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Chapter Sixteen
The Final Passage
Introduction
• Why is it so difficult to contemplate our
death?
• What is the grief process like?
• How do people in different developmental
stages experience the death of a loved one?
16.1 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?
Sociocultural Definitions of Death
• All cultures have their own views of death
• Mourning rituals differ from culture to culture
– Examples: Orthodox Jews cover all the mirrors in a
house; ancestor worship in many Asian cultures
• Some of the most famous structures on Earth
result from customs regarding death
– Examples: Taj Mahal; Egyptian pyramids
Legal and Medical Definitions
• How do we determine that a person has died?
– Clinical death: the lack of heartbeat/respiration
• Standard definition for hundreds of years
– Whole-brain death: several criteria
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No spontaneous movement in response to any stimuli
No spontaneous respirations for at least one hour
Total lack of responsiveness to painful stimuli
No eye movements, blinking, or pupil responses
No postural activity, yawning, or swallowing
No motor reflexes
Legal and Medical Definitions
(cont’d.)
– Whole-brain death (cont’d.)
• A flat EEG for at least 10 minutes
• No change in any of these criteria when tested 24 hours
later
• Whole-brain standard is used everywhere in
the U.S.
• Some medical professionals call for a single
assessment or a simpler one
• Some religions find brain death controversial
Legal and Medical Definitions
(cont’d.)
• Persistent vegetative state: situation in which
a person’s cortical functioning ceases while
brainstem activity continues
– Person does not recover
– Does not allow for consciousness
– Family members face difficult ethical decisions
regarding what to do for the person
Ethical Issues
• Bioethics: the study of the interface between
human values and technological advances in
health and life sciences
– Based on respect for individual freedom and the
impossibility of establishing any single version of
morality from rational argument or common
sense
– People must weigh the benefits and harms
regarding keeping one in a persistent vegetative
state, beginning risky treatment, etc.
Ethical Issues (cont’d.)
• Euthanasia: the practice of ending life for
reasons of mercy
– Usually is a scenario when a person is being kept
alive by machines or has a terminal illness
– Should a person be able to make the judgment
that another’s life should end?
– Active euthanasia: the deliberate ending of
someone’s life
• Example: administering a drug overdose
Ethical Issues (cont’d.)
• Euthanasia (cont’d.)
– Passive euthanasia: allowing a person to die by
withholding available treatment
• Example: disconnecting a ventilator, not getting
chemotherapy treatments, etc.
– There is controversy regarding whether there
really is a difference between active and passive
euthanasia
– Many people in the U.S. have religious reasons for
not supporting euthanasia, especially active forms
Ethical Issues (cont’d.)
• Euthanasia (cont’d.)
– Western Europeans tend to view active
euthanasia positively; Eastern Europeans and
Muslims tend not to
– Cases regarding euthanasia often end up in court
• Example: Terry Schiavo in Florida
• Physician-assisted suicide: the process in
which physicians provide dying patients with a
fatal dose of medication that the patient selfadministers
Ethical Issues (cont’d.)
• Physician-assisted suicide (cont’d.)
– Most people support it for terminally ill people in
great pain
– The Netherlands became the first country to
officially legalize physician-assisted suicide
– Oregon and Washington have laws that support it,
with some restrictions
• Three requests must be made by the patient, spaced
three days apart
• Screen for issues such as depression
Ethical Issues (cont’d.)
Number of Oregon Death With Dignity Act prescription (Rx) recipients and deaths, 1998–
2010.
Ethical Issues (cont’d.)
• Most people fail to tell family members what
they want to happen to them at the end of
their lives
• How does one make intentions known?
– Living will: a document in which a person states
his or her wishes about life support and other
treatments
– Durable power of attorney for health care: person
appoints another to act as his or her agent for
health care decisions
Ethical Issues (cont’d.)
• In order for legal methods to work, relatives
and physicians must know about the existence
of these documents and where they are
• Do not resuscitate (DNR) order: a medical
order that means CPR is not started should
the heart and breathing stop
– Medical teams usually initiate CPR right away
16.2 Thinking About Death:
Personal Aspects
• Learning Objectives:
– How do feelings about death change over
adulthood?
