent to help further medical science.

Funeral Arrangements

• Funerals provide an organized way of responding to death that is tied to religious custom and cultural tradition.– Offer family and community a ritual that allows them to grieve

publicly and say farewell to the person who died– Helps to provide closure that can help observers begin to move

on with their lives

• Family members of the deceased decide how simple or elaborate they prefer the funeral to be, whether to embalm, bury, or cremate the deceased’s body.– Matters may be spelled out by religious or family custom– Family members may have disagreements over them

Funeral Arrangements (cont’d)

• Funerals may be one of American families’ largest expenses.

• Guidelines to arrange a funeral– Have a good, logical friend go with you to arrange the funeral,

shop around for a funeral home and cemetery– Talk about services and costs– Veterans are entitled to a free burial plot in a national cemetery,

but the family incurs the costs of transporting the body– Caskets may range from $500-$50,000 in cost– Ask the funeral director to show you models that you can afford

Legal and Financial Matters

• Financial matters following death may include issues concerning estates, inheritance, outstanding debts, insurance, and amounts owed for funeral expenses.

• It can be difficult for family members to focus on these matters during a time of grief.– They should seek legal counsel if they have questions

concerning how to handle the deceased person’s affairs and to protect their own financial interests.

• An attorney will be needed to settle the estate, especially if it is sizeable or if complex matters arise.

Grief and Bereavement

• Bereavement– An emotional state of longing and deprivation that is

characterized by feelings of grief and a deep sense of loss

• Mourning– Describes culturally prescribed ways of displaying grief– Different cultures prescribe different periods of mourning and

different rituals for expressing grief.

• Coping with loss requires time and the skills needed to come to terms with the loss and move ahead with one’s life.– Having a supportive social network helps

Grieving• Sometimes grief never ends, it is only lessened.• People may grieve publicly or privately.

• Grief – involves a combination of emotions

• depression, loneliness, feelings of emptiness, disbelief and numbness, apprehension about the future, guilt, even anger

– may include relief that the deceased person is no longer suffering intense pain and by a heightened awareness of one’s own mortality

– may compromise the immune system, increasing vulnerability to disease; the death of a loved puts one at greater risk of committing suicide, especially during the first week following the loss

Are There Stages of Grieving?

• John Bowlby (1961) – First to hypothesize four stages to grieving

• shock-numbness, yearning-searching, disorganization-despair, and reorganization

• Kübler-Ross (1969) adapted Bowlby’s stage theory to describe her 5-stage reaction of terminally ill patients to knowledge of their own impending death.– Denial-isolation, anger, bargaining, depression, and acceptance

Are There Stages of Grieving? (cont’d)

• Jacobs’ (1993) theory included– numbness-disbelief, separation distress, depression-mourning,

and recovery

• Maciejewski et al. (2007) administered five items measuring disbelief, yearning, anger, depression, and acceptance of the death – surveyed 233 bereaved individuals from 1 to 24 months following

their losses– disbelief was highest just after the loss and waned over the

course of two years– acceptance of the loss was nonexistent at the outset, growing

gradually, and peaking two years later– yearning, anger, and depression rise suddenly in the predicted

order and then each wanes gradually– Jacobs theory supported

Fig. 19-5, p. 404

Advice for Coping

• Take care of yourself.• Allow yourself to feel your loss.

– Share your feelings with a trusted friend or a counselor.– Covering up or trying to erase feelings with tranquilizers may

prolong grieving.

• Don’t reject offers of help from friends and family; tell them what you need.

• Give yourself time to grieve.– Don’t let other people push you into moving on “to the next

stage” unless you are ready to do so.

• Join a bereavement support group; sharing experiences can help you cope better and work through your grief.

Advice for Helping a Bereaved Friend or Relative Cope

• Spending time with the bereaved person can help.– Be a good listener.

• Don’t be afraid to talk about the deceased person, but don’t force talking about them either.– Follow the grieving person’s cues.

• Not talking about the departed person can make it more difficult for the bereaved person to work through feelings of grief.

• Keep in touch regularly.– Don’t assume that because you don’t get a call, the person

doesn’t want to talk.

Advice for Helping a Bereaved Friend or Relative Cope (cont’d)

• The bereaved person may be too depressed or lack the energy to reach out.– Offer to help with chores like shopping, running errands,

babysitting

• Don’t minimize the loss and avoid clichés.– “You’re young, you can have more children”– “It was for the best”