Lifespan Development

Lifespan Development Module # 11: Death and Dying

Module Learning Outcomes Explore the experiences and emotions related to death and dying 11.1: Describe the leading causes and types of deaths 11.2: Examine emotions related to death and dying 11.3: Examine care and practices related to death

Most Common Causes of Death

Learning Outcomes: Most Common Causes of Death 11.1: Describe the leading causes and types of deaths 11.1.1: Examine the leading causes of death in the United States and worldwide 11.1.2: Explain physiological death 11.1.3: Describe social and psychological death

Most Common Causes of Death • In 1900, the most common causes of death were infectious diseases while chronic disease were the most common causes of death in the United States in 2016 • Many of the top causes of death are linked at least in part to lifestyle choices and are preventable or avoidable if the proper actions are taken • The top 10 deadliest disease worldwide in 2015 include heart disease, stroke, lower respiratory infections, COPD, trachea, bronchus, and lung cancers, diabetes, Alzheimer’s or other dementia, dehydration, tuberculosis, and cirrhosis • The major causes of death vary significantly among age groups with unintentional injuries a leading cause of death for the widest variety of ages

The Process of Dying • A person’s physiological, social, and psychological death can occur at different times • Physiological death occurs when the vital organs no longer function and may take 72 or fewer hours • Digestive and respiratory systems begin to shut down • Circulation slows and mottling may occur • Agonal breathing, the gasping, labored breaths caused by an abnormal pattern of brainstem reflex may occur • Someone is brain dead when there is no longer brain activity, referred to as clinically dead • A vegetative state occurs when the cerebral cortex no longer registers electrical activity but the brain stem continues to be active

The Process of Dying, continued • Social death begins earlier than physiological death and occurs when others begin to withdraw from someone who is terminally ill or has a terminal illness diagnosis • Doctors as well as family members and friends may spend less time with patients after their prognosis becomes poor and • People in nursing homes may live as socially dead for years with no one visiting or calling • Psychological death occurs when the dying person begins to accept death and withdraw from others and regress into the self • This can take before physiological death and may even bring it closer as people give up their will to live • Interventions based on the idea of self-empowerment for terminally ill individuals has been associated with a perceived ability to manage and control things resulting in better mental health

Practice Question 1 Which top cause of death was most prevalent across multiple age groups in the United States according to 2016 statistics? • Heart disease • Congenital anomalies • Malignant Neoplasms • Unintentional injury

Practice Question 2 Which aspect of death is characterized by the failure of vital organs, often resulting in difficulty with eating and breathing? • Physiological • Social • Psychological • Behavioral

Emotions Related to Death

Learning Outcomes: Emotions Related to Death 11.2: Examine emotions related to death and dying 11.2.1: Explain common perceptions and attitudes toward death 11.2.2: Explain attitudes towards death from different ages throughout the lifespan 11.2.3: Explain bereavement and types of grief 11.2.4: Explain Kübler-Ross’ stages of loss 11.2.5: List and describe the stages of grief based on various models

Attitudes about Death Bereavement is the outward expressions of grief and mourning and funeral rites are expressions of loss reflecting personal and cultural beliefs Culture does not provide set rules for how death is viewed and experienced Regardless of variations in conceptions and attitudes toward death, ceremonies provide survivors a sense of closure after a loss In most cultures, after the last offices have been performed and before the onset of decay, relations or friends arrange for ritual disposition of the body There are various methods of destroying human remains, depending on religious or spiritual beliefs and practical necessity

Bereavement and Grief • Grief is the psychological, physical, and emotional experience and reaction to loss • Grief reactions vary depending on whether a loss was anticipated or unexpected and whether it occurred suddenly or after a long illness • Struggling with the question of responsibility and what if is particularly felt by those who lose a loved one to suicide • Bereavement describes the state of being following the death of someone • Anticipatory grief occurs when a death is expected and survivors have time to prepare to some extent before the loss • Complicated grief involves a distinct set of maladaptive or self-defeating thoughts, emotions, and behaviors that occur as a negative response to a loss • Disenfranchised grief may be experienced by those who have to hide the circumstances of their loss or whose grief goes unrecognized

Bereavement and Grief, continued • It has been said that intense grief lasts about two years or less but grief is throughout life • Layers of grief include an initial denial marked by shock and disbelief and anger towards those who could not save the person’s life or that life did not turn out as expected • Grief and mixed emotions go hand in hand with normal contradictions arising throughout our grieving • We are often asked to grieve privately, quickly, and to medicate our suffering • The fading affect bias suggests that negative events tend to lose their emotional intensity at a faster rate than pleasant events

Stages of Loss • Kübler-Ross described five stages of loss experienced by someone facing the news of their impending death that provide a framework (not a linear progression) for understanding the psychological experience of an impending death • Denial is often the first reaction to overwhelming, unimaginable news and protects us by allowing the news to enter slowly • Anger provides us with protection by energizing us to fight against something and providing structure to an unknown situation • Bargaining involves trying to think of what could be done to turn the situation around • Depression involves feeling the full weight of loss and an important part of the process of dying • Acceptance involves learning how to carry on and incorporate this aspect of the life span into daily existence

