This chapter discusses death, dying, and bereavement. It covers where death typically occurs, an overview of hospice care philosophy and types, comparisons of hospital and home-based hospice care, developmental understanding of death, theoretical perspectives on dying and grieving, factors that influence the grieving process, and preventing long-term problems from grief. Key aspects of hospice care are that it views death as normal and involves families in patient care with the goal of palliative rather than curative medical care. Theoretical models of grieving suggest it occurs in stages or involves alternating between loss-oriented and restoration-oriented processes.

1. Chapter 19:
Death, Dying, and Bereavement

2. In This Chapter

3. The Experience of Death
Death Itself
Characteristics
 Clinical death
 Brain death
 Social death

4. The Experience of Death
Where Death Occurs
 Hospitals in the U.S. (45%)
 Decedent’s home (25%)
 Long-term Care (22%)
 Hospice (14%)
 Other (6%)

5. The Experience of Death
Hospice Care
Philosophy
 Death viewed as normal
 Families and the patient encouraged to
prepare for death
 Family are involved in patient’s care
 Control of care is in the hands of the patient
and family
 Medical care is palliative rather than curative

6. Hospice Care
Types of Hospice Care
 Home-based programs
 Hospital-based programs
 Special hospice centers
 Hospice

7. Hospice
Hospital-based and Home-based Care
Comparison
Hospital-Based Care Home-Based Care
Patient Pain Same Same
Length of Survival Same Same
Patient Satisfaction with
Care
Same Same
Family Satisfaction with
Care
Higher Lower
Family Sense of Burden Higher Lower
Let’s take a minute to review some of these comparisons.

8. Dying, Death, and Bereavement
Hospice Care
Hospice Care
Pros
 Reduced cost of death
 Less burden on central caregiver
Cons
 Increased family worry about pain
management

9. Developmental Understanding
of Death

10. The Meaning of Death for Adults
Death as Loss: Age
Age differences
Young adults: Loss of opportunity to
experience things; loss of family
relationships
Older adults: Loss of time to complete inner
work

11. The Meaning of Death for Adults
Death as Loss: Ethnic Differences
Ethnic differences
Mexican Americans: Increase time spent with
family or loved ones
White and African-Americans: Would not
change their lifestyle
See Table 19.2 for responses to hypothetical
impending death

12. Stop and Think!
At what age do you think
people are most fearful of
death?
What prompted your answer?

13. Fear of Death
 Middle-aged adults most fearful of death
 Sense of unique invulnerability prevents
intense fear of death in young adults
 Older adults think and talk more about death
than anyone else

14. Fear of Death
Religious beliefs
Religious beliefs and fear of death
 Very religious adults less afraid of death
 Those totally irreligious may also fear
death less

15. Figure 19.1 Age, Ethnicity and Fear of Death

16. Fear of Death
Personal Worth
Fear of death reduced
 Adults accomplish goals or believe they
have become the person they set out to be
 Belief that life has purpose or meaning
How is this related to Erikson’s stage of
integrity versus despair?

17. Your loved one is dying of a terminal illness.
Would you use a hospice center? Why or
why not?
If you were told that you had a terminal disease
and only 6 months to live, how would you
want to spend your time until you died?
On a scale of 1– 5, with 5 being high, how much
do you fear death?
Questions To PonderQuestions To PonderQuestions To PonderQuestions To Ponder

18. The Process of Dying
Preparation for Death
Kinds of preparations
 Practical preparations
 Deeper preparations
 Older adults more likely to have made
these arrangements

19. The Process of Dying
Preparation for Death
Final preparations
 Unconscious changes just before death
 Terminal drop for psychological health

20. Theoretical Perspectives on Dying
Elisabeth Kubler-Ross’s Stages of Dying

21. Theoretical Perspectives on Dying
Criticisms of Kubler-Ross’s Theory
 Methodological problems
 Cultural specificity
 Stage concept unsupported

22. Theoretical Perspectives on Dying
Alternate Views
Two additional views
Shneidman: Dying process has many “themes”
Corr: Coping with death involves taking care of
specific tasks

23. Theoretical Perspectives on Dying
Responses to Impending Death
Greer: Attitudes and behavioral choices can
influence course of terminal disease
Five groups/stages
 Denial (positive avoidance)
 Fighting spirit
 Stoic acceptance
 Helplessness/hopelessness
 Anxious preoccupation

24. Theoretical Perspectives on Dying
Responses to Impending Death
Greer concluded that the message may be:
“Those who struggle the most, fight the
hardest, express their anger and hostility
openly, and who find some sources of joy in
their lives live longer.”

