CHAPTER 17 Death, Dying, & Grieving

Definitions & Legal Issues Sociocultural Definitions Grief expressed differently in different cultures Death viewed in 10 main ways: 1. As an image or object Sympathy cards, tombstones, color black (in the West) 2. As a statistic Mortality rates, patients who die from a certain disease, murder suicide rates, life expectancy tables 3. As an event Funeral, memorial service 4. As a boundary Questioning self, family, outcome 5. As a state of being What happens? 6. As a thief of meaning Takes you with more to do 7. As an analogy Dead as a doornail, dead wrong, dead heat 8. As fear & anxiety How will it happen? What about others? 9. As a mystery What’s it like, what happens after death? 10. As a reward or punishment Everyone meets justice

Sociocultural Definitions

Grief expressed differently in different cultures

Death viewed in 10 main ways:

1. As an image or object

Sympathy cards, tombstones, color black (in the West)

2. As a statistic

Mortality rates, patients who die from a certain disease, murder suicide rates, life expectancy tables

3. As an event

Funeral, memorial service

4. As a boundary

Questioning self, family, outcome

5. As a state of being

What happens?

6. As a thief of meaning

Takes you with more to do

7. As an analogy

Dead as a doornail, dead wrong, dead heat

8. As fear & anxiety

How will it happen? What about others?

9. As a mystery

What’s it like, what happens after death?

10. As a reward or punishment

Everyone meets justice

Legal & Medical Definitions Clinical Death: Lack of heartbeat & respiration Brain Death: 1. No spontaneous movement in response to stimuli 2. No spontaneous respirations for at least 1 hour 3. Total lack of response to painful stimuli 4. No eye movements, blinking, or pupil responses 5. No postural activity, swallowing, yawning, or vocalizing 6. No motor reflexes 7. A flat EEG for at least 10 minutes 8. No change in any of these in 24 hours To be declared brain dead all 8 must be met Lack of brain activity must occur in both the brain stem & cortex Persistent vegetative state: Cortical functioning ceases while brainstem activity continues No recovery from this

Clinical Death:

Lack of heartbeat & respiration

Brain Death:

1. No spontaneous movement in response to stimuli

2. No spontaneous respirations for at least 1 hour

3. Total lack of response to painful stimuli

4. No eye movements, blinking, or pupil responses

5. No postural activity, swallowing, yawning, or vocalizing

6. No motor reflexes

7. A flat EEG for at least 10 minutes

8. No change in any of these in 24 hours

To be declared brain dead all 8 must be met

Lack of brain activity must occur in both the brain stem & cortex

Persistent vegetative state:

Cortical functioning ceases while brainstem activity continues

No recovery from this

Ethical Issues Euthanasia: Ending of a life for reasons of mercy Moral dilemma in decision of circumstances Active Euthanasia Deliberately ending someone’s life based on a clear statement of the person’s wishes or a decision made by someone else who has legal authority Usually when one is in a persistent vegetative state or suffering at the end of a terminal illness Passive Euthanasia Allowing a person to die by withholding available treatment

Euthanasia:

Ending of a life for reasons of mercy

Moral dilemma in decision of circumstances

Active Euthanasia

Deliberately ending someone’s life based on a clear statement of the person’s wishes or a decision made by someone else who has legal authority

Usually when one is in a persistent vegetative state or suffering at the end of a terminal illness

Passive Euthanasia

Allowing a person to die by withholding available treatment

Making intentions known Legality of Euthanasia In many areas, euthanasia is legal only when person has made wishes known 2 ways to make wishes known: 1. Living will States wishes about life support & other treatments 2. Durable power of attorney Make wishes known & names a legal authority to speak for the person

Legality of Euthanasia

In many areas, euthanasia is legal only when person has made wishes known

2 ways to make wishes known:

1. Living will

States wishes about life support & other treatments

2. Durable power of attorney

Make wishes known & names a legal authority to speak for the person

The Hospice Assisting Dying People Emphasizes pain management, or palliative care, & death with dignity Concern is making the person as peaceful & comfortable as possible, not to delay death Primarily aimed at controlling pain & restoring normal functioning Hospice services requested only after person or physician believes no treatment or cure possible

Assisting Dying People

Emphasizes pain management, or palliative care, & death with dignity

Concern is making the person as peaceful & comfortable as possible, not to delay death

Primarily aimed at controlling pain & restoring normal functioning

Hospice services requested only after person or physician believes no treatment or cure possible

The Hospice 2 Types 1. Inpatient provides all care for client 2. Outpatient provides a nurse to visit the client at home Not a hospital Role of staff is to be with client, not treat the client Often attention is paid to personal appearance & grooming Hospice clients more mobile, less anxious, & less depressed Quality of personal care is higher & quality of life better in hospice Considerations: 1. Is person completely informed re: nature & prognosis of condition? 2. What options are available in the progress of the disease? 3. What are the person’s expectations, fears, & hopes? 4. How well do the people in the person’s social network communicate with each other? 5. Are family members available to participate in terminal care? 6. Is a high-quality hospice care program available?

