Approaching DeathApproaching Death

Death and DyingDeath and Dying

Death and DyingDeath and Dying

““Immortality” of youthImmortality” of youth Denial of mortalityDenial of mortality

AnxietyAnxiety

Historical and Cultural ViewsHistorical and Cultural Views

ability to accept death ability to accept death specific meanings (stop breathing, specific meanings (stop breathing,

heartbeat, brain death)heartbeat, brain death) individual variationindividual variation cultural variation (spiritual, natural, cultural variation (spiritual, natural,

welcome event)welcome event)

Western history: natural eventWestern history: natural event 20th Century: withdrawn from daily life experiences20th Century: withdrawn from daily life experiences care of dyingcare of dying

Disposition of deceased: dramaturgical (Fulton & Disposition of deceased: dramaturgical (Fulton & Metress, 1995: language of funeral directors)Metress, 1995: language of funeral directors) ““interment” vs. burialinterment” vs. burial ““casket” vs. coffincasket” vs. coffin ““remains,” “diseased,” “loved one” vs. corpse, dead remains,” “diseased,” “loved one” vs. corpse, dead

bodybody ““lying in repose” vs. deadlying in repose” vs. dead

““denial” of death, “social”death: avoidancedenial” of death, “social”death: avoidance

Cultural denial of death?Cultural denial of death?Behaviours? Avoidance?Behaviours? Avoidance?

Collectively?Collectively?Individually?Individually?

Reasons?Reasons?Effects of avoidance?Effects of avoidance?Feelings about death? Regrets?Feelings about death? Regrets?A “good” death?A “good” death?

Research on Death and DyingResearch on Death and Dying

Kubler-Ross (1970)Kubler-Ross (1970)Openness, disclosureOpenness, disclosure thanatology: study of deaththanatology: study of death five emotional stagesfive emotional stages

Denial, anger, bargaining, depression, Denial, anger, bargaining, depression, acceptanceacceptance

Inconsistencies in StagesInconsistencies in Stages

appearance, reappearance of denial, appearance, reappearance of denial, anger, depression during dying processanger, depression during dying process

age of dying personage of dying personyoung: separation from loved onesyoung: separation from loved onesadolescents: focus on quality of present adolescents: focus on quality of present

lifelifeeffect of condition on appearance social effect of condition on appearance social

relationshipsrelationships

young adult: rage and depressionyoung adult: rage and depressionend of life at beginningend of life at beginning

middle adulthood: concern about middle adulthood: concern about obligations, responsibilitiesobligations, responsibilities

late adulthood: contextual late adulthood: contextual death of spousedeath of spouse illness, pain, dependencyillness, pain, dependencyacceptance relatively easyacceptance relatively easy

Health Care Policy for the Dying Health Care Policy for the Dying ProcessProcess

““Medicalization” of death vs. “normative” Medicalization” of death vs. “normative” part of life?part of life?

Perspectives, definitions of death?Perspectives, definitions of death?Death anxiety?Death anxiety?Preparation for death?Preparation for death?

Hospice CareHospice Carevs. “Medicalization” of Deathvs. “Medicalization” of Death

““good death”: swift, comfortable, dignity, good death”: swift, comfortable, dignity, loved ones presentloved ones present

more common prior to extreme medical more common prior to extreme medical interventionintervention

alternative to hospital carealternative to hospital care

London, 1950s: first hospiceLondon, 1950s: first hospiceProvide medical care, no artificial life support Provide medical care, no artificial life support

systems to terminally illsystems to terminally illAllow visitors, free movementAllow visitors, free movementCushion fear, loneliness of impending deathCushion fear, loneliness of impending death

Problems:Problems:Rapid growth: need for well-trained personnelRapid growth: need for well-trained personnelLegal, ethical questions: premature death?Legal, ethical questions: premature death?Potential burn-out of professionals, volunteers Potential burn-out of professionals, volunteers

(personal involvement, intimacy)(personal involvement, intimacy)

Living Will, Passive EuthanasiaLiving Will, Passive Euthanasia

specify how much medical care in terminal specify how much medical care in terminal illnessillness

inaction (e.g., no respirator) that allows inaction (e.g., no respirator) that allows person to die in natural course of illnessperson to die in natural course of illness

ethics: quality of life?ethics: quality of life?

