1. Chapter 19 Death, Dying, and Bereavement
Today, most people in industrialized nations die in hospitals.
For 20% of people, death is a gentle and relatively painless process. For the rest, it is not.
An adult brain starved of oxygen for 2 to 4 minutes or more is irreversibly damaged.
More people have long and drawn out deaths today than in the past because of medicaion and medical technology.

2. Phases of Dying Agonal phase Clinical death Mortality
Gasps and muscle spasms during first moments in which regular heartbeat disintegrates
Clinical death
Interval in which heartbeat, circulation, breathing, brain functioning stop, but resuscitation still possible
Mortality
Permanent death

3. Persistent vegetative state
Defining Death
Brain death
irreversible cessation of all activity in brain and brain stem
standard for death in most industrialized nations
Persistent vegetative state
cerebral cortex no longer registers electrical activity
brain stem remains active
The use of brain death as the definition of death may not be sufficient. For example, it does not tell us what to do in the case of a persistent vegetative state. Approximately 10,000 Americans are in a persistent vegetative state.

4. Death with Dignity
Integrity of person’s life is fostered by the quality of communication with and care for dying person:
assurance of support
compassionate care
esteem and respect
candidness about death’s certainty
information to make reasoned end-of-life choices
A century ago, most deaths occurred at home and people of all ages shared in the care of the dying. Also, because childhood and infant mortality rates were high, most people knew someone younger than themselves who had died. Today, most people (with the exception of those living in particularly violent neighborhoods) are insulated from the process of death. This makes people feel more distant from death and more likely to deny it.
Young children may believe that certain people (those like them or close to them) do not die. They also tend to think that dead things still have some capabilities of living things, such as thinking, feeling, and dreaming.
An understanding of death can help children accept it – and adults should not use cliches or misleading statements to help children understand.

5. Death Anxiety Cultural variations influenced by religious teachings
for Westerners, spirituality, meaning of life more important than religious commitment
Individual variations
women more anxious than men
low among adults with deep faith in higher being
reduced by sense of symbolic immortality
Women have more death anxiety.
Death anxiety can be reduced by:
Spirituality (a sense of life’s meaning; rather than religious commitment per se)
A well-developed personal philosophy of death
Faith in some form of higher force or being
Growing older (death anxiety declines with age)
Ego integrity
Symbolic immortality: sense that a person will continue to live on through her children, work, or personal influence

6. Age, Gender, and Death Anxiety
Figure Relationship of age and gender to death anxiety
Figure 19.1
(Adapted from Tomer, Eliason, & Smith, 2000.)

7. Kübler-Ross’s Theory Denial Anger Bargaining Depression Acceptance
Denial – denying the prospect of death
Anger – at having to die; may be directed at others
Bargaining – for extra time
Depression – about the loss of your own life
Acceptance – state of peace and quiet about upcoming death; detachment from all but the closest friends or relatives; may have a “flicker” of hope
© Lesley Rigg/Shutterstock 7

8. Evaluating Kübler-Ross
Stages are not a fixed sequence, not universal
Does not allow for context
May lead to caregiver insensitivity
Best seen as coping strategies
1969
A person may not pass through all of these stages and may not pass through them in this order.
Kubler-Ross suggests accepting the dying person’s denial
Although Ross suggests depression is a necessary step on the way to acceptance, person’s caring for the dying person should be careful to respond to the person’s wishes in order to decrease hopelessness and despair.
Although Kubler-Ross suggested her theory be interpreted flexibly, calling it a “stage” theory lead to a more strict interpretation. Some health care workers have tried to “force” people through the stages of the theory.
© Monkey Business Images/Shutterstock 8

9. Appropriate Death
Makes sense in terms of person’s pattern of living, values
Preserves or restores significant relationships
As free of suffering as possible
Also includes
achieving a sense of control
confronting and preparing for death
Appropriate death: one that makes sense in terms of the individual’s pattern of living and values, restores significant relationships, and is as free of suffering as possible.

