END-OF-LIFE ISSUES:
- Death in general:
- Different cutural attitudes, esp. in cultures that believe in continuity to an afterlife
Anthropologists say: dead people often appear in dreams among the living, so their spirit is considered to still be alive and present.
Ancestor worship is very important in many societies, esp. Asian
- Medical & legal criteria: "whole-brain" death (older criterion of "clinical" death was lack of heartbeat or respiration)
- Persistent Vegetative State:
Raises ethical issues-- when to withhold care, when to remove feeding tube, etc.
- Euthenasia = ending life for reasons of mercy ("putting person out of their misery")
Active = deliberate; Passive = withholding care or feeding
Many West European countries allow euthenasia; most East European and Islamic countries do not. - Approaching the end of life
- "Living Will" and other medical directives help reveal patient's feelings, beliefs, and wishes; this relieves the family of responsibility for the decision
- Physician-assisted suicide: Netherlands, Switzerland, Belgium, Colombia allow, also Oregon and a few other states
Netherlands requires: 1. Intolerable condition w/ no hope of improvement; 2. No relief available; 3. Patient is competent to make decision; 4. Patient makes
request repeatedly over time;
5. Two physicians must review and agree with patient. (Other laws permitting this are similar.)
Alternative: life-sustaining care is very expensive and takes an emotional toll of family
- Approaching the end of life--
- Think personally: Write your own obituary (200 w. or less); list survivors, accomplishments.
Now list accomplishments not mentioned; friends and how affected. Rewrite if desired.
- Randy Deusch (pioneer of Virtual Reality): after diagnosis with terminal cancer, he gave lectures about achieveing his childhood dreams
- Life-course: When parents die and we become the oldest living generation, we begin to think more often about death and mortality.
To many, this happens in mid-life.
Older adults are typically more accepting of their own mortality, esp. if they have had a satisfying life
- Terminal phase of illness-- some diseases have a recognizable final phase, others do not.
- Some deaths are quick; some are drawn out and anticipated
- Death Anxiety = fear or anxiety of death, incl. conscious and non-conscious thoughts
Terror Management theory (for military, etc.): --can lead to:
1. Threat avoidance 2. Health behavior 3. Risky (health-defeating) behavior
Talking about death can reduce death anxiety (but it's unclear how long this effect lasts)
- Hospice option: Comfort the dying; Pain management ("palliative care"); "Death with dignity"
Can be inpatient or home-based; can (increasingly) include a "death doula"
Much individuality-- attention to wishes of family members, too
- Wills and other preparations:
- End-of-life planning; writing out a scenario
- Make your end-of-life intentions known: living will, Power of Attorney
- Important to include conditions for "DNR--Do Not Resuscitate" order
- Patient rights: 1. Make own decisions; 2, Accept or refuse medical treatment;
3. Make an Advanced Healthcare Directive
- Ask a lawyer in your jurisdiction what can and cannot be legally binding
- Five stages (conditions) of grief (Elizabeth Kübler-Ross)--
(not always in sequential order, sometimes intermixed):
1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance
Same stages with grief at someone else's death, or at facing your own death
If death is forseen (as in many cancers), anticipatory grief may precede death (needs research)
- Surviving the loss:
- Acknowledge the reality
- Deal with emotional turmoil
- Adjust to new situation
- Loosen ties (incl. emotional) to the deceased
- "Grief work" = coming to terms psychologically. Religious beliefs help.
- "Anniversary reaction" may occur on anniversary of death
- Coping with grief:
- Four-component model:
- 1. Context: risk factors; was it sudden or lingering and expected?
- 2. "Continuation of subjective meaning associated with loss"
- 3. Changing representations of the lost relationship
- 4. Role of coping and emotional regulation
- "Grief work as rumination" hypothesis-- prolonged grieving may increase distress, depression
- Widowed spouses often suffer deteriorating health (or death) within first year of loss
- Dual-process model (favored by many experts):
- 1. Loss-oriented stressors (adjusting to the absence)
- 2. Restorative-oriented stressors (adjusting to life's new situations)
- This model often matches what people report, incl, alternation between (1) & (2)
- Model of "Adaptive Grieving Dynamics": Grief never ends; griever experiences both (or alternately):
positive (heartening) and negative (lamenting) experiences;
also integrating (assimilating changes) and tempering (avoiding unpleasantries)
Ambiguous loss (as in disappearance or natural disaster with no clear evidence of death):
- Loss but no resolution or closure
- Hope for safe survival (this fades with time)
- Pain of not knowing what happened to missing loved one
- Similar to "here but gone" ambiguity of Alzheimer patient with almost no function left
Sometimes: Complicated or prolonged grief disorder (persistent and intrusive)--
- Includes Separation distress-- upsetting memories, feelings of isolation
- Also includes Traumatic distress-- anger & detachment, mistrust of others
- These reactions are maladaptive; also present across many cultures
Sometimes: "Disenfranchised grief"-- significant to griever but usually not to others, e.g., loss of a beloved pet
Dying and Bereavement across the lifespan (Grieving at different age levels):
- Children under age 6 often do not appreciate or understand permanence of the loss.
- Children from ~age 6 on understand permanence, mourn, then alternate between grief and normal activity;
then increases in normal activity; usually few lasting effects after a year.
- Adolescents: Hard-hit if it's a friend or age-mate; Grieve a lot but usu. privately;
Little effect on development
- Adulthood: Varied, but usually adjust after a while.
The following are generally more traumatic:
- Death of a boyfriend/girlfriend/fiance(e)/young spouse (esp. if children)--
"Every time I look at [child], I'm reminded of [lost spouse]"
- Death of child (incl. during pregnancy)-- effects may be long-lasting
- Death of a parent hard in many cases, but less so if death is expected
(very old, or after prolonged illness).
- Sometimes (esp. in Alzheimer's disease) loss of functions seems like death;
physical loss seems like a second death.
- Senior years: Repeated losses can lead to sorrow, isolation, depression
Loss of child or grandchild very hard-- the emotional pain is often long-lasting
Loss of marital partner is most devastating--
--poor health outcomes; increased mortality within a year or two;
even social supports help very little.
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