The Right to Die: Assisted Suicide The Right to Die: Assisted Suicide and Active Euthanasiaand Active Euthanasia

providing means to person to end lifeproviding means to person to end life intentionally terminating life of suffering intentionally terminating life of suffering

personpersonNetherlands: legal euthanasiaNetherlands: legal euthanasiaNorth America: Jack KevorkianNorth America: Jack Kevorkian

assisted suicide? Value of life?assisted suicide? Value of life? legal restrictions?legal restrictions?

NetherlandsNetherlands Patient experiencing unbearable painPatient experiencing unbearable pain Patient consciousPatient conscious Death request voluntaryDeath request voluntary Patient must have time to consider alternativesPatient must have time to consider alternatives No other reasonable solutions to problemNo other reasonable solutions to problem Death cannot inflict unnecessary suffering on Death cannot inflict unnecessary suffering on

othersothers Must be more than one person involved in Must be more than one person involved in

euthanasia decisioneuthanasia decision Only doctor can euthanize the patientOnly doctor can euthanize the patient

Death AnxietyDeath Anxiety

(Conte, Weiner, & Plutchik, 1982)(Conte, Weiner, & Plutchik, 1982)Death Anxiety QuestionnaireDeath Anxiety Questionnaire fear of unknownfear of unknown fear of suffering fear of suffering fear of loneliness fear of loneliness fear of personal extinction fear of personal extinction

nursing home residents, seniors, university nursing home residents, seniors, university studentsstudents

ages 30 to 80 yearsages 30 to 80 yearsno differences in mean scores (M=8.5)no differences in mean scores (M=8.5)no correlation with sex, educationno correlation with sex, educationseparate study: adolescents had higher separate study: adolescents had higher

scores than older participantsscores than older participantsemotional stressesemotional stressescognitive maturity (meaning of death)cognitive maturity (meaning of death)

Cicirelli (1999) higher death anxiety in:Cicirelli (1999) higher death anxiety in:YoungerYoungerLower SESLower SESFemaleFemaleWhiteWhiteExternal locus of controlExternal locus of controlLess religiousnessLess religiousness

Quality of End of LifeQuality of End of Life

Singer et al. (1999): Canadian sampleSinger et al. (1999): Canadian sampleReceiving adequate pain and symptom Receiving adequate pain and symptom

managementmanagementAvoiding inappropriate prolongation of Avoiding inappropriate prolongation of

dyingdyingAchieving sense of controlAchieving sense of controlRelieving burdenRelieving burdenStrengthening relationships with loved Strengthening relationships with loved

onesones

Bereavement and GriefBereavement and Grief Mourning: expression of griefMourning: expression of grief Prescribed rituals: funeralsPrescribed rituals: funerals

Auger (2000): 4 functionsAuger (2000): 4 functions Provide supportive relationship for bereavedProvide supportive relationship for bereaved Reinforce reality of deathReinforce reality of death Acknowledge open expression of feeling of loss and griefAcknowledge open expression of feeling of loss and grief Mark a fitting conclusion to life of personMark a fitting conclusion to life of person

Social supportSocial support network of familialnetwork of familial small memorial servicessmall memorial services failure to express grief: depressionfailure to express grief: depression

Phases of Mourning (Parkes, 1972)Phases of Mourning (Parkes, 1972)shockshock longinglongingdepression, despair (anger)depression, despair (anger) recovery (perspective)recovery (perspective)

Current Perspective (Lund, 1996)Current Perspective (Lund, 1996)

stress with resiliencystress with resiliency adjustment related to self-esteem, coping skillsadjustment related to self-esteem, coping skills diversity diversity

between between individuals: thoughts, feelings, behavioursindividuals: thoughts, feelings, behaviours withinwithin individuals: simultaneous negative (anger, individuals: simultaneous negative (anger,

loneliness) and positive (personal strength) feelingsloneliness) and positive (personal strength) feelings

no stages:no stages: rapidly changing feelingsrapidly changing feelingsdealing with personal limitsdealing with personal limits fatigue, lonelinessfatigue, loneliness learning new skillslearning new skillsnew relationshipsnew relationshipsno specific time markersno specific time markers

Achieving RecoveryAchieving Recovery

cultural facilitation of mourning:cultural facilitation of mourning:meaningful ritualsmeaningful ritualsemotional support: friends listeningemotional support: friends listeningpractical helppractical help

lengthy processlengthy processwaves of sorrow: anniversary reactionswaves of sorrow: anniversary reactionshealthy responsehealthy response

Bereavement overloadBereavement overload

elderly at riskelderly at riskseveral deaths in rapid successionseveral deaths in rapid successionunable to complete mourning process for unable to complete mourning process for

one death before another occursone death before another occurs

Anticipatory GriefAnticipatory Griefexpected deathexpected deathdying person, mourners share affectiondying person, mourners share affectionhelps dull pain of losshelps dull pain of loss

Sudden death (no anticipatory grieving)Sudden death (no anticipatory grieving)Most difficulty in copingMost difficulty in coping loss of young person vs. at end of long, full loss of young person vs. at end of long, full

lifelifeemotions: guilt, denial, anger, sorrowemotions: guilt, denial, anger, sorrow

Social/Cultural Supports for Social/Cultural Supports for Grieving?Grieving?

