Death & Dying

And how we cope with grief and loss

Prepared by: Fanhao

Kong Jun 29, 2021
 Keydric. (2019, October 13)

https://www.youtube.com/watch?v=oEygbbZK-u0&ab_channel=Keydric
Overview

1 2 3 4
Definitions Statistics Good Death The Right to Die

5 6 7
Grieving Applications Questions
Definitions
The definition of death has changed a lot as medical technology has advanced
Heart stops - may be restarted with shock
Breathing stops - may be maintained with respirator
Brain inactivity - could be
Persistent vegetative state (PVS) - low level brain activity
Brain death/irreversible coma - persistent brain inactivity
Uniform Determination of Death Act (1981) definition:
irreversible cessation of circulatory & respiratory function, or
irrersible cessation of all brain function.

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Statistics
Leading Causes of Death in US in 2020
1. Heart disease (690,882)
75% of the elderly population (age
2. Cancers (598,932)
beyond 65) will struggle with heart
3. COVID-19 (345,323)
disease, cancer, stroke, lung disease,
4. Unintentional injuries (192,176)
or dementia during the last year of
5. Stroke (159,050)
their life.
6. Chronic lower respiratory diseases (151,637) Lynn. (2000)

7. Alzheimer disease (133,382)

8. Diabetes (101,106)
9. Influenza and peneumonia (53,495)
10. Kidney disease (52,260)
11. Suicide (44,834)
Ahmad & Anderson. (2021) 02
Statistics
“One in hundred of them (nursing home residents) had a
plan about what to do when their hearts stopped beating...
And only one in 500 of them had plan about what to do if
they became seriously ill” (TED-Ed, 2013, 4: 22).

Peter Saul
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Good Death
Institute of Medicine’s Definition Contributors to a good death
A Good death is “one that is free from • Physical symptoms
avoidable distress and suffering, for patients, • Psychological and cognitive symptoms
family, and caregivers; in general accord with • Economic and caregiving needs
the patients’ and families’ wishes; and • Social relationships and support
reasonably consistent with clinical, cultural, • Spiritual and existential beliefs
and ethical standards.” • Hopes and expectations

Emanuel and Emanuel (1998)

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Good Death
End-of-life Care
• End-of-life care refers to medical care and support provided during the period associated with
death and dying. The care happends before the heart stops functioning and breathing stops
(Lapid et al. 2020).
• Palliative Care - Relieving pain & discomfort with medication, techonology, care, and setting,
which involved working with professionals such as physiotherapists, paramedics, nurses,
doctors, and social wokers (Dalal & Brueara, 2017).
• Hospice Care - Reducing pain & suffering with medical care and psychological, spiritual, and
supportive counseling among people with terminal illness, usually with less than six months
to live.

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The Right to Die
Choice of when and how to die
• The right to die is interpreted as a law allowing a terminally ill individual to self-administer or
seek help from a physician to use prescribed life-ending medication.
• Tenzek & Depner (2017) opine that terminally ill patients can request physician-assisted dying
to relieve immense suffering.
• Once the patient gives the consent, the doctor administers the lethal dose of medication at
an agreed time.
• The caregiver attending the terminally ill patient should ensure the family members fulfill the
patient's wishes.
• The ultimate right to die lies with the individual.

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The Right to Die
Terminologies
Advance Directives (living wills) - written legal instructions specifying desired level of life-saving
medical intervention used when a person cannot communicate or make decision.
Euthanasia - terminationg a life in a painless manner to end suffering
Active - actively ending life with lethal substance (illegal in most states)
Passive - withholding or withdrawing treatment (generally more acceptant)
Do Not Resusciatate (DNR) - do not restart heartbeat, no CPR
Discontinuation of water and food, medications, and respirators (Gandsman, 2018)
Physician-assisted suicide - can either passive or active. usually involved in prescribing a lethal
substance for the patient to take.
Involuntary euthanasia is often administered to constant vegetative state patients that are not
expected to gain consciousness (Mulholland, 2020).
Double Effect - giving palliative medication despite chance of death (Broderick & Blewitt, 2019)
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Grieving
The natural response to death
• Events such as bereavement may cause overwhelming emotional agony to affected
individuals.
• Emotional instability, feelings of fury, disbelief, and shock often occur.
• Grief can cause physical changes that affects one’s weight and sleep patterns.
• Although there is no standard process of grieving, the five stages model suggested by
Elisabeth Kübler-Ross provides a good insight into what a dying person or grieving individual
may experience.

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Grieving
Kübler-Ross Model

09 Adult Swim UK. (2019, August 4)

Grieving
Kübler-Ross Model
• Denial - initial shock and numbness, pretend the news are not reall
• Anger - blame start, functions as an emotional outlet
• Bargaining - attempt to regain control
• Depression - constant feeling of sadness, may involed loss of interest
• Acceptance - acceptance of the harsh reality Corr, C. A. (2020)

Crticism of the Kübler-Ross Model

• Kübler Ross wrote in her book that, “Most of my patients have exhibited two or three stages
simultaneously and these do not always occur in the same order” (Corr, 2020).
• The Kübler Ross Model lack of empirical evidence.
• This is a old theory.

