Death and Dying

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DEATH AND DYING

INTRODUCTION

The terms "death" and "dying" are not synonymous and have no unequivocal definitions. Death may beconsidered the absolute cessation of vital functions, while dying is the process of losing these functions. Dying may also beseen as a developmental concomitant of living, a part of the birth-to-death continuum.

What Is Death?

Death is defined as the cessation of all vital functions of the body including the heartbeat, brain activity(including the brain stem), and breathing. It can arrive unannounced at any time and is not the special province of the veryaged.

Meanings of Death

Weissman (2000) distills meanings of death into four categories: (1) Death is an illusion and an extensionof life, a prologue to another form of life; death means transition, not extinction. (2) Death is an inevitable and inexorable factof life, a confrontation with finitude; it is an endpoint in the "contract" between the living and life's parameters. (3) Death is anexplanation and expiation of life, a final judgment on the life process; it offers retribution or reward, a release from mortality'sconstraints. (4) Death is an exigency and a defeat of life, a tragedy, negating life's values, signifying failure and futility. Each of these theories about death is in fact a belief about life (Zisook & Downs, 2000).From biological point of view, death is the permanent cessation of all vital functions. From broader psychological, societal andcultural perspectives, death is much more than the end stage of a biological process. Concepts of death are highly subjective,are exceedingly complex, and change over time. Furthermore the meanings of death are highly coloured by the attitudes of theindividuals who hold them as well as the situational context in which these individuals find themselves.

Dimensions of Death

Death has three dimensions. Impersonal dimension of death considers it as an impersonal event, strippedof human element and the dead are simply dead bodies classified or discarded according to various categories. We stand in animpersonal and unilateral I-It relation to specimens whose unique existence does not matter. It is death of an object that entailsno personal grief or loss. Obituaries of strangers have impersonal significance because emotional loss is missing (Weisman,1985).Interpersonal dimension of death is concerned with the objective fact of the death of the other one. Our subjective death is notinvolved; it is the loss of a significant person that affects us. It is represented by I-You; the typical response is grief and bereavement. While impersonal death refers to “it is dead”, Interpersonal death means “someone else is dead”. Interpersonaldeath changes the psychosocial field and, in turn, alters the interpersonal experience of those affected.Intrapersonal death refers to the inner experience of personal mortality, which most people dread but find difficult to anticipate.It is the only dimension that really matters. The impact of the dead body or death of the other one is important only because of their importance for subjective death (Weisman and Haekett, 1961).

ATTITUDE TOWARDS DEATH: LIFE CYCLE CONSIDERATIONS

How could we understand why people sometimeswithdraw from friends who are terminally ill? How can we comprehend intimate relationships without insight into the fear of loss? Even the youngest children are aware of separation and its threat to their survival.

Children

Young children do occasionally express spontaneous insight into the finality of death, as when encountered a deadanimal or withered plant (Encyclopedia of Psychology, 2000). Nagy (1948) reported three stages of development of death

