1. Dying and Bereavement

2. Most people in Kuwait die in hospitals.
Socio-cultural definitions of death:
Different cultures view death in divers ways.
Customs and expectations differ in rituals of bereavement and mourning.
Within a culture there is a diversity in the view of death, mourning and bereavement.

3. There are at least 10 ways in which death can be viewed:
Death as an image or an object.
Death as a statistic .
Death as an event.
Death as a boundary.
Death as a state of being.
Death as an analogy.
Death as fear and anxiety.
Death as a 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 respiration for 1 hour.
Lack of response to pain.
No eye movement, blinking or pupil responses.
No postural activity, swallowing or yawning.
No motor reflexes.
No change in any of those in 24 hours.

5. Thinking About Death , Personal Aspects
How do we think about death?
Impersonal death
Death of a stranger, does not touch us personally.
Interpersonal death
Loss of someone who matter to us, constitutes a disruption of some part of our selves.
Intrapersonal death
One’s own death, most crucial for health professionals to grasp.

6. A Life Course Approach to Dying:
Young adults shift from formal operational thinking to post formal makes it possible to integrate feelings and emotions with their thinking about death, lessening their feelings of immortality
Middle aged adults begin thinking about their own death as they deal with the death of their parents
Oldest adults are generally less anxious about death
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.

7. Stages of Dying Order of these stages is unpredictable.
Denial
Anger
Bargaining
Depression
Acceptance
Order of these stages is unpredictable.
Importance in any particular case is unpredictable.

8. 1. Denial: shock and disbelief
A primary primitive defense mechanism.
A predictable reaction to sudden overwhelming news of any sort.
Range of responses:
Rejection of the physician’s “verdict” .
Completely repressing any memory of the conversation on the likelihood of death.

9. 2. Anger: hostility and resentment
Natural response to the threat posed by our own critical illness or that of a loved one.
Individual’s natural response to unmet needs for protection or nurturance.
Critically ill patients have a right to be angry.
Patient’s anger is valid regardless of it being inappropriately expressed.

10. 3. Bargaining: looking for a way out
An effort to retain control in a powerless situation.
Vows to survive only until a personal landmark or anniversary.
Striking deals with physicians to accept treatment only under certain circumstances.

11. 4. Depression: Clinical depression:
No longer able to deny, patients experience sadness and loss.
A universal response among terminal patients.
Even psychologically healthy individuals experience depression during the course of a terminal illness.
Clinical depression:
Demand medical intervention.
Neurovegitative symptoms.
Anhedonia : inability to experience pleasure.
Psychomotor retardation : speak slowly

12. 5. Acceptance Acceptance of the inevitability of death with peace
Most patients fail to achieve a truly clear-headed acceptance of their death.

13. Terror management theory:
Death Anxiety
Terror management theory:
Continuation of one’s life is the primary motive behind all behaviors, Therefore, fear of dying is consistent with this motive.
Death anxiety includes pain, body malfunction, humiliation, rejection, etc….
Each of these factors can be assessed in any of the three levels: public, private and unconscious.
Death anxiety maybe lower in older adults due to integrity and a positive life review.
Emotional problems are predictable of higher death anxiety

14. Learning to Deal With Death Anxiety
Adolescents engage in more risk-taking behavior which suggest less death anxiety.
Reduction of death anxiety 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.

15. Surviving The Loss
The Grieving Process: a condition caused by losing someone.
Bereavement: is the state or condition caused by going through loss.
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.

16. People must do several things during grief.
Acknowledge the reality of the loss.
Work through the emotional turmoil.
Adjust to the environment where the deceases is absent.
Loosing the ties with the deceases.
It’s important to remember that grief is a process, we must avoid several mistakes:
We must not underestimate the length of time people need to deal with the various issues.
One year is needed and two years may be required.

17. Risk Factors in Grief
Rosenblatt reports that people still feel the effects of the death of family members 50 years after the event.
The length of time didn’t diminish the depth of emotions experience.
Religiosity has been investigated as a source of support for people following the loss of a loved one.
The results are mixed as to whether this factor provides help or not.

18. Two processes have been proposed to explain grief:
Coping with Grief
Two processes have been proposed to explain grief:
1. The Four Component Model lists:
The context of the loss.
The continuation of subjective meaning associated with loss.
The changing representations of the loss relationship over time.
The role of coping and emotion-regulation processes.
2. Dual Process Model:
The dual process model of coping with bereavement (DPM) lists 2 types of stressors
Loss-oriented stressors (those having to do with the loss itself)
Restoration-oriented stressors

19. Normal Grief Reactions
Coming to terms with bereavement is called grief work.
Grief work consists of coping, affect, change of relationship.
Many people experience anniversary reactions which are changes in behavior related to feelings of sadness on the date of the loss.
Traumatic grief involves:
Symptoms of separation distress: preoccupation with the deceased to the point that it interferes with everyday functions.
Symptoms of traumatic distress: mistrust, anger and detachment from others.

20. Is It Normal to Grief ?
Grief is vital in order to accept a deep loss and carry on with your life.
If one doesn’t grieve at the time of death, or shortly after, one may keep the grief bottled up inside.
This may cause emotional problems or physical illness later on, working through grief can be a painful process, but it make all the difference to future emotional and physical well-being.

21. Normal Grief Reaction Stage 1 : hours to day Stage 2 : weeks to months
Denial, disbelief
Psychological numbness
Stage 2 : weeks to months
Sadness
Physical anxiety reactions
Poor sleep
Lost appetite
Guilt feelings
Experience of presence
Preoccupation with memories of the deceased
Social withdrawal

22. Abnormal Grief Stage 3 : weeks to months Symptoms resolve
Social activities resumed
Memories of good times
Abnormal Grief
Abnormally intense grief
Prolonged grief
Delayed grief
Inhibited and distorted grief

23.  Good Luck 