Endings: Death and Dying
Chapter 19
Robert S. Feldman
DYING AND DEATH ACROSS THE LIFESPAN
What is death?
Functional death
defined by absence of heartbeat & breathing
Brain death
No signs of brain activity, as measured by electrical brain waves
Legal death
Depends on the state
Most rely on brain death, but some use respiration & hearbeat
Death across the Life Span: Causes and Reactions
Infancy and childhood
Miscarriage & still birth
SIDS
Accidents: most frequent cause of death during childhood (MV, fires, drowning)
Homicides: number has tripled in past 50 years, 4th leading cause of death for kids 1-9
Parental reactions: profound grief
Death across the Life Span: Causes and Reactions
Childhood
No concept of death until around the age of 5
Around the age of 5, better understanding of finality and irreversibility of death
By about age 9, acceptance of universality and finality of death
By middle childhood, understanding of some customs involved with death (e.g., funerals, cremation, and cemeteries)
Death across the Life Span: Causes and Reactions
Adolescence
Most frequent cause: accidents (MVA)
Other causes: homicide, suicide, cancer, AIDS
View of death are often unrealistic (Personal fable)

Terminal Illness
Denial
Depression
Death across the Life Span: Causes and Reactions
Young Adulthood
Accidents leading cause, followed by suicide, homicide, AIDS, cancer
Disease more prevalent cause by end of stage
Prime time of life, death seems unthinkable
Creates feelings of anger and impatience
Concerns
Desire to develop intimate relationships
Future planning
Death across the Life Span: Causes and Reactions
Middle Adulthood
Fear of death often greatest of any stage
May lead people to think of number of years they have left vs. number of years already lived
Causes
Heart attack or stroke most frequent
Death across the Life Span: Causes and Reactions
Late Adulthood
Realize death is imminent
Face an increasing number of deaths in their environment
Less anxious about dying
Causes: cancer, stroke, heart disease
Terminal decline, a significant drop in performance in cognitive areas such as memory and reading that may foreshadow death within the next few years
Suicide in Later Life
Rate for men climbs steadily during late adulthood
No age group has a higher rate of suicide than white men over the age of 85
Severe depression
Some form of dementia
Loss of a spouse
Is life always worth living?
A Closer Look at Patient Choices
Terminal Decline
Suffering
Burden to loved ones
Decrease in value to society


CONFRONTING DEATH
Are there steps toward death?
Kübler-Ross
Developed a theory of death and dying
Built on extensive interviews with people who were dying
With input from those who cared for them
Kübler-Ross Theory
Evaluating Kübler-Ross’ Theory
PROS
One of first people to observe systematically how people approach their own deaths
Increased public awareness and affected practices and policies related to dying

CONS
Largely limited to those who are aware that they are dying
Less applicable to people who suffer from diseases in which the prognosis is uncertain
Stage-like increments questioned
Anxiety levels not included



Should people be free to select the nature of their own death?
Choosing the Nature of Death
DNR
Issues
Differentiates of “extreme” and “extraordinary” measures from those that are simply routine
Determines individual’s current quality of life and whether it will be improved or diminished by a particular medical intervention
Determines decision-maker role
Doctors and Decisions
Medical personnel are reluctant to suspend aggressive treatment.

Physicians often claim to be unaware of patients’ wishes

Physicians and other health care providers may be reluctant to act on DNR requests
Trained to save patients
To avoid legal liability issues
Living Wills
Living will: legal document specifying medical treatments a person does/does not want
Health care proxy: person designated to make health care decisions, authorized in living will or durable power of attorney
Durable power of attorney: legal document appointing health care proxy
Euthanasia and Assisted Suicide
Euthanasia
Passive: remove respirator or other equipment & allow death to happen naturally
Voluntary active: take some action such as large dose of medication to end life prematurely

Assisted suicide
Provide means for the person to commit suicide

Caring for the Terminally Ill
Place of Death
Home care
Hospice care: institution devoted to the terminally ill, designed to provide supportive environment for patient & family
Hospital care



GRIEF AND BEREAVEMENT
Mourning and Funerals: Final Rites
Costs
Average funeral and burial costs $7,000
Survivors susceptible to suggestions to “provide the best” for deceased
Determined by social norms and customs
Function of Funerals
All funeral customs serve similar functions.
A way to mark the endpoint of the dead person’s life
Provide a formal forum for the feelings of the survivors
Allow people to share grief and comfort one another
Bereavement and Grief: Adjusting to the Death of a Loved One
What is the difference?
Bereavement: acknowledgment of the objective fact that one has experienced a death
Grief: the emotional response to one’s loss
Grieving in the Western World
1st stage: grief typically entails shock, numbness, disbelief, or outright denial
2nd stage: people begin to confront the death and realize extent of their loss
3rd stage: people reach accommodation stage

Death of Long-term Spouse
Almost always traumatic experience that is usually followed by intense grief and anguish
Strength of relationship with can have effect on grieving process
Almost half of those in satisfying marriages able to get past grief within 6 months
May have better interpersonal skills & better support system
More likely to have talked with spouse about wishes if one of them died
Often better chance to say final goodbyes

When Grief Goes Awry
No particular timetable for grieving
For some people (but not all) grieving may take considerably longer than a year
Only 15 to 30 percent of people show relatively deep depression following loss of loved one
Those who show most intense distress immediately after a death are most apt to have adjustment difficulties and health problems later
Consequences of Grief and Bereavement
Negative
Widowed people are particularly at risk of death (7X higher in 1st year, especially men & younger women
More negative effects if person is already insecure, anxious, or fearful, overly dependent, or lacking in social support
Sudden death

Positive
Remarriage lowers risk of death for survivors, especially for widowers

Helping a Child Cope with Grief

Be honest

Encourage expressions of grief

Reassure children that they are not to blame for the death

Understand that children’s grief may surface in unanticipated ways

Children may respond to books for young persons about death