Death and Dying
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This document summarizes information about death, dying, and grief. It discusses the definitions of death and a good versus bad death. It outlines the clinical criteria for determining brain death in adults and children. It describes the stages of death and dying as well as the stages of grief. It discusses the duration of grief, phenomenology of grief, and complicated forms of bereavement including chronic, hypertrophic, and delayed grief. It covers biological perspectives on grief and compares bereavement to major depressive disorder. It provides an overview of grief therapy. In concluding, it states that being aware of one's dying imbues humans with values and a desire to make the most of their time.
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Death and Dying
- 1. Death and Dying Max Angelo G. Terrenal Post Graduate Medical Intern 2013-2014 Veterans Memorial Medical Center
- 2. Death Absolute cessation of vital function
- 3. Free from avoidable distress and suffering for patients, families, and caregivers Good Death
- 4. Needless suffering Dishonoring of patient or family wishes or values Offending norms of decency Bad Death
- 5. Losing these functions Developmental concomitant of living Part of birth-to-death continuum Dying
- 6. Clinical Criteria for Brain Death in Adults and Children Coma Absence of motor responses corneal reflexes caloric responses gag reflex coughing in response to tracheal suctioning sucking and rooting reflexes pupillary responses to light and at midposition with respect to dilatation (4-6 mm)
- 7. Clinical Criteria for Brain Death in Adults and Children Interval between two evaluations, according to patient's age Term to 2 mos old, 48 hr >2 mos to 1 yr old, 24 hr >1 yr to <18 yr old, 12 hr >18 yr old, interval optional
- 8. Stages of Death and Dying
- 9. Stage 1 Shock and Denial
- 10. Stage 2 Anger
- 16. Grief subjective feeling precipitated by the death of a loved one
- 17. process by which grief is resolved Mourning
- 19. Duration of Grief • the bereaved is expected to return to work or school in a few weeks • to establish equilibrium within a few months • to be capable of pursuing new relationships within 6 months to 1 year
- 21. initial shock , disbelief, and denial
- 23. restitution
- 26. Chronic Grief Close relationship Lack of social support
- 28. Delayed Grief Absent or inhibited grief Prolonged denial
- 29. Biological Perspectives • immune functioning • decreased lymphocyte proliferation • impaired functioning of natural killer cells
- 31. Bereavement Symptoms may meet syndromal criteria for major depressive episode, but survivor rarely has morbid feelings of guilt and worthlessness, suicidal ideation, or psychomotor retardation MDD Any symptoms as defined by DSMIV-TR
- 32. Bereavement Considers self bereaved MDD May consider self weak, defective, bad
- 33. Bereavement Dysphoria often triggered by thoughts or reminders of the deceased. MDD Dysphoria often autonomous and independent of thoughts or reminders of the deceased
- 34. Bereavement Onset is within the first 2 mos of bereavement. MDD Onset at any time
- 35. Bereavement MDD Functional Clinically significant impairment is distress or transient and mild impairment
- 36. Bereavement No family or personal history of major depression. MDD Family and/or personal history of major depression.
- 37. Grief Therapy
- 38. • should not routinely see a psychiatrist • mild sedative • antidepressant medication or antianxiety agents are rarely indicated • group counselling
- 39. Dying, and the individual's awareness of it, imbues humans with values, passions, wishes, and the impetus to make the most of time
- 40. Thank you
Notas do Editor
- Death may be considered the absolute cessation of vital functionTwo terms that have been used to the quality of living as death comes near
- Free from avoidable distress and suffering for patients, families, and caregiversReasonable consistent with clinical, cultural and ethical standards
- Needless sufferingDishonoring of patient or family wishes or valuesOffending norms of decency
- Absence of respiratory drive at a PaCO2 that is 60 mm Hg or 20 mm Hg above normal base-line values
- On being told that they are dying, people initially react with shock. They may appear dazed at first and then may refuse to believe the diagnosis; they may deny that anything is wrong. Denial is resisting the whole idea of deathIt’s like saying “No not me”It is a form of defense mechanism to allow one to absorb difficult information at one’s own pace.Some persons never pass beyond this stage and may go from doctor to doctor until they find one who supports their position. The degree to which denial is adaptive or maladaptive appears to depend on whether a patient continues to obtain treatment even while denying the prognosis.
