Approaching%20Death

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Approaching Death

• Death and Dying

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Death and Dying

• Immortality of youth
• Denial of mortality
• Anxiety

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Historical and Cultural Views

• ability to accept death
• specific meanings (stop breathing, heartbeat,
  brain death)
• individual variation
• cultural variation (spiritual, natural, welcome
  event)

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• Western history natural event
• 20th Century withdrawn from daily life
  experiences
• care of dying
• Disposition of deceased dramaturgical (Fulton
  Metress, 1995 language of funeral directors)
• interment vs. burial
• casket vs. coffin
• remains, diseased, loved one vs. corpse,
  dead body
• lying in repose vs. dead
• denial of death, socialdeath avoidance

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• Cultural denial of death?
• Behaviours? Avoidance?
• Collectively?
• Individually?
• Reasons?
• Effects of avoidance?
• Feelings about death? Regrets?
• A good death?

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Research on Death and Dying

• Kubler-Ross (1970)
• Openness, disclosure
• thanatology study of death
• five emotional stages
• Denial, anger, bargaining, depression, acceptance

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Inconsistencies in Stages

• appearance, reappearance of denial, anger,
  depression during dying process
• age of dying person
• young separation from loved ones
• adolescents focus on quality of present life
• effect of condition on appearance social
  relationships

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• young adult rage and depression
• end of life at beginning
• middle adulthood concern about obligations,
  responsibilities
• late adulthood contextual
• death of spouse
• illness, pain, dependency
• acceptance relatively easy

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• Health Care Policy for the Dying Process
• Medicalization of death vs. normative part of
  life?
• Perspectives, definitions of death?
• Death anxiety?
• Preparation for death?

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Hospice Carevs. Medicalization of Death

• good death swift, comfortable, dignity, loved
  ones present
• more common prior to extreme medical intervention
• alternative to hospital care

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• London, 1950s first hospice
• Provide medical care, no artificial life support
  systems to terminally ill
• Allow visitors, free movement
• Cushion fear, loneliness of impending death

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• Problems
• Rapid growth need for well-trained personnel
• Legal, ethical questions premature death?
• Potential burn-out of professionals, volunteers
  (personal involvement, intimacy)

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Living Will, Passive Euthanasia

• specify how much medical care in terminal illness
• inaction (e.g., no respirator) that allows person
  to die in natural course of illness
• ethics quality of life?

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The Right to Die Assisted Suicide and Active
Euthanasia

• providing means to person to end life
• intentionally terminating life of suffering
  person
• Netherlands legal euthanasia
• North America Jack Kevorkian
• assisted suicide? Value of life?
• legal restrictions?

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Netherlands

• Patient experiencing unbearable pain
• Patient conscious
• Death request voluntary
• Patient must have time to consider alternatives
• No other reasonable solutions to problem
• Death cannot inflict unnecessary suffering on
  others
• Must be more than one person involved in
  euthanasia decision
• Only doctor can euthanize the patient

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Death Anxiety

• (Conte, Weiner, Plutchik, 1982)
• Death Anxiety Questionnaire
• fear of unknown
• fear of suffering
• fear of loneliness
• fear of personal extinction

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• nursing home residents, seniors, university
  students
• ages 30 to 80 years
• no differences in mean scores (M8.5)
• no correlation with sex, education
• separate study adolescents had higher scores
  than older participants
• emotional stresses
• cognitive maturity (meaning of death)

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• Cicirelli (1999) higher death anxiety in
• Younger
• Lower SES
• Female
• White
• External locus of control
• Less religiousness

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Quality of End of Life

• Singer et al. (1999) Canadian sample
• Receiving adequate pain and symptom management
• Avoiding inappropriate prolongation of dying
• Achieving sense of control
• Relieving burden
• Strengthening relationships with loved ones

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Bereavement and Grief

• Mourning expression of grief
• Prescribed rituals funerals
• Auger (2000) 4 functions
• Provide supportive relationship for bereaved
• Reinforce reality of death
• Acknowledge open expression of feeling of loss
  and grief
• Mark a fitting conclusion to life of person
• Social support
• network of familial
• small memorial services
• failure to express grief depression

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• Phases of Mourning (Parkes, 1972)
• shock
• longing
• depression, despair (anger)
• recovery (perspective)

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Current Perspective (Lund, 1996)

• stress with resiliency
• adjustment related to self-esteem, coping skills
• diversity
• between individuals thoughts, feelings,
  behaviours
• within individuals simultaneous negative (anger,
  loneliness) and positive (personal strength)
  feelings

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• no stages
• rapidly changing feelings
• dealing with personal limits
• fatigue, loneliness
• learning new skills
• new relationships
• no specific time markers

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Achieving Recovery

• cultural facilitation of mourning
• meaningful rituals
• emotional support friends listening
• practical help
• lengthy process
• waves of sorrow anniversary reactions
• healthy response

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Bereavement overload

• elderly at risk
• several deaths in rapid succession
• unable to complete mourning process for one death
  before another occurs

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• Anticipatory Grief
• expected death
• dying person, mourners share affection
• helps dull pain of loss
• Sudden death (no anticipatory grieving)
• Most difficulty in coping
• loss of young person vs. at end of long, full
  life
• emotions guilt, denial, anger, sorrow

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Social/Cultural Supports for Grieving?

