1. © 2009 Allyn & Bacon Publishers 19 Death, Dying, and Bereavement This multimedia product and its contents are protected under copyright law. The following are prohibited by law: any public performance or display, including transmission of any image over a network; preparation of any derivative work, including the extraction, in whole or part, of any images; any rental, lease, or lending of the program.

2. © 2009 Allyn & Bacon Publishers The Experience of Death Death Itself Clinical death: The few minutes after the heart stops pumping, breathing stops, no evidence of brain activity but resuscitation still possible Brain death: The person no longer has reflexes or any response to vigorous external stimuli; may still be able to breathe and survive for some time Social death: Decedent treated like a corpse by others

3. © 2009 Allyn & Bacon Publishers Where Death Occurs Hospitals in the U.S. –Once the majority of deaths –Now slightly under half of deaths Decedent’s home –Currently 24% of deaths Nursing home –Currently 22% of deaths –Among old old, death in nursing home common

4. © 2009 Allyn & Bacon Publishers Hospice Care Alternative form terminal care Writings of Elizabeth Kubler-Ross emphasized a “good death” and “death with dignity” Patient and family have more control over the process More likely to have the death at home but –Can also occur in a homelike setting

5. © 2009 Allyn & Bacon Publishers Hospice Care Philosophy Death viewed as normal Families and the patient encouraged to prepare for death Family should be involved in patient’s care Control of care should be in the hands of the patient and family Medical care should be palliative rather than curative –Control pain and maximize comfort

6. © 2009 Allyn & Bacon Publishers Types of Hospice Care Home-based programs –One family caregiver – usually spouse – provides constant care for dying person, supported by specially trained nurses Special hospice centers –Small number of patients in last stages of terminal illness cared for in homelike settings Hospital-based programs –Provide palliative care and utilize daily family involvement in the patient’s care

7. © 2009 Allyn & Bacon Publishers Hospice Care Hospital-based and home-based hospice care provide similar experiences: No differences reported in patients’ pain, length of survival, or satisfaction with care Family members most satisfied with hospital- based hospice care Home-based care produced a greater sense of burden for caregivers

8. © 2009 Allyn & Bacon Publishers Hospice Care Economic costs of death are reduced by hospice care Home-based care tremendous burden on the central caregiver, often the spouse Patients and family worry more about pain management in hospice care than in hospital care

9. © 2009 Allyn & Bacon Publishers The Meaning of Death across the Lifespan Children’s and Adolescents’ Understanding of Death Preschool aged children do not understand inevitable, universal and irreversible nature of death Believe some lucky people can avoid death, for example, by magic Teaching young children about biological life can help them understand death Personal life experiences bring death home to both children and adolescents

10. © 2009 Allyn & Bacon Publishers Children’s and Adolescents’ Understanding of Death School-aged children –Understand permanence and universality of death Adolescents –Understand death is inevitable –Unrealistic beliefs about personal death contribute to adolescent suicide Sometimes even believe that death is a pleasurable experience

11. © 2009 Allyn & Bacon Publishers The Meaning of Death for Adults Early adulthood Unique invulnerability – believe bad things, including death, happen to others but not to self Believe they possess unique characteristics protecting them from death –Show increased fear of death following open discussion of the process of dying –Sudden loss of a loved one often shakes young adult ideas about death and invulnerability –So do early deaths, such as Princess Diana’s

12. © 2009 Allyn & Bacon Publishers The Meaning of Death for Adults Middle and Late Adulthood Death changes roles and relationships of everyone else in the family One’s view of time may be shaped by death Middle-aged and older adults preoccupied with the past are more often fearful and anxious about death

13. © 2009 Allyn & Bacon Publishers The Meaning of Death for Adults Death as loss Young adults worry about loss of opportunity to experience things and about loss of family relationships Older adults worry more about the loss of time to complete inner work Mexican Americans would increase time spent with family or loved ones White and African-Americans most likely to say would not change their lifestyle

