Death Dying and Grieving

“I don’t mind dying, I just The Issue of Dying Across the Life Span
don’t want to be there when Childhood
it happens.”- Woody Allen – Until around 5-7 don’t understand the
DEATH permanence, universality, and lack of
•The final stage of growth functioning in death
• Experienced by everyone – Age 12 accurately perceive
• The young ignore its existence • Parent euphemisms (just went to sleep)
• The old begin to think of their own • attending funerals, etc?
Death imposes two kinds of burdens Would you want children under 10 to attend
1. Preparing oneself for one’s own death your funeral?
2. Deal with the interpersonal aspects of YES
death that will affect one’s loved ones White: 47.9%
grief, anguish, anger, anxiety, denial African American: 68.4%
Hispanic: 57.6%
Societal Meanings of Death Asian: 40.4%
• Modern American Age: NO 20-39 (7.4%), 40-59 (7.4%), 60+
– Medical failure (21.9%)
• More traditional societies (Kalish & Reynolds, 1976)
– Natural part of life cycle Adolescence
Circle of Life Community Coalition - More experienced with death and grief
End of Life Toolkit - Loss of sibling, friend or parent (survivor’s
US: Societal Changes – early 1900’s guilt)
and now - Positive outcome includes greater
Early 1900’s…. appreciation for life
• Focus was on “comfort” Adulthood
• Died of infection Middle-aged
• Died at home • understand next in line to die
• Family was caregiver • change in perception of time
• Death was short and (lived vs amount left)
sudden * death of a parent
2005…… * death of a child - violates the natural order
• Focus is on “cure” • Transition to being the oldest generation
• Die of chronic illness Late Adulthood- Older adults
• Die in institutions • Least concerned with dying
• Institution staff are Loss of a partner
caregivers Loss of child or grandchild
• Death is prolonged **although think about death more
In recent survey (AARP)
Cross Cultural Views on Death -2,000 Americans age 45 and older were
• Eastern philosophies-death is natural questioned about their fear of dying.
• Buddhists & Hindus 30% of those 45-49 expressed fear of dying
~ physical death is rebirth (reincarnation) 15 of those 75 and older expressed fear of
~ end of rebirths that is their goal, not the end dying
of death, More women overall (24%) than men overall
…which is the goal of Christianity (18% ) were afraid of dying
• Western-death is to be postponed, threat Late Adulthood- Older adults
oneness with the universe (Cicerilli, 1999)
Focus is not on the self N=388, Young & Old
• Western-death is to be postponed, threat Old: think about death more
Old: less afraid about death
 Death Dying and Grieving
Old : more fearful vs
Old : fear more pain & artificial life support
(Cicerilli, 2002)
Meaning of Death?
1) Eventually meeting with God or
nonexistence
2) Preparation to leave a legacy
3) Limited time to do things
WHY not afraid?
• goals have been fulfilled
• living longer than expected
• coming to terms with finitude
• dealing with the deaths of friends
Dying Process
• Stages of Death and Dying (Elizabeth
KublerRoss, 1960: 200 terminally ill )
– Denial: Not me!
– Anger: Why me??? ?Why now??
– Bargaining: Yes, me…but!
– Depression: Yes…me…
– Acceptance: Yes, me.
Emotional stages
Have to have all stages to accept death?
Bereavement: State of having sustained
a loss
Older adults undergo much bereavement
Widowed men (up to age 75) are almost
twice as likely to die than married men
Grief: reaction to loss (Lindemann, 1944)
~ upset stomach
~ shortness of breath
~ tightness in throat
~ sighing
~ decreased muscular strength
Grieving practices vary (Rituals)
By culture: weeping/partying
By ethnicity: wake/Shiva
Reaction to loss: Grieving Practices
Rituals - Jewish
Funeral: begins with “cutting away” (black
ribbon or garment)
Shiva (7 days after burial): parents, children,
spouses and siblings of the
deceased, preferably all together in the
deceased's home
Mourners sit on low stools or the floor instead
of chairs
do not wear leather shoes
do not shave or cut their hair
do not wear cosmetics
do not work
do not do things for comfort or pleasure
(bathe, have sex, put on fresh clothing)
Mourners wear the clothes that they tore at
the time of learning of the death or at the
funeral
Mirrors in the house are covered
"Baruch dayan emet," Blessed be the one true
Judge
Rituals
Wakes / Visitations
Viewing of body (70-80%)
Social gathering
Reading a will and executing it
Wearing black
Reaction to loss (Grief):
 Death Dying and Grieving
Reaction to loss:

Fantasy Death Exercise

• What are your criteria for a ‘good’ death?
