Death and Dying

Sarah Hammett, Ruth Dennison, and Roman Liskevich

Death

“No one wants to die. Even people who want to go to heaven don’t want to die to get there. And yet death is the destination we all share. No one has ever escaped it. And that is as it should be, because Death is very likely the single invention of Life. It is Life's change agent. It clears out the out the old to make way for the new”. Steve Jobs

Death and Dying

As medicine progressed there were newer guidelines for being termed dead.

Not having a heartbeat and respiration didn’t qualify someone for being dead.

New technology allowed a person to have his his/her heart and circulatory system to be sustained on a ventilator and feeding tubes to give nutrients to the individual.

Sometimes people who were plugged up to these machines never regained consciousness, so we had to find a new term for being dead.

What is Death

In the first edition of the Encyclopedia Britannica, death was defined as “the separation of the soul and the body.”

The latest definition of death is three times as long and the more we learn about death the harder it gets to defining it

About three centuries ago it was fairly simple to determine if someone was dead.

If someone was thought to have died the family would have called the priest to come and make sure.

The priest would come and do some simple tests like put a mirror right by their mouth see if it clouded up by breathing

If the family needed further proof he would put feather on the nose to see if it moved. O things were so simple back in the day.

Brain Death

Doctors started to use terms like “persistent vegetative state”, and “irreversible coma” to describe people who had been in some kind of traumatic injury were they had brain damage that was irreversible.

Medicine could now keep people alive when their own brain couldn’t, but a persons consciousness , his personality was gone forever

Brain death or the irreversible end of all brain activity due to total necrosis of the the cerebral neurons following loss of brain oxygenation.

Cause of Brain Death

Technically everybody dies of brain death, a young person might suffer a gunshot to the brain or an older person might suffer a stroke and doesn't get oxygen to the brain, eventually we all die of brain death.

The brain can be without oxygen for six minutes after the heart stops, severe brain damage occurs after 6 minutes without oxygen.

There is a difference between brain damage leading to death and brain damage leading to a comma.

Coma VS Brain Death

Being brain dead and being in a coma is not the same thing.

Patients who suffer brain death are not in a coma.

Patients in a coma may or may not progress to brain death

Patients in a coma may come out of it and wake up but patients who are brain dead will never wake up again.

A patient can only be either in a vegetative state or brain dead, there's no such thing as almost brain dead, its yes or no.

Determining Brain Dead

The patient must pass all of these tests to be determined brain dead

There are several tests done to determine if a patient is brain dead.

1. The patient has no response to command

2. The patient is flaccid, with areflexic extremities

3. The pupils are nonreactive

4. Patient has no oculocephalic reflex

5. The patient has corneal reflex

6. The patient has no response to supra orbital stimulation

7. The patient has no oculovestibular reflex

8. The patient has no gag reflex

9. The patient has no spontaneous respiration.

Dying Brain

Assistant living

Assistant living is for senior who are in some need of help with some daily assistance.

Assistant living differs from nursing homes in that patients in assistant living can do most thing themselves, and they don’t need intensive care.

The benefit of assistant living is the trained staff that can help patients who cant do something because of a illness.

The national average for assistant living is $3,300 a month and in Huntsville its $1,900.

Nursing Home

Nursing homes are for patients who don’t need to be in a hospital but cant be at home.

Nursing homes are not only for the elderly but for anyone who requires 24 hour care.

The cost in the of nursing home care has risen 4 percent in the last year with a private room being $84,000 a year or $229 a day.

The average cost in Huntsville is $179 per day.

Death and Burial

A person can have a will made out telling how he/she wants to be buried.

Most people in the US want to be buried in a casket but there are many(mostly in the Pacific and Asia) who prefer to be cremated.

Religious and cultural beliefs also play a role in how a person want to be buried(or cremated).

Funeral Home

The price of a funeral can cost depends on how much you want to spend.

The basic service for a funeral with staff is $1495

Embalming costs another $595 and cosmetics are another $295

The casket costs anywhere from $900 to over $10,000!

The burial costs another $1000

Cremation is a lot cheaper and cost only $1,345.

Funeral Home

The price of a funeral can cost depends on how much you want to spend.

The basic service for a funeral with staff is $1495

Embalming costs another $595 and cosmetics are another $295

The casket costs anywhere from $900 to over $10,000!

The burial costs another $1000

Cremation is a lot cheaper and cost only $1,345.

Hospice care is end-of-life care by medical professionals and volunteers who give medical, psychological and spiritual support. The goal is to help those dying have peace, comfort and dignity. The caregivers try to control pain and other symptoms so a person can remain as alert and comfortable as possible. This type of care is called palliative care Hospice programs also provide services to a patient's family.

