Death and Dying
Death is an inevitable, universal, final and a natural part of the lifecycle. The western culture perspective on death is that it is an unnatural event that is to be fought off.
“Physicians and other health professionals, at all levels of training should receive concrete, insightful, and culturally sensitive instruction in the optimal care of dying patients” (Position 6, Position Statement on the Care of the Dying Patient, American Geriatric Society , 1998).
Bereavement Experiences/Grief responses
Bereavement and grief are all significant events in individual’s lives and all health care professionals are likely to, at some stage, need to be involved with people experiencing these emotions – they are an integral and inevitable part of the human experience. Grief and bereavement care is an important component in the health care continuum. Many factors can determine the way an individual reacts to bereavement.
Grief – the acute psychological reaction to one’s perception of loss.
Mourning – the longer process of resolving the acute grief reaction.
Bereavement – the state of having experienced a significant loss; (Dening (1994) defined it as ‘being robbed of anything we value’) – it is a normal part of the healing process.
Four tasks of mourning :
1) Accepting the reality of the loss
2) Working through the pain of grief
3) Adjusting to an environment in which the deceased is missing
4) Emotionally relocating the deceased and moving on in life
Grief reaction may be complicated if they are chronic, delayed, exaggerated or masked. Reactions to death are variable and do not necessarily follow set patterns. Death and dying have different meanings for different individuals. Rituals, such as funerals, can help ease the mourning process.
Individuals will each have their own way of handling grief, yet Robnett (1999) offers the following generic advice as being helpful in talking to the bereaved person:
• as much time as allows, let the person talk about their loved one and their loss. Asking about the deceased person is generally acceptable and may even be desired. Shedding tears is a natural, healthy experience that can aid the healing process.
• assure the bereaved person that their feelings are legitimate. Euphemisms, cliches, and sympathising remarks are generally regarded as not helpful (eg “I understand”, “It’s all for the best”).
• It is okay not to have the right words or the answers – just being there and offering your care and support does help.
• allow the bereaved to make decisions (well meaning individuals often attempt to take over the decision making for grieving persons)
• recommend counselling for those who need additional help
A pathological grief reaction occurs when the bereaved person is not able to express or work through their grief unable to recover from the loss and adapt to life without the deceased person.
DSM-IV (1994) differentiates between normal bereavement and major depression – a major depressive episode should be considered if:
• marked grieving symptoms that have persisted for more than 2 months
• guilt about things other than actions taken or not taken by the survivor around the time of death
• thoughts of death other than the survivor feeling that he or she would be better off dead or should have died with the deceased person
• morbid preoccupation with worthlessness
• marked psychomotor retardation
• prolonged and marked functional impairment
• hallucinatory experiences other than hearing the voice or transiently seeing the image of the deceased person
A persons approach to death will be shaped by social, cultural and religious backgrounds; physical and functional status; social isolation and loneliness; and the meaningfulness of everyday life. A range of carefully integrated approaches is needed to manage the patient that is terminally ill.
People who are dying:
• most want opportunity to make decisions regarding death
• many will want to complete ‘unfinished business’; ‘mend fences’ in personal relationships
• open communication with the dying is the preferable approach
• want preservation of dignity and to be valued
• all differ in what they consider important their preferences should be paramount
• care should be guided by the preferences of the dying person
a psychosocial ‘death’ can begin well before physical ‘death’ (ie disengagement theory)
related to the social status of those who are dying implies that social value has declined so low that they are no longer considered part of the living world
eg talking about the person in their presence without acknowledging that they can hear; making decisions for people that they are capable of making
eg treating them in a dehumanising way, being given mechanical care without addressing social needs
if personal control is taken away go into ‘failure-to-thrive’ syndrome further decline
Theoretical psychological stages of facing a terminal illness :
1) Denial/isolation – “can’t happen to me”, “why me?” – considered a defence mechanism
2) Anger – after they recognise that denial can no longer be used anger, resentment, rage can be difficult to care for as anger can be projected onto health care providers
3) Bargaining – develops hope that death can be postponed or delayed – begin to bargain or negotiate (often with God)
4) Depression – begins to accept the certainty of their death depression, grief, crying, withdrawal
5) Acceptance – develop a sense of ‘peace’, an acceptance of fate and often a desire to be left alone
However - some may go through different stages in different sequences and some may repeat some. For some individuals denial and anger may be a healthier response than acceptance. There may be a variety of reactions rather than the above proposed orderly progression of stages.
These types of programs or philosophies provide a non-curative medical and support services for those with a terminal illness. The aim is to help persons dying to live as fully as possible on a daily basis by trying to provide a blend of institutional care and home care – the primary emphasis is on quality of life.
The World Health Organisation defines palliative care as: “An approach that improves the quality of life of patients and their families facing the problems associated with life threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems physical, psychological and spiritual”.
symptomatic relief/pain control
enhancement of quality of life
regards dying as a normal process; does not hasten or postpone it
addresses psychological needs
supports family and helps them cope
assistance with spiritual needs
Tips for talking with those that are dying :
• be at some eye level
• don’t be afraid to touch
• avoid excessive small talk
• don’t insist on acceptance, if they are in denial (and don’t insist on denial if they are in acceptance)
• allow expression of anger or guilt
• don’t be afraid to ask prognosis
• encourage reminiscence – especially if have memories in common
• share your feelings
• express your regard for them
• don’t be afraid to say goodbye
The patient’s perspective on a “good death :
• Control of pain and other symptoms
• Avoid inappropriate prolongation of dying
• Relieve burden on the family
• Achieve a sense of control
• Strengthen relationships with loved ones
Definition of Death:
Death has needed to be redefined due to the ability to keep the human body biologically alive for longer periods of time. Previously death was the cessation of biological functioning (respiration and circulation), but with these advances in technology it became increasing difficult to make the medical pronouncement of “death”. Brain death (the cessation of electrical activity in the brain, determined by ECG) meets the legal criteria for death in most jurisdictions.
Brain Death Criteria (UK):
Brain death is the death of the brain stem, recognised by:
deep coma with absent respirations (ie on a ventilator)
the absence of drug intoxication and hypothermia
the absence of hypoglycaemia, acidosis and electrolyte imbalances
In USA, an ECG is required to confirm absence of cerebral activity.
The United Nations Vital Statistics definition of death is ‘the permanent disappearance of every vital sign’.