Other Models on Grief • Worden’s model of grief explained it through four different tasks the individual must complete • Accepting the loss has occurred • Working through and experiencing the pain associated with grief • Adjusting to the changes the loss created in the environment • Moving past the loss on an emotional level • Parkes broke down grief into four stages: shock, yearning, despair, and recovery • Strobe and Shut suggested individuals cope with grief through an ongoing process: • Loss-oriented: grief work, intrusion on grief, denying changes toward restoration, and breaking of bonds or ties • Restoration-oriented: attending to life changes, distracting oneself from grief, doing new things, establishing new roles and relationships

Other Models on Grief, continued • Theories that have been developed help explain and understand how the grief process has shifted over time • Healthy grieving includes the following strategies: • Talk about the death to help surviving individuals understand what happened and remember the deceased positively • Accept the multitude of feelings • Take care of yourself and your family can help with moving through each day effectively • Reach out and help others dealing with the loss • Remember and celebrate the lives of your loved ones

Class Activity: A Good Death? • How would you define a “good death”? • What criteria are important for determining a good death for the person dying, family or loved ones, and any healthcare professionals? • How does grief change based on whether a death is considered “good”?

Facing Death

Learning Outcomes: Facing Death 11.3: Examine care and practices related to death 11.3.1: Explain the philosophy and practice of palliative care 11.3.2: Describe hospice care 11.3.3: Summarize Dame Cicely Saunders’ writings about total pain of the dying 11.3.4: Differentiate attitudes toward hospice care based on race and ethnicity 11.3.5: Describe euthanasia, passive-euthanasia, and physician-assisted suicide

Palliative Care and Hospice • Palliative care is an interdisciplinary approach to specialized medical and nursing care for people with life-limiting illnesses • The goal is to improve the quality of life for both the person and family through relief of symptoms, pain, physical stress, and mental stress • Palliative care is provided by a multi-disciplinary team who work with the primary care physician and other hospital or hospice staff to provide additional support to the patient • It is appropriate at any state in a serious illness and not limited to end-of-life • Hospice care involves palliation without curative intent and is typically used by people without further options or who have decided not to pursue further options • The biggest difference between hospice and palliative care is the type of illness people have, where they are in their illness especially related to prognosis, and their goals/wishes regarding curative treatment

Palliative Care and Hospice, continued • Hospice care involves caring for dying patients by helping them to be as free from pain as possible, providing them with assistance to complete legal documents, providing social support, and helping family members cope • The focus is on five topics: communication, collaboration, compassionate caring, comfort, and cultural (spiritual) care • The patient is allowed to go through the dying process without invasive treatments • Dame Cicely Saunders emphasized focusing on the patient rather than the disease and introduced the notion of “total pain” • Saunders’ focus on the broad effects of death on dying individuals and their families has provided the foundation for modern day hospice care

Hospice Care in Practice • Early hospices were independently operated and dedicated to giving patients as much control over their own death process as possible • Although hospice care has become more widespread, new programs are subjected to more rigorous insurance guidelines that dictate the types and amounts of medications used, length of stay, and types of patients eligible for hospice • The majority of hospice patients are cancer patients who do not enter hospice until the last few weeks prior to death with the average length of stay less than 30 days and many patients in hospice for less than a week • Hospice care focused on alleviating physical pain and providing spiritual guidance • Not all racial and ethnic groups feel the same way about hospice

Euthanasia and Physician-Assisted Suicide • Euthanasia refers to helping a person fulfill their wish to die and can happen through voluntary euthanasia or physician-assisted suicide • Voluntary euthanasia can be passive or active • Passive euthanasia involves no longer feeding someone or giving them food • Active euthanasia is when there is an administration of a lethal dose of medication to someone who wishes to die • A dying individual may ask a friend or family member to administer a lethal dose of medication, often leaving lasting impact • Physician-Assisted Suicide occurs when a physician prescribes the means by which a person can end his or her own life

Euthanasia and Physician-Assisted Suicide, continued • Physician-Assisted Suicide is mandated by a set of laws and backed by legal authority • Currently it is legal in the District of Columbia and several states including Oregon, Hawaii, Vermont, and Washington • The Netherlands, Switzerland, and Belgium have also made it legal • The laws that govern physician-assisted suicide vary between states • In 2000, the U.S. Supreme Court upheld the right of states to determine their laws on physician-assisted suicide and holds the position that the moral and ethical debate continues

Practice Question 3 Which type of euthanasia involves withholding food, water, or necessary medication from an individual who wishes to die? • Active euthanasia • Physician-assisted suicide • Passive euthanasia • Physician-assisted euthanasia

Class Activity: Working with the Terminally Ill • Imagine that you are training others to work with people who are terminally ill or in grief. • Advise your group about how to work most effectively with those populations. • Identify at least two ways to effectively address the needs of the terminally ill physically, emotionally, and psychologically. • Identify at least two ways to effectively address the emotional and psychological needs of grieving family members or caregivers. • Share your ideas in a group and discuss how they are similar and different.

Quick Review • What are the leading causes of death in the United States and worldwide? • What is meant by physiological death? • What are social and psychological death? • What are some common perceptions and attitudes toward death? • How are attitudes towards death similar and different from different ages throughout the lifespan? • What are bereavement and types of grief? • What are Kübler-Ross’ stages of loss?

Quick Review, continued • What are included in the stages of grief based on various models? • What is the philosophy and practice of palliative care? • How is hospice care delivered? • What is included in Dame Cicely Saunders’ writings about total pain of the dying? • What is similar and different in attitudes toward hospice care based on race and ethnicity? • What are euthanasia, passive-euthanasia, and physician-assisted suicide?

Lifespan Development