2The Death System and Cultural Contexts The Death System and Its Cultural VariationsComponents 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 memorialsTimes: hours or days when death takes place, or when it is remembered.Objects: associated with death or remembranceSymbols: from religions or other belief systems associated with deathRobert Kastenbaum (2009)
3The Death System and Cultural Contexts The Death System and Its Cultural VariationsCultural variations in the death systemAncient Greeks – to live a full life and die with gloryIn 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 deathIn most societies, death is not viewed as the end of existence as the spiritual body is believed to live on
4The Death System and Cultural Contexts Changing Historical Circumstances:The age group in which death most often occurs, most often among older adultsLife expectancy has increased from 47 years for a person born in 1900 to 78 years for someone born todayLocation of death; 80% of deaths in the U.S. today occur in institutions or hospitals
5Defining Death and Life/Death Issues Issues in Determining DeathBrain Death: a person is brain dead when all electrical activity of the brain has ceased for a specified period of timeA 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 portionsDefining death has gotten more complicated. It used to be dependent on the end of certain biological functions like breathing and blood pressure and the signs of rigor mortis.A person’s lower brain portions can continue to keep the person alive even when cortical function has ended. Some people argue that the cessation of cortical functioning should constitute brain death, because all of the qualities we associate with being human are housed in the higher portions of the brain.Supporters of cortical death policy argue that death should be declared when activity in the cortex (higher portion of the brain) has ceased, since this portion of the brain houses all the functions that make a person uniquely human.
6Defining Death and Life/Death Issues Decisions Regarding Life, Death, and Health CareNatural Death Act and Advance DirectiveLiving Will is designed to be filled in while the individual can still think clearlyAdvance directive: states that life-sustaining procedures shall not be used to prolong their lives when death is imminentThe organization “Choice in Dying,” created the living will. California’s Natural Death Act allows a person who has been diagnosed by 2 physicians as terminally ill to sign an advanced directive, which states that life sustaining procedures shall not be used to prolong their lives when death is imminent.Euthanasia means “easy death.”
7Defining Death and Life/Death Issues Decisions Regarding Life, Death, and Health CareEuthanasia: the act of painlessly ending the lives of individuals who are suffering from an incurable disease or severe disabilityPassive euthanasia: treatment is withheldActive euthanasia: death deliberately inducedCase 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/ 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.After a series of trials, Kevorkian was convicted of second-degree murder and given a 10- to 15-year sentence. He was released from prison at age 79 for good behavior in June 2007 and promised not to participate in any further assisted suicides.
8Oregon passed the Death with Dignity Act in 1994. Active euthanasia is a crime in most countries and in every state in the U.S. except for OregonOregon passed the Death with Dignity Act inBy 2001, 91 individuals were known to have died by active euthanasia in Oregon.Most physicians surveyed oppose active euthanasiaCan a comatose patient's life-support systems be disconnected when the patient has left no written instructions to that effect? Does the family of a comatose patient have the right to overrule the attending physician's decision to continue life-support systems? These questions have no simple or universally agreed-upon answers
9Defining Death and Life/Death Issues Decisions Regarding Life, Death, and Health CareNeeded: Better Care for Dying IndividualsDeath in America is often lonely, prolonged, and painfulA “good death” involves physical comfort, support from loved ones, acceptance, and appropriate medical care
10Defining Death and Life/Death Issues Decisions Regarding Life, Death, and Health CareFail-safe measures for avoiding pain at the end of lifeMake a living willGive someone power of attorneyGive doctors specific instructions such as “Do not resuscitate” or “Do everything possible”Discuss with the family whether or not you want to die at homeCheck insurance to see if it covers home care or hospice care
11Decisions Regarding Life, Death, and Health Care Hospice: a program committed to making the end of life as free from pain, anxiety, and depression as possibleBegan in London at the end of the 1960shospice care emphasizes palliative care, which involves reducing pain and suffering and helping individuals die with dignityMakes every effort to include the dying patient’s family membersIncludes home-based programs today, supplemented with care for medical needs and staffHospices are more likely to serve patients with cancer than with other terminal illnesses.Hospice advocates suggest that it is possible to control pain for almost any dying individual.Today most hospices are home-based.For hospice services to be covered by Medicare, a patient must be deemed by a physician to have six months or fewer to live. Also, some hospice providers require that the patient have a family caregiver in the home (or nearby) before agreeing to provide services for the patient
12A Developmental Perspective On Death Causes of DeathCauses of death vary across the life span:Prenatal death through miscarriageSIDS is the leading cause of infant death in the U.S.Accidents or illness cause most childhood deathsMost adolescent and young adult deaths result from suicide, homicide, or motor vehicle accidentsMiddle-age and older adult deaths usually result from chronic diseases
13A Developmental Perspective On Death Attitudes Toward Death at Different Points in the Life SpanChildhoodYoung children believe the dead can be brought back to lifeAround 9 years of age, children view death as universal and irreversibleHonesty is the best strategy in discussing death with childrenInfants do not have a concept of death and may experience brief separations as total losses. However, loss of a parent can lead to bereavement which can affect the infant’s health.Kids 3 to 5 have little or no idea what death means and generally do not get upset if they see a dead animal or by being told that a person has died. Young children may also believe that only people who want to die or who are bad or careless may die, and they may blame themselves for the death of someone they know well – thinking that the death happened because they disobeyed the person.
