Adolescent/Adult Development

Epilogue: Death and Dying

Apr 29-May 1, 2009Classes #41-42

Deciding How to Die

• Practices and rituals relating to dying, death, and bereavement are universal, but there are variations

• Rituals may be changing with globalization

• One of first steps in understanding death is to accept it– for most of human history, death accepted

as unanticipated, unavoidable, and quick– today, because of medical miracles, death

less of everyday event

Medical Professionals

• As illness came to be perceived as a domain of medicine rather than of religion, we began to believe physicians could work medical miracles

• Elizabeth Kübler-Ross brought solid research and compassionate attention to the psychological needs of the dying

Medical Professionals

• In the early 21st century, only 1/2 of medical books discuss care of dying

• In recent years, more physicians are more accepting of death

• 3 innovations are helping to help the dying achieve a “good death”– hospice care– palliative care – end-of-life decision making

Hospice Care • Hospice—institution where

terminally ill patients receive palliative care– provides skilled medical

treatment, but avoids death-defying interventions

– human dignity respected

• Dying person and the family are considered to be the “unit of care”– sometimes the home is

where care given

Palliative Care

• Designed mainly to relieve pain and suffering of patient and family– Double effect

• primarily relieves pain, but could also hasten death

• Psychological symptoms of patients and their families more difficult to treat– depression, anxiety

?Hospice is a concept rooted in the centuries-old idea of offering a place of shelter and rest, or "hospitality" to weary and sick travelers on a long journey

Dame Cicely Saunders at St. Christopher's Hospice in London first applied the term "hospice" to specialized care for dying patients in 1967

Today, hospice care provides humane and compassionate care for people in the last phases of incurable disease so that they may live as fully and comfortably as possible

What Is Hospice Care?

Hospice Care

• Hospices try to help as many people as possible, but do not reach everyone– patients must be diagnosed as terminally ill– patients and caregivers must accept diagnosis

of terminal illness– hospices were typically designed for adults

with terminal cancer, not older adults with severe illnesses

– hospice care is expensive– availability depends mainly on location

Interdisciplinary Team

Typically, an interdisciplinary health care team of physicians, nurses, social workers, counselors, home health aides, clergy, therapists, and trained volunteers cares for you, offering support based on their particular areas of expertise

Together, they provide comprehensive palliative care aimed at relieving symptoms and giving social, emotional, and spiritual support.

Legal Preparations

• Explicit guidelines for a person’s preferences for end-of-life care are needed because he or she often becomes incapable of making or expressing decisions about medical care

Legal Preparations

• Passive Euthanasia– situation in which a seriously ill person is

allowed to die naturally via cessation of medical interventions

• Active Euthanasia– a situation where someone takes action to

bring about another’s death, with the intention of ending that person’s suffering

Legal Preparations

• Living will– document that indicates what medical

intervention should occur

• Health care proxy– the person chosen to make medical

decisions if the person who chose becomes unable to make his/her own decisions

• Living wills are only a start• Hospitals today ask about living wills

and advance directives upon admission– some people resist signing them

• End-of-life care involves probabilities, not certainties, until the very last moment

• What quality of life is acceptable?

Disagreements About End-of-Life Care

Disagreements About End-of-Life Care

• Problems with Designated Proxy– many proxies choose measures neither

they nor the dying person want• may involve clashing cultural values

– family members may disagree bitterly about how much suffering is acceptable

– even if patient has signed living will and specified proxy, hospital staff may ignore them

Euthanasia

• Legally, decisions made in living wills and by health care proxies are to be honored

• Active euthanasia is fiercely controversial, even if the dying person requests it– is illegal in almost every part of the world

Euthanasia

• Physician-Assisted Suicide– Form of active euthanasia in which a

doctor provides the means for someone to end his or her life

• Voluntary Euthanasia– Form of active euthanasia in which, at

patient’s request, someone else ends his or her life

Euthanasia

• Several places have legalized physician-assisted suicide– the Netherlands– Switzerland– Belgium– Oregon

Euthanasia

• In Oregon, the following conditions must exist:– Person must be terminally ill• Less than 6 months to live

– Two doctors must confirm diagnosis of terminal illness• Both doctors must certify patient’s judgment

unimpaired – Person must ask for lethal drugs at least 2x

orally and 1 time in writing• 15 days must elapse between first request

and written prescription

The “Death Machine”...

