gerontology essay
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10.docxIntroduction
As we are all aware, one of the natural consequences of aging and living a long life is the end of life and dying. Working in the field of aging requires supporting older adults through end of life issues and helping families deal with loss and bereavement. The more we understand about the physical, spiritual, cultural, emotional and health aspects of life and death, the better we will be equipped to do our jobs well. Understanding the options and resources available will help us to better deal with the complex issues of end of life care.
Topics and Learning Objectives
Topics
The philosophy of palliative care and how it differs at home, in a hospice, in a hospital, or in a day program
Issues of loss and bereavement for older adults and the people who care about/for them
Societal and cultural approaches to the end of life
Self-care for the worker caring for older adults at the end of life
Learning Objectives
By the end of the module, you should be able to:
1. Examine the meaning and effectiveness of palliative care.
2. Understand your personal perspective and the impact of caring for clients at the end of life.
3. Consider various cultural norms and traditions that influence how clients cope with dying and death.
Death and Old Age
Death was common in all age groups within the past few centuries. For example, 1 out of 3 women died by the age of 20, less than 50% died by the age of 44, and approximately 70% died by the age of 65 years within the last 200 years. Longer life expectancy now means death occurs in old age rather than in mid-adulthood as it did in the past. Most theories and research studies avoid death and/or dying issues despite these enormous changes, because of the serious ethical hurdles involved and the difficulties surrounding the measurement of death and dying effects.
Current Theories on Death and Dying
Disengagement Theory holds that death is less disruptive if elderly people have become disengaged from social roles as they age. Erikson’s Developmental Stage Theory contends that the last stage of life leads to a life review. This stage is defined as the ego integrity vs. despair stage. This stage leads to either ego transcendence (a deep concern for others and culture) if you reach integrity or ego despair (great turmoil as health declines) if you reach despair, both of which nonetheless fuel the dying process.
Recent Research on Death and Dying
Koster and Prather (1999) found that people have 5 concerns at the end of life:
1. Avoiding a drawn-out death
2. Getting pain relief
3. Having control of treatment options
4. Staying in touch with loved ones
5. Becoming a burden
They concluded that older people think about death more than young people. As well, older people show less fear and more acceptance of death than younger people. This may be because they have had a longer period of life to wrap their minds around the concept of death; they have had more experiences overall and more opportunities to learn, reflect, and develop advanced coping mechanisms. With decreased fear of death, hopelessness is replaced by happiness in the elderly.
Interestingly, death-related feelings appear to be influenced by a senior’s religion, but the findings are confusing. Some studies indicate that people with mild or uncertain religious belief fear death most, and religious people who believe in the afterlife are more accepting of death. At the same time, other studies have shown that very religious people are more fearful of death because of the fear they will not do the things they want to do before death.
Institutional Death
Where we reside when death is approaching influences the type and frequency of death-related feelings. For example, people in institutions think about death more often than those in other housing situations. As aresult, the death rate is high in institutions compared to hospitals and community dwellings. Why? Seniors are surrounded by death within the nursing home.
Hospital staff are uncomfortable with death, which contributes to the negative feelings. The hospital staff attaches more value to elderly people when they are comfortable discussing and recognizing their death, but most staff report being very uncomfortable because they do not want to discuss dying-related issues with the patient. Doctors do not feel comfortable discussing the prognosis of death with seniors, which greatly strains the exchange between doctors and patients. Staff, in general, hold few discussions of death and dying among themselves or their patients. The staff feel guilty and angry about dying, and, subsequently, they avoid patients because death is seen as a "failure": staff are trained to save lives, despite the inevitable realization of death. Death and dying do not fit the current model of health care, which supports acute care and the goal of making the patient "well."
Stages of Dying
Two foundational researchers in this field are Kubler-Ross (who wrote several books on death and dying) and
Saunders (who opened a hospice).