– How do people deal with their own death?
– What is death anxiety?
• How do people show it?
– How do people deal with end-of-life issues and
create a final scenario?
– What is hospice?
A Life-Course Approach to Dying
• Why do people start thinking about their own
mortality at midlife?
– Start to think about how long they have left to live
• Can lead to changes in occupation or strengthening
relationships
• Older adults are usually more accepting of
death and less anxious about it than other age
groups
Dealing with One’s Own Death
• The trajectory of death depends on the type
of illness (see Figure 16.2)
– Green line: clear and rapid period of decline
– Red line: conditions with some periods of rapid
decline followed by recovery, but with a general
decline over a period of time
– Gold line: a long-term chronic condition that
results in death
• What are some examples of each of these?
Dealing with One’s Own Death
(cont’d.)
The three main trajectories of decline at the end of life.
Dealing with One’s Own Death
(cont’d.)
• Kübler-Ross described five reactions that
represent the ways people deal with the
process of death:
– Denial, anger, bargaining, depression, and
acceptance
• Not everyone experiences in the same order if at all
• Corr identified four dimensions of the types of
tasks dying people must face:
– Bodily needs, psychological security, interpersonal
attachments, and spiritual energy and hope
Dealing with One’s Own Death
(cont’d.)
• Corr’s theory (cont’d.)
– A holistic approach that recognizes the coping
efforts of family member and caregivers as well as
the dying person
• Kastenbaum and Thuell emphasize the
socioenvironmental context within which
dying occurs
– Example: does moving from independent living to
an assisted care facility influence how the person
copes with dying?
Death Anxiety
• Death anxiety: people’s anxiety or fear of
death and dying
• Terror management theory: addresses the
issue of why people engage in certain
behaviors in order to achieve particular
psychological states based on their concerns
about mortality
– Assumes that a person’s primary motive is
continuing his or her life
Death Anxiety (cont’d.)
• Brain activity in the right amygdala, cingulate
cortex, and the right caudate nucleus is
associated with death anxiety
• Why might people express different feelings
about death in public as compared to their
thoughts when they are alone?
• Some degree of death anxiety is appropriate,
but too much can interrupt daily functioning
and routines
Death Anxiety (cont’d.)
• How do people deal with death anxiety?
– Teenagers often engage in risky behaviors and
“live life to the fullest”
– Exercises such as writing your own obituary can
help lower death anxiety
– Death education programs exist to combine
presenting factual information about death and
reducing people’s fears and anxiety
Creating a Final Scenario
• End-of-life issues: management of the final
phase of life, after-death disposition of their
body and memorial services, and distribution
of assets
– Most people want to discuss arrangements if
given the chance
– Allows one to consider traditional care and
alternatives
– People can make a will to make sure their wishes
are carried out
Creating a Final Scenario (cont’d.)
• End-of-life issues (cont’d.):
– Final scenario: people making their choices known
about how they do and do not want their life to
end
• Affirming love and resolving conflicts in relationships is
an important part of this process
• Health care workers recognize the importance of the
final scenario and give patients the chance to create
one
• Helps family and friends to interpret the person’s
death and open communication
The Hospice Option
A hospice worker describes her experiences as a caregiver to patients who are dying.
The Hospice Option (cont’d.)
• Hospice: an approach that assists dying
people that emphasizes pain management, or
palliative care, and death with dignity
– Make the person as peaceful and comfortable as
possible, not delay an inevitable death
– Palliative care: focused on providing relief from
pain and other symptoms of disease at any point
during the disease process
– Hospice care focuses on the client and family and
helps them to approach death
The Hospice Option (cont’d.)
• How is hospice care different from care a
patient would receive in the hospital?
• People usually decide on hospice care when
they have cancer, AIDS, cardiovascular
disease, or other terminal conditions, and
when they are in their last six months of life
– Trust in one’s physician is important in selecting
hospice care
– 2/3 of hospice patients are over age 65
The Hospice Option (cont’d.)
• What do families need to consider before
choosing hospice?