14A Developmental Perspective On Death Attitudes Toward Death at Different Points in the Life SpanAdolescenceDeath 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’ livesDevelop more abstract conceptions about death than childrenchildren probably do not view death as universal and irreversible until about 9 years of age (Cuddy-Casey & Orvaschel, 1997). Most children under 7 do not see death as likely. Those who do, perceive it as reversible.Adolescents’ capability for abstract thought allows them to consider more religious or philosophical views of death.
15A Developmental Perspective On Death Attitudes Toward Death at Different Points in the Life SpanAdulthoodThere is no evidence that a special orientation toward death develops in early adulthood.Middle-aged adults actually fear death more than young adultsOlder adults are forced to examine the meanings of life and death more frequently than younger adultsOlder adults are more likely to have directly experienced death than younger adults.
16Facing One’s Own DeathKnowledge of death’s inevitability permits us to establish priorities and structure our timeA recent study examined the concerns of 36 dying individuals from 38 to 92 years of age with a mean age of 68Privacy and autonomy in regard to their familiesInadequate information about physical changes and medication as death approachedMotivation to shorten their lives(Terry & others, 2006).when asked how they would spend their six remaining months of life, younger adults described such activities as traveling and accomplishing things they previously had not done; older adults described more inner-focused activities—contemplation and meditation, for example (Kalish & Reynolds, 1976).
17Facing One’s Own Death 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 grievingAcceptance: a sense of peace comesWhat Kubler-Ross contributed is appreciation for the process of the dying person and attention to the needs of people attempting to cope with terminal illnesses.The existence of the five-stage sequence has not been demonstrated by either Kübler-Ross or independent research.The stage interpretation neglected the patients' situations, including relationship support, specific effects of illness, family obligations, and institutional climate in which they were interviewed.some psychologists prefer to describe them not as stages but as potential reactions to dyingA recent study of more than 100 patients with advanced congestive heart failure who were studied at two times six
18Stages of Dying?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 endA 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).
19Facing One’s Own DeathKübler-Ross’ Stages of Dying
20Facing One’s Own Death Perceived Control and Denial Perceived control may be an adaptive strategy for remaining alert and cheerfulDenial insulates and allows one to avoid coping with intense feelings of anger and hurtCan be maladaptive depending on extentRemember from Chapter 17 that giving nursing home residents options for control improved their attitudes and increased their longevity (Rodin & Langer, 1977).When people are lead to believe they can influence and control events – such as prolonging their lives – they become more alert and cheerful.
21Facing One’s Own Death The Contexts in Which People Die More than 50% of Americans die in hospitals and nearly 20% die in nursing homesHospitals offer many important advantages:Professional staff membersTechnology may prolong lifeMost people say that they would like to die at home (Jackson & others, 2010; Kalish & Reynolds, 1976), although a home setting does compromise the availability of emergency medical treatment.
22Coping With The Death Of Someone Else Communicating with a Dying PersonOpen communication with a dying person is very important because:They can close their lives in accord with their own ideas about proper dyingThey may be able to complete plans and projects, and make arrangements and decisionsThey have the opportunity to reminisce and converse with othersThey have more understanding of what is happening to them
23Coping With The Death Of Someone Else Dimensions of GrievingGrief: emotional numbness, disbelief, separation anxiety, despair, sadness, and loneliness that accompany the loss of someone we lovePining or yearning reflects an intermittent, recurrent wish or need to recover the lost personGrief is not a simple emotional process and may not end anytime soon after the lossProcess 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.Normal, uncomplicated grief which resolves within 6 months of the death of the loved is experienced by 80 to 90% of survivors, who are able to function competently in their lives.Someone who loses someone they were emotionally dependent upon is at risk for complicated grief.
