Death and Grieving
©2008 McGraw-Hill Ryerson Ltd.
Death and Grieving
Defining Death and Life/Death Issues
Death and Socio-historical, Cultural
Contexts
A Developmental Perspective on Death
Facing One’s Own Death
Coping with the Death of Someone Else
©2008 McGraw-Hill Ryerson Ltd.
Defining Death and
Life/Death Issues
Issues in
Determining
Death
Decisions Regarding
Life, Death, and
Health Care
©2008 McGraw-Hill Ryerson Ltd.
Defining Death and Life/Death Issues
Issues in Determining Death
Brain death – a
neurological
definition of death
that states a person
is brain dead when
all electrical
activity of the brain
has ceased for a
specified period of
time.
©2008 McGraw-Hill Ryerson Ltd.
Defining Death and Life/Death Issues
Issues in Determining Death
 The higher portions of the brain die first.
 The brain’s lower portions monitor vital functions.
 People whose higher brain areas have died may
continue breathing & have a heartbeat.
 The current definition of brain death (for most
physicians) includes the death of both the higher
cortical functions & lower brain stem functions.
©2008 McGraw-Hill Ryerson Ltd.
Defining Death and Life/Death Issues
Decisions Regarding Life, Death, and
Health Care
 Living Wills and DNRs
 Euthanasia
 Needed: Better Care for
Dying Individuals
©2008 McGraw-Hill Ryerson Ltd.
Defining Death and Life/Death Issues
Living Will
 Recognizing that terminally ill patients might
prefer to die rather than linger in a painful or
vegetative state, an organization called “Choice
in Dying” created the Living Will.
 The Living Will document is designed to be filled
in while the individual can still think clearly &
expresses their desire that extraordinary medical
procedures not be used to sustain life when the
medical situation becomes hopeless.
©2008 McGraw-Hill Ryerson Ltd.
Defining Death and Life/Death Issues
DNRs
 DNR, or Do Not Resuscitate is an order
preventing medical staff within a medical
institution to use either specified or all
means to prolong a person’s life or to
resuscitate the person if their heart stops.
 DNR can be arranged without a living will.
©2008 McGraw-Hill Ryerson Ltd.
Defining Death and Life/Death Issues
Euthanasia
 Euthanasia is the act of painlessly ending the lives of
individuals who are suffering from an incurable disease or
severe disability.
 Sometimes referred to as “mercy killing.”
 Passive euthanasia – occurs when a person is allowed to
die by withholding available treatment, such as
withdrawing a life-sustaining device.
 Active euthanasia – occurs when death is deliberately
induced, as when a lethal dose of a drug is injected.
©2008 McGraw-Hill Ryerson Ltd.
Defining Death and Life/Death Issues
Attitudes about Euthanasia
 Passive euthanasia for terminally ill patients is accepted.
 Precise boundaries for passive euthanasia & the exact
mechanisms by which treatment decisions should be
implemented are not entirely agreed upon.
 Active euthanasia is a crime in most countries & in all U.S.
states except Oregon.
 Walker, Gruman & Blank’s (1999) recent survey of more
than 900 physicians found most opposed active euthanasia
& believed that adequate pain control eliminated the need
for active euthanasia.
©2008 McGraw-Hill Ryerson Ltd.
Defining Death and Life/Death Issues
Needed: Better Care for Dying Individuals
 The Canadian Senate report on end-of-life found:
 Only 1-in-10 Canadians received proper care as they die.
 Dying individuals often get too little or too much care.
 Many experience severe pain during their last days.
 Regulations are needed that allow physicians flexibility in
prescribing painkillers for dying patients who need them.
 Many health-care professionals are not trained to provide
adequate end-of-life care.
©2008 McGraw-Hill Ryerson Ltd.
Defining Death and Life/Death Issues
Palliative Care
 Palliative care is a humanized program
committed to making the end of life as free
from pain, anxiety, & depression as possible.
 Palliative care goals contrast with those of
hospitals, which are to cure illness & prolong
life.
©2008 McGraw-Hill Ryerson Ltd.
Death and
Socio-Historical Cultural
Contexts
Changing
Historical
Circumstances
©2008 McGraw-Hill Ryerson Ltd.
