CHAPTER 17CHAPTER 17

Death, Dying, & GrievingDeath, Dying, & Grieving

Definitions & Legal Issues

Sociocultural DefinitionsGrief expressed differently in different culturesDeath viewed in 10 main ways:1. As an image or objectSympathy cards, tombstones, color black (in the West)2. As a statisticMortality rates, patients who die from a certain disease, murder suicide rates, life expectancy tables3. As an eventFuneral, memorial service4. As a boundaryQuestioning self, family, outcome

5. As a state of beingWhat happens?6. As a thief of meaningTakes you with more to do7. As an analogyDead as a doornail, dead wrong, dead heat8. As fear & anxietyHow will it happen? What about others?9. As a mysteryWhat’s it like, what happens after death?10. As a reward or punishmentEveryone meets justice

Legal & Medical DefinitionsLegal & Medical Definitions

Clinical Death:Lack of heartbeat & respiration

Brain Death:1. No spontaneous movement in response to stimuli2. No spontaneous respirations for at least 1 hour3. Total lack of response to painful stimuli4. No eye movements, blinking, or pupil responses5. No postural activity, swallowing, yawning, or vocalizing6. No motor reflexes7. A flat EEG for at least 10 minutes8. No change in any of these in 24 hoursTo be declared brain dead all 8 must be metLack of brain activity must occur in both the brain stem & cortexPersistent vegetative state:Cortical functioning ceases while brainstem activity continuesNo recovery from this

Ethical IssuesEthical Issues

Euthanasia:Euthanasia:

Ending of a life Ending of a life for reasons of for reasons of mercymercy

Moral dilemma Moral dilemma in decision of in decision of circumstancescircumstances

Active EuthanasiaActive EuthanasiaDeliberately ending Deliberately ending someone’s life based someone’s life based on a clear statement of on a clear statement of the person’s wishes or the person’s wishes or a decision made by a decision made by someone else who has someone else who has legal authoritylegal authorityUsually when one is in Usually when one is in a persistent vegetative a persistent vegetative state or suffering at state or suffering at the end of a terminal the end of a terminal illnessillness

Passive EuthanasiaPassive EuthanasiaAllowing a person to Allowing a person to die by withholding die by withholding available treatmentavailable treatment

Making intentions known Legality of

EuthanasiaIn many areas, euthanasia is legal only when person has made wishes known2 ways to make wishes known:1. Living willStates wishes about life support & other treatments 2. Durable power of attorneyMake wishes known & names a legal authority to speak for the person

The HospiceThe Hospice

Assisting Dying Assisting Dying PeoplePeopleEmphasizes pain management, or palliative care, & death with dignityConcern is making the person as peaceful & comfortable as possible, not to delay deathPrimarily aimed at controlling pain & restoring normal functioningHospice services requested only after person or physician believes no treatment or cure possible

The HospiceThe Hospice2 Types2 Types1. Inpatient provides all care for client2. Outpatient provides a nurse to visit the client at homeNot a hospitalRole of staff is to be with client, not treat the clientOften attention is paid to personal appearance & groomingHospice clients more mobile, less anxious, & less depressedQuality of personal care is higher & quality of life better in hospice

Considerations:Considerations:1. Is person completely informed re: nature & prognosis of condition?2. What options are available in the progress of the disease?3. What are the person’s expectations, fears, & hopes?4. How well do the people in the person’s social network communicate with each other?5. Are family members available to participate in terminal care?6. Is a high-quality hospice care program available?

Dealing with One’s Own Death

Kubler-Ross’s theoryKubler-Ross’s theory5 Emotional States Dealing with 5 Emotional States Dealing with Terminal PatientsTerminal PatientsDenial, Anger, Bargaining, Depression, AcceptanceEmotions can overlap & experienced in different orderNot everyone progresses through the stages at the same rate or in the same orderEmphasis is on differences between the various stagesDuration of stage or specific phase varies widely from person to person

A Final A Final ScenarioScenario

Making Making ChoicesChoicesAbout how one wants & does not want their life to end

End-of-life End-of-life IssuesIssuesManagement of the final phase of life, after-death disposition of the body & memorial services, & distribution of assetsDeciding how the end of life should be handled helps people take control of their dying

GrievingGrievingBereavement:Bereavement:State or condition caused by loss through death

Grief:Grief:Sorrow, hurt, anger, guilt, confusion, & other feelings that arise after suffering a loss

