Approaching Death Death and Dying

“Immortality” of youth “Immortality” of youth Denial of mortality Denial of mortality Anxiety Anxiety

Historical and Cultural Views ability to accept death ability to accept death specific meanings (stop breathing, heartbeat, brain death) specific meanings (stop breathing, heartbeat, brain death) individual variation individual variation cultural variation (spiritual, natural, welcome event) cultural variation (spiritual, natural, welcome event)

Western history: natural event Western history: natural event 20th Century: withdrawn from daily life experiences 20th Century: withdrawn from daily life experiences care of dying care of dying Disposition of deceased: dramaturgical (Fulton & Metress, 1995: language of funeral directors) Disposition of deceased: dramaturgical (Fulton & Metress, 1995: language of funeral directors) “interment” vs. burial “interment” vs. burial “casket” vs. coffin “casket” vs. coffin “remains,” “diseased,” “loved one” vs. corpse, dead body “remains,” “diseased,” “loved one” vs. corpse, dead body “lying in repose” vs. dead “lying in repose” vs. dead “denial” of death, “social”death: avoidance “denial” of death, “social”death: avoidance

Cultural denial of death? Cultural denial of death? Behaviours? Avoidance? Behaviours? Avoidance? Collectively? Collectively? Individually? Individually? Reasons? Reasons? Effects of avoidance? Effects of avoidance? Feelings about death? Regrets? Feelings about death? Regrets? A “good” death? A “good” death?

Research on Death and Dying Kubler-Ross (1970) Kubler-Ross (1970) Openness, disclosure Openness, disclosure thanatology: study of death thanatology: study of death five emotional stages five emotional stages Denial, anger, bargaining, depression, acceptance Denial, anger, bargaining, depression, acceptance

Inconsistencies in Stages appearance, reappearance of denial, anger, depression during dying process appearance, reappearance of denial, anger, depression during dying process age of dying person age of dying person young: separation from loved ones young: separation from loved ones adolescents: focus on quality of present life adolescents: focus on quality of present life effect of condition on appearance social relationships effect of condition on appearance social relationships

young adult: rage and depression young adult: rage and depression end of life at beginning end of life at beginning middle adulthood: concern about obligations, responsibilities middle adulthood: concern about obligations, responsibilities late adulthood: contextual late adulthood: contextual death of spouse death of spouse illness, pain, dependency illness, pain, dependency acceptance relatively easy acceptance relatively easy

Health Care Policy for the Dying Process Health Care Policy for the Dying Process “Medicalization” of death vs. “normative” part of life? “Medicalization” of death vs. “normative” part of life? Perspectives, definitions of death? Perspectives, definitions of death? Death anxiety? Death anxiety? Preparation for death? Preparation for death?

Hospice Care vs. “Medicalization” of Death “good death”: swift, comfortable, dignity, loved ones present “good death”: swift, comfortable, dignity, loved ones present more common prior to extreme medical intervention more common prior to extreme medical intervention alternative to hospital care alternative to hospital care

London, 1950s: first hospice London, 1950s: first hospice Provide medical care, no artificial life support systems to terminally ill Provide medical care, no artificial life support systems to terminally ill Allow visitors, free movement Allow visitors, free movement Cushion fear, loneliness of impending death Cushion fear, loneliness of impending death

Problems: Problems: Rapid growth: need for well-trained personnel Rapid growth: need for well-trained personnel Legal, ethical questions: premature death? Legal, ethical questions: premature death? Potential burn-out of professionals, volunteers (personal involvement, intimacy) Potential burn-out of professionals, volunteers (personal involvement, intimacy)

Living Will, Passive Euthanasia specify how much medical care in terminal illness specify how much medical care in terminal illness inaction (e.g., no respirator) that allows person to die in natural course of illness inaction (e.g., no respirator) that allows person to die in natural course of illness ethics: quality of life? ethics: quality of life?