• Similarities, differences, roles?

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Finding Comfort

• social support friends listening, sympathizing,
  not ignoring pain, complex emotions in recovery
• recognize bereavement is lengthy process (months,
  years) sorrow, memory are integral parts of
  recovery
• over time bereaved should become involved in
  other activities, but not be expected to forget
  loved one
• successful recovery deeper appreciation of
  growth, development of all human relationships

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Adult Development from Adolescence to Old Age

• Multidimensional, multidirectional change,
  throughout lifespan

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• Final Exam
• December 12 2 hours
• Chapters 8, 10, 11, 12 (50 Multiple Choice),
  lecture material (5/7 short answer)

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Successful Aging

• Survival in late adulthood
• Quality of life, satisfaction
• Transcend physical limitations
• Mental health, optimal adaptation
• Positive outlook
• Self-understanding
• Components
• Absence of disease, disability
• No risk factors

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• Maintaining high cognitive and physical function
• Active and competent
• Engagement with life
• Productive activity, involvement with other
  people

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• Not avoidance of aging maintaining adaptability
• Consistent with reality of aging
• Successful aging is the norm
• paradox of well-being (Mroczek Kolarz, 1998)
• 32,000 US adults surveyed
• Assumed objective difficulties
• Generally fel good about selves and situation
• 30-40 over 65 report selves as very happy

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• Positive affect highest for older
• reflects personality (extroverts)
• set point perspective
• - temperament sets boundaries for levels of
  well-being throughout life
• - extroverts more successful dealings with
  others
• - positive interpretations of life events

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Successful Aging

• Hardiness and thriving (Perls, 1995)
• Genetic determiners of hardiness in oldest old
• Adaptive capacity (ability to overcome disease or
  injury)
• Functional reserve how much of organ required
  for adequate performance (determines ability to
  deal with disease)

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Survivability

• Beyond age 97, chances of dying at a given age
  lower than expected
• Mortality rate (deaths/ in age group)
• exceeds 1.0 if entire group dies in less than one
  year
• Indicates oldest members of our species tend to
  be healthier than traditional views of aging
  would predict
• Additional support from medflies
• Chance of dying at any age peaks at 50 days
  (_at_15)
• If survive to 100 days, chance of dying at any
  given day _at_5

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• More hardy
• Slower rate of progress of symptoms of disease
  than in less hardy
• Threshold for disease lowers more slowly

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• Symptoms of age-related disease (e.g.,
  Alzheimers) appear later (b vs. a)
• Morbidity, mortality, disability compressed into
  shorter period

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Possible explanations for hardiness

• Longevity genes increased resistance against
  oxygen radicals
• Slow rate of damage
• Low complement of deleterious genes
• E.g., Apolipoprotien E (apo-E) related to risk of
  Alzheimer's
• Gene for protein apo-E less prevalent in
  oldest-old survivors
• 18 of 90-103 year-olds
• 25 of under-65 year-olds

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• Adaptive capacity (ability to cope with and
  overcome disease or injury) higher in more-hardy
• Functional reserve (how much of an organ is
  required for its adequate performance) higher

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• Autopsy studies of healthy oldest-old brains
• No outward signs of disease, but level of
  neurofibrillary tangles would indicate dementia
  in younger brain
• Excess reserve of brain function compensates for
  processes damaging the brain

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Two Basic Principles of Normal Aging

• Variability of aging rates
• Longitudinal studies (e.g., Baltimore Study)
• Aging rates vary remarkably (60 year olds like
  40 some 40 year-olds like 60, physically)
• Differences in appearance mirrored on
  physiological tests
• Variability increases as age increases
• Individual aging rates vary across years, and
  across physical systems

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• Variability of Aging Patterns
• Several aging paths
• Cross-sectional research
• Some functions decline in a regular way over time
• Other functions are stable, unchanged or decline
  only in terminal phase of life

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• Physiological loss, but only when an age-related
  illness is experienced
• E.g., heart disease correlated with a decline in
  heart pumping capacity with age
• Without heart disease, pumping capacity as well
  at age 70 as at age 30

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• Terminal Loss Pattern
• Loss in a normally stable function may be sign of
  impending death
• E.g., immune system of lymphocytes (white
  blood cells) stable normally stale
• Decline occurred in minority of Baltimore Study
  sample
• Reported good health good physical exams
• At next follow-up for study subgroup more
  likely to have died

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• Loss occurs, but body compensates for the change
• E.g., brain neural loss but robust individual
  cell growth (new dendrites, new connections) may
  help preserve thinking and memory
• Physical Aging not only loss
• Stability
• Resiliency
• Capacity for growth