1. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Chapter 21 Death and Grieving

2. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. “Sustained and soothed by an unfaltering trust, approach thy grave, Like one who wraps the Drapery of his couch About him, and lies down to pleasant dreams.” -William Cullen Bryant American Poet, 19 th Century

3. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Learning Goals 1.Evaluate issues in determining death and decisions regarding death. 2.Describe the roles of sociohistorical and cultural contexts in understanding death. 3.Discuss death and attitudes about it at different points in development. 4.Explain the psychological aspects involved in facing one’s own death and the contexts in which people die. 5.Identify ways to cope with the death of another person.

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6. Issues in Determining Death Brain death - a neurological definition of death which states that a person is brain dead when all electrical activity of the brain has ceased for a specified period of time. The brain’s lower portions monitor vital functions, thus people whose higher brain areas have died may continue breathing and have a heartbeat. The current definition of brain death for most physicians includes the death of both the higher cortical functions and lower brain stem functions.

7. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Other Considerations for Determining Death Some medical experts argue that the criteria for death should include only higher cortical functioning. They argue that the functions we associate with being human, such as intelligence and personality, are located in the higher cortical part of the brain. They believe that when these functions are lost, the “human being” is no longer alive.

8. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Decisions Regarding Life, Death, and Health Care Natural Death Act and Advanced Directives Euthanasia Needed: Better Care for Dying Individuals

9. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. The Living Will Recognizing that terminally ill patients might prefer to die rather than lingering in a painful or vegetative state, an organization called “Choice in Dying” created the Living Will. This document is designed to be filled in while the individual can still think clearly and expresses the person’s desire that extraordinary medical procedures not be used to sustain life when the medical situation becomes hopeless.

10. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Natural Death Act and Advanced Directives Physicians’ concerns over malpractice suits and the efforts of Living Will supporters have produced natural death legislation in many states. California’s Natural Death act permits individuals who have been diagnosed by two physicians as terminally ill to sign an advanced directive. This advanced directive states that life-sustaining procedures not be used to prolong their lives when death is imminent. All 50 states now accept advanced directives.

11. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Euthanasia The act of painlessly ending the lives of individuals who are suffering from an incurable disease or severe disability. Sometimes referred to as “mercy killing.” Passive euthanasia - occurs when a person is allowed to die by withholding available treatment, such as withdrawing a life-sustaining device. Active euthanasia - occurs when death is deliberately induced, as when a lethal dose of a drug is injected.

12. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Attitudes About Euthanasia The trend is toward acceptance of passive euthanasia for terminally ill patients. The precise boundaries and the exact mechanisms by which treatment decisions should be implemented are not entirely agreed upon. Active euthanasia is a crime in most countries and in all U.S. states except Oregon. In a recent survey of more than 900 physicians, most opposed active euthanasia and said that adequate pain control often eliminates the need for it and that the primary role of the physician is to preserve life.

13. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Needed: Better Care for Dying Individuals A recent report concluded that death in America is often lonely, prolonged, and painful. Dying individuals often get too little or too much care. Too many experience severe pain during the last days and months of life. It is recommended that regulations be changed to make it easier for physicians to prescribe painkillers for dying patients who need them. The report also noted many health-care professionals are not trained to provide adequate end-of-life care.

14. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Suggestions for the End of Life Make a living will, and be sure there is someone who will draw your doctor’s attention to it. Give someone the power of attorney and make sure this person knows your wishes regarding medical care. Give your doctors specific instructions—from “Do not resuscitate” to “Do everything possible”—for specific circumstances. If you want to die at home, talk it over with your family and doctor. Check to see whether your insurance plan covers home care and hospice care.

15. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Hospices A humanized program committed to making the end of life as free from pain, anxiety, and depression as possible. The hospice’s goals contrast with those of a hospital, which are to cure illness and prolong life. Hospice care emphasizes palliative care, which involves reducing pain and suffering and helping individuals die with dignity.

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17. Changing Historical Circumstances One historical change already presented is the increasing complexity of determining when someone is truly dead. Another change is the age group death strikes most often—200 years ago it was children, now it is the elderly. Life expectancy has increased by 50 years since 1900. With a mobile society, more people die apart from their families. The care of the dying has shifted away from families.

18. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Death in Different Cultures Americans are conditioned to live life as though they were immortal. People in many countries face death all around them on a daily basis. Even in areas where life is better, the presence of dying family members and large funeral attendance is a regularity. These aspects of life help prepare the young for death and provide them with guidelines on how to die.

19. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Perceptions of Death In most societies, death is not viewed as the end of existence—though the biological body has died, the spiritual body is believed to live on. Some cultures: –believe death is caused by magic and demons. –believe death is caused by natural forces. –focus on reincarnation. –view death as punishment, while for others it represents redemption. –fear death, while others embrace it.

20. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Evidence of the Denial of Death The tendency of the funeral industry to gloss over death and fashion lifelike qualities in the dead The adoption of euphemistic language for death The persistent search for a fountain of youth The rejection and isolation of the aged, who may remind us of death The adoption of the concept of a pleasant and rewarding afterlife, suggesting that we are immortal The medical community’s emphasis on the prolongation of biological life rather than an emphasis on diminishing human suffering

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22. Causes of Death and Expectations About Death Death can occur at any point in the human life span. In childhood, death occurs most often because of accidents or illness. Death in adolescence is more likely to occur because of motor vehicle accidents, suicide, and homicide. Younger adults are more likely to die from accidents. Older adults are more likely to die from chronic diseases. Younger adults who are dying often feel cheated more than do older adults who are dying.

23. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Attitudes Toward Death at Different Points in the Life Span Childhood Adolescence Adulthood

24. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Childhood Attitudes Toward Death Infants don’t have even a rudimentary concept of death, but once they develop an attachment, they can experience loss or separation and anxiety. Children 3-5 years old don’t have a true idea of what death really means, often confusing death with sleep. Young children believe that the dead can be brought back to life spontaneously. It is believed children don’t believe death is universal and irreversible until about age 9.

25. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Explaining Death to Children Most psychologists believe that honesty is the best strategy in discussing death with children. Respond to children’s queries about death based on their maturity level. Death can be explained to preschool children in simple physical and biological terms. What children need the most is reassurance that they are loved and will not be abandoned. Regardless of age, adults should be sensitive and sympathetic, encouraging them to express their own feelings and ideas.

26. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Adolescent Attitudes Toward Death In adolescence, the prospect of death is so remote that it does not have much relevance. The subject of death may be avoided, glossed over, kidded about, neutralized, and controlled by a cool spectator-like orientation. Adolescents develop more abstract conceptions of death than children do. They also develop religious and philosophical views about the nature of death and whether there is life after death. Adolescents are especially likely to think that they are invincible and unique and immune to death.

27. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Adult Attitudes Toward Death There is no evidence that a special orientation toward death develops in early adulthood. An increase in consciousness about death accompanies individuals’ awareness that they are aging. This usually intensifies in middle adulthood, as those in midlife fear death more than do young adults or older adults. Older adults think about death more and talk about it more than in previous adult stages.

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29. Kubler-Ross’ Stages of Dying Denial and Isolation Anger Bargaining Depression Acceptance

30. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Denial and Isolation In the first stage of dying, Kübler-Ross states that individuals refuse to believe that their condition is terminal. These individuals attempt to convince themselves that lab tests were inaccurate or that the disease will go into remission. Dying individuals in this stage also seek isolation from others.

31. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Anger In this second stage of dying, the dying person recognizes that denial can no longer be maintained. Denial often gives way to anger, resentment, rage, and envy. The dying person’s question is: “Why me?” At this point, the dying person becomes increasingly difficult to care for, as anger may become displaced and projected onto physicians, nurses, family members, and God. The realization of loss is great and those who represent life are targets of resentment and jealousy.

32. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Bargaining In the third stage of dying, Kübler-Ross states that the person develops the hope that death can somehow be postponed or delayed. Some people enter into a bargaining or negotiation —often with God—as they try to delay their death. In exchange for a few more days, weeks, or months of life, the person promises to lead a reformed life dedicated to God or to the service of others.

33. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Depression In Kübler-Ross’ fourth stage of dying, the dying person comes to accept the certainty of death. At this point, a period of depression or preparatory grief may appear. The dying person may become silent, refuse visitors, and spend much time crying or grieving. Attempts to cheer up the dying person at this stage should be discouraged, says Kübler-Ross, because the dying person has a need to contemplate impending death.

34. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Acceptance In the fifth stage of dying, the person develops a sense of peace; an acceptance of one’s fate; and, in many cases, a desire to be left alone. In this stage, feelings and physical pain may be virtually absent. Kübler-Ross views this stage as the end of the dying struggle, the final resting stage before death.

35. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Criticisms of Kübler-Ross According to psychology death expert Robert Kastenbaum, the existence of the five-stage sequence has not been demonstrated by research. He also believes that the stage interpretation neglected the patients’ total life situations, including relationship support, specific effects of illness, family obligations, and institutional climate in which they were interviewed. Some psychologists prefer to describe the stages as reactions to dying rather than stages.

36. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. The Contributions of Kübler-Ross She made the important contribution of calling attention to people attempting to cope with life- threatening illnesses. She did much to encourage needed attention to the quality of life for dying persons and their families.

37. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Perceived Control and Denial Perceived control and denial may work together as an adaptive strategy for some older adults who face death. When individuals are led to believe they can influence and control events, they may become more alert and cheerful. Denial may also be a fruitful way for some individuals to approach death. Denial can protect us from the tortuous feeling that we are going to die. Denial can be maladaptive if it prevents treatment.

38. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. The Contexts in Which People Die For dying individuals, the context in which they die is important. More than 50% of Americans die in hospitals. Nearly 20% die in nursing homes. Hospitals offer important advantages in that professional staff members are readily available, and the medical technology may prolong life. Most individuals say they would rather die at home, and many choose a hospice.

39. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Coping with the Death of Someone Else Communicating with the Dying Person Grieving Making Sense of the World Losing a Life Partner Forms of Mourning and the Funeral

40. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Communicating with a Dying Person Most psychologists believe that it is best for dying individuals to know that they are dying, and that significant others know they are dying. Dying individuals can thus close their lives in accord with their own idea of proper dying. They can complete plans and projects. They can make arrangements for survivors. They can participate in decisions about a funeral. They will have the opportunity to reminisce.

41. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Suggestions for Conversing with a Dying Individual Experts believe that conversation should not focus on mental pathology or preparation for death, but should focus on strengths of the individual and preparation for the remainder of life. Communication should be directed at internal growth. Caring for a dying individual can come from: –an attentive physician – a concerned nurse –a sensitive spouse – an intimate friend

42. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Grieving Dimensions of Grieving Cultural Diversity in Healthy Grieving

43. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Dimensions of Grieving The emotional numbness, disbelief, separation anxiety, despair, sadness, and loneliness that accompany the loss of someone we love. Pining or yearning reflects a recurrent need to recover the lost person. Separation anxiety includes pining but also focuses on places and things associated with the deceased, as well as crying. Numbness, disbelief, and outbursts of panic are typical immediate reactions. Despair, sadness, and hopelessness are included.

44. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. The Ups and Downs of Grieving Rapidly changing emotions Meeting the challenges of learning new skills Detecting personal weaknesses and limitations Creating new patterns of behavior Forming new friendships and relationships

45. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Issues Related to Grieving Researchers have found that the grieving process is more like a roller-coaster ride than an orderly progression of stages with clear-cut time frames. For most individuals the roller-coaster dimensions of grief become more manageable over time, with fewer abrupt highs and lows. Long-term grief is sometimes masked and can lead to depression and suicidal behavior. Good family communication may help reduce the incidence of depression and suicidal thoughts.

46. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Cultural Diversity in Healthy Grieving In contrast to Western beliefs, maintenance of ties with the deceased is accepted and sustained in the religious rituals of Japan. In the Arizona Hopi, the deceased are forgotten as quickly as possible and life is carried on as usual. In Egypt, the bereaved are encouraged to dwell at length on their grief. In Bali, the bereaved are encouraged to laugh and be joyful, rather than be sad. Diverse grieving patterns are culturally embedded.

47. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Making Sense of the World A beneficial aspect of grieving is that it stimulates many individuals to make sense of their world. A common occurrence is to go over again and again all of the events that led up to the death. When death is caused by an accident or disaster, the effort to make sense of it is pursued more vigorously. The bereaved want to put the death in a perspective they can understand—divine intervention, a logical sequence of cause and effect, etc.

48. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Losing a Life Partner Those left behind after the death of an intimate partner suffer profound grief and often endure financial loss, loneliness, increased physical illness, and psychological disorders. The bereaved are also at increased risk for many health problems, including death. Optimal adjustment after a death depends on several factors. Women do better than men in our society, due to their networks of friends and close relationships.

49. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Forms of Mourning and the Funeral Mourning varies cross-culturally. The funeral is an important aspect of mourning in many cultures. One consideration is what to do with the body. Approximately 80% of corpses are buried. A recent study showed that bereaved individuals who were religious derived more psychological benefits from a funeral, participated more actively in rituals, and adjusted more positively to the loss.