CH 19 Death, Dying & Bereavement

clinical death
*a period during which vital signs are absent

* resuscitation is still possible

brain death
*the point at which vital signs are absent
-including brain activity

*resuscitation is no longer possible

social death
the point at which family members & medical personnel treat the deceased person as a corpse

hospice care
*an approach to care for the terminally ill

* emphasizes individual & family control of the process of dying

3 types of hospice care
*home-based programs
~family caregivers supported by specially trained health-care workers

*hospice centers
~ a small # of patients care for by specially trained health-care workers in a homelike setting

*hospital based programs
~palliative care
~ provided by hospital personnel with daily involvement of family members

palliative care
*a form of care for the terminally ill

*focuses on relieving patients’ pain rather than curing their disease

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A person who has survived on life support for several years has experienced what type of death?
*brain death

A growing number of families are turning to _____ care for their dying loved ones, a form of care that emphasizes the normative nature of death.
*hospice care

what are the characteristics of clinical, brain & social death?
*death = nonspecific term

*medical personnel refer to clinical & brain death

*social death occurs when deceased person is treated like a corpse by those around him

how do hospice & hospital care differ with respect to their effects on the terminally ill?
*about 1/2 of adults in industrialized countries die in hospitals

*hospice care emphasizes
~ patient & family control of dying process
~palliative care rather than curative treatment

what are the characteristics of children & adolescent ideas about death?
*until age 6 or 7
~ children don’t understand death is permeant & inevitable
~involves loss of function

~ understand the physical aspects of death more than children do
~sometimes have distorted views about death (especially their own mortality)

how do young, middle-aged & older adults think about death?
*young adults
– think they have unique characteristics that protect them from death

*for middle-aged adults & older adults death has many possible meanings:
– a signal of changes in family roles
– a transition to another state (such as life after death)
– a loos of opportunity & relationships

*awareness of death may help person organize their remaining time

unique invulnerability
*the belief that bad things happen only to others
-including death

*usually seen in young adults

what factors are related to fear of death in adults?
*fear of death peaks in mid-life & then after it drops sharply

*older adults talk more about death but are less afraid of it

*deeply religious adults may help a person organize their remaining time

how do adults prepare for death?
*many prepare in practical ways:
-buying life insurance
_writing a will
-making a living will

*reminiscence may also serve as preparation

*there are signs of deeper personality changes immediately before death:
– more dependence & docility
-less emotionality & assertiveness

at what age do children start to understand that death is a biological event?
6 or 7

young adults’ thinking about death is often influenced by a set of beliefs called _____ ____.
unique invulnerability

which age group (middle-aged or elderly) fears death most?

as a result of the terminal psychological changes that occur in the 3 years prior to death, individuals become more: ____, ____, _____ & ____.
*conventional (conforming to the norm)
*docile (submissive)

How did Kubler-Ross explain the process of dying?
5 stages of dying:

*research fails to support the hypothesis that all dying adults go through all 5 stages or that the stages occur in this order

*emotion most commonly observed = depression

Kubler-Ross’ 5 stages of dying
– people’s first reaction to news of terminal diagnosis is disbelief

-once diagnosis is accepted as real, individuals become angry

– anger & stress are managed by thinking of the situation in terms of exchanges
– i.e. if i take my medicine,i’ll longer
if i pray hard enough, God will heal me

– feelings of despair follow when disease advances despite individual’s compliance with medical & other advice

– grieving for the losses associated with one’s death results in acceptance

what are some other views of the process of dying?
*critics of Kubler-Ross suggest that her finding may be culture specific

*also argue that process of dying is less stage-like than her theory claims

How do people vary in the ways they adapt to impending death?
*research with cancer & aids patients suggests that:
– those who are most pessimistic & docile in response to diagnosis & treatment have shorter life expectancies
-those who fight hardest & even display anger = live longer

*dying adults who have better social support live longer than those who lack such support
– have support from family & friends or from specially created support groups

the scientific study of death & dying

Edwin Shneidman’s “themes” of death process (alternative view to Kubler-Ross)
*suggested alternative approach of dying process that has many ‘themes’ that can appear, disappear & reappear in 1 patient in the process of dealing with death.

