The Final Passage

Sociocultural Definitions of Death

• Different cultures view death in diverse ways• Customs and expectations also differ in

rituals of bereavement and mourning• Even within a culture there is diversity in the

view of death, mourning, and bereavement

There Are at Least 10 Ways Death Can Be Viewed

• Death as an image or object

• Death as a statistic• Death as an event• Death as a boundary• Death as a state of

being

• Death as a thief of meaning

• Death as an analogy• Death as fear and

anxiety• Death as reward or

punishment

Legal and Medical Definitions

• The traditional definition of clinical death was a lack of heartbeat and respiration

• Today, brain death is the most used definition:– No spontaneous movement to stimulation– No spontaneous respiration for 1 hour– Lack of response to pain– No eye movements, blinking, or pupil responses– No postural activity, swallowing, or yawning– No motor reflexes– A flat EEG for 10 minutes– No change in any of these in 24 hours

Legal and Medical Definitions (Cont)

• All eight criteria must be met and other possible conditions ruled out

• In most hospitals, the lack of brain activity must extend to the brainstem and cortex

• Activity only in the brainstem is called a persistent vegetative state, from which the person does not recover

Ethical Issues

• Bioethics is the study of the combination of human values and technological advances– Bioethics grew from the increasing concern

for respect for individual freedom and the difficult task of defining morality in medical care

Euthanasia

• Euthanasia is the practice of ending life for reasons of mercy– Extends from the advances that allow for

life to be extended by extraordinary means, and the concern for quality of life and respect for the individual

Active Euthanasia

• Active euthanasia is the deliberate ending of someone’s life

• Moral and religious concerns are involved in the issue of active euthanasia

• Physician-assisted suicide has become an increasingly controversial issue

• Some states have passed laws specifically making physician-assisted suicide legal, others have banned it

Passive Euthanasia

• Allowing a person to die by withholding available treatment is called passive euthanasia

• A survey in England showed that caregivers agreed that dementia patients should not receive treatments when critically ill

• Most cases of passive euthanasia end up in court which has asserted that without advance directives, nourishment cannot be stopped

Making Your Intentions Known

– There are two ways to tell others of your choice about final decisions• A living will in which a person states

their preferences and intentions in the event that they may be unable to make their intentions known

• A durable power of attorney names an individual who will have the legal authority to make decisions and speak for the person

A durable power of attorney, like the one shown here, is a way to make you end-of-life wishes known to others.

A Life Course Approach to Dying

• Young adults integrate feeling and emotions with their thinking about death, lessening their feelings of immortality

• Middle-age adults think about their own death as they deal with the death of their parents

• Older adults are less anxious about death because of achievement of ego integrity and because of declining joy of living

Dealing With One’s Own Death

• Reactions to impending death can vary in its development, especially with different causes of terminal illness– Diseases such as cancer may have a

terminal phase in which a patient may be able to predict and prepare for death

– Some diseases that do not have a terminal phase may create a condition in which a person’s death could occur at any time

Kubler-Ross’ Theory– Elisabeth Kubler-Ross began working with

terminally ill patients– During this time, terminally ill patients were

not always told they were dying, and death was not generally a topic of discussion. Her research was controversial

– Kubler-Ross began to study patients’ reactions to their terminal illness and found that most people experienced certain emotional states

Kubler-Ross’ Stages of Dying

• Denial: Shock and disbelief• Anger: Hostility and resentment• Bargaining: Looking for a way out• Depression: No longer able to deny, patients

experience sadness and loss• Acceptance: Acceptance of the inevitability of

death with peace and detachment• Though not all people experience all stages

in the same order, discussion of death helps to move toward acceptance

A Contextual Theory of Dying

• Stage theories imply order to the transition toward acceptance that may not exist

• Stage theories do not state what moves a person through the stages

• Observations suggest that people vary greatly in the duration of a particular stage

• There is no single correct way to die• Each person’s own view of their death and

need for health care may impact their movement through the stages

Death Anxiety• Terror management theory asserts that the

continuation of one’s life is the primary motive behind all behavior. Fear of dying is consistent with this motive

• Research suggests that death anxiety includes pain, body malfunction, humiliation, rejection, etc. Each of these factors can be assessed in any of three levels: public, private, and unconscious

Death Anxiety (Cont)

• Death anxiety may be lower in older adults due to ego integrity and a positive life review. Emotional problems are predictive of higher death anxiety

Learning to Deal with Death Anxiety

• Adolescents engage in more risk-taking behavior which suggests less death anxiety

• Reduction can be achieved by contemplating one’s own death by writing one’s own obituary, planning one’s own funeral, etc.

• Death education strives to address death anxiety by presenting factual information about death and reducing sensitivity to the issues involved

Creating a Final Scenario

• Discussions of the issues of management of the final phase of life and the after-death disposition of their body are called end-of-life issues

• Hospitals and nursing homes teach about advance directives like durable power of attorney and living wills

• Making one’s choices known and providing information about how one wants their life to end is called a final scenario

The Hospice Option

• An alternative to going to a hospital or nursing home during a terminal illness is hospice care. This involves assisting dying people with pain management and a death with dignity

• The emphasis of hospice is on quality of life• The primary goal of hospice is to make the

person comfortable and peaceful, not to delay an inevitable death

The Hospice Option (Cont)

• St. Christopher’s Hospice in England was founded by Dr. Cicely Saunders and is the model for modern hospices

• When no treatment or cure is possible, hospice care is requested. The family and the patient is viewed as a unit

• May be inpatient or outpatient• An emphasis is placed on patient dignity• Patients show less anxiety and depression

The Hospice Option (Cont)

• Key questions about the possible use of hospice services:– Does the person know the truth about their

condition?– What options are available for patient care?– What are the patients expectations?– How well do the people in the person’s social

network communicate?– Are family members available to provide care?– Is a high-quality hospice care program available?

The Grieving Process

• Bereavement is the state or condition caused by loss through death

• Grief is the sorrow, hurt, anger, guilt, confusion, and other feelings that arise after suffering a loss

• Mourning is the way in which we express our grief

• Mourning rituals can be fairly standard across a culture. Grief varies greatly