1. Epilogue Death and Dying
PowerPoints prepared by Cathie Robertson, Grossmont College

2. Deciding How to Die
Practices and rituals relating to dying, death, and bereavement are universal, but there are variations
Rituals may be changing with globalization
One of first steps in understanding death is to accept it
for most of human history, death accepted as unanticipated, unavoidable, and quick
today, because of medical miracles, death less of everyday event

3. Medical Professionals
As illness came to be perceived as a domain of medicine rather than of religion, we began to believe physicians could work medical miracles
Elizabeth Kübler-Ross brought solid research and compassionate attention to the psychological needs of the dying

4. Medical Professionals, cont.
In the early 21st century, only 1/2 of medical books discuss care of dying
In recent years, more physicians are more accepting of death
3 innovations are helping to help the dying achieve a “good death”
hospice care
palliative care
end-of-life decision making

5. Hospice Care
Hospice—institution where terminally ill patients receive palliative care
provides skilled medical treatment, but avoids death-defying interventions
human dignity respected
Dying person and the family are considered to be the “unit of care”
sometimes then the home is where care given

6. Hospice Care, cont.
Hospices try to help as many people as possible, but do not reach everyone
patients must be diagnosed as terminally ill
patients and caregivers must accept diagnosis of terminal illness
hospices were typically designed for adults with terminal cancer, not older adults with severe illnesses
hospice care is expensive
availability depends mainly on location

7. Palliative Care
Designed mainly to relieve pain and suffering of patient and family
Double effect—primarily relieves pain, but could also hasten death
Psychological symptoms of patients and their families more difficult to treat
depression, anxiety

8. Legal Preparations
Explicit guidelines for a person’s preferences for end-of-life care are needed because he or she often becomes incapable of making or expressing decisions about medical care
Passive euthanasia—situation in which a seriously ill person is allowed to die naturally via cessation of medical interventions

9. Legal Preparations, cont.
Active euthanasia—a situation where someone takes action to bring about another’s death, with the intention of ending that person’s suffering
Living will—document that indicates what medical intervention should occur
Health care proxy—the person chosen to make medical decisions if the person who chose becomes unable to make his/her own decisions

10. Disagreements About End-of-Life Care
Living wills are only a start
Hospitals today ask about living wills and advance directives upon admission
some people resist signing them
End-of-life care involves probabilities, not certainties, until the very last moment
What quality of life is acceptable?

11. Disagreements About End-of-Life Care, cont.
Problems with Designated Proxy
many proxies choose measures neither they nor the dying person want
may involve clashing cultural values
family members may disagree bitterly about how much suffering is acceptable
even if patient has signed living will and specified proxy, hospital staff may ignore them

12. Euthanasia
Legally, decisions made in living wills and by health care proxies are to be honored
Active euthanasia is fiercely controversial, even if the dying person requests it
is illegal in almost every part of the world

13. Euthanasia, cont.
Physician-assisted suicide—form of active euthanasia in which a doctor provides the means for someone to end his or her life
Voluntary euthanasia—form of active euthanasia in which, at patient’s request, someone else ends his or her life

14. Euthanasia, cont.
Several places have legalized physician-assisted suicide
the Netherlands
Switzerland
Belgium
Oregon

15. Euthanasia, cont. In Oregon, the following conditions must exist
person must be terminally ill—less than 6 months to live
2 doctors must confirm diagnosis of terminal illness
both doctors must certify patient’s judgment unimpaired
person must ask for lethal drugs at least 2x orally and 1 time in writing
15 days must elapse between first request and written prescription

16. Preparing for Death Responses to death vary greatly
It has been denied, sought, feared, fought, avoided, and welcomed by all involved

17. Avoiding Despair Kübler-Ross helped us to understand death
Acceptance of death was elusive before
Kübler-Ross’s 5 Stages
denial
anger
bargaining
depression
acceptance

18. Avoiding Despair. cont.
Others that study death (thanatology) have disagreed about the stages
5 stages appear and reappear throughout process
Research has clarified some patterns
older people more likely to plan for death
concern is more likely to be for a “good death”—swift, painless, dignified, and occurring at home

19. Cultural Variations
Hope takes the form of the desire that death be held at pay
can also be expressed as a belief in an afterlife or the significance of person’s life in context of family and community

20. Death in Religions of Africa and Asia
In many traditional African religions, adults gain new status through death and the joining of ancestors
For Muslims, death affirms religious faith
life is transitory, so people should be ready for death at any time

21. Death in Religions of Africa and Asia, cont.
For Buddhists, death and disease are among life’s inevitable sufferings
may bring spiritual enlightenment
For Hindus, helping the dying to surrender their ties to the world and prepare for the next is a particularly important obligation for the family
a holy death is welcomed by dying person
eases person into the next life

22. Death in North America
Indigenous tribes (over 400) all consider death an affirmation of nature and community values
Jews hope for life to be sustained; thus, death is not emphasized and the dying person is not left alone
Many Christians believe that death is not an end, but rather the beginning of eternity in heaven or heal; so death may either be welcomed or feared

23. Spiritual and Cultural Affirmation
Religious and spiritual concerns often reemerge at death
It is common for dying people to return to their roots
For many, spiritual beliefs and a connection to community offer hope at time of dying

24. Coping with Bereavement
The considerable variations in practices that follow death are due to religion and culture
Bereavement—sense of loss following a death

25. Forms of Sorrow Grief—individual’s emotional response to bereavement
private
Mourning—culturally prescribed ceremonies and behaviors for expressing grief at the death of a loved one
public
The two are connected
mourning is designed by religions and cultures
grief, though personal and private, follows social rules

26. Forms of Sorrow, cont.
Mourning customs are designed by various cultures and religions to channel grief into reaffirmation
Crucial to reaffirmation is people’s search for the meaning in death
Unexpected or violent deaths are particularly likely to shock and to precipitate a search for meaning
September 11, 2001

27. Contemporary Challenges
Mourning has become more private, less emotional, and less religious
funeral trends
cremation vs. burial
As mourning diminishes, grief becomes less welcome; people are less likely to be given time to grieve

28. Contemporary Challenges, cont.
“Disenfranchised grief” is the practice of excluding certain people from mourning
the unmarried partner
the young child
the ex-spouse
the friend from work
Any kind of prohibition, restriction, or exclusion can make healing, hope, and affirmation more difficult for bereaved of all ages

29. Contemporary Challenges, cont.
Murders and suicides often trigger police investigations, etc., that interfere with the grief process
Inadequate grief is thought to harm the larger community as well

30. Responses to Bereavement
What Friends Can Do to Help the Bereaved Person
first, be aware that powerful, complicated, and unexpected emotions are likely
do not judge another person’s sorrow
understand that culture and cohort play a role in the different responses to death

31. Responses to Bereavement, cont.
Bereavement is an ongoing, often lengthy process; sympathy, honesty, and social support may be needed for months or even years
especially true for families
Recovery begins with acceptance of grief and may lead to reaffirmation of life

32. Conclusion
Working through the emotions can help the person have a deeper appreciation of him/herself and life, including human relationships