DYING and

BEREAVEMEN
T
 Ten Different Views of Death

Death as an
Death as a Death as an Death as a
image or
statistic event boundary
object

Death as a
Death as a Death as an Death as fear
thief of
state of being analogy and anxiety
meaning

Death as
Death as a
reward or
mystery
punishment
 Definitions and Ethical Issues:
Learning Objectives

How is death defined?

What legal and medical criteria are used to determine when death
occurs?

What are the ethical dilemmas surrounding euthanasia?

What issues surround the costs of life-sustaining care?

 Thanatology: the study of death,
dying, grief, bereavement, and
social attitudes toward these
issues
Sociocultural
Definitions of
Death
Death is a very
difficult concept to
define precisely

Different cultures
have different
meanings for it
Legal and Medical Definitions

 Clinical death: lack of heartbeat and respiration

traditionally signified death
 Today, whole brain death is required
 The person is in a coma and the cause of the coma is
known
 All brainstem reflexes have permanently stopped
working
 Breathing has permanently stopped
 Somewhat different criteria for determining brain
death are applied at different hospitals
 Brain death is also controversial from some religious
perspectives
Legal and Medical Definitions:
Requirements
 Persistent vegetative state: irreversible lack of
cortical functioning, but continued brainstem activity
 This state allows for spontaneous heartbeat and
respiration, but not for consciousness
 The whole-brain standard does not permit a declaration
of death for someone who is in a persistent vegetative
state
 Ethical Issues

Bioethics: study of interface Decisions must:

between human values and
technological advances in the
health and life sciences
Grew out of respect for individual freedom Honor the importance of individual choice
and the difficulty of establishing what is Weigh a treatment’s relative benefit versus
moral through common sense or rational harm to a patient
argument
Dealing with One’s Own Death

 Dying “trajectories” vary across diseases, causing

different reactions to impending death
 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
Sean Davison has
become the centre of
South Africa’s
euthanasia debate after
publishing the story of
how he assisted his
mother in her wish to
die.
 Euthanasia

Euthanasia: merciful Poses the moral dilemma Dilemma often arises

ending of life of deciding under which when the person:
circumstances to end a
person’s life

Must consider the morality of is being kept alive by a

“killing” a person versus machine
“letting” the person die suffers from a terminal illness
Euthanasia

 Can be carried out in two different ways:

 Active euthanasia: deliberate ending of a person’s life
 Passive euthanasia: allowing a person to die by
withholding available treatment
 Decision to carry out both types must be based on a
clear statement of the person’s wishes or a decision
made by another person with the legal authority to do
so
Physician-Assisted Suicide
 Physician-assisted suicide occurs when physicians
provide dying patients with a fatal dose of medication
that the patient self-administers
 Legal in some countries; clear guidelines set
 The patient’s condition is intolerable with no hope for
improvement
 No relief is available
 The patient is competent
 The patient makes a request repeatedly over time
 Two physicians review the case and agree
 Euthanasia would not only be for people who
are "terminally ill.

Euthanasia can become a means of health

care cost containment

Arguments Euthanasia will become non-voluntary

Against
Euthanasia Legalizing euthanasia and assisted suicide
leads to suicide contagion.

Euthanasia is a rejection of the importance

and value of human life.
 Thinking About Death: Personal Aspects:
Learning Objectives

HOW DO FEELINGS HOW DO PEOPLE DEAL WHAT IS DEATH

ABOUT DEATH CHANGE WITH THEIR OWN ANXIETY, AND HOW DO
OVER ADULTHOOD? DEATH? PEOPLE SHOW IT?
  The shift from formal-operational to
postformal thinking helps young people
integrate emotions/thoughts about death
 Parents’ death helps middle-aged adults
think about their own death
A Life-  Older adults are generally less anxious
Course about death and accept it more
Approach to  Attachment theory is the best framework for
Dying understanding how adults deal with death
and how they grieve
Dealing with One’s Own Death