Death in
Different
Cultures
Death and Socio-historical Cultural Contexts
Changing Historical Circumstances
 One historical change already presented is the increasing
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complexity of determining when someone is truly dead.
Another change is the age group death strikes most often—
200 years ago it was children, now it is the elderly.
Life expectancy has increased by 50 years since 1900.
In the past, most people died at home.
80% of all deaths now occur in institutions, minimizing
our exposure to death.
Care of the dying has shifted away from families.
©2008 McGraw-Hill Ryerson Ltd.
Death and Socio-historical Cultural Contexts
Perceptions of Death
 In most societies, death is not viewed as the end of
existence—though the biological body has died, the
spiritual body is believed to live on.
 Some cultures:
 believe death is caused by magic and demons.
 believe death is caused by natural forces.
 focus on reincarnation.
 view death as punishment, while for others it represents
redemption.
 fear death, while others embrace it.
©2008 McGraw-Hill Ryerson Ltd.
Death and Socio-historical Cultural Contexts
Death in Different Cultures
 North Americans are death avoiders & death
deniers.
 People in many countries face death on a daily
basis.
 In some countries, the presence of dying family
members & large funeral attendance are part of
everyday cultural reality.
 These aspects of life help prepare the young for
death & provide them with guidelines on how to
die.
©2008 McGraw-Hill Ryerson Ltd.
Death and Socio-historical Cultural Contexts
Evidence of the Denial of Death
 The funeral industry glosses over death & fashions lifelike
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qualities in the dead
Euphemistic language for death is used (passed away).
There is a persistent search for a fountain of youth
Rejection & isolation of the aged, who may remind us of
death, is common.
Belief in the concept of a pleasant & rewarding afterlife,
suggests that we are immortal
Medical practices emphasis prolonging biological life
rather than an emphasizing diminishing human suffering
©2008 McGraw-Hill Ryerson Ltd.
A Developmental
Perspective
On Death
Causes of
Death and
Expectations
about Death
Attitudes
toward Death
at Different Points
in the Life Span
©2008 McGraw-Hill Ryerson Ltd.
A Developmental Perspective on Death
Causes of Death and Expectations about
Death
 Death can occur at any point in the human life span.
 Childhood deaths occur mostly due to accidents or illness.
 Adolescent deaths are more likely to occur because of
motor vehicle accidents, suicide, & homicide.
 Younger adults are more likely to die from accidents.
 Older adults are more likely to die from chronic diseases.
 Younger adults who are dying feel cheated by death more
than do older adults who are dying.
©2008 McGraw-Hill Ryerson Ltd.
A Developmental Perspective on Death
Attitudes toward Death at Different
Points in the Life Span
 Childhood
 Adolescence
 Adulthood
©2008 McGraw-Hill Ryerson Ltd.
A Developmental Perspective on Death
Childhood
 Infants have no concept of death, but once they develop an
attachment, they can experience loss, separation & anxiety.
 Children 3–5 years old don’t have a true idea of what death
really means, often confusing death with sleep.
 Young children believe death is reversible & the dead can
be brought back to life spontaneously.
 Cuddy-Casey & Orvaschel’s (1997) research found
children don’t understand death is universal & irreversible
until about age 9.
©2008 McGraw-Hill Ryerson Ltd.
A Developmental Perspective on Death
Explaining Death to Children
 Psychologists recommend :
 honesty in discussing death with children.
 Answering children’s questions about death based on the
child’s age & maturity level.
 Death can be explained to preschool children in simple
physical & biological terms.
 Children need reassurance that they are loved & that they
will not be abandoned.
 Regardless of age, adults should be sensitive &
sympathetic, encouraging children to express their own
feelings & ideas.
©2008 McGraw-Hill Ryerson Ltd.
A Developmental Perspective on Death
Adolescence
 The prospect of death is so remote for adolescents that it
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does not have much relevance.
Death may be avoided, glossed over, kidded about,
neutralized, & controlled by a cool spectator-like
orientation.
Adolescents have more abstract conceptions of death than
children do.
Adolescents develop religious & philosophical views about
the nature of death & whether there is life after death.
Adolescents are especially likely to think that they are
invincible, unique & immune to death.
©2008 McGraw-Hill Ryerson Ltd.
