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Chapter
13: Death, Dying and Bereavement - Summary
Chapter Thirteen Summary Outline
I. Twentieth-Century Mortality Trends
a.
Changing demography of death
·
Idea of death as an event most likely to occur
in old age is relatively new
·
Infant mortality rate often used as a key measure
of quality of life
·
More than half of all deaths in the U.S. occur
after age 50
·
Heart disease accounts for more than 1 in 3 deaths
·
Cancer explains 1 in 5 deaths
·
Stroke accounts for about 1 of 10 deaths
b. Sex, race, ethnicity and social class
·
At every age females can expect to live longer
than males
·
Racial and ethnic minorities
are likely to die earlier than whites, primarily due to being
socio-economically disadvantaged
·
At very old age African Americans have lower
mortality rates than whites
·
Native American, on average, live about 4 years less than whites
·
Native Americans who live to age 76 have lower age-specific death rates than whites
·
Among Latino groups the overall mortality rate
is close to the national average for all races and ethnicities
·
Latino elders are twice as likely to die of diabetes,
chronic liver disease, and cirrhosis
·
American-born Asians have a longer life expectancy
than their white counterparts
·
Whether male or female, people in lower socioeconomic
groups live shorter lives than those of higher social class
·
Medical care is not equal across socioeconomic
class lines
·
People live the longest lives in nations with
the smallest gaps between social classes
·
The United States ranked 9th among
nations
·
The long term affect of the “second shift”
on mortality rates for women is yet to be determined
II. Deaths in American Society
a.
Fear of death and attitudes toward dying
·
Stereotyped assumptions about attitudes toward
death are often incorrect
·
Feelings & beliefs about death vary for people
of all ages
b.
Dying as a social process
·
Position in social class structure influences
how we die
·
Discrimination about the kind of care given to
the dying exists
·
Ageist assumptions lead to older people often
receiving less treatment than younger people when dying
·
Expectations about the duration of terminal illness
are socially defined
·
The shape of a terminal illness varies and is
socially defined
c.
Awareness of dying: Glaser and Strauss model
·
Closed awareness
·
Suspected awareness
·
Mutual pretense awareness
·
Open awareness
d.
Physical and social death
·
Defining death is always problematic
·
Kastenbaum offers a useful distinction between
physical death and personal death
·
Social death describes the situation whereby
the person is treated as if an object
e.
The bureaucratization of death
·
Over three-fourths of U.S. deaths take place
in some kind of health care facility
·
Less than 1 in 5 deaths in the U.S occur at home
·
Only about 6 percent of the very old die at home
·
Death has become medicalized and bureaucratized
·
Medical and nursing personnel have structured
routines
·
Record keeping requirements are often extensive
·
Disposal of the deceased follows a hierarchical
pattern
·
Procedures surrounding dying and death are structured
and geared toward greater efficiency
·
Bureaucratization and medicalization contribute
to the impersonal nature of the dying experience
·
Dying and death have become big business
·
Funeral industry chains dominate the more than
$25 billion funeral business in the United States
·
Death is financially costly for survivors and
people who prepay their own funerals
·
Average cost of a funeral in the U.S. is $4,500,
three times the cost in Great Britain
·
Embalming is not required by law, except in certain
circumstances
·
About 21 percent of the dead in the U.S. are
cremated
III. Is There a ‘Right to Die’?
a.
Advance directives
·
Congress passed the Patient Self-Determination
Act in 1990, requiring health care facilities receiving Medicare
funds to inform patients about their right to prepare advance
directives or living wills
·
All states provide immunity to physicians and
other health care professionals if they do not follow the patient’s
wishes expressed in a living will and carry no penalty if an
advance directive is disregarded
·
An estimated 90 percent of patients do not have
advance directives
·
Typically physicians do not provide adequate
details for patients to make informed choices about the life
extension procedures
·
Preference choices about life sustaining measures
that are made when relatively healthy often differ from those
made when confronted with illness or health crisis
·
What is reasonable in terms of life and death
decisions is not always clear
·
Refusal of surgery or extensive medical treatment
does not necessarily mean one is mentally incompetent
b.
Hospice
·
Costs are covered by Medicare and most private
and Medicaid insurance programs
·
Use has largely been among people dying of terminal
cancer and more recently AIDS
IV.
Euthanasia and Assisted Suicide
a.
Passive euthanasia
·
First euthanasia bill drafted in Ohio in 1906
·
Euthanasia Society of American founded in 1938
·
1976 Karen Ann Quinlan case focused national
attention on the right to withhold life-extension
treatment
·
1990 the U.S. Supreme Court made its first euthanasia
decision in the case of Nancy Cruzan to allow the refusal of
medical treatment
b.