• The only hitch, as in life, is that you have to
die.
• Imagine you are there right now
• Notice where you are, what your are doing,
who is with you, what it is like, perhaps
sounds, smells, other sensory specifics…
• Sudden death in sleep (Older Adults too)
• Dying at home
• Dying engaged in meaningful activity
Common Ideal Death Scenarios
Themes for a ‘Good’ Death
• Home
• Comfort
• Sense of completion (tasks accomplished)
• Saying goodbye
• Life-review
• Love
 Death Dying and Grieving
THE DEATH SYSTEM
In most societies, death is not viewed as the
end of existence because the spiritual body is
believed to live on
People in the U.S. tend to be death avoiders
and death deniers
Changing Historical Circumstances:
The age group in which death most often
strikes
Life expectancy has increased from 47 to 78
years
Location of death
ISSUES IN DETERMINING DEATH
Brain Death: a person is brain dead when all
electrical activity of the brain has ceased for a
specified period of time
Includes both the higher cortical functions
and the lower brain-stem functions
LIFE, DEATH, AND HEALTH CARE
Advance directive & living wills are designed
to be filled in while the individual can still
think clearly
Designed for situations in which the
individual is in a coma and cannot express his
or her desires
Many states have natural death legislation
People engaged in end-of-life planning are
more likely to:
Have been hospitalized in the year prior
Believe that patients rather than physicians
should make health-care decisions
Have less death anxiety
Have survived the painful death of a loved
one
ADVANCE DIRECTIVE & LIVING WILLS
LIVING WILL
I, __________, of __________, being of sound
mind, do hereby willfully and voluntarily make
known my desire that my life not be prolonged
under any of the following conditions, and do
hereby further declare:
1. If I should, at any time, have an incurable
condition caused by any disease or illness, or
by any accident or injury, and be determined
by any two or more physicians to be in a
terminal condition whereby the use of "heroic
measures” or the application of life-sustaining
procedures would only serve to delay the
moment of my death, and where my attending
physician has determined that my death is
imminent whether or not such "heroic
measures" or life-sustaining measures are
employed, I direct that such measures and
procedures be withheld or withdrawn and that
I be permitted to die naturally.
2. In the event of my inability to give
directions regarding the application of life-
sustaining procedures or the use of "heroic
measures", it is my intention that this
directive shall be honored by my family and
physicians as my final expression of my right
to refuse medical and surgical treatment, and
my acceptance of the consequences of such
refusal.
3. I am mentally, emotionally and legally
competent to make this directive and I fully
understand its import.
4. I reserve the right to revoke this directive at
any time.
5. This directive shall remain in force until
revoked.
IN WITNESS WHEREOF, I have hereto set my
hand and seal this _____ day of __________,
20___.
Signed: __________
Declaration of Witnesses
The declarant is personally known to me and I
believe him to be of sound mind and
emotionally and legally competent to make the
herein contined Directive to Physicians. I am
not related to the declarant by blood or
marriage, nor would I be entitled to any
portion of the declarant's estate upon his
decease, nor am I an attending physician of
the declarant, nor an employee of the
attending physician, nor an employee of a
health care facility in which the declarant is a
patient, nor a patient in a health care facility
in which the declarant is a patient, nor am I a
person who has any claim against
any portion of the estate of the declarant upon
his death.
