Dying and Bereavement Essay: 

Definitions and Ethical Issues

Death is more complex than the dictionary definition would suggest. We divide the society along different lies by culture. Western culture divides people along their chronological age, Melanesians divide separate the living from the very sick, very old, and dead. Other cultures view death, sleep and illness together or view the terminally ill as dead. Humans have developed varying rituals surrounding mourning that place certain responsibilities on the living to perform for the dead.  Legal and Medical definitions of death have also arisen to deal with ethical concerns regarding human rights and expectation of care. Clinical death refers to the cessation of heart beat and respiration, while brain death refers to a complete and permanent lack of brain activity. Because of technology a person can be sustained in a persistent vegetative state for many years which leads to ethical dilemmas regarding whether or not these people should be kept on life support. The main issue under consideration in bioethics is euthanasia which can active or passive depending on whether actions have to be taken such as administering a drug or if simply removing a feeding tube for example is enough. In order to prevent family members from making these difficult decisions some  people decide to sign a Do Not Resuscitate Order or DNR that says that they do not want life saving measures taken. Others explicitly hand control over to individual family members using Power of Attorney documents. These are common when the patient fears that they will not have the power of self-determination. Another issue that pertains to death is the reality that care is expensive and at a certain point the benefit to person outweighs the costs of carrying it out.

Thinking about Death

Many people are afraid of death, to the extent that it is considered the norm. People’s feelings about death tend to vary according to their age. For people who die young and are just starting out in their lives there is a strong sense of unfairness. The explanation for these feelings are contained in attachment theory. When a person is young there are many things happening to them, they are getting married, going to school their lives are full of friends etc. To some degree there is a sense of immortality. As people get older and enter into middle age, a cognitive shift starts to occur where the reality of death sinks it. Around this stage in life a person’s parents die and the realization sets in that they are next in line for death. These realizations can lead to changes in the way that people live their lives to take better advantage of the time that they have left. Older people have a more relaxed and accepting view of death and for many life is less enjoyable with fewer attachments making them more ready to die.  According to Kubler Ross there are five modes of thought about dying; denial, anger, bargaining, depression and acceptance. Movement through these modes is not linear and these feelings can overlap. In general it is difficult to be conclusive about the theories regarding dying because there are so many variations and no one way of dying is to be considered the right way. Dying can be considered in a very holistic way and the interactions between care takers, family members etc. is complex. Death anxiety is the idea that death makes us uncomfortable yet it is inevitable and we develop ways of coping with it that manifests into our daily lives. Some people choose to avoid reference to death by forgoing funerals while others engage in risky behavior that seemingly allows them to face death. Humans have also developed more structured ways of dealing with death such as religion and the anxiety of it permeates into academia and into the arts e.g. philosophy and drama. Programs have been developed to help the dying cope with this anxiety.

End of Life Issues

Changes in society mean that we interact with dying people less often and it is unlikely that we will be surrounded by friends and family when we die. Instead we are more likely to die in institutionalized settings. Many people prefer to discuss the arrangements of both the dying and the post death process such as where they want to be and whether they want to be buried or cremated. Other issues that have to be considered are wills and inheritances. Although many people might not want to discuss the death it is important that they dying person be allowed to construct the final scenario, or the way their death runs its course.  Hospices are an option. These places specialize in end of life needs such as pain management and palliative care with the goal of providing the best possible quality of life. They are different from hospitals because the patient comes there as the last place, after there is no other treatment. The goal is more to fulfil in the social and comfort needs of the client. Hospices can be in patient or outpatient with the outpatient model becoming more popular. In-house hospices have no restriction on vesting hours and welcomes the family as part of the process. In general people prefer hospices to hospital and appear to have a better quality of life and more involvement from the family. Most of the people who go to hospices are suffering from terminal illnesses although hospices might not be equipped to deal with the exact situation of every person. For this reason it is important to have a conversation about the needs of the individual. Kastenbaum(1999) say there are six questions that people explore in deciding whether or not to go to a hospice. Persons must be fully informed about their prognosis and options. The person’s fears and hopes needed to be articulated and the communications skills of their social network needs to be determined as well as whether they will participate in care. Whether or not the hospice option is available is also a critical issue.

The Grieving Process

When a loved one dies we experience bereavement, grief and go through mourning. The emotions of grief can be typical while mourning is influenced by culture e.g. black dresses. We feel differently about people’s deaths depending on their age. The deaths of older adults are felt keenly but with less emotional value than that of a child. The way people experience grief has to be put in multiple perspectives, the context and the coping strategies vary from person to person, like dying there are stages of grieving and like dying there can be overlap between the states The person must realize that the loss has really happened and work through the feelings that come with the realization. Then they have to readjusts to a life without the person and let them go. Even though a person may appear to have recovered in a few weeks it may take years to even start to rebuild. A person does not really recover from the loss and the impact can last a lifetime. Unexpected deaths can be harder to come to grips with than expected death although the exact reason for this not understood. It may be because there is an opportunity to adjust to the idea although studies show that widows grieve for the husbands just as intensely in either situation. There are many emotions associated with grief and mourning to terms with them is called grief work. Because of patterns in grief, maximum stress reduction occurs when interventions take place before the death. Some health effects may occur with middle aged people seeing the worse o them. There are times when the feelings of grief are too intense and last too long, becoming abnormal. Without psychological aid, these feelings are unlikely to abate. Regardless of age a dying parent is a source of grief for many people although feelings of relief are associated with greater mental impairment in the parent. The death of a child is seen as an aberration and parents may never recover from it. Even when the child dies in the womb the loss is significant. The feelings of loss in grandparents should not be overlooked. The death of a spouse is a unique kind of loss that affects men and women differently. In general men experience greater depression. Level of dependence plays a factor in bereavement as spouses that were more dependent had more anxiety.

Interesting and Non Interesting Points

I thought it was interesting that people who are less likely to check when they are crossing the street and engaging in risky behavior are more likely to commit suicide and are likely to live shorter lives. I am not sure what the ramifications for that are or what it really means. Does it mean that people who are unhappy with their lives subconsciously seek a way out of it or that they are simply less involved in the day to day reality of the world and therefore more prone to accidents. In any event I wonder if there is any application for practitioners when it comes to risk taking behavior like these.

I did not like the section about Kubler Ross. She was dying and she was a person not a guru. She may have felt as if there were things she had not completed and she could have felt frustrated and angry by her own weakness in the face of death. It seems as if she invaded her privacy in this moment. Why would she admitted to even see Ross at this time when Ross did not want to take visitors? Additionally, the author of the book assumes that Ross did not make peace wither her mortality before she died but provides no evidence of this. All in all I find the statement unsympathetic to the human reality of death.

Summary of Chapter from the Following Book

Cavanaugh,J; Blanchard-Fields,F;Norris,. (2008). Adult Development and Aging. Scarborough, ON: Nelson.