 Dying trajectories vary across diseases

 Some diseases (cancer) have a clear and rapid period of
declining: terminal phase
 Other diseases, (congestive heart failure) have no clear
terminal phase
  Psychiatrist Elizabeth Kübler-Ross (1969,
1974) interviewed terminally ill patients and
identified a common set of emotional
responses to the knowledge that one has a
serious, and probably fatal, illness
Kübler-  Kübler-Ross’s “stages of dying” called
Ross attention to the emotional needs and
reactions of dying people
  Denial: shock, disbelief
 Anger: hostility, resentment (“Why me?”)
 Bargaining: looking for a way out
 Depression: no longer able to deny, patients
Kübler- experience sorrow, loss, guilt, and shame
Ross’s  Acceptance: acceptance of death’s
inevitability with peace and detachment
Stages of
 Discussion of death helps to move toward
Dying acceptance
  Kübler-Ross’s theory has been criticized
 Dying is not stagelike
 The nature and course of an illness affects
reactions to it
 Individuals differ widely in their emotional
Criticism responses to dying
 Personality traits, coping styles, and
of social competencies vary and influence
Kubler- the experience of dying

Ross
 A Contextual Theory of Dying

Stage theories do not state There is no single correct People vary in how they
what moves a person way to die approach Corr’s four
through the stages “tasks” or issues for the
dying:

Bodily needs
Psychological security
Interpersonal attachments
Spiritual energy and hope
Death Anxiety
 Death anxiety: anxiety or fear of death and dying
 Terror management theory: our deeply rooted fear
of mortality makes not dying the primary motive
underlying all behaviors
 Older adults represent existential threats to younger and
middle-aged adults
 Death anxiety consists of several components
 Men have more death anxiety than women
 Women are more fearful of the dying process
Learning to  Enjoy what you do have without many
regrets
deal with
 Adolescent risk-taking is correlated with
death less death anxiety
anxiety  Increasing one’s death awareness (e.g.,
writing one’s obituary, planning one’s
funeral)
 Death education can significantly reduce
fear
 Presents factual information about death,
dying, and advanced directives; increases
sensitivity to others dealing with death
 End-of-Life Issues: Learning
Objectives

WHAT ARE END-OF- WHAT IS HOSPICE? HOW DOES ONE

LIFE ISSUES? WHAT HOW DOES HOSPICE MAKE ONE’S END-
IS A FINAL RELATE TO END-OF- OF-LIFE DESIRES
SCENARIO? LIFE ISSUES? AND DECISIONS
KNOWN?
Creating a Final Scenario

 End-of-life issues: discussing and formalizing

management of life’s final phases, after-death
disposition of one’s body, and lawful
distribution of assets (e.g., through a will)
 Baby boomers are far more proactive and
matter-of-fact about these issues
 Final scenario: making one’s choices known
and providing information about how one
wants one’s life to end, including the process of
separating from family and friends
  Hospice: assisting dying people with pain
management and a dignified death (as
opposed to hospitals or nursing homes)
 Palliative care: care that is focused on relief
from pain or other disease symptoms
The  Emphasizes patient’s quality of life

Hospice  Goal is to make the person comfortable and

peaceful, but not to delay an inevitable death
Option
 Hospice support includes the option for
death doulas
 Living will: stating one’s wishes about life
support and other treatments

Healthcare power of attorney: person

appoints someone to act as an agent for their
Making healthcare decisions
End-of-
Life Do not resuscitate (DNR) order: forbids
Intentions medical personnel from initiating
cardiopulmonary resuscitation (CPR) if the
Known patient’s heart and breathing stop
Patient Self-
Determination
and Competency  The Patient Self-Determination Act requires
Evaluation most healthcare facilities to provide
information to patients in writing that they
have the right to:
 Make their own healthcare decisions
 Accept or refuse medical treatment
 Make an advance healthcare directive
 Concerns regarding implementation:
 Capacity
 Competency
 The Grieving Process:
Learning Objectives

How do people
What feelings do How do people cope
experience the grief
grieving people have? with grief?
process?

What is the difference

What are the types of What is disenfranchised
between normal and
ambiguous loss? grief?
complicated grief?
  Bereavement: the state or condition caused
by loss through death
 Grief: the sorrow, hurt, anger, guilt,
confusion, and other feelings that arise after
The suffering a loss (varies greatly)
Grieving  Mourning: culturally approved ways in
Process: which grief is expressed (fairly standard
Basic within a culture)