The Right to Die: Assisted Suicide and Active Euthanasia providing means to person to end life providing means to person to end life intentionally terminating life of suffering person intentionally terminating life of suffering person Netherlands: legal euthanasia Netherlands: legal euthanasia North America: Jack Kevorkian North America: Jack Kevorkian assisted suicide? Value of life? assisted suicide? Value of life? legal restrictions? legal restrictions?

Netherlands Patient experiencing unbearable pain Patient experiencing unbearable pain Patient conscious Patient conscious Death request voluntary Death request voluntary Patient must have time to consider alternatives Patient must have time to consider alternatives No other reasonable solutions to problem No other reasonable solutions to problem Death cannot inflict unnecessary suffering on others Death cannot inflict unnecessary suffering on others Must be more than one person involved in euthanasia decision Must be more than one person involved in euthanasia decision Only doctor can euthanize the patient Only doctor can euthanize the patient

Death Anxiety (Conte, Weiner, & Plutchik, 1982) (Conte, Weiner, & Plutchik, 1982) Death Anxiety Questionnaire Death Anxiety Questionnaire fear of unknown fear of unknown fear of suffering fear of suffering fear of loneliness fear of loneliness fear of personal extinction fear of personal extinction

nursing home residents, seniors, university students nursing home residents, seniors, university students ages 30 to 80 years ages 30 to 80 years no differences in mean scores (M=8.5) no differences in mean scores (M=8.5) no correlation with sex, education no correlation with sex, education separate study: adolescents had higher scores than older participants separate study: adolescents had higher scores than older participants emotional stresses emotional stresses cognitive maturity (meaning of death) cognitive maturity (meaning of death)

Cicirelli (1999) higher death anxiety in: Cicirelli (1999) higher death anxiety in: Younger Younger Lower SES Lower SES Female Female White White External locus of control External locus of control Less religiousness Less religiousness

Quality of End of Life Singer et al. (1999): Canadian sample Singer et al. (1999): Canadian sample Receiving adequate pain and symptom management Receiving adequate pain and symptom management Avoiding inappropriate prolongation of dying Avoiding inappropriate prolongation of dying Achieving sense of control Achieving sense of control Relieving burden Relieving burden Strengthening relationships with loved ones Strengthening relationships with loved ones

Bereavement and Grief Mourning: expression of grief Mourning: expression of grief Prescribed rituals: funerals Prescribed rituals: funerals Auger (2000): 4 functions Auger (2000): 4 functions Provide supportive relationship for bereaved Provide supportive relationship for bereaved Reinforce reality of death Reinforce reality of death Acknowledge open expression of feeling of loss and grief Acknowledge open expression of feeling of loss and grief Mark a fitting conclusion to life of person Mark a fitting conclusion to life of person Social support Social support network of familial network of familial small memorial services small memorial services failure to express grief: depression failure to express grief: depression

Phases of Mourning (Parkes, 1972) Phases of Mourning (Parkes, 1972) shock shock longing longing depression, despair (anger) depression, despair (anger) recovery (perspective) recovery (perspective)

Current Perspective (Lund, 1996) stress with resiliency stress with resiliency adjustment related to self-esteem, coping skills adjustment related to self-esteem, coping skills diversity diversity between individuals: thoughts, feelings, behaviours between individuals: thoughts, feelings, behaviours within individuals: simultaneous negative (anger, loneliness) and positive (personal strength) feelings within individuals: simultaneous negative (anger, loneliness) and positive (personal strength) feelings

no stages: no stages: rapidly changing feelings rapidly changing feelings dealing with personal limits dealing with personal limits fatigue, loneliness fatigue, loneliness learning new skills learning new skills new relationships new relationships no specific time markers no specific time markers

Achieving Recovery cultural facilitation of mourning: cultural facilitation of mourning: meaningful rituals meaningful rituals emotional support: friends listening emotional support: friends listening practical help practical help lengthy process lengthy process waves of sorrow: anniversary reactions waves of sorrow: anniversary reactions healthy response healthy response

Bereavement overload elderly at risk elderly at risk several deaths in rapid succession several deaths in rapid succession unable to complete mourning process for one death before another occurs unable to complete mourning process for one death before another occurs

Anticipatory Grief Anticipatory Grief expected death expected death dying person, mourners share affection dying person, mourners share affection helps dull pain of loss helps dull pain of loss Sudden death (no anticipatory grieving) Sudden death (no anticipatory grieving) Most difficulty in coping Most difficulty in coping loss of young person vs. at end of long, full life loss of young person vs. at end of long, full life emotions: guilt, denial, anger, sorrow emotions: guilt, denial, anger, sorrow

Social/Cultural Supports for Grieving? Similarities, differences, roles? Similarities, differences, roles?

