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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