A Developmental Perspective on Death
Adulthood
 There is no evidence that a special orientation
towards death develops in early adulthood.
 An increase in consciousness about death
accompanies individuals’ awareness that they are
aging.
 Kalish & Reynolds’ (1976) study found adults at
midlife fear death more than do young adults or
older adults.
 Older adults think about death more & talk about
it more than in previous adult stages.
©2008 McGraw-Hill Ryerson Ltd.
Facing One’s
Own Death
Kubler-Ross’s
Stages of Dying
Perceived
Control
and Denial
©2008 McGraw-Hill Ryerson Ltd.
The Contexts
in Which
People Die
Facing One’s Own Death
Kübler-Ross’s Stages of Dying
 Denial and Isolation
 Anger
 Bargaining
 Depression
 Acceptance
©2008 McGraw-Hill Ryerson Ltd.
Facing One’s Own Death
Denial and Isolation
 Kübler-Ross (1969) divided the behaviour &
thinking of dying persons into 5 stages.
 In the first stage, denial & isolation, people
refuse to believe that their condition is terminal.
 People attempt to convince themselves that lab
tests were inaccurate or that the disease will go
into remission.
 Dying individuals in this stage also seek isolation.
©2008 McGraw-Hill Ryerson Ltd.
Facing One’s Own Death
Anger
 In the 2nd stage of dying, anger, the dying person
recognizes that denial can no longer be maintained.
 Denial gives way to anger, resentment, rage, & envy.
 The dying person’s question is: “Why me?”
 The dying person becomes increasingly difficult to
care for, as anger may become displaced & projected
onto physicians, nurses, family members, & God.
 The realization of loss is great & those who represent
life are targets of resentment
©2008 McGraw-Hill Ryerson Ltd.
Facing One’s Own Death
Bargaining
 In the 3rd stage of dying, bargaining, Kübler-Ross
states that the person develops the hope that death
can somehow be postponed or delayed.
 Some people enter into a bargaining or
negotiation—often with God—as they try to delay
their death.
 In exchange for a few more days, weeks, or months
of life, the person promises to lead a reformed life
dedicated to God or to the service of others.
©2008 McGraw-Hill Ryerson Ltd.
Facing One’s Own Death
Depression
 In Kübler-Ross’ 4th stage of dying, depression,
the dying person accepts that death is certain.
 At this point, a period of depression or preparatory
grief may appear.
 The dying person may become silent, refuse
visitors, & spend time crying or grieving.
 Attempts to cheer up the dying person at this stage
should be discouraged because the person has a
need to contemplate impending death.
©2008 McGraw-Hill Ryerson Ltd.
Facing One’s Own Death
Acceptance
 In the 5th stage of dying, acceptance, the person
develops a sense of peace; an acceptance of one’s
fate; & in many cases, a desire to be left alone.
 Feelings & physical pain may be virtually absent.
 Kübler-Ross views this stage as the end of the
dying struggle, the final resting stage before death.
©2008 McGraw-Hill Ryerson Ltd.
Facing One’s Own Death
Criticisms of Kubler-Ross
 Psychology death expert Robert Kastenbaum refutes
the existence of Kübler-Ross’ 5 stage sequence.
 Research has not demonstrated the process exists.
 Kastenbaum (2000) believes the stage
interpretation neglects the patients’ total life
situations, including relationship support, specific
effects of illness, family obligations, & the
institutional climate in which they were interviewed.
 Some psychologists prefer to describe the stages as
reactions to dying.
©2008 McGraw-Hill Ryerson Ltd.
Facing One’s Own Death
Contributions of Kubler-Ross
 Kübler-Ross made the important contribution of
calling attention to people attempting to cope
with life-threatening illnesses.
 She did much to encourage needed attention to
the quality of life for dying persons & their
families.
©2008 McGraw-Hill Ryerson Ltd.
Facing One’s Own Death
Perceived Control and Denial
 Perceived control & denial may work together as an
adaptive strategy for some older adults facing death.
 Individuals who believe they can influence & control
events, become more alert & cheerful.
 Denial may be a useful way for some individuals to
approach death.
 Denial protects us from the tortuous feeling that we
are going to die.
 Denial can be maladaptive if it prevents treatment.