– Is the person completely informed about the
prognosis of her condition?
– What options are available at this point in the
progress of the disease?
– What are the person’s expectations, fears, and
hopes?
– Do people in the person’s social network
communicate well with each other?
The Hospice Option (cont’d.)
• What families need to consider (cont’d.):
– Are family members available to participate
actively in terminal care?
– Is a high-quality hospice care program available?
– Is hospice covered by insurance?
• Traditional medicine has been influenced by
hospice: pain management interventions
• Family members should honor the dying
person’s wish for hospice or alternatives
16.3 Surviving the Loss
• Learning Objectives:
– How do people experience the grief process?
– What feelings do grieving people have?
– What is the difference between typical and
prolonged grief?
Surviving the Loss (cont’d.)
• Bereavement: the state or condition caused by
loss through death
• Grief: the sorrow, hurt, anger, guilt, confusion,
and other feelings that arise after
experiencing a loss
• Mourning: the ways in which we express our
grief
– Highly influenced by culture
– Wearing black, attending funerals, etc.
Surviving the Loss (cont’d.)
The Grief Process
Learn about the ups and downs of the grieving process by hearing one family’s story of
tragedy, loss, and forgiveness.
The Grief Process (cont’d.)
• There is no right way to grieve
– However, all of us confront certain issues
• Grief involves changes in coping and is an
active process that deals with:
– Acknowledging the reality of the loss
– Working through emotional turmoil
– Adjusting to an environment in which the
deceased is absent
– Loosening ties to the deceased
The Grief Process (cont’d.)
• Grieving is a highly individual experience
– Usually takes at least a year to recover from the
loss, sometimes two
– People usually do not recover from the loss; they
learn to live with it
• It is helpful to let a grieving person know that
you are sorry for his loss, you are there for
support, and that you truly mean it
Typical Grief Reactions
• Sadness, denial, anger, loneliness, and guilt
are typical reactions to grief
• Grief work: the psychological side of coming to
terms with bereavement
– Survivors need time to express the many feelings
that they have
– Five themes emerge during the process that deal
with one’s feelings as a survivor and their
memories of the deceased person
• Coping, affect, change, narrative, and relationship
Typical Grief Reactions (cont’d.)
• Physiological reactions to grief exist
– Sleep disturbances and neurological/circulatory
problems have been reported among widows
• Anniversary reaction: changes in behavior
related to feelings of sadness on the
anniversary date of a loss
• Grief can last a long time, but people generally
move on with their lives after a short period of
time and deal with their feelings well
Coping with Grief
• Two integrative approaches to grief:
– Four-component model and dual-process model
• In the four-component model, understanding
grief is based on:
– The context of the loss
– The continuation of subjective meaning associated
with the loss
– Changing representations of lost relationship
– The role of coping and emotion regulation
processes
Coping with Grief (cont’d.)
• The four-component model posits that:
– Dealing with grief is a complicated process that
can only be understood through as a complex
outcome that unfolds over time
– Helping grieving people involves helping them
make meaning from the loss
– Encouraging people to express grief may not be
helpful
Coping with Grief (cont’d.)
• Grief-work-as-rumination hypothesis:
– Views extensive grief processing as a form of
rumination that may increase distress
• The dual-process model (DPM) of coping with
bereavement:
– Integrates loss-oriented stressors, concerning the
loss itself, and restoration-oriented stressors,
related to moving on with life
Coping with Grief (cont’d.)
• The dual-process model (DPM):
– Posits that dealing with stressors is a dynamic
process
• See Figure 16.4
– Explains how it is possible for people to be
overwhelmed with grief one day and handling life
well the next
Coping with Grief (cont’d.)
The DPM of coping with bereavement shows the relationship between dealing with the
stresses of the loss itself (loss oriented) and moving on with life (restoration oriented).
Complicated or Prolonged Grief
Disorder
• Complicated or prolonged grief disorder:
distinguished from depression and normal
grief in terms of separation distress and
traumatic distress
• Separation distress
– Symptoms include preoccupation with the
deceased to the point where it interferes with
daily functioning, upsetting memories of the
deceased, longing and searching for the deceased,
and isolation
Complicated or Prolonged Grief
Disorder (cont’d.)
