Chapter 10: Death and Dying Lifespan Development: A Psychological Perspective By Martha Lally and Suzanne Valentine-French (Published 2017) In this chapter: Definitions of death Types of care for dying people Funeral rituals in different religions Grief, bereavement, and mourning Developmental responses to death Learning objectives: Death and dying Define death Describe what characterizes physical and social death Compare the leading causes of death in the United States with those of developing countries Explain where people die Describe how attitudes about death and death anxiety change as people age Explain the philosophy and practice of palliative care Describe the roles of hospice and family caregivers Explain the different types of advanced directives Describe cultural differences in end of life decisions Learning objectives: Death and dying (continued) Explain the different types of euthanasia and their controversies Describe funeral rituals in different religions Differentiate among grief, bereavement, and mourning List and describe the stages of loss based on Kübler-Ross’s model and describe the criticisms of the model Explain the dual-process model of grief Identify the impact of losing a child and parent Identify the four tasks of mourning Explain the importance of support groups for those in grief Defining death: Physical death Uniform Determination of Death Act: Irreversible cessation of circulatory and respiratory functions, or Irreversible cessation of all functions of the entire brain, including the brain stem Death process (Bell, 2010) Weeks before passing Reduced appetite Increased sleep, restlessness, disorientation, care needs Days before passing Decreased consciousness, blood pressure, urine volume Pauses in breathing Murmuring to people others cannot see Reaching in air or picking at covers Death process (Bell, 2010 continued) Days to hours before passing Comatose-like state Inability to swallow Extremities and skin become cold and discolored Shallow breaths Defining death: Social death Dehumanizing and withdrawing from someone who is terminally ill (Glaser & Strauss, 1966) Ignoring them, talking about them if they were not present, making decisions without consulting them first Visiting less often, talking about superficial topics May occur with friends/family or health care providers Why does this happen? Feelings of inadequacy Wanting to distance oneself from the reality of death Need for emotional distance to protect against grief and burnout Causes of death: United States In general: Chronic diseases (heart disease, cancer, chronic lower respiratory diseases) But this varies by age Congenital abnormalities most common cause under 1 year of age Unintentional injury most common cause ages 1-44 Malignant neoplasms most common ages 45-64 Heart disease most common age 65 and over Figure 10.2 Leading causes of death in the United States in 2015 Causes of death: The world World Health Organization: 68% of deaths from cardiovascular disease, cancer, diabetes, and chronic lung diseases 23% from communicable diseases, neonatal and maternal mortality, and nutritional problems 9% from injuries Figure 10.3 Leading causes of death worldwide in 2012 Causes of death: The world (continued) High-income countries: 70% of deaths are among people aged 70+ Chronic diseases are primary cause of death Low-income countries: Almost 40% of deaths are among children under age 15 Childbirth complications a common cause of death for infants Only 20% of deaths are among people aged 70+ Almost 1/3 of deaths from infectious diseases Where do people die? In the U.S.: Hospitals most common places to die Rates declining due to changes in Medicare policies Rates of hospital deaths vary worldwide May reflect cultural views about eldercare Figure 10.4 Inpatient hospital deaths in the U.S., 2000-2010 How people understand death: Infants and young children Infants: React to separation caused by death May lose weight, sleep less, become sluggish and less interactive Early and middle childhood: Believe death is temporary or reversible (up to age 9) Worry they may have caused the death (e.g., by misbehaving or wishing it) How people understand death: Older children and adolescents Late childhood: Understand death is permanent and universal But may think that people die because they did something “bad” May worry about their family dying Adolescence: Understand death as well as adults May become preoccupied with death Personal fable produces feelings of unique invulnerability May engage in risky behaviors How people understand death: Early and middle adulthood Early adulthood: Low rates of death anxiety because death seems very remote Middle adulthood: Highest rates of death anxiety Often caused by worries about responsibilities How people understand death: Late adulthood Late adulthood: Lowest rates of death anxiety Fewest responsibilities Have had more time to experience life Have had more experience with death More concerned with how they will die Curative and palliative care Curative care aims to promote complete recovery May not be a realistic goal for all situations Palliative care focuses on providing comfort and relief from physical and emotional pain Not just for terminally ill people But may not focus on curing the patient Hospice care Provides medical, psychological, and spiritual support Both to patient and to family May be provided in home or other facility Tries to make death as pain- and anxietyfree as possible A closer look: Hospice care Must have life expectancy of ≤ 6 months 2013: 1.5 million people received hospice care Insurance regulations may affect access to care Cultural differences in feelings about hospice care Family caregivers National Institute of Medicine (2015): 66 million Americans