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THE FINAL CHALLENGE: DEATH AND DYING
LEARNING OBJECTIVES
After students have read and studied the material in this chapter, they should be able to answer the
following questions:
1. How is death defined? Why is the definition of death controversial?
2. How does the social meaning of death vary across groups?
3. What is average life expectancy and factors influence an individual’s life expectancy?
4. What is the difference between programmed theories of aging and damage theories of aging?
What are specific examples of each type of theory?
5. What are Kübler-Ross's stages of dying? How valid and useful is this theory?
6. What is the Parkes-Bowlby attachment explanation of grief?
7. What is the infant's understanding of separation and death? How do children's conceptions of
death compare to a "mature" understanding of death?
8. What factors might influence a child's understanding of death? What is a dying child's
understanding of death? How do dying children cope with the prospect of their own death?
9. How do adolescents understand and cope with death?
10. How is one’s reaction to death of another influenced by the relationship to the deceased (e.g.,
spouse, parent)?
11. What factors contribute to effective and ineffective coping with grief? What differentiated
normal and prolonged grief?
12. What can be done for those who are dying and for those who are bereaved to better understand
and face the reality of death? What role might hospices play?
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CHAPTER OUTLINE
I.
Life and death issues
A. What is death?
1. Biological definitions of death
a. biological death is a process not a single event
i. different systems die at different rates
b. total brain death-- irreversible loss of functioning in entire brain with the
following criteria…
i. body is totally unresponsive to stimuli
ii. failure to move for one hour and failure to breathe for three
minutes after removed from ventilator
iii. no reflexes
iv. register a flat electroencephalogram (EEG) indicating there is no
activity within the brain
v. process repeated after 24 hours
c. right-to-die and individuals in long-term vegetative state
i. Karen Ann Quinlan famous case
ii. irreversible coma but not “dead” as lower brain still functioned
d. death can be declared is irreversible cessation of circulatory and
respiratory systems or loss of all brain functions
c. euthanasia-- meaning “happy or good death” in which process of death is
hastened in person who is suffering
2. Social meanings of death
a. cultural and historical differences in experiences of death
i. Western society, death taken out of home and put into hospitals
ii. funeral and grieving activities vary by culture (e.g., laughing to
weeping)
iii. preservation and/or disposing of corpse varies by culture (e.g.,
smoking., embalming, eaten, buried)
iv. Puerto Ricans tend to display intense, hysterical emotions
v. Japanese Americans more restrained
vi. Jewish shiva-- one week mourning period accompanied by
withdrawal from normal activities
B. What kills us and when?
1. Life expectancy at birth-- average number of years a newborn is expected to life
a. increased this century in U.S. to 75 for white men and 80 for white
women
b. steady increase over centuries
2. Infancy is most vulnerable period
3. Adolescence time of good health (car accidents, homicide, suicide leading causes
of death)
3. Leading causes of death change across the life span
a. by middle age, begin to include chronic conditions
C. Theories of aging: Why do we age and die?
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1. Programmed theories of aging-- emphasize systematic, genetic control over aging
2. Damage theories of aging—more haphazard and due to errors in cells and organ
deterioration
3. Programmed theories
a. maximum life-- ceiling number of years anyone with a species can live
i. about 110-120 years in humans
ii. humans comparatively long-lived
iii. fact that different species have different life expectancies may be
due to effects of species-wide genes
b. Hayflick limit-- human cells can divide a limited number of times
i.. may explain differences in maximum life span by species
ii. may be due to shortening of telomeres-- stretches of DNA that
form end of chromosomes
iii. telomeres shorten until cells cease to replicate
c. progeria-- genetic disorder caused by dominant gene that leads to
extremely premature aging
d. genetically guided systematic changes in hypothalamus that affect
neuroendocrine and immune systems
2. Damage theories
a. free-radical theory-- toxic by product of normal metabolic processes
within the cell
i. electron free molecules that damage cell body and cell DNA
ii.. “age spots” on skin are examples of free radical damage
iii. antioxidants-- substances (e.g., vitamin E and C) that inhibit free
radical activity
3. Nature and nurture conspiring
a. mutual influence of environment (e.g., toxins) and genetic factors
II.
The experience of dying
A. Kübler-Ross's stages of dying
1. Five stages
a. denial and isolation-- “No, it cannot be me”
b. anger-- “Why me?”
i. often directed at doctors or family members
c. bargaining-- “Okay, but please let…”
d. depression-- “All is lost”
e. acceptance-- “The struggle is over and it’s time for the rest of the
journey”
2. Hope-- runs throughout the other five responses
B. Criticisms and alternate views
1. Use of term “stage” is inappropriate
a. death seldom follows the stages in order Kübler-Ross proposed
b. many do not display all the stages
c. better thought of as some common emotions to dying
d. many experience rapid shifts in emotions (e.g., denial to acceptance to
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denial)
2. Little attention on how responses are shaped by specific illnesses and events
a. pattern different for those with slow steady progression toward death
versus more erratic pattern (e.g., bad-remission-bad)
3. Does not account for how individual personality influences the experience of
dying
a. life satisfaction levels before illness critical
i. individuals highly satisfied less angry
b. coping abilities critical
III.
The experience of bereavement: An attachment model
A. Terminology
1. Bereavement-- state of loss
2. Grief-- emotional response to loss
3. Mourning-- culturally defined ways of expressing grief
4. Anticipatory grief-- grieve for a terminally ill person prior to their death
a. does not eliminate grief felt after actual death
B. Parkes-Bowlby model of bereavement includes four reactions of…
1. Numbness-- sense of unreality and shock experienced during first few hours/days
following death
2. Yearning-- pangs (waves) of grief coming from 5-14 days after death as form of
separation anxiety
a. separation anxiety-- distress at being parted from object of attachment
3. Disorganization and despair-- passage of time yearn and grief less frequent and
less intense
4. Reorganization-- begin to invest less energy in grief for deceased and transition
into life without person
C. Bereavement is long, complex, and highly individualized event
1. Some people minimal grief experience
2. Some people average level of grief
3. Some people chronic grief experience
a. intense, long-lived, serious life disruptive
b. may need therapy
IV.
