DEALING WITH DEATH AND BEREAVEMENT

(Papalia)

THANATOLOGY is the study of death and dying.

HOSPICE CARE PALLIATIVE CARE

Personal, patient- and family-centered care for a
person with a terminal illness.
 Hospice: a program committed to making
the end of life as free from pain, anxiety, and
depression as possible
Care aimed at relieving/reducing pain and
suffering and allowing the terminally ill to die in
peace, comfort, and dignity.
 type of care emphasized in a hospice

TERMINAL DROP (TERMINAL DECLINE)

Frequently observed decline in cognitive abilities near the end of life.

Kübler-Ross Five Stages in Coming to Terms with Death

Stage 1: DENIAL AND ISOLATION This can’t be happening to me!
No, it can’t be me.
Stage 2: ANGER Why me?
Resentment, rage, envy, anger
Stage 3: BARGAINING If I can only live to see my daughter married, I
won’t ask for anything more.
Hopeful to postponement
Stage 4: DEPRESSION Accept the certainty of her or his death
Preparatory grief
Stage 5: ACCEPTANCE A sense of peace, an acceptance of her or his
fate, and, in many cases, a desire to be left alone

GRIEF
Emotional response experienced in the early phases of bereavement.
BEREAVEMENT
Loss, due to death, of someone to whom one feels close and the process of adjustment to the loss.

The Classic Grief Work Model

Shock and disbelief Immediately following a death;
may last several weeks, especially after a
sudden or unexpected death
Preoccupation with the memory last 6 months to 2 years or so;
of the dead person tries to come to terms with the death but
cannot yet accept it
Resolution bereaved person renews interest in everyday
 activities;
fond feelings mingled with sadness

Grieving: Multiple Variations

Recovery Pattern Mourner goes from high to low distress.
Delayed Grief Pattern There may be moderate or elevated initial grief,
and symptoms gradually worsen over time.
Chronic Grief The mourner remains distressed for a long time.
Painful and acceptance most difficult when a
loss is ambiguous, as when a loved one is
missing and presumed dead.
Resilience Mourner shows a low and gradually diminishing
level of grief in response to the
death of a loved one.

TERROR MANAGEMENT THEORY

Humans’ unique understanding of death, in concert with self-preservation needs and capacity for fear,
results in common emotional and psychological responses when mortality, or thoughts of death, are
made salient.
 Common Response:
More committed to cultural worldview e.g., stronger adherence to a religious ideology

High self-esteem should buffer people against anxiety and fear over death. Feeling significant and
valuable to others can help people believe they are more than their physical body.
Mortality salience has been associated with attachment processes.
 Seeking comfort from loved ones is a common response in humans undergoing threat and is a
regulatory strategy to reduce anxiety.
 Enhanced commitment, attraction, forgiveness, and intimacy

Medical, Legal, and Ethical Issues: The “Right to Die”

I. EUTHANASIA
 Means “good death” and is intended to end suffering or to allow a terminally ill person to die with
dignity.
PASSIVE EUTHANASIA ACTIVE EUTHANASIA
Withholding or discontinuation of life-prolonging Deliberate action taken to shorten the life of a
treatment of a terminally ill person in order to terminally ill person in order to end suffering or
end suffering or allow death with dignity. to allow death with dignity; also called mercy
killing.
E.g., medication, life support systems,
or feeding tubes

II. ADVANCE DIRECTIVES

Document specifying the type of care wanted by the maker in the event of an incapacitating or terminal
illness.
 May take the form of a LIVING WILL or more legal form – durable power of attorney
 DURABLE POWER OF ATTORNEY Legal instrument that appoints an individual to make
decisions in the event of another person’s incapacitation.

III. ASSISTED SUICIDE: PROS AND CONS

Suicide in which a physician or someone else helps a person take his or her own life.
PRO
ETHICAL ARGUMENT  Autonomy and self-determination 
 Mentally competent persons’
right to control the quality of their 
own lives and the timing and
nature of their death
 Preserving the dignity and
personhood of the dying human
being
MEDICAL ARGUMENT  Doctor is obligated to take all
measures necessary to relieve
suffering
 The patient, not the doctor, is the
one who takes the actual step to
end life
LEGAL ARGUMENT  Legalizing assisted suicide would 
permit the regulation of practices
that now occur anyway out of 
compassion for suffering
AGAINST
Belief that taking a life, even with
consent, is wrong; and
Concern for protection of the
disadvantaged i.e., Autonomy is often
limited by poverty or disability or
membership in a stigmatized social
group, and they fear that persons in
these categories may be subtly
pressured into choosing suicide with
cost containment as an underlying
factor.
 Misdiagnosis possibility
 Potential future availability of new
treatments
 Likelihood of incorrect prognosis
 Belief that helping someone die is
incompatible with a physician’s role as
healer
Concerns about enforceability of
safeguards
Lawsuits when family members
disagree about the propriety of
 patients terminating a life
 Adequate safeguards against
abuse can be put in place
through a combination of
legislation and professional
regulation

 The opponents claim that people who want to die are often temporarily depressed and
might change their minds with treatment or palliative care.

