CHAPTER 13

Death and Dying

Lecture guidelines

As pointed out in the opening to the chapter, knowing the facts and figures on mortality provides useful data about a society's overall health. Furthermore, variations in mortality rates across age, sex, and race groups provide important diagnostic information about the social problems existing within a country or culture. Furthermore, with changes in the definition of death, there are many social and ethical issues that have implications for end-of-life care.

Cultural variations in attitudes toward death and death rituals provide another rich source of information to enhance the lecture. Instructors can draw from their own cultural background, travels, and opportunities to learn about death in ancient or non-Western civilizations. Students can also share their own perspectives and backgrounds in class discussions.

The topic of end-of-life care is very new within medicine and even newer within psychology. The AMA and Institute of Medicine have developed extensive documents regarding how dying patients are best treated.

Finally, the area of bereavement is being revisited within psychology as it is recognized that continued attachment to a lost family member or friend has beneficial aspects. Grief counselors are recognizing that it is not necessarily best to rid oneself of memories and emotional ties to the dead person. In this lecture, these issues can be raised with students, particularly those who have experienced the loss of someone close to them.

This is not the last chapter of the book-- on purpose. Although death is the natural ending of a course on adult development and aging, the last chapter will look at the productivity and creativity of older people in the context of successful aging. At the same time, it is worth recognizing that the ability to move beyond the inevitable losses that older adults experience is part of the process of successful aging.

Videos and Films

There are many resources available for instructors to supplement the material in this lecture- so many that it would be possible to spend the entire class time viewing relevant videos. Therefore, the instructor must choose judiciously among the many available options and rather than show one film in its entirety, select the best portions of two or three. The options include documentary materials on PBS and various cable networks in which the topic of death has been treated. More sensationalistic attitudes toward death can also be illustrated by excerpts from news stories describing deaths of famous people (such as Michael Jackson) or stories covering disasters (such as earthquakes, tsunamis, hurricanes, to name a few).

The History Channel produced several interesting documentaries on death, funerals, and cultural practices throughout history as well as web resources (e.g. https://www.history.com/news/7-lost-burial-sites), Returning once again to “The Kominsky Method,” several episodes cover funerals, mourning, and bereavement that could be used to highlight the lecture material.

Discussion questions

What do we know about death?

Which dying trajectory would you prefer to have happen to you and your loved ones? Why?

What does the concept of the dying trajectory add to our understanding of the dying process?

Have you ever been with a dying person? What types of symptoms did that person exhibit?

What is the difference between an age-specific and an age-adjusted death rate? Why are both needed?

What can we learn about a population from knowing its mortality rate?

Why has the mortality rate decreased over the past 100 years? How much more do you think it will decrease in the next century?

What do death rates by age, sex, and race, indicate about a group in the population?

Why is it that people with a college education have lower mortality rates?

What factors lead some poor countries to have lower death rates than other poor countries? What does the mortality rate of a country say about the health and living conditions of its people?

What can be applied from studying mortality rates in other countries to understanding health status in our own country?

Sociocultural perspectives on death and dying

What would it be like to live in a culture in which death was not feared?

How does belief in the afterlife relate to a culture's views of death?

How did medical advances in the 20^th century change contemporary society's views of death?

What does the Death with Dignity movement signify about current attitudes toward death and dying?

Psychological perspectives on death and dying

Do you think the five stages of dying provide a useful perspective for understanding the dying process? Why or why not?

What alternatives would you propose as a way of thinking about the dying process?

Do these social-psychological processes such as legitimization of biography provide a more useful perspective than the stages of dying proposed by Kubler-Ross? Why or why not?

Have you ever heard a person engage in the legitimization of biography? What was that like? How do these processes relate to Erikson's concept of ego integrity?

Issues in end-of-life care

What changes in medical care of the dying necessitated the PSDA?

Will you or have you written an AD? What will or did it include?

How can the experience of dying patients be improved?

What is the difference between palliative care and other forms of terminal treatment?

Bereavement

Do you agree with the recommendation that assistance with mundane tasks such as help around the home and buying groceries can help ease the psychological burdens on the dying and their families?

Why are bereaved persons at risk for physical disease?

Have you witnessed the symptoms of bereavement in yourself or others? Did they correspond to the description provided here? How were they different?

How do you think it feels for a person married 40 to 50 years or more to experience the death of a spouse? Have you witnessed this process in a relative or friend?

How are men and women differentially affected by the loss of a spouse?