• Traumatic distress
– Symptoms include disbelief about the death;
mistrust, anger, and detachment from others as a
result of the death; feeling shocked by the death;
and experiencing the physical presence of the
deceased
• How might complicated grief cause problems
in social relationships?
16.4 Dying and Bereavement
Experiences Across the Life Span
• Learning Objectives:
– What do children understand about death?
• How should adults help them deal with it?
– How do adolescents deal with death?
– How do adults deal with death?
• What are the special issues they face concerning the
death of a child or parent?
– How do older adults face their own death or the
loss of a child, grandchild, or partner?
Dying and Bereavement Experiences
Across the Life Span (cont’d.)
• American society tends to distance itself from
death
– Uses euphemisms such as “passed away”
– Eliminates many rituals
• How can people learn about death in its
natural context?
Childhood
• At 5-7 years of age, children realize that death
is permanent, it happens to everyone, and
biological functions cease to exist
– Cognitive-language ability, psychosocial
development, and coping skills are involved in this
understanding
• Bereavement in childhood does not usually
have long-lasting effects
– Openness and honesty about the meaning of
death are important
Childhood (cont’d.)
• Explanations regarding death should be kept
simple to facilitate understanding
• Children need to know that it is okay to feel
sad and show their feelings
• Researchers believe it is important for children
to attend the funeral of a loved one or have a
private viewing
Adolescence
• 40%-70% of college-age students experience a
death of someone close to them
• Teenagers sometimes have trouble making
sense of a death
• Bereavement sometimes involves chronic
illness, guilt, low self-esteem, poor school/job
performance, and substance abuse
– Particularly if the loss was unexpected
– Personal growth usually follows long-term
Adulthood
• Many young adults believe that their peers
who die are cheated out of their future
• Losing one’s partner in young adulthood is
very traumatic and usually unexpected
– Desire to stay connected through memories
– Must challenge basic assumptions about the self,
relationships, and life options
• Surviving spouses usually start transforming
perspectives by the one-year anniversary
Adulthood (cont’d.)
• Losing one’s child is perhaps the worst type
of loss
– Many parents never recover and may end their
relationship
– High anxiety, problems in functioning, and
disrupted relationships with other children are
common problems, depending on the cause of
death
– Parents who lose children through stillbirth,
abortion, or neonatal death are often overlooked
Adulthood (cont’d.)
• Losing one’s parent often leads to redefining
relationships with other family members
• Losing a parent at a young age can lead to
worries about dying young
• When an older parent dies, the adult child is
usually more accepting of death and happy
that the parent’s suffering is over
Late Adulthood (cont’d.)
• Older people usually experience deaths of
those close to them as traumatic
• The loss of a child still causes intense grief that
can last decades
– Affects relationships with surviving children
• Losing a grandchild also causes emotional
upset, guilt, and regrets
– Tend to control and hide grief behavior to shield
their child (the parent)
Late Adulthood (cont’d.)
• Losing a partner in late-life is a deeply
personal loss
– Grief can occur for as long as 30 months
• Survivors with close confidants are better off
than those with many acquaintances
• Bereaved widows and widowers tend to give
their marriages more positive ratings than the
nonbereaved
– See Figure 16.5
Late Adulthood (cont’d.)
In general, bereaved spouses rate their marriages more positively than nonbereaved
spouses, and they tend to be more positive the more depressed they are after the loss.
Late Adulthood (cont’d.)
• Older women tend to sanctify their deceased
husbands
– Serves to validate that the marriage was strong,
show that the widow is a good and worthy person,
and that she is capable of rebuilding her life
• Gay and lesbian couples often face other
feelings and reactions on top of normal grief
– Family members may not make the partner feel
welcomed at the funeral
• Makes achieving a sense of closure difficult
Conclusion
• We understand death through an interaction
of psychological and sociocultural forces
• As with the beginning of life, death is also a
complex interaction of biological,
psychological, sociocultural, and life-cycle
factors
– Perspectives on what happens after death is also
an interaction of these factors