1. Death and the Dying Process  Types of Death  Basic Statistics  Social Aspects of Death  Do Not Resuscitate  Euthanasia

2. Types of Death Thanatologists: People who study death and dying. Two types of death: Functional Death: Absence of a heart-beat and breathing. Brain Death: Diagnosis of death based on the cessation of all signs of brain activity. Measured by electrical brain waves.

3. Basic Statistics America has a very high infant mortality rate: Ranks behind 35 other countries Why is this? Accurate statistics on our part More drug use than almost any other country In early adulthood the leading cause of death is accidents This is followed by Suicide, Homicide, AIDS, and Cancer

5. Basic Statistics 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

6. Basic Statistics 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.

7. Social Aspects of Death 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.

9. Social Aspects of Death 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.

10. Social Aspects of Death Elisabeth Kubler-Ross Made many observations and interviews with people who were dying and with those who cared for them. Based on her observations, she suggested that people pass through five basic steps as they move toward death.

11. Social Aspects of Death 1. Denial: People resist the idea that they are going to die. They may argue that their test results have been mixed up, that an X-ray has been read incorrectly, or that their physician does not know what he or she is talking about. A patient can flatly reject the diagnosis Sometimes memories of weeks in the hospital are forgotten.

12. Social Aspects of Death 2. Anger: A dying person may be angry at everyone They may be angry at people who are in good health, their spouses and other family, those who are caring for them, and their children. They can lash out at others and get loud. Many become very angry with God. Questions Asked: Why are the bad people not dieing and why am I? This can lead to the next stage.

13. Social Aspects of Death 3. Bargaining: Dying people try to negotiate their way out of death. They may declare that they will dedicate their lives to the poor if God saves them. Maybe if they can live just long enough to see a son married, or a child born, they will willingly accept death. “If you are good, you will be rewarded” The reward for being “good” is to “live”

14. Social Aspects of Death 4. Depression: Realizing that the issue is set in stone and that bargaining will not stop this, they become overwhelmed with a huge sense of loss. Reactive depression: Feelings of sadness are based on events that have already occurred Loss of dignity that may accompany medical procedures End of a job Knowledge that one will never return from the hospital. Preparatory depression: Sadness over future losses. Death will bring an end to their relationships with others and that they will never see future generations.

15. Social Aspects of Death 5. Acceptance: Final stage of dying is acceptance. Once acceptance has arrived they are fully aware that death is impending. They will have virtually no feelings, positive or negative, about the present or future. In essence, they have made peace with themselves and may wish to be left alone.

16. Social Aspects of Death 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

17. Social Aspects of Death 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 (80%), and fewer die in nursing homes or a hospice.

18. Social Aspects of Death Women feel the loss of a life partner more than men because They live longer than men A widowed man is more likely to remarry They 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

19. Do Not Resuscitate Written order from a doctor that resuscitation should not be attempted if a person suffers cardiac or respiratory arrest. Sometimes known as a no-code order. Such an order may be instituted on the basis of an advance directive from a person. Or from someone entitled to make decisions on their behalf, such as a health care proxy. In some jurisdictions, such orders can also be instituted on the basis of a physician's own initiative, usually when resuscitation would not alter the ultimate outcome of a disease. DNR is more commonly done when a person who has an inevitably fatal illness wishes to have a more natural death without painful or invasive medical procedures. DNR order came into being in the U.S. in the 1960s when defibrillation allowed the reversal of cardiac arrest, but this may prolong the life of the patient for only a short time.

20. Euthanasia Defined: The practice of assisting people who are terminally ill to die more quickly. There are three types of euthanasia: 1. Passive Euthanasia Withholding common treatments (Antibiotics, drugs, or surgery) or giving a medication (Morphine) to relieve pain, knowing that it may also result in death. Passive euthanasia is currently the most accepted form as it is currently common practice in most hospitals. 2. Non-aggressive Euthanasia: The practice of withdrawing life support Quite controversial 3. Aggressive Euthanasia: Using lethal substances or force to kill Extremely controversial Physician-Assisted Suicide: Term for aggressive voluntary euthanasia.

21. Death and Grieving The Death System and Cultural Contexts Defining Death and Life/Death Issues A Developmental Perspective on Death Facing One’s Own Death Coping with the Death of Someone Else

22. Death in Different Cultures Perceptions of death vary; reflect diverse values and philosophies Individuals more conscious of death in times and places of war, poverty, disease. Most societies have Philosophical or religious beliefs about death Rituals that deal with death View that death does not end existence Death and Cultural Contexts

23. U.S. Denial and Avoidance of Death Funeral industry emphasizes lifelike qualities Euphemisms — softening language for death Persistent search for “fountain of youth” Rejection and isolation of aged Concept of pleasant and rewarding afterlife Medical emphasis — prolonging life, not easing suffering Death and Cultural Contexts

24. Changing Historical Circumstance Death becoming increasingly complex When to determine death has occurred Life expectancy has increased Most die apart from families Care for dying shifted away from family Minimized exposure to death and its pain Death and Cultural Contexts

25. Issues in Determining Death Brain death — neurological definition of death All electrical activity of brain has ceased for a specified period of time Flat EEG recording Some medical experts argue criteria for death should include only higher cortical functioning Defining Death and Life/Death Issues

26. Decisions Regarding Life, Death, and Health Care Natural Death Act and Advance Directive Expresses person’s desires regarding extraordinary medical procedures that might be used to sustain life when medical situation becomes hopeless Defining Death and Life/Death Issues