Mourning:Mourning:The ways in which grief is expressed

The Grief The Grief ProcessProcess

GrievingA complicated processDoes not have clearly marked stagesWhen someone dies, must reorganize life establishing new patterns of behavior, & redefine friendships with family & friends

Processes in Grief

ProcessesProcesses::1. Acknowledging the 1. Acknowledging the reality of the lossreality of the loss

2. Working though the 2. Working though the emotional turmoilemotional turmoil

3. Adjusting to the 3. Adjusting to the environment where the environment where the deceased is absentdeceased is absent

4. Loosen ties to the 4. Loosen ties to the deceaseddeceased

Mistakes Mistakes to Avoid:to Avoid:What works for one person What works for one person may not work for anothermay not work for anotherDon’t underestimate the Don’t underestimate the amount of time needed to amount of time needed to deal with various issuesdeal with various issuesTakes at least 2 years to Takes at least 2 years to begin recoverybegin recoveryThere is no recovery, it is There is no recovery, it is living with the lossliving with the loss

Risk Factors in Risk Factors in GriefGrief

Most Important Factors are:Most Important Factors are:Mode of death, personal factors (e.g. personality, religiosity, age, gender), & interpersonal context (social support, kinship relationship)Greater the attachment, greater the griefChurch attendance helps some deal with bereavementThis is due more to social supportSocial support helps buffer the effects of bereavement for older rather than middle age adults

Normal Grief Normal Grief ReactionsReactions

Grief WorkGrief WorkThe psychological The psychological side of coming to side of coming to terms with terms with bereavementbereavement

CopingCopingWhat people do to What people do to deal with their loss deal with their loss in terms of what in terms of what helps themhelps them

AffectAffectPeople’s emotional People’s emotional reactions to the reactions to the death of their loved death of their loved oneone

ChangeChangeWays in which Ways in which survivors’ lives survivors’ lives change as a result of change as a result of the lossthe loss

NarrativeNarrativeThe stories survivors The stories survivors tell about the tell about the deceaseddeceased

RelationshipRelationshipReflects who the Reflects who the deceased person was deceased person was & the nature of the & the nature of the ties between that ties between that person & the survivorperson & the survivor

Grief Over TimeGrief Over Time

Grief Grief CounselingCounselingReports of better outcomes when religious or spiritual issues are included in the therapeutic process

Coping with Coping with GriefGrief

4 Components to 4 Components to Grief:Grief:1. Context of the loss1. Context of the loss2. The continuation of 2. The continuation of subjective meaning associated subjective meaning associated with the losswith the loss3. The changing 3. The changing representations of the lost representations of the lost relationship over timerelationship over time4. The role of coping & 4. The role of coping & emotion-regulation processesemotion-regulation processes

Dealing with Dealing with GriefGriefComplex & only understood as Complex & only understood as a complex outcome that a complex outcome that unfolds over timeunfolds over time

Dual Process Dual Process Model:Model:Defines 2 broad stressorsDefines 2 broad stressors1. Loss-oriented stressors1. Loss-oriented stressorsThose having to do with the Those having to do with the loss itselfloss itself2. Restoration-oriented 2. Restoration-oriented stressorsstressorsRelating to adapting to the Relating to adapting to the survivor’s new life situationsurvivor’s new life situation

Traumatic Grief Traumatic Grief ReactionsReactions

Not Everyone can Cope Well & Not Everyone can Cope Well & Begin Rebuilding a LifeBegin Rebuilding a LifeTraumatic Grief Involves:Traumatic Grief Involves:1. Symptoms of separation distress1. Symptoms of separation distress2. Preoccupation with the deceased to the point of 2. Preoccupation with the deceased to the point of interference with everyday functioninginterference with everyday functioning3. Symptoms of traumatic distress3. Symptoms of traumatic distress4. Feelings of disbelief about the death, mistrust, anger, 4. Feelings of disbelief about the death, mistrust, anger, & detachment from others as a result of the death, & detachment from others as a result of the death, feeling shocked by the death, & the experience of feeling shocked by the death, & the experience of somatic symptoms of the deceasedsomatic symptoms of the deceasedGrief can be still quite strong 10 years after the lossGrief can be still quite strong 10 years after the loss

Bereavement Across the Life-SpanBereavement Across the Life-Span: : ChildhoodChildhood