Similarities, differences, roles?Similarities, differences, roles?

Finding ComfortFinding Comfort

social support: friends listening, sympathizing, social support: friends listening, sympathizing, not ignoring pain, complex emotions in recoverynot ignoring pain, complex emotions in recovery

recognize bereavement is lengthy process recognize bereavement is lengthy process (months, years): sorrow, memory are integral (months, years): sorrow, memory are integral parts of recoveryparts of recovery

over time: bereaved should become involved in over time: bereaved should become involved in other activities, but not be expected to forget other activities, but not be expected to forget loved oneloved one

successful recovery: deeper appreciation of successful recovery: deeper appreciation of growth, development of all human relationshipsgrowth, development of all human relationships

Adult Development from Adult Development from Adolescence to Old AgeAdolescence to Old Age

Multidimensional, multidirectional change, Multidimensional, multidirectional change, throughout lifespanthroughout lifespan

Final ExamFinal ExamDecember 12: 2 hoursDecember 12: 2 hoursChapters 8, 10, 11, 12 (50 Multiple Chapters 8, 10, 11, 12 (50 Multiple

Choice), lecture material (5/7 short Choice), lecture material (5/7 short answer)answer)

Successful AgingSuccessful Aging

Survival in late adulthoodSurvival in late adulthoodQuality of life, satisfactionQuality of life, satisfaction

Transcend physical limitationsTranscend physical limitationsMental health, optimal adaptationMental health, optimal adaptation

Positive outlookPositive outlookSelf-understandingSelf-understanding

ComponentsComponentsAbsence of disease, disabilityAbsence of disease, disabilityNo risk factorsNo risk factors

Maintaining high cognitive and physical Maintaining high cognitive and physical functionfunctionActive and competentActive and competent

Engagement with lifeEngagement with lifeProductive activity, involvement with other Productive activity, involvement with other

peoplepeople

Not avoidance of aging: maintaining Not avoidance of aging: maintaining adaptabilityadaptabilityConsistent with reality of aging:Consistent with reality of aging:

Successful aging is the normSuccessful aging is the norm““paradox of well-being” (Mroczek & Kolarz, 1998)paradox of well-being” (Mroczek & Kolarz, 1998)

32,000 US adults surveyed32,000 US adults surveyed Assumed objective difficultiesAssumed objective difficulties Generally fel good about selves and situationGenerally fel good about selves and situation 30-40% over 65 report selves as “very happy”30-40% over 65 report selves as “very happy”

Positive affect: highest for olderPositive affect: highest for olderreflects personality (extroverts)reflects personality (extroverts)set point perspectiveset point perspective

- temperament sets boundaries for - temperament sets boundaries for levels of well-being throughout lifelevels of well-being throughout life

- extroverts: more successful - extroverts: more successful dealings with othersdealings with others

- positive interpretations of life - positive interpretations of life eventsevents

Successful AgingSuccessful Aging

Hardiness and thriving (Perls, 1995)Hardiness and thriving (Perls, 1995)Genetic determiners of “hardiness” in oldest Genetic determiners of “hardiness” in oldest

oldoldAdaptive capacity (ability to overcome Adaptive capacity (ability to overcome

disease or injury)disease or injury)Functional reserve: how much of organ Functional reserve: how much of organ

required for adequate performance required for adequate performance (determines ability to deal with disease)(determines ability to deal with disease)

SurvivabilitySurvivability

Beyond age 97, chances of dying at a Beyond age 97, chances of dying at a given age lower than expectedgiven age lower than expected

Mortality rate (#deaths/# in age group) Mortality rate (#deaths/# in age group) exceeds 1.0 if entire group dies in less than one yearexceeds 1.0 if entire group dies in less than one year

Indicates oldest members of our species tend Indicates oldest members of our species tend to be healthier than traditional views of aging to be healthier than traditional views of aging would predictwould predict

