Presentation on theme: "Chapter Sixteen The Final Passage: Dying and Bereavement"— Presentation transcript:
1 Chapter Sixteen The Final Passage: Dying and Bereavement
2 16.1 Definitions & Ethical Issues Learning Objectives How is death defined?What legal and medical criteria are used to determine when death occurs?What are the ethical dilemmas surrounding euthanasia?
3 Sociocultural Definitions of Death Different cultures view death in diverse waysCustoms and expectations also differ in rituals of bereavement and mourningEven within a culture there is diversity in the view of death, mourning, and bereavement
4 There Are at Least 10 Ways Death Can Be Viewed Death as an image or objectDeath as a statisticDeath as an eventDeath as a boundaryDeath as a state of beingDeath as a thief of meaningDeath as an analogyDeath as fear and anxietyDeath as reward or punishment
5 Legal and Medical Definitions The traditional definition of clinical death was a lack of heartbeat and respirationToday, whole-brain death is the most used definition:No spontaneous movement to stimulationNo spontaneous respiration for 1 hourLack of response to painNo eye movements, blinking, or pupil responsesNo postural activity, swallowing, or yawningNo motor reflexesA flat EEG for 10 minutesNo change in any of these in 24 hours
6 Legal and Medical Definitions (Cont) All eight criteria must be met and other possible conditions ruled outIn most hospitals, the lack of brain activity must extend to the brainstem and cortexActivity only in the brainstem is called a persistent vegetative state, from which consciousness does not occur, the person does not recover
7 Ethical IssuesBioethics is the study of the combination of human values and technological advancesBioethics grew from the increasing concern for respect for individual freedom and the difficult task of defining morality in medical care
8 EuthanasiaEuthanasia is the practice of ending life for reasons of mercyExtends from the advances that allow life to be extended by extraordinary means, and the concern for quality of life and respect for the individual
9 Active EuthanasiaActive euthanasia is the deliberate ending of someone’s lifeMoral and religious concerns are involved in the issue of active euthanasiaPhysician-assisted suicide has become an increasingly controversial issueSome states have passed laws specifically making physician-assisted suicide legal, others have banned it
10 Passive EuthanasiaAllowing a person to die by withholding available treatment is called passive euthanasiaMost cases of passive euthanasia end up in court which in Nancy Cruzan’s case asserted that without advance directives, nourishment cannot be stoppedIn Terri Schiavo’s case nourishment was withheld
11 Physician Assisted Suicide Physicians provide a fatal dose of medication that a person self administersLegal in OR and WA, the NetherlandsFive criteria for itThe patient’s condition is intolerable with no hope for improvement, physician has outlined other optionsNo relief is availableThe patient is competentThe patient makes the request repeatedly over time,15 days between two oral and one written requestTwo physicians have reviewed the case and agree with the patient’s request.
12 Making Your Intentions Known There are two ways to tell others of your choice about final decisionsA living will in which a person states their preferences and intentions in the event that they may be unable to make their intentions known regarding life supportA durable power of attorney names an individual who will have the legal authority to make decisions and speak for the person
13 Making Your Intentions Known DNR order means CPR will not be given should a person’s heart of respiration cease
14 Caption: A durable power of attorney, like the one shown here, is a way to make your end-of-life wishes known to others.
15 16.2 Thinking About Death: Personal Aspects Learning Objectives How do feelings about death change over adulthood?How do people deal with their own death?What is death anxiety, and how do people show it?How do people deal with end-of-life issues and create a final scenario?What is hospice?
