Death, Dying, and Bereavement

How We Die- one-quarter of people in industrialized nations die suddenly, and most are
victims of heart attacks. For the other , death is long and drawn out. This process is
extended today due to life-saving medical technology. Is this a blessing or a curse?
Physical changes of death take place in 3 stages:
o Agonal phase is the first moments in which the body can no longer
sustain life.
o Clinical death is a short interval in which resuscitation is still possible.
o Mortality is permanent death.
Defining death
o Brain death is generally accepted as the definition of death.
o Persistent vegetative state is a coma-like status and may extend for some
time. The question for such a patient is how long and how far does one go
in sustaining life at this point? People have awakened from such a state
with most of their cognitive abilities intact. Who feels comfortable playing
God in such a situation? Families are often faced with the question of
when to pull the plug, if the patient has no advanced directives.
Death with dignity is the desire of most people, even if they must go through an
extended dying period. This death involves supporting the dying patient through
the physical and psychological distress, being candid about deaths eventuality,
helping them learn enough about their condition to make reasonable choices about
treatment. Retaining personal control is related to extended life.
Understanding of and Attitudes toward death- our culture is death-denying, compared
with earlier generations and more natural societies. In our culture, most young people
reach adulthood having had little contact with death, and adults are often reluctant to
bring up the topic.
Childhood
o Development of the death concept occurs between ages 7 and 10, as
children are faced with the 3 components of the death concept:
Permanence
Universality
Nonfunctionality
o Individual and cultural variations- when adults talk about death
candidly, children can gain a good grasp of the facts of death and have an
easier time accepting it. Religious teachings also affect childrens
concepts. Children first face death for the most part in dealing with the
death of a pet, so parents need to treat this event with reverence and
educate the child about what is happening.
Adolescence is problematic in dealing with death, since they have a cognitive
understanding of death, but not a totally rational understanding. This is displayed
by their high levels of risk taking..
o Gap between logic and reality

o Enhancing adolescents understanding- Adults need to discuss death

with teens to bridge the logical concept and personal experiences
Adulthood- people become more conscious of the finiteness of their lives as they
pass from early to middle adulthood. Elders actually focus more on the
practicalities of how and when death may happen, as well as how they wish their
deaths to be treated.
Death anxiety relates to the cultural views of death. Fear of death generally
declines with age, reaching its lowest level in late adulthood and in adults with
deep faith in a higher being. Women suffer more anxiety about death than men.
People with mental health problems display the most severe death anxiety. It has
been postulated that people with lengthy Alzheimers disease are extremely
fearful of death and this is their way of resisting the process.
Thinking and Emotions of Dying People
Do the Stages of Dying Exist?
o Kubler-Rosss Theory describes 5 responses that dying people display.
They have been conceptualized as stages, but they do not follow a linear
pattern. Dying people also display other coping strategies.
Denial
Anger
Bargaining
Depression
Acceptance
o Evaluation of Kubler-Rosss Theory
Contextual Influences on Adaptations to Dying
o Appropriate death- is one that makes sense in terms of the individuals
pattern of living and values, preserves or restores significant relationships,
and is as free of suffering as possible. A host of contextual variables are
included, such as nature of the disease, personality and coping style,
family members and health professionals truthfulness and sensitivity,
spirituality, religion, and cultural background affect the way people
respond to their own dying. Goals:
Maintaining a sense of identity
Clarifying the meaning of ones life
Maintaining and enhancing relationships
Achieving a sense of control over the time that remains
Confronting and preparing for death
o Nature of the Disease
o Personality and Coping Style
o Family Members and Health Professionals Behavior
o Communicating with Dying People
Be truthful about the diagnosis and course of the disease
Listen carefully and acknowledge feelings
Maintain realistic hope
Assist in the final transition

