Psyc 222Developmental Psychology II

Dean Owen, Ph.D., LPCCDean Owen, Ph.D., LPCC

Spring 2011Spring 2011

Unit 9: Unit 9:

Death, Dying and BereavementDeath, Dying and Bereavement

I am standing upon theI am standing upon theseashore. A ship at my sideseashore. A ship at my sidespreads her white sails to thespreads her white sails to themorning breeze and starts formorning breeze and starts forthe blue ocean. She is anthe blue ocean. She is anobject of beauty andobject of beauty andstrength. I stand and watchstrength. I stand and watchher until at length she hangsher until at length she hangslike a speck of white cloudlike a speck of white cloudjust where the sea and skyjust where the sea and skycome to mingle with eachcome to mingle with eachother.other.

Then someone at my sideThen someone at my sidesays: "There, she is gone!"says: "There, she is gone!"..

Gone where?"Gone where?"Gone from my sight. That is all. SheGone from my sight. That is all. Sheis just as large in mast and hull andis just as large in mast and hull andspar as she was when she left myspar as she was when she left myside and she is just as able to bearside and she is just as able to bearher load of living freight to herher load of living freight to herdestined port.destined port.

Her diminished size is in me, not inHer diminished size is in me, not inher. And just at the moment whenher. And just at the moment whensomeone at my side says: "There,someone at my side says: "There,she is gone!" there are other eyesshe is gone!" there are other eyeswatching her coming, and otherwatching her coming, and othervoices ready to take up the gladvoices ready to take up the gladshout: 'Here she comes!“shout: 'Here she comes!“

And that is dying.And that is dying.Henry Van DykeHenry Van Dyke

How we dieHow we die

Death fundamentallyDeath fundamentallyoccurs when there isoccurs when there issufficient damage to onesufficient damage to oneor more body systems theor more body systems thecontinued life function iscontinued life function isnot possible.not possible.

How we dieHow we die

The bodily systems can beThe bodily systems can bedamaged by two basicdamaged by two basicprocesses……processes……

Disease (Chronic or Acute)Disease (Chronic or Acute)Injury (Chronic or Acute)Injury (Chronic or Acute)Chronic: Slow onset, continuous, and usually progressive…..Chronic: Slow onset, continuous, and usually progressive…..

Acute: Rapid OnsetAcute: Rapid Onset

How we dieHow we die

Disease:Disease:Genetic predisposition to Genetic predisposition to

develop dysfunction develop dysfunction body systems…body systems…

Infection: Body is Infection: Body is invaded by organisms invaded by organisms from outside the body.from outside the body.

How we dieHow we die

Injury:Injury:Inflicted damage or trauma…..Inflicted damage or trauma…..

How we dieHow we die

Homicide/SuicideHomicide/Suicide

How we dieHow we die

For about 20% itFor about 20% itis a gentle processis a gentle processmany time easedmany time easedby the use ofby the use ofdrugs to mask thedrugs to mask thepain andpain anddestructive eventdestructive eventoccurring.occurring.

How we dieHow we die

In childhood and adolescence the cause is unintentionalIn childhood and adolescence the cause is unintentionalinjury…accidents injury…accidents

In adulthood the In adulthood the cause is primarily cause is primarily cardiovascular or cardiovascular or cancer cancer

Three Phases of DeathThree Phases of Death1. Agonal phase: Coming from the Greek word 1. Agonal phase: Coming from the Greek word

agon which means struggle: The agonal phase agon which means struggle: The agonal phase refers to gasps and muscle spasms during the refers to gasps and muscle spasms during the first moments in which the regular heartbeat first moments in which the regular heartbeat stops.stops.

2. Clinical death: This refers to a brief period in 2. Clinical death: This refers to a brief period in which cardiac function, circulation, breathing and which cardiac function, circulation, breathing and brain functioning stop but resuscitation is still brain functioning stop but resuscitation is still possible. possible.

3. Mortality: At this phase the individual passes into 3. Mortality: At this phase the individual passes into permanent death.permanent death.

