DEATH AND DYING Chapter 19 Copyright © 2011 Pearson Education, Inc. All rights reserved.

DYING AND DEATH ACROSS THE LIFESPAN

What is death? Although the question seems straightforward, defining the point at which life ceases and death occurs is surprisingly complex Functional death: is defined by an absence of heartbeat and breathing. Although this definition seems unambiguous, it is not completely straightforward. Brain death: occurs when all signs of brain activity, as measured by electrical brain waves, have ceased. Legal death: of death in most localities in the United States relies on the absence of brain functioning, although some laws still include a definition relating to the absence of respiration and heartbeat. Define: Functional death Brain death Legal definition The difficulty in establishing legal and medical definitions of death may reflect some of the changes in understanding and attitudes about death that occur over the course of people's lives.

Death across the Life Span: Causes and Reactions Despite its economic wealth, the United States has a relatively high infant mortality rate In 48 other countries infants died less often in the first year of birth than in the United States (World Fact Book, 2012) Infancy and childhood Miscarriage Still birth Sudden infant death Accidents #1 Homicides #4 Infancy and childhood: Although the rate has declined since the mid-1960s, the United States ranks behind 35 other countries in the proportion of infants who die during the first year of life. Parent reactions Death of a child produces the most profound sense of loss and grief. In fact, there is no worse death in the eyes of most parents, including the loss of a spouse or of one's own parents. Parents’ extreme reaction is partly based on the sense that the natural order of the world, in which children “should” outlive their parents, has somehow collapsed. Their reaction is often coupled with the feeling that it is their primary responsibility to protect their children from any harm, and they may feel that they have failed in this task when a child dies (Gilbert, 1997; Strength, 1999). Parents are almost never well equipped to deal with the death of a child, and they may obsessively ask themselves afterward, over and over, why the death occurred. Because the bond between children and parents is so strong, parents sometimes feel that a part of themselves has died as well. The stress is so profound that the loss of a child significantly increases the chances of admission to a hospital for a mental disorder.

Death across the Life Span: Causes and Reactions Childhood No concept of death until around the age of 5 Around the age of 5, better understanding of finality and irreversibility of death By about age 9, acceptance of universality and finality of death By middle childhood, understanding of some customs involved with death (e.g., funerals, cremation, and cemeteries) Childhood: Children themselves do not really begin to develop a concept of death until around the age of 5. Although they are well aware of death before that time, they are apt to think of it as a temporary state that involves a reduction in living, rather than a cessation. For children who believe this, death is not particularly fearsome; rather, it is something of a curiosity. If people merely tried hard enough—by administering medicine, providing food, or using magic—dead people might “return” (Lonetto, 1980). Cause of death Motor-vehicle accidents, child abuse and beatings, and pedestrian injuries are the leading causes of trauma-related deaths among preschool children According to reports from the National Pediatric Trauma Registry: Car accidents accounted for about 30 percent of the deaths, child abuse and beatings totaled 21 percent and pedestrian injuries -- caused, for instance, by a child running into a street and being struck by a car -- reached 18 percent.

Death across the Life Span: Causes and Reactions Adolescence View of death are often unrealistic Sense of invincibility Personal fable Imaginary audience Terminal Illness Denial Depression Define: Personal fable, a set of beliefs that causes them to feel unique and special—so special, in fact, that they may believe they are invulnerable and that the bad things that happen to other people won't happen to them. Most frequent cause of death among adolescents is accidents, most often involving motor vehicles. Other frequent causes include homicide, suicide, cancer, and AIDS.

Death across the Life Span: Causes and Reactions Young Adulthood Prime time of life Death seems unthinkable Creates feelings of anger and impatience Concerns Desire to develop intimate relationships and express sexuality Future planning Death at such a point in life seems close to unthinkable, its occurrence is particularly difficult. Because they are actively pursuing their goals for life, they are angry and impatient with any illness that threatens their future. Leading cause of death continues to be accidents, followed by suicide, homicide, AIDS, and cancer. By the end of early adulthood, however, disease becomes a more prevalent cause of death. Young adults who have a terminal illness face additional burdens. Should they marry, even though it is likely that the partner will soon end up widowed? Should a couple seek to conceive a child if the child is likely to be raised by only one parent? How soon should one's employer be told about a terminal illness, when it is clear that employers sometimes discriminate against unhealthy workers? None of these questions is easily answered.