Definitions
  Grief involves choices in how we cope and
actively involves:
 Acknowledging the loss’s realty
 Working through the emotional turmoil
The
 Adjusting to an environment where the
Grieving deceased is absent
Process  Loosening ties to the deceased
  Grief is a process
 No two people grieve in the same way
 We must not underestimate how long people
need to deal with various issues (at least one
The year is needed, and two years is not
Grieving uncommon)
 We learn to live with the loss and move on,
Process rather than “recovering” from it
 The Parkes/Bowlby attachment model of
bereavement describes four predominant
reactions to loss
 Numbness
 A sense of unreality and disbelief
 Yearning
 Severe pangs of grief, feelings of
panic, bouts of uncontrolled weeping,
physical pain
 Disorganization and despair
 Depression, despair, and apathy
predominate.
 Reorganization
 Feel ready for new activities.
 Identity is revised
MODELS OF DYING AND
BEREAVEMENT
Risk Factors in Grief

Purported risk factors are kinship relationship, social

support, mode of death, age, personality, religiosity,
and gender

Older people suffer fewer health problems, but social

support reduces this age effect

Anticipatory grief: going through a period of

anticipating a loved one’s death, which supposedly
buffers its impact
  Grief reactions vary in intensity, such as
sadness-anger-hatred, confusion-
helplessness-emptiness, loneliness-
acceptance-relief
 Most common are sadness, denial, anger,
Typical loneliness, and guilt
Grief  Grief work: psychological facets of coming
Reactions to terms with bereavement
 Anniversary reactions
  Grief over time
 Grief tends to peak within the first six
months following the death of a loved one.
Typical  Some continue to grieve over much longer
periods of time. For example, people
Grief reported feeling the effects of family
Reactions member’s deaths 50 years after the event
  Expressions of grief differ with ethnicity
and culture
 Example: Latino – more than European-
American men – express grief behaviorally

Typical  Some cultures construct a “relationship” with

the deceased (e.g., “ghosts,” appearances in
Grief dreams)
Reactions  Grief normally peaks 6 months after death,
but can continue 5 and even 50 years later
  Four-component model:
 The context of the loss
 The continuation of subjective meaning
associated with loss
Coping  The changing representations of the lost
with Grief relationship over time
 The role of coping and emotion-regulation
processes
  Two implications of four-component model:
 A need to make meaning from the loss
 Extensive grieving is helpful, while avoiding
grieving is harmful
 Grief work as rumination hypothesis:
Coping extensive rumination may actually increase
with Grief distress
 Resilient people use effective coping
methods, such as automated processes
(distraction, attending to positive emotions)
  Dual process model (DPM): Dynamic
process in which bereaved cycle back and
forth between two broad types of stressors,
ultimately balancing the two
 Loss-oriented stressors: stressors related to
Coping the loss itself (e.g., grief work)
with Grief  Restoration-oriented stressors: stressors
present when adapting to the survivor’s new
life situation (e.g., finding new relationships
and activities)
  Model of Adaptive Grieving Dynamics
(MAGD): based on two sets of pairs of
adaptive grieving dynamics:
 Lamenting and heartening responses
 Integration and tempering responses
Coping  Lamenting: distressful, disheartening
with Grief  Heartening: gratifying, uplifting
 Integrating: assimilating, internalizing
 Tempering: avoiding the overwhelming
  Ambiguous loss: refers to situations of loss
in which there is no resolution or closure
 Two types:
 The first type refers to a missing person who
is physically absent but still very present
Coping psychologically
with Grief  A second type of ambiguous loss involves a
loved one who is psychologically absent but
who is still physically present
 In both types, normal closure is not possible
  Two types of distress distinguish this
disorder from normal grief and depression:
 Separation distress: isolation;
preoccupation with, upsetting memories of,
longing for the deceased to the point of
Complicated or interfering with everyday functioning
Prolonged Grief
 Traumatic distress: disbelief and shock
Disorder
about the death, experiencing the deceased’s
presence; mistrust, anger, and detachment
from others
Disenfranchised
Grief

 Type of grief that results from a loss that

appears insignificant to others, but is highly
consequential to the person who suffers the
loss
 Stems from the social expectations we place
on people to “move on” after loss
 Failure on the part of others to understand
and empathize with the personal impact of
loss, for example the loss of a pet
 Dying/Bereavement Across the Life Span:
Learning Objectives

How do adults deal with

What do children understand
How do adolescents deal with death? What special issues do
about death? How should
death? they face concerning the
adults help them deal with it?
death of a child or parent?