Defining DeathDefining Death

For much of history the absence of a heartbeat and respiration For much of history the absence of a heartbeat and respiration signaled death……doctors carried a mirror to be held up to the signaled death……doctors carried a mirror to be held up to the mouth and nose of an individual to detect respiration….mouth and nose of an individual to detect respiration….

Deep Coma could produce Deep Coma could produce symptoms that were symptoms that were similar to death…There similar to death…There were cases where were cases where individuals spontaneously individuals spontaneously recovered consciousness recovered consciousness so there was general fear so there was general fear of premature burial……of premature burial……The safety coffin…..The safety coffin…..

Defining DeathDefining DeathSince basic cardiac and respiratory function can be supported by Since basic cardiac and respiratory function can be supported by

machines, a new definition has become more widely used….machines, a new definition has become more widely used….Brain Brain deathdeath: the cessation of neurological activity in the brain and brain : the cessation of neurological activity in the brain and brain stem.stem.

Defining DeathDefining Death

Persistent Vegetative StatePersistent Vegetative StateA condition of deepA condition of deepunconsciousness (coma) in whichunconsciousness (coma) in whichthere is no cortical activity but subthere is no cortical activity but subcortical (brain stem) activitycortical (brain stem) activityremains. remains.

Is there a “Good Death”Is there a “Good Death”

Definition: Definition: There is no single definition of what constitutes a good There is no single definition of what constitutes a good death. The definition of a good death will vary for each death. The definition of a good death will vary for each patient. In 1997 The Institute of Medicine (IOM) patient. In 1997 The Institute of Medicine (IOM) defined a good death as: defined a good death as:

A decent or good death is one that is:A decent or good death is one that is:1.1. free from avoidable distress and suffering for patients, free from avoidable distress and suffering for patients,

families, and caregivers;families, and caregivers;2.2. in general accord with patients' families' wishes;in general accord with patients' families' wishes;3.3. and reasonably consistent with clinical, cultural, and and reasonably consistent with clinical, cultural, and

ethical standards.ethical standards.

Is there a “Good Death”Is there a “Good Death”

Factors important for a good death include: Factors important for a good death include:

Control of symptoms Control of symptoms Preparation for death Preparation for death Opportunity for closure or "sense of completion" of the life Opportunity for closure or "sense of completion" of the life Good relationship with healthcare professionalsGood relationship with healthcare professionals

A central concept to a 'good' death is one that allows a person to dieA central concept to a 'good' death is one that allows a person to dieon his or her own terms relatively pain free with dignity. on his or her own terms relatively pain free with dignity.

An appropriate death is often considered to be one that occursAn appropriate death is often considered to be one that occursnaturally and in old age, one that follows the natural order of thingsnaturally and in old age, one that follows the natural order of thingse.g older members die before younger ones.e.g older members die before younger ones. Perhaps the best definition an appropriate death is a death that Perhaps the best definition an appropriate death is a death that someone might chose for him or herself if he/she had the choice. someone might chose for him or herself if he/she had the choice.

Also known asAlso known as: Appropriate death, desired death, dignified death : Appropriate death, desired death, dignified death

Considering a Good Death in GhanaConsidering a Good Death in Ghana

Sjaak van der Geest Professor of Medical Anthropology at theSjaak van der Geest Professor of Medical Anthropology at theUniversity of Amsterdam studied what residents in Kwahu-University of Amsterdam studied what residents in Kwahu-Tafo, a rural town in Southern Ghana, considered to be a GoodTafo, a rural town in Southern Ghana, considered to be a GoodDeath. For the Southern Ghanaians the characteristics of a Death. For the Southern Ghanaians the characteristics of a Good Death included: Good Death included:

A good death was a A good death was a peaceful death. peaceful death. "Peaceful" in this community meant:"Peaceful" in this community meant:The dying person had finished up all of his or her business.The dying person had finished up all of his or her business.The dying person had made peace with others before his orThe dying person had made peace with others before his orher death. her death.

