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Chapter 16:
Understanding Death,
Dying, and Bereavement
Understanding Death, Dying, and Bereavement
• Chapter Objectives
– To understand the role of mortality in shaping
psychosocial development
– To define the biological state of death
– To describe factors associated with the
process of dying and the modern ideal of a
good death
– To describe death-related rituals and their
functions
– To analyze factors that affect grief and
bereavement
Understanding Death, Dying, and Bereavement
• Thanatology is the field of science that
addresses dying and death, as well as the
psychological mechanisms of coping with them
Understanding Death, Dying, and Bereavement
• Mortality And Psychosocial Development
– In infancy, as one achieves a balance
between trust and mistrust, an outlook of
hopefulness emerges
– This outlook shapes one’s orientation toward
risk, toward transitions, and ultimately, toward
death
– If one has lived a life of hopefulness about the
future, this same orientation is likely to extend
toward one’s beliefs about death, a sense that
whatever follows the death of the physical
body is going to be good
Understanding Death, Dying, and Bereavement
• Mortality And Psychosocial Development (cont.)
– In the resolution of the crisis of identity versus
role confusion one confronts the need to
impose a sense of meaning on one’s life
– The crisis of generativity versus stagnation
brings the issue of mortality even more to
center stage
– Developing a point of view about death is a
major developmental task during later
adulthood
– Finally, the crisis of immortality versus
extinction brings the confidence of continuity
Understanding Death, Dying, and Bereavement
• Mortality And Psychosocial Development (cont.)
– Over time, direct personal experiences with
dying and death have changed
– Beginning with the works of Elizabeth KüblerRoss, the needs of the dying person were
given a voice
Understanding Death, Dying, and Bereavement
• Definitions Of Death
– The definition of death has changed
– Used for 100s of years, the criteria for death
were lack of a heartbeat and lack of
respiration called cardiopulmonary death
Understanding Death, Dying, and Bereavement
• Definitions Of Death (cont.)
– In 1981, the President’s Commission for the
Ethical Study of Problems in Medicine and
Biomedical and Behavioral Research
identified eight criteria for determination of
whole-brain death
• No spontaneous movement in response to any
stimuli
• No spontaneous respirations for at least one hour
• Total lack of responsiveness to even the most
painful stimuli
• No eye movements, blinking, or pupil responses
Understanding Death, Dying, and Bereavement
• Definitions Of Death (cont.)
– In 1981, the President’s Commission for the
Ethical Study of Problems in Medicine and
Biomedical and Behavioral Research
identified eight criteria for determination of
whole-brain death (cont.)
• No postural activity, swallowing, yawning, or
vocalizing
• No motor reflexes
• A flat electroencephalogram (EEG) for at least ten
minutes
• No change in any of these criteria when they are
tested again 24 hours later
Understanding Death, Dying, and Bereavement
• Definitions Of Death (cont.)
– In addition to these eight criteria, certain other
conditions such as deep coma have to be
ruled out
– There are two areas in the brain that control
different types of life functions: the brainstem
controls heartbeat and respiration; and the
cortex controls sensory integration and
cognitive function
– It is possible for a person’s brainstem
functions to continue even when there is no
cortical functioning, called a persistent
vegetative state
Understanding Death, Dying, and Bereavement
• Definitions Of Death (cont.)
– Because there are a variety of technologies
that can extend life when a person is no
longer able to communicate his or her
preferences, it is recommended that adults
prepare some form of advance directive such
as a durable power of attorney or a living will
Understanding Death, Dying, and Bereavement
• The Process Of Dying
– People can experience death in many
different ways
– A dying trajectory is the time during which the
person’s health goes from good to death
– Certain illnesses such as some cancers or
AIDS result in a gradual decline. Under these
conditions, people have more time to
acknowledge their death and to plan for it
Understanding Death, Dying, and Bereavement
• The Process Of Dying (cont.)
– Some people experience unpredictable,
sudden death in the midst of a healthy life as
in an automobile accident, by homicide, or a
heart attack. This trajectory does not allow the
person to confront the reality of death
Understanding Death, Dying, and Bereavement
• The Process Of Dying (cont.)
– For some, death involves an ambiguous
decline in which periods of illness may
alternate with periods of remission such as in
the case of leukemia or muscular dystrophy.
For these people, there is a complex process
of learning to live with a terminal disease in
which there may be periods of health as well
as periods of decline
Understanding Death, Dying, and Bereavement
• Case Study: Too Late To Die Young
– Thought Questions
• What are the challenges of facing an ambiguous
trajectory? For the dying person? For close
relatives?
• What are some of the possible reasons for
Harriet’s depression at age 30?
• According to psychosocial theory, what are some
of the life themes that Harriet is facing at age 4?
At age 30?
• How might her psychosocial development be
affected by her illness at age 4 and age 30? By
her sense of herself as someone who is dying?
Understanding Death, Dying, and Bereavement
• Case Study: Too Late To Die Young (cont.)
– Thought Questions (cont.)
• What are some of Harriet’s coping strengths?
Weaknesses?
• If you were Harriet’s parents, what would you do to
try to prepare Harriet for her life? For her death?