Death across the Life Span: Causes and Reactions Middle Adulthood Life-threatening disease not surprising Fear of death often greatest Causes Heart attack or stroke Fears about death are often greater in middle adulthood than at any time previously—or even in later life. These fears may lead people to look at life in terms of the number of years they have remaining as opposed to their earlier orientation toward the number of years they have already lived. Most frequent cause of death in middle adulthood is heart attack or stroke. Although the unexpectedness of such a death does not allow for preparation, in some ways it is easier than a slow and painful death from a disease such as cancer.

Death across the Life Span: Causes and Reactions Late adulthood Realize death is imminent Face an increasing number of deaths in their environment Less anxious about dying Causes Cancer, stroke, and heart disease Terminal death a significant drop in performance in cognitive areas such as memory and reading may foreshadow death within the next few years. Terminal decline, a significant drop in performance in cognitive areas such as memory and reading may foreshadow death within the next few years.

Terminal Decline Suffering Burden to loved ones Decrease in value to society

Adding Years If the major causes of death were eliminated, the average seventy-year-old person would live another seven years. (Source: Hayward, Crimmins, & Saito, 1997.) Copyright © 2011 Pearson Education, Inc. All rights reserved.

Suicide in Later Life Rate for men climbs steadily during late adulthood No age group has a higher rate of suicide than white men over the age of 85 Severe depression Some form of dementia Loss of a spouse

Differing Conceptions of Death Has one person died a better death than the other? Depends on values related to cultural and subcultural teachings Differing views Death as punishment Death as judgment about contributions to society Death as start of redemption or start of eternal life Religious influence Christian and Jewish Sunni Muslim Druze Some societies view death as a punishment or as a judgment about one's contributions to the world. Others see death as redemption from an earthly life of travail. Some view death as the start of an eternal life, while others believe that there is no heaven or hell and that an earthly life is all there is. Christian and Jewish 10-year-olds tended to view death from a more “scientific” vantage point (in terms of the cessation of physical activity in the body) than Sunni Moslem and Druze children of the same age, who are more likely to see death in spiritual terms. For members of Native American tribes, death is seen as a continuation of life. Copyright © 2011 Pearson Education, Inc. All rights reserved.

CONFRONTING DEATH

Are there steps toward death? Kübler-Ross Developed a theory of death and dying Built on extensive interviews with people who were dying With input from those who cared for them

Kübler-Ross Theory Figure 19-2 Moving Toward the End of Life There are five steps toward death, according to Kübler-Ross (1975).

Evaluating Kübler-Ross’ Theory PROS One of first people to observe systematically how people approach their own deaths Increased public awareness and affected practices and policies related to dying CONS Largely limited to those who are aware that they are dying Less applicable to people who suffer from diseases in which the prognosis is uncertain Stage-like increments questioned Anxiety levels not included Some people report feelings of yearning rather than anger or depression Significant concerns about the accuracy of Kübler-Ross's account of how people react to impending death. In response to some of these concerns, other theorists have developed some alternative ideas.

Other Theorists Edwin Shneidman “Themes” in people's reactions to dying that occur—and recur—in any order throughout the dying process incredulity, a sense of unfairness, fear of pain or even general terror, and fantasies of being rescued Charles Corr People who are dying face a set of psychological tasks Tasks include minimizing physical stress, maintaining the richness of life, continuing or deepening their relationships with other people, and fostering hope, often through spiritual searching. Edwin Shneidman: phenomenological and hermeneutical perspective on suicide; acknowledged as the father of suicidology, draws on his unique combination of front-line experiences and extensive grasp of many diverse but relevant conceptual frameworks such as sociology, psychoanalysis, philosophy, and literature; his themes include such feelings and thoughts as (Leenaars & Shneidman, 1999). Charles Carr:

Should people be free to select the nature of their own death? Ask: Why? Why not?

Choosing the Nature of Death DNR Issues Differentiates of “extreme” and “extraordinary” measures from those that are simply routine Determines of individual's current quality of life and whether it will be improved or diminished by a particular medical intervention Determines of decision-maker role Define: DNR: DNR signifies that rather than administering any and every procedure that might possibly keep a patient alive, no extraordinary means are to be taken. For terminally ill patients, “DNR” may mean the difference between dying immediately or living additional days, months, or even years, kept alive only by the most extreme, invasive, and even painful medical procedures.