14. © 2009 Allyn & Bacon Publishers Fear of Death Middle-aged adults most fearful of death Sense of unique invulnerability prevents intense fear of death in young adults Older adults think and talk more about death than anyone else –Leads to less fear and anxiety –May fear a period of end-of-life uncertainty more than death itself

15. © 2009 Allyn & Bacon Publishers Fear of Death Religious beliefs Very religious adults less afraid of death –View death as a transition from one life to another –Most Americans believe in an afterlife –Religion provides adults with death stories that help them cope with their own deaths Those totally irreligious may also fear death less

16. © 2009 Allyn & Bacon Publishers Figure 19.1 Age, Ethnicity and Fear of Death

17. © 2009 Allyn & Bacon Publishers Fear of Death Personal Worth Adults who have accomplished goals or believe they have become the person they set out to be have less fear of death Belief that life has purpose or meaning reduces fear of death Supports Erikson’s theory of ego integrity versus despair stage at end of life

18. © 2009 Allyn & Bacon Publishers Questions to Ponder Your loved one is dying of a terminal illness. Would you use a hospice center? Why or why not? If you were told that you had a terminal disease and only 6 months to live, how would you want to spend your time until you died? On a scale of 1– 5, with 5 being high, how much do you fear death?

19. © 2009 Allyn & Bacon Publishers Preparation for Death Practical preparations –Purchasing life insurance –Making a will –Directives regarding end-of-life care – living will Direct health care professionals about wishes for feeding tubes, or invasive measures to prolong life –Advance funeral planning Older adults more likely to have made these arrangements

20. © 2009 Allyn & Bacon Publishers Preparation for Death Deeper preparation Some process of reminiscence Unconscious changes just before death – terminal drop for psychological health –Drop in memory and learning –Individuals become less emotional, introspective, and aggressive; more conventional, dependent and warm

21. © 2009 Allyn & Bacon Publishers The Process of Dying Elisabeth Kubler-Ross’s Stages of Dying Denial Anger Bargaining Depression Acceptance

22. © 2009 Allyn & Bacon Publishers The Process of Dying: Criticisms Methodological problems –Kubler-Ross only interviewed 200 cancer patients nor did she explain her sample Cultural specificity –Cross-cultural studies suggest diversity in beliefs about what is a “good death” The stage concept –Not all dying patients exhibit all five emotions, and seldom in a specific order –Only depression common among Western patients

23. © 2009 Allyn & Bacon Publishers Alternate Views Shneidman: thanatologist (scientific studies of death) –Dying process has many “themes.” Terror, uncertainty, rescue fantasies, incredulity, fear of pain and many more Corr –Coping with death involves taking care of specific tasks, e.g., maximizing psychological security –For health professionals, thinking in terms of helping the patient perform tasks is more helpful than themes.

24. © 2009 Allyn & Bacon Publishers Responses to Impending Death Attitudes and behavioral choices can influence the course of a terminal disease Steven Greer –62 women with breast cancer –Identified five groups Denial (positive avoidance) Fighting spirit Stoic acceptance Helplessness/hopelessness Anxious preoccupation

25. © 2009 Allyn & Bacon Publishers Responses to Impending Death Steven Greer 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 Difficult patients who question and challenge those around them last longer Optimism may also help survival Social support important This may be appropriate for cancer-like illnesses, but not others, such as heart disease

26. © 2009 Allyn & Bacon Publishers Theoretical Perspectives on Grieving Freud: Death of a loved one is an emotional trauma Ego tries to insulate itself from unpleasant emotions through defense mechanisms such as denial BUT Defense mechanisms provide only temporary relief To stay healthy, people must eventually examine their emotions directly This approach urges emotional expression and “working through” grief

27. © 2009 Allyn & Bacon Publishers Psychoanalytic Theory More traumatic death hypothesized to be more often followed by physical or mental problems including post-traumatic stress disorder Grief therapy with children makes use of defense mechanisms –Sublimation – expressing feelings through art –Identification – watch popular films to discuss young characters’ feelings and compare characters’ feelings with their own