16 A Life Course Approach to Dying Young adults integrate feeling and emotion with their thinking about death, lessening their feeling of immortalityMiddle-age adults think about their own death as they deal with the death of their parentsOlder adults are less anxious about death because of achievement of ego integrity, completion of most of life’s tasks,and because of declining joy ofliving
17 Dealing With One’s Own Death Reactions to impending death can vary in its development, especially with different causes of terminal illnessDiseases such as cancer may have a terminal phase in which a patient may be able to predict and prepare for deathSome diseases that do not have a terminal phase may create a condition in which a person’s death could occur at any time
18 Kubler-Ross’ TheoryElisabeth Kubler-Ross began working with terminally ill patientsDuring this time, terminally ill patients were not always told they were dying, and death was not generally a topic of discussion. Her research was controversialKubler-Ross began to study patients’ reactions to their terminal illness and found that most people experienced certain emotional states
19 Kubler-Ross’ Stages of Dying Denial - Shock and disbeliefAnger - Hostility and resentmentBargaining - Looking for a way outDepression - No longer able to deny, patients experience sadness and lossAcceptance - Acceptance of the inevitability of death with peace and detachmentThough not all people experience all stages or in the same order, discussion of death helps to move toward acceptance
20 A Contextual Theory of Dying Stage theories imply order to the transition toward acceptance that may not existStage theories do not state what moves a person through the stagesObservations suggest that people vary greatly in the duration of a particular stageThere is no single correct way to dieEach person’s own view of their death and need for health care may impact their movement through the stages
21 A Contextual Theory of Dying Four tasks of a dying person-Bodily needsPsychological securityInterpersonal attachmentsSpiritual energy and hope
22 Death AnxietyTerror management theory asserts that the continuation of one’s life is the primary motive behind all behavior. Fear of dying is consistent with this theoryResearch suggests that death anxiety includes pain, body malfunction, humiliation, rejection, non-being, punishment, interruption of goals, being destroyed, and negative impact on survivors etc. Each of these factors can be assessed in any of three levels: public, private, and unconscious
23 Death Anxiety (Cont)Death anxiety may be lower in older adults due to ego integrity and a positive life review. Emotional problems are predictive of higher death anxiety
24 Learning to Deal With Death Anxiety Adolescents engage in more risk-taking behavior which suggests less death anxietyReduction can be achieved by contemplating one’s own death by writing one’s own obituary, planning one’s own funeral, etc.Death education strives to address death anxiety by presenting factual information about death and reducing sensitivity to the issues involved
25 Creating a Final Scenario Discussions of the issues of management of the final phase of life and the after-death disposition of their body are called end-of-life issuesHospitals and nursing homes teach about advance directives like durable power of attorney and living willsImportant to make wishes known re estate and personal belingings through a willMaking one’s choices known and providing information about how one wants their life to end is called a final scenario
26 The Hospice OptionAn alternative to going to a hospital or nursing home during a terminal illness is hospice care. This involves assisting dying people with pain management and a death with dignity. This approach is called palliative careThe emphasis of hospice is on quality of lifeThe primary goal of hospice is to make the person comfortable and peaceful, not to delay an inevitable death
27 The Hospice Option (Cont) St. Christopher’s Hospice in England was founded by Dr. Cicely Saunders in 1967 and is the model for modern hospicesWhen no treatment or cure is possible, hospice care is requested. The family and the patient is viewed as a unitMay be inpatient or outpatientAn emphasis is placed on patient dignityPatients show less anxiety and depression
28 The Hospice Option (Cont) Key questions about the possible use of hospice services:Does the person know the truth about their condition?What options are available for patient care?What are the patient’s expectations, fears?How well do the people in the person’s social network communicate?Are family members available to provide care?Is a high-quality hospice care program available?Is hospice covered by insurance?
29 16.3 Surviving the Loss: The Grieving Process Learning Objectives How do people experience the grief process?What feelings do grieving people have?What is the difference between normal and abnormal grief?
30 The Grieving ProcessBereavement is the state or condition caused by loss through deathGrief is the sorrow, hurt, anger, guilt, confusion, and other feelings that arise after suffering a lossMourning is the way in which we express our griefMourning rituals can be fairly standard across a culture. Grief varies greatly
31 The Grief Process People must do several things during grief Acknowledge the reality of the lossWork through the emotional turmoilAdjust to the environment where the deceased is absentLoosen the ties to the deceasedIt is important to remember that grief is a process. We must avoid several mistakesNo two people grieve exactly the sameWe must not underestimate the length of time people need to deal with the various issues. One year is needed and 2 years may be required. Some people grieve for years, perhaps the rest of their life
32 Risk Factors in GriefMode of death affects the grief process. When death is anticipated, people experience anticipatory grief that allows for working through some of the issues ahead of timeThe strength of attachment to the deceased makes a difference in the amount of time and difficulty of the grief processSeveral risk factors have been researched: lack of social support, kinship,personal factors, personalityreligiosity, gender, age,income,
33 Normal Grief Reactions Coming to terms with bereavement is called grief workGrief work consists of coping, affect, change, personal growth, and relationshipMany people experience anniversary reactions, which are changes in behavior related to feelings of sadness on the date of the loss. Men have higher mortality rates after bdreavement bereavement, womenmore depression andcomplicated grief.
