1. Adolescent/Adult Development Epilogue: Death and Dying Apr 29-May 1, 2009 Classes #41-42

2. Deciding How to Die Practices and rituals relating to dying, death, and bereavement are universal, but there are variations Rituals may be changing with globalization One of first steps in understanding death is to accept it –for most of human history, death accepted as unanticipated, unavoidable, and quick –today, because of medical miracles, death less of everyday event

3. Medical Professionals As illness came to be perceived as a domain of medicine rather than of religion, we began to believe physicians could work medical miracles Elizabeth Kübler-Ross brought solid research and compassionate attention to the psychological needs of the dying

4. Medical Professionals In the early 21st century, only 1/2 of medical books discuss care of dying In recent years, more physicians are more accepting of death 3 innovations are helping to help the dying achieve a “good death” –hospice care –palliative care –end-of-life decision making

5. Hospice Care Hospice—institution where terminally ill patients receive palliative care –provides skilled medical treatment, but avoids death-defying interventions –human dignity respected Dying person and the family are considered to be the “unit of care” –sometimes the home is where care given

6. Palliative Care Designed mainly to relieve pain and suffering of patient and family – Double effect primarily relieves pain, but could also hasten death Psychological symptoms of patients and their families more difficult to treat –depression, anxiety

7. ? Hospice is a concept rooted in the centuries-old idea of offering a place of shelter and rest, or "hospitality" to weary and sick travelers on a long journey Dame Cicely Saunders at St. Christopher's Hospice in London first applied the term "hospice" to specialized care for dying patients in 1967 Today, hospice care provides humane and compassionate care for people in the last phases of incurable disease so that they may live as fully and comfortably as possible What Is Hospice Care?

8. Hospice Care Hospices try to help as many people as possible, but do not reach everyone –patients must be diagnosed as terminally ill –patients and caregivers must accept diagnosis of terminal illness –hospices were typically designed for adults with terminal cancer, not older adults with severe illnesses –hospice care is expensive –availability depends mainly on location

9. Interdisciplinary Team  Typically, an interdisciplinary health care team of physicians, nurses, social workers, counselors, home health aides, clergy, therapists, and trained volunteers cares for you, offering support based on their particular areas of expertise  Together, they provide comprehensive palliative care aimed at relieving symptoms and giving social, emotional, and spiritual support.

10. Legal Preparations Explicit guidelines for a person’s preferences for end-of-life care are needed because he or she often becomes incapable of making or expressing decisions about medical care

11. Legal Preparations Passive Euthanasia – situation in which a seriously ill person is allowed to die naturally via cessation of medical interventions Active Euthanasia – a situation where someone takes action to bring about another’s death, with the intention of ending that person’s suffering

12. Legal Preparations Living will – document that indicates what medical intervention should occur Health care proxy – the person chosen to make medical decisions if the person who chose becomes unable to make his/her own decisions

13. Living wills are only a start Hospitals today ask about living wills and advance directives upon admission –some people resist signing them End-of-life care involves probabilities, not certainties, until the very last moment What quality of life is acceptable? Disagreements About End-of-Life Care

14. Problems with Designated Proxy –many proxies choose measures neither they nor the dying person want may involve clashing cultural values –family members may disagree bitterly about how much suffering is acceptable –even if patient has signed living will and specified proxy, hospital staff may ignore them

15. Euthanasia Legally, decisions made in living wills and by health care proxies are to be honored Active euthanasia is fiercely controversial, even if the dying person requests it –is illegal in almost every part of the world

16. Euthanasia Physician-Assisted Suicide – Form of active euthanasia in which a doctor provides the means for someone to end his or her life Voluntary Euthanasia – Form of active euthanasia in which, at patient’s request, someone else ends his or her life

17. Euthanasia Several places have legalized physician- assisted suicide –the Netherlands –Switzerland –Belgium –Oregon

18. Euthanasia In Oregon, the following conditions must exist: –Person must be terminally ill Less than 6 months to live –Two doctors must confirm diagnosis of terminal illness Both doctors must certify patient’s judgment unimpaired –Person must ask for lethal drugs at least 2x orally and 1 time in writing 15 days must elapse between first request and written prescription

19. The “Death Machine”...  Dr. Jack Kevorkian was convicted in March 1999 of second-degree murder after inducing the death of Thomas Youk, a man who had amyotropic lateral sclerosis, commonly known as Lou Gehrig's disease. Kevorkian's conviction came after replaying Youk's videotaped death on the "60 Minutes" CBS television news magazine. He was sentenced to a 10 to 25 years in prison.

