1. The Final Passage

2. Sociocultural Definitions of Death
Different cultures view death in diverse ways
Customs and expectations also differ in rituals of bereavement and mourning
Even within a culture there is diversity in the view of death, mourning, and bereavement

3. There Are at Least 10 Ways Death Can Be Viewed
Death as an image or object
Death as a statistic
Death as an event
Death as a boundary
Death as a state of being
Death as a thief of meaning
Death as an analogy
Death as fear and anxiety
Death as reward or punishment

4. Legal and Medical Definitions
The traditional definition of clinical death was a lack of heartbeat and respiration
Today, brain death is the most used definition:
No spontaneous movement to stimulation
No spontaneous respiration for 1 hour
Lack of response to pain
No eye movements, blinking, or pupil responses
No postural activity, swallowing, or yawning
No motor reflexes
A flat EEG for 10 minutes
No change in any of these in 24 hours

5. Legal and Medical Definitions (Cont)
All eight criteria must be met and other possible conditions ruled out
In most hospitals, the lack of brain activity must extend to the brainstem and cortex
Activity only in the brainstem is called a persistent vegetative state, from which the person does not recover

6. Ethical Issues
Bioethics is the study of the combination of human values and technological advances
Bioethics grew from the increasing concern for respect for individual freedom and the difficult task of defining morality in medical care

7. Euthanasia
Euthanasia is the practice of ending life for reasons of mercy
Extends from the advances that allow for life to be extended by extraordinary means, and the concern for quality of life and respect for the individual

8. Active Euthanasia
Active euthanasia is the deliberate ending of someone’s life
Moral and religious concerns are involved in the issue of active euthanasia
Physician-assisted suicide has become an increasingly controversial issue
Some states have passed laws specifically making physician-assisted suicide legal, others have banned it

9. Passive Euthanasia
Allowing a person to die by withholding available treatment is called passive euthanasia
A survey in England showed that caregivers agreed that dementia patients should not receive treatments when critically ill
Most cases of passive euthanasia end up in court which has asserted that without advance directives, nourishment cannot be stopped

10. Making Your Intentions Known
There are two ways to tell others of your choice about final decisions
A living will in which a person states their preferences and intentions in the event that they may be unable to make their intentions known
A durable power of attorney names an individual who will have the legal authority to make decisions and speak for the person

11. A durable power of attorney, like the one shown here, is a way to make you end-of-life wishes known to others.

12. A Life Course Approach to Dying
Young adults integrate feeling and emotions with their thinking about death, lessening their feelings of immortality
Middle-age adults think about their own death as they deal with the death of their parents
Older adults are less anxious about death because of achievement of ego integrity and because of declining joy of living

13. Dealing With One’s Own Death
Reactions to impending death can vary in its development, especially with different causes of terminal illness
Diseases such as cancer may have a terminal phase in which a patient may be able to predict and prepare for death
Some diseases that do not have a terminal phase may create a condition in which a person’s death could occur at any time

14. Kubler-Ross’ Theory
Elisabeth Kubler-Ross began working with terminally ill patients
During this time, terminally ill patients were not always told they were dying, and death was not generally a topic of discussion. Her research was controversial
Kubler-Ross began to study patients’ reactions to their terminal illness and found that most people experienced certain emotional states

15. Kubler-Ross’ Stages of Dying
Denial: Shock and disbelief
Anger: Hostility and resentment
Bargaining: Looking for a way out
Depression: No longer able to deny, patients experience sadness and loss
Acceptance: Acceptance of the inevitability of death with peace and detachment
Though not all people experience all stages in the same order, discussion of death helps to move toward acceptance

16. A Contextual Theory of Dying
Stage theories imply order to the transition toward acceptance that may not exist
Stage theories do not state what moves a person through the stages
Observations suggest that people vary greatly in the duration of a particular stage
There is no single correct way to die
Each person’s own view of their death and need for health care may impact their movement through the stages

17. Death Anxiety
Terror management theory asserts that the continuation of one’s life is the primary motive behind all behavior. Fear of dying is consistent with this motive
Research suggests that death anxiety includes pain, body malfunction, humiliation, rejection, etc. Each of these factors can be assessed in any of three levels: public, private, and unconscious

18. Death Anxiety (Cont)
Death anxiety may be lower in older adults due to ego integrity and a positive life review. Emotional problems are predictive of higher death anxiety

19. Learning to Deal with Death Anxiety
Adolescents engage in more risk-taking behavior which suggests less death anxiety
Reduction can be achieved by contemplating one’s own death by writing one’s own obituary, planning one’s own funeral, etc.
Death education strives to address death anxiety by presenting factual information about death and reducing sensitivity to the issues involved

20. Creating a Final Scenario
Discussions of the issues of management of the final phase of life and the after-death disposition of their body are called end-of-life issues
Hospitals and nursing homes teach about advance directives like durable power of attorney and living wills
Making one’s choices known and providing information about how one wants their life to end is called a final scenario

21. The Hospice Option
An alternative to going to a hospital or nursing home during a terminal illness is hospice care. This involves assisting dying people with pain management and a death with dignity
The emphasis of hospice is on quality of life
The primary goal of hospice is to make the person comfortable and peaceful, not to delay an inevitable death

22. The Hospice Option (Cont)
St. Christopher’s Hospice in England was founded by Dr. Cicely Saunders and is the model for modern hospices
When no treatment or cure is possible, hospice care is requested. The family and the patient is viewed as a unit
May be inpatient or outpatient
An emphasis is placed on patient dignity
Patients show less anxiety and depression

23. The Hospice Option (Cont)
Key questions about the possible use of hospice services:
Does the person know the truth about their condition?
What options are available for patient care?
What are the patients expectations?
How well do the people in the person’s social network communicate?
Are family members available to provide care?
Is a high-quality hospice care program available?

24. The Grieving Process
Bereavement is the state or condition caused by loss through death
Grief is the sorrow, hurt, anger, guilt, confusion, and other feelings that arise after suffering a loss
Mourning is the way in which we express our grief
Mourning rituals can be fairly standard across a culture. Grief varies greatly