1. Endings: Death and Dying
Chapter 19
Robert S. Feldman

2. What is death? Functional death-absence of heartbeat and breathing
Brain death-all electrical brain waves have ceased
Legal death-in most cases, considered the absence of brain functioning
Define:
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 definition 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.
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.
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3. Death across the Life Span: Causes and Reactions
Infancy and childhood
Miscarriage grief due to the
Still birth ‘unnatural’ order
Sudden infant death of things
Accidents
Motor vehicles
Fires
Drowning
Homicides
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.
During childhood, the most frequent cause of death is accidents, most of them due to motor vehicle crashes, fires, and drowning.
However, a substantial number of children in the United States are victims of homicides, which have nearly tripled in number since 1960.
By the early 1990s, death by homicide had become the fourth leading cause of death for children between the ages of 1 and 9 (Finkelhor, 1997; Centers for Disease Control, 2004).
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.
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4. 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 (happens to everyone) 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.
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5. Death across the Life Span: Causes and Reactions
Adolescence
View of death are often unrealistic-”can’t happen to me”
Sense of invincibility Leading causes
Personal fable death-accidents
Imaginary audience homicide, suicide,
Terminal Illness cancer and AIDS
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.
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6. 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.
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7. Death in young adulthood
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.

8. Death across the Life Span: Causes and Reactions
Middle Adulthood
Life-threatening disease not surprising
Fear of death often greatest
Causes
Most frequents cause: 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.
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9. 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 decline-decrease in cognitive and reading functions indicates death may
be imminent in 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.
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10. 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
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11. 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
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12. Types of Depression in stage 4
Reactive depression-
Sadness at what has been lost
Job
Ability to function
Relationships
Preparatory depression-
Sadness over the lack of a future
Seeing children graduate/get married
Inability to spend the rest of their life with spouse

13. Kübler-Ross Theory
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14. 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
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.
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15. Choosing the Nature of Death
DNR
Issues
States that no ‘extraoridnary’ measures should be taken
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.
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17. 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
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.
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18. Living Wills 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.
See figure 19-3 on page 651 for an example of a living will…
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19. Euthanasia and Assisted Suicide
Passive-removing any medical equipment that
may keep the person alive. Allows patient to die naturally.
Voluntary active-when a caregiver or medical personnel decides to end a patient’s life before its time
Assisted suicide
Kevorkian
Oregon-Right to die law
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.
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20. 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.
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21. 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.
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22. What is the difference?
Bereavement-Acknowledging that one has experienced a loss
Grief-emotional response that follows
Everyone handles grief differently
3 stages to grief
Define:
Bereavement is acknowledgment of the objective fact that one has experienced a death, while grief is the emotional response to one’s loss.
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23. 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. Starting their life over again or beginning to adjust to the change.
Ultimately, most people are able to emerge from the grieving process and live new lives, independent from the person who has died. They 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.
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24. 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
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25. 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
Some studies find that the 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 who have been widowed.
Those who were 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. Bereaved people who lack 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. Finally, people who are unable to make sense of the death or find meaning in it (such as a new appreciation of life) show less overall adjustment.
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26. Becoming an Informed Consumer of Development
Helping a Child Cope with Grief
Be honest
Encourage expressions of grief
Reassure children that they are not to blame for the death
Understand that children’s grief may surface in unanticipated ways
Children may respond to books for young persons about death
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