1. ©2008 The McGraw-Hill Companies, Inc. All rights reserved. Chapter 21: Death and Grieving

2. ©2008 The McGraw-Hill Companies, Inc. All rights reserved. Defining Death and Life/Death Issues

3. ©2008 The McGraw-Hill Companies, Inc. All rights reserved. Brain death occurs when all electrical activity in the brain ceases. Higher portions of the brain die sooner than the lower portions. There is controversy over what medical experts should use as criteria for death. When does intelligence and personality end?

4. ©2008 The McGraw-Hill Companies, Inc. All rights reserved. Termination of medical treatments is controversial: –Dying patients in comas need living wills. –Physicians have concerns over malpractice suits in the absence of a living will or defining laws. –Euthanasia is often called mercy killing: Passive euthanasia—treatment is withheld. Active euthanasia—death deliberately induced. –Euthanasia evokes a variety of emotions among health-care professionals and family members.

5. ©2008 The McGraw-Hill Companies, Inc. All rights reserved. Active euthanasia was made famous by Dr. Jack Kevorkian in the U.S. as “assisted suicide.” Active euthanasia is a crime in most countries and in the U.S. Oregon has a law allowing doctors to prescribe enough medication for a person to end his/her own life, but the doctor cannot aid in any way, and it must be certified that the patient is terminally ill. Most physicians surveyed oppose active euthanasia. Better care is needed for dying persons, as death is often lonely, prolonged, and painful.

6. ©2008 The McGraw-Hill Companies, Inc. All rights reserved. The hospice movement: –Is a new kind of medical institution. –Began in London at the end of the 1960s. –Is dedicated to reducing pain and helping patients die with dignity, known as palliative care. –Makes every effort to include the dying patient’s family members. –Includes home-based programs today, supplemented with care for medical needs and staff.

7. ©2008 The McGraw-Hill Companies, Inc. All rights reserved. Death and Cultural Contexts

8. ©2008 The McGraw-Hill Companies, Inc. All rights reserved. Death has changed historically: –200 years ago, 1 out of every 2 children died before age 10, and one parent usually died before a child grew up. –Today, death occurs mostly among the elderly. –Life expectancy has increased from 47 years for a person born in 1900 to 77 years for a person born today –Over 80% of all U.S. deaths occur in hospitals.

9. ©2008 The McGraw-Hill Companies, Inc. All rights reserved. Culture affects how death is experienced: –Americans live as if they were immortal. –India and Africa have many young children and infants dying of malnutrition and disease. –Most societies throughout history have had religious or philosophical beliefs about death, and rituals surrounding it. –Some societies welcome death while others fear it. –In most societies, death is not an end to existence.

10. ©2008 The McGraw-Hill Companies, Inc. All rights reserved. A Developmental Perspective on Death

11. ©2008 The McGraw-Hill Companies, Inc. All rights reserved. Causes of death vary across the life span: –Prenatal death through miscarriage. –Death during birth or shortly afterwards. –Accidents or illness cause most childhood deaths. –Most adolescent deaths result from suicide, homicide, or motor vehicle accident. –Deaths among young adults are increasing due to AIDS. –Middle-age and older adult deaths usually –result from chronic diseases.

12. ©2008 The McGraw-Hill Companies, Inc. All rights reserved. Attitudes toward death vary at different points in the life span: –Young children use illogical reasoning to explain death, believing magic or treatment can return life. –Others claim separation anxiety is an indicator of a child’s awareness of separation and loss. –Those in middle and late childhood have more realistic perceptions of death—that it is a finality.

13. ©2008 The McGraw-Hill Companies, Inc. All rights reserved. Children and youth can reexperience grief as they age, and it may affect future relationships. Many strategies, including honesty, should be adopted when discussing death with children: –Extent of explanations will vary according to a child’s age. Most adolescents: –Avoid the subject of death until a loved one or close friend dies. –Describe death in abstract terms and have religious or philosophical views about it.

14. ©2008 The McGraw-Hill Companies, Inc. All rights reserved. Concerns about death increase as one ages: –Awareness usually intensifies in middle age. –Older adults are more often preoccupied by it and want to talk about it more. –One’s own death usually seems more appropriate in old age, possibly a welcomed event, and there is an increased sense of urgency to attend to unfinished business.

15. ©2008 The McGraw-Hill Companies, Inc. All rights reserved. Facing One’s Own Death

16. ©2008 The McGraw-Hill Companies, Inc. All rights reserved. Knowledge of death’s approach forces the dying person to change their attitudes and behaviors. Kübler-Ross identified 5 stages in dying: –Denial and isolation – “It can’t be!” –Anger – “Why me?” –Bargaining – “Just let me do this first!” –Depression – withdrawal, crying, and grieving. –Acceptance – a sense of peace comes. In facing their own deaths, some people struggle desperately until the end.

17. ©2008 The McGraw-Hill Companies, Inc. All rights reserved. The quality of one’s life is linked to how death will be approached: –Meaning and purpose bring peaceful acceptance. –An unfulfilled life brings distress and despair. Perceived control and denial may be adaptive strategies for remaining alert and cheerful. Denial insulates and allows one to avoid coping with intense feelings of anger and hurt. In the U.S., most people die in hospitals, and fewer die in nursing homes or a hospice.

18. ©2008 The McGraw-Hill Companies, Inc. All rights reserved. Coping with the Death of Someone Else

19. ©2008 The McGraw-Hill Companies, Inc. All rights reserved. No loss is greater than that of a loved one. Open communication with a dying person is very important because it gives them: –A chance to plan activities for the time left. –An opportunity to reminisce. –A chance to examine what is happening to them. Effective strategies for open communication vary and should be directed toward internal growth.

20. ©2008 The McGraw-Hill Companies, Inc. All rights reserved. Grief is not a simple emotional process and may not end anytime soon after the loss. A variety of cognitive factors influence the severity of the grief process. Good family communications and grief counselors can help grievers cope with feelings of separation and loss. Cross-culturally, people in some societies forget the deceased as quickly as possible, while in other societies they try to hold on.

21. ©2008 The McGraw-Hill Companies, Inc. All rights reserved. Grieving forces one to try and make sense of the world—reliving one or more events over and over. Finding meaning may enhance or ease the ability to cope. Researchers have identified 3 types of meaning-making coping: –Personal – cognitive acceptance is sought. –Family – members search for common factors. –Community – a broader level of loss.

22. ©2008 The McGraw-Hill Companies, Inc. All rights reserved. Women feel the loss of a life partner more than men because: –Widows outnumber widowers 5 to 1, because they live longer than men. –A widowed man is more likely to remarry. –Widows usually marry older men. Cross-culturally, many widows fall into poverty after the loss of a life partner. Impact on one’s physical and psychological health is linked to how long one grieves and remains widowed.

23. ©2008 The McGraw-Hill Companies, Inc. All rights reserved. Funerals are an important aspect of mourning and a source of closure in many cultures. Forms of mourning include: –Making some type of funeral arrangement. –Deciding on burial or cremation for the body. –Holding ceremonies after the funeral—in some cultures. –Being supported as a family by the community. –Dividing the mourning into time periods. –Designating one time frame for mourning.