2 Types

1. Inpatient provides all care for client

2. Outpatient provides a nurse to visit the client at home

Not a hospital

Role of staff is to be with client, not treat the client

Often attention is paid to personal appearance & grooming

Hospice clients more mobile, less anxious, & less depressed

Quality of personal care is higher & quality of life better in hospice

Considerations:

1. Is person completely informed re: nature & prognosis of condition?

2. What options are available in the progress of the disease?

3. What are the person’s expectations, fears, & hopes?

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

5. Are family members available to participate in terminal care?

6. Is a high-quality hospice care program available?

Dealing with One’s Own Death Kubler-Ross’s theory 5 Emotional States Dealing with Terminal Patients Denial, Anger, Bargaining, Depression, Acceptance Emotions can overlap & experienced in different order Not everyone progresses through the stages at the same rate or in the same order Emphasis is on differences between the various stages Duration of stage or specific phase varies widely from person to person

Kubler-Ross’s theory

5 Emotional States Dealing with Terminal Patients

Denial, Anger, Bargaining, Depression, Acceptance

Emotions can overlap & experienced in different order

Not everyone progresses through the stages at the same rate or in the same order

Emphasis is on differences between the various stages

Duration of stage or specific phase varies widely from person to person

A Final Scenario Making Choices About how one wants & does not want their life to end End-of-life Issues Management of the final phase of life, after-death disposition of the body & memorial services, & distribution of assets Deciding how the end of life should be handled helps people take control of their dying

Making Choices

About how one wants & does not want their life to end

End-of-life Issues

Management of the final phase of life, after-death disposition of the body & memorial services, & distribution of assets

Deciding how the end of life should be handled helps people take control of their dying

Grieving Bereavement: State or condition caused by loss through death Grief: Sorrow, hurt, anger, guilt, confusion, & other feelings that arise after suffering a loss Mourning: The ways in which grief is expressed

Bereavement:

State or condition caused by loss through death

Grief:

Sorrow, hurt, anger, guilt, confusion, & other feelings that arise after suffering a loss

Mourning:

The ways in which grief is expressed

The Grief Process Grieving A complicated process Does not have clearly marked stages When someone dies, must reorganize life establishing new patterns of behavior, & redefine friendships with family & friends

Grieving

A complicated process

Does not have clearly marked stages

When someone dies, must reorganize life establishing new patterns of behavior, & redefine friendships with family & friends

Processes in Grief Processes: 1. Acknowledging the reality of the loss 2. Working though the emotional turmoil 3. Adjusting to the environment where the deceased is absent 4. Loosen ties to the deceased Mistakes to Avoid: What works for one person may not work for another Don’t underestimate the amount of time needed to deal with various issues Takes at least 2 years to begin recovery There is no recovery, it is living with the loss

Processes:

1. Acknowledging the reality of the loss

2. Working though the emotional turmoil

3. Adjusting to the environment where the deceased is absent

4. Loosen ties to the deceased

Mistakes to Avoid:

What works for one person may not work for another

Don’t underestimate the amount of time needed to deal with various issues

Takes at least 2 years to begin recovery

There is no recovery, it is living with the loss

Risk Factors in Grief Most Important Factors are: Mode of death, personal factors (e.g. personality, religiosity, age, gender), & interpersonal context (social support, kinship relationship) Greater the attachment, greater the grief Church attendance helps some deal with bereavement This is due more to social support Social support helps buffer the effects of bereavement for older rather than middle age adults

Most Important Factors are:

Mode of death, personal factors (e.g. personality, religiosity, age, gender), & interpersonal context (social support, kinship relationship)

Greater the attachment, greater the grief

Church attendance helps some deal with bereavement

This is due more to social support

Social support helps buffer the effects of bereavement for older rather than middle age adults