©2008 McGraw-Hill Ryerson Ltd.
Facing One’s Own Death
The Contexts in Which People Die
 For dying individuals, the context in which they
die is important.
 75% of Canadians die in hospitals or long-term
care facilities.
 Hospitals offer important advantages in that
professional staff members are readily available, &
the medical technology may prolong life.
 Kalish & Reynolds (1976) identified most
individuals say they would rather die at home.
©2008 McGraw-Hill Ryerson Ltd.
Coping with the
Death of Someone Else
Communicating
with a Dying
Person
Forms of
Mourning and
the Funeral
Grieving
Making Sense
of the World
©2008 McGraw-Hill Ryerson Ltd.
Losing a
Life Partner
Coping with the Death of Someone Else
Communicating with a Dying Person
 Most psychologists believe that it is best for dying
individuals to know that they are dying, & that
significant others know they are dying.
 Dying individuals can thus close their lives in
accord with their own idea of proper dying.
 They can complete plans and projects.
 They can make arrangements for survivors.
 They can participate in decisions about a funeral.
 They will have the opportunity to reminisce.
©2008 McGraw-Hill Ryerson Ltd.
Coping with the Death of Someone Else
Grieving
 Dimensions of
Grieving
 Cultural Diversity in
Healthy Grieving
©2008 McGraw-Hill Ryerson Ltd.
Coping with the Death of Someone Else
Dimensions of Grieving
 Emotional numbness, disbelief, separation anxiety,
despair, sadness, & loneliness accompany the loss of
someone we love.
©2008 McGraw-Hill Ryerson Ltd.
Coping with the Death of Someone Else
Dimensions of Grieving
 Pining or yearning reflects a recurrent need to
recover the lost loved one.
 Separation anxiety includes pining but also focuses
on places & things associated with the deceased, as
well as crying.
 Numbness, disbelief, & outbursts of panic are
typical immediate reactions.
 Despair, sadness, & hopelessness are part of grief.
©2008 McGraw-Hill Ryerson Ltd.
Coping with the Death of Someone Else
Cultural Diversity in Healthy Grieving
 In contrast to Western
 In Egypt, the bereaved are
beliefs, maintenance of ties encouraged to dwell at
with the deceased is
length on their grief.
accepted & sustained in
 In Bali, the bereaved are
the religious rituals of
encouraged to laugh & be
Japan.
joyful, rather than be sad.
 In the Arizona Hopi, the
 Diverse grieving patterns
deceased are forgotten as
are culturally embedded.
quickly as possible & life is
carried on as usual.
©2008 McGraw-Hill Ryerson Ltd.
Coping with the Death of Someone Else
Making Sense of the World
 A beneficial aspect of grieving is that it stimulates
many individuals to make sense of their world.
 A common occurrence is to go over again & again all
of the events that led up to the death.
 When death is caused by an accident or disaster, the
effort to make sense of it is pursued more vigorously.
 The bereaved want to put the death in a perspective
they can understand—divine intervention, a logical
sequence of cause & effect, etc.
©2008 McGraw-Hill Ryerson Ltd.
Coping with the Death of Someone Else
Losing a Life Partner
 Those left behind after the death of an intimate partner
suffer profound grief & often endure financial loss,
loneliness, increased physical & psychological problems.
©2008 McGraw-Hill Ryerson Ltd.
Coping with the Death of Someone Else
Losing a Life Partner
 Those left behind after the death of an intimate
partner suffer profound grief & often endure
financial loss, loneliness, increased physical
illness, & psychological disorders.
 The bereaved are also at increased risk for many
health problems, including death.
 Optimal adjustment after a death depends on
several factors.
 Women do better than men in our society, due to
their networks of friends & close relationships.
©2008 McGraw-Hill Ryerson Ltd.
Coping with the Death of Someone Else
Forms of Mourning and the Funeral
 Mourning varies cross-culturally.
 Funeral rituals are an important aspect of
mourning in many cultures.
 One consideration is what to do with the body.
 Approximately 80% of corpses are buried.
 Studies showed that bereaved individuals who
were religious derived more psychological benefits
from a funeral, participated more actively in
rituals, & adjusted more positively to the loss.
©2008 McGraw-Hill Ryerson Ltd.