24Coping With The Death Of Someone Else GrievingGood family communications can help reduce the incidence of depression and suicidal thoughtsProlonged 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 supportedExamples: ex-spouse, abortion, stigmatized death (such as AIDS)A recent study revealed that the death of a loved one is most frequently followed by yearning and acceptance with most of the negative feelings associated with the death diminishing by six months after the death (Maciejewski & others, 2007). In this study, yearning was more common than depression following a loved one's death.A recent study of almost 300 recently widowed men and women revealed that in the course of their bereavement experiencing humor, laughter, and happiness was strongly related to more favorable bereavement adjustment (lower levels of grief and depression) (Lund & others, 2008–2009).Disenfranchised grief may intensify an individual's grief because it cannot be publicly acknowledged
25The Severity of GriefCognitive 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.Normal, uncomplicated grief which resolves within 6 months of the death of the loved is experienced by 80 to 90% of survivors, who are able to function competently in their lives.
26Coping With The Death Of Someone Else GrievingDual-Process Model of Coping and BereavementTwo Main Dimensions1) Loss-oriented stressorsfocus 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 stressorsInvolve 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 restorationRestoration-oriented stressors involve the secondary stressors that emerge as indirect outcomes of bereavement. They can include a changing identity (such as from “wife” to “widow”) and mastering skills (such as dealing with finances).Although loss and restoration coping can occur concurrently, over time there often is an initial emphasis on coping with loss followed by greater emphasis on restoration (Milberg & others, 2008).
27Coping With The Death Of Someone Else GrievingCoping and Type of DeathImpact of death on surviving individuals is strongly influenced by the circumstances under which the death occursSudden deaths are likely to have more intense and prolonged effects on surviving individuals
28Coping With The Death Of Someone Else GrievingCultural Diversity in Healthy GrievingSome cultures emphasize the importance of breaking bonds with the deceased and returning quickly to autonomous lifestylesNon-Western cultures suggest that beliefs about continuing bonds with the deceased vary extensivelyThere is no one right, ideal way to grieveThe diversity of grieving is nowhere more clear than in two Muslim societies—one in Egypt, the other in Bali. In Egypt, the bereaved are encouraged to dwell at length on their grief, surrounded by others who relate similarly tragic accounts and express their own sorrow. By contrast, in Bali, the bereaved are encouraged to laugh and be joyful.
29Coping With The Death Of Someone Else Making Sense of the WorldGrieving often stimulates individuals to try to make sense of their worldA reliving of the events leading to the death is commonWhen a death is caused by an accident or a disaster, the effort to make sense of it is often pursued more vigorouslyAnd a recent study revealed that finding meaning in the death of a spouse was linked to a lower level of anger during bereavement (Kim, 2009).Meaning-making coping involves drawing on beliefs, values, and goals to change the meaning of a stressful situation, especially in times of chronic stress as when a loved one dies
30Coping With The Death Of Someone Else Losing a Life PartnerThe death of an intimate partner often brings profound griefWidows outnumber widowers because women live longer than menWidowed women are probably the poorest group in AmericaThe poorer and less educated they are, the lonelier they tend to be.Many widows are lonelyIn the United States, 14 percent of men and 42 percent of women 65 years of age and older were widowed in 2008 (Administration on Aging, 2009).the negative economic consequences for widowed women are greater for African American and Latino women than for non-Latino White women (Angel, Jimenez, & Angel, 2007).A six-year longitudinal study of individuals 80 years of age and older found that the loss of a spouse, especially in men, was related to a lower level of life satisfaction over time (Berg & others, 2009).However, another study revealed that nearly half of surviving spouses experienced low levels of distress from three years predeath to 18 months postdeath (Bonanno, Wortman, & Nesse, 2004). For either widows or widowers, social support helps them adjust to the death of a spouse (Bennett, 2009). The Widow-to-Widow program, begun in the 1960s, provides support for newly widowed women. Volunteer widows reach out to other widows,
31Coping With The Death Of Someone Else Forms of MourningApproximately two-thirds are buried and one-third are crematedCremation 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 culturesCultures vary in how they practice mourningIn one study, bereaved individuals who were personally religious derived more psychological benefits from a funeral, participated more actively in the rituals, and adjusted more positively to the loss (Hayslip, Edmondson, & Guarnaccia, 1999).In the United States, the trend is away from public funerals and displaying the dead body in an open casket and toward private funerals followed by a memorial ceremony (Callahan, 2009).The Amish are a conservative group with approximately 80,000 members in the United States, Ontario, and several small settlements in South and Central America.The family and community also have specific and important roles in mourning in traditional Judaism. The program of mourning is divided into graduated time periods, each with its appropriate practices