10. Factors That Influence Thoughts About Dying
Nature and course of illness
Personality and coping style
Behavior of family members and health professionals
Spirituality, religion, culture
© Alexander Raths/Shutterstock
Factors that affect the way people cope with their own death:
Nature of the disease: course of the illness and its symptoms
Personality and coping style: poorly adjusted people are usually more distressed
Family members’ and health professionals behavior: Persons caring for the dying should be honest, have social support, low in death anxiety
Spirituality, religion, and culture: a strong sense of spirituality and/or faith reduces fear of death; cultural attitudes toward death may affect a person’s coping

11. Traditional Places of Death
Home:
most preferred option: intimacy, loving care
only about 25% die at home
need for adequate caregiver support
Hospital:
intensive care unit can be depersonalizing
comprehensive treatment programs optimal
Nursing home:
focus usually not on terminal care
improves greatly when combined with hospice care
Home: May be difficult because medical improvements allow older and sicker people to die at home. ½ of all AIDS patients die at home. Support for the caregiver is essential. Relationships may be conflict ridden and most homes lack adequate equipment to care for a dying person.
Hospital: 80% of deaths take place in the hospital. May depersonalize the death experience the patient and family.

12. Hospice Approach
Comprehensive program of support for dying and their families:
patient and family as unit of care
interdisciplinary team
palliative (comfort) care
home or homelike setting
bereavement services
Hospice is a philosophy, not a medical facility, so it can be applied in diverse ways and settings.
About ½ of all people dying of cancer and over 30% dying of AIDS choose hospice. Medicare and Medicaid benefits are available for hospice, and hospices also serve dying children and their families.
© James Steidl/Shutterstock 12

13. Forms of Euthanasia Passive withdrawal of treatment
advance medical directive: living will, durable power of attorney
Voluntary active
medical staff or others act to end life at patient’s request
Assisted suicide
medical staff provide means for patient to end own life
remains controversial
Involuntary active
medical staff end life without patient’s consent

14. International Public Opinion on Voluntary Active Euthanasia
Figure Public opinion favoring voluntary active euthanasia in five nations
Figure 19.2
(From Harris Interactive, 2011; Pew Research Center, 2006.)

15. Advance Medical Directives
Written statement of desired medical treatment in case of incurable illness
Living will: specifies desired treatments
Durable power of attorney:
authorizes another person to make health-care decisions on one’s behalf
more flexible than living will
can ensure partner’s role in decision making even in relationships not sanctioned by law

16. Assisted Suicide Doctor provides drugs for patient to use
Legal in few nations, tacitly accepted in many
Legal in only four U.S. states
Few choose this option
Highly controversial:
opposed by many, including AMA
some find option comforting

17. Grief Process Avoidance Confrontation Restoration
“emotional anesthesia”
Confrontation
most intense grief
Restoration
dual-process model of coping with loss
alternate between dealing with emotions and with life changes
Avoidance: shock followed by disbelief: may last hours to weeks. Includes feeling “numb.”
Confrontation: confronting the reality of the loss. Most intense experience of grief. May include a range of emotional response as well as absent-mindedness and depression.
Accommodation: the person starts to adapt to the loss and adjust to the world without the person. Forms an inner representation of the person rather than relying on physical presence.
© Cris Kelly/Shutterstock 17

18. Grieving Sudden or Prolonged Deaths
Sudden, unanticipated
Avoidance from shock and disbelief
Survivor may not understand reasons
Suicide especially hard to bear
Prolonged, expected
Anticipatory grieving: allows emotional preparation
Reasons for death usually known

19. Difficult Grief Situations
Parents losing a child
Children or adolescents losing a parent or sibling
Adults losing an intimate partner
Bereavement overload
© Giideon/Shutterstock 19

20. Bereavement Interventions
General support
sympathy, understanding
patient listening, “being there”
Interventions
support groups
help with reorganizing daily life
Children and adolescents
after violent death, prevent unnecessary reexposure
Difficult situations
sudden, violent, unexplainable, or ambiguous deaths
grief therapy, individual counseling

21. Resolving Grief Give yourself permission to feel loss.
Accept social support.
Be realistic about course of grieving.
Remember the deceased.
When ready, invest in new activities and relationships.
Master new tasks of daily living.

22. Death Education
Courses in death and dying offered at many educational levels
Lecture format: imparts knowledge but may increase discomfort
Experiential format:
role playing, discussions, guests, field trips
may reduce death anxiety

23. Goals of Death Education
Increase understanding of physical, psychological changes in dying
Help students learn to cope with death of loved ones
Prepare informed consumers of medical, funeral services
Promote understanding of social, ethical issues

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