Understanding Death, Dying, and Bereavement
• The Good Death
– The Hospice Education Institute (2001) offers
the following goals for high quality end-of-life
care:
• Promote relief from pain
• Integrate the psychological and spiritual aspects of
patient care
• Offer a support system to help patients live as
actively as possible until death
• Help the family cope during the patient’s illness
and their own bereavement
Understanding Death, Dying, and Bereavement
• The Good Death (cont.)
– Spouse was at peace with the idea of dying
– Spouse was aware of impending death
– Respondent and spouse discussed the death
– Respondent was with spouse at the moment
of death
– The spouse led a full life
– The spouse was not in pain
– The spouse did not receive negligent care
Understanding Death, Dying, and Bereavement
• Hospice Care
– Hospice is an integrated system of medicine,
nursing, counseling, and spiritual care for the
dying person and family
– Its goal is to achieve the highest possible
quality of life for the dying person and the
family, alleviating physical and emotional pain
to the degree possible, while supporting
family strengths to cope with the process of
dying, loss of the loved one, and long-term
bereavement
Understanding Death, Dying, and Bereavement
• Hospice Care (cont.)
– Hospice care differs from traditional hospital
care in that the focus is on enhancing quality
of life for the dying person and his or her
loved ones rather than treating the disease or
intervening to delay the end of life
Understanding Death, Dying, and Bereavement
• Hospice Care (cont.)
– Clear guidelines have been established for
the range and quality of services hospices
must offer in order to received Medicare
reimbursements, and an increasing range of
educational and training programs have
emerged to provide professional
interdisciplinary training for those working in
hospice and end-of-life care settings
Understanding Death, Dying, and Bereavement
• Euthanasia
– Euthanasia is the practice of ending
someone’s life for reasons of mercy
– Passive euthanasia refers to withholding
treatment or removing life-sustaining
nourishment and breathing aids
– Active euthanasia are activities designed to
end a person’s life
– Mercy killing involves taking a person’s life
Understanding Death, Dying, and Bereavement
• Euthanasia (cont.)
– Physician-assisted suicide involves either the
administration of a lethal dose of some
medication by a physician or arranging for a
terminally ill patient to administer his or her
own lethal dose of medication using a suicide
machine
Understanding Death, Dying, and Bereavement
• Ethical Issues at the End of Life
– End of life decisions are not only relevant for
the elderly; they may be addressed when
parents decide to limit treatment for a
terminally ill child; when family members
decide to remove life support for an adult who
is in a vegetative state, or when a person
seeks assisted suicide in order to avoid the
inevitability of decline into an immobile or
helpless state
Understanding Death, Dying, and Bereavement
• Ethical Issues at the End of Life (cont.)
– The matter is made even more complex as
decisions about ending life conflict with the
commitment of the medical profession to
prolong life
– As a result of many new technologies,
medications, and genetic interventions, there
are ongoing innovations that may be effective
in slowing the progression of a disease or
sustaining life even if the condition cannot be
cured
Understanding Death, Dying, and Bereavement
• Ethical Issues at the End of Life (cont.)
– Most people agree that when a dying person
who is in extreme pain asks a doctor to end
his or her life that request should be honored
– Despite public opinion supporting measures
to actively end life, these measures are illegal
in the United States, with the exception of
Oregon, and continue to be a topic of ethical
controversy
Understanding Death, Dying, and Bereavement
• Ethical Issues at the End of Life (cont.)
– Some opponents argue that legalizing
assisted suicide might put unnecessary
pressure on the elderly to end their lives
rather than be a burden to their families or to
use precious financial resources for end-of-life
care.
Understanding Death, Dying, and Bereavement
• Death-Related Rituals
– The American culture’s rituals surrounding
death of a loved on permit adults to cope with
death-related anxiety
– The elaborate arrangements for a burial
service allow adults to work through the reality
of their own death by focusing on aspects of it
over which they can exercise some control
– To appreciate how people cope with death, it
is helpful to consider the cultural rituals that
have emerged for structuring the response to
death
Understanding Death, Dying, and Bereavement
• Death-Related Rituals (cont.)
– Care of the Body
• Most funeral preparations include specific
practices for caring for the corpse and cultures
have different practices concerning how quickly the
body is to be disposed of after death
– Care of the Spirit
• Most cultures believe that there is a spiritual
component of a person’s being that is not
destroyed as the body decomposes or burns
• Certain funeral practices are designed to help the
spirit make a transition to whatever existence the
culture believes take place after death
Understanding Death, Dying, and Bereavement
• Death-Related Rituals (cont.)
– Care of the Surviving Family, Friends, and
Community
• Death rituals are important for helping the people
who remain to cope with their grief and to reorient
their lives in a world without the person who died
• These rituals allow society to elaborate the
meaning of death and to decrease the ambiguity
surrounding death
• In the United States, people typically have a will,
which is read to the heirs; a ritual that provides for
the distribution of resources and assets according
to the deceased person’s wishes
Understanding Death, Dying, and Bereavement
• Grief and Bereavement
– Grief is the cognitive and emotional reactions
that follow the death of a loved one
– Grief can vary in duration and intensity, and it
can fade and reappear at unexpected
moments
– Bereavement is the long-term process of
adjustment to the death of a loved one and is
more all-encompassing than grief
– In the face of bereavement, there is a need to
work through the reality of the loss as well as
the feelings that accompany it
Understanding Death, Dying, and Bereavement
• Grief and Bereavement (cont.)