The dying person was at peace with his or her own death.The dying person was at peace with his or her own death.A good death is one that does not occurs as a result of: A good death is one that does not occurs as a result of:

Violence, Accident, Fearsome disease, Foul means Violence, Accident, Fearsome disease, Foul means

Considering a Good Death in GhanaConsidering a Good Death in GhanaA good death is one that occurs without much pain. A good death is one that occurs without much pain. A good death comes naturally after a long and well-spent life. A good death comes naturally after a long and well-spent life. A good death takes place in the home, surrounded by children and A good death takes place in the home, surrounded by children and

grandchildren. grandchildren. A good death is a death which is accepted by the relatives. A good death is a death which is accepted by the relatives.

For these residents of this rural community in Ghana the epitome of For these residents of this rural community in Ghana the epitome of a Good Death is a peaceful one that occurs at home, surrounded a Good Death is a peaceful one that occurs at home, surrounded by children and grandchildren. by children and grandchildren.

Common Requirements of a Good DeathCommon Requirements of a Good Death Their requirements of a Good Death are very similar to those Their requirements of a Good Death are very similar to those wished for by people in the United States, or in the United wished for by people in the United States, or in the United Kingdom Perhaps there are some common characteristics of a Kingdom Perhaps there are some common characteristics of a good death that defy many cultural and national boundaries. good death that defy many cultural and national boundaries.

SourceSource: : Van der Geest, S. (2006).Van der Geest, S. (2006).

Remoteness of DeathRemoteness of Death

During earlier times:During earlier times:

Most deaths occurred at homeMost deaths occurred at home

People of all ages cared for the sick and old and were People of all ages cared for the sick and old and were present at the moment of death.present at the moment of death.

Family members prepared the deceased for burial.Family members prepared the deceased for burial.

Burial was typically conducted by family and friends.Burial was typically conducted by family and friends.

Because higher mortality rates for all people, death a Because higher mortality rates for all people, death a common event in most communities.common event in most communities.

Remoteness of DeathRemoteness of Death

Today:Today:

Most non accidental deaths occur in hospitals.Most non accidental deaths occur in hospitals.

Lower mortality rates and better health care mean many Lower mortality rates and better health care mean many young people grow into young adults with little or no young people grow into young adults with little or no personal experience with death and loss.personal experience with death and loss.

When death occurs, others from hospitals and funeral When death occurs, others from hospitals and funeral homes perform the necessary activities of preparing homes perform the necessary activities of preparing the body for burial and conducting the burial.the body for burial and conducting the burial.

For most modern people in western cultures, death is a For most modern people in western cultures, death is a rare event that occurs mostly on TV, in movies or in far rare event that occurs mostly on TV, in movies or in far away places.away places.

Development of a Death Concept in ChildhoodDevelopment of a Death Concept in Childhood

Children in middle childhood typically acquire an Children in middle childhood typically acquire an understanding of death. understanding of death.

Once very basic ideas of biology are known…plants and Once very basic ideas of biology are known…plants and animals are alive for a while and then they cease to animals are alive for a while and then they cease to exist the concept is transferred to humans….and is exist the concept is transferred to humans….and is composed of five ideas:composed of five ideas:

1.1. Permanence: Death if foreverPermanence: Death if forever2.2. Inevitability: All living things will dieInevitability: All living things will die3.3. Cessation: All living functions ceaseCessation: All living functions cease4.4. Applicability: Death applies only to living thingsApplicability: Death applies only to living things5.5. Causation: Death is caused bodily failure or damageCausation: Death is caused bodily failure or damage

Adolescent concepts of deathAdolescent concepts of death

Adolescents appear to have a cognitive or logical Adolescents appear to have a cognitive or logical understanding of death but often fail to appreciate its understanding of death but often fail to appreciate its reality in their own lives.reality in their own lives.

Teenagers often explore alternative ideas about death Teenagers often explore alternative ideas about death incorporating ideas from religion, philosophy or even incorporating ideas from religion, philosophy or even from ideas communicated in popular culture and from ideas communicated in popular culture and media.media.

