Dr. Reem Al-Sabah

Dept. of Community Med. & Behavioral

Sciences

Death & Dying

Leading Causes of Death 2006

Kuwait USA 1 Ischemic Heart Disease Heart Disease

2 All neoplasms Malignant Neoplasms

3 Other heart diseases Cerebrovascular

4 Cardiovascular diseases Chronic lower respiratory

disease

5 Transport accidents Unintentional Injury

6 Congenital/Chromosomal

anomalies

Diabetes Mellitus

7 Certain conditions

originating in the perinatal

period

Alzheimer’s disease

Thanatology: the study of death and dying

What is Death?

Defining death is a difficult.

WHO definition of death:

“Death is the permanent disappearance of all

evidence of life at any time after birth has

taken place” (United Nations, 1953).

Definition of Death

1. The end of life. The cessation of life.

2. The permanent cessation of all vital bodily

functions.

3. The cessation of all vital functions (traditionally demonstrated by an absence of spontaneous respiratory and cardiac functions).

When does a human life end?

The traditional standard, a human being is

dead when the heart and lungs have

irreversibly ceased to function.

In some cases, permanent loss of

consciousness may precede

cardiopulmonary failure.

Medical technologies (e.g., mechanical respirators, electronic pacemakers…etc) has increased the temporal separation between various system failures.

Availability of transplantable organs.

"dead-donor rule": organs necessary for life may not be procured before donors are dead, since the removal of such organs would otherwise cause death.

Two landmark reports helped to generate a movement away from exclusive reliance on the traditional standard:

the 1968 report of the Harvard Medical School Ad

Hoc Committee. A 1981 presidential commission report, Defining

Death. This document included what became the

Uniform Determination of Death Act (UDDA).

Today the US follows the UDDA in recognizing: whole-brain death-- the irreversible cessation of all functions of the entire brain -- as a legal standard of death.

The Uniform Determination of Death Act

(UDDA)

It states that: "An individual who has sustained either:

(1) irreversible cessation of circulatory and respiratory functions, or

(2) irreversible cessation of all functions of the entire brain, including the brain stem is dead.

A determination of death must be made in accordance with accepted medical standards."

This definition was approved by the American Medical Association in 1980 and by the American Bar Association in 1981. Today all fifty states and the District of Columbia follow the UDDA as a legal standard of death.

A person can be legally dead even if his/her

cardiopulmonary system continues to function.

A brain-based standard of death: if a

patient's entire brain is non-functioning, so that

breathing and heartbeat are maintained only by

artificial life-supports.

Diagnosis of total brain failure

Can be made only when each of the following four

conditions has been met:

1. The patient has a documented history of injury that

does not suggest a potentially transient cause of

symptoms, such as hypothermia or drug

intoxication.

2. The patient is verified to be in a completely

unresponsive coma.

3. The patient demonstrates no brainstem reflexes.

4. The patient shows no drive to breathe during the

apnea test.

Islamic definition of death

A Symposium Held in Kuwait 17-19 December 1996

1. Signs which signify death: An individual is considered dead in one of the following two situations:

A. Complete irreversible cessation of respiratory and cardiovascular systems.

B. Complete irreversible cessation of the functions of the brain including the brain stem.

This should be confirmed upon by the accepted in medical standards.

2. Guidelines for diagnosing brain and brain stem death:

The presence of a reliable medical specialist well experienced in the clinical diagnosis of brain and brain stem death and the various implications of such diagnosis.

Prescribed observation necessitates complete medical coverage in a specialized suitably equipped institution.

Second opinion should be accessible whenever sought.

The Dying Process

“A dying individual is a living individual”

All deaths involve a complex interplay of

cognitive, social, and biological processes.”

(Rebok & Hoyer, 1979)

Death is a natural part of the life span.

The dying process is unique to each individual.

Death can occur suddenly or as a process over time. The signs of approaching death mirror a slowing down of the body.

Death is a unique experience for each person coming in its own time and in its own way.

Dying happens to the whole person, not just the body. The individual is affected physically, emotionally, socially, mentally and spiritually.

Even though one is physically dying, the emotional-social and spiritual dimensions have tremendous potential for growth during the dying process.

Restlessness or agitation which may be a result of less oxygen to the brain, metabolic changes or physical pain.

Occasional or constant confusion which may be related to separation from the normal routines of living (may also be the result of a disease, or the dying process).

Levels of consciousness (being alert and aware) may vary.

Mental changes

Sleepiness, with ability to be awakened and awareness of surroundings.

The senses may be dulled and there may be little awareness of what is happening in the environment.

Sleep may be so deep that the dying person cannot be awakened and is unresponsive.

Emotional-social changes

Looking back at one’s life in search of meaning and contributions – life review.

Saying good-bye to people and places, forgiving and being forgiven, facing regrets – life closure.

Acceptance or coming to terms with ongoing losses and eventual death.

The Grief Process- definitions Bereavement : the state of being that results from

the death of a significant other.

Grief : the outcome of being bereaved and involves a variety of reactions that constitute the grief process. (Grief can be the result of loss not involving death such as loss of job, loss of a limb, loss of status).

Mourning: the social prescription for the way in which we are expected to display our grief and often reflects the practices of one’s culture (e.g., wearing black)

Five Stages of Grief (The Grief Cycle)

Elisabeth kübler-Ross

Stage Interpretation example

Denial -Usually temporary shock response

to bad news. –Isolation from people,

even family members, avoiding the

dying person.

“I feel fine. This can't be

happening, not to me!”

Anger Can be expressed in different ways.

Angry with themselves, and/or with

others, especially those close to

them.

“Why me? It's not fair! NO!

NO! How can this happen!”

Bargaining A brief stage, hard to study because

it is often between patient and God.

“Just let me live to see my

children graduate. I'll do

anything, can't you stretch it

out? A few more years.”

Depression Mourning for losses . It shows that

the person has at least begun to

accept the reality

“I'm so sad, why bother with

anything? I'm going to die . . .

What's the point?”

Acceptance It takes a while to reach this stage

and a person who fights until the

end will not reach it. realizing that

death is inevitable.

“It's going to be OK.” ; “I can't

fight it, I may as well prepare

for it.”

Words of Caution Kübler-Ross did not intend this to be a rigid series of

sequential or uniformly timed steps.

It's not a process (fixed and consistent) as such, it's a model or a framework.

People do not always experience all of the five 'grief cycle' stages. The stages are not linear; neither are they equal in their experience. People's grief reactions are unique.

The model is a description not a prescription.

When we know more about what is happening to us or other people’s emotions we can deal with it better.

The dying Role

3 key elements:

1. Practical: tasks people need to arrange at the

end of their lives.

2. Relational: reconciling the dying role with

other roles

3. Personal: finishing one’s life story

Complicated Grief

It is some compromise , distortion, or failure to

of one or more of the tasks of mourning, given

the amount of time since the death.

The bereaved is attempting two things:

To deny, repress, or avoid aspects of the loss, its

pain, and the full realization of its implications for

the mourner;

To hold onto, and avoid relinquishing, the lost

loved one.

Factors related to the mourner that may

increase risk for unresolved grief

Involvement in a “conflicted” relationship with the person who died.

Previous or current mental health problems.

Perceived lack of social support.

Unresolved losses from the past.

A sudden/unanticipated death, particularly when it is violent or random.

The cause of death is an extremely lengthy illness.

The loss of a child.

The perception of preventability.

Types of Complicated (unresolved) Grief

Absent Grief -- as if the death never occurred—complete denial or shock.

Inhibited grief: Less than expected signs of grieving, and is usually manifested in the physical body in place of grief reactions.

Delayed grief: expression of grief some time after the death. A different loss may trigger a magnified grief reaction that is really tied to the earlier one.

Chronic Grief : the bereaved person continuously exhibits intense grief reactions which are more appropriate for early bereavement and last longer than what is considered the normal grief period

Symptoms of Chronic (unresolved)

Grief

Mummification: Preservation of the

environment just as it was when the person

was alive

Identification: manifesting symptoms, or

problems, mannerisms that are the same as

those of the deceased prior to death.

Idealization: recalling only positive

characteristics of the deceased . If carried to

the extreme it can be destructive (unlikely to

invest in other relationships).

Idealization and identification of the deceased

is only a problem if it hinders the person’s

ability to resolve their grief over time.

Other Symptoms of Unresolved Grief

1. Psychosomatic medical illness.

2. Changes in relationships with friends and relatives.

3. Furious hostility.

4. Lack of emotion.

5. Acts detrimental to social and economic existence.

6. Depression, insomnia, feelings of worthlessness,

bitter self-accusation, need for self-punishment.

7. Inability to discuss the deceased without crying or

having the voice crack.

8. Minor event triggers full-blown grief reaction.

Developmental Concepts of

Death

Himebauch A, Arnold R and May C. Grief in children and developmental concepts of death. June 2005 End-of-Life Physician Education Resource Center www. eperc.mcw.edu.

Age group Understanding of death

0-2yrs (infants) •No cognitive understanding of death

•Behavioral regression due to separation

anxiety

2-6yrs

(Preschool)

•Death is temporary and reversible

•Magical thinking

6-8yrs

(School Age)

•Death is final and irreversible

•Not universal or could happen to them

•Somatic complaints may be present

8-12yrs

(Pre-Adolescence)

•An adult understanding of death

•Final, irreversible, and universal

•Intellectualize death

12-18yrs

(Adolescence)

•Also an adult understanding of death

•Strong emotional reactions with difficulty

identifying and expressing feelings