How do older adults face the

loss of a child, grandchild, or
partner?
  Preschoolers: death is temporary and
magical
 5–7 years: death is permanent, eventually
happens to everyone; reflects the shift to
concrete-operational thought
Childhood
 Older children: problem-focused coping and
a better sense of personal control appears
 Children flip back and forth between grief
and normal activity
Adolescence  Surveys indicate that 40–70% experience
the loss of a family member or friend during
the college years
 Their first experience of death is particularly
difficult and its effects severe, especially if
the death was unexpected
 Chronic illness, lingering guilt, low self-
esteem, poorer school & job performance,
substance abuse, relationship problems, and
suicidal thinking
  Young adults may feel that those who die at
this point are cheated out of their future
 Loss of a partner in young adulthood is very
difficult because the loss is so unexpected;
Adulthood grief can last for 5–10 years
 Losing a spouse in middle adulthood results
in challenging basic assumptions about self,
relationships, and life options
  Losing a child at any age is extremely
traumatic for parents
 Mourning is intense; some never
reconcile the loss, and parents may
divorce
 Young parents report high anxiety, feelings
of negativity and guilt
 Loss of a child during childbirth is traumatic
Death of due to strong attachment, even though
One’s society expects a quick recovery
Child  The loss of a young adult child for middle-
aged parents is equally devastating, causing
anxiety, problems functioning, and
difficulties in relationships with surviving
siblings
  When a parent dies, the loss hurts but also
causes the loss of a buffer between
ourselves and death
 Death of a parent may result in a loss of a
source of guidance, support, and advice
Death of  The loss of a parent may result in complex
One’s emotions including relief, guilt, and a
feeling of freedom
Parent
 Losing a parent due to Alzheimer’s disease
may feel like a second death
  Older adults are often less anxious about
death and more accepting of it
 Elders may feel that their most important
Late life tasks have been completed
Adulthood  Older adults are more likely to have
experienced loss before
Death of
One’s Child or
 Older bereaved parents may feel guilty
Grandchild in about how their pain about losing one child
Late Life affected relationships with surviving
children
 Many grieving parents report that the
relationship with the deceased child was the
closest they ever had
 Bereaved grandparents tend to hide their
grief behavior in an attempt to shield the
grieving parents from more pain
  U.S. society expects the surviving spouse to
mourn briefly, but older bereaved spouses
may grieve for 30+ months
 Depressed survivors’ memories of the
Death of relationship are positively biased, while
those of the non-depressed are more
One’s negative
Partner  May reflect pre-death quality of the
relationship
The End
  All customs are designed to treat the body with respect therefore, autopsies and
embalming are generally prohibited.
 Viewing the corpse is also considered disrespectful.
 The emotional needs of the survivors are very important but there are differences among
Reform, Conservative, and Orthodox Jewish practices.
 No funeral is allowed on Saturday (the Sabbath) or on major religious holidays and
music and flowers are not encouraged.
 Eulogies are given by rabbis, family and friends and if the deceased person was held in
high regard, there are usually several eulogies. Family members and others accompany
the casket to the grave and are encouraged to place a shovel of earth on the casket, as a
sign of the finality of death.
 The period of mourning lasts for one year.
Jewish  The mourner's "Kaddish" or declaration of faith is said at the gravesite
Observances  "Sitting Shiva" refers to the seven-day mourning period immediately following burial.
 The family cooks no food and a candle or lamp is kept burning in the memory of the
deceased.
 The Kaddish is said every day during this time.
 Some people observe a period of three days following the burial during which visitors
are not received and the time is devoted to lamentation.
 After the first seven days, survivors are encouraged to rejoin society but still maintain
mourning by reciting the Kaddish twice daily for thirty days.
 Many mourners wear a black pin with a torn ribbon, or a torn garment during the
funeral and for the next week as a symbol of grief.
 Newborn babies may be named after the deceased.
 The first anniversary is marked by the unveiling of a tombstone at a special ceremony.
 The Sacraments of the Sick are prayers that are said as the person is dying, and involve
confession and communion.
If a person dies before the sacraments are given, the priest will anoint the deceased
conditionally within three hours of the time of death.
There is often a wake and, if so, the priest will conduct the service or say the rosary.
There are distinct phases to "The Mass of Christian Burial":
 Prayers at the funeral home;
 Welcoming the body to the church;

Roman  Covering the casket with a white cloth;

