1. PSYCHOLOGY OF DEATH AND DYING Prof. Dr. Doina Cosman

2. Tanatology Coined in the 1960’s in USA as a consequence of Elisabeth Kubler-Ross’ book On death and dying) the study of behaviours, affects, attitudes and beliefs concerning death and the process of dying It entails: Paliative care, assistance to terminally ill patients, organ transplant, euthanasia, the right to die

3. Death – 4 causes 1.Natural 2.Accidental 3.Suicide 4.Homicide

4. Differential diagnosis murder - suicide Suicide is suggested by: 1.The region of trauma lesions – precordial, neck; right temporal region 2.Absence of other lesions of extreme violence 3.Scars of previous suicide attempts 4.Clothing: clean and orderly 5.Desperate actions or written documents 6.The testimony of survivors (family, friends, neighbours) 7.Method. Differential between hanging and strangulation; differential between drowning and murder by immersion masked in suicide

5. Differential diagnosis suicide/accident Hunting accidents Accidental drowning Accidental falling from a tall building/balcony/roof etc. Overdose (especially prescription drugs) Psychological authopsy in order to clarify the circumstances of the event

6. Death and dying These are not synonimous terms The (process of) dying starts at birth Ongoing processes of cellular and tissular death and regeneration take place throughout our lives, at distinctive and genetically-programmed intervals depending on the tissue It is a coordinated an integrated process which ensures the life of the organism as a macrosystem

7. Definition of death Permanent and irreversible cessation of breathing, heart beating and cerebral functions, accompanied by cessation of consciousness Physiological – cessation of tissular activity Genetic – programmed deconstruction of the organism generated by translation errors, mutations and impairment of protein activity Biochemical – from organic to anorganic Biological - natural selection that eliminates what is not useful to the species Philosophical – natural, necessary and universal phenomenon

8. How do we diagnose death? It is an ethical issue especially in the age of organ transplants National Institute of Neurological Disease and Stroke – a person is dead if: in irreversible coma, apnea, without reflexes, and with a flat line on the electroencephalogram (EEG), ongoing as such at least 6 hours from the onset of coma or apnea

9. Other criteria of death Complete lack of mobility and muscle tone Cessation of consciousness Fixed bilateral midriasis, lack of corneal sensitivity and clarity, ocular hypotonia – suggesting irreversible lesions of the medula oblongata (the most resistant region of the CNS) Spontaneous breathing has stopped for more than 5 minutes Heart rate stopped, not influenced by atropin Arterial pressure plummeted Poikilotermia and irreversible plummeting of body temperature to 35-30 degrees Celsius

10. The stages of dying Preagony – specific, individual psychological changes Agony – loss of reality check, delirium, dream-like states with re-living of memories, vegetative chaos and anesthesia Clinical death – cessation of respiratory and circulatory functions, of reflexes and EEG activity, coma Actual death – the body becomes cold, rigid and dehidrated, with cadaveric lividities and tissue decay

11. Management and care of terminally ill patients 3 basic purposes: 1. Safety and protection 2. Death in dignity 3. Death according to the person’s wishes

12. 7 C’s in assisting terminally ill patients Concern Competence Communication Children Cohesion Cheerfulness Consistency

13. Psychological management of terminally ill patients Empathy of caretakers Appeal to spirituality and religiousness Presence of friends, family Focus on positive outcomes and sucesses in the person’s life Absence of: religious feelings, real social support and positive outlook on life history (with a sense of purposelessness and void) generate severe psychological distress Dignity and positive framing of dying take into account the somatic, psychological, cultural and spiritual specificities of the person

14. Euthanasia and assisted death Ethical dilemma There are laws in some countries that regulate euthanasia and assisted death and approve under specific circumstances and in carefully selected cases Ethics, morals, human values and the hyppocratic oath clearly forbid euthanasia and assisted death

15. Conclusions Dying is a process with specific stages Death entails ethical, cultural and spiritual issues Death is a universal event in all species; longevity is genetically programmed for each species and – to a certain extent, even for individuals The doctor can only delay the moment of death and alleviate physical and psychological suffering during the final stages of the process of dying Not all illnesses can be cured or treated appropriately

16. Conclusions Caring for the terminally ill patient is centered on the patient’s needs and on the therapeutic relationship The main objective of the doctor and family, working together, is to avoid or diminish suffering, to improve quality of life, to ensure dignity, freedom of will and spirit of the dying person, to defend and preserve spiritual values and humanity