Finding Comfort social support: friends listening, sympathizing, not ignoring pain, complex emotions in recovery social support: friends listening, sympathizing, not ignoring pain, complex emotions in recovery recognize bereavement is lengthy process (months, years): sorrow, memory are integral parts of recovery recognize bereavement is lengthy process (months, years): sorrow, memory are integral parts of recovery over time: bereaved should become involved in other activities, but not be expected to forget loved one over time: bereaved should become involved in other activities, but not be expected to forget loved one successful recovery: deeper appreciation of growth, development of all human relationships successful recovery: deeper appreciation of growth, development of all human relationships

Adult Development from Adolescence to Old Age Multidimensional, multidirectional change, throughout lifespan Multidimensional, multidirectional change, throughout lifespan

Final Exam Final Exam December 12: 2 hours December 12: 2 hours Chapters 8, 10, 11, 12 (50 Multiple Choice), lecture material (5/7 short answer) Chapters 8, 10, 11, 12 (50 Multiple Choice), lecture material (5/7 short answer)

Successful Aging Survival in late adulthood Survival in late adulthood Quality of life, satisfaction Quality of life, satisfaction Transcend physical limitations Transcend physical limitations Mental health, optimal adaptation Mental health, optimal adaptation Positive outlook Positive outlook Self-understanding Self-understanding Components Components Absence of disease, disability Absence of disease, disability No risk factors No risk factors

Maintaining high cognitive and physical function Maintaining high cognitive and physical function Active and competent Active and competent Engagement with life Engagement with life Productive activity, involvement with other people Productive activity, involvement with other people

Not avoidance of aging: maintaining adaptability Not avoidance of aging: maintaining adaptability Consistent with reality of aging: Consistent with reality of aging: Successful aging is the norm Successful aging is the norm “paradox of well-being” (Mroczek & Kolarz, 1998) “paradox of well-being” (Mroczek & Kolarz, 1998) 32,000 US adults surveyed 32,000 US adults surveyed Assumed objective difficulties Assumed objective difficulties Generally fel good about selves and situation Generally fel good about selves and situation 30-40% over 65 report selves as “very happy” 30-40% over 65 report selves as “very happy”

Positive affect: highest for older Positive affect: highest for older reflects personality (extroverts) set point perspective - temperament sets boundaries for levels of well-being throughout life - extroverts: more successful dealings with others - positive interpretations of life events

Successful Aging Hardiness and thriving (Perls, 1995) Hardiness and thriving (Perls, 1995) Genetic determiners of “hardiness” in oldest old Genetic determiners of “hardiness” in oldest old Adaptive capacity (ability to overcome disease or injury) Adaptive capacity (ability to overcome disease or injury) Functional reserve: how much of organ required for adequate performance (determines ability to deal with disease) Functional reserve: how much of organ required for adequate performance (determines ability to deal with disease)

Survivability Beyond age 97, chances of dying at a given age lower than expected Beyond age 97, chances of dying at a given age lower than expected Mortality rate (#deaths/# in age group) Mortality rate (#deaths/# in age group) exceeds 1.0 if entire group dies in less than one year exceeds 1.0 if entire group dies in less than one year Indicates oldest members of our species tend to be healthier than traditional views of aging would predict Indicates oldest members of our species tend to be healthier than traditional views of aging would predict Additional support from medflies Additional support from medflies Chance of dying at any age peaks at 50 days Chance of dying at any age peaks at 50 days If survive to 100 days, chance of dying at any given If survive to 100 days, chance of dying at any given

