Chapter 13 Dying and Bereavement



Chapter 13 Dying and Bereavement

Sociocultural Definitions of Death

Sociocultural definitions of death vary greatly around the world

customs surrounding death also vary

In Western culture, several meanings have developed

Legal and Medical Definitions of Death

Clinical death : Lack of heart beat and respiration

Has been used for centuries as the criteria for death

Brain death: Includes eight specific criteria, all of which must be met

The most widely used definition in the United States and other industrialized countries

Persistent vegetative state

When brain-stem functioning continues after cortical functioning stops

Ethical Issues

Bioethics Examines the interaction between human values and technological advances

The most important bioethical issue is euthanasia

Euthanasia: The practice of ending life for reasons of mercy

Two types of euthanasia are distinguished

Active euthanasia--- Deliberately ending someone’s life through some sort of intervention or action

Passive euthanasia ---Ending someone’s life by withholding treatment

Living will and durable power of attorney

Personal preferences for medical intervention

The purpose of both is to make one’s wishes about the use of life support known in the event one is unconscious or otherwise incapable of expressing them

These can also serve as the basis for Do Not Resuscitate (DNR) medical order which is used when cardiopulmonary resuscitation is needed

The Price of Life-Sustaining Care

A growing debate concerns the costs for keeping someone alive through technology and includes financial, personal, and moral costs

The most obvious are financial costs which are usually staggering

Personal emotional costs are often underestimated, but can be devastating and long-lasting

Thinking About Death: Personal Aspects

A life course approach to dying

Young adults report a sense of being cheated by death

Middle-aged adults begin to confront their own mortality and undergo a change in their sense of time lived and time until death

Older adults are more accepting of death

Dealing with One’s Own Death

Kübler-Ross’s includes five stages:

Denial ---the first reaction is likely to be shock and disbelief

Denial is a normal part of getting ready to die

Anger---at some point people express anger as hostility, resentment, frustration, and envy

Bargaining--in the bargaining phase people look for a way out or a person sets a timetable

Depression--when one can no longer deny the illness feelings of depression become common

Acceptance--In the acceptance stage, the person accepts the inevitability of death and often seems detached from the world and at peace

It is important to note that some people do not progress through all of these stages, and some people move through them at different rates

People may be in more than one stage at a time and do not necessarily go through them in order

A Contextual Theory of Dying

Emphasizes the tasks and issues that a dying person must face

A contextual theory would be able to incorporate differences in reasons people die and the places that people die

Corr identified four dimension of tasks that must be faced

Bodily needs, psychological security, interpersonal attachments, and spiritual energy and hope

Death Anxiety

Death anxiety is essentially universal in Western culture

However, defining and measuring it is difficult

Several components have been identified, including

Interruption of goals

Negative impact on survivors

These components can be expressed at public, private, and unconscious levels

Death anxiety is demonstrated in many different ways

Less common ways to express death anxiety

Learning To Deal With Death Anxiety

Several ways to deal with anxiety exist:

Living life to the fullest

Personal reflection

Death Education

End-of-Life Issues: Creating a Final Scenario

End-of-life issues

Managing the final aspects of life

After-death disposition of the body and memorial services

Distribution of assets

Final Scenario: Making choices about what people do and do not want done

A crucial aspect of the final scenario is the process of separation from family and friends

Bringing closure to relationships

End-of-Life Issues: The Hospice Option

Hospice: An approach to assisting dying people that emphasizes pain management (palliative care) and death with dignity

Hospice care emphasizes quality of life rather than quantity of life

The goal is a de-emphasis on the prolongation of death for terminally ill patients

Both inpatient and outpatient hospices exist

The role of the staff is to be with patients, not to do things for patients

Research shows that hospice patients have better psychological status than hospital patients

the patients tend to be more mobile, less anxious, and depressed

family members tend to stay more involved in the care of hospice patients

How Do People Decide To Explore The Hospice Option?

Kastenbaum lists six key considerations:

Is the person completely informed about he nature and prognosis of his or her condition?

What options are available at this point in the progress of the person’s disease?

What are the person’s expectations, fears, and hopes?

How well do the people in the person’s social network communicate with each other?

Are family members available to participated actively in terminal care?

Is a high-quality hospice care program available?

adults can not benefit from hospice care unless:

Family reluctance to face the reality of terminal illness and participate in the decision-making process is changed

Physicians reluctance to approve hospice care for patients until the very end is changed

Survivors: The Grieving Process

Bereavement is the state or condition caused by loss through death

Grief--the sorrow, hurt, anger, guilt, confusion, or other feelings that arise after a loss

Mourning--The way we express or grief

Mourning is heavily influenced by cultural norms

Society assigns different values on the death of people of different ages

For example, the older the person is at death the less tragic it is perceived to be

The social view of the degree to which a death is considered tragic is an important aspect of the dying process

Experiencing Grief

Grief is an active process in which a person:

must acknowledge the reality of the loss

Work through the emotional turmoil

Adjust to the environment where the deceased is absent

Loosen ties to the deceased

How these are accomplished is an individual matter

The amount of time to deal with death is highly individual

Most agree at least 1 year is necessary

Expected Versus Unexpected Death

Grief is equally intense in both expected and unexpected death

May begin before the actual death when the patient has a terminal illness

Unexpected death often is called high-anxiety death

Expected death is often called low-anxiety death

Because deaths are usually less mysterious than unexpected deaths

Normal Grief Reactions

Normal feelings include:

Sorrow

Sadness

Denial and disbelief

Guilt

Religious feelings

Grief work: The psychological side of coming to terms with bereavement

Anniversary reaction: Grief that often returns around the anniversary of the death

Effects of normal grief on adults’ health

In general, experiencing the death of a loved one does not directly influence physical health

Middle-aged adults have the most difficulty dealing with grief

People who have a hard time coping tend to have low self-esteem before losing a loved one

Abnormal Grief Reactions

Abnormal grief usually involves excessive guilt and self-blame

Older adults who are still having difficulty coping longer than two years after the death:

Tended to have lower self-esteem prior to bereavement

Were more confused

Had a greater desire to die themselves

Cried more

Were less able to keep busy right after the death

Types of Loss and Grief

Society makes judgements about how much grief one should have after different types of loses

arbitrary time limits on the grieving process

Death of one’s parent

The death of a parent serves to remind people of their own mortality and deprives them of a very important person in their lives

Death of one’s child

The death of a child, including miscarriage and perinatal death, is thought to be the most traumatic type of loss

Death of one’s spouse

Death of a spouse is a great loss of a lover and companion

Widowhood is more depressing for men than women

Bereaved spouses tend to have positive bias about their marriage

Comparing Types of Loss

In general, bereaved parents are the most depressed and have more grief reactions in general

The intensity of depression in a bereaved person after a loss is related to the perceived importance of the relationship with the deceased person

Survivors are more often and more seriously depressed after the death of someone particularly important to them

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