end-of-life issues

TERESITA H. SISON, MD, DSBPP, DPCAM, FPSMS

End-of-Life Issues
 Death, Dying, and Bereavement

Death may be considered the absolute cessation

of vital functions,
Dying is the process of losing these functions.
Dying may also be seen as a developmental concomitant
of living, a part of the birth-to-death continuum.
 Good death is one that is free from avoidable
distress and suffering for patients, families, and
caregivers and is reasonably consistent with
clinical, cultural, and ethical standards.

Bad Death is characterized by needless

suffering, a dishonoring of the patient or familys
wishes or values, and a sense among participants
or observers that norms of decency have been
offended
 Legal Aspects of Death

According to law, physicians must sign the death

certificate, which attests to the cause of death
(e.g., congestive heart failure or pneumonia).

They must also attribute the death to natural,

accidental, suicidal, homicidal, or unknown
causes. A medical examiner, coroner, or
pathologist must examine anyone who dies
unattended by a physician and perform an
autopsy to determine the cause of death.
 Stages of Death and Dying

Stage 1: Shock and Denial.

On being told that they are dying,
persons initially react with shock.
They may appear dazed at first
and then may refuse to believe
the diagnosis; they may deny that
anything is wrong.
Some persons never pass beyond
this stage and may go from doctor
to doctor until they find one who
supports their position.
 Stage 2: Anger.
Persons become frustrated, irritable,
and angry at being ill. They
commonly ask, Why me? They may
become angry at God, their fate, a
friend, or a family member; they may
even blame themselves. They may
displace their anger onto the hospital
staff members and the doctor, whom
they blame for the illness.
Patients in the stage of anger are
difficult to treat
 Stage 3: Bargaining.
Patients may attempt to negotiate
with physicians, friends, or even
God; in return for a cure, they
promise to fulfill one or many
pledges, such as giving to charity
and attending church regularly.
Some patients believe that if they
are good (compliant,
nonquestioning, cheerful), the
doctor will make them better.
 Stage 4: Depression. In
the fourth stage, patients show clinical
signs of depressionwithdrawal,
psychomotor retardation, sleep
disturbances, hopelessness, and,
possibly, suicidal ideation. The
depression may be a reaction to the
effects of the illness on their lives
(e.g., loss of a job, economic hardship,
helplessness, hopelessness, and
isolation from friends and family), or it
may be in anticipation of the loss of
life that will eventually occur.
 Stage 5: Acceptance.
In the stage of acceptance,
patients realize that death is
inevitable, and they accept the
universality of the experience.
Their feelings can range from
a neutral to a euphoric mood.
Under ideal circumstances,
patients resolve their feelings
about the inevitability of death
and can talk about facing the
unknown.
 Those with strong religious beliefs and a
conviction of life after death sometimes find
comfort in the ecclesiastical maxim, Fear not
death; remember those who have gone before
you and those who will come after.
 Near-Death Experiences

Near-death descriptions are often

strikingly similar, involving an out-of-
body experience of viewing ones body
and overhearing conversations,
feelings of peace and quiet, hearing a
distant noise, entering a dark tunnel,
leaving the body behind, meeting dead
loved ones, witnessing beings of light,
returning to life to complete unfinished
business, and a deep sadness on
leaving this new dimension.
A term to describe this experience is
unio mystica, which refers to an
oceanic feeling of mystic unity with an
infinite power.
 Life Cycle Considerations about
Death and Dying
The clinical diversity of death-related attitudes
and behaviors between children and adults has
its roots in developmental factors and age
dependent differences in causes of death
As opposed to adults, who usually die from
chronic illness, children are apt to die from
sudden, unexpected causes.
Almost half of the children who die between the
ages of 1 and 14 years and nearly 75 percent of
those who die in late adolescence and early
adulthood die from
accidents, homicides, and suicides.
Children

Childrens attitudes toward death mirror their

attitudes toward life. Although they share with
adolescents, adults, and elderly adults similar
fears, anxieties, beliefs, and attitudes about
dying, some of their interpretations and reactions
are age specific.
Dying children are often aware of their condition
and want to discuss it.
 They often have more sophisticated views about
dying than their medically well counterparts,
engendered by their own failing health,
separations from parents, subjection to painful
procedures, and the deaths of hospital chums.
At the preschool, preoperational stage of
cognitive development, death is seen as a
temporary absence, incomplete and reversible,
like departure or sleep. Separation from the
primary caretaker(s) is the main fear of
preschool-age children.
Adolescents

Capable of formal cognitive operations,

adolescents understand that death is inevitable
and final but may not accept that their own death
is possible.
The major fears of dying teenagers parallel those
of all teenagers
losing control, being imperfect, and being different.
Concerns about body image, hair loss, or loss of bodily
control can generate great resistance to continuing
treatment.
 Alternating emotions of despair, rage, grief,
bitterness, numbness, terror, and joy are
common.
The potential for withdrawal and isolation is great
because teenagers may equate parental support
with loss of independence or may deny their fears
of abandonment by actually repulsing friendly
gestures.
Adults