Catholic  Sprinkling the casket with holy water;

observances  The Eucharist is celebrated;

 Prayers are said after the Mass;
 Casket is escorted to back of church;
 At the cemetery, the grave is blessed.
 Consecration is a reaffirmation that the person will rise again and prayers address not
only the dead but the survivors so that their faith in eternal life is encouraged.
 The one-month anniversary of the death is often celebrated by a Mass, as are those of
other anniversaries.
 Common practices include:
A family gathering at the funeral home to make arrangements, with the family elders
assuming ultimate responsibility for the ceremony;
There is great respect for the body;
Warm clothes may be used for burial and watertight caskets are used to keep the elements
out;
Stoic attitudes are common, and depression may result from the internalization of grief.
An open casket allows for respect to elders;
Often poems in calligraphy are left for the deceased.
Buddhist, Among Chinese a cooked chicken may be placed by the casket as a last meal for the deceased
Confucian, and spirits and it is buried with the body.
Music is often used and a band may wait outside the funeral home and accompany the
or Taoist procession to the cemetery.

practices The funeral route, burial location, and the choice of the monument are important.
Incense may be burned at the grave and some populations may offer sacrifices at the funeral.
A gathering of family and friends for a meal after the funeral shows respect for the spirit of
the deceased, and gives thanks to those who came to pay their respect.
A picture or plaque is usually kept in the home and displayed with items that create a shrine
 Traditions differ in every country and the Turkish interpretation of Islam is in some ways
different than those in other Arabic countries.
These comments are basically relevant for some cultures:
Death is considered an act of God so is not questioned.
Faithful followers believe that all the events in the life-course of an individual, including
the time and type of death, are pre-written by God.
People in grief are encouraged to show their feelings openly (crying loudly cleans the
soul).
Any expression of rebellion against God's decision to take a person away is considered a
sin.

Islamic For seven days, the family members are never left alone.
Friends visit the house and talk with the family members about the circumstances of the
Traditions death. They bring food, as no cooking is supposed to be done in a funeral home during
those seven days.
Traditionally, no television, radio or any musical devices would be allowed for 40 days.
There is a religious prayer at the 40th and another at the 52nd day after the death.
Muslims are very sensitive to where their beloved ones are buried (cemetery for Muslims
with prayers led by a Muslim. . The body is buried without the coffin and wrapped in white
clothes - the body should touch the earth.
The body must be washed/bathed with certain rituals before the funeral ceremony begins -
usually at either a special section of the mosque or in the morgue of the hospital.
When meeting with someone who has lost a relative, conversations start by saying: "May
you be alive and May God's blessings be on him/her - the deceased."
  There are a wide range of Protestant observances, including: A
family gathering at the family home or funeral home; Caskets, open
or closed, are part of passage; Memorial items may be placed in the
casket; Cremation is an accepted option for some; Black dress is a
part of mourning. Funeral services include music and testimonials.
Music may include traditional hymns and/or songs of praise
celebrating the Christian experience and the hope of everlasting life.
Protestant Gravesite visits may be made and memorial services are common,
observances and sometimes replace funerals and other immediate observances of
death. Flowers and donations are preferred ways to express
condolences and church members and friends will usually assist in
providing the food needs of the family. The period of time will vary
according to the needs of the family. There is no formal structure to
observe the death, month after month or year after year
You tell me …African
tradition
 The last of the five major rites is the Rite of Ancestorship, which concerns
passing over into the spirit world. This final initiation rite is an extension of
the elder/older distinction because the status that a person has in life is
the same status that they bring with them when they pass on. There is
virtually no African society that believes that when a person dies this ends all
ties and communication with the living. Rather, African philosophy from one
culture to another agrees that the spirit of the deceased is still with the living
community, and that a distinction must be made in the status of the various
spirits, as there are distinctions made in the status of the living.

 One of the most important distinctions is the difference between an older

person who dies and who is seen as nothing more than a “dead relative,” and
a respected elder who passes on and is revered as an honored
“ancestor.” The dead relative dies without honor and is someone who is not
remembered as a great person or someone who should be followed or
emulated. On the other hand, a respected elder who passes on becomes a
respected ancestor and is given the highest honor. This group of ancestor
wield great power and are often called upon in matters of trouble or
uncertainty to help influence a favorable outcome. Thus, ancestors are
respected elders who have passed away and who continue to serve as an
extension of the family and community.