Chapter 17

The Final Challenge:Death and Dying

Biological Definitions of Death

• Harvard: Total Brain Death

– Unresponsive to stimuli

– No movement or breathing

– No reflexes

– Flat EEG

• Euthanasia: “happy” or “good” death

– Hastening death of someone suffering incurable illness or injury

1) Active euthanasia2) Passive euthanasia3) Assisted suicide

Death with dignityTerry Schiavo

Social Meanings of Death

• Modern American

– Medical failure

• More traditional societies

– Natural part of life cycle

• Grieving practices vary

– By culture: weeping/partying

– By ethnicity: wake/Shiva

Life Expectancy

• Expected age at death

– U.S.: 78 years

– White females: 81 years

– White males: 76 years

– Black females: 76.5 years

– Black males: 70 years

– Ancient Rome: 30 years

Japan, China, Sweden: 80 years

Figure 17.1

What Kills Us and When?

• Leading cause of death– Preschool and school children: unintentional injuries (car

accidents)– Adolescence and early adulthood: accidents (especially

car accidents), homicides, and suicides– 45–64 age group: cancers– 65 years and older: heart disease

© 2015. Cengage Learning. All rights reserved.

What Kills Us and When?

© 2015. Cengage Learning. All rights reserved.

Progeria

Perspectives on Dying

• Kübler-Ross’s five stages of dying– Denial

• Defense mechanism; anxiety-provoking thoughts are kept out of conscious awareness

– Anger

• Why me?– Bargaining

• Bargainer begs for some concession from G-d, the medical staff, or family members

Perspectives on Dying

• Kübler-Ross’s five stages of dying– Depression

• Depression, despair, and a sense of hopelessness become the predominant emotional responses

– Acceptance

• Accept the inevitability of death in a calm and peaceful manner

Perspectives on Dying

• Criticisms of Kübler-Ross’s five stages of dying– Emotional responses to dying are not

stage-like– The nature and course of an illness affects

reactions to it– Individuals differ widely in their responses– Dying people focus on living, not just dying

Perspectives on Dying

• One study (Nissim et al., 2012) found dying patients have the goals of:– Controlling dying– Valuing life in the present– Creating a living legacy

Attachment Model of Bereavement

• Bereavement: the state of loss

• Grieving: emotional expressions

– Anticipatory grief

• Mourning: culturally approved reactions

• Parks/Bowlby Model

– Reaction to separation from a loved one

– Numbness, yearning, despair, reorganization (not stages)

Perspectives on Bereavement

Perspectives on Bereavement

• The dual-process model of bereavement– Bereaved oscillate between coping with:

• Emotional blow of the loss

• Practical challenges of living– Loss-oriented coping– Restoration-oriented coping

The Dual-Process Model

Figure 17.2

The Infant

• Object permanence – “all gone”

• Attachment by 6-8 months

– Separation anxiety at loss

– Protest, yearning, searching despair

– Behavioral: eating, sleeping, regression

• Less distress if attached to other parent

• Eventual new attachments and recovery

Grasping the Concept of Death

• Young children are:– Highly curious about death– Think about it with some frequency– Build it into their play– Can talk about it

The Child• The mature concept of death

– Finality, irreversibility, universality, biological causality

• Age 3-5: universality

– Dead live under altered circumstances (hunger pangs, wishes, beliefs)

– Reversible - like sleep

• Age 5-7: finality, irreversibility, universality (death caused by an external agent)

• Age 10: biological causality is understood

• Level of cognitive development, experience determine understanding

Grasping the Concept of Death

The Dying Child

• Young child aware of impending death

• Adults often secretive

• Same range of emotions as dying adults

• Anxiety revealed in behavior

• Control is helpful

• Need support of important others

The Bereaved Child

• Children do grieve

• Express grief differently than adults do

– Misbehavior, strike out, rage

• Lack adult coping skills

– Will use denial, avoidance

• Most adjust successfully

The Adolescent

• Higher levels of understanding

• Concerns of adolescence

– Body image, identity, independence

• May carry on internal dialogue with dead

• Devastated at death of close friend

• Adult-like grieving

The Adult

• Death of family member difficult

• Death of spouse more expected with age

– More difficult when young (non-normative)

• Elevated levels of stress

• Risk increases for illness and death

• Signs of recovery in 2nd year

• Complicated grief

Loss of a Child

• No loss more difficult

• Experienced as untimely, unjust

• Broken attachments

• Guilt at failure to protect child

• May continue relationship w/dead child

• Marital problems often increase afterward

The Loss of a Parent

• Lasting problems may occur if young

• Less tragic than unexpected death

• Adjustment not as difficult

• Guilt: not doing enough for parent

Grief Work Perspective

• Emotions must be confronted: detachment

• Psychoanalytic, also popular view

• May be a culturally biased belief

• Grief work may actually cause more distress

• Delayed grief reaction predicted w/out it

– Not supported by research

• Detachment not necessary

• Continuing bonds (Bo

Who Copes and Who Succumbs

• Secure infant attachment related to coping

• Low self-esteem related to more difficulty

• Cause of death influences bereavement

• Support system essential

• Additional life stressors detrimental

• Positive outcomes often found

Hospice

• Dying person decides what is needed

• De-emphasize prolonging life

• Pain control emphasized

• Normal setting (if possible)

• Bereavement counseling for entire family

• Research shows positive outcomes