Some of the most often expressed fears of adult

patients entering hospice care, listed in the
approximate order of frequency, include fears of
(1) separation from loved ones, homes, and jobs;
(2) becoming a burden to others;
(3) losing control;
4) what will happen to dependents;
(5) pain or other worsening symptoms;
(6) being unable to complete life tasks or
responsibilities;
 (7) dying;
(8) being dead
(9) the fears of others (reflected fears);
(10) the fate of the body;
(11) the afterlife. Problems in communication
arise out of trepidation, making it important for
those involved in health care to provide
environments of trust and safety in which
people can begin to talk about uncertainties,
anxieties, and concerns.
 Late-age adults often accept that their
time has come. Their main fears include
long, painful, and disfiguring deaths;
prolonged vegetative states; isolation; and
loss of control or dignity.
 Elderly patients may talk or joke openly about
dying and sometimes welcome it. In their 70s and
beyond, they rarely harbor illusions of
indestructibilitymost have already had several
close calls: Their parents have died, and they
have gone to funerals for friends and relatives.
 Management
Caring for a dying patient is highly individualized.
Caretakers need to deal with death honestly,
tolerate wide ranges of effects, connect with
suffering patients and bereaved loved ones, and
resolve routine issues as they arise.
 BEREAVEMENT, GRIEF, AND
MOURNING
Bereavement, grief, and mourning are terms that
apply to the psychological reactions of those who
survive a signifficant loss.
Grief is the subjective feeling precipitated by the
death of a loved one.
The term is used synonymously with mourning, although,
in the strictest sense
Mourning is the process by which grief is
resolved; it is the societal expression of post
bereavement behavior and practices.
 Bereavement literally means the state of being
deprived of someone by death and refers to being
in the state of mourning. Regardless of the one
points that differentiate these terms, the
experiences of grief and bereavement have
sufficient similarities to warrant a syndrome that
has signs, symptoms, a demonstrable course, and
an expected resolution.
 Normal Bereavement Reactions
The first response to loss
1. protest, is followed by a longer period of searching
behavior.
As hope to reestablish the attachment bond diminishes,
searching behaviors give way to 2. despair and
3. detachment before bereaved individuals eventually
4. reorganize themselves around the recognition that
the lost person will not return.
 Anticipatory Grief
In anticipatory grief, grief reactions are
brought on by the slow dying process of a
loved one through injury, illness, or high-
risk activity.
 Anniversary Reactions
When the trigger for an acute grief reaction is a special
occasion, such as a holiday or birthday, the rekindled
grief is called an anniversary reaction.

It is not unusual for anniversary reactions to occur each

year on the same day the person died or, in some cases,
when the bereaved individual becomes the same age the
deceased person was at the time of death.
 Mourning

From earliest history, every culture records its

own beliefs, customs, and behaviors related to
bereavement.
Specific patterns include rituals for mourning
(e.g., wakes or Shiva), for disposing of the body,
for invocation of religious ceremonies, and for
periodic official remembrances.
 Bereavement

Because bereavement often evokes depressive

symptoms, it may be necessary to demarcate
normal grief reactions from major depressive
disorder.
 Complicated Bereavement

Complicated bereavement has a confusing array

of terms to describe it
abnormal, atypical, distorted, morbid,
traumatic, and unresolved, to name a few
types.
Three patterns of complicated, dysfunctional grief
syndromes have been identified
chronic, hypertrophic, and delayed grief.
 Chronic Grief
The most common type of complicated grief
often highlighted by bitterness and idealization
of the dead person.
Most likely to occur when the relationship
between the bereaved and the deceased had
been extremely close, ambivalent, or
dependent or when social supports are lacking
and friends and relatives are not available to
share the sorrow over the extended period of
time needed for most mourners.
 Hypertrophic Grief
Most often seen after a sudden and unexpected
death, bereavement reactions are
extraordinarily intense in hypertrophic grief.
Delayed Grief
Absent or inhibited grief when one normally
expects to find overt signs and symptoms of
acute mourning is referred to as delayed grief.
This pattern is marked by prolonged denial;
anger and guilt may complicate its course.
 Traumatic Bereavement
Traumatic bereavement refers to grief that is
both chronic and hypertrophic. This syndrome is
characterized by recurrent, intense pangs of grief
with persistent yearning, pining, and longing for
the deceased; recurrent intrusive images of the
death; and a distressing admixture of avoidance
and preoccupation with reminders of the loss.
Positive memories are often blocked or
excessively sad, or they are experienced in
prolonged states of reverie that interfere with
daily activities. A history of psychiatric illness
Phases of Grief
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