34 Grief Over Time Grief tends to peak at 6 months Rosenblatt reports that people still feel the effects of the deaths of family members 50 years after the eventThe length of time did not diminish the depth of the emotions experiencedReligiosity has been investigated as a source of support for people following the loss of a loved one. The results are mixed as to whether this factor provides help
35 Coping With GriefTwo processes have been proposed to explain griefThe four component model understanding grief is bases on 4 things:The context of the lossThe continuation of subjective meaning associated with lossThe changing representations of the loss relationship over timeThe role of coping and emotion-regulation processes
36 Four Component Model Implications: Helping a grieving person means helping them make meaning of the lossEncouraging people to express their grief may not be helpfulRumination hypothesis –rejects the necessity of grief processing for recovery, but views extensive grief processing as rumination that may increase distress. Rumination is seen as a type of avoidance because people are not moving on
37 The Dual Process Model of Coping with Bereavement (DPM) Lists two types of stressorsLoss-oriented stressors - those having to do with the loss itselfRestoration-oriented stressors - those related to adapting to the survivor’s new life situation
38 Complicated or Prolonged Grief Reactions Traumatic grief involvesSymptoms of separation distress - preoccupation with the deceased to the point that it interferes with everyday functions, isolation following the lossSymptoms of traumatic distress – disbelief , shock about the death, mistrust, anger, and detachment from others
39 Caption: Children show their grief in many ways, including through physiological ways (Somatic), emotional (Intrapsychic), and Behavioral ones.
40 16.4 Dying and Bereavement Experiences Across the Life Span Learning Objectives What do children understand about death? How should adults help them deal with it?How do adolescents deal with death?How do adults deal with death? What are the special issues they face concerning the death of a child or parent?How do older adults face the loss of a child, grandchild, or partner?
41 ChildhoodAreas of developmental change affecting a child’s understanding of death and griefCognitive-language abilityPsychosocial developmentCoping skillsChildren’s coping methods may include:RegressionGuilt for causing the deathDenialDisplacementRepressionWishful thinking that the deceasedwill return
42 Childhood (Cont)Bereavement in childhood usually does not have long-lasting effects such as depression, if the child gets adequate careA child may have difficulty with the concept of death if adults are not open and honest with themThe use of euphemisms such as “gone away,” or “only sleeping,” can confuse and cause literal interpretation. Preschoolers may see the death as a magical event
43 Adolescence40-70% of college students will experience the loss of a family member or friend in the past two yearsYoung adolescents are reluctant to express or discuss their grief and they may be more likely to experience psychosomatic symptomsAdolescents who lose a parent may show many similar behaviors to those who have lost a sibling
44 Adolescence Effects of bereavement can be severe Expresses in chronic illness, guilt, low self esteem, poor performance in school and on the job, substance abuse, problems with interpersonal relationships, and suicidePeers often uncomfortable talking with bereaved and may avoid them
45 AdulthoodYoung adults may feel that those who die at this point are cheated out of their futureLoss of a partner in young adulthood is very difficult because the loss is so unexpected and need to deal with grief of their childrenLosing a spouse in middle adulthood results in challenging basic assumptions about self, relationships, and life optionsLoss in middle adulthood may result in shifting of thinking of how long they have lived to how much time they have left
46 Death of One’s Child in Young and Middle Adulthood Mourning is intense and some never reconcile the loss, may terminate the relationship with their partnerYoung parents who lose a child to SIDS report high anxiety, more negative view of the world, and guiltA parent’s attachment to a child begins before the birth and loss of a child during childbirth can be very traumaticPeople are expected by society to recover quickly from such an experience
47 Death of One’s ParentWhen a parent dies, the loss hurts but also causes the loss of a buffer between ourselves and death. We may feel that we are now next in lineDeath of a parent may result in a loss of a source of guidance, support, love, and advice,The loss of a parent may result in complex emotions including relief, guilt, and a feeling of freedom
48 Late AdulthoodOlder adults are often less anxious about death and more accepting of itElders may feel that their most important life tasks have been completedOlder adults are more likely to have experienced loss before
49 Death of One’s Child or Grandchild in Late Life Older bereaved parents may have guilt that the pain of a loss of a child affected the relationships with surviving childrenLoss of a grandchild causes intense emotional upset, regrets about the relationship with the deceased grandchild, need to restructure relationship with surviving family,Bereaved grandparents tend to hide their grief behavior in an attempt to shield the grieving parents from the level of grief being felt
50 Death of One’s PartnerSociety expects the surviving spouse to mourn for a period of time and then “move on”. Different cultures have varying “acceptable” lengths of time expectationsThe support system for the bereaved spouse is or is not important in determining the duration and outcome of griefLoss of a spouse leaves a positive bias for the memory of the relationship with the deceased
51 Death of One’s PartnerBereaves spouses who can talk about their feelings exhibit reduced feelings of hopelessness, fewer intrusive thoughts, fewer obsessive-compulsive behaviorsCognitive behavioral therapy is a successful intervention
52 Caption: In general, bereaved spouses rate their marriages more positively than non-bereaved spouses, and tend to be more positive the more depressed they are after their losses.
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