1. Life-Span Development Thirteenth Edition
2/3 of deaths in the US (approx. 2million per year) occur among older adults, and most in hospitals.
Chapter 20: Death, Dying, and Grieving
©2011 The McGraw-Hill Companies, Inc. All rights reserved

2. The Death System and Cultural Contexts
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
Robert Kastenbaum (2009)

3. The Death System and Cultural Contexts
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

4. The Death System and Cultural Contexts
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

5. Defining Death and Life/Death Issues
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
Defining 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.

6. Defining Death and Life/Death Issues
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
The 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.”

7. Defining Death and Life/Death Issues
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/ 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.

8. Oregon 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 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
Can 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

9. Defining Death and Life/Death Issues
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

10. Defining Death and Life/Death Issues
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

11. Decisions Regarding Life, Death, and Health Care
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.
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

12. A Developmental Perspective On Death
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

13. A Developmental Perspective On Death
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
Infants 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.

14. A Developmental Perspective On Death
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
children 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.

15. A Developmental Perspective On Death
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
Older adults are more likely to have directly experienced death than younger adults.

16. Facing One’s Own Death
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).
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) .

17. Facing 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 grieving
Acceptance: a sense of peace comes
What 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 dying
A recent study of more than 100 patients with advanced congestive heart failure who were studied at two times six

18. Stages 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 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).

19. Facing One’s Own Death
Kübler-Ross’ Stages of Dying

20. Facing One’s Own Death 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
Remember 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.

21. Facing One’s Own Death 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
Most 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.

22. Coping With The Death Of Someone Else
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

23. Coping With The Death Of Someone Else
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.
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.

24. Coping With The Death Of Someone Else
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)
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

25. The Severity of Grief
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.
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.

26. Coping With The Death Of Someone Else
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
Restoration-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).

27. Coping With The Death Of Someone Else
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

28. Coping With The Death Of Someone Else
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
The 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.

29. Coping With The Death Of Someone Else
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
And 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

30. Coping With The Death Of Someone Else
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
In 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,

31. Coping With The Death Of Someone Else
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
In 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