1. Death, Dying, and Bereavement Chapter 19:

2. IN THIS CHAPTER The Experience of DeathThe Meaning of Death Across the LifespanThe Process of DyingTheoretical Perspectives on GrievingThe Experience of Grieving

3. LEARNING OBJECTIVES 19.1 What are the characteristics of clinical death, brain death, and social death? 19.2 How do hospice and hospital care differ with respect to their effects on terminally ill patients? 19.3 What are the characteristics of children’s and adolescents’ ideas about death? 19.4 How do young, middle-aged, and older adults think about death? 19.5 What factors are related to fear of death in adults? 19.6 How do adults prepare for death? 19.7 How did Ku ̈ bler-Ross explain the process of dying? 19.8 What are some other views of the process of dying? 19.9 How do people vary in the ways they adapt to impending death?

4. LEARNING OBJECTIVES (con’t) 19.10 How does Freud’s psychoanalytic theory view grief? 19.11 What are the theories of Bowlby and Sanders regarding grief? 19.12 What theories of grief have been proposed by critics of psychoanalytic and attachment theories? 19.13 How do funerals and ceremonies help survivors cope with grief? 19.14 What factors influence the grieving process? 19.15 How does grief affect the physical and mental health of widows and widowers?

5. THE EXPERIENCE OF DEATH Death Itself Characteristics Clinical death Brain death Social death

6. WHERE DEATH OCCURS IN THE UNITED STATES

7. THE EXPERIENCE OF DEATH Hospice Care Philosophy Death viewed as normal Families and the patient are encouraged to prepare for death. Family are involved in a patient’s care. Control of care is in the hands of the patient and family. Medical care is palliative rather than curative.

8. HOSPICE CARE Types of Hospice Care Home-based programs Hospital-based programs Special hospice centers Hospice

9. 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

10. DEVELOPMENTAL UNDERSTANDING OF DEATH Preschoolers: reversibleSchool-agers: permanent and universalAdolescents: inevitable; sometimes unrealistic Early adulthood: unique invulnerability; challenged by early death Middle and late adulthood: finality, inevitability, universality

11. COPYCAT SUICIDE AND THE INTERNET Teens’ access to the internet and skills to create online videos and websites have created a venue for creating celebrity status through committing suicide. Prosuicide forums and informational websites provide reliable methods for committing suicide. In many cases, teenaged suicide victims consult such sites prior to killing themselves. Intervention Training parents and teachers to recognize signs of depression and substance abuse More research is needed to help adults deal with the impact of social media as related to teen suicide.

12. Reflection 1.Do you agree with Mr. Jones’s decision to discourage students from discussing Brent’s death? Why or why not? 2.In your opinion, what steps should governments, school officials, and/or parents take to address the issue of dissemination of information about suicide methods to adolescents on the Internet?

13. THE MEANING OF DEATH FOR ADULTS Death as Loss: Age Age Differences Young adults: loss of opportunity to experience things; loss of family relationships; unique invulnerability Middle and late adults: loss of time to complete inner work; finality, inevitability, and universality

14. 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

15. STOP AND THINK! At what age do you think people are most fearful of death? What prompted your answer?

16. FEAR OF DEATH Middle-aged adults are most fearful of death. A sense of unique invulnerability prevents intense fear of death in young adults. Older adults think and talk more about death than anyone else.

17. FEAR OF DEATH Religious Beliefs Religious Beliefs and Fear of Death Very religious adults are less afraid of death. Those totally irreligious may also fear death less.

18. 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?

19. THE PROCESS OF DYING Preparation for Death Kinds of Preparations Practical preparations Deeper preparations Older adults are more likely to have made these arrangements.

20. SAYING GOODBYE Kellehear and his colleagues provided a view of the variety of ways in which the dying say goodbye. One-fifth planned no farewells. Three-fifths wanted to engage in farewells near the end of life to protect family and friends. One-fifth began farewells earlier and used many different strategies. Benefits of Farewells Farewells are a kind of gift; they balance the relationship state, and allow the dying person to disengage.

