END OF LIFE ISSUES AND

PALLIATIVE CARE

PRESENTED BY – DR. RIYA SINGH

JUNIOR RESIDENT 1
DEATH AND DYING

 DEATH : It is considered as the absolute cessation of vital functions.

 As per the American Medical Association and the National Conference of Commissioners
on Uniform State Laws , death is considered as
1. Irreversible cessation of circulatory and respiratory functions or
2. Irreversible cessation of all the functions of the entire brain, including the brain stem.

 DYING : It is defined as the process of losing the vital functions.

STAGES OF DEATH AND DYING

 Given by Elisabeth Kubler- Ross

 Consists of 5 stages:
1. Shock and Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance
1. SHOCK AND DENIAL : On being told they are dying; a person initially reacts with
shock and refuses to accept the diagnosis.
2. ANGER : Patient becomes frustrated, irritable and angry at being ill. Ask questions like
“Why me?”. Displace their anger on God, family members, friends , doctor and hospital
staff or might even blame themselves.
3. BARGAINING : Patients attempts to negotiate with physicians, friends or even God in
return for a cure.
4. DEPRESSION : Patient shows clinical signs of depression (withdrawal, psychomotor
retardation, sleep disturbances, hopelessness, etc.) Depression may be a reaction to the
effects of the illness on their lives or it may be in anticipation of the loss of life that will
eventually occur.
5. ACCEPTANCE : Patients realize that death is inevitable, and the accept the universality
of the experience. Feelings can range from a neutral to a euphoric mood.
CONSIDERATIONS ABOUT DEATH AND
DYING
 CHILDREN : Attitude towards death mirror their attitude towards life.
 In preschool children – Death is seen as a temporary absence. Separation from the primary
caretaker is the main fear.
 In school-age children – recognize death as a final reality but view it as something that happens to
older people.
 ADOLESCENTS : Understand that death is inevitable and final but may not accept that
their death is possible.
 ADULTS : Multiple fears. Some of them are
 Separation from loved ones, homes ,and jobs
 Losing control
 Becoming a burden
 What will happen to the dependents etc.
BEREAVEMENT AND GRIEF
 GRIEF : It is the subjective feeling precipitated by the death of a loved one.

 BEREAVEMENT : The state of being deprived of someone by death an refers to being

in a state of mourning ( the process by which grief is resolved )
 Normal Bereavement Reactions :
1. Protest
2. Searching Behavior
3. Despair and detachment
4. Reorganize
BEREAVEMENT VS MAJOR DEPRESSIVE
DISORDER
BEREAVEMENT MAJOR DEPRESSIVE DISORDER
(MDD)
1. May meet syndromal criteria for MDD, but survivor 1. Any symptoms as defined by DSM-V
rarely has morbid feelings of guilt and worthlessness,
suicidal ideations, or psychomotor retardation.

2. Dysphoria – triggered by thoughts or reminders of 2. Dysphoria – autonomous and independent of thoughts of

deceased. deceased

3. Onset – within the first 2 months of bereavement 3. Onset at any time

4. Duration of depressive symptoms – less than 2 months 4. Depression often becomes chronic , intermittent or
episodic

5. Functional impairment is transient and mild 5. Clinically significant distress or impairment

 BEREAVEMENT : DSM-V VS ICD-10
DSM-V ICD-10
Diagnostic name Persistent Complex Bereavement Adjustment Disorder, Grief Reaction
Disorder
Duration Symptoms from each group should Occurs while adapting to a period of
be experienced for 12months in life change
adults or 6 months in children

Symptoms Since the death of someone close, Distress/Emotional disturbance:

should experience symptoms out of • Depression
proportion with sociocultural norms : • Anxiety
• Worry
• Difficulty coping, planning,
carrying out daily routines
• Disturbances of conduct
(adolescents)

Symptoms group B:
• Longing for the deceased
• Sorry/pain about the death

• Preoccupied with the lost

person , circumstances
surrounding the death

Required number of symptoms
Symptom group C :
• Difficulty accepting the death
• Cannot believe or is numb to the
loss
• Difficulty thinking about positive
memories
• Bitter or angry about the loss
• Self – blame
• Avoids things that remind them of
the lost person
• Cannot trust others
• Wants to die to be with the person
• Feels alone/detached
• Feels empty or unable to function
without the lost person
• Trouble seeing their purpose
independent of the lost person
• Trouble/reluctance pursuing other
interests
Symptom group B : 1 symptom Any combination of the above
Symptom group C : 6 symptoms
COMPLICATED BEREAVEMENT

 3 patterns of complicated, dysfunctional grief syndromes have been identified.