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Chapter 20: Death, Dying, and Grieving ©2011 The McGraw-Hill Companies, Inc. All rights reserved
©2011 The McGraw-Hill Companies, Inc. All rights reserved. 2 The Death System and Its Cultural Variations Components comprising the death system: People: involved with death at some point, either their own death or the death of others. Places or contexts: hospitals, funeral homes, cemeteries, hospices, battlefields, and memorials Times: hours or days when death takes place, or when it is remembered. Objects: associated with death or remembrance Symbols: from religions or other belief systems associated with death
©2011 The McGraw-Hill Companies, Inc. All rights reserved. 3 The Death System and Its Cultural Variations Cultural variations in the death system Ancient Greeks – to live a full life and die with glory In the United States, we are more insulated from death and from dying people, and tend to live as though immortal. Most societies have a ritual that deals with death In most societies, death is not viewed as the end of existence as the spiritual body is believed to live on
©2011 The McGraw-Hill Companies, Inc. All rights reserved. 4 Changing Historical Circumstances: The age group in which death most often occurs, most often among older adults Life expectancy has increased from 47 years for a person born in 1900 to 78 years for someone born today Location of death; 80% of deaths in the U.S. today occur in institutions or hospitals
©2011 The McGraw-Hill Companies, Inc. All rights reserved. 5 Issues in Determining Death Brain Death: a person is brain dead when all electrical activity of the brain has ceased for a specified period of time A flat EEG – recorded for a specific period of time is one criterion of death. Includes both the higher cortical functions and the lower brain- stem functions. Higher portions of the brain die sooner than the lower portions
©2011 The McGraw-Hill Companies, Inc. All rights reserved. 6 Decisions Regarding Life, Death, and Health Care Natural Death Act and Advance Directive Living Will is designed to be filled in while the individual can still think clearly Advance directive: states that life-sustaining procedures shall not be used to prolong their lives when death is imminent
©2011 The McGraw-Hill Companies, Inc. All rights reserved. 7 Decisions Regarding Life, Death, and Health Care Euthanasia: the act of painlessly ending the lives of individuals who are suffering from an incurable disease or severe disability Passive euthanasia: treatment is withheld Active euthanasia: death deliberately induced Case of Terry Schiavo who had suffered brain damage related to cardiac arrest and a lack of oxygen to the brain. She spent 15 years in a vegetative state until a court ordered that her feeding tube be removed. Appeals led to 2 reinsertions of the tube, but she died on 3/18/05 13 days after it had been removed for the 3rd time. Jack Kevorkian was convicted of 2nd degree murder for his assistance in active euthanasia for a number of patients.
©2011 The McGraw-Hill Companies, Inc. All rights reserved. Active euthanasia is a crime in most countries and in every state in the U.S. except for Oregon Oregon passed the Death with Dignity Act in By 2001, 91 individuals were known to have died by active euthanasia in Oregon. Most physicians surveyed oppose active euthanasia
©2011 The McGraw-Hill Companies, Inc. All rights reserved. 9 Decisions Regarding Life, Death, and Health Care Needed: Better Care for Dying Individuals Death in America is often lonely, prolonged, and painful A “good death” involves physical comfort, support from loved ones, acceptance, and appropriate medical care
©2011 The McGraw-Hill Companies, Inc. All rights reserved. 10 Decisions Regarding Life, Death, and Health Care Fail-safe measures for avoiding pain at the end of life Make a living will Give someone power of attorney Give doctors specific instructions such as “Do not resuscitate” or “Do everything possible” Discuss with the family whether or not you want to die at home Check insurance to see if it covers home care or hospice care
©2011 The McGraw-Hill Companies, Inc. All rights reserved. 11 Hospice: a program committed to making the end of life as free from pain, anxiety, and depression as possible Began in London at the end of the 1960s hospice care emphasizes palliative care, which involves reducing pain and suffering and helping individuals die with dignity Makes every effort to include the dying patient’s family members Includes home-based programs today, supplemented with care for medical needs and staff Hospices are more likely to serve patients with cancer than with other terminal illnesses.
©2011 The McGraw-Hill Companies, Inc. All rights reserved. 12 Causes of Death Causes of death vary across the life span: Prenatal death through miscarriage SIDS is the leading cause of infant death in the U.S. Accidents or illness cause most childhood deaths Most adolescent and young adult deaths result from suicide, homicide, or motor vehicle accidents Middle-age and older adult deaths usually result from chronic diseases
©2011 The McGraw-Hill Companies, Inc. All rights reserved. 13 Attitudes Toward Death at Different Points in the Life Span Childhood Young children believe the dead can be brought back to life Around 9 years of age, children view death as universal and irreversible Honesty is the best strategy in discussing death with children
©2011 The McGraw-Hill Companies, Inc. All rights reserved. 14 Attitudes Toward Death at Different Points in the Life Span Adolescence Death regarded as remote and may be avoided, glossed over, or kidded about. Death of friends, siblings, parents, or grandparents bring death to the forefront of adolescents’ lives Develop more abstract conceptions about death than children
©2011 The McGraw-Hill Companies, Inc. All rights reserved. 15 Attitudes Toward Death at Different Points in the Life Span Adulthood There is no evidence that a special orientation toward death develops in early adulthood. Middle-aged adults actually fear death more than young adults Older adults are forced to examine the meanings of life and death more frequently than younger adults
©2011 The McGraw-Hill Companies, Inc. All rights reserved. 16 Knowledge of death’s inevitability permits us to establish priorities and structure our time A recent study examined the concerns of 36 dying individuals from 38 to 92 years of age with a mean age of 68 Privacy and autonomy in regard to their families Inadequate information about physical changes and medication as death approached Motivation to shorten their lives (Terry & others, 2006).