o Spirituality, Religion, & Culture

A Place to Die- most people want to die at home, but caring for a dying patient is highly
stressful.
Home- Even with hospice help, most homes are poorly equipped to handle the
medical and comfort-care needs of the dying.
Hospital most sudden deaths occur in the emergency room. If the staff is
sympathetic in explaining the process to family, their anger, frustration and
confusion can be reduced. Intensive care is especially depersonalizing as patients
are hooked up to machines for extended periods of time. Concerns about
following protocols and efficiency in treatment can interfere with an easy,
appropriate death. It is such an artificial environment for family members to be in
that many people have great difficulty staying the course through the process.
Hospice Approach strives to meet the dying persons physical, emotional, social,
and spiritual needs and emphasizes quality of life over life-prolonging measures.
o Patient and family as a unit of care
o Meeting patients emotional as well as spiritual needs, controlling pain
o Interdisciplinary team- doctor, nurse, aides, counselor, pharmacist
o Patient kept in home or homelike atmosphere
o Palliative, or comfort care is designed to ease pain without any
expectation of cure. So more pain-killing medications can be prescribed.
o On-call services
o Follow-up bereavement services include group support and other means
of improving family functioning or psychological well-being among
survivors. This can extend one to two years after the death.
The Right to Die is becoming a volatile subject in our culture, as the same techniques
that preserve life can prolong an inevitable death, at the risk of diminishing quality of life
and personal dignity.
Euthanasia is ending the life of a person suffering from an incurable condition.
o Passive euthanasia is withholding or withdrawing life-sustaining
treatment from a hopelessly ill patient. It is widely accepted and practiced.
But if one faces ambiguity regarding his/her care in the face of disputed
medical advice, it is best to design ones own directives about care:
Advance medical directive is a legal document that ensures what
a persons wishes are about end-of-life care. There are specific
instructions about treatment or lack of treatment in certain cases.
Living will contains specific instructions for treatment.
Durable power of attorney for health care is more flexible, as it
authorizes another person to make health care decisions for a dying
person. This is an important role, so people should be well-aware
of the persons views about end-of-life issues before appointing
them as power of attorney. That person should also discuss with
the ill person what his/her wishes are in various circumstances.

o Voluntary active euthanasia is a condition in which doctors or others

comply with a suffering patents request to die before the natural end to
life. There is growing support for this to be made legal in the US, and it is
in Oregon, with many requirements. It is controversial, since there is the
fear that it could be used to kill a vulnerable person who could not speak
for him/herself, yet did not want to die. It puts doctors in very difficult
positions, as they take a vow to do no harm with their treatments.
Lessons from Australia and the Netherlands
o Assisted suicide is even more controversial, as Dr. Kervorkian found,
when he actually threw the switch on his killing machine, leading to his
conviction of murder and incarceration. In the past he had been
prosecuted, but all other patients had the ability to throw the switch
themselves, so he resisted conviction. Some of the conditions that have
been considered as justifiable in aiding suicide:
Patient requests suicide repeatedly and freely and is suffering
intolerably, with no good options
Doctor thoroughly explores comfort-care alternatives with the
patient
Practice is consistent with the doctors values
Independent monitoring is necessary to prevent abuse
Bereavement: Coping with the Death of a Loved One
Bereavement is the experience of losing a loved one by death.
Grief is the intense physical and psychological distress that accompanies loss.
Mourning involves customs that are culturally prescribed expressions of thoughts
and feelings which may aid people in working through their grief.
Grief process is often a roller coaster ride of emotions that gradually aid recovery
from loss over time. The process includes:
o Avoidance
o Confrontation
o Restoration
Dual-process model of coping with loss suggests that effective
coping involves switching between dealing with the emotional
consequences of loss and attending to life changes, which offer
temporary distraction and relief from painful grieving.
Personal and situational variables impact each persons ability to process a loss.
o Sudden, unanticipated vs. Prolonged, expected death- a sudden death is
often accompanied by denial and traumatic confrontation due to the
unexpected nature of the death. A prolonged, timely death allows the
bereaved person to deal with grief through:
Anticipatory grief- acknowledging that the loss is inevitable and
being able to prepare emotionally for it.
o Parents grieving the loss of a child is intense as this is off-time and
unexpected. The grief may be difficult and prolonged. It often results in

the parents divorcing, as they can no longer support one another

emotionally, yet they desperately need support.
o Children and Adolescents Grieving the loss of a parent
o Adults grieving the loss of an intimate partner- once again, this is
something affected by age. Younger widowed partners have a harder time
adjusting than elders who are widowed. This can be particularly difficult
for a homosexual partner who is barred by family members from
participating in the funeral.
o Bereavement Overload occurs when a person experiences several deaths
at once or in close succession. Multiple losses deplete the coping resources
of the best adjusted people, leaving them stuck in grief with poor means of
resolution. AIDS may be the challenge for members of the gay
community, but also care accidents that take out many members of a
family. Elders may suffer this as they experience multiple losses in their
elder years, friends, family members, other acquaintances. This can also
be a severe problem for teens or children who face school shootings. The
longer the exposure to the trauma, the more difficult the grieving.
o Cultural Variations in Mourning Behavior
Bereavement interventions include sympathy and understanding from friends
and family, self-help groups, and grief therapy.
Suggestions for resolving grief after a loved one dies
o Give yourself permission to feel the loss
o Accept social support
o Be realistic about the course of grieving
o Remember the deceased
o At the appropriate time, invest in new activities & relationships

Death Education- Goals

Increasing students understanding of the physical and psychological changes
that accompany dying
Helping students learn how to cope with the death of a loved one
Preparing students to be informed consumers of medical & funeral services
Promoting understanding of social and ethical issues involving death