– The depression and confusion accompanying
grieving may decrease the survivors’
sensitivity to their own physical health and
pose risks to their mental health as well
– Among people who have lost a spouse,
intense depression is more likely to be
experienced by those who described their
marriage as positive and vital
Understanding Death, Dying, and Bereavement
• Grief Work
– In the face of bereavement, there is a need to
work through the reality of the loss as well as
the feelings that accompany it
– Lindemann’s 3 Phases of Grief Reaction:
• The person must achieve “emancipation from
bondage to the deceased”
• The person must make an adjustment to all the
aspects of the environment from which the
deceased is missing
• The person must begin to form new relationships—
what we have called redirecting energy to new
roles
Understanding Death, Dying, and Bereavement
• Grief Work (cont.)
– Questions have been raised about how
universally applicable Lindemann’s idea of
grief work really is. In some cultures, intense
emotional expressions of grief are considered
inappropriate
– The context of death and its meaning for
those who mourn suggests a more
individualized view of the adaptive process of
bereavement
Understanding Death, Dying, and Bereavement
• Five Patterns of Bereavement Among Widows
– The common grief pattern
• These people had low levels of depression before
the spouse dies. They experienced an increase in
depression six months after the loss. They
returned to the same low level of depression after
18 months characterized them before the loss
– The resilient pattern
• People in this group had low levels of depression
before the death of the spouse and continued to
have low levels after the death of the spouse
Understanding Death, Dying, and Bereavement
• Five Patterns of Bereavement Among Widows
(cont.)
– Chronic grief pattern
• These people had low pre-loss depression but
showed increased grief responses at 6 months and
18 months after the loss
– Chronic depression pattern
• These people had high levels of depression before
the loss and depression continued at high levels at
6 and 18 months
– Depressed-improved pattern
• These people had elevated levels of depression
before the loss, but lower depression scores at 6
and 18 months after the loss
Understanding Death, Dying, and Bereavement
• Factors that Affect the Distress of Survivors
– Bereavement may be more difficult for those
who lose a loved one in a sudden death
– Bereavement may be difficult if the dying
person is unable to receive effective pain
control in their last days of life
Understanding Death, Dying, and Bereavement
• Factors that Affect the Distress of Survivors
(cont.)
– Ambiguous loss is another especially difficult
challenge for loved ones
• A person is missing and may be dead, as in
soldiers who are missing in action or people who
may have died in a disaster, but there are no
physical remains
• A person is physically present but unable to
participate in any meaningful way in family
interactions, as when a person is in a coma or in
late stages of Alzheimer’s disease
Understanding Death, Dying, and Bereavement
• Factors that Affect the Distress of Survivors
(cont.)
– Religiosity leads to lower levels of anxiety and
anger for the survivors and may provide them
with an analysis of the meaning of the death
of their loved one
– Finally, bereavement may be difficult if the
survivor has experienced many positive
benefits of caregiving, including feelings of
being needed, important, and effective as they
addressed the needs of an ailing spouse
Understanding Death, Dying, and Bereavement
• Factors that Affect the Distress of Survivors
(cont.)
– Unacknowledged and Stigmatized Loss
– The bereavement process is influenced by a
society’s interpretation of who the legitimate
mourners are and who has experienced a
legitimate death
Understanding Death, Dying, and Bereavement
• Factors that Affect the Distress of Survivors
(cont.)
– Stigmatized deaths are those in which people
attribute the death to an immoral, illegal, or
evil cause
• Death by suicide is an example of a stigmatized
death in which survivors may feel guilty about not
having been able to prevent the death and anger
at that person for killing themselves
• AIDS is another example of a stigmatized loss
Understanding Death, Dying, and Bereavement
• Psychosocial Growth Through Bereavement
– Bereavement brings new opportunities for
psychosocial growth
– The intense experiences of sadness and
emptiness are universal human emotions.
Even though they are unpleasant, the
emotions associated with grief connect people
to their essential human nature
– Grief stimuli leads to greater levels of
understanding of oneself and others
– When a person who is close dies, it stimulates
reflection about that relationship
Understanding Death, Dying, and Bereavement
• Psychosocial Growth Through Bereavement
(cont.)
– The death of a loved one may stimulate the
process of life review by causing you to think
about the meaning of your own life
– The loss of someone whose presence serves
to help you define your identity will require a
redefinition of your identity
– When a person you admire dies, it often
promotes new levels of identification with the
deceased
Understanding Death, Dying, and Bereavement
• Psychosocial Growth Through Bereavement
(cont.)
– Introjection is different from identification, in
that the person feels that the lost person is in
them Introjection allows the bereaved person
to keep the dead person alive and to preserve
their relationship
– The depth of emotion created by the death of
someone close helps a person understand
the value of their own life and the emotions
that significant others will experience when
they die