Normal Grief Reactions Grief Work The psychological side of coming to terms with bereavement Coping What people do to deal with their loss in terms of what helps them Affect People’s emotional reactions to the death of their loved one Change Ways in which survivors’ lives change as a result of the loss Narrative The stories survivors tell about the deceased Relationship Reflects who the deceased person was & the nature of the ties between that person & the survivor

Grief Work

The psychological side of coming to terms with bereavement

Coping

What people do to deal with their loss in terms of what helps them

Affect

People’s emotional reactions to the death of their loved one

Change

Ways in which survivors’ lives change as a result of the loss

Narrative

The stories survivors tell about the deceased

Relationship

Reflects who the deceased person was & the nature of the ties between that person & the survivor

Grief Over Time Grief Counseling Reports of better outcomes when religious or spiritual issues are included in the therapeutic process

Grief Counseling

Reports of better outcomes when religious or spiritual issues are included in the therapeutic process

Coping with Grief 4 Components to Grief: 1. Context of the loss 2. The continuation of subjective meaning associated with the loss 3. The changing representations of the lost relationship over time 4. The role of coping & emotion-regulation processes Dealing with Grief Complex & only understood as a complex outcome that unfolds over time Dual Process Model: Defines 2 broad stressors 1. Loss-oriented stressors Those having to do with the loss itself 2. Restoration-oriented stressors Relating to adapting to the survivor’s new life situation

4 Components to Grief:

1. Context of the loss

2. The continuation of subjective meaning associated with the loss

3. The changing representations of the lost relationship over time

4. The role of coping & emotion-regulation processes

Dealing with Grief

Complex & only understood as a complex outcome that unfolds over time

Dual Process Model:

Defines 2 broad stressors

1. Loss-oriented stressors

Those having to do with the loss itself

2. Restoration-oriented stressors

Relating to adapting to the survivor’s new life situation

Traumatic Grief Reactions Not Everyone can Cope Well & Begin Rebuilding a Life Traumatic Grief Involves: 1. Symptoms of separation distress 2. Preoccupation with the deceased to the point of interference with everyday functioning 3. Symptoms of traumatic distress 4. Feelings of disbelief about the death, mistrust, anger, & detachment from others as a result of the death, feeling shocked by the death, & the experience of somatic symptoms of the deceased Grief can be still quite strong 10 years after the loss

Not Everyone can Cope Well & Begin Rebuilding a Life

Traumatic Grief Involves:

1. Symptoms of separation distress

2. Preoccupation with the deceased to the point of interference with everyday functioning

3. Symptoms of traumatic distress

4. Feelings of disbelief about the death, mistrust, anger, & detachment from others as a result of the death, feeling shocked by the death, & the experience of somatic symptoms of the deceased

Grief can be still quite strong 10 years after the loss

Bereavement Across the Life-Span : Childhood Preschool Death is temporary & magical Not until around 5 – 7 do they realize it is permanent 3 Areas of Change Affect their understanding of death 1. Cognitive-language ability 2. Psychosocial development 3. Coping skills Children’s feelings of loss of a loved one vary with age In middle childhood, child may feel responsible

Preschool

Death is temporary & magical

Not until around 5 – 7 do they realize it is permanent

3 Areas of Change

Affect their understanding of death

1. Cognitive-language ability

2. Psychosocial development

3. Coping skills

Children’s feelings of loss of a loved one vary with age

In middle childhood, child may feel responsible

Bereavement Across the Life-Span : Childhood Limited Ability to Cope Typical reactions in early childhood: Regression, guilt for causing the death, denial, displacement, repression, & wishful thinking Reactions in later childhood: Problems in school, anger, & physical ailments With maturity, coping skills improve Some they get from observing adults Bereavement During Childhood No long-lasting effects unless child does not get adequate care following the death Understanding death can be difficult for children if adults aren’t open & honest about the meaning of death Explain death to them in their own terms & that whatever they feel is okay Mostly, provide loving support

Limited Ability to Cope

Typical reactions in early childhood:

Regression, guilt for causing the death, denial, displacement, repression, & wishful thinking

Reactions in later childhood:

Problems in school, anger, & physical ailments

With maturity, coping skills improve

Some they get from observing adults

Bereavement During Childhood

No long-lasting effects unless child does not get adequate care following the death

Understanding death can be difficult for children if adults aren’t open & honest about the meaning of death

