© 2012 McGraw-Hill Companies, Inc. All rights reserved.McGraw-Hill/Irwin© 2012 McGraw-Hill Companies, Inc. All rights reserved. Health Psychology 8 th edition Shelley E. Taylor Chapter Twelve: Psychological Issues in Advancing and Terminal Illness

© 2012 McGraw-Hill Companies, Inc. All rights reserved.12-2 Death across the Life Span Death in infancy or childhood: - U.S. infant mortality rate is high deaths per 1,000 births - countries that have lower rates: - have national medical programs - provide free or low-cost maternal care - racial disparities in infant mortality rates exist in the U.S. due to inequities in access to health care resources

© 2012 McGraw-Hill Companies, Inc. All rights reserved.12-3 Death across the Life Span (cont.) Causes of death: - Sudden Infant Death Syndrome (SIDS): - causes are not entirely known - infant simply stops breathing - gentle death for child - enormous psychological toll for parents - sleeping position has been reliably related to SIDS

© 2012 McGraw-Hill Companies, Inc. All rights reserved.12-4 Death across the Life Span (cont.) Causes of death: - death between ages 1 to 15 years - #1 cause of death is accidents (40%) - #2 cause of death is cancer (especially leukemia) Children’s understanding of death: - young children (< 5 years) associate death with sleep, not as something final and irreversible - children 5-9 years do not understand biological death - at ages 9 or 10, death is seen as universal and inevitable

© 2012 McGraw-Hill Companies, Inc. All rights reserved.12-5 Death across the Life Span (cont.) Death in adolescence and young adulthood: - for those aged 15 to 24, death is due to: - #1 unintentional injury (car accidents) - #2 homicide - #3 suicide - #4 cancer Reactions to young adult death: - death of a young adult is considered tragic - young adults feel shock, outrage and an acute sense of injustice

© 2012 McGraw-Hill Companies, Inc. All rights reserved.12-6 Death across the Life Span (cont.) Death in middle age: - death becomes more common - people develop chronic illnesses that ultimately kill them Premature death: - death before the projected age of 77 - usually occurs due to heart attack or stroke - most people say they would prefer a sudden, painless, non-mutilating death

© 2012 McGraw-Hill Companies, Inc. All rights reserved.12-7 Death across the Life Span (cont.) Death in old age: - dying is not easy, but it may be easier in old age - initial preparations may have been made - some friends and relatives have died - may have come to terms with issues - typically die of degenerative diseases - psychosocial factors predict declines in health

© 2012 McGraw-Hill Companies, Inc. All rights reserved.12-8 Psychological Issues in Advancing Illness Continued treatment and advancing illness: - treatments may have debilitating side effects - patients find themselves repeated objects of surgical or chemical therapy Is there a right to die? - Do Not Resuscitate (DNR) order - receptivity of suicide and assisted suicide

© 2012 McGraw-Hill Companies, Inc. All rights reserved.12-9 Psychological Issues in Advancing Illness (cont.) Moral and legal issues: - euthanasia: - ending the life of a person with a painful terminal illness - (1994) Oregon passed law permitting physician-assisted dying - (1997) Supreme Court says that physician-assisted dying is not a constitutional right, but legislation is up to states - living will: – a request that extraordinary life-sustaining procedures not be used if person is unable to make this decision on his/her own

© 2012 McGraw-Hill Companies, Inc. All rights reserved Psychological Issues in Advancing Illness (cont.) Psychological and social issues related to dying: - changes in the patient’s self-concept: - difficult maintaining control of biological functions - mental regression, inability to concentrate - issues of social interaction: - fear that their condition will upset visitors - withdrawal may occur for multiple reasons: - fear of depressing others - fear of becoming an emotional burden

© 2012 McGraw-Hill Companies, Inc. All rights reserved Psychological Issues in Advancing Illness (cont.) Communication issues: - death is still a taboo subject in U.S. - many people feel it is proper to avoid the topic - medical staff, family and patient: - may believe the others don’t want to discuss death