Hospice patients are usually expected to live 6 months or less. Hospice care can take place

At home At a hospice center In a hospital In a skilled nursing facility

Source Cited: National Cancer Institute

Hospice Care:

“Hospice is covered by Medicare nationwide and Medicaid is covered in Alabama. Most insurance providers also cover the cost of hospice care. Medicare covers the full scope of medical and support services provided by hospice. There is little to no expense to the patient.” -Hospice of North Alabama

Hospice of North Alabama (aging and terminally ill patients)Hospice Family Care(terminally ill patients and families) Commercial

Hospice Care options in Huntsville Area (patients must be referred by a doctor) :

Patients have the right to choose where they get their hospice services, and what services they use. Most hospice centers offer patients the following services:

Case Manager (nurse): Periodically visits the patient to check patient's physical, emotional, and spiritual health. The case manager then decided what can be done for the patient to make them as comfortable as possible.

Hospice Aide: Visits patient at scheduled times. Assists in bathing/grooming, recording vitals. Aide regularly reports the patient's status to the Case Manager.

Social Worker: Coordinates patient's resources.

Chaplains: Provides pastoral care, often gives patient their last rites.

Volunteers: Provide care when family members are unable to, provides companionship for patient. Generally helps the family when needed (grocery shopping, errands, etc) so that the family may spend their time with the patient.

Source: Hospice of North Alabama

What Hospice Does

Advance Directives What are Advance

Directives?Legal documents that express an individuals' desires regarding their end-of-life care.

Living Wills express what procedures an individual does or does not want to extend their life. This includes; dialysis and breathing machines, if an individual wants to be resuscitated if heart or lungs stop, whether a feeding tube can be used on an individual, and whether the individual would like to donate organs or tissues upon death.

Advanced Directives in Alabama(Source: caringinfo.org) If you wish to revoke the

Advanced Directives you have three options:

Destroy the legal document.

Write a formal revocation with your signature and date.

Orally express your desire to revoke the order to an individual over the age of 19. This individual must then write and sign confirmation that they heard you revoke your directives.

Under Alabama law Advance Directives that prohibit the use of feeding tubes, and life-sustaining treatments for patients that are pregnant will be ignored.

Under Alabama law, separate documents are needed to prevent ambulance and emergency room personnel from providing CPR.

Expected Lifespan:

48

65

73

7981

46

61

67

72

76

40

52

64

76

88

100

1900 1940 1960 1990 2013

Source: http://demog.berkeley.edu/~andrew/1918/figure2.html

This shift from family care to professional care has minimized our exposure to the painful circumstances surrounding the death of a loved one. Even though the news exposes us to stories of death, because there is often no personal connection we are allowed to have distance from death. Because of this, we are not as death-obsessed or as fearful of death as previous generations.

Source: Santrock

THEN (Early 1900's

TODAY

One out of two children died before age 10. By adulthood, children had lost one parent (on average).

Death mostly occurs amongst aging adults.

Most people died at home, cared for by family.

80% of deaths occur in hospitals or care institutions.

Leading Causes of Death:

1900

1. Pneumonia

2. Tuberculosis

2013

1. Heart Disease

2. Cancer

Source: cdc.gov

1937

1. Heart Disease

2. Pneumonia

1850

1. Tuberculosis

2. Cholera

Death in a Digital Age

Google recently introduced its “Inactive Account Manager”, which allows users to determine whether they want to open accounts to loved ones, or have the information deleted after their passing (this is determined by a selected amount of inactivity).

Online profiles (i.e. facebook) often become makeshift memorials after someone dies, with the bereaved writing on their wall or tagging them in images to pay their respects. Some sites even offer a service that sends an email to a loved one of your choosing after you die. One such site, deathswitch.com is designed to send loved ones important account numbers, passwords, and short messages after your passing. It regularly prompts you to enter a password via email, and when you miss several reminders, it determines that you are either dead or disabled. Many funeral homes now offer “streaming” services so loved ones that are deployed, or unable to travel can view the funeral.

Also known as “Stages of Loss” because it applies to both accepting your own death as well as grieving the loss of a loved one. Cyclical. Even though a person may go through the stages several times before finally reaching true acceptance. There is no set time frame to the stages of grief, they can last years. Many people who have gone through the stages say that it comes in “waves”.

Image: ShutterstockText:Santrock, J.W. (2007). A Topical Approach to Life-Span Development.

Stage 1: Denial and Isolation

Person denies that they are going to die. “No. This couldn't happen to me.” Common reaction to terminal illness. Is only temporary, and is usually “cured” when a person is confronted with evidence of their illness; doctor bills, failing health, etc.

This is a natural coping mechanism that gives an individual time to process the idea of their imminent death.