25. Theoretical Perspectives on Dying
Psychoanalytic Theory
 Traumatic death often followed by physical
or mental problems
 Grief therapy with children makes use of
defense mechanisms (sublimation,
identification)

26. Theoretical Perspectives on Grieving
Freud: Death of a loved one is an emotional
trauma
 Ego tries to insulate itself from unpleasant
emotions through defense mechanisms such as
denial
BUT
 Defense mechanisms provide only temporary
relief
How do people grieve in healthy ways?

27. Theoretical Perspectives on Grieving
Attachment Theory
Bowlby
 Intense grief likely to occur at loss of any
attachment figure
 Quality of attachment related to grief

28. Theoretical Perspectives on Grieving
Attachment Theory
Bowlby: Four stages of grief

29. Theoretical Perspectives on Grieving
Attachment Theory
Sanders five stages of grief comparable to
Bowlby:
 Shock
 Awareness
 Conservation/withdrawal
 Healing
 Renewal

30. Theoretical Perspectives on Grieving
Attachment Theory
Revisionist Views
 Avoiding expressions of grief neither
prolongs grief nor inevitably creates mental
health problems
 Grieving does not occur in fixed stages
 Many themes present simultaneously but
one or another may dominate at one point in
time
 Adults develop different patterns of grieving

31. Figure 19.2 Jacobs’s Model of Grieving

32. Theoretical Perspectives on Grieving
Patterns of Grieving
Wortman and Silver
 Normal
 Chronic
 Delayed
 Absent

33. Theoretical Perspectives on Grieving
Dual-Process Model
Alternates between:

34. Theoretical Perspectives on Grieving
The Experience of Grieving: Death Rituals
Psychosocial functions of death rituals such
as funerals
 Help family and friends manage grief by
giving a specific set of roles
 Bring family members together in unique
ways
 Establish shared milestones for families

35. Theoretical Perspectives on Grieving
The Process of Grieving
Factors Associated with Grief: Age of the
Bereaved
 Children express feelings of grief like teens
and adults
 Teens often show prolonged grief responses

36. Theoretical Perspectives on Grieving
Factors Associated with Grief
Modes of Death and Grief
 Caregiver widows may show depression.
 Death with intrinsic meaning reduces grief.
 Sudden and violent deaths evoke more
intense grief.
 Suicide produces unique responses in
survivors.

37. Theoretical Perspectives on Grieving
Widowhood and Effects of Grief
 Immediate and long term effects on the
immune system
 Incidence of depression among widows and
widowers rises substantially

38. Theoretical Perspectives on Grieving
Pathological Grief
 Depression-like symptoms lasting longer
than 2 months
 Grief lasting longer than 6 months can lead
to long-term depression and physical
ailments
 Problems may continue for up to 2 years
after death of loved one
 BUT cultural practices may mimic
pathological grief

39. Theoretical Perspectives on Grieving
Sex Differences
 Spouse death more negative for men than
for women.
 Risk of death higher in men immediately
after a spouse’s death.
 Widowers withdraw in multiple ways.
 Alcohol use may influence depression.
 Social relationships remain important for
both sexes.

40. Theoretical Perspectives on Grieving
Preventing Long-Term Problems
 “Talk-it-out” approach to managing grief can help
prevent grief-related depression.
 Developing coherent personal narrative of events
surrounding spouse’s death helps manage grief.
 Participating in support groups helps.
 Appropriate amount of time off from work to grieve
is important.