Assisted suicide or active euthanasia
·
1990 Dr. Jack Kevorkian assisted Janet Adkins,
an Alzheimer’s patient, to die
·
Kevorkian attracted much media and legal attention
throughout the 1990’s
·
1999 Dr. Kevorkian convicted of second –degree
murder in the death of Thomas Younk
·
November 2001, Dr. Kevorkian’s appeal was rejected
by the Michigan Court of Appeals
·
Popular support for “death with dignity”
is growing
·
Hemlock Society is dedicated to the right to
choose euthanasia
·
1994 Oregon voters approved an act permitting
terminally ill patients to obtain a physician’s prescription
to end life in a humane and dignified manner
·
1997 the U.S. Supreme Court upheld state statutes
that bar assisted suicide
·
As of 2002, only Oregon had a statue allowing
physician-assisted suicide and then only for terminally ill
patients
·
In Canada, euthanasia and assisted suicide are
punishable by up to 14 years in prison
·
The Netherlands is the only European nation where
euthanasia is legal
·
Critics of the Dutch system argue that euthanasia
is differentially applied and not always voluntary
V.
Bereavement, Grief and Mourning
a.
All are shaped by the historical period in which people
live and their culture
b.
Grief is both a symbol of caring
for the person who has died and a reaction to the social vacuum
created by the death
·
Acute grief affects all aspects of an individual
·
Acute grief may induce physical and psychological
symptoms
·
Grief work is a necessary
process following the death of a loved one
·
Death of a significant other is potentially more
devastating now than it was in preindustrial societies due
to changes in the social response
c.
Worden (1982) proposed four tasks of mourning that ease
the loss
·
Accept the reality that the dead person will
not return
·
Experience the pain of grief rather than suppress
or deny it
·
Adjust to an environment in which the deceased
is missing, including loss of roles played by him or her
·
Withdraw emotional energy from the deceased and
reinvest in new relationships
d.
There is wide variation in how grief is expressed
·
Constructed by historic-cultural patterns
·
By survivors’ social characteristics
·
By available social supports
·
Be feelings toward the deceased
·
By individual personalities
·
Multiple examples of varying societal responses
noted
VI.
Widowhood
a.
Response to loss of spouse depends on several factors
·
Closeness of the marital bond
·
The extent to which the bereaved person depended
on the spouse
·
How important the marriage was to the individual’s
self-definition
b.
Lopatas’ studies found well-educated, middle-class women
were more likely to experience the death of a spouse as disruptive
to their self-concept than were working- or lower-class women
c.
Becoming widowed may lead to idealization of the dead
spouse
d.
Adaptation to widowhood is affected by several factors
(Lopata, 1996)
·
Economic resources
·
Supportive social networks
·
Health
·
Self concept
e.
Widowers are somewhat more likely to die within a year
after bereavement than widows
Key Terms & Concepts
Infant Mortality Rate
The number of deaths among infants under age one per
1,000 births.
Closed Awareness
Describes the social situation, in the Glaser &
Strauss understanding of awareness of dying among non-comatose
people, where the hospital staff and physician know the patient
is dying but the patient is unaware of the fact due to inability
to recognize the signs of terminal
Suspected Awareness
According to Glaser & Strauss, occurs when the patient
suspects but is uncertain that the illness is fatal
Mutual Pretense
The state of awareness, described by Glaser & Strauss,
where the patient, staff, and family know that the illness is terminal
but do not discuss it openly
Open Awareness
The state of awareness, described by Glaser & Strauss,
that occurs when everyone knows and openly admits that death is
approaching
Physical Death
The cessation of life; permanent cessations of all vital
functions and signs
Personal Death
The state whereby an individual may remain technically
alive but unable to initiate action or to respond to others in
a meaningful way. One has lost autonomy and
control over even the most basic functions and actions of life.
Social Death
The point at which socially relevant attributes of the patient
begin permanently to cease to be operative as conditions for treating
him. In effect where the person is treated
as if already dead but is still alive.
Advance Directives
A type of living will whereby a mentally competent person
states in writing their preferences for terminal care. The directives
become effective when a person becomes incompetent to make health
care decisions during the course of a terminal illness or if the
individual is in a permanent coma.
Hospice
Care designed to enable terminally ill people to carry
on as an alert, pain-free life as possible and to manage symptoms
in their own homes or in home-like settings.
Bereavement
The objective situation of having lost someone significant.
Grief
The emotional response to one’s loss.
Mourning
Denotes the actions and manner of expressing grief, which
most often reflects the practices of one’s culture.
Grief Work
A process whereby comes to terms with the loss of a loved
one, readjusts to the environment without that person and is able
to again form new relationships.
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