Doctors and Decisions Medical personnel are reluctant to suspend aggressive treatment. Physicians often claim to be unaware of patients’ wishes Physicians and other health care providers may be reluctant to act on DNR requests Trained to save patients To avoid legal liability issues Many became physicians in order to SAVE lives Medical personnel are reluctant to carry out the wishes of the terminally ill and their families to suspend aggressive treatment. Even when it is certain that a patient is going to die, and patients determine that they do not wish further treatment, physicians often claim to be unaware of their patients’ wishes. Physicians and other health care providers may be reluctant to act on DNR requests in part because they are trained to save patients, not permit them to die, and in part to avoid legal liability issues.

Living Wills To gain more control over decisions regarding the nature of their death, people are increasingly signing living wills Living will Health care proxy Durable power of attorney Living will: legal document that designates the medical treatments a person does or does not want if the person cannot express his or her wishes. Some people designate a specific person, called a health care proxy, to act as their representative in making health care decisions. Health care proxies are authorized either in living wills or in a legal document known as durable power of attorney.

Euthanasia and Assisted Suicide Passive Voluntary active Assisted suicide Kevorkian Issue of “informed consent” Very ill people make poor decisions Pain avoidance can lead to wishing for death Assisted suicide, in which a person provides the means for a terminally ill individual to commit suicide. Euthanasia: the practice of assisting terminally ill people to die more quickly. Popularly known as “mercy killing,” euthanasia can take a range of forms. Passive euthanasia involves removing respirators or other medical equipment that may be sustaining a patient's life, to allow them to die naturally. This happens when medical staff follow a DNR order, for example. In voluntary active euthanasia caregivers or medical staff act to end a person's life before death would normally occur, perhaps by administering a dose of pain medication that they know will be fatal. Assisted suicide, as we have seen, lies between passive and voluntary active euthanasia.

PROS CONS What are the arguments? SUPPORT—the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment—found that patients often outlive physicians’ predictions of when they will die. In fact, in some cases, patients have lived for years after being given no more than a 50 percent chance of living for 6 more months. Even if patients ask or sometimes beg health care providers to help them die, they may be suffering from a form of deep depression.

Pros Does the right belong solely to an individual, a person's physicians, his or her dependents, the government, or some deity? In the United States, it is assumed that all have the absolute right to create lives by bringing children into the world, some people argue that we should also have the absolute right to end our lives.

Cons Practice is morally wrong. Prematurely ending someone's life, no matter how willing that person may be, is the equivalent of murder. Physicians are often inaccurate in predicting how long a person's life will last. Emotional state of the patient may be unstable.

How Long Do “Terminal” Patients Really Live? According to the large SUPPORT study, a significant percentage of a group of 3,693 patients given no more than a 50 percent chance of living for six months survived well beyond that period. Why do you think this happened? (Source: Based on Lynn et al., 1997.)

Caring for the Terminally Ill Place of Death Home care Hospice care Hospital care In home care, dying people stay in their homes and receive treatment from their families and visiting medical staff. Many dying patients prefer home care, because they can spend their final days in a familiar environment, with people they love and a lifetime accumulation of treasures around them. Hospice care is care for the dying provided in institutions devoted to those who are terminally ill; hospices are designed to provide a warm, supportive environment for the dying. They do not focus on extending people's lives, but rather on making their final days pleasant and meaningful.

GRIEF AND BEREAVEMENT

Mourning and Funerals: Final Rites Costs Average funeral and burial costs $7,000 Survivors are susceptible to suggestions to “provide the best” for deceased Determined by social norms and customs Funeral is not only a public acknowledgment that an individual has died, but recognition of everyone's ultimate mortality and an acceptance of the cycle of life.

Cultural Differences in Grieving Western societal rituals (some variations) Body preparation Celebration of a religious rite Military customs Other customs – like Masons, or family, or personal wishes Prior to the funeral, body is prepared and dressed in special clothing. Celebration of a religious rite, the delivery of a eulogy, a procession of some sort, and some formal period, which relatives and friends visit the mourning family and pay their respects. Military funerals typically include the firing of weapons and a flag draped over the coffin.