Which of the types of loss do you think is hardest for an individual to experience? Why?

What is the role of religion in the bereavement process? Why is this not discussed by current theories of bereavement?

Why did traditional theories of bereavement regard the working through of a death as a necessary part of adaptation to loss? What has caused that view to change?

Multiple choice questions

AgeFeed

Coping with loss tips

AgeFeed recommends that individuals can cope with loss of loved ones through which activity?

1. donating their possessions to charity
2. holding onto your private memories
3. playing their favorite songs
4. digitizing your photographs of them

Coping with loss tips

Based on AgeFeed’s tips about coping with the loss of loved ones, you might want to consider:

1. dedicating a physical space in their honor.
2. donating to others their favorite books.
3. keeping one room of your home as a memorial.
4. leaving seats empty for them at family gatherings.

What do we know about death?

Anorexia-cachexia syndrome

Psychologists working with dying patients need to be aware of the anorexia-cachexia syndrome, the process that occurs when the dying:

1. lose appetite and muscle mass.
2. begin to have somatic delusions.
3. try to wander outside of the hospital.
4. no longer wish to see family.

Dying trajectory

A woman’s 90-year-old grandfather was in vigorous health right up until the time he died as the result of suddenly contracting a virus. His death came so suddenly that she only just made it home a few hours before his death. The grandfather’s __________ fits the pattern of sudden death from an unexpected cause.

1. social death
2. death ethos
3. advance directive
4. dying trajectory

Type of dying trajectory

A dying trajectory involving decline marked by sudden dips in functioning would characterize which type of disease?

1. osteoporosis
2. arthritis
3. influenza
4. coronary heart failure

Age-adjusted death rate

The _______ death rate provides the most accurate statistical measure to index a country’s “health.”

1. crude
2. age-adjusted
3. overall
4. regional

Definition of death

The definition of death was changed by Nova Scotia in 2019 to incorporate which feature of loss of brain functioning?

1. recognize familiar objects and people
2. memory for recent events
3. control and co-ordinate critical functions
4. making appropriate decisions

Uniform determination of death

Which law was passed in the United States to serve as a model for individual states to adopt?

1. Uniform Determination of Death
2. Ethical Standards for End-of-Life Care
3. Patient Self-Determination
4. Respecting Human and Organ Tissue Donation

Age-adjusted death rate definition

Weighted averages of deaths in the population on the basis of age are known as what type of death rate?

1. time-adjusted
2. decade-adjusted
3. age-adjusted
4. crude

Age-adjusted death rate in 2017

In 2017, the age-adjusted death rate in the U.S. (per 100,000) was:

1. 844.3
2. 731.9
3. 821.5
4. 863.8

Hispanic paradox

The fact that individuals of Hispanic origin have the longest life expectancy is referred to as the:

1. ethnic death rate shift.
2. life expectancy effect.
3. Hispanic mortality paradox.
4. immigration quandary.

Age-specific death rate 85+

The age-specific death rate is highest for which age group in the U.S.?

1. 45-54
2. 65-74
3. 85 and older
4. 55-64

Cause of death 25-44

In the U.S., the number one cause of death for ages 25-44 is:

1. heart disease.
2. unintentional injuries.
3. suicide.
4. cancer.

Cancer 25-44

Cancer is the leading cause of death for which age group in the U.S.?

1. 65 and older
2. unintentional injuries.
3. 45-64
4. 15-24

State highest mortality

Which state in the U.S. has the highest age-adjusted mortality rate?

1. West Virginia
2. Tennessee
3. Kentucky
4. Texas

Country lowest mortality

The lowest crude mortality rate in the world is in which country?

1. Bulgaria
2. United States
3. Argentina
4. Qatar

Social class and mortality

Researchers believe that the main reason for the relationship between social class and mortality appears to be due to which factor in lower class occupations?

1. Poor supervision by employers in providing deadlines
2. Insufficient choice in determining pace and timing of work
3. Less time to spend with friends and family
4. Lower salary and longer hours

Never married

People with which marital status have the highest age-adjusted mortality rate in the U.S.

1. Married
2. Divorced
3. Never married
4. Separated

Education and mortality

Researchers believe that the main reason for the relationship between education and mortality appears to be due to which factor associated with higher education?

1. More control in choice of occupation.
2. Better health and lifestyle habits.
3. Greater likelihood of living in cities.
4. Higher familiarity with technology.