This period is marked by: Avoidance, Confusion, Fear, Numbness, and Blame.

Source: Santrock & Kubler-Ross, 1968

Stage 2: Anger

Happens when they are forced to face the fact that they are dying, and denial is no longer possible. It becomes harder for medical staff, loved ones, and other professionals to care for the dying person as their anger will become displaced onto those around them. Dying persons may become increasingly resentful and jealous of others in good health.

This stage is marked by: Frustration, Anxiety, Irritation, Embarrassment, and Shame.

Source: Santrock & Kubler-Ross, 1968 Image:

mesothelioma.com

Stage 3: Bargaining

The hope that death can be postponed. Some will try to bargain-most often with a higher power-to delay their death.

This stage is often marked by: Reaching out to others, Desire to tell their story, Struggle to find meaning.

Source: Santrock

Stage 4: Depression

The dying person accepts that they are going to die. They become silent, and may refuse visitors. They spend much of the time crying, and grieving their own death. This behavior should not be discouraged, as it is necessary for the dying person to prepare themselves. This is a defense mechanism, in which the dying person is distancing themselves from loved ones in order to save them from the pain of their eventual death. “Cheering them up” can lead to them feeling guilt or shame, which may only further the depression.

This stage is marked by: Lack of energy, Helplessness.

Text: SantrockImage: xkcd.com

Stage 5: Acceptance

The dying person becomes at peace with their death. However, they may still want to be left alone. Feelings and pain may be absent by this stage.

This stage is marked by: Exploring options (“bucket lists”), Finalizing plans, and Making amends. Source: Santrock

Image: www.dcmetrotheaterarts.com

Kubler-Ross Stages of DyingRobot Chicken's Stages of LossCons of the 5 Stages:

-Not enough research support.

-Ignores individual circumstances.

Pros:

-Helps individuals cope with dying.

Perceived Control and Denial

Perceived Control: Coping mechanism. When led to believe that they are in control of their fate, aging or dying adults may become happier and more active.

“I have cancer, cancer does not have me.”

Denial is also an effective coping tool. It can be adaptive (eases the initial shock) or maladaptive (prevents individual from truly facing their death). Denial can not be classified as good or bad, but judged on a

case by case basis.

Ben has been told that he has a cancerous tumor that can be removed by a simple operation. Ben refuses the operation, saying that “the tumor is small, so it's not worth the risks of surgery”.

You Decide: Maladaptive or Adaptive?

Bobby has been given six months to live. He begins to make plans to complete his bucket list. He even spends most of his savings on a trip that will take place after his “expiration date”.

To Review

In this clip:

Perceived Control (shaving head, instead of waiting for hair to fall out from chemo, using it as a dating strategy, etc.)

5 Stages.

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Communicating with a Dying Person

Psychologists believe it’s best for the terminally ill patient to know that they are dying. Advantages:

1.Close their lives in accord with their own ideas, getting closure and saying their good-byes

2. Complete plans or projects, make arrangements for survivors and participate in funeral and burial

decisions3. Reminisce and converse with important people

in their life4. Understand what is happening within their body

and what the medical staff is doing

Source: Essential of Life-Span Development

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How should I talk with a loved one who is dying?

Love: Communicate love through verbal and non-verbal expressions

Identity: Focus on the relationship between the living and the dying

Spirituality: Statements of religious faith and experiences

Everyday Talk: Sharing the mundane

Source: How Should I Talk with a Loved One Who is Dying?http://www.natcom.org/CommCurrentsArticle.aspx?id=862

What is Grief?"Grief is a natural response to loss. It’s the

emotional suffering you feel when something or someone you love is taken away. The more

significant the loss, the more intense the grief will be. You may associate grief with the death of a

loved one—which is often the cause of the most intense type of grief—but any loss can cause grief.“

Grief is also described as "The emotional numbness, disbelief, separation anxiety, despair,

sadness, and loneliness that accompany the loss of someone we love."

Prolonged Grief Type of grief that involves enduring despair and is still

unresolved over an extended period of time.

Negative Consequences of prolonged grief

Physical health: Fatigue, sleeping problems, loss of appetite, and pain

Mental health: loss of motivation and anxiety symptoms

Disenfranchised Grief an individual's grief over a deceased person that is a

socially ambiguous loss that can't be openly mourned or supported.

Widowhood Effect the increased probability of death among grieving mates

within weeks or months of their spouses passing.

“

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Steps for Coping with Grief and Loss

Get Support

1. Turn to Family & Friends 2. Join a Support Group

3. Go to a Grief Counselor4. Draw Comfort from your Faith

Source: Help Guidehttp://www.helpguide.org/mental/grief_loss.htm

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Steps for Coping with Grief and Loss Cont.