LIFE REVIEW
 Process of reminiscence that enables a person to see the significance of his or her life.
 Life review can occur at any time.
 Life review therapy and reminiscence interventions can help focus the natural process
of life review and make it more conscious, purposeful, and efficient.

Methods:
1. recording an autobiography;
2. constructing a family tree;
3. spending time with scrapbooks, photo albums, old letters, and other memorabilia;
4. making a trip back to scenes of childhood and young adulthood;
5. reuniting with former classmates or colleagues or distant family members;
6. describing ethnic traditions; and
7. summing up one’s life’s work.
 DEATH, DYING, AND GRIEVING
(Santrock)
ROBERT KASTENBAUM (1932–2013) emphasizes that the DEATH SYSTEM in any culture
comprises the following components:
PEOPLE. Everyone is involved with death at some point; with more systematic role
with death e.g., funeral industry and the clergy; in life-threatening contexts e.g.,
firefighters, police officers
PLACES OR CONTEXTS. Hospitals, funeral homes, cemeteries, hospices, battlefields,
and memorials
TIMES. Times to honor those who have died; anniversaries; Memorial Day
OBJECTS. Caskets and clothes, armbands, and hearses in specific colors; USA black,
China white
SYMBOLS. Skull and crossbones; last rites; religious ceremonies

ISSUES IN DETERMINING DEATH

 Thirty years ago, the end of certain biological functions:
E.g., breathing and blood pressure, and the rigidity of the body (rigor mortis) were
considered to be clear signs of death.
 In recent decades, defining death has become more complex.

BRAIN DEATH
A neurological definition of death.
 A person is brain dead when all electrical activity of the brain has ceased for a specified
period of time.
 A flat EEG recording is one criterion of brain death.
 The higher portions of the brain often die sooner than the lower portions.
 Because the brain’s lower portions monitor heartbeat and respiration, individuals
whose higher brain areas have died may continue to breathe and have a heartbeat;
 The definition of brain death currently followed by most physicians includes the death
of both the higher cortical functions and the lower brain stem functions.

 Supporters of the cortical death policy argue that the functions we associate with being
human, such as intelligence and personality, are located in the higher cortical part of
the brain.
 They believe that when these functions are lost, the “human being” is no longer alive.
DECISIONS REGARDING LIFE, DEATH, AND HEALTH CARE
Advance Care Planning
Process of patients thinking about and communicating their preferences about end-of-life
care.
Living Will
Legal document that reflects the patient’s advance care planning; advance directive
Euthanasia (“easy death”)
Passive vs. Active (See Papalia)
Assistive suicide
Requires the patient to self-administer the lethal medication and to determine when and where
to do this.
 Active euthanasia involves the physician or a third party administering the lethal
medication.
Hospice v. Palliative care (See Papalia)

KUBLER-ROSS STAGES OF DYING (See Papalia)

PERCEIVE CONTROL AND DENIAL
 Perceived control may work as an adaptive strategy for some older adults who face
death.
 Denial also may be a fruitful way for some individuals to approach death. It can be
adaptive or maladaptive.
 Denial is neither good nor bad; its adaptive qualities need to be evaluated on an
individual basis.

GRIEVING
DIMENSION OF GRIEVING
GRIEF The emotional numbness, disbelief, separation anxiety, despair, sadness, and
loneliness that accompany the loss of someone we love.
Dimensions:
1. Pining (yearning): intermittent, recurrent wish or need to recover the lost person;
2. Separation anxiety: not only includes pining and preoccupation with thoughts of the
deceased person but also focuses on places and things associated with the deceased,
as well as crying or sighing;
 3. Despair and sadness: include a sense of hopelessness and defeat, depressive
symptoms, apathy, loss of meaning for activities that used to involve the person who is
gone, and growing desolation.
PROLONGED GRIEF DISORDER
COMPLICATE GRIEF; grief that involves enduring despair and remains unresolved over an
extended period of time.
Following are studies that provide information about various aspects of complicated or
prolonged grief disorder:
 In a recent meta-analysis, 9.8 percent of adult bereavement cases were classified as
characterized by prolonged grief disorder;
 The older individuals were, the more likely prolonged grief disorder was present.
 Prolonged grief was more likely to occur when individuals had lost their spouse, lost a
loved one unexpectedly, or spent time with the deceased every day in the last week of
the person’s life.
 Adults with depression were more likely to also have complicated grief.
 Complicated grief was more likely to be present in older adults when the grief was in
response to the death of a child or a spouse.
 Among individuals diagnosed with complicated grief, 40 percent reported at least one
full or limited-symptom grief-related panic attack in the past week.
 Cognitive-behavior therapy reduced prolonged grief symptoms.
DISENFRANCHISED GRIEF
An individual’s grief over a deceased person that is a socially ambiguous loss and can’t be
openly mourned or supported.
 E.g., death of an ex-spouse, a hidden loss such as an abortion, and circumstances of
the death that are stigmatized such as death because of AIDS

