Death & Dying Dr. Reem Al-SabahDept. of Community Med. & Behavioral Sciences
Leading Causes of Death 2006 Kuwait USA1 Ischemic Heart Disease Heart Disease2 All neoplasms Malignant Neoplasms3 Other heart diseases Cerebrovascular4 Cardiovascular diseases Chronic lower respiratory disease5 Transport accidents Unintentional Injury6 Congenital/Chromosomal Diabetes Mellitus anomalies7 Certain conditions Alzheimer’s disease originating in the perinatal period
Thanatology: the study of death and dying What is Death? Defining death is a difficult. WHO definition of death: “Death is the permanent disappearance of all evidence of life at any time after birth has taken place” (United Nations, 1953).
Definition of Death1. The end of life. The cessation of life.2. The permanent cessation of all vital bodily functions.3. The cessation of all vital functions (traditionally demonstrated by an absence of spontaneous respiratory and cardiac functions).
When does a human life end? The traditional standard, a human being is dead when the heart and lungs have irreversibly ceased to function. In some cases, permanent loss of consciousness may precede cardiopulmonary failure.
Medical technologies (e.g., mechanical respirators, electronic pacemakers…etc) has increased the temporal separation between various system failures. Availability of transplantable organs. "dead-donor rule": organs necessary for life may not be procured before donors are dead, since the removal of such organs would otherwise cause death.
Two landmark reports helped to generate a movement away from exclusive reliance on the traditional standard: the 1968 report of the Harvard Medical School Ad Hoc Committee. A 1981 presidential commission report, Defining Death. This document included what became the Uniform Determination of Death Act (UDDA). Today the US follows the UDDA in recognizing:whole-brain death-- the irreversible cessation of allfunctions of the entire brain -- as a legal standard ofdeath.
The Uniform Determination of Death Act (UDDA) It states that: "An individual who has sustained either:(1) irreversible cessation of circulatory and respiratory functions, or(2) irreversible cessation of all functions of the entire brain, including the brain stem is dead. A determination of death must be made in accordance with accepted medical standards." This definition was approved by the American Medical Association in 1980 and by the American Bar Association in 1981. Today all fifty states and the District of Columbia follow the UDDA as a legal standard of death.
A person can be legally dead even if his/hercardiopulmonary system continues to function. A brain-based standard of death: if apatients entire brain is non-functioning, so thatbreathing and heartbeat are maintained only byartificial life-supports.
Diagnosis of total brain failureCan be made only when each of the following four conditions has been met:1. The patient has a documented history of injury that does not suggest a potentially transient cause of symptoms, such as hypothermia or drug intoxication.2. The patient is verified to be in a completely unresponsive coma.3. The patient demonstrates no brainstem reflexes.4. The patient shows no drive to breathe during the apnea test.
Islamic definition of death A Symposium Held in Kuwait 17-19 December 19961. Signs which signify death:An individual is considered dead in one of thefollowing two situations:A. Complete irreversible cessation of respiratory and cardiovascular systems.B. Complete irreversible cessation of the functions of the brain including the brain stem.This should be confirmed upon by the accepted inmedical standards.
2. Guidelines for diagnosing brain and brain stemdeath: The presence of a reliable medical specialist well experienced in the clinical diagnosis of brain and brain stem death and the various implications of such diagnosis. Prescribed observation necessitates complete medical coverage in a specialized suitably equipped institution. Second opinion should be accessible whenever sought.
The Dying Process “A dying individual is a living individual” All deaths involve a complex interplay of cognitive, social, and biological processes.” (Rebok & Hoyer, 1979) Death is a natural part of the life span. The dying process is unique to each individual.
Death can occur suddenly or as a process over time. The signs of approaching death mirror a slowing down of the body. Death is a unique experience for each person coming in its own time and in its own way. Dying happens to the whole person, not just the body. The individual is affected physically, emotionally, socially, mentally and spiritually. Even though one is physically dying, the emotional- social and spiritual dimensions have tremendous potential for growth during the dying process.
Mental changes Restlessness or agitation which may be a result of less oxygen to the brain, metabolic changes or physical pain. Occasional or constant confusion which may be related to separation from the normal routines of living (may also be the result of a disease, or the dying process). Levels of consciousness (being alert and aware) may vary.
Sleepiness, with ability to be awakened and awareness of surroundings. The senses may be dulled and there may be little awareness of what is happening in the environment. Sleep may be so deep that the dying person cannot be awakened and is unresponsive.
Emotional-social changes Looking back at one’s life in search of meaning and contributions – life review. Saying good-bye to people and places, forgiving and being forgiven, facing regrets – life closure. Acceptance or coming to terms with ongoing losses and eventual death.