PreschoolDeath is temporary & magicalNot until around 5 – 7 do they realize it is permanent3 Areas of ChangeAffect their understanding of death1. Cognitive-language ability2. Psychosocial development3. Coping skillsChildren’s feelings of loss of a loved one vary with ageIn middle childhood, child may feel responsible

Bereavement Across the Life-Bereavement Across the Life-SpanSpan: : ChildhoodChildhood

Limited Ability to Limited Ability to CopeCopeTypical reactions in early childhood:Regression, guilt for causing the death, denial, displacement, repression, & wishful thinkingReactions in later childhood:Problems in school, anger, & physical ailmentsWith maturity, coping skills improveSome they get from observing adults

Bereavement Bereavement During ChildhoodDuring ChildhoodNo long-lasting effects unless child does not get adequate care following the deathUnderstanding death can be difficult for children if adults aren’t open & honest about the meaning of deathExplain death to them in their own terms & that whatever they feel is okayMostly, provide loving support

Bereavement Across the Bereavement Across the Life-SpanLife-Span: : AdolescenceAdolescence

More Experience with Death & Grief than Many RealizeMay have trouble making sense of death of someone closeEffects can be severe, & unresolved grief has been linked to agitated depression, chronic illness, enduring guilt, low self-esteem, poorer performance in school & on the job, & problems in interpersonal relationships

Reluctant to Discuss Grief with Loss of SiblingDon’t want to appear different from their peersBecome vulnerable to psychosomatic symptomsHeadaches & stomach painsWith loss of parent, many show similar behaviors as loss of siblingFamily dynamics change with lossWith loss of peer comes survivor guilt

Bereavement Across the Life-SpanBereavement Across the Life-Span: : AdulthoodAdulthood

ReactionsReactionsNatural consequence of Natural consequence of forming attachments & losing forming attachments & losing themthemLoss of partner is usually Loss of partner is usually unexpected & traumaticunexpected & traumaticWith young widows, level of With young widows, level of grief does not diminish grief does not diminish significantly until 5 – 10 years significantly until 5 – 10 years after the lossafter the lossMaintains strong attachment Maintains strong attachment to deceasedto deceasedIn midlife, survivor challenges In midlife, survivor challenges basic assumptions about self, basic assumptions about self, relationships, & life optionsrelationships, & life options

Death of a Child in Young Death of a Child in Young & Middle Adulthood& Middle Adulthood

With SIDS, With SIDS, Anxiety is HighAnxiety is HighVery negative view of world & guiltAttachment to child begins before birth, esp. for mothersParents experiencing miscarriage, still-born, or neonatal death expected to recover quicklyMany report deep sense of loss

Death of ParentDeath of Parent

Loss of a Loss of a ParentParentLoss of key relationship & psychological buffer between one’s self & deathFeelings of loss reflect a sense of letting go, loss of a buffer, acceptance of one’s own eventual death, & sense of relief that parent’s suffering is over

Late AdulthoodLate Adulthood

Death of Child or Death of Child or GrandchildGrandchildReevaluation loss shortly after and years laterMany years later can feel sense of loss & continued difficulty coming to terms with itLoss of a grandchild is similarFamily dynamics must be restructured

Death of One’s PartnerDeath of One’s PartnerDeep personal lossSocial support significant in outcome of grieving process during 1st 2 years after deathQuality of support importantBereaved spouse’s ratings of marriageThe more depressed the spouse, the more positive the marriage’s ratingDepressed nonbereaved spouses gave marriage negative ratingsSome widows “sanctify” their husbandsCognitive-behavioral therapy is especially effective intervention to help make sense of loss & deal with other thoughts & feelings

WidowhoodWidowhood Death of Spouse Death of Spouse Usually Follows Usually Follows Period of Period of CaregivingCaregivingWidows & widowers Widows & widowers not only lose spouse not only lose spouse but friends & family but friends & family who feel who feel uncomfortable uncomfortable including a single including a single person rather than a person rather than a couple in social couple in social functionsfunctions

Men & Women Men & Women React Differently React Differently to Widowhoodto WidowhoodWidowers higher risk Widowers higher risk of dying soon after of dying soon after spouse either by spouse either by suicide or natural suicide or natural causescausesFor many women, For many women, widowhood means widowhood means povertypovertyOlder widowers less Older widowers less likely to form new, likely to form new, close friendshipsclose friendshipsWidowers 5 times Widowers 5 times more likely to more likely to remarry remarry