Take Care of Yourself

1. Face Your Feelings2. Express Your Feelings (Journaling)

3. Look after your Physical Health4. Don’t let anyone tell you how to feel

5. Plan ahead for “Grief Triggers”

Source: Help Guidehttp://www.helpguide.org/mental/grief_loss.htm

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Right to Die Debate

Does a person have the right to choose to die? To commit suicide?

Euthanasia: Doctor-Assisted Suicide

“The laws of the Netherlands and Belgium define euthanasia as ‘the act, undertaken by a third party, which

intentionally ends the life of a person at his or her request, and in both countries euthanasia can only be effected by a

doctor’.”

Two Criteria for Euthanasia in Belgium & Netherlands:

1.After getting a second opinion, patient has to be capable of letting their wishes clearly known repeatedly over a

period of time

2. Patient must be suffering from "unbearable physical or psychological pain“

Source: The Internationalhttp://www.theinternational.org/articles/307-bringing-death-to-light-is-there-a-righ

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Marc and Eddy Verbessem

Deaf from BirthGoing Blind

“Nothing to Live For” Loss of Independence

Something to think aboutSource: Google Imagehttp://www.google.com/image

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Dr. Ezekiel J. Emanuel, an oncologist and former White House adviser, wrote in The Atlantic that providing assisted suicide to those not suffering unbearable physical pain is a slippery slope: “Once legalized, physician-assisted suicide and euthanasia would become routine. Over time doctors

would become comfortable giving injections to end life and…comfort would make us want to extend the option to

others who, in society’s view, are suffering and leading purposeless lives.” He continues to say, “Physician-

assisted suicide and euthanasia should not be performed simply because a patient is depressed, tired of life, worried about being a burden, or worried about being dependent. All these may be signs that not every effort has yet been

made.”

Source: The Internationalhttp://www.theinternational.org/articles/307-bringing-death-to-light-is-there-a-righ

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Oregon Death with Dignity Act (1997)1st U.S. State to Pass Death with Dignity Law

Proponents: Argued that mentally competent, terminally ill adults have the right to request their physician's aid in hastening their dying.

Opponents: Violates religious teachings on the sanctity of life and leads to a "slippery slope" toward euthanasia.

*Washington and Montana now also allow physician-assisted suicide.

Source: U.S. Supreme Court Upholds Oregon's Right-to-Die Law http://www.beliefnet.com/News/2006/01/U-S-Supreme-Court-Upholds-Oregons-Right-To-Die-Law.aspxTime USAhttp://www.time.com/time/nation/article/0,8599,2075644,00.html

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Dr. Jack Kevorkian

A.K.A. Doctor Death

Said he assisted in over 130 deaths

His work spurred the debate on ethics of euthanasia in U.S.

Served 8 years for Second-Degree Murder

Sources:Google Images http://www.google.com/imagesBio.True Story http://www.time.com/time/nation/article/0,8599,2075644,00.html

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Cultural Differences in Death

Most Cultures: Death is not viewed as the end of existence – though the biological

body has died, the spirit is believed to live on (Hedayat, 2006).

Grief, whether in response to the death of a loved one, to the loss of a treasured possession, or to a significant life change, is a universal

occurrence that crosses all ages and cultures.

South America: Hispanics are family oriented, end of life care given by family members and strong support systemAnticipatory Grief: feelings of loss before loved one has died.

Ireland: Irish Wake with music and dancing, pre-planning funerals

Hawaii: Ancient Burial Method, Buried in a Cave or Sand Dunes or Burial at SeaModern Method, In Casket in Ground, mourners wear brightly-colored garments as black is not worn at funerals.

Sources: Death in Cultures Around the Worldhttp://dying.lovetoknow.com/Category:Death_in_Cultures_Around_the_World

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Israel: Rend or Tear Clothing at news of death or at the funeral, sometimes rabbi will give family a torn ribbon to wear to signify the loss.Shiva: Seven day mourning period, turn mirrors backwards or cover, sit and reminisce.

India: Most are Buddhist. Monks chant verses to them while they are dying and while the person is being ready for funeral fire (cremation). Monks attend funeral with family and are given food and candles by the family.

United States: Death Avoiders and Death Deniers. Funeral homes prepare body. Visitation, Funeral, Graveside

Sources: Death in Cultures Around the World and Buddha.nethttp://dying.lovetoknow.com/Category:Death_in_Cultures_Around_the_Worldhttp://www.buddhanet.net/d_cermon.htm

Remains of the Day

The Death and Dying Group Recommends (for further interest)Ben Breedlove: My Story

“The Last Lecture”

Elizabeth Kubler-Ross on DyingJoan Didion, “The Year of Magical Thinking”