The Grief Process- definitions Bereavement : the state of being that results from the death of a significant other. Grief : the outcome of being bereaved and involves a variety of reactions that constitute the grief process. (Grief can be the result of loss not involving death such as loss of job, loss of a limb, loss of status). Mourning: the social prescription for the way in which we are expected to display our grief and often reflects the practices of one’s culture (e.g., wearing black)
Five Stages of Grief (The Grief Cycle) Elisabeth kübler-Ross
Stage Interpretation example Denial -Usually temporary shock response “I feel fine. This cant be to bad news. –Isolation from people, happening, not to me!” even family members, avoiding the dying person. Anger Can be expressed in different ways. “Why me? Its not fair! NO! Angry with themselves, and/or with NO! How can this happen!” others, especially those close to them.Bargaining A brief stage, hard to study because “Just let me live to see my it is often between patient and God. children graduate. Ill do anything, cant you stretch it out? A few more years.”Depression Mourning for losses . It shows that “Im so sad, why bother with the person has at least begun to anything? Im going to die . . . accept the reality Whats the point?”Acceptance It takes a while to reach this stage “Its going to be OK.” ; “I cant and a person who fights until the fight it, I may as well prepare end will not reach it. realizing that for it.” death is inevitable.
Words of Caution Kübler-Ross did not intend this to be a rigid series of sequential or uniformly timed steps. Its not a process (fixed and consistent) as such, its a model or a framework. People do not always experience all of the five grief cycle stages. The stages are not linear; neither are they equal in their experience. Peoples grief reactions are unique. The model is a description not a prescription. When we know more about what is happening to us or other people’s emotions we can deal with it better.
The dying Role3 key elements:1. Practical: tasks people need to arrange at the end of their lives.2. Relational: reconciling the dying role with other roles3. Personal: finishing one’s life story
Complicated Grief It is some compromise , distortion, or failure to of one or more of the tasks of mourning, given the amount of time since the death. The bereaved is attempting two things: To deny, repress, or avoid aspects of the loss, its pain, and the full realization of its implications for the mourner; To hold onto, and avoid relinquishing, the lost loved one.
Factors related to the mourner that may increase risk for unresolved grief Involvement in a “conflicted” relationship with the person who died. Previous or current mental health problems. Perceived lack of social support. Unresolved losses from the past. A sudden/unanticipated death, particularly when it is violent or random. The cause of death is an extremely lengthy illness. The loss of a child. The perception of preventability.
Types of Complicated (unresolved) Grief Absent Grief -- as if the death never occurred—complete denial or shock. Inhibited grief: Less than expected signs of grieving, and is usually manifested in the physical body in place of grief reactions. Delayed grief: expression of grief some time after the death. A different loss may trigger a magnified grief reaction that is really tied to the earlier one. Chronic Grief : the bereaved person continuously exhibits intense grief reactions which are more appropriate for early bereavement and last longer than what is considered the normal grief period
Symptoms of Chronic (unresolved) Grief Mummification: Preservation of the environment just as it was when the person was alive Identification: manifesting symptoms, or problems, mannerisms that are the same as those of the deceased prior to death.
Idealization: recalling only positive characteristics of the deceased . If carried to the extreme it can be destructive (unlikely to invest in other relationships). Idealization and identification of the deceased is only a problem if it hinders the person’s ability to resolve their grief over time.
Other Symptoms of Unresolved Grief1. Psychosomatic medical illness.2. Changes in relationships with friends and relatives.3. Furious hostility.4. Lack of emotion.5. Acts detrimental to social and economic existence.6. Depression, insomnia, feelings of worthlessness, bitter self-accusation, need for self-punishment.7. Inability to discuss the deceased without crying or having the voice crack.8. Minor event triggers full-blown grief reaction.
Developmental Concepts of DeathHimebauch A, Arnold R and May C. Grief in children and developmentalconcepts of death. June 2005 End-of-Life Physician Education ResourceCenter www. eperc.mcw.edu.
Age group Understanding of death0-2yrs (infants) •No cognitive understanding of death •Behavioral regression due to separation anxiety2-6yrs •Death is temporary and reversible(Preschool) •Magical thinking6-8yrs •Death is final and irreversible(School Age) •Not universal or could happen to them •Somatic complaints may be present8-12yrs •An adult understanding of death(Pre-Adolescence) •Final, irreversible, and universal •Intellectualize death12-18yrs •Also an adult understanding of death(Adolescence) •Strong emotional reactions with difficulty identifying and expressing feelings