Teenagers often engage in high risk behaviors and do not Teenagers often engage in high risk behaviors and do not take death personally. The myth of personal take death personally. The myth of personal immortality is present and slowly is abandoned with immortality is present and slowly is abandoned with maturity and life experience.maturity and life experience.

The concept of death in adulthoodThe concept of death in adulthood

Early Adulthood: Death is rarely a consideration orEarly Adulthood: Death is rarely a consideration orthought for most during these years as the focus isthought for most during these years as the focus isyypically upon career, family, and home. yypically upon career, family, and home.

Middle Adulthood: Most become aware that life is finiteMiddle Adulthood: Most become aware that life is finiteand begin to accept that they will somedayand begin to accept that they will someday

Older Adulthood: As death nears most individuals in thisOlder Adulthood: As death nears most individuals in thisage group will consider the dying process more than theage group will consider the dying process more than thestate of being dead.state of being dead.

Death AnxietyDeath Anxiety

Generally, individuals with a sense of spirituality or a Generally, individuals with a sense of spirituality or a deep faith in a higher force will experience less fear of deep faith in a higher force will experience less fear of death. death.

Older adults with the ability to regulate negative emotion Older adults with the ability to regulate negative emotion and a sense of symbolic immortality are less anxious and a sense of symbolic immortality are less anxious about death than younger individuals.about death than younger individuals.

Across cultures, women are typically more anxious about Across cultures, women are typically more anxious about death than are men.death than are men.

Helen Kubler-Ross and the stages of griefHelen Kubler-Ross and the stages of grief

Although these ideas were first suggested as stages in the Although these ideas were first suggested as stages in the process of dying, they have since been applied to other process of dying, they have since been applied to other kinds of loss.kinds of loss.

1. Denial1. Denial

2. Anger2. Anger

3. Bargaining3. Bargaining

4. Depression4. Depression

5. Acceptance5. Acceptance

A Place to DieA Place to Die

Only about 1 in 4 Americans die at home.Only about 1 in 4 Americans die at home.

Even with high quality equipment and paid staff,Even with high quality equipment and paid staff,attending to and caring for a dying person is veryattending to and caring for a dying person is verydemanding and difficult.demanding and difficult.

Deaths in hospitals typically occur in emergency roomsDeaths in hospitals typically occur in emergency roomsand are typically result of an acute or sudden event.and are typically result of an acute or sudden event.There is frequently anger and confusion among theThere is frequently anger and confusion among thesurviving family members.surviving family members.

Other hospital deaths occur in intensive care units (ICUs)Other hospital deaths occur in intensive care units (ICUs)which is especially depersonalizing because of the use ofwhich is especially depersonalizing because of the use ofmachines to support body systems at the end of life.machines to support body systems at the end of life.Doctors are trained to cure and preserve life……Doctors are trained to cure and preserve life……

A Place to DieA Place to Die

Deaths in nursing homes are common.Deaths in nursing homes are common.

High quality terminal care is lacking due primarily to the High quality terminal care is lacking due primarily to the extreme cost of equipment and qualified staff.extreme cost of equipment and qualified staff.

Too many patients receive too little attention and many Too many patients receive too little attention and many die without having their needs met.die without having their needs met.

Patients in nursing homes often become “invisible” if Patients in nursing homes often become “invisible” if family members are not fully invested in their care.family members are not fully invested in their care.

HospiceHospice

The hospice concept attempts to provide palliative or The hospice concept attempts to provide palliative or comfort related care in an attempt to meet the dying comfort related care in an attempt to meet the dying person’s physical, emotional, social and spiritual person’s physical, emotional, social and spiritual needs at the end of life.needs at the end of life.

The hospice concept reduces suffering for the dying and The hospice concept reduces suffering for the dying and provides valuable support to the family during the provides valuable support to the family during the times leading up to death.times leading up to death.

Questions or comments ??Questions or comments ??