The document discusses various aspects of death, dying, and grieving, including cultural contexts and changing societal views toward death. It outlines the components of the death system, advanced care planning, euthanasia, the experience of dying individuals, and the grieving process across different stages of life. Additionally, it highlights the importance of communication, coping mechanisms, and cultural diversity in mourning practices.

1. Death, Dying, and
Grieving
Chapter 20
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2. 20 - 2
Chapter Outline
• What is the death system and what is its
cultural & historical context?
• How can death be defined?
• What is the developmental perspective on
death?
• How do people face their own death?
• How do we cope with the death of someone
else?

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Components of the Death System
Kastenbaum (2012)
• People: everyone (at some point of time);
those in funeral industry; policemen; firemen
• Places or contexts: e.g. hospitals, funeral
homes,
• Times: anniversaries & memorial events
• Objects: e.g. caskets, armbands
• Symbols: e.g. religious ceremonies connected
to death

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Cultural Variations of the Death System
• Ancient Greeks – to live a full life and die with glory
• Most societies have rituals that deal with death
• In times of war, famine, natural disasters: individual
consciousness of death increases
• In most societies, death is not viewed as the end of
existence as the spiritual body is believed to live on
• Norouzieh (2005): Americans tend to be death
avoiders & death deniers; in some societies – daily
overdisplay of death in crowded city streets &
impoverished segments of society

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Changing Historical Circumstances
• Age group in which death most often occurs:
– 1800: children before age 10 – ratio 1:2; one
parent would have died before children grew up
– Now: older adults
• Life expectancy:
– 1900 - 47 years; now - 78 years
• Location of death:
– USA today: 80% of deaths occur in institutions or
hospitals, away from family

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Issues in Determining Death
• Recent decades: not easy to determine death
• Brain death: neurological definition:
– Person is brain dead when all electrical activity of
the brain has ceased for a specified period of time
– A flat EEG reading for a specified period of time is
one criterion of brain death
• Includes both the higher cortical functions and the
lower brain-stem functions
– Issue: Some medical experts argue criteria for
death should include only higher cortical
functioning (eg. Intelligence, personality)
associated with making us human

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Advanced Care Planning
• Process of patients thinking about & communicating
their preferences about end-of-life care
• “Choice in Dying” created the living will , a legal
document that reflects the patient’s advance care
planning
– Must be signed while individual is still able to think clearly
– Accepted in all 50 states of USA
• Recently: POLST (Physician Orders for Life Sustaining
Treatment):
– Must involve health care professional & patient or
surrogate conferring to determine & state patient’s wishes

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Euthanasia (mercy killing):
• Act of painlessly ending lives of individuals who are suffering
from an incurable disease or severe disability; 2 types:
– Passive euthanasia – Available treatment is withheld; preferred type
– Active euthanasia - Death deliberately induced, considered a crime in
most countries & in USA (except for Oregon & Washington)
• Well-publicized cases:
– Terri Schiavo: in vegetative state for 15 years; finally passive
euthanasia applied March 18, 2005, died 13 days later
– Dr. Jack Kevorkian: convicted of 2nd
degree murder for using active
euthanasia involving “assisted suicide” of terminally ill patients
• Issue of whether:
– a patient’s life-support system be disconnected if patient has left no
written instructions
– Family of comatose patient can overrule attending doctors’ decision
to continue life-support systems

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Needed: Better care for dying individuals
• Death in America: lonely, prolonged, and painful
• A “good death” involves physical comfort, support from loved
ones, acceptance, and appropriate medical care
• Cowley & Hager (1995): suggested fail-safe measures for
avoiding pain at end of life:
– Make a living will
– Give someone power of attorney
– Give doctors specific instructions
– Discuss with family whether or not you want to die at home
– Check insurance to see if it covers home care or hospice care

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Hospice
• A program committed to making the end of life as
free from pain, anxiety, and depression as possible
– Emphasizes palliative care
• Reducing pain and suffering, helping individuals die with dignity
• Hospice movement started late 1960s in London,
now spread world-wide
• Hospice more likely to serve those with terminal
cancer than those with other life-threatening
conditions
• Can be home-based, community-based, or

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Causes of Death
• Death can occur at any point in the life span
• Prenatal stage: miscarriage
• During birth process & soon after birth: Birth defects
• Infancy: SIDS leading cause of infant death in the
U.S.
• Childhood Years: Accidents or illness
• Adolescence and young adulthood: deaths result
from suicide, homicide, or motor vehicle accidents
• Middle-age and older adult deaths usually result
from chronic diseases

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Attitudes Toward Death
at Different Points in the Life Span
Childhood
•Young children (3 -5 years) believe the dead can be brought
back to life
•Around 9 years of age, children view death as universal and
irreversible
•Death of parent is especially difficult for children
•Honesty is the best strategy in discussing death with children
– Elaboration of explanation depends on child’s maturity level
•Most dying children know they have a terminal illness
– How well they cope depends on their developmental level, social
support & coping skills