© 2012 McGraw-Hill Companies, Inc. All rights reserved Psychological Issues in Advancing Illness (cont.) The issue of nontraditional treatment: -when health deteriorates and communication deteriorates: - patients may turn away from traditional care - patients may seek alternative remedies - life savings may be invested in hopes of a “miracle cure”

© 2012 McGraw-Hill Companies, Inc. All rights reserved Adjustment to Dying Kϋbler-Ross’s 5 stages of adjustment to death: - denial: - a mistake must have been made; test results were mixed up - anger: - Why me? Why not him? Or her? - bargaining: - a pact with God, good works for more time or for health - depression: - a time of “anticipatory grief” - acceptance: - tired, peaceful (not always pleasant), calm descends

© 2012 McGraw-Hill Companies, Inc. All rights reserved Adjustment to Dying (cont.) Differing evaluations of Kϋbler-Ross’s theory: - her work is invaluable - her work has not identified stages of dying: - there is not a predetermined order - some patients never go through a particular “stage” - her work does not fully acknowledge the importance of anxiety

© 2012 McGraw-Hill Companies, Inc. All rights reserved Psychological Management of the Terminally Ill Medical staff and the terminally ill patient: - the significance of hospital staff to the patient: - dying need help for simple things, such as brushing teeth or turning over - they assist with pain management - they are the patient’s source of realistic information - they are privy to a most personal and private act: dying

© 2012 McGraw-Hill Companies, Inc. All rights reserved Psychological Management of the Terminally Ill (cont.) Risks of terminal care for staff: - emotionally and physically straining for hospital staff - they provide palliative care, care designed to make the patient comfortable, rather than curative care, care designed to cure the patient’s disease

© 2012 McGraw-Hill Companies, Inc. All rights reserved Psychological Management of the Terminally Ill (cont.) Achieving an appropriate death: - Avery Weisman’s goals for the staff: - informed consent - safe conduct - significant survival - anticipatory grief - timely and appropriate death

© 2012 McGraw-Hill Companies, Inc. All rights reserved Psychological Management of the Terminally Ill (cont.) Individual counseling with the terminally ill: - therapy for dying patients is becoming an increasingly available and utilized option - thanatologists, those who study death and dying, suggest behavioral and cognitive-behavioral therapies - clinical thanatology involves symbolic immortality

© 2012 McGraw-Hill Companies, Inc. All rights reserved Psychological Management of the Terminally Ill (cont.) Family therapy with the terminally ill: - family and patient may have different ways of adjusting to the illness The management of terminal illness in children: - most stressful of all terminal care - hardest to accept and psychologically painful - family may need counseling as well

© 2012 McGraw-Hill Companies, Inc. All rights reserved Alternatives to Hospital Care for the Terminally Ill Hospice care: - designed to provide palliative care and emotional support to dying patients and their families - may be provided in the home, but commonly provided in free-standing or hospital-affiliated units called hospices - oriented toward improving a patient’s social support system

© 2012 McGraw-Hill Companies, Inc. All rights reserved Alternatives to Hospital Care for the Terminally Ill (cont.) Home care: - care for dying patients in the home - choice of care for many terminally ill patients - psychological factors are legitimate reasons for home care - very stressful for family members

© 2012 McGraw-Hill Companies, Inc. All rights reserved Problems of Survivors The adult survivor: - little to do but grieve - grief: – psychological response to bereavement - feeling of hollowness - preoccupation with image of deceased person - expressions of hostility towards others - guilt over death - most widows and widowers are resilient to their loss

© 2012 McGraw-Hill Companies, Inc. All rights reserved Problems of Survivors The child survivor: - may expect the dead person to return - may believe a parent left because the child was “bad” - may feel “responsible” for a sibling’s death

© 2012 McGraw-Hill Companies, Inc. All rights reserved Problems of Survivors Death education: - courses on dying, which may include volunteer work with dying patients, have been developed for college students - provides realistic expectations about what modern medicine can achieve and the kind of care the dying wants and needs - Tuesdays with Morrie was a best seller