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Chapter 14

Death and Dying

Death and Society

Death as Enemy; Death Welcomed
A continuum of societal attitudes and beliefs
Attitudes formed by
Religious belief; Modern science and technology; direct & indirect experience

Death in Old Age

The past
Death common among all ages; Living to old age rare; Most deaths from acute illness
Today
Longer life expectancy
Most death from disease in old age
Most deaths from one or more chronic illness

Death in Old Age: Three Typical Death Trajectories

20%
Will die from fatal illness (i.e. cancer)
25%
Will die from illness (i.e., emphysema)
40%
Will die from illness (i.e. Alzheimer’s)

The Experience of Dying

Five Concerns at Life’s End
Avoiding a drawn-out death
Getting pain relief
Control of treatment options
Staying in touch with loved ones
Fear of becoming a burden

The Experience of Dying

Age Differences in Feelings About Death
Older people
85+
Gender differences
Older women more fearful than older men
More fear of pain
More fear of artificial means of life

The Experience of Dying

Religious belief
Mild or uncertain religious belief
Have most fear of death
Strong or no religious belief
Have least fear of death

Institutional Death

Medical personnel trained to keep people alive
Most institutions function on medical model principles
Medical education
Focus on acute care

Institutional Death

Training needed?
Palliative care
End-of-life treatment
Psychological issues at end of life
Unique needs of older people
Unique needs of minority elders

Stages of Death and Dying (Kubler-Ross)

Denial: “not me”
Anger: “why me?”
Bargaining: “yes me...but”
Depression: “yes me”
Acceptance: “my time is close and it’s ok”

Hospice Care

Hospice Program Goals
Control pain
Allow a simple death
Give love and care
Types of Hospice in USA
Hospice Program Goals

Figure 14.1 Growth in U.S. Hospice Programs: 1974–2007

Figure 14.2 Total Hospice Patients Served, by Year

Palliative Care

Comfort care
Provide relief to terminally ill person through symptom and pain management
Maintain high quality of life as long as life lasts
Can be provided through hospice
Most exist in acute care hospitals
Some in patient’s home

Palliative Care for the Elderly

Broadens health care options
Acknowledges limits of curative medicine
Accepts death as a part of life
Takes time
Follows natural course of individual’s death
Treats the whole person
Includes caregivers and social support system

Palliative Care for the Elderly: Challenges

Funding limits on some services
Caregiver services
Bereavement counseling
Health care worker and public lack of knowledge about palliative care

Palliative Care for the Elderly

Strategies to meet challenges
Gradual shift from treatment to palliative care
Two stage program
Health & social support for families home care
Home care workers; Respite care
Partnership between formal and informal care resources

Ethical Issues

Is it ethical to stop treating illness?
Does decision not to treat with machines cause death?
How much information should health providers give a dying person?
When should a doctor allow a person to die?

Advance Directives

Various types
Lets health care providers and families know what the older person wishes
Federal and state laws govern advance directives
Federal level
Patient Self-Determination Act 1990

Types of Advance Directives

Minorities and Advance Directives
Power of Attorney
Right to make financial or health care decisions on behalf of older person if they lose mental capacity
Living will
Wishes at the end of life
Written legal document

Use and Challenges of Advance Directives

People put off creating them!
May not be knowledgeable; Don’t know value
Don’t want to think about poor health or death
Whites more willing than African-American to discuss wishes
African-Americans in long term care least likely to have AD

Euthanasia & Physician-Assisted Suicide

Passive Euthanasia
Not actively causing death
Allowing death to happen
May or may not result in death
Active Euthanasia
Actively helping someone achieve a painless death

Figure 14.3 A Sample POLST Paradigm Form from Oregon

Physician Assisted Suicide

Is active euthanasia, or “mercy killing”
Public is ambivalent
Request usually from someone in pain or depressed
Only places that have societal support
Switzerland, the Netherlands, Belgium, the state of Oregon and the state of Washington

Physician Assisted Suicide: Oregon

Does not allow active euthanasia
Does allow a type of physician assisted suicide
Death with Dignity Act, 1997
Allows physicians to prescribe drugs that help a person end own life

Mourning and Grief

Each culture and society has own rituals and process of mourning
Common purpose in all
Bereavement
Feeling of loss through death of a loved one
The objective fact that someone has died
Bereavement leads to grief

Mourning and Grief

Three Stages of Grief (Lindemann, 1944)
Initial response phase
Shock & disbelief
Review phase
Search for meaning of the death
Recovery phase
Looking for social contact

Mourning and Grief

Phases and Stages of grief and grief work not the same for everyone
May last for years in some cases
May come in cycles; Is never truly over
Patterns of grief influenced by
How person died; Sudden/over time; Relationship; Age of deceased/bereaved