28. © 2009 Allyn & Bacon Publishers Attachment Theory Bowlby Intense grief likely to occur at the loss of any person to whom one is attached Quality of attachment related to grief Four stages of grief –Numbness –Yearning –Disorganization and despair –Reorganization

29. © 2009 Allyn & Bacon Publishers Attachment Theory Sanders Five stages of grief somewhat comparable to Bowlby: Shock Awareness Conservation/withdrawal Healing Renewal

30. © 2009 Allyn & Bacon Publishers Alternate Perspectives Revisionist Views Research suggests: 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 Compromise model: themes have a trajectory (Jacobs, Figure 19.2)

31. © 2009 Allyn & Bacon Publishers Figure 19.2 Jacob’s Model of Grieving

32. © 2009 Allyn & Bacon Publishers Patterns of Grieving: Wortman and Silver Normal –Person feels great distress immediately following the loss with relatively rapid recovery Chronic –Distress continues at high level for years Delayed –Person feels little distress first few months but high distress months or years later (least common) Absent –Person feels no notable distress either immediately or at later time (quite common)

33. © 2009 Allyn & Bacon Publishers Dual-Process Model Alternate: Confrontation –Confronting loss and grieving with: Restoration –Focus on moving forward in life

34. © 2009 Allyn & Bacon Publishers The Experience of Grieving Psychosocial functions of death rituals such as funerals Help family and friends manage grief by giving a specific set of roles to play –Expected and prohibited behaviors –Role content differs markedly from culture to culture Bring family members together like no other occasion –Inspire shared reminiscences and renew family relationships –Can strengthen family ties, and clarify new roles Funerals establish shared milestones for families –Ceremony and ritual help survivors understand meaning of death –Place death in philosophical or religious context

35. © 2009 Allyn & Bacon Publishers The Process of Grieving : Factors Associated with Grief: Age of Bereaved Children express feelings of grief like teens and adults –Sadness, crying, loss of appetite, age-appropriate anger –Resolve their grief within the first year after death Teens often show prolonged grief responses –More likely to grieve for celebrities –More likely to idealize peers’ suicides –Counter-factual thinking about their ability to have prevented the death

36. © 2009 Allyn & Bacon Publishers Factors Associated with Grief Modes of Death Widows who have cared for spouses during illness less often show depression after death. Death that has intrinsic meaning reduces grief Sudden and violent deaths evoke more intense grief –Random crime –Politically motivated mass murder (such as 9-1-1) Suicide produces unique responses in survivors –Family and close friends report feelings of rejection and anger –Many feel that they should have prevented the suicide –Bereaved less likely to discuss the loss

37. © 2009 Allyn & Bacon Publishers Widowhood and Effects of Grief Immediate and long term effects on the immune system –Immune system responses suppressed initially after death but returned to normal a year later –Ethnicity may affect physical responses to grief Incidence of depression among widows and widowers rises substantially –Length of depression can be highly variable –Mental health history, lack of social support, quality of relationship with spouse, and economic changes influence length and quality of depression

38. © 2009 Allyn & Bacon Publishers Pathological Grief Depression-like symptoms following death of loved one lasting longer than 2 months Grief lasting longer than 6 months can lead to long- term depression and physical ailments such as cancer and heart disease Problems may continue for up to 2 years after death of loved one BUT cultural practices may dictate how long grief should last—do not confuse with pathological grief

39. © 2009 Allyn & Bacon Publishers Sex Differences Death of a spouse more negative for men than for women Risk of death from natural causes or suicide higher in men immediately after death of a spouse Widowers withdraw from social activities Widowers find it difficult to return to earlier levels of emotional functioning Alcohol use may play a role in higher levels of depression Social relationships important for both sexes of survivors

40. © 2009 Allyn & Bacon Publishers Preventing Long-Term Problems “Talk-it-out” approach to managing grief can help prevent grief-related depression Developing coherent personal narrative of events surrounding spouse’s death helps manage grief Participating in support groups helps Appropriate amount of time off from work to grieve is important