Kubler-Ross identified five stages of dying:
1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance
Researchers debate these stages. Many emotions are displayed and may not fit this stage approach. It may be very individual and several steps may be skipped or repeated on several occasions, depending on how long the person lives. The profile of a cancer patient who enters unexpected remission will resemble that of a person who is dying and then dies, but at some point, there will be a dissection of the stages as the cancer patient departs from the recognition and acceptance of death.
Hospice Care
The history of hospice care began with the first hospice in 1967 in London. The goal was to meet the needs of dying people because no service sector was currently doing this. The hospital setting did not make dying comfortable for the family and the individual, which was one of the large aims when the first hospice centre was resurrected. Hospices offer many services beyond the hospital setting. These are identified below.
Current Hospice Services
The following are a list of services offered by hospices:
In- and out-patient services
Home visiting program
Day care for children of staff
Private rooms for elderly residents
Allow cooking by family members
Provide rooms for family to stay overnight
The hospice environment promotes comfort in the last stages of dying. Staff try to achieve this through very good pain management. A pain-control mixture called the Brompton mix (made from heroin, cocaine, Stemetil syrup, and chloroform water) and natural-death options are the major ways this is achieved. The staff provide patient-specific relief and dose seniors before symptoms reoccur rather than waiting for the patient to complain of symptoms, which reduces the amount of drugs required and creates a comfortable feeling in the patient, who does not have to anticipate the arrival of pain.
They also provide the option to die at home or return, if pain is too much to bear. Special comfort and pampering is provided to the patient and the family (when needed). Support programs are available for the family as well as the individual.
Palliative Care
The palliative-care program promotes active, compassionate care for elderly in the dying stages. The focus is again on symptom control as well as spiritual support, bereavement support, and education. They exist within the hospital but are very similar to a hospice. There has been extensive growth in the past 25 years, where palliative-care programs now mostly support cancer patients. The programs need to be tailored to individual seniors. We need to create more home-based palliative-care programs. These are difficult for administering services, though, because of the current structure of the health care system.
What solutions are available? The government needs to make changes to the current health care system to improve funding for better palliative-care doctors and better funding for non-patient-related services (e.g., bereavement counselling). Most programs favour married women living with their husbands. There is also a definite need for better education to increase public awareness.
Ethical Issues
The following are a some ethical issues for consideration.
To Tell or Not to Tell the Patient that He or She is Dying
It may be beneficial not to tell the patient in some cases, depending on the individual and the illness. It may provide some people a sense of control to know death is approaching, but it may remove all hope and will in others. Discussion or open awareness may be beneficial as it reduces isolation and the loneliness that accompanies the knowledge of death in many individuals. Telling people what they want to know is often the approach staff and doctors adopt.
When Should a Person be Allowed to Die?
An individual must be mentally competent to make a decision about his or her care at or around the time of death. Decisions made while competent do not have to be followed legally, according to the law, when a person is no longer able to make decisions about their care. We need clear laws to guide doctors about what to do. A Natural Death Act should be available. Health care directives have been used in many instances, but greater clarification is required.
The Case for Euthanasia
Euthanasia, mercy killing, or assisted suicide is currently prohibited in Canada (Manitoba, 1990). Both living wills and advanced directives, which are more precise regarding how to treat the patient around the time of death, are accepted. The problem is that people may change their minds closer to death. We need to allow people to die with dignity. Coercion may underlie decisions made near or prior to illness. In many cases, if a treatment is started, a doctor can’t terminate it despite an advanced directive, which further complicates matters.
A durable power of attorney is necessary. Still, very often, doctors may refuse the decision, be unavailable, or, even worse, act too early according to a directive, which ends a life earlier than would have been anticipated.
Mourning and Grief
Three stages have been identified and described about how a person responds to the death of a loved one:
1. Shock and disbelief (lasts for several weeks)
2. Review of what happened (i.e., the death): The person may berate him or herself, search for
meaning, or search for the deceased person (lasts one year)
3. Recovery involves searching for social contacts and gaining back strength and competence