Signed: _____________
LIFE, DEATH, AND HEALTH CARE
Euthanasia: the act of painlessly ending the
lives of individuals who are suffering from an
incurable disease or severe disability
Passive euthanasia: treatment
is withheld
 Death Dying and Grieving
Active euthanasia: death deliberately
induced
Trend is toward acceptance of passive
euthanasia in the case of terminally ill
patients
Experts do not agree on the boundaries or
mechanisms by which treatment decisions
should be implemented
Active euthanasia was made famous by
Dr. Jack Kevorkian in the U.S. as
“assisted suicide”
Active euthanasia is a crime in most
countries and in the U.S. (except Oregon)
Patients who have a desire for euthanasia
are often:
Less religious
Have been diagnosed with depression
Have a lower functional living status
Hospice: a program committed to
making the end of life as free from pain,
anxiety, and depression as possible
Palliative care: reducing pain and
suffering, helping individuals die with dignity
Makes every effort to include the
dying patient’s family members
Includes home-based programs today,
supplemented with care for medical needs and
staff
Family members report better psychological
adjustment to the death of a loved one when
hospice care is used
A “good death” involves physical comfort,
support from loved ones, acceptance, and
appropriate medical care.
ATTITUDES TOWARD DEATH
Death of a parent is especially difficult for
children
Most psychologists believe that honesty is
the best strategy in discussing death with
children
Depends on the child’s maturity level
Terminally ill children may distance
themselves from their parents as death
approaches
Most adolescents:
Avoid the subject of death until a loved one
or close friend dies
Describe death in abstract terms and have
religious or philosophical views about it
Often think that they are somehow immune
to death
Concerns about death increase as one ages:
Awareness usually intensifies in middle age
Middle-aged adults often fear death more
than young adults or older adults
Older adults are more often preoccupied by
it and want to talk about it more
One’s own death usually seems more
appropriate in old age, possibly a welcomed
event, and there is an increased sense of
urgency to attend to unfinished business
KÜBLER-ROSS’S STAGES OF DYING
Denial and Isolation: “It can’t be!”
Anger: “Why me?”
Bargaining: “Just let me do this first!”
Depression: withdrawal, crying, and
grieving
Acceptance: a sense of peace comes
PERCEIVED CONTROL AND DENIAL
Perceived control may be an adaptive
strategy for remaining alert and cheerful
Denial insulates and allows one to avoid
coping with intense feelings of anger and hurt
Can be maladaptive depending on extent
CONTEXTS IN WHICH PEOPLE DIE
More than 50% of Americans die in
hospitals
Nearly 20% die in nursing homes
Hospitals offer many important advantages:
Professional staff members
Technology may prolong life
Most individuals say they would rather die
at home
GRIEVING
Grief: emotional numbness, disbelief,
separation anxiety, despair, sadness, and
loneliness that accompany the loss of
someone we love
Grief is a complex, evolving process with
multiple dimensions
More like a roller-coaster ride than an
orderly progression of stages
Cognitive factors are involved in the severity
of grief
Good family communications and grief
counselors can help grievers cope with feelings
of separation and loss
Prolonged Grief: approximately 10%–20% of
survivors have difficulty moving on with their
life after 6 months have passed
 Death Dying and Grieving
Disenfranchised Grief: an individual’s grief are buried; 20% are cremated
involving a deceased person that is a socially Funerals are an important aspect of
ambiguous loss that can’t be openly mourned mourning in many cultures
or supported Cultures vary in how they practice
Examples: ex-spouse, abortion, stigmatized mourning
death (such as AIDS)
Dual-Process Model:
Loss-oriented stressors: focus on the
deceased individual
Can include grief work and both positive
and negative reappraisal of the loss
Restoration-oriented stressors: secondary
stressors that emerge as indirect outcomes of
bereavement
Changing identity and mastering new skills
Effective coping involves cycling between
coping with loss and coping with restoration
GRIEVING
Impact of death on surviving individuals is
strongly influenced by the circumstances
under which the death occurs
Traumatic, violent, or sudden deaths are
likely to have more intense and prolonged
effects
Can be accompanied by PTSD-like
symptoms
GRIEVING
Cultural Diversity:
Some cultures emphasize the importance of
breaking bonds with the deceased
and returning quickly to autonomous lifestyles
Beliefs about continuing bonds with the
deceased vary extensively
There is no one right, ideal way to grieve
LOSING A LIFE PARTNER
Widows outnumber widowers 5 to 1
Women live longer than men
A widowed man is more likely to remarry
Widows usually marry older men
Widowed women are probably the poorest
group in America
Women tend to do better than men because
women typically have better networks of
friends and relatives
Older women do better than younger women
Religiosity and coping skills are related to
well-being following the loss of a spouse in late
adulthood
FORMS OF MOURNING
Approximately 80%