-pervasive uncertainty
-fantasies of being rescued
-feelings of unfairness
-concern with reputation after death
-fear of pain

Charles Corr’s model of process of dying (alternative view to Kubler-Ross)
*Corr viewed coping with dying is like coping with any other problem
-certain specific ‘tasks’ need to be taken care of

*His 4 suggested tasks for the dying person
1. satisfying bodily needs & minimizing physical stress
– psychological security
– autonomy
– richness of life
3. sustaining & enhancing significant interpersonal attachments
4. identifying, developing or reaffirming sources of spiritual energy

*he didn’t deny importance of various emotional themes described by Shneidman
– he argues that for health professionals who deal with dying individuals, its more helpful to think in terms of the patient’s tasks ~ because the dying person may need help in performing some or all of them

Responses of Death
*Denial (positive avoidance)
*fighting spirit
*stoic acceptance (fatalism)
*anxious preoccupation

Denial (positive avoidance)
*person rejects evidence about diagnosis

*person insists that surgery was just precautionary

fighting spirit
* person maintains an optimistic attitude & searches for more info about disease

* these people often see their disease as a challenge & plan to fight it with every available method

stoic acceptance (fatalism)
*person acknowledges diagnosis but makes no effort to seek further info about it


* person ignores diagnosis & carry on normal life as much as possible

* a passive response toward death

* person acts overwhelmed by diagnosis

*person sees themselves as dying gravely ill & as devoid of hope

* a passive response toward death

anxious preoccupation
* women in this category had originally been included in teh helplessness group
– were included in helplessness group but were later separated out

*the category includes those whose response to the diagnosis is:
– strong & persistent anxiety (anxiety about death)

*if they seek more information, they interpret each ache or pain as a possible recurrence

how does Freud’s psychoanalytic theory view grief?
*emphasizes loss as:
– an emotional trauma
– the effects of defense mechanisms
– the need to work through feelings of grief

what are the theories of Bowlby & Sanders of grief?
*Bowlby’s attachment theory views grief as:
– natural response to loss of an attachment figure

*Attachment theorist suggest that grief process involves several stages

what theories of grief have been proposed by critics of psychoanayltic & attachment theories?
*alternative views suggest that neither Freud’s nor Bowlby’s theory accurately characterizes grief experience

*responses to grief are more individual than either theory might suggest

*the dual-process model suggests that the bereaved individuals alternate between confrontation & restoration phases

Bowlby’s(*) & Sander’s 4 stages of grief?
1. Numbness* & Shock
2. Yearning* & Awareness
3. Disorganization/dispair* & Conservation/withdrawal
4. Reorganization* & Healing/Renewal

Numbness* & Shock
* characteristic of 1st few days after death of love one & occasionally longer

* mourner experiences
– disbelief
– confusion
– restlessness feelings of unreality
– a sense of helplessness

Yearning* & Awareness
*the bereaved person tries to recover the lost person

*may actively search or wander as if searching

*may report that they see the dead person

*mourner feels full of:
– anger
– anxiety
– fear
– frustration

*may sleep poorly & weep often

Disorganization/dispair* & Conservation/withdrawal
*searching creases & the loss is accepted

*acceptance of loss brings:
– depression & despair
-sense of helplessness

*this stage is often accompanied by:
– fatigue
-desire to sleep all the time

Reorganization* & Healing/Renewal
*Bowlby views this stage as only 1 (Reorganization)
– & Sanders 2 (Healing/Renewal)

*both see this as the period when the individual takes control again

*some forgetting occurs

*some sense of hope emerges along with:
– increased energy
– better health
– better sleep patterns
– reduced depression

Wortman & Silver’s alternate view on pattern of grieving
*suggests that grieving does not include all of the elements
– they don’t agree that distress is an inevitable response to loss
– their research challenges the notion that failure to experience distress = sign that individual has not grieved “properly”

*their 4 distinct patterns of grieving
– normal
– chronic
– delayed

normal pattern of grieving
* person feels great distress immediately following loss

*recovers relativity rapidly

chronic pattern of grieving
*person’s distress continues at a high level over several years after loss

delayed pattern of grieving
*the grieving person feels little distress in first few months