related cognitions in children. Stage one present until age five, lacks appreciation of death as final and complete cessation.Separation is the theme most clearly comprehended by the youngest children. Stage two children think of death as final but notinevitable. A strong tendency to personify is noted in this stage. Stage three beginning at age nine or ten is marked bycomprehension of death as both final and inevitable. The prospect of personal mortality seems to be accepted. Anecdotalreports suggest that the child’s discovery of death begins much earlier than the most cognitive theorists seem prepared toaccept.The affective and cognitive development of children colors their understanding of death and their subsequent fears about dying.At the preschool, preoperational stage of cognitive development, death is seen as a temporary absence, incomplete andreversible, like departure or sleep. Separation from the primary caretakers is the main fear of a preschooler. This fear surfacesas an increase in nightmares, more aggressive play, or concern about the deaths of others rather than in direct discourse.Regression to more infantile behaviors signals increasing dependence on parents. Dying preschoolers need reassurance fromtheir parents that they are loved, that they have done nothing wrong, that they are not responsible for their illness, and that theywill not be abandoned.School-aged children manifest concrete-operational thinking and recognize death as a final reality. However, they view deathas something that happens to old people, not to them. Between the ages of 6 and 12 years children have active fantasy lives of violence and aggression, often dominated by themes of death and killing. Death may be personified as a skeleton or bogeymanthat takes people away. Dying school-aged children ask questions about their illness if encouraged to do so; however, if theyreceive cues that the subject is taboo, they may withdraw and participate less fully in their own care.Many of us hesitate to talk about death, particularly with youngsters. But death is an inescapable fact of life which we mustdeal with, and so must our children. By talking to them about death, we may discover what they know and do not know; if theyhave misconceptions, fears, or worries. We can then help them by providing information, comfort, and understanding.Long before we realize it, children become aware of death. They see dead birds, insects, and animals lying by the road. Theymay see death at least once a day on television. They hear about it in fairy tales and act it out in their play. Death is a part of everyday life, and children, at some level, are aware of it.Mixed messages are confusing, and may deepen apprehensions and misunderstandings and may leave children confused.Children look to adults for cues about how to behave in certain situations. It is usually easier to talk about death when we areless emotionally involved. Taking opportunities to talk to children about dead flowers, trees, insects, or birds may be helpful.Some young children show intense curiosity about dead insects and animals. They may wish to examine them closely, or ask detailed questions about what happens physically to dead things. Although this interest may seem repulsive or morbid to us, itis a way of learning about death. Children should not be made to feel guilty or embarrassed about their curiosity. Their interestmay provide an opportunity to explain, for the first time, that all living things die and make room for new living things. If thedeath is violent, a murder or an assassination, it is probably a good idea to say something to reassure children about their safety.Be open to their questions. Answer them truthfully and as completely as possible, given the age of the child. If you don’t knowthe answer, just say so. If they want to attend the funeral, let them. If they want to view the body with the rest of the family,don’t prevent them if they are mature enough to understand inevitability and irreversibility of death. Avoid euphemisms. Watchyour terminology. Do not equate death with a journey or sleep or the child may be afraid to go to bed. Do not say the person is

"with Jesus" without further explanation. The child may hate Jesus for taking his/ her loved ones away from them. Make surethe child understands the difference between minor illness and fatal illness. The child may think they will die the next time theyget a cold (NIH, 1995).

Adolescents

Capable of formal cognitive operations, adolescents understand that death is inevitable and final. Their major fears parallel those of all teenagers: loss of control, being imperfect, and being different. Concerns about body image, hair loss, or loss of bodily control may generate great resistance to continuing treatment. Alternating emotions of despair, rage, grief, bitterness, numbness, terror, and joy are common. An adolescent's cognitive capacity to understand death may not translate intoan understanding that their own personal death is possible. The potential for withdrawal or isolation is great because teenagersmay equate parental support with loss of independence or may deny their fear of abandonment by actually repulsing friendlygestures. Teenagers must be part of the decision-making process surrounding their death. Many are capable of great courage,grace, and dignity in facing death.

Adults

Unlike children and teenagers, older adults often readily accept that their time has come. Although they may not behappy to die, they can be reconciled to it.According to Erikson, the eighth and final stage in the life cycle brings either a sense of integrity or despair. As elderly adultsenter the last phase of their lives, they reflect on their time and how it has been lived. Integrity of the self allows an individualto accept inevitable disease and death without fear of succumbing helplessly. However, if a person looks back on life as a seriesof missed opportunities or as filled with personal misfortunes, the sense is of bitter despair, a preoccupation with what mighthave been if only this or that had happened; then death is viewed with fear because it symbolizes emptiness and failure(Zisook, & Downs, 2000).

DEATH ANXIETY AND ITS CORRELATES

Fear and anxiety are among the most frequently used words to characterize orientations toward death throughout the life span.Investigations typically assume that death universally elicits anxiety. Where manifest fear is not present, defensive denial isinferred (Goldings et al., 1966; Jeffres et al., 1961). Conscious fear of death is thought to occur only when there is a serious breakdown of the individual’s defenses, as in extreme psychopathology (Kastenbaum and Costa, 1977).Janet Belsky (1999) defines "death anxiety" as "the thoughts, fears, and emotions about that final event of living that weexperience under more normal conditions of life". In other words, as people live their lives day to day, they suffer differentdegrees of anxiety about death.The various factors psychologists have studied in attempting to measure death anxiety include: age, environment, religiousfaith and ego integrity, or a personal sense of fulfillment and/or self-worth. A complicating aspect of studying death anxiety isthat actually "measuring" anxiety as it relates to these variables has been difficult. The studies used in examining death anxietydo not experimentally manipulate the variables, thus limiting conclusions to correlations (Forner & Neimeyer, 1999). Anadditional confounding factor is the distinction between "death" and "dying." In other words, is the greater source of anxietyassociated with death, itself, or the process of dying. In spite of these challenges, a number of researchers have reportedconclusive findings relating to the impact of the variables noted above on death anxiety.

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