Dr. Jack Kevorkian was convicted in March 1999 of second-degree murder after inducing the death of Thomas Youk, a man who had amyotropic lateral sclerosis, commonly known as Lou Gehrig's disease. Kevorkian's conviction came after replaying Youk's videotaped death on the "60 Minutes" CBS television news magazine. He was sentenced to a 10 to 25 years in prison.

Thomas Youk, 52, injected with a lethal dose of chemicals by Kevorkian

Preparing for Death

• Responses to death vary greatly• It has been denied, sought, feared,

fought, avoided, and welcomed by all involved

Avoiding Despair

• Kübler-Ross helped us to understand death

• Acceptance of death was elusive before• Kübler-Ross’s 5 Stages

– denial– anger– bargaining– depression– acceptance

Avoiding Despair

• Others that study death (thanatology) have disagreed about the stages

• 5 stages appear and reappear throughout process

• Research has clarified some patterns– older people more likely to plan for death– concern is more likely to be for a “good

death”—swift, painless, dignified, and occurring at home

Cultural Variations

• Africa and Asia• North America

• In many traditional African religions, adults gain new status through death and the joining of ancestors

• For Muslims, death affirms religious faith– life is transitory, so people should be ready

for death at any time

Death in Religions of Africa and Asia

Death in Religions of Africa and Asia.

• For Buddhists, death and disease are among life’s inevitable sufferings– may bring spiritual enlightenment

• For Hindus, helping the dying to surrender their ties to the world and prepare for the next is a particularly important obligation for the family– a holy death is welcomed by dying person– eases person into the next life

• Indigenous tribes (over 400) all consider death an affirmation of nature and community values

• Jews hope for life to be sustained– thus, death is not emphasized and the dying

person is not left alone

• Many Christians believe that death is not an end, but rather the beginning of eternity in heaven or hell– so death may either be welcomed or feared

Death in North America

• Religious and spiritual concerns often reemerge at death

• It is common for dying people to return to their roots

• For many, spiritual beliefs and a connection to community offer hope at time of dying

Spiritual and Cultural Affirmation

• Bereavement– sense of loss following a death

• The considerable variations in practices that follow death are due to religion and culture

Coping with Bereavement

Forms of Sorrow

• Grief– individual’s emotional response to bereavement– private

• Mourning– culturally prescribed ceremonies and behaviors

for expressing grief at the death of a loved one– public

• The two are connected – mourning is designed by religions and cultures– grief, though personal and private, follows

social rules

Forms of Sorrow

• Mourning customs are designed by various cultures and religions to channel grief into reaffirmation

• Crucial to reaffirmation is people’s search for the meaning in death

• Unexpected or violent deaths are particularly likely to shock and to precipitate a search for meaning– Example: September 11, 2001

• Mourning has become more private, less emotional, and less religious– funeral trends

• cremation vs. burial

• As mourning diminishes, grief becomes less welcome

• People are less likely to be given time to grieve

Contemporary Challenges

Contemporary Challenges

• “Disenfranchised grief” is the practice of excluding certain people from mourning– the unmarried partner– the young child– the ex-spouse– the friend from work

• Any kind of prohibition, restriction, or exclusion can make healing, hope, and affirmation more difficult for bereaved of all ages

Contemporary Challenges

• Murders and suicides often trigger police investigations, etc., that interfere with the grief process

• Inadequate grief is thought to harm the larger community as well

• What Friends Can Do to Help the Bereaved Person– first, be aware that powerful, complicated,

and unexpected emotions are likely– do not judge another person’s sorrow– understand that culture and cohort play a

role in the different responses to death

Responses to Bereavement

Responses to Bereavement

• Bereavement is an ongoing, often lengthy process; sympathy, honesty, and social support may be needed for months or even years– especially true for families

• Recovery begins with acceptance of grief and may lead to reaffirmation of life

• Working through the emotions can help the person have a deeper appreciation of him/herself and life, including human relationships

Conclusion