21. You Decide Decide which of these two statements you most agree with and think about how you would defend your position: 1.Neither a person who is ill nor her loved ones should ever give up on life. They should always be thinking in terms of how to help the sick person survive rather than focusing on saying goodbye. 2.Acknowledging the reality of approaching death is the best way to help a person who is ill and those who are close to her cope with the stress of losing a loved one.

22. THE PROCESS OF DYING Preparation for Death Final Preparations Unconscious changes just before death Terminal drop for psychological health

23. THEORETICAL PERSPECTIVES ON DYING Elisabeth Ku ̈ bler-Ross’s Stages of Dying DenialAngerBargainingDepressionAcceptance

24. STAGES OF DYING PROPOSED BY KU ̈ BLER-ROSS

25. THEORETICAL PERSPECTIVES ON DYING Criticisms of Ku ̈ bler-Ross’s Theory Methodological problems Cultural specificity Stage concept unsupported

26. THEORETICAL PERSPECTIVES ON DYING Alternate Views Two Additional Views Shneidman: the dying process has many “themes” Corr: coping with death involves taking care of specific tasks.

27. THEORETICAL PERSPECTIVES ON DYING Responses to Impending Death Greer: attitudes and behavioral choices can influence the course of terminal disease. Five Groups/Stages Denial (positive avoidance) Fighting spirit Stoic acceptance Helplessness/hopelessness Anxious preoccupation

28. 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.”

29. THEORETICAL PERSPECTIVES ON DYING Psychoanalytic Theory Traumatic death is often followed by physical or mental problems for the survivors. Grief therapy with children makes use of defense mechanisms (sublimation, identification).

30. THEORETICAL PERSPECTIVES ON GRIEVING Freud: death of a loved one is an emotional trauma. The 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?

31. THEORETICAL PERSPECTIVES ON GRIEVING Attachment Theory Bowlby Intense grief likely to occur at loss of any attachment figure Quality of attachment related to grief

32. THEORETICAL PERSPECTIVES ON GRIEVING Attachment Theory Bowlby: Four Stages of Grief NumbnessYearningDisorganization and despairReorganization

33. THEORETICAL PERSPECTIVES ON GRIEVING Attachment Theory Sanders’s Five Stages of Grief Comparable to Bowlby’s Shock Awareness Conservation/withdrawal Healing Renewal

34. 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.

35. THEORETICAL PERSPECTIVES ON GRIEVING Patterns of Grieving Wortman and Silver Normal Chronic Delayed Absent

36. THEORETICAL PERSPECTIVES ON GRIEVING Dual-Process Model Alternates between: Confrontation Restoration

37. 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.

38. 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.

39. 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.

40. 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 Declines in physical and mental health follow bereavement fairly consistently, but how long such effects last may be highly variable.

41. ETHNICITY AND THE WIDOWHOOD EFFECT Widowhood effect: the death of one spouse is soon followed by the death of the other. Varies considerably across ethnic groups in U.S. Higher risk among white widows and widowers Differential risk for various configurations of biracial and Hispanic couples Protective factor in African-American and Hispanic female culture

42. Critical Analysis 1.In Chapter 18, you learned that African-American and Hispanic American elders are more likely to share a household with relatives than their white peers are. In your view, how does the ethnic- group difference in living arrangements contribute to the findings on the widowhood effect? 2.You have also learned that African-American and Hispanic American men have shorter average life expectancies than white men do. How might this difference contribute to the absence of the widowhood effect among African-American and Hispanic American women?

43. THEORETICAL PERSPECTIVES ON GRIEVING Sex Differences Spouse death has more negative effects for men than for women. The risk of death is 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.

44. THEORETICAL PERSPECTIVES ON GRIEVING Complicated Grief Depression-like symptoms lasting longer than two months Grief lasting longer than six months can lead to long-term depression and physical ailments. Problems may continue for up to two years after death of the loved one—but cultural practices may mimic pathological grief.

45. THEORETICAL PERSPECTIVES ON GRIEVING Treatment of Complicated Grief “Talk-it-out” approach to managing grief can help prevent grief-related depression. Developing a coherent personal narrative of events surrounding a spouse’s death helps manage grief. Participating in support groups helps. Am appropriate amount of time off from work to grieve is important.