Additional support from medfliesAdditional support from medfliesChance of dying at any age peaks at 50 days Chance of dying at any age peaks at 50 days

(@15%)(@15%)If survive to 100 days, chance of dying at any If survive to 100 days, chance of dying at any

given day @5%given day @5%

More hardyMore hardySlower rate of progress of symptoms of Slower rate of progress of symptoms of

disease than in less hardydisease than in less hardyThreshold for disease lowers more slowlyThreshold for disease lowers more slowly

Symptoms of age-related disease (e.g., Symptoms of age-related disease (e.g., Alzheimers) appear later (b vs. a)Alzheimers) appear later (b vs. a)

Morbidity, mortality, disability compressed into Morbidity, mortality, disability compressed into shorter periodshorter period

Possible explanations for Possible explanations for hardinesshardiness

Longevity genes: increased resistance against Longevity genes: increased resistance against oxygen radicalsoxygen radicals Slow rate of damageSlow rate of damage

Low complement of deleterious genesLow complement of deleterious genes E.g., Apolipoprotien E (apo-E) related to risk of E.g., Apolipoprotien E (apo-E) related to risk of

Alzheimer'sAlzheimer's Gene for protein apo-E less prevalent in oldest-old Gene for protein apo-E less prevalent in oldest-old

survivorssurvivors 18% of 90-103 year-olds18% of 90-103 year-olds 25% of under-65 year-olds25% of under-65 year-olds

Adaptive capacity (ability to cope with and Adaptive capacity (ability to cope with and overcome disease or injury) higher in more-overcome disease or injury) higher in more-hardyhardy

Functional reserve (how much of an organ is Functional reserve (how much of an organ is required for its adequate performance) higherrequired for its adequate performance) higher

Autopsy studies of “healthy” oldest-old Autopsy studies of “healthy” oldest-old brainsbrainsNo outward signs of disease, but level of No outward signs of disease, but level of

neurofibrillary tangles would indicate neurofibrillary tangles would indicate dementia in younger braindementia in younger brain

Excess reserve of brain function compensates Excess reserve of brain function compensates for processes damaging the brainfor processes damaging the brain

Two Basic Principles of Normal Two Basic Principles of Normal AgingAging

Variability of aging ratesVariability of aging ratesLongitudinal studies (e.g., Baltimore Study)Longitudinal studies (e.g., Baltimore Study)

Aging rates vary remarkably (60 year olds like 40; Aging rates vary remarkably (60 year olds like 40; some 40 year-olds like 60, physically)some 40 year-olds like 60, physically)

Differences in appearance mirrored on Differences in appearance mirrored on physiological testsphysiological tests

Variability increases as age increasesVariability increases as age increasesIndividual aging rates vary across years, and Individual aging rates vary across years, and

across physical systemsacross physical systems

Variability of Aging PatternsVariability of Aging PatternsSeveral aging paths:Several aging paths:

Cross-sectional researchCross-sectional researchSome functions decline in a regular way over timeSome functions decline in a regular way over timeOther functions are stable, unchanged or decline Other functions are stable, unchanged or decline

only in terminal phase of lifeonly in terminal phase of life

Physiological loss, but only when an age-Physiological loss, but only when an age-related illness is experiencedrelated illness is experiencedE.g., heart disease correlated with a decline in E.g., heart disease correlated with a decline in

heart pumping capacity with ageheart pumping capacity with ageWithout heart disease, pumping capacity as well at Without heart disease, pumping capacity as well at

age 70 as at age 30age 70 as at age 30

Terminal Loss PatternTerminal Loss PatternLoss in a normally stable function may be sign of Loss in a normally stable function may be sign of

impending deathimpending deathE.g., immune system: # of lymphocytes (white E.g., immune system: # of lymphocytes (white

blood cells) stable normally staleblood cells) stable normally stale Decline occurred in minority of Baltimore Study sampleDecline occurred in minority of Baltimore Study sample Reported good health; good physical examsReported good health; good physical exams At next follow-up for study – subgroup more likely to At next follow-up for study – subgroup more likely to

have diedhave died

Loss occurs, but body compensates for the Loss occurs, but body compensates for the changechange E.g., brain: neural loss but robust individual cell E.g., brain: neural loss but robust individual cell

growth (new dendrites, new connections) may help growth (new dendrites, new connections) may help preserve thinking and memorypreserve thinking and memory

Physical Aging: not only lossPhysical Aging: not only loss StabilityStability ResiliencyResiliency Capacity for growthCapacity for growth