are caregivers 2/3 of them are women Physical, financial, and emotional burden Declining numbers of caregivers as Baby Boomers age Advance care planning Documents pertaining to end-of-life care Advance directives are initiated by patient Living wills specify health care wishes Durable power of attorney for health care names someone to make health care decisions Medical orders are written by a medical professional on behalf of a seriously ill patient Cultural differences in end-of-life decisions: Patient autonomy General U.S. views: Patients should be told the truth about their health Patients should be autonomous in medical decisions Other countries: Use euphemisms to describe conditions (Japan, some African nations) Hide truth (Pakistan, China) Family members should make medical decisions (Korea) Doctors should make medical decisions Cultural differences in end-of-life decisions: Views of treatment Caucasians more likely to express preference for stopping treatment African Americans and Hispanics more likely to want everything possible done May reflect distrust of medical system Hispanics less likely to use durable power of attorney May be concerned about offending other relatives Figure 10.10 End-of-life preferences by race and ethnicity Euthanasia Intentionally ending one’s life when suffering from a terminal illness or severe disability Active – Intentionally causing death, usually through a lethal dose of medication Physician-assisted suicide – A physician prescribes the means by which a person can die Allowed in 6 states as of 2016 Passive – Withdrawing life-sustaining support Religious practices after death: Hindu Belief in reincarnation means funerals occur quickly Body is cremated and ashes are (if possible) dispersed in one of India’s holy rivers Religious practices after death: Orthodox Judaism Body washed and wrapped in a simple white shroud and placed in plain wood coffin Males are also wrapped in their prayer shawls Burial must occur as soon as possible after death Family members gather and receive visitors (sitting shiva) Religious practices after death: Muslim Deceased are buried as soon as possible Community is involved in the ritual Body is washed and wrapped in a plain white shroud (kafan) Prayers are said, followed by the burial Body is placed directly in the earth without a casket Positioned on the right side, facing Mecca, Saudi Arabia Religious practices after death : Roman Catholic Anointing of the Sick occurs before death Final communion Funeral rites include wake, mass, and burial Grief, bereavement, and mourning Grief – The normal process of reacting to a loss Bereavement – The period after a loss during which grief and mourning occurs Duration depends on attachment and circumstances of loss Mourning – The process by which people adapt to a loss Greatly influenced by cultural beliefs, practices, and rituals Typical grief reactions Mental, physical, social and/or emotional responses Feelings of numbness, anger, guilt, anxiety, sadness and despair Difficulty concentrating, sleep and eating problems, loss of interest in pleasurable activities, physical problems, and even illness Typically lessen within 6-10 weeks Complicated grief Feelings of disbelief, a preoccupation with the dead loved one, distressful memories, feeling unable to move on with one’s life, and a yearning for the deceased May last six months or longer May be hard to distinguish from major depressive disorder Requires examination of client’s history More likely to occur with traumatic forms of bereavement Disenfranchised grief Grief that is not socially recognized Often associated with stigmatized situations Losing loved ones to AIDS or suicide Abortions May be associated with losses not taken seriously Death of a pet or ex-spouse Psychological losses (e.g., partner developing Alzheimer’s disease) No formal mourning practices or recognition by others Lack of social support may intensify symptoms Anticipatory grief Grief that occurs when a death is expected Survivors can prepare for the eventual loss Example: Losing loved one to long-term illness May bring feelings of relief May cause some guilt too Kübler-Ross’ stages of death Process of adjustment Denial Anger Bargaining Depression Acceptance Important to consider psychological needs of dying people Kübler-Ross’ stages of death: Criticisms Questionable validity Stages may not help person adapt Overreliance on model may assume set pattern No set timetable Order of stages not universal Dual-process model of grieving Two types of orientations of grieving people Loss orientation emphasizes feelings of loss and yearning (looking back) Restoration orientation emphasizes reestablishing roles and activities (looking forward) Bereaved person must shift back and forth Grief: Loss of a child Bereaved parents have increased risk of mortality, physical and mental health problems 8% of bereaved mothers attempted or committed suicide within 6 months (Archer, 1999) Intensity of grief may vary with: Age of child Circumstances of death Frequency of childhood death in society Grief: Loss of a parent Normative life event in adulthood Unmarried sons have hardest time coping May produce adjustment problems in childhood Adults may be too preoccupied to attend to children’s needs Children may not understand death Lack of medical understanding Confusing terminology (“went to Heaven”) Mourning Are people given enough time? Workplace leave policies Emotional and practical adjustment Support groups may be helpful Viewing death as normal part of life may help Worden’s four tasks of mourning Acceptance that the loss has occurred Working through the pain of grief Adjusting to life without the deceased Starting a new life while still maintaining a connection with the deceased
