Death and Dying

A Brief Practical Overview

Kathy Bharrathsingh kathybharrathsingh@yahoo.ca

Content Overview
Theoretical Perspectives
Grief reactions to Dying Stages of Dying: Kubler Ross - DABDA A few FYI practicals

(~12 mins)

Death & Dying: Some relevant denitions

Q& A

(~15 mins)

How do I die, let me count the ways

Denitions of Types of Death
There are many types of death, and it's good to know some denitions. How we interpret the state of death can inuence our thoughts, feelings and actions

Necrobiosis. Individual cells die all the time. The cells in your body today weren't there years ago, except your nerve cells. Necrobiosis is the death of cells over the lifespan of an organism. After necrobiosis, a cell is replaced with a new one in a continual process throughout a human's life. Necrosis. When many cells die at once, it isn't the normal
continual necrobiosis of life. Necrosis is the death of an organ or part of an organ. In medicine this is called infarction (yes, that's how it's supposed to be spelled.)

Brain Death. A brain deprived of oxygen survives for 3

to 7 minutes, making it the rst organ to die when circulation or respiration ceases or is impeded, whatever the cause of trouble may be. After a few minutes, the brain can't be brought back to life by any means available today. This is brain death, and it's the reason why clinical death, the period in which a person can be resuscitated, is so short. Once the brain goes, the heart doesn't know how to pump and the lungs don't know how to breath.

Clinical Death. No breathing, no circulation, and no

brain activity characterize clinical death. But that's only half. The other side, the most integral part which separates clinical death from somatic death, is that clinical death begins at the very onset of the symptoms of death, say right after cardiac arrest has cause the heart to stop. It lasts for about four minutes, and it is the interval in which life can be brought back through CPR. After a short few minutes, death is permanent, because the state of the body has gone from clinical death to...
http://library.thinkquest.org/C0122781/science/semantics.htm

Somatic death. Eventually an organism ceases to be in the process of dying and proceeds to be dead. Somatic death is the death-- the permanent, irreversible death-- of an organism as a whole. In humans it is usually after brain death, as the other vital organs are unable to function without the brain. With modern technology, though, one can be brain dead but still have circulation and respiration articially. In such a case one isn't somatically dead because other organs are still alive. Once articial support is removed somatic death occurs, because the person is then entirely and completely inactive with regard to brain, circulation, and respiration.

Some Denitions
Grief, Bereavement, Mourning
Grief1 is dened as the primarily emotional/affective process of reacting to the loss of a loved one through death. The focus is on the internal, intrapsychic process of the individual. Grief reactions may include components such as the following: Numbness and disbelief. Anxiety from the distress of separation. A process of mourning often accompanied by symptoms of depression. Eventual recovery.
Grief reactions can also be viewed as anticipatory, normal, or complicated.

Bereavement2 is dened as the objective situation one faces after having lost an important person via death. Bereavement is conceptualized as the broadest of the three terms and a statement of the objective reality of a situation of loss via death

Mourning1 is dened as the public display of grief. While grief focuses more on the internal or intrapsychic experience of loss, mourning emphasizes the external or public expressions of grief. Mourning is inuenced by ones beliefs, religious practices, and cultural context.

1. Jacobs S (1993). Pathologic Grief: Maladaptation to Loss. Washington, DC: American Psychiatric Press. 2. Stroebe MS, Hansson RO, Schut H, et al., eds. (2008): Handbook of Bereavement Research and Practice: Advances in Theory and Intervention. Washington, DC: American Psychological Association.

Grieving
Every person is unique = individual differences in grief experiences Coping with death easy process, dealing with it in cookbook fashion

How we grieve, how we cope, depends on a number of factors, including: personality relationship with the person who died cultural and religious beliefs coping skills availability of support systems socio-economic status
http://www.cancer.gov

Types of Grief Reactions

Anticipatory grief refers to a grief reaction that occurs in anticipation of an impending loss.[8] and is dened as the total set of cognitive, affective, cultural, and social reactions to expected death felt by the patient and family.[10] The term anticipatory grief is most often used when discussing the families of dying persons, although dying individuals themselves can experience anticipatory grief. The following aspects of anticipatory grief have been identied among survivors: -depression. -heightened concern for the dying person. -rehearsal of the death. -attempts to adjust to the consequences of the death.
Casarett D, Kutner JS, Abrahm J, et al.: Life after death: a practical approach to grief and bereavement. Ann Intern Med 134 (3): 208-15, 2001.

Normal or Common Grief is marked by a gradual movement toward an acceptance of the loss. Normal grief usually includes some common emotional reactions that include: -emotional numbness -shock, disbelief, and/or denial -crying; sighing; having dreams, illusions, and even hallucinations of the deceased -anger - sadness, despair, insomnia, -fatigue, guilt, loss of interest, and disorganization in daily routine

Patterns of Complicated Grief are described in comparison to normal grief and highlight variations from the normal pattern. Inhibited or absent grief: A pattern in which persons show little evidence of the expected separation distress, seeking, yearning, or other characteristics of normal grief. Delayed grief: A pattern in which symptoms of distress, seeking, yearning, etc., occur at a much later time than is typical. Chronic grief: A pattern emphasizing prolonged duration of grief symptoms. Distorted grief: A pattern characterized by extremely intense or atypical symptoms.

Jacobs S: Pathologic Grief: Maladaptation to Loss. Washington, DC: American Psychiatric Press, Inc., 1993.

Bonanno GA, Boerner K: The stage theory of grief. JAMA 297 (24): 2693; author reply 2693-4, 2007.

DABDA
Elizabeth Kubler-Ross
1. Denial"I feel ne."; "This can't be happening, not to me."