22. Thomas Youk, 52, injected with a lethal dose of chemicals by Kevorkian

23. Preparing for Death Responses to death vary greatly It has been denied, sought, feared, fought, avoided, and welcomed by all involved

24. Avoiding Despair Kübler-Ross helped us to understand death Acceptance of death was elusive before Kübler-Ross’s 5 Stages –denial –anger –bargaining –depression –acceptance

25. Avoiding Despair Others that study death (thanatology) have disagreed about the stages 5 stages appear and reappear throughout process Research has clarified some patterns –older people more likely to plan for death –concern is more likely to be for a “good death”— swift, painless, dignified, and occurring at home

26. Cultural Variations Africa and Asia North America

27. In many traditional African religions, adults gain new status through death and the joining of ancestors For Muslims, death affirms religious faith –life is transitory, so people should be ready for death at any time Death in Religions of Africa and Asia

28. Death in Religions of Africa and Asia. For Buddhists, death and disease are among life’s inevitable sufferings –may bring spiritual enlightenment For Hindus, helping the dying to surrender their ties to the world and prepare for the next is a particularly important obligation for the family –a holy death is welcomed by dying person –eases person into the next life

29. Indigenous tribes (over 400) all consider death an affirmation of nature and community values Jews hope for life to be sustained – thus, death is not emphasized and the dying person is not left alone Many Christians believe that death is not an end, but rather the beginning of eternity in heaven or hell – so death may either be welcomed or feared Death in North America

30. Religious and spiritual concerns often reemerge at death It is common for dying people to return to their roots For many, spiritual beliefs and a connection to community offer hope at time of dying Spiritual and Cultural Affirmation

31. Bereavement – sense of loss following a death The considerable variations in practices that follow death are due to religion and culture Coping with Bereavement

32. Forms of Sorrow Grief – individual’s emotional response to bereavement –private Mourning – culturally prescribed ceremonies and behaviors for expressing grief at the death of a loved one –public The two are connected –mourning is designed by religions and cultures –grief, though personal and private, follows social rules

33. Forms of Sorrow Mourning customs are designed by various cultures and religions to channel grief into reaffirmation Crucial to reaffirmation is people’s search for the meaning in death Unexpected or violent deaths are particularly likely to shock and to precipitate a search for meaning –Example: September 11, 2001

34. Mourning has become more private, less emotional, and less religious –funeral trends cremation vs. burial As mourning diminishes, grief becomes less welcome People are less likely to be given time to grieve Contemporary Challenges

35. “Disenfranchised grief” is the practice of excluding certain people from mourning –the unmarried partner –the young child –the ex-spouse –the friend from work Any kind of prohibition, restriction, or exclusion can make healing, hope, and affirmation more difficult for bereaved of all ages

36. Contemporary Challenges Murders and suicides often trigger police investigations, etc., that interfere with the grief process Inadequate grief is thought to harm the larger community as well

37. What Friends Can Do to Help the Bereaved Person –first, be aware that powerful, complicated, and unexpected emotions are likely –do not judge another person’s sorrow –understand that culture and cohort play a role in the different responses to death Responses to Bereavement

38. Bereavement is an ongoing, often lengthy process; sympathy, honesty, and social support may be needed for months or even years –especially true for families Recovery begins with acceptance of grief and may lead to reaffirmation of life

39. Working through the emotions can help the person have a deeper appreciation of him/herself and life, including human relationships Conclusion