Occupation and mortality

A study of mortality rates associated with occupation showed that workers in higher status jobs at the managerial and professional levels were more affected by _____________ than workers in lower status jobs.

1. pressures to perform
2. lack of control over job conditions
3. economic downturns
4. poorer health habits

Air pollution

The role of the environment in affecting health risk factors was demonstrated in a study showing the effect of ____________ on mortality rates.

1. noise levels
2. ultraviolet light
3. climate change
4. air pollution

Fitness trackers

Research on fitness trackers in older women provided evidence that walking __________ steps can help to lower mortality rates.

1. 15,000
2. 4400
3. 7500
4. 10,000

Hip fracture and death

Older adults who fracture their hips may have double the risk for mortality due to which potential complication?

1. chronic respiratory disease
2. paralysis of lower limbs
3. systemic septic infection
4. osteoarthritis

Chronotype and mortality

People with which chronotype, or preferred sleep-wake cycle, show higher mortality rates?

1. early morning
2. late morning
3. evening
4. afternoon

Social networks and mortality

The role of social relationships in mortality was indicated by a study of men showing that network size predicted _____% of the relationship between job status and mortality.

1. 27
2. 12
3. 33
4. 54

Sociocultural perspectives on death and dying

Death ethos

The death ethos of a culture can be inferred, for example, from:

1. belief in the presence of ghosts.
2. whose deaths are publicly celebrated.
3. physical changes preceding death.
4. age distribution of mortality.

How classify death ethos

Which type of information would a cultural anthropologist use to classify a culture’s death ethos?

1. class differences in mortality rates
2. life expectancy by social class
3. the language people use to describe death
4. average cost of a long-term hospital stay

Beautiful death

A cultural anthropologist is search through burial records and photos of gravestones from England in the 1800s. The evidence suggests that the English believed it was noble to die for a cause and that death should be glorified. This evidence is consistent with the ethos of ______ death.

1. tamed
2. invisible
3. beautiful
4. dignified

Book of the Dead

In Ancient Egypt, the ______________ was considered to be the guidebook to ensure that an individual would be guided through the underworld and into the afterlife.

1. Joy of Heaven
2. Sword of Moses
3. Saga of the King
4. Book of the Dead

Tamed death

The death ethos known as “tamed death” was prevalent during which time and place in history?

1. Western Europe until the early Middle Ages
2. Late fourteenth century China
3. Early revolutionary America
4. South America in the 1500s

Invisible death

Which aspect of death and dying in current Western society suggests a prevailing “invisible death” ethos?

1. transferring dying patients to a hospice
2. using cremation instead of burial to dispose of the body
3. crime dramas whose theme involves forensics
4. moving patients from home to hospitals to die

Psychological perspectives on death and dying

Terror Management Theory

According to the perspective known as ________________ Theory, activating a person’s thoughts about death may trigger a set of positive changes, including closer relationships, greater creativity, and more connection to others.

1. Terror Management
2. Life Review
3. Legitimization of Biography
4. Death with Dignity

Death with dignity

The concept of “death with dignity” as it developed in the late 20^th Century implies which approach to dying patients?

providing them with privacy so that they can die alone

extending life for as long as possible with artificial supports

respecting their wishes to control their death

restricting their communication to only closest family members

Good death

A patient in the final stages of terminal cancer writes out her wishes for the amount of time she will be kept alive before entering hospice care. The ability to exert this degree of autonomy is reflected in the concept of the ___________ death.

1. social
2. immediate
3. good
4. accepted

Denial

A woman was diagnosed with terminal cancer but she is convinced that, despite the odds, she mother will survive this disease. The medical staff has made it clear that she only has months left to live. It appears that the woman is in which of the Kübler-Ross stages of dying?

1. bargaining
2. resistance
3. depression
4. denial

Bargaining

In the Kübler-Ross model of the five stages of dying, people who feel that they could change their odds after being diagnosed with a terminal disease by giving money to charity might be considered to be in which stage?

1. bargaining
2. acceptance
3. contemplation
4. denial

Curve instead of stages

Critics of the Kübler-Ross stages of dying believe that it may more realistically be viewed not as stages but as a(n):

1. funnel
2. curve
3. circle
4. pyramid

Awareness of finitude

The “awareness of finitude” described by Marshall involves which process?

1. Reaching acceptance of death.
2. Spending one’s last day at work.
3. Ending a long-term unhappy relationship.
4. Passing the age when one’s parents died.

Legitimization of biography

Making sense of the story of your life prior to death is a process known as:

1. legitimization of biography
2. death with dignity
3. terror management
4. the good death

Advance Directive

Life support orders as part of an Advance Directive would include directions regarding which bodily functions?

1. bladder control
2. digestion
3. hearing
4. mobility

MOLST

What is known as “MOLST” in an advance directive refers to which healthcare team orders?

1. minimal
2. mitigation
3. medical
4. management

Healthcare proxy

A healthcare proxy would be involved in which set of decisions for a dying patient?

1. preferred place of burial
2. type of hospice room decorations
3. clothing to be worn at the funeral
4. specific life-sustaining treatments

Palliative care

It is most likely that a dying patient would receive palliative care in which treatment setting?

1. intensive care unit
2. rehabilitation facility
3. hospice
4. physician’s office

Institute of Medicine

The Institute of Medicine recommends which approach to delivery of end-of-life care?

1. palliative
2. person-centered
3. physician-assisted
4. awareness of finitude

Patient Self-Determination Act

The Patient Self-Determination Act of 1990 included the provision that all hospital patients be given the opportunity to write a(n):

1. death ethos.
2. advance directive.
3. family geneology.
4. terminal plan.

Adverse impact on MD’s

In a study of physicians involved in assisting the ending of the lives of their patients, approximately ____% reported ongoing, adverse personal impact.

1. 5-10
2. 30-50
3. 80-90
4. 70-75

Peaceful awareness

A 56-year-old mother and grandmother dying from terminal cancer expressed to her family her feelings that though she would miss them, she was accepting of her imminent death. The term that refers to her state of mind is:

1. dying trajectory.
2. peaceful awareness.
3. palliative acceptance.
4. anticipatory bereavement.

Bereavement

Stigma of stillbirth

Research on the topic finds that a complicating factor for a mother who loses a child through stillbirth can be her experience of:

1. infection
2. stigma
3. guilt
4. anticipation

Restorative function

A woman is in the process of grieving for her husband of 35 years. She decides to focus her energy on cleaning his clothes and possessions out of her home and donating as much as she can to charity. In the dual-process model of bereavement, the widow’s behavior represents which function?

1. attachment
2. restorative
3. sustained
4. loss

Dual-process model

The dual-process model of coping with bereavement proposes that the most adaptive way to adapt to loss is to:

1. become entirely immersed in one’s feelings about the loss.
2. share one’s reactions on social media.
3. focus only on dealing with the practical consequences of the loss.
4. alternate between restoration and loss as coping methods.

Short answer questions

What do we know about death?

1. What are the medical symptoms that are often present when death is imminent?
2. Summarize four trends occurring in mortality rates throughout the world.
3. Describe the four dying trajectories. Indicate what types of deaths are most highly associated with each trajectory.
4. What are possible reasons for the Hispanic paradox?
5. Which five countries have the highest crude death rate? Which five have the lowest?
6. Name and describe six psychosocial factors related to mortality.

Sociocultural perspectives on death and dying

1. Summarize the timeline of changes in attitudes toward death and dying from the Middle Ages to the present.
2. What are five key indicators of a society’s death ethos?

Psychological perspectives on death and dying

1. Summarize the five stages of dying in the theory of Kübler-Ross.
2. Briefly analyze the processes of awareness of finitude, legitimization of biography, and life review. How are these three processes related to each other?
3. What are the three categories of decisions that must be made in advance care planning?
4. Describe the continuum from life-prolonging to palliative care in end-of-life planning.
5. What are the four principles of end-of-life care supported by the Institute of Medicine?

Bereavement

1. Contrast the traditional views of bereavement with more contemporary views based on attachment theory.
2. What are the two processes proposed to occur in bereavement according to the dual-process model of bereavement?

Essay questions

1. How do mortality rates enhance our understanding of the factors influencing adult development and aging in terms of the biopsychosocial perspective? Be sure to elaborate on the biological, psychological, and sociocultural meaning of mortality rates.
2. Examine historical trends in attitudes toward death and dying and contrast previous views with contemporary portrayals of death. In your opinion, how do these changes in attitudes affect the experience of dying for individuals?
3. If you were a counselor working with dying patients and their families, how would you handle end-of-life decisions?
4. What is your position on euthanasia and physician-assisted suicide?
5. A recently widowed woman sees you in therapy for help in adapting to bereavement. Which theory of bereavement would you use as the basis for your treatment? Why?