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Grieving
Classic Approaches
Freud: grief work - one must withdraw their emotional attachments and detach from the lost object,
and successful resolution involves decathecting (Broderick & Blewitt, 2019).

Bowlby’s take on grieving process is based on his attachment theory.

• Shock (disbelief)
• Protest (restlessness or irritability)
• Despair (sadness)
• Reorganization (acceptance)

The main difference between these two approaches is that, Bowlby believed that bereaved individuals
find new ways to hold memory of the deceased instead of detaching (Broderick & Blewitt, 2019).
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Grieving
Complicated or Abnormal Grief
Grief - emotional suffering
Complicated grief - prolonged grief that causes distress & impairment
indicators - identity disruption, disbelief, avoidance, emotional pain, difficulties moving on,
numbness, a sense that life is meaningless, and loneliness for over one year
(Boelen, Eisma, Smid, & Lenferink, 2020)

Bowlby define abnormal/complicated grief as grief that is either excessive and protracted or absent.
• Chronic grief - prolonged grief.
• Absence of grieving - maladaptive defense against the trauma of loss (Broderick & Blewitt,
2019).

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Grieving
Dual-process Model
• Coined by Henk Schut and Margaret Stroebe in the
1990s.
• The theory centers on the idea that grief functions in
two significant ways.
• Loss-oriented emotions include anger, loneliness, and
sadness (Stroebe & Schut, 2010).
• Restoration-oriented behaviors tend to restore
normality and order.
• Oscillation - tendency of the individual to move back
and forth between the two stressors.
Stroebe & Schut, (2010)

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Application
What can we do?
• End-of-life Care
• More research
• Education

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References
• Adult Swim UK. (2019, August 4). Robot Chicken | Sinking Feeling | Adult Swim UK 🇬🇧. YouTube. https://www.youtube.com/watch?v=6IHhAKnCtKc&ab_channel=AdultSwimUK
• Ahmad FB, Anderson RN. (2021) The Leading Causes of Death in the US for 2020. JAMA, 325(18):1829–1830.
• Boelen, P. A., Eisma, M. C., Smid, G. E., & Lenferink, L. (2020). Prolonged grief disorder in section II of DSM-5: a commentary. European journal of psychotraumatology, 11(1), 1771008.
• Broderick, P. C., Blewitt, P. (2019). The Life Span: Human Development for Helping Professionals, 5th edition. Pearson. 622.
• Charlier, P., & Annane, D. (2018). Time for a new definition of death?. Resuscitation, 127, e14-e15.
• Corr, C. A. (2015). Let’s stop “staging” persons who are coping with loss. Illness, Crisis & Loss, 23(3), 226-241.
• Corr, C. A. (2020). Elisabeth Kubler-Ross and the “Five Stages” Model in a Sampling of Recent American Textbooks. OMEGA-Journal of Death and Dying, 82(2), 9.
• Dalal, S., & Bruera, E. (2017). End‐of ‐life care matters: Palliative cancer care results in better care and lower costs.  The oncologist, 22(4), 361.
• Emanuel, E. J., Emanuel, L. L. (1998). The promise of a good death. Lancet , 351, 21-29.
• Gandsman, A. (2018). “Old age is cruel”: The right to die as an ethics for living. The Australian Journal of Anthropology, 29(2), 209-221.
• Lapid, M. I., Koopmans, R., Sampson, E. L., Van den Block, L., & Peisah, C. (2020). Providin quality end-of-life care to older people in the era of COVID-19: Perspectives from five
countries. International psychogeriatrics, 32(11), 1345-1352.
• Lynn, J. (2000). Learning to care for people with chronic illness facing the end of life. Journal of the American Medical Association, 284, 2508–2513.
• Keydric. (2019, October 13). Irish man leaves funny recording for his funeral. YouTube. https://www.youtube.com/watch?v=oEygbbZK-u0&ab_channel=Keydric
• Mulholland, K. C. (2020). Protecting the Right to Die: The Patient Self Determination Act of 1990. In Who Decides? (pp. 165-186). Routledge.
• National Conference of Commissioners on Uniform State Laws. (1981). Uniform Determination of Death Act.
• Stroebe, M., & Schut, H. (2010). The dual process model of coping with bereavement: A decade on. OMEGA-Journal of Death and Dying, 61(4), 273-289.
• Stosny, S. (2018). The Function of Anger and Resentment. Psychology Today.
• TED-Ed. (2013, June 9). Let’s talk about dying - Peter Saul. YouTube. https://www.youtube.com/watch?v=lkvKGafoyIY&ab_channel=TED-Ed
• Tenzek, K. E., & Depner, R. (2017). Still searching: a meta-synthesis of a good death from the bereaved family member perspective.  Behavioral Sciences, 7(2), 25.
• Veatch, R. M. (2018). The definition of death: Problems for public policy. In Dying: Facing the facts (pp. 405-432). Taylor & Francis.
• Weeks JC, Cook EF, O'Day SJ, et al. Relationship Between Cancer Patients' Predictions of Prognosis and Their Treatment Preferences. JAMA. 1998;279(21):1709–1714.
• Xia N, Li H. (2018). Loneliness, Social Isolation, and Cardiovascular Health. Antioxid Redox Signal. 2018;28(9):837-851.
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