- Persons become frustrated, irritable, and angry at being ill. The usually say “Why me?”They may become angry at God, their fate, a friend, or a family member; they may even blame themselves. They may displace their anger onto the hospital staff members and the doctor, whom they blame for the illness. Patients in the stage of anger are difficult to treat. Physicians treating angry patients must realize that the anger being expressed cannot be taken personally. An empathic, nondefensive response can help defuse patients' anger and can help them refocus on their own deep feelings (e.g., grief, fear, loneliness) that underlie the anger. Physicians should also recognize that anger may represent patients' desire for control in a situation in which they feel completely out of control.
- This stage is when they try to negotiate their way out of death.Patients may attempt to negotiate with physicians, friends, or their God; in return for a cure, they promise to fulfill one or many pledges, such as giving to charity and attending church regularly. Some patients believe that if they are good (compliant, nonquestioning, cheerful), the doctor will make them better.
- In the fourth stage, patients show clinical signs of depression, social withdrawal, psychomotor retardation, sleep disturbances, hopelessness, and, possibly, suicidal ideation. The depression may be a reaction to the effects of the illness on their lives or it may be in anticipation of the loss of life that will eventually occur. (Reactivevs Preparatory)The patient may fit the criteria for a major depressive disorder in which case may require treatment with antidepressant medication or electroconvulsive therapy (ECT). All persons feel some sadness at the prospect of their own death, and normal sadness does not require biological intervention. But major depressive disorder and active suicidal ideation can be alleviated and should not be accepted as normal reactions to impending death.
- In the stage of acceptance, patients realize that death is inevitable, and they accept the universality of the experience.People in this stage usually says “It’s part of life”patients resolve their feelings about the inevitability of death and can talk about facing the unknown.
- Near-death descriptions are often strikingly similar, involving an out-of-body experience of viewing one's body and overhearing conversations, feelings of peace and quiet, hearing a distant noise, entering a dark tunnel, leaving the body behind, meeting dead loved ones, witnessing beings of light, returning to life to complete unfinished business, and a deep sadness on leaving this new dimension. peaceful and lovingit feels real to participantsA term to describe this experience is uniomystica, which refers to an oceanic feeling of mystic unity with an infinite power.They usually fit the patient’s belief system.
- After the death of a loved one, a painful period of adjustment follows, involving bereavement and grief
- The term is used synonymously with mourning, although, in the strictest sense, mourning is the process by which grief is resolvedit is the societal expression of postbereavementbehavior and practices
- Bereavement literally means the state of being deprived of someone by death and refers to being in the state of mourning
- As with Kübler-Ross' stages of dying, the grieving stages do not prescribe a correct course of grief; rather, they are general guidelines describing an overlapping and fluid process that varies with the survivors three partially overlapping phases or states
- an intermediate period of acute discomfort and social withdrawal
- culminating period of restitution and reorganization
- The first response to loss, protest, is followed by a longer period of searching behavior. As hope to reestablish the attachment bond diminishes, searching behaviors give way to despair and detachment before bereaved individuals eventually reorganize themselves around the recognition that the lost person will not return.
- Phases of Uncomplicated Grief
- Three patterns of complicated, dysfunctional grief syndromes have been identified as chronic, hypertrophic, and delayed griefChronic grief is most likely to occur when the relationship between the bereaved and the deceased had been extremely close, ambivalent, or dependent or when social supports are lacking and friends and relatives are not available to share the sorrow over the extended period of time needed for most mourners.Most often seen after a sudden and unexpected death, bereavement reactions are extraordinarily intense in hypertrophic grief. Hypertrophic grief frequently takes on a long-term course, albeit one attenuated over time.Absent or inhibited grief when one normally expects to find overt signs and symptoms of acute mourning is referred to as delayed grief. This pattern is marked by prolonged denial; anger and guilt may complicate its course.
- Chronic grief is most likely to occur when the relationship between the bereaved and the deceased had been extremely close, ambivalent, or dependent or when social supports are lacking and friends and relatives are not available to share the sorrow over the extended period of time needed for most mourners.
- Most often seen after a sudden and unexpected death, bereavement reactions are extraordinarily intense in hypertrophic grief. Hypertrophic grief frequently takes on a long-term course
- Absent or inhibited grief when one normally expects to find overt signs and symptoms of acute mourning is referred to as delayed grief. This pattern is marked by prolonged denial; anger and guilt may complicate its course.