Chapter 19: Death, Dying, and Bereavement

In This Chapter The Experience of DeathThe Meaning of Death Across the LifespanThe Process of DyingTheoretical Perspectives on GrievingThe Experience of Grieving

The Experience of Death Death Itself Characteristics  Clinical death  Brain death  Social death

The Experience of Death Where Death Occurs  Hospitals in the U.S. (45%)  Decedent’s home (25%)  Long-term Care (22%)  Hospice (14%)  Other (6%)

The Experience of Death Hospice Care Philosophy  Death viewed as normal  Families and the patient encouraged to prepare for death  Family are involved in patient’s care  Control of care is in the hands of the patient and family  Medical care is palliative rather than curative

Hospice Care Types of Hospice Care  Home-based programs  Hospital-based programs  Special hospice centers  Hospice

Hospice Hospital-based and Home-based Care Comparison Hospital-Based CareHome-Based Care Patient PainSame Length of SurvivalSame Patient Satisfaction with Care Same Family Satisfaction with Care HigherLower Family Sense of BurdenHigherLower Let’s take a minute to review some of these comparisons.

Dying, Death, and Bereavement Hospice Care Hospice Care Pros  Reduced cost of death  Less burden on central caregiver Cons  Increased family worry about pain management

Developmental Understanding of Death

The Meaning of Death for Adults Death as Loss: Age Age differences Young adults: Loss of opportunity to experience things; loss of family relationships Older adults: Loss of time to complete inner work

The Meaning of Death for Adults Death as Loss: Ethnic Differences Ethnic differences Mexican Americans: Increase time spent with family or loved ones White and African-Americans: Would not change their lifestyle See Table 19.2 for responses to hypothetical impending death

Stop and Think! At what age do you think people are most fearful of death? What prompted your answer?

Fear of Death  Middle-aged adults most fearful of death  Sense of unique invulnerability prevents intense fear of death in young adults  Older adults think and talk more about death than anyone else

Fear of Death Religious beliefs Religious beliefs and fear of death  Very religious adults less afraid of death  Those totally irreligious may also fear death less

Figure 19.1 Age, Ethnicity and Fear of Death

Fear of Death Personal Worth Fear of death reduced  Adults accomplish goals or believe they have become the person they set out to be  Belief that life has purpose or meaning How is this related to Erikson’s stage of integrity versus despair?

Your loved one is dying of a terminal illness. Would you use a hospice center? Why or why not? If you were told that you had a terminal disease and only 6 months to live, how would you want to spend your time until you died? On a scale of 1– 5, with 5 being high, how much do you fear death? Questions To Ponder

The Process of Dying Preparation for Death Kinds of preparations  Practical preparations  Deeper preparations  Older adults more likely to have made these arrangements

The Process of Dying Preparation for Death Final preparations  Unconscious changes just before death  Terminal drop for psychological health

Theoretical Perspectives on Dying Elisabeth Kubler-Ross’s Stages of Dying

Theoretical Perspectives on Dying Criticisms of Kubler-Ross’s Theory  Methodological problems  Cultural specificity  Stage concept unsupported

Theoretical Perspectives on Dying Alternate Views Two additional views Shneidman: Dying process has many “themes” Corr: Coping with death involves taking care of specific tasks

Theoretical Perspectives on Dying Responses to Impending Death Greer: Attitudes and behavioral choices can influence course of terminal disease Five groups/stages  Denial (positive avoidance)  Fighting spirit  Stoic acceptance  Helplessness/hopelessness  Anxious preoccupation

Theoretical Perspectives on Dying Responses to Impending Death Greer concluded that the message may be: “Those who struggle the most, fight the hardest, express their anger and hostility openly, and who find some sources of joy in their lives live longer.”

Theoretical Perspectives on Dying Psychoanalytic Theory  Traumatic death often followed by physical or mental problems  Grief therapy with children makes use of defense mechanisms (sublimation, identification)

Theoretical Perspectives on Grieving Freud: Death of a loved one is an emotional trauma  Ego tries to insulate itself from unpleasant emotions through defense mechanisms such as denial BUT  Defense mechanisms provide only temporary relief How do people grieve in healthy ways?

Theoretical Perspectives on Grieving Attachment Theory Bowlby  Intense grief likely to occur at loss of any attachment figure  Quality of attachment related to grief

Theoretical Perspectives on Grieving Attachment Theory Bowlby: Four stages of grief NumbnessYearningDisorganization and despairReorganization

Theoretical Perspectives on Grieving Attachment Theory Sanders five stages of grief comparable to Bowlby:  Shock  Awareness  Conservation/withdrawal  Healing  Renewal

Theoretical Perspectives on Grieving Attachment Theory Revisionist Views  Avoiding expressions of grief neither prolongs grief nor inevitably creates mental health problems  Grieving does not occur in fixed stages  Many themes present simultaneously but one or another may dominate at one point in time  Adults develop different patterns of grieving

Figure 19.2 Jacobs’s Model of Grieving

Theoretical Perspectives on Grieving Patterns of Grieving Wortman and Silver  Normal  Chronic  Delayed  Absent

Theoretical Perspectives on Grieving Dual-Process Model Alternates between: Confrontation Restoration

Theoretical Perspectives on Grieving The Experience of Grieving: Death Rituals Psychosocial functions of death rituals such as funerals  Help family and friends manage grief by giving a specific set of roles  Bring family members together in unique ways  Establish shared milestones for families

Theoretical Perspectives on Grieving The Process of Grieving Factors Associated with Grief: Age of the Bereaved  Children express feelings of grief like teens and adults  Teens often show prolonged grief responses

Theoretical Perspectives on Grieving Factors Associated with Grief Modes of Death and Grief  Caregiver widows may show depression.  Death with intrinsic meaning reduces grief.  Sudden and violent deaths evoke more intense grief.  Suicide produces unique responses in survivors.

Theoretical Perspectives on Grieving Widowhood and Effects of Grief  Immediate and long term effects on the immune system  Incidence of depression among widows and widowers rises substantially

Theoretical Perspectives on Grieving Pathological Grief  Depression-like symptoms lasting longer than 2 months  Grief lasting longer than 6 months can lead to long-term depression and physical ailments  Problems may continue for up to 2 years after death of loved one  BUT cultural practices may mimic pathological grief

Theoretical Perspectives on Grieving Sex Differences  Spouse death more negative for men than for women.  Risk of death higher in men immediately after a spouse’s death.  Widowers withdraw in multiple ways.  Alcohol use may influence depression.  Social relationships remain important for both sexes.

Theoretical Perspectives on Grieving Preventing Long-Term Problems  “Talk-it-out” approach to managing grief can help prevent grief-related depression.  Developing coherent personal narrative of events surrounding spouse’s death helps manage grief.  Participating in support groups helps.  Appropriate amount of time off from work to grieve is important.