The infant
A Limited understanding and impact until at least 6 months of age
1. Acquisition of object permanence allows for the experience of “missing” an
object
2. Distress at being separated from caregivers
a. protest loss by yearning and searching
b. may show despair (depression-like) symptoms
i. poor appetite
ii. change in sleep pattern
iii. clinginess
C. Lack understanding that death is permanent separation
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V.
The child
A. Grasping the concept of death
1. Children must acquire a "mature" understanding of death
a. finality-- end of movement, thought, sensations, and life
b. irreversibility-- cannot be undone
c. universality-- inevitable
d. biological causality-- result of internal processes (that may be caused by
external forces)
2. Preschool children
a. believe the dead retain some life functions
b. view death as reversible
c. do not believe it is universal
d. believe that an external agent (often something eaten) caused the death
3. School-age children (5-7) have more advanced conceptualization of death
a. understand that death involves the cessation of life
b. it is irreversible and universal
c. do not completely understand causality of death
4. Understanding of death depends on both level of cognitive development
and life experiences
5. Understanding of death influenced by cultural factors
a. in cultures promoting idea of reincarnation, death not said to be
irreversible
b. Jews and Christian tend to talk to children about death using “mature”
language
c. own life experience (especially a life threatening illness in childhood) can
impact thoughts/behaviors concerning death and dying
d. adult use of euphemisms (e.g., “grandma has gone to live with God”) can
confuse children
i. honest, but not highly detailed responses to children’s questions
about death are best
B. The dying child
1. Typically more aware that they are dying than adults realize
2. Experience a wide range of emotional responses
a. may demonstrate fear/anxiety in play behavior
b. seek normalcy in relationships and peer activities
C. The bereaved child
1. Children do grieve
2. Their grief is expressed differently than an adult's grief
3. Particularly vulnerable to long-term negative effects of bereavement
4. Anxiety concerning separation common
5. Common grief symptoms include…
a. negative mood
b. dependency
c. temper tantrums
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6. Some carry negative adjustment pattern into adolescence and adulthood
VI.
The adolescent
A. Attainment of formal operational thought (Piaget) allows for mature understanding of
death and dying
B. Achieves a mature understanding of death, but reactions to death reflect themes of the
adolescent period
1. Death is irreversible, however, may continue in risky behavior
2. Dying adolescents highly concerned about negative changes in appearance (e.g.,
hair or weight loss)
3. Dying adolescents may show anger that adult goals will never be attained
C. Loss of someone on which the teenager was highly dependent (e.g., parent, friend) can
lead to extremely emotional response
B. Some reluctance to express grief (fear of seeming abnormal)
VII.
The adult
A. Death and the family life cycle
1. The loss of a spouse
a. precipitates other changes (e.g., changes in residence, job status)
i. emotional difficulty caring for dying spouse
b. at-risk for illness and even death
i. increase in levels of stress-related hormones
c. first year most difficult, but recovery may take years
d. bereaved reactions are diverse, with most eventually recovering and
moving on
2. The loss of a child
a. experienced as unexpected, untimely, and unjust
b. can be devastating
i. many experience negative physical symptoms
ii. may experience guilt or self-blame
c. age of child has little impact
d. effects on marriage-- strains relationships
e. effects on siblings-- may feel neglected by parents, anxious about own
health, guilty, pressure to replace lost child for parents
f. effects on grandparents-- guilty, helpless
3. The loss of a parent
a. not as disruptive as death of spouse or child
i. tends to occur when individual older and cognitively mature
ii. often less unexpected
b. can be very distressing
B. Challenges to the grief work perspective
1. Grief work perspective-- in order to cope with death the bereaved must confront
loss
a. chronic grief (long-lasting, and intense) and absence, inhibition, or delay
of
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grief (lack of common reactions) both associated by Freudians with
denial
b. cross-cultural research shows wide variety of successful grief patterns
c. grief work perspective often not supported by research
i. expression of few negative emotions after death can be associated
with positive dealing with death
d. do not need to completely break from the deceased but rather revise
internal working model of self/others to compensate for loss
i. continuing attachment to deceased can be mentally healthy
2. Is no one normal and effective way to grieve
C. Who copes and who succumbs?
1. Personal resources
a. early experiences in positive attachment relationships
b. personality and coping style
i. high self-esteem and sense of control positive
ii. history of depression may increase difficulty in dealing with loss
2. The nature of the loss
a. relationship to the deceased
i. closer is worse (e.g., child, best friend)
b. suddenness or unexpectedness of the death is worse
3. The context of supports and stressors
a. social support helps
b. additional stressors (e.g., financial problems) hurt
D. Bereavement and human development
1. Potential to foster growth in self, religiosity, family-relationships
VIII.
Taking the sting out of death
A. For the dying
1. hospice option-- program to support dying individuals
a. philosophy of care rather than cure
b. care may take place at home or at care facility
i. dying person and family the decision makers
ii. deemphasis on cure
iii. emphasis on pain control
iv. emphasis on comfort of setting
v. bereavement counseling available
2. Appears to have positive effect on dying individual (e.g., fewer medical
interventions) and family (greater satisfaction with care)
3. death with dignity good option for some
B. For the bereaved
1. hospice provides grief counseling
2. support may include counseling for depression
3. can improve communication among family members
4. built-in mutual support group for the bereaved
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