*they feel high levels of stress months or years after loss

absent pattern of grieving
* person feels no notable level of distress
-immediately or at any later time

dual-process model
*developed by Stroebe & Schut
– takes a different approach to grief

*proposes that bereaved individuals alternate between 2 phases:
– confrontation
– restoration

*suggests that the attachment relationship between the bereaved individual & the deceased influences the grieving process
– like Bowlby’s model suggests

*emphasizes the loss of a loved one as an analogous to other forms of stress

confrontation phase
*an emotional state in which bereaved individuals confront their loss & actively grieve

restoration phase
*bereaved individuals focus on moving forward with their lives

*provides the bereaved individuals with respite from the emotional turmoil
– that is seen in the confrontation phase

the emotional response to a death

how do funerals & ceremonies help survivors cope with grief?
*funerals & other rituals after death serve important functions including:
– defining roles for the bereaved
– bringing family together
– giving meaning to the deceased’s life & death

what factors influence grieving process?
*grief responses depend on a number of variables

*grief process is shaped by
-age of bereaved
-mode of death

how does grief affect the physical & mental health of widows & widowers?
*death of a spouse evokes the most intense & long lasting grief

*widows & widowers show high levels of illness & death in the months immediately following the death of a spouse
– perhaps as a result to the effects of grief on the immune system

* widowers appear to have a more difficult time than widows do in managing grief

age of bereaved (children)
*children express feelings of grief very much the same as teens & adults do
– sad facial expressions
– crying
– loss of appetite
– age-appropriate displays of anger

*most children resolve feelings of grief within first year following the death

age of bereaved (adolescents)
*adolescents may be more likely than children or adults to experience prolonged grief
– continue to have problems with grief related behaviors
(i.e. intrusive thoughts)

*teen grief responses are probably related to their general cognitive characteristics

* they often judge real world by idealized images
– they may get caught up in fantasizing about how the world would be different if a friend/loved one had not died

*prolonged grieving among adolescents may be rooted in their tendency in “what if” thinking
– this kind of thinking lead teens to believe they could have prevented the death
-causes them to develop irrational guilt feelings

age of bereaved (adults)
*express feelings of grief very much the same as teens & children do
– sad facial expressions
– crying
– loss of appetite
– age-appropriate displays of anger

mode of death
*how an individual dies contributes to the grief process of those in mourning

*deaths with meaning (death of soldier) or due to illness = less likely to suffer from grief related depression
– i.e. illness was long and painful & solider dying while defending country has intrinsic meaning

*sudden & violent deaths evoke more intense grief responses
– especially those involving suicide
– mourners start to suffer from PTSD & depression

*death in context of a natural disaster is associated with:
-prolonged grieving & development of symptoms of PTSD
-such events bring to mind the inescapable reality of the fragility of human life

benefits of public memorial services & mode of death
*common experiences of survivors are recognized

* the differences between controllable & noncontrollable aspects of life are emphasized
-can help survivors cope with this kind of grief

*can also be helpful to survivors whose loved ones died as a result of “politcally motivated” mass murders
– i.e 1995 bombin of a federal govt office building

*experienced following a death of a loved one by the survivors

*is a change in status
– as in the case of a spouse becoming a widow or widower

the behavioral response of the bereaved person

*examine all aspects of death, including:
– biological (the cessation of physiological processes)
– psychological (cognitive, emotional, and behavioral responses)
– social (historical, cultural, and legal issues).

pathological grief
*symptoms of depression brought on by death of a loved one

mode of death & suicide
responses of the family & close friends

*their grief is complicated by feeling that they could or should have have done something to prevent suicide

*are less likely to discuss the loss with other family &friends because of:
– their sense that suicide in the family is a source of shame

*suicide survivors may be more likely than others who have lost loved ones to experience long term negative effects

mode of death & death from violent crime
*inability to find meaning is the most frustrating aspect of the grieving process for people who lost a love one who lost loved one in a violent crime

grief process =

initial phase…
*survivors protect themselves against frustration through cognitive defenses
-focusing on tasks that are immediately necessary

next phase…
* survivors often channel their grief & anger into the criminal justice process
-through which they hope that the perpetrator of crime is justly punished

*many survivors become involved in organizations:
– that support crime victims & survivors of murdered loved ones
– that seek to prevent violence

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