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Attitudes Toward Death
at Different Points in the Life Span
Adolescence
•Death may be regarded as remote and may be avoided, glossed
over, or kidded about. (Personal Fable)
•Death of friends, siblings, parents, or grandparents bring death
to the forefront of adolescents’ lives
•Develop more abstract conceptions about death than children

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Attitudes Toward Death
at Different Points in the Life Span
Adulthood
•Middle-aged adults actually fear death more than young adults
or older adults
•Older adults are forced to examine the meanings of life and
death more frequently than younger & middle-aged adults
– Older adults have more direct experience with death (of friends &
relatives)
•Older adults who are dying feel less cheated & more
emotionally calm than younger adults who are dying

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Facing One’s Own Death:
Kübler-Ross’ stages of dying (1969)
• Behavior & thinking of dying persons go through 5 stages:
– 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
• Criticisms:
– Existence of 5 stages not demonstrated by Kubler-Ross herself and
independent research
– Neglected to consider patient’s situations (relationship support, type
of illness, family obligations, institutional climate in which they were
interviewed)
• Some psychologsits prefer to describe them as potential
reactions to dying

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Perceived Control and Denial
• Perceived control may be an adaptive strategy for
remaining alert and cheerful
• Denial can insulate and allows one to avoid coping
with intense feelings of anger and hurt
– Can be maladaptive if e.g. keeps person from having a lif-
saving operation

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Contexts in Which People Die
• Important for the dying person
• More than 50% of Americans die in hospitals and nearly 20%
die in nursing homes
• Increasing no prefer the hospice
• Hospitals offer no. of important advantages:
– Professional staff members readily available
– Availability of medical technology to prolong life
• Many prefer to die at home but may feel:
– They will be a burden at home
– Limited space at home
– Dying at home may alter relationships
– Competency & availability of emergency medical treatment

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Communicating with a Dying Person
• Open communication very important because:
– They can close their lives in accord with their own ideas
about proper dying
– They may be able to complete plans and projects, and
make arrangements and decisions
– They have the opportunity to reminisce and converse with
others
– They have more understanding of what is happening to
them
– See p. 636 Connecting development to life: Effective
strategies for communicating with a dying person

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Grieving
Dimensions of Grieving
•Grief: complex, evolving process with multiple
dimensions - Emotional numbness, disbelief, separation
anxiety, despair, sadness, and loneliness that
accompany the loss of someone we love
•Cognitive factors are involved in the severity of grief –
if more negative beliefs & self-blame, more severe the
grief
•Good family communications can help reduce the
incidence of depression and suicidal thoughts

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Grieving
• Prolonged grief disorder: Grief that involves
enduring despair and remains unresolved over an
extended period of time
– Has negative consequences for physical & mental health
• Disenfranchised grief - an individual’s grief involving
a deceased person that is a socially ambiguous loss
that can’t be openly mourned or supported
– Examples: Ex-spouse, abortion, stigmatized death (such as
AIDS)

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Grieving
Dual-Process model of Coping and Bereavement
•Two main dimensions:
– Loss-oriented stressors: focus on deceased individual; can include
positive & negative reappraisals of the loss
– Restoration-oriented stressors: involve secondary stressors as indirect
outcome of breavement e.g. identity change (wife -> widow) &
mastering skills
•Effective coping involves oscillation between coping with loss
and coping with restoration
Coping and Type of Death
•Impact of death on surviving individuals is strongly influenced by the
circumstances under which the death occurs
•Sudden deaths are likely to have more intense and prolonged effects on
surviving individuals

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Cultural Diversity in Healthy Grieving
• Some cultures emphasize the importance of breaking
bonds with the deceased and returning quickly to
autonomous lifestyles
• Non-Western cultures suggest that beliefs about
continuing bonds with the deceased vary extensively
• There is no one right, ideal way to grieve

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Making Sense of the World
• Grieving stimulates individuals to try to make sense
of their world
• A reliving of the events leading to the death is
common
• When a death is caused by an accident or a disaster,
the effort to make sense of it is often pursued more
vigorously e.g. MH370

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Losing a Life Partner
• Death of an intimate partner brings profound grief
• Widows outnumber widowers because women live longer
than men
• Widowed women are probably the poorest group in America
• Many widows are lonely & benefit considerably from social
support
• Optimal adjustment depends on several factors:
– Women do better than men
– Older widows do better than younger widows
– Widowers more likely to have money & to remarry than widows
– Social support benefits both widows & widowers
– Religiosity & coping skills are related to optimal adjustment

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Forms of Mourning
• USA: 2007 - Approximately 66% are buried and 34%
are cremated; cremation expected to increase to
44% in 2015
• Funerals are an important aspect of mourning in
many cultures
• Cultures vary in how they practice mourning
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