2. Anger"Why me? It's not fair!"; "How can this happen to me?"; "Who is to blame?"

3. Bargaining"Just let me live to see my children graduate."; "I'll do anything for a few more years."; "I will give my life savings if..."

4. Depression"I'm so sad, why bother with anything?"; "I'm going to die... What's the point?"; "I miss my loved one, why go on?"

5. Acceptance"It's going to be okay."; "I can't ght it, I may as well prepare for it." In this last stage, the individual begins to come to terms with their mortality or that of their loved one.

Helping The Client To Let Go

The Five Final Tasks
INGREDIENTS To know that we have said what we needed to say. One is our willingness to simply acknowledge that we are dying.
(Ira Byock)

THE FIVE FINAL TASKS Will you forgive me?

actually ask for it? Is there a forgiving that I need from you? Most likely something from a long time ago? Something I have carried with me for so long... Can I

I forgive you

Whether very soon or somewhere down the line does not matter. We have a finite amount of time left. Let's use it well by being honest about what is going on. It allows everyone around us to be honest too.

Am I willing to let go of old wounds and hurts in the face of my dying? Let it just be? Let it rest? And can I say this to you face?

Thank you

What a gift to say thank you one more time. Even if there is neither enough time nor enough words to thank you... for everything.

Two is our openness to talk about dying with our loved ones. Especially with
our loved ones. Yes, talk about death. Say what needs to be said. Hear what wants to be said.

I love you

This is something we can never say often enough. Never hear often enough. It feels so good to hear and say it, even one more time.

Three is to actually take the time to talk. To make the time to listen. To allow the silences in
between. To speak from our hearts. To hear with our hearts. To make room for feelings. All our feelings.

Good bye

Can we actually say it, and mean it? Let it sink in, that this is a final good bye, at least in earthly terms? Feel all its weight? Feel all its finality? Am I ready to say good bye for good?

Byock, Ira (2004). The Four Things That Matter Most: A Book About Living. Free Press.

SPIRITUALITY can help

A study of 160 people with less than three months to live showed that those who felt they understood their purpose in life or found special meaning, faced less fear and despair in the nal weeks of their lives than those who had not. In this and similar studies, spirituality helped dying individuals deal with the depression stage more aggressively than those who were not spiritual.

Santrock, J.W. (2007). A Topical Approach to Life-Span Development. New York: McGraw-Hill.

Palliative Performance Scale (PPS)

Palliative Performance Scale (PPS) : This is a clinical assessment instrument developed at the Victoria Hospice that is used to assess the functional status of palliative care patients and to communicate their status among care provider team members.
PPS v2.0 Instrument
Click here to download a PDF copy of PPS version 2. PPS Level 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% Ambulation Full Full Full Reduced Reduced Mainly Sit/Lie Mainly in Bed Totally Bed Bound Totally Bed Bound Totally Bed Bound Death Return to Top Activity & Evidence of Disease Normal activity & work No evidence of disease Normal activity & work Some evidence of disease Normal activity with Effort Some evidence of disease Unable Normal Job/Work Significant Disease Unable hobby/house work Significant disease Unable to do any work Extensive disease Unable to do most activity Extensive disease Unable to do any activity Extensive disease Unable to do any activity Extensive disease Unable to do any activity Extensive disease Self-Care Full Full Full Full Considerable assistance necessary Considerable assistance required Mainly assistance Total Care Total Care Total Care Intake Normal Normal Normal or reduced Normal or reduced Normal or reduced Normal or reduced Normal or reduced Normal or reduced Minimal to sips Mouth care only Conscious Level Full Full Full Full Full or Confusion Full or Confusion Full or Drowsy +/- Confusion Full or Drowsy +/- Confusion Full or Drowsy +/- Confusion Drowsy or Coma +/- Confusion

0%

http://web.his.uvic.ca/Research/NET/tools/PrognosticTools/PalliativePerformanceScale/index.php

A LESSON WE CAN ALL LEARN SOMETHING FROM

Dying in Action

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References
Becker, E. (1963). Denial of Death. Free Press, New York. Byock, Ira (2004). The Four Things That Matter Most: A Book About Living. Free Press, New York. Byock, Ira (1998). Dying Well. Riverhead Press, New York. Ferris FD, Balfour HM, Bowen K, Farley J, Hardwick M, Lamontagne C, Lundy M, Syme A, West P. A (2002). Model to Guide Hospice Palliative Care. Ottawa, ON: Canadian Hospice Palliative Care Association. Kastenbaum, R.J. (1997). Death, Society and Human Experience. Allyn & Bacon,, New York. Kramp. E.T., & Kramp, D.H. Living with the end in mind. (1998). Three Rivers Press, New York. Kbler-Ross, E. (1969) On Death and Dying. Routledge. Kbler-Ross, E. (2005) On Grief and Grieving: Finding the Meaning of Grief Through the Five Stages of Loss. Simon & Schuster Ltd. Lanza, R & Berman, B. (2010). How Life and Consciousness are the Keys to Understanding the True Nature of the Universe. BenBella Books. Leary, T. (1997). Design for Dying. Harper-Collins, San-Francisco. Rosenberg, L. (2000). Living in the Light of Dying. Shambhala Publications, Boston, MA. Stroebe MS, Hansson RO, Stroebe W, et al., eds. (2001): Handbook of Bereavement Research: Consequences, Coping, and Care. Washington, DC: American Psychological Association. Taylor, T. (2002). The Buried Soul: How Humans Invented Death. Beacon Press, Boston. Similar to PPS instrument, you can nd other Prognostic Instrument Links @ http://web.his.uvic.ca/Research/NET/tools/PrognosticTools/ OtherPrognosticInstrumentLinks.php

Questions & Answers