Cultural Differences in Grieving Non-Western rituals different from Western Examples: Shave heads, let hair and beard grow Noisy celebration and silence High emotional display of emotion and no display of emotion

Feldman concludes that all funerals basically serve the same underlying function. They serve as a way to mark the endpoint for the life of the person who has died—and provide a formal forum for the feelings of the survivors, a place where they can come together and share their grief and comfort one another.

Bereavement and Grief: Adjusting to the Death of a Loved One

What is the difference? Bereavement is acknowledgment of the objective fact that one has experienced a death Grief is the emotional response to one's loss. Define: Bereavement

Grieving in the Western World 1st stage: grief typically entails shock, numbness, disbelief, or outright denial 2nd stage: people begin to confront the death and realize extent of their loss 3rd stage: people reach accommodation stage Most people emerge from the grieving process and live new lives, independent from the person who has died. Form new relationships, and some even find that coping with the death has helped them to grow as individuals. They become more self-reliant and more appreciative of life.

Death of Long-term Spouse Death of spouse Strength of relationship with can have effect on grieving process Almost always traumatic experience that is usually followed by intense grief and anguish Almost half of those who reported having satisfying marriages were able to get past their grief within six months of the death of their spouses People who enjoy close and happy marriages tend to have strong interpersonal skills on which to rely during their time of loss. They may be better equipped to call upon friends, family, and even a professional counselor if necessary to assist them through their grieving period. Surviving partners of strained marriages might feel more sadness over never having achieved a desired level of closeness, or they might regret not having an opportunity to resolve lingering conflicts, or they might feel guilty about not working harder to make their marriage better when they had the chance. Surviving spouses who enjoyed a close marriage are more likely to have settled lingering issues and to have talked through what would happen after either of them died; they therefore are more likely to feel secure in knowing what their departed would have wanted for them in widowhood. Finally, spouses who have a close and secure relationship may simply have a better opportunity to say their final goodbyes as one of the partners’ heath fails.

Close Marriages Almost half of those who reported having satisfying marriages were able to get past their grief within six months of the death of their spouses People who enjoy close and happy marriages tend to have strong interpersonal skills on which to rely during their time of loss. They may be better equipped to call upon friends, family, and even a professional counselor if necessary to assist them through their grieving period.

Close Marriages Surviving spouses who enjoyed a close marriage are more likely to have settled lingering issues and to have talked through what would happen after either of them died; they therefore are more likely to feel secure in knowing what their departed would have wanted for them in widowhood. Finally, spouses who have a close and secure relationship may simply have a better opportunity to say their final goodbyes as one of the partners’ heath fails.

Strained marriages Surviving partners of strained marriages might feel more sadness over never having achieved a desired level of closeness, or they might regret not having an opportunity to resolve lingering conflicts, or they might feel guilty about not working harder to make their marriage better when they had the chance. Slower recovery Increased possibility of permanent personality and relationship changes

When Grief Goes Awry No particular timetable for grieving For some people (but not all) grieving may take considerably longer than a year Only 15 to 30 percent of people show relatively deep depression following loss of loved one Those who show most intense distress immediately after a death are most apt to have adjustment difficulties and health problems later on

Consequences of Grief and Bereavement Negative Widowed people are particularly at risk of death More negative consequences if person is already insecure, anxious, or fearful, overly dependent, or lacking in social support Sudden death Positive Remarriage lowers risk of death for survivors, especially for widowers

Survivor Risks risk of death is as much as seven times higher than normal in the first year after the death of a spouse. At particular risk are men and younger women Those highly dependent on the person who died, and who therefore feel more vulnerable without them, are apt to suffer more after the death, as are those who spend a great deal of time reflecting on a loved one's death and their feelings of grief. Those lacking social support from family, friends, or a connection to some other group, religious or otherwise, are more likely to experience feelings of loneliness, and therefore are more at risk. Those unable to make sense of the death or find meaning in it show less overall adjustment.

How Helpful Is Grief Counseling? Effectiveness and the necessity of grief counseling services has recently been called into question Meta-analysis of more than 60 studies of therapeutic interventions for bereaved people concluded that these grief counseling did not help significantly more than the mere passage of time There are many variations on how people react to the death of a loved one, friend, or acquaintance Care should be taken about applying preconceptions about the course of grief as people cope with death

Helping a Child Cope with Grief Be honest Encourage expressions of grief Reassure children that they are not to blame for the death (But be careful NOT to introduce idea!) Understand children's grief may surface in unanticipated ways Children may respond to books for young persons about death