27. Euthanasia Painlessly ending lives of persons suffering from incurable diseases or severe disabilities Passive euthanasia — withholding of available treatments, allowing the person to die Active euthanasia — death induced deliberately, as by injecting a lethal dose of drug Publicized controversy: assisted suicide Defining Death and Life/Death Issues

28. Needed: Better Care for Dying Individuals Death in U.S.: often lonely, prolonged, painful Plan for your death Make a living will Give someone power of attorney Give your doctor specific instructions Discuss desires with family and doctor Check insurance plan coverage Defining Death and Life/Death Issues

29. Needed: Better Care for Dying Individuals Hospice — humanized program committed to making the end of life as free from pain, anxiety, and depression as possible Palliative care — reducing pain and suffering and helping individuals die with dignity Defining Death and Life/Death Issues

30. Causes of Death Death can occur at any point in human life span Prenatal — miscarriage, stillborn Childhood — accidents or illness Adolescence — motor vehicle accidents, suicide, and homicide Older adults — chronic diseases A Developmental Perspective of Death

31. Death and Children Honesty may be best way to discuss death with children Explained in simple physical or biological terms to preschool children Be sensitive and sympathetic, encouraging feelings and questions Not unusual for terminally ill children to distance themselves in final stages, may be a result of depression A Developmental Perspective of Death

32. Attitudes Toward Death at Different Points in the Life Span Childhood Adolescence Adulthood Infant has no concept of death; perceptions of death develop in middle/late childhood; even very young children concerned about separation and loss Develop more abstract concepts of death; common to think they are immune to death Middle-aged adults fear death more than young adults or older adults; older adults think about death more A Developmental Perspective of Death

33. Suicide A Developmental Perspective of Death Serious physical illness Feelings of disparity, isolation, failure, loss Serious financial problems Drug use or prior suicide attempts Antidepressant links –Cultural and gender differences exist –Rare in childhood, risk increase in adolescence –Most adolescent attempts fail –Linked to genetic and situational factors –Gay or lesbian links not clear Risk factors

34. Suicide in U.S. Adolescence 3rd leading cause of death in ages10-19 19% of high school students seriously considered or tried suicide in last 12 mos Adulthood and Aging Suicide rates increase in adulthood Older adults use more lethal ways, are more successful Racial and gender differences exist A Developmental Perspective of Death

35. Facing One’s Own Death Most dying individuals want to make decisions regarding their life and death Complete unfinished business Resolve problems and conflicts Put their affairs in order Facing One’s Own Death

36. Kubler-Ross’ Stages of Dying Denial and isolation Anger Bargaining Denies s/he is going to die Denial gives way to anger, resentment, rage, and envy Develops hope that death can somehow be postponed Depression Acceptance Comes to accept the certainty of her or his death Develops sense of peace and may desire to be left alone Facing One’s Own Death

37. Perceived Control and Denial When individuals believe they can influence and control events, they may become more alert and cheerful Denial can be adaptive or maladaptive Facing One’s Own Death

38. The Contexts in Which People Die Context of dying is important for most Most would rather die at home but worry over Burden at home Limited space May alter relationships Competency and availability of emergency medical treatment Facing One’s Own Death

39. Communicating with the Dying Person Establish your presence Eliminate distraction Limit visit time Don’t insist on acceptance Allow expressions of guilt or anger Discuss alternatives, unfinished business Ask if there is anyone s/he would like to see Encourage the dying individual to reminisce Talk with the individual when s/he wishes to talk Express your regard Coping with the Death of Someone Else

40. Grieving Grief: emotional numbness; a complex emotional state of… Disbelief Separation anxiety Despair Sadness Loneliness Complicated grief Disenfranchised grief Coping with the Death of Someone Else

41. Model of Grieving Dual-process model for effective coping Loss-oriented stressors Restoration-oriented stressors Coping and type of death Sudden or violent deaths have more intense and prolonged effects Many such deaths accompanied by PTSD

42. Cultural Diversity in Healthy Grieving Persistent holding on to deceased may be therapeutic Hopi of Arizona forget quickly Egyptians dwell on grief Netherlands: integrate loss into their lives Healthy coping involves Growth Flexibility Appropriateness within the cultural context

43. Making Sense of the World Grieving stimulates many to try to make sense of their world — positive themes linked to hopeful future and better adjustment Effort to make sense of it pursued more vigorously when caused by an accident or disaster Coping with the Death of Someone Else

44. Losing a Life Partner Those left behind after the death of an intimate partner suffer profound grief and often endure Financial loss Loneliness linked to poverty and education Increased physical illness Psychological disorders, including depression Coping with the Death of Someone Else

45. Adjustment to Widowhood Women live longer Widowed men more likely to remarry Measures of older women’s health Physical and mental health Health behaviors and outcomes Overall, women adjust better than men Older widows do better than younger widows Support programs aid adjustment Coping with the Death of Someone Else

46. Forms of Mourning Approximately 80 percent of corpses are disposed of by burial, the remaining 20 percent by cremation Funeral industry is source of controversy Funeral is important aspect of mourning in many cultures Cultures vary in how they practice mourning Coping with the Death of Someone Else

47. The Amish, Traditional Judaism, and Mourning Amish Conservative group; family-oriented society Live same unhurried pace as ancestors Time of death met with calm acceptance Neighbors notify community; funeral at home High level of support to family for one year Coping with the Death of Someone Else

48. The Amish, Traditional Judaism, and Mourning Traditional Judaism Mourning in graduated time periods; each with appropriate practices 1st period: Aninut — between death and burial 2nd period: Avelut period — mourning proper Shivah period — 7-day begins at burial Sheloshim period — 30-day period after burial Mourning over for all but parents who mourn another 11 months Coping with the Death of Someone Else