Chapter 19

Dealing with Death & Bereavement

Cultural context

Customs related to disposal and remembrance of the dead, transfer of possessions, expressions of grief; care of toward the dying

 

Mortality

Top cause for death are diseases.

Care of the dying

Hospice care- personal, patient and family centered care for the terminally ill

 

Focus is on palliative care- relief of pain and suffering, control of symptoms, maintaining satisfactory quality of life, allowing patient to die in peace and dignity.

Psychological Issues

• Confronting one’s own death

• In absence of identifiable illness, at 100, tend to suffer functional declines, lose interest in eating and drinking, and die a natural death

Terminal drop or terminal decline- widely observed decline in cognitive abilities shortly before death; decline in verbal ability significant

 Near death experiences: sense of being out of

body and visions of bright lights or mystical encounters

 May result from physiological changes or

psychological responses to threat of death

Kubler-Ross- Five Stages of coming to terms with death:

1. Denial2. Anger3. Bargaining for more time4. Depression5. Acceptance Not everyone will experience all five stages

or in same sequences; may bounce between or return to stages

Patterns of Grieving

Bereavement- the loss of someone close and process of adjusting to it.

 

Brings change in status and role

 

Grief- emotional response initially experienced

Grief workShock and disbelief- immediately following the

death; feel lost and confused; awareness of loss sinks in, numbness then overwhelming feelings of sadness, crying, may last weeks

 Preoccupation with memory of the dead person-

may last 6 months to 2 years, attempts to come to terms, unable to do so. May relive death and not accept it; may feel dead person is present; relieves at anniversary

 Resolution- renews interests in everyday situations, memories of the dead person bring fond feelings with sadness.

Commonalities

• Depression is not universal in its expression or experience

• High distress at outset does not necessarily avert long-term problems

• Not everyone needs to work through a loss

• Returning to normal not on a schedule

• Cannot always resolve their grief and accept their loss

Common grief- depression that sets in immediately after bereavement and subsides over time

 

No empirical support for absent or delayed grief, but rather resilience- a low and gradually diminishing level of distress. May accept death as natural process

 

Grief therapy

Helps the bereaved cope with their loss

Childhood and Adolescence

• Ages 5-7, begins to understand death as irreversible;

• Also that it is universal (all things must die) and therefore inevitable; and a dead person is nonfunctional (all life functions end at death)

• Pre-5, difficult to grasp

• Table 19-2 (page 721-722)

How children show grief depends on cognitive and emotional ability. Some express through anger, acting out, refusal to acknowledge death;

 

Help children understand death and bereavement process; make as few changes to routines, household as possible

Adulthood

May experience little or major problems with death.

 

Surviving Loss of Spouse

Women: difficult when structured life pleasing or caring for husband; not only loose companion but important, central role. Men may experience similar

Quality of marital relationship affects degree to which widowhood affects mental health

 

If have become high dependent on spouse, tended to become more anxious and more difficult time grieving- longer mourning

Men who lost their wives within 5 year period, 21% died if not remarried; women 10% more likely to die

 

Loss of spouse may be loss of the protective shield- the one who reminded to take pills, care for, etc

 

Practical problems of care, poverty

Women- can be catalyst for growth, discovering submerged aspects of self, learning to be more independent; search for personal meaning

 

May seek new companion, some seek new marriage- though not necessary- only companionship

Losing parent in adulthood• Experience emotional distress.

• Helps to force resolution of important developmental issues; achieving stronger sense of self; more realistic goals and awareness of own mortality; greater responsibility, commitment, and attachment to others

• May have to assume responsibility for surviving parent and in keeping family together

Losing a child• Unprepared; comes as a cruel, unnatural

shock; an untimely event that should not have happened

• Parents may blame themselves; may hasten parent’s death

• If terminally ill, parents who discuss openly the impending death tend to achieve a sense of closure that helps to cope with the loss

Mourning a miscarriage

Most end to avoid talking about it; grief becomes more intense and wrenching without support

 

Often overcome with frustration and helplessness; often found support by supporting spouse.

The Right to Die

• Suicide- 20-60% had tried suicide before completing it

• Many care accidents and drug overdoses are actually unidentified suicides

• 10% who attempt suicide kill themselves within 10 years

• 60% of nonfatal self-inflicted injuries treated in emergency rooms among teenage girls and young women are probable suicide attempts

• women attempt suicide more than men; however, men are more likely to complete a suicide- using more lethal methods

• men over 50- 30% of all suicides, risk rises for men 85 and older- more likely to be depressed and socially isolated.

• Older people are more likely to be effective with suicide the first time.

• Family history of suicide dramatically increases risk

• Genetics- mood and impulse control problems, increases risk

• 8/10 people who killed themselves gave warning signs (withdrawing; talking about death or suicide; giving away possessions; abusing substances; personality changes; unusual anger, boredom, or apathy; neglect self care and appearance, avoid usual activities, complain of physical problems that may have no medical basis; eat/sleep too much or not at all; depression; hopelessness.

• When finally make decision to kill self, often appear improved mood, happier, and this is misinterpreted as being less at risk when in fact it is the final acceptance to die.

Aid in dyingActive Euthanasia- mercy killings, action

taken directly and deliberately to shorten a life in order to end suffering or allow a terminally ill person to die with dignity. Illegal.

Passive Euthanasia- withholding or discontinuing treatment that might help extend the life of a terminally ill patient; medication, life-support systems, feeding tubes. Some circumstances is legal.

Must be voluntary of person dying.

Assisted suicide- physician or other helps a person bring about a self-inflicted death.

Advance directivesConstitutional right to refuse or discontinue

life-sustaining treatment- to request passive euthanasia. Must be mentally competent. This is a written document; contains instructions. Living will is one type. 

Durable power of attorney- appoints someone to make decisions when person unable to make their own decisions

Assisted suicide- physician or other helps a person bring about a self-inflicted death.

Advance directivesConstitutional right to refuse or discontinue

life-sustaining treatment- to request passive euthanasia. Must be mentally competent. This is a written document; contains instructions. Living will is one type. 

Durable power of attorney- appoints someone to make decisions when person unable to make their own decisions

Ethical arguments for and against assisted suicides.