Death and dying

Death occurs when all vital functions of the body including heartbeat, brainactivity (including the activity of the brain stem), and breathing stop irreversibly. Other signs of death include no pupil reaction to light, no jaw reflex (the jaw will contact involuntarily like the knee if tapped with a reflexhammer), no gag reflex (touching the back of the throat will induce vomiting), and no response to pain.

As medical technology improves, physicians, lawyers, religious leaders, and society as a whole must grapple with a changing definition of death. In the 1990s, the advancement in of organ transplant techniques, together with new technological tools to support life even when major organ systems fail, have made it necessary to develop more precise legal definitions of death and forcedsociety to confront new philosophical ideas about death. Challenges for the future include deciding who should receive organs for transplant, which peopleshould be kept on life support and for how long, and when, if ever, terminally ill people should be allowed to choose their own deaths through assisted suicide. Attitudes toward death and dying, perhaps more than any other healthissue, are deeply bound to a person's philosophical, cultural, and religiousbackgrounds, making it difficult for society as a whole to come to a consensus about these issues.

One response to the challenge of deciding when a person should be resuscitated or kept on life support has been the development of a living will. This legal document is executed by a person who wants to control his or her future medical situation. It is legally executed and witnessed by others before the person becomes gravely ill. A living will outlines the conditions under which the person would and would not like to be resuscitated or kept on artificial life support. Such a document is most effective in helping family members makedifficult decisions when it is coupled with an intimate discussion of one'swishes with family members and one's personal physician. However, living wills are not fool-proof, and their requirements and effectiveness vary from state to state.

Assisted suicide, also called euthanasia, is another death-related issue facing Americans as they start the twenty-first century. Assisted suicide allowsa terminally ill person, with the assistance of a licensed physician, to legally choose the time and place to end his or her life. This issue has been brought to the attention of the public primarily by the activities of Dr. Jack Kevorkian, a Michigan pathologist and fervent advocate of euthanasia. Dr. Kevorkian has repeatedly assisted at suicides, then used the courts to challengea patient's right to choose doctor-assisted death. His legal results have been mixed, but he has been extremely effective in bringing the issue public notice. Individual states, lead by Oregon, have begun reconsidering their assisted suicide laws through ballot measures and court actions, but the outcome has in no way been decided. Some European countries, such as the Netherlands, already permit selective assisted suicide.

Death comes in many forms, sometimes expectedly during a terminal illness, sometimes unexpectedly from accident or rapid-onset medical conditions. As of 1997, the three leading causes of death in the United States were heart disease, cancer, and stroke. These were followed by chronic obstructive pulmonary diseases, accidents, pneumonia and influenza, diabetes mellitus, and suicide.

In the nineteenth century, most people died at home, but with the improvements in medical technology, many people in the twentieth century ended their lives in hospitals. Although hospitals provide an excellent level of medical care, they often remove control from the family and do not provide adequate support for the emotional needs of the dying person or his loved ones. In the 1990s there developed concerted public effort to improve care of the dying. Hospice care represents one of the advances made in this direction. Hospices are places where terminally ill people who are near death can live out therest of their lives with dignity and with minimal medical intervention whilesurrounded by loved ones. Patients usually receive medication to relie·e pain and suffering, but no restorative treatment. Some hospice organizations also provide support to family members so that a person may die in comfort at home if he or she chooses.

Death is a great mystery and calls forth a whole range of emotions from boththe dying and their loved ones. However, when a person is diagnosed with a terminal illness and has time to prepare for death, there are a series of reactions common to most people regardless of their cultural and religious orientation. Elisabeth KĂ¼bler-Ross, an expert on death and dying, describes these stages as follows:

  • Denial. The person refuses to believe that he orshe will really die, perhaps insisting the doctor has made a mistake.
  • Negotiation. The person tries to bargain his way out of death by making promises to himself and his god about how he will behave if his life is spared.
  • Anger. Many people become angry with everyone around them because they feel they do not deserve to die. The anger is often tied to fear as they realize that they really are terminally ill.
  • Depression. Many people withdraw from loved ones and need to spend time alone thinking and coming to terms with their grief.
  • Acceptance. Not all people accept their impending death, but many do so with grace and dignity.

Helping Others Cope With Death

Death is traumatic not only for the dying, but for the people who love them.Individual differences in a person's reaction to death are influenced by manyfactors such as their family, cultural, and ethnic background, their life experiences, their previous experiences with death, their socioeconomic statusand their age.

Children under age three generally have no understanding of the meaning of death. They react to the emotions of others around them and often become crankyand irritable. For children of this age, caregivers can help keep routines normal, provide verbal and physical affection and reassurance, and make an effort to cope in healthy ways with their own grief.

Pre-school children between the ages of three and six often think death is reversible, like going to sleep, and that the deceased person will return. Theymay believe that their thoughts or actions caused the death and that their thoughts and actions can bring the person back to life. When the person does not return, they may feel they are being punished for not being "good enough."Preschoolers may ask the same questions over and over in an effort to make sense of death. Likewise in an effort to understand, they may connect events that are not logically connected. Children of this age are very affected by the emotions of the people around them.

Caregivers can help pre-schoolers cope with loss by maintaining routines. Young children can show grief for only short periods, and may escape into play.Play opportunities, and opportunities to draw and talk about their fears anduncertainties are helpful. Children need to understand the physical reality of death, even if they do not understand the emotional or spiritual aspects, and need to be reassured that they are not responsible for the death. Under the stress of coping with death, many children become more aggressive, irritable, and revert to behaviors more typical of younger children. For example, toilet-trained children may revert to wetting their pants, or children who havebeen dressing themselves may insist that they cannot get dressed without help. Although it may be difficult to be patient with these behaviors, they are perfectly normal.

As children progress through elementary school, they begin to grasp the finality of death. They may fear that death is contagious and worry that other people close to them will also be taken away. They may still blame themselves for causing the death. Some children become fascinated with the physical processes involved in death and dying and ask many questions related to the disposal of the body. Children this age still have difficulty understanding spiritual and religious concepts related to death. Like younger children, elementaryage children may become more aggressive, have difficulty sleeping, develop problems in school and with social behavior, and develop unnatural fears or phobias related to death.

Caregivers can help by honestly addressing children's questions, fears, bad dreams, and irrational thoughts. Children of this age are not satisfied with cliches like "don't worry" or "everything will be all right." They benefit from a warm, loving, consistent environment and the opportunity to talk, draw, and play out their concerns. They often seek specific information on why and how a person died in an effort to make sense of death.

Pre-teens understand the finality of death and begin to be concerned about how the death will change their world. They often ask few questions, are self-conscious about their fears, and are reluctant to talk about death, although they may show an increased interested in the spiritual aspects of life and death and in religious rituals. Pre-teens are emotionally fragile, and may showtheir distress with changed behavior, including anger, disrupted relationships with friends, school phobia, difficulty sleeping, and changes in eating patterns.

Providing support for a pre-teen involves encouraging them to express their feelings, if not in spoken words, then in drawing, writing, or music. Many pre-teens act out and become aggressive. They need help in understanding and identifying their feelings and channeling their emotions into productive activities. Many pre-teens regress to behaviors of younger children, while some tryto assume adult responsibilities. A warm, loving, open, stable environment helps them weather their emotional storms.

Teenagers experience death in basically the same ways adults do. They see death as an interruption in their lives and as the enemy. They may react in wildly emotional ways or show almost no reaction at all. Most teens prefer to grieve with their friends, rather than with adults. They may romanticize death and obsess about