Explain death to them in their own terms & that whatever they feel is okay

Mostly, provide loving support

Bereavement Across the Life-Span : Adolescence More Experience with Death & Grief than Many Realize May have trouble making sense of death of someone close Effects can be severe, & unresolved grief has been linked to agitated depression, chronic illness, enduring guilt, low self-esteem, poorer performance in school & on the job, & problems in interpersonal relationships Reluctant to Discuss Grief with Loss of Sibling Don’t want to appear different from their peers Become vulnerable to psychosomatic symptoms Headaches & stomach pains With loss of parent, many show similar behaviors as loss of sibling Family dynamics change with loss With loss of peer comes survivor guilt

More Experience with Death & Grief than Many Realize

May have trouble making sense of death of someone close

Effects can be severe, & unresolved grief has been linked to agitated depression, chronic illness, enduring guilt, low self-esteem, poorer performance in school & on the job, & problems in interpersonal relationships

Reluctant to Discuss Grief with Loss of Sibling

Don’t want to appear different from their peers

Become vulnerable to psychosomatic symptoms

Headaches & stomach pains

With loss of parent, many show similar behaviors as loss of sibling

Family dynamics change with loss

With loss of peer comes survivor guilt

Bereavement Across the Life-Span : Adulthood Reactions Natural consequence of forming attachments & losing them Loss of partner is usually unexpected & traumatic With young widows, level of grief does not diminish significantly until 5 – 10 years after the loss Maintains strong attachment to deceased In midlife, survivor challenges basic assumptions about self, relationships, & life options

Reactions

Natural consequence of forming attachments & losing them

Loss of partner is usually unexpected & traumatic

With young widows, level of grief does not diminish significantly until 5 – 10 years after the loss

Maintains strong attachment to deceased

In midlife, survivor challenges basic assumptions about self, relationships, & life options

Death of a Child in Young & Middle Adulthood With SIDS, Anxiety is High Very negative view of world & guilt Attachment to child begins before birth, esp. for mothers Parents experiencing miscarriage, still-born, or neonatal death expected to recover quickly Many report deep sense of loss

With SIDS, Anxiety is High

Very negative view of world & guilt

Attachment to child begins before birth, esp. for mothers

Parents experiencing miscarriage, still-born, or neonatal death expected to recover quickly

Many report deep sense of loss

Death of Parent Loss of a Parent Loss of key relationship & psychological buffer between one’s self & death Feelings of loss reflect a sense of letting go, loss of a buffer, acceptance of one’s own eventual death, & sense of relief that parent’s suffering is over

Loss of a Parent

Loss of key relationship & psychological buffer between one’s self & death

Feelings of loss reflect a sense of letting go, loss of a buffer, acceptance of one’s own eventual death, & sense of relief that parent’s suffering is over

Late Adulthood Death of Child or Grandchild Reevaluation loss shortly after and years later Many years later can feel sense of loss & continued difficulty coming to terms with it Loss of a grandchild is similar Family dynamics must be restructured Death of One’s Partner Deep personal loss Social support significant in outcome of grieving process during 1st 2 years after death Quality of support important Bereaved spouse’s ratings of marriage The more depressed the spouse, the more positive the marriage’s rating Depressed nonbereaved spouses gave marriage negative ratings Some widows “sanctify” their husbands Cognitive-behavioral therapy is especially effective intervention to help make sense of loss & deal with other thoughts & feelings

Death of Child or Grandchild

Reevaluation loss shortly after and years later

Many years later can feel sense of loss & continued difficulty coming to terms with it

Loss of a grandchild is similar

Family dynamics must be restructured

Death of One’s Partner

Deep personal loss

Social support significant in outcome of grieving process during 1st 2 years after death

Quality of support important

Bereaved spouse’s ratings of marriage

The more depressed the spouse, the more positive the marriage’s rating

Depressed nonbereaved spouses gave marriage negative ratings

Some widows “sanctify” their husbands

Cognitive-behavioral therapy is especially effective intervention to help make sense of loss & deal with other thoughts & feelings

Widowhood Death of Spouse Usually Follows Period of Caregiving Widows & widowers not only lose spouse but friends & family who feel uncomfortable including a single person rather than a couple in social functions Men & Women React Differently to Widowhood Widowers higher risk of dying soon after spouse either by suicide or natural causes For many women, widowhood means poverty Older widowers less likely to form new, close friendships Widowers 5 times more likely to remarry

Death of Spouse Usually Follows Period of Caregiving

Widows & widowers not only lose spouse but friends & family who feel uncomfortable including a single person rather than a couple in social functions

Men & Women React Differently to Widowhood

Widowers higher risk of dying soon after spouse either by suicide or natural causes

For many women, widowhood means poverty

Older widowers less likely to form new, close friendships

Widowers 5 times more likely to remarry