More hardy More hardy Slower rate of progress of symptoms of disease than in less hardy Slower rate of progress of symptoms of disease than in less hardy Threshold for disease lowers more slowly Threshold for disease lowers more slowly

Symptoms of age-related disease (e.g., Alzheimers) appear later (b vs. a) Symptoms of age-related disease (e.g., Alzheimers) appear later (b vs. a) Morbidity, mortality, disability compressed into shorter period Morbidity, mortality, disability compressed into shorter period

Possible explanations for hardiness Longevity genes: increased resistance against oxygen radicals Longevity genes: increased resistance against oxygen radicals Slow rate of damage Slow rate of damage Low complement of deleterious genes Low complement of deleterious genes E.g., Apolipoprotien E (apo-E) related to risk of Alzheimer's E.g., Apolipoprotien E (apo-E) related to risk of Alzheimer's Gene for protein apo-E less prevalent in oldest-old survivors Gene for protein apo-E less prevalent in oldest-old survivors 18% of year-olds 18% of year-olds 25% of under-65 year-olds 25% of under-65 year-olds

Adaptive capacity (ability to cope with and overcome disease or injury) higher in more- hardy Adaptive capacity (ability to cope with and overcome disease or injury) higher in more- hardy Functional reserve (how much of an organ is required for its adequate performance) higher Functional reserve (how much of an organ is required for its adequate performance) higher

Autopsy studies of “healthy” oldest-old brains Autopsy studies of “healthy” oldest-old brains No outward signs of disease, but level of neurofibrillary tangles would indicate dementia in younger brain No outward signs of disease, but level of neurofibrillary tangles would indicate dementia in younger brain Excess reserve of brain function compensates for processes damaging the brain Excess reserve of brain function compensates for processes damaging the brain

Two Basic Principles of Normal Aging Variability of aging rates Variability of aging rates Longitudinal studies (e.g., Baltimore Study) Longitudinal studies (e.g., Baltimore Study) Aging rates vary remarkably (60 year olds like 40; some 40 year-olds like 60, physically) Aging rates vary remarkably (60 year olds like 40; some 40 year-olds like 60, physically) Differences in appearance mirrored on physiological tests Differences in appearance mirrored on physiological tests Variability increases as age increases Variability increases as age increases Individual aging rates vary across years, and across physical systems Individual aging rates vary across years, and across physical systems

Variability of Aging Patterns Variability of Aging Patterns Several aging paths: Several aging paths: Cross-sectional research Cross-sectional research Some functions decline in a regular way over time Some functions decline in a regular way over time Other functions are stable, unchanged or decline only in terminal phase of life Other functions are stable, unchanged or decline only in terminal phase of life

Physiological loss, but only when an age- related illness is experienced Physiological loss, but only when an age- related illness is experienced E.g., heart disease correlated with a decline in heart pumping capacity with age E.g., heart disease correlated with a decline in heart pumping capacity with age Without heart disease, pumping capacity as well at age 70 as at age 30 Without heart disease, pumping capacity as well at age 70 as at age 30

Terminal Loss Pattern Terminal Loss Pattern Loss in a normally stable function may be sign of impending death Loss in a normally stable function may be sign of impending death E.g., immune system: # of lymphocytes (white blood cells) stable normally stale E.g., immune system: # of lymphocytes (white blood cells) stable normally stale Decline occurred in minority of Baltimore Study sample Decline occurred in minority of Baltimore Study sample Reported good health; good physical exams Reported good health; good physical exams At next follow-up for study – subgroup more likely to have died At next follow-up for study – subgroup more likely to have died

Loss occurs, but body compensates for the change Loss occurs, but body compensates for the change E.g., brain: neural loss but robust individual cell growth (new dendrites, new connections) may help preserve thinking and memory E.g., brain: neural loss but robust individual cell growth (new dendrites, new connections) may help preserve thinking and memory Physical Aging: not only loss Physical Aging: not only loss Stability Stability Resiliency Resiliency Capacity for growth Capacity for growth