DUAL-PROCESS MODEL OF COPING WITH BEREAVEMENT

A model of coping with bereavement that emphasizes oscillation between two dimensions:
1. Loss-oriented stressors: focus on the deceased individual and can include grief work
and both positive and negative reappraisals of the loss;
a. Positive appraisal: acknowledging that death brought relief at the end of
suffering;
b. Negative appraisal: yearning for the loved one and ruminating about the death.
 2. Restoration-oriented stressors: the secondary stressors that emerge as indirect
outcomes of bereavement; e.g., changing identity and mastering skills
 Recently, a variation of the dual-process model has been developed for families; focuses
on such matters as reduced finances, legal consequences, and changed family
relationships.
COPING AND TYPE OF DEATH
 Deaths that are sudden, untimely, violent, or traumatic are likely to have more intense
and prolonged effects on surviving individuals and make the coping process more
difficult for them;
 Accompanied by post-traumatic stress disorder (PTSD) symptoms;
 The death of a child can be especially devastating and extremely difficult for parents to
cope with.

CULTURAL DIVERSITY IN HEALTHY GRIEVING

 What is needed is an understanding that healthy coping with the death of a loved one
involves growth, flexibility, and appropriateness within a cultural context.

MAKING SENSE OF THE WORLD

Four Meaning-Making Processes
(1) sense making (seeking biomedical explanations for the death, revisiting parents’ prior
decisions and roles, and assigning blame);
(2) benefit finding (exploring possible positive consequences of the death, such as ways to
help others; providing feedback to the hospital; and making donations);
(3) continuing bonds (reminiscing about the child, sharing photographs, and participating in
community events to honor the child); and
(4) identity reconstruction (changes in the parents’ sense of self, including changes in
relationships, work, and home).

 Making sense was an important factor in their grieving of a violent loss by accident,
homicide, or suicide.

LOSING A LIFE PARTNER

 Approximately three times as many women as men are widowed.
  Those left behind after the death of an intimate partner often suffer profound grief, die
earlier, and may endure financial loss, loneliness, increased physical illness, and
psychological disorders, including depression.
 Researchers have found that religiosity and coping skills are related to well-being
following the loss of a spouse in late adulthood.
 Social support helps them adjust to the death of a spouse.
FORMS OF MOURNING
 CREMATION is more popular in the Pacific region of the United States, less popular in
the South. Cremation also is more popular in Canada than in the United States and most
popular of all in Japan and many other Asian countries.
 FUNERAL is an important aspect of mourning in many cultures; funeral directors and
their supporters argue that the funeral provides a form of closure to the relationship
with the deceased, especially when there is an open casket.
 One way to avoid being exploited during bereavement is to purchase funeral
arrangements in advance, but many people are reluctant to do this.

AMISH
 a conservative Christian group; family-oriented society
 At the time of death, close neighbors assume the responsibility of notifying others of
the death.
 The Amish community handles virtually all aspects of the funeral.
 Calm acceptance of death, influenced by a deep religious faith, is an integral part of the
Amish culture.
 Following the funeral, a high level of support is given to the bereaved family for at least
a year.
 Visits to the family, special scrapbooks and handmade items for family members, new
work projects started for the widow, and quilting days that combine fellowship and
productivity are among the supports given to the bereaved family.

TRADITIONAL JUDAISM
 The program of mourning is divided into graduated time periods, each with its
appropriate practices;
1. Aninut: period between death and burial;
2. Avelut: mourning proper
 a. Shivah: period of 7 days, commences with the burial; especially important
b. Sheloshim: 30-day period following the burial, including shivah;
 At the end of sheloshim, the mourning process is considered over for all but one’s
parents;
 In its entirety, the elaborate mourning system of traditional Judaism is designed to
promote personal growth and to reintegrate bereaved individuals into the community.