Death, Dying, and Bereavement

In This Chapter
The Experience of Death
The Meaning of Death Across the Lifespan
The Process of Dying
Theoretical Perspectives on Grieving
The Experience of Grieving

The Experience of Death
Death Itself
Characteristics
 Clinical death
 Brain death
 Social death

The Experience of Death
Where Death Occurs
 Hospitals in the U.S. (45%)
 Decedent’s home (25%)
 Long-term Care (22%)
 Hospice (14%)
 Other (6%)

The Experience of Death
Hospice Care
Philosophy
 Death viewed as normal
 Families and the patient encouraged to prepare for death
 Family are involved in patient’s care
 Control of care is in the hands of the patient and family
 Medical care is palliative rather than curative

Types of Hospice Care
 Home-based programs
 Hospital-based programs
 Special hospice centers
 Hospice

Hospice
Hospital-based and Home-based Care
Comparison
Hospital-Based Care Home-Based Care
Patient Pain
Length of Survival
Patient Satisfaction with
Care
Same
Same
Same
Same
Same
Same
Lower Family Satisfaction with
Care
Higher
Family Sense of Burden Higher Lower
Let’s take a minute to review some of these comparisons.

Dying, Death, and Bereavement
Hospice Care
Hospice Care
Pros
 Reduced cost of death
 Less burden on central caregiver
Cons
 Increased family worry about pain management

Developmental Understanding of Death

The Meaning of Death for Adults
Death as Loss: Age
Age differences
Young adults: Loss of opportunity to experience things; loss of family relationships
Older adults: Loss of time to complete inner work

The Meaning of Death for Adults
Death as Loss: Ethnic Differences
Ethnic differences
Mexican Americans: Increase time spent with family or loved ones
White and African-Americans: Would not change their lifestyle
See Table 19.2 for responses to hypothetical impending death

Stop and Think!

Fear of Death
 Middle-aged adults most fearful of death
 Sense of unique invulnerability prevents intense fear of death in young adults
 Older adults think and talk more about death than anyone else

Fear of Death
Religious beliefs
Religious beliefs and fear of death
 Very religious adults less afraid of death
 Those totally irreligious may also fear death less

Figure 19.1 Age, Ethnicity and Fear of Death

Fear of Death
Personal Worth
Fear of death reduced
 Adults accomplish goals or believe they have become the person they set out to be
 Belief that life has purpose or meaning
How is this related to Erikson’s stage of integrity versus despair?

Your loved one is dying of a terminal illness.
Would you use a hospice center? Why or why not?
If you were told that you had a terminal disease and only 6 months to live, how would you want to spend your time until you died?
On a scale of 1 – 5, with 5 being high, how much do you fear death?

The Process of Dying
Preparation for Death
Kinds of preparations
 Practical preparations
 Deeper preparations
 Older adults more likely to have made these arrangements

The Process of Dying
Preparation for Death
Final preparations
 Unconscious changes just before death
 Terminal drop for psychological health

Theoretical Perspectives on Dying
Elisabeth KublerRoss’s Stages of Dying

Theoretical Perspectives on Dying
Criticisms of KublerRoss’s Theory
 Methodological problems
 Cultural specificity
 Stage concept unsupported

Theoretical Perspectives on Dying
Alternate Views
Two additional views
Shneidman: Dying process has many “themes”
Corr: Coping with death involves taking care of specific tasks

Theoretical Perspectives on Dying
Responses to Impending Death
Greer: Attitudes and behavioral choices can influence course of terminal disease
Five groups/stages
 Denial (positive avoidance)
 Fighting spirit
 Stoic acceptance
 Helplessness/hopelessness
 Anxious preoccupation

Theoretical Perspectives on Dying
Responses to Impending Death
Greer concluded that the message may be:
“Those who struggle the most, fight the hardest, express their anger and hostility openly, and who find some sources of joy in their lives live longer.”

Theoretical Perspectives on Dying
Psychoanalytic Theory
 Traumatic death often followed by physical or mental problems
 Grief therapy with children makes use of defense mechanisms (sublimation, identification)

Theoretical Perspectives on Grieving
Freud: Death of a loved one is an emotional trauma
 Ego tries to insulate itself from unpleasant emotions through defense mechanisms such as denial
BUT
 Defense mechanisms provide only temporary relief
How do people grieve in healthy ways?

Theoretical Perspectives on Grieving
Attachment Theory
Bowlby
 Intense grief likely to occur at loss of any attachment figure
 Quality of attachment related to grief

Theoretical Perspectives on Grieving
Attachment Theory
Bowlby: Four stages of grief
Numbness
Yearning
Disorganization and despair
Reorganization

Theoretical Perspectives on Grieving
Attachment Theory
Sanders five stages of grief comparable to
Bowlby:
 Shock
 Awareness
 Conservation/withdrawal
 Healing
 Renewal

Theoretical Perspectives on Grieving
Attachment Theory
Revisionist Views
 Avoiding expressions of grief neither prolongs grief nor inevitably creates mental health problems
 Grieving does not occur in fixed stages
 Many themes present simultaneously but one or another may dominate at one point in time
 Adults develop different patterns of grieving

Figure 19.2 Jacobs’s Model of Grieving

Theoretical Perspectives on Grieving
Patterns of Grieving
Wortman and Silver
 Normal
 Chronic
 Delayed
 Absent

Theoretical Perspectives on Grieving
Dual-Process Model
Alternates between:
Confrontation
Restoration

Theoretical Perspectives on Grieving
The Experience of Grieving: Death Rituals
Psychosocial functions of death rituals such as funerals
 Help family and friends manage grief by giving a specific set of roles
 Bring family members together in unique ways
 Establish shared milestones for families

Theoretical Perspectives on Grieving
The Process of Grieving
Factors Associated with Grief: Age of the
Bereaved
 Children express feelings of grief like teens and adults
 Teens often show prolonged grief responses

Theoretical Perspectives on Grieving
Factors Associated with Grief
Modes of Death and Grief
 Caregiver widows may show depression.
 Death with intrinsic meaning reduces grief.
 Sudden and violent deaths evoke more intense grief.
 Suicide produces unique responses in survivors.

Theoretical Perspectives on Grieving
Widowhood and Effects of Grief
 Immediate and long term effects on the immune system
 Incidence of depression among widows and widowers rises substantially

Theoretical Perspectives on Grieving
Pathological Grief
 Depression-like symptoms lasting longer than 2 months
 Grief lasting longer than 6 months can lead to long-term depression and physical ailments
 Problems may continue for up to 2 years after death of loved one
 BUT cultural practices may mimic pathological grief

Theoretical Perspectives on Grieving
Sex Differences
 Spouse death more negative for men than for women.
 Risk of death higher in men immediately after a spouse’s death.
 Widowers withdraw in multiple ways.
 Alcohol use may influence depression.
 Social relationships remain important for both sexes.

Theoretical Perspectives on Grieving
Preventing Long-Term Problems
 “Talk-it-out” approach to managing grief can help prevent grief-related depression.
 Developing coherent personal narrative of events surrounding spouse’s death helps manage grief.
 Participating in support groups helps.
 Appropriate amount of time off from work to grieve is important.