©2011 The McGraw-Hill Companies, Inc. All rights reserved. 17 Kübler-Ross’ Stages of Dying: Denial and Isolation: “It can’t be!” Anger: “Why me?” Bargaining: “Just let me do this first!” Depression: withdrawal, crying, and grieving Acceptance: a sense of peace comes
©2011 The McGraw-Hill Companies, Inc. All rights reserved. Research does not support the idea that dying people go through these stages or go through any stages in any predictable order. In facing their own deaths, some people struggle desperately until the end A recent study of more than 100 patients with advanced congestive heart failure who were studied at two times six months apart found that as the patients perceived they were closer to death, they became more spiritual (Park, 2009).
©2011 The McGraw-Hill Companies, Inc. All rights reserved. 19 Kübler-Ross’ Stages of Dying
©2011 The McGraw-Hill Companies, Inc. All rights reserved. 20 Perceived Control and Denial Perceived control may be an adaptive strategy for remaining alert and cheerful Denial insulates and allows one to avoid coping with intense feelings of anger and hurt Can be maladaptive depending on extent
©2011 The McGraw-Hill Companies, Inc. All rights reserved. 21 The Contexts in Which People Die More than 50% of Americans die in hospitals and nearly 20% die in nursing homes Hospitals offer many important advantages: Professional staff members Technology may prolong life
©2011 The McGraw-Hill Companies, Inc. All rights reserved. 22 Communicating with a Dying Person Open communication with a dying person is very important because: They can close their lives in accord with their own ideas about proper dying They may be able to complete plans and projects, and make arrangements and decisions They have the opportunity to reminisce and converse with others They have more understanding of what is happening to them
©2011 The McGraw-Hill Companies, Inc. All rights reserved. 23 Dimensions of Grieving Grief: emotional numbness, disbelief, separation anxiety, despair, sadness, and loneliness that accompany the loss of someone we love Pining or yearning reflects an intermittent, recurrent wish or need to recover the lost person Grief is not a simple emotional process and may not end anytime soon after the loss Process is more of a roller coaster rather than orderly progression of clear-cut stages with clear-cut time frames. Complicated grief: involves enduring despair and is still unresolved over an extended period of time.
©2011 The McGraw-Hill Companies, Inc. All rights reserved. 24 Grieving Good family communications can help reduce the incidence of depression and suicidal thoughts Prolonged Grief: difficulty moving on with their life; experienced by 10-20% of survivors. Disenfranchised Grief: an individual’s grief involving a deceased person that is a socially ambiguous loss that can’t be openly mourned or supported Examples: ex-spouse, abortion, stigmatized death (such as AIDS)
©2011 The McGraw-Hill Companies, Inc. All rights reserved. Cognitive factors are involved in the severity of grief after a loved one has died. One study focused on 329 adults who had suffered the loss of a first-degree relative (Boelen, van den Bout, & van den Hout, 2003). The more negative beliefs and self-blame the adults had, the more severe were their symptoms of traumatic grief, depression, and anxiety.
©2011 The McGraw-Hill Companies, Inc. All rights reserved. 26 Grieving Dual-Process Model of Coping and Bereavement Two Main Dimensions 1) Loss-oriented stressors focus on the deceased person and can include grief work and finding the positive aspects of the loss (relief from suffering) and experiencing the negative (yearning and rumination) 2) Restoration-oriented stressors Involve secondary stressors that emerge as indirect outcomes of bereavement. Examples include developing a new identity and learning new skills (such as managing finances). Effective coping involves oscillation between coping with loss and coping with restoration
©2011 The McGraw-Hill Companies, Inc. All rights reserved. 27 Grieving Coping and Type of Death Impact of death on surviving individuals is strongly influenced by the circumstances under which the death occurs Sudden deaths are likely to have more intense and prolonged effects on surviving individuals
©2011 The McGraw-Hill Companies, Inc. All rights reserved. 28 Grieving Cultural Diversity in Healthy Grieving Some cultures emphasize the importance of breaking bonds with the deceased and returning quickly to autonomous lifestyles Non-Western cultures suggest that beliefs about continuing bonds with the deceased vary extensively There is no one right, ideal way to grieve
©2011 The McGraw-Hill Companies, Inc. All rights reserved. 29 Making Sense of the World Grieving often stimulates individuals to try to make sense of their world A reliving of the events leading to the death is common When a death is caused by an accident or a disaster, the effort to make sense of it is often pursued more vigorously
©2011 The McGraw-Hill Companies, Inc. All rights reserved. 30 Losing a Life Partner The death of an intimate partner often brings profound grief Widows outnumber widowers because women live longer than men Widowed women are probably the poorest group in America The poorer and less educated they are, the lonelier they tend to be. Many widows are lonely
©2011 The McGraw-Hill Companies, Inc. All rights reserved. 31 Forms of Mourning Approximately two-thirds are buried and one-third are cremated Cremation is less popular in the South region of the US and more popular in the Pacific region. Funerals are an important aspect of mourning in many cultures Cultures vary in how they practice mourning
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