Chapter 17
17
THE FINAL CHALLENGE:
DEATH AND DYING
LEARNING OBJECTIVES
After reading and studying the material in this chapter, the student should be able to understand
the following ideas/concepts:
17.1 MATTERS OF LIFE AND DEATH
• Discuss the biological definition of death and the issues it raises.
• Distinguish between active euthanasia, passive euthanasia, and physician-assisted suicide
• Analyze trends in the likelihood of death and causes of death across the life span.
17.2 THE EXPERIENCE OF DEATH
• Assess Elisabeth Kübler-Ross’s stages of dying and the limitations of her view of the
17.3 THE INFANT
• Explain how infants might first come to understand death.
attachment figure and how these responses resemble grief.
17.4 THE CHILD
• Summarize the four key components of an understanding of biological death and when
17.5 THE ADOLESCENT
• Explain how understandings of death change in adolescence.
17.6 THE ADULT
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17.7 TAKING THE STING OUT OF DEATH
• Assess how the hospice/palliative care approach differs from the standard medical
benefit bereaved individuals.
CHAPTER OUTLINE
I Matters of Life and Death
A. What Is Death?
1. Biological definitions of death
a. Biological death is a process, not a single event
i. Basic bodily process can be maintained by life-supporting machines in
people who are in a coma and whose brains have ceased to function
b. 1968 Harvard Medical School committee defined criteria for total brain
death—irreversible loss of functioning in entire brain (both higher centers of
d. Debate over what parts of the brain must cease to function for a person to be
pronounced dead
i. Karen Ann Quinlan famous case in 1975
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ii. Terri Schiavo’s case led to the question of whether feeding and hydration
should be stopped
(i) Suffered cardiac arrest in 1990 (possibly as a result of an eating
e. Different positions on issues of when a person is dead
i. Harvard position is quite conservative (as are laws of most states)
ii. More “liberal” criteria for death would be when cerebral cortex is
irreversibly dead, even if primitive body functions still maintained by
primitive area of brain
f. Defining life and death more complicated when it was demonstrated that at
least some people in a coma or “vegetative states” may have more awareness
2. Life and death choices
a. Euthanasia – meaning “happy, or good, death,” in which process of death is
hastened in person who is suffering
i. Active euthanasia or “mercy killing” – deliberately and directly causing
death (e.g., administering lethal dose of drug to pain-racked patient in late
b. Societal view of euthanasia and assisted suicide
i. Overwhelming support among medical professionals and general public
for passive euthanasia
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vii. Advanced directives can also be written to specify who can make
decisions if ill patient is not able, to decide whether organs will be donated
and other post-death instructions
viii. Oregon became first state to legalize physician-assisted suicide;
individuals who are terminally ill with six or fewer months to live can
request lethal injection (same request is available in some European
3. Social meanings of death
a. Social and psychological differences in meaning of death
i. Societies have evolved some manner of reacting to the universal
experience of death (e.g., interpreting its meaning, disposing of the corpse,
expressing grief)
b. Experience of dying varies by culture
i. Cross-cultural study of 41 cultures found that in 21 there was some kind of
practice (e.g., not sharing food, stabbing, driving from their homes) to
hasten death in frail, elderly individuals
ii. Funeral and grieving activities vary by culture (e.g., laughing to weeping;
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vii. Different ethnic and racial mourning practices; Irish Americans often
believe that dead deserved a good send off as in a wake with food, drinks,
and jokes; African Americans tend to express grief in rowdy celebration;
Jews often have a restrained week of mourning for the dead (a shivah)
then honor the person at one-month and one-year marks
B. What Kills Us and When?
1. Life expectancy at birth – average number of years a newborn is expected to live
a. 2010 U.S. estimate life expectancy at birth is 78 years
b. Increased this century in U.S. to 76 for white men and 81 for white women
i. Female hormones may protect individuals from high blood pressure and
with highest life expectancy (e.g., Japan, Sweden)
2. Infancy is most vulnerable period for dying
a. Current infant mortality rate in the U.S. about 7 per 1,000 live births (lower
for European Americans; higher for African Americans)
b. After infancy, relatively small chance of dying in childhood or adolescence;
death rates then climb steadily throughout adulthood
3. Leading causes of death change across life
a. Infant deaths typically the result of complication of birth or congenital
C. Theories of Aging: Why Do We Age and Die?
1. Two key categories of aging theories: programmed theories of aging (emphasize
systematic, genetic control over aging) and damage theories of aging (more
haphazard and due to errors in cells and organ deterioration)
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d. Humans comparatively long-lived (maximum life: mouse three-and-a-half
f. Many genes likely involved in aging process through regulation of cell
division
i. Genes that become less active with age in normal adults are inactive in
children with progeria—premature aging disorder caused by a
spontaneous (rather than inherited) mutation in a single gene
ii. Babies with progeria appear normal at first but age prematurely and die on
the average in their teens (often due to heart disease or stroke)
g. “Evolutionary puzzle” concerning genes and lifespan
cell aging later in life
h. Possibility of “aging clock” in every cell
i. Hayflick limit – human cells can divide a limited number of times (50
times plus or minus 10)
ii. Capacity for cell reproduction related to differences in maximum lifespan
by species (mouse 14 to 28; tortoise 90 to 125 divisions)
i. Other programmed theories
i. Genetically driven systematic changes in neuroendocrine system and
immune system
ii. Possible that hypothalamus serves as an aging clock, systematically
altering levels of hormones and brain chemicals in later life so that we die
iii. Possible that aging is related to genetically governed changes in the
3. Damage theories
a. Damage theories view aging in terms of an accumulation of haphazard or
random damage to cells and organs over time (wear and tear)
