Death and Dying Thanatology Study of death and dying, especially the social and emotional aspects It reveals: the reality of hope in death. choices in dying. affirmation in mourning. reaffirmation of life.

How Death Has Changed in the Past 100 Years Death occurs later. Dying takes longer. Death often occurs in hospitals. Causes of death have changed. And after death…it is unclear. See Table EP.1 for additional details.

Cultures, Epochs, and Death All known ancient societies shared three themes. Actions during life affected destiny after death. Afterlife was assumed. Mourners said particular prayers and made specific offerings, in part to prevent the spirit of the dead from haunting and hurting them.

Cultures, Epochs, and Death Contemporary religions Each faith has distinct rituals and practices surrounding death. Death always evokes strong emotions. Death is considered a passage; not an endpoint.

Religions and Hope People who think they might die soon are more likely than others to believe in life after death. Virtually every world religion provides rites and customs to honor the dead and comfort the living. Although not everyone observes religious customs, those who care for the dying and their families need extraordinary sensitivity to cultural traditions.

Understanding Death Throughout the Life Span Death in childhood Children’s different perspective of death are punctuated with impulsivity may seem happy one day and sad the next do not “get over” the death of a parent, nor dwell on it may take certain explanations literally Fatally ill children typically fear abandonment  frequent and caring contact is more important than logic. Older children seek specific facts and become less anxious about death and dying. JOHAN ORDOÑEZ/AFP/GETTY IMAGESJOHAN ORDOÑEZ/AFP/GETTY IMAGES Sorrow All Around: When a 5-day-old baby died in Santa Rosa, Guatemala, the entire neighborhood mourned. Symbols and a procession help with grief: The coffin is white to indicate that the infant was without sin and will therefore be in heaven

Understanding Death Throughout the Life Span Adolescence and emerging adulthood Teenagers seem to have little fear of death Take risks, place a high value on appearance, and seek thrills May be their way of controlling anxiety Terror management theory (TMT) The idea that people adopt cultural values and moral principles in order to cope with their fear of death

Causes of Death for 15- to 24-Year-Olds, United States Typhoid Versus Driving into a Tree: In 1905, most young adults in the United States who died were victims of diseases, usually infectious ones like tuberculosis and typhoid. In 2012, 3 times more died violently (accidents, homicide, suicide) than of all diseases combined.

Understanding Death Throughout the Life Span Death in adulthood When adults become responsible for work and family, death is to be avoided or at least postponed. Many adults quit taking addictive drugs, start wearing seat belts, and adopt other precautions. Death anxiety usually increases from one’s teens to one’s 20s and then gradually decreases. Ages 25 to 60: Terminally ill adults worry about leaving something undone or leaving family members—especially children—alone.

Understanding Death Throughout the Life Span Death in late adulthood Death anxiety decreases and hope rises. One sign of mental health among older adults is acceptance of their own mortality and altruistic concern about those who will live on after them. Many older adults accept death and plan. Family becomes more important when death seems near. Acceptance of death does not mean that the elderly give up on living! Many older adults accept death (e.g., they write their wills, designate health care proxies, reconcile with estranged family members, plan their funeral).

A Toothache Worse Than Death? A cohort of young adults (average age 21) and old adults (average age 74) were divided into three groups. Those who wrote about dental pain are represented by the zero point on this graph. Compared with them, those older adults who thought about death were less punitive, but younger adults were more so. The difference in the ratings of the young and old was more pronounced if their thoughts were unconscious than if they were overt. A cohort of young adults (average age 21) and old adults (average age 74) were divided into three groups. One group wrote about their musings of their own death (giving them overt thoughts about dying), another did a puzzle with some words about death (giving them unconscious thoughts about death), and the third wrote about dental pain (they were the control group). Then they all judged how harshly people should be punished for various moral transgressions. Those who wrote about dental pain are represented by the zero point on this graph. Compared with them, those older adults who thought about death were less punitive, but younger adults were more so. The difference in the ratings of the young and old was more pronounced if their thoughts were unconscious than if they were overt.

Cultures, Epochs, and Death Near-death experience Episode in which a person comes close to dying but survives and reports having left his or her body and having moved toward a bright white light while feeling peacefulness and joy. Near-death experiences often include religious elements. Survivors often adopt a more spiritual, less materialistic view of life. To some, near-death experiences prove that there is a heaven, but scientists are more skeptical.

What cultural contrasts and underlying universals do you see? Praise Famous Men The funerals of two men, Chris Kelly (left) half of the Kriss Kross rap duo, and Paul Celluci (right), former governer of Massachusetts, show cultural contrasts and underlying universals. What cultural contrasts and underlying universals do you see?

Choices in Dying Good death A death that is peaceful, quick, and painless and that occurs after a long life, in the company of family and friends, and in familiar surroundings People in all religious and cultural contexts hope for a good death. Bad death Lacks these six characteristics and is dreaded, particularly by the elderly

Attending to the Needs of the Dying Kübler-Ross identified emotions experienced by dying people, which she divided into five stages. Denial (“I am not really dying.”) Anger (“I blame my doctors, or my family, or God for my death.”) Bargaining (“I will be good from now on if I can live.”) Depression (“I don’t care about anything; nothing matters anymore.”) Acceptance (“I accept my death as part of life.”)

Honest Conversation Stage model based on Maslow’s hierarchy of needs Physiological needs (freedom from pain) Safety (no abandonment) Love and acceptance (from close family and friends) Respect (from caregivers) Self-actualization (appreciating one’s past and present) Self-transcendence (acceptance of death) The last stage was later suggested by Maslow; other researchers have not found sequential stages in this area.

Better Ways to Die Most dying people want to spend time with loved ones and talk honestly with medical and religious professionals. Many thanologists find that the “stages” of death may not go in order and some may never occur. Hospital personnel need to respond to each dying person as an individual. Each person responds to death in their own way, some may not want the whole truth.

The Hospice CHRIS STOWERS/PANOS PICTURES Hospice An institution or program in which terminally ill patients receive palliative care Hospice caregivers provide skilled treatment to relieve pain and discomfort; they avoid measures to delay death and their focus is to make dying easier Two principles for hospice care: Each patient’s autonomy and decisions are respected. Family members and friends are counseled before the death, shown how to provide care, and helped after the death. JERRY WOLFORD/POLARIS/NEWSCOM Same Situation, Far Apart: As It Should Be- Dying individuals and their families benefit from physical touch but suffer from medical practices (gowns, tubes, isolation) that restrict movement and prevent contact. A good death is likely for these two patients— a man with his family in a Catholic hospice in Andhra Pradesh, India (top), and a husband with his wife in their renovated hotel/hospital room in North Carolina (bottom).

Not with Family Almost everyone prefers to die at home, yet most people die in an institution, often surrounded by medical personnel and high-tech equipment, not by the voices and touch of loved ones. The “other” category is even worse, as it includes most lethal accidents or homicides.

Barriers to Entering Hospice Care

Palliative Medicine Palliative care Double effect Care designed not to treat an illness but to provide physical and emotional comfort to the patient and support and guidance to his or her family Double effect An ethical situation in which an action (such as administering opiates) has both a positive effect (relieving a terminally ill person’s pain) and a negative effect (hastening death by suppressing respiration)

Better Ways to Die No longer does death necessarily occur when a vital organ stops. A wide array of treatments and interventions may be used to postpone or prevent death. Many life-support measures and medical interventions circumvent the diseases and organ failures that once caused death.

Better Ways to Die . Evidence of death American Academy of Neurology experts reviewed recent studies regarding end-of-life brain functioning. Little consensus and only two confirmed measures Dead people no longer breathe spontaneously and their eyes no longer respond to pain.

Dead or Not? Yes, No, and Maybe

Hastening or Postponing Death Passive euthanasia A situation in which a seriously ill person is allowed to die naturally, through the cessation of medical intervention DNR (do not resuscitate) A written order from a physician (sometimes initiated by a patient’s advance directive or by a health care proxy’s request) that no attempt should be made to revive a patient during cardiac or respiratory arrest

Hastening or Postponing Death Active euthanasia A situation in which someone takes action to bring about another person’s death, with the intention of ending that person’s suffering Legal under some circumstances in the Netherlands, Belgium, Luxembourg, and Switzerland, but it is illegal (yet rarely prosecuted) in most other nations Physician-assisted suicide A form of active euthanasia in which a doctor provides the means for someone to end his or her own life

When Physician-Assisted Suicide Is Legal Slippery slope Argument that a given action will start a chain of events that will culminate in an undesirable outcome Concern: Hastening death when terminally ill people request may cause a society to slide into killing sick people who are not ready to die—especially the old and the poor.

Acceptance of Active Euthanasia Among Austrian Medical Students Theory and Practice: Active euthanasia remains controversial, among doctors as well as lay people. As you see from this survey of young Austrian doctors, the medical profession overall is more accepting than it used to be. As you know, surveys do not always reflect behavior: Some physicians who do not accept active euthanasia in theory find themselves helping patients who want to die.

Advance Directives An individual’s instructions for end-of-life medical care, written before such care is needed. Living will A document that indicates what kinds of medical intervention an individual wants or does not want if he or she becomes incapable of expressing those wishes Health care proxy A person chosen by another person to make medical decisions if the second person becomes unable to do so

Affirmation of Life Normal grief Bereavement Grief Mourning The sense of loss following a death Grief The powerful sorrow that an individual feels at the death of another Mourning The ceremonies and behaviors that a religion or culture prescribes for people to employ in expressing their bereavement after a death

Disenfranchised grief Complicated Grief Absent grief A situation in which overly private people cut themselves off from the community and customs that allow and expect grief; can lead to social isolation Disenfranchised grief A situation in which certain people, although they are bereaved, are prevented from mourning publicly by cultural customs or social restrictions Incomplete grief A situation in which circumstances interfere with the process of grieving The grief process may be incomplete if mourning is cut short or if other people are distracted from their role in recovery. Grief that impedes a person’s future life

Mourning What is mourning? How mourning helps Public and ritualistic expression of bereavement, the ceremonies and behaviors that a religion or culture prescribes to honor the dead How mourning helps Shared mourning rituals provide familial support. Customs help people move from grief to reaffirmation. Public expression of grief helps to channel and contain private grief.

Mourning Placing blame and seeking meaning Common impulse after death for the survivors (e.g., for medical measures not taken, laws not enforced, unhealthy habits not changed) The bereaved sometimes blame the dead person, sometimes themselves, and sometimes distant others. Nations may blame one another for public tragedies. Blame is not necessarily rational. © MONIRUL ALAM/DRIK/MAJORITY WORLD/THE IMAGE WORKS Life in the Balance: The death of a young child is especially devastating to families. This girl is in a hospital in Bangladesh; she is suffering from cholera, which kills more than 2,000 children a year worldwide, most of them in areas with unsafe water supplies.

Placing Blame And Seeking Meaning Often starts with preserving memories (e.g., displaying photographs, telling anecdotes) Support groups offer help when friends are unlikely to understand (e.g., groups for parents of murdered children). Organizations devoted to causes such as fighting cancer and banning handguns often find supporters among people who have lost a loved one to that particular circumstance. Close family members may start a charity.

Diversity of Reactions Reactions to death are varied Other people need to be especially responsive to whatever needs a grieving person may have. Most bereaved people recover within a year A feeling of having an ongoing bond with the deceased is no longer thought to be pathological.