i. Early cells replicate faithfully, late cells show random damage
ii. Biological aging is about random change rather than genetically
programmed change
b. Free radicals – toxic and chemically unstable byproducts of everyday
metabolism, or the everyday chemical reactions in cells such as those involved
in breaking down food
i. Free radicals produced when oxygen reacts with certain molecules within
relationship between metabolic rate and longevity
4. Nature and nurture conspiring
a. Programmed theories view aging and dying as part of natures’ plan
i. Maximum lifespan, Hayflick’s limit, changes in gene activity with aging
suggest that aging and dying are genetically controlled
5. Extending life?
a. Lifespans of 200 to 600 years unlikely, but average age of death could move
toward 112, and individuals at that age may function like modern 78-year-olds
b. Stem cells may allow us to replace aging cell or modify aging processes
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iv. Caloric restriction works by reducing the number of free radicals and other
toxic products of metabolism; it also may alter gene activity and trigger
the release of hormones that slow metabolism and protect cells against
oxidative damage
v. Long-lived humans are rarely obese
vi. Individuals who lived in Biosphere II and who consumed about 1,800
ix. (Exploration box on centenarian (people who live to be 100) secrets)
Checking Mastery
1. Why was Terry Schiavo not dead according to the total brain death definition of
death?
➢ Answer: The total brain death definition of death requires lack of functioning in
2. What would be most likely to kill a 10-year-old? A 70-year-old?
➢ Answer: Children are most often killed by unintentional injuries or accidents
II The Experience of Death
A. Perspectives on Dying
1. Kübler-Ross’s stages of dying
2. Book On Death and Dying in 1969 revolutionized the care of dying people
3. Based on interviews with terminally ill patients, Kübler-Ross detected a common
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conscious awareness
iii. Individual may insist that the diagnosis is wrong or may be convinced that
he or she will beat the odds and recover
iv. Care provider and family member often engage in their own denial
b. Anger – “Why me?”
i. Rage or resentment often directed at doctors or family members
f. Hope, a sixth response that runs throughout the other five responses
5. Problems with Kübler-Ross’s theory
a. Kübler-Ross deserves credit for sensitizing society to emotional needs of the
dying
b. Main criticism – dying process simply not stage-like
i. Many do not display all the stages
distinct stages of dying
6. Second criticism – little attention on how responses or trajectory of responses are
shaped by specific illnesses and events
a. Pattern different for those with slow, steady progression toward death versus
more erratic pattern
7. Third criticism – overlooks influences of personality on how a person experiences
dying
a. People who previously have faced life’s problems directly and effectively and
B. Perspective on Bereavement
1. Key terms
a. Bereavement – state of loss
b. Grief – emotional response to loss
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2. Parkes/Bowlby attachment model
a. Conceptualizing grieving in context of attachment theory (influenced by
Bowlby’s ethological theory of attachment)
i. Parkes, “loss and love are two sides of the same coin”
b. Model of bereavement includes four predominant reactions that overlap
considerably and as such should not be viewed as clear-cut stages
i. Numbness – sense of unreality and shock experienced during first few
c. Research shows reaction peaks occur at times predicted by theory, however,
acceptance was the strongest response at all stages, yearning was the second
strongest response, and remaining responses relatively weak; worst of
grieving process is over in first six months after loss
3. The dual-process model of bereavement
a. Pattern of grief “messier” and more individualized than Parkes/Bowlby phases
suggest
b. Dual-process model of bereavement – bereaved oscillate between coping and
4. Bereavement is complex and multidimensional process involving many ever-
shifting emotions that vary greatly from one person to another and that often takes
a long time
a. Modest disruptions in cognitive, emotional, physical, and interpersonal
functions common (last for a year or so)
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Checking Mastery
1. What are three main criticisms of Kübler-Ross’s stage theory of dying?
➢ Answer: Kübler-Ross’s theory has been criticized because emotional responses to
2. How does attachment theory inform the Parkes/Bowlby model of bereavement?
➢ Answer: Attachment theory, the basis for the Parkes/Bowlby model of
retrieve the loved one and move into a phase of disorganization and despair).
3. What oscillates in the dual process model of bereavement?
➢ Answer: Two types of coping oscillate in the dual-process model of bereavement:
III The Infant
A. Notion of Objects Being and “Missing” to Begin to Understand Death
2. Disappearance of the loved one is the most direct evidence of death for infants,
and at this level Bowlby’s attachment theory helpful
a. Distress similar to symptoms of separation anxiety (e.g., protest loss by
crying, yearning, and searching)
b. Separation from attachment figure same reaction as bereaved adults
Checking Mastery
1. What kinds of experiences in infancy may pave the way for an understanding of the
concept of death?
➢ Answer: Experiences in which people disappear and are “all gone,” as in peek-a-
later understanding of death as a permanent separation.
2. When in infancy would you expect an infant to show grief reactions if a parent were
to die?
➢ Answer: Grief reactions in infancy are not evident until an attachment forms at
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IV The Child
A. Grasping the Concept of Death
1. Young children highly curious about death, yet beliefs considerably different than
adults
2. Children must acquire a “mature” understanding of death that is characterized by:
a. Finality – end of movement, thought, sensations, and life
3. Preschool children
a. Understand the universality of death
4. School-age children (five to seven years) have more advanced conceptualization
of death
a. Understand finality, irreversibility, and universality
5. Understanding of death depends on level of cognitive development, culture, and
life experiences
a. Breakthrough in death understanding tied to transition from preoperational to
concrete operational stage and IQ
b. Understanding of death influenced by cultural factors
i. Christian and Jewish children in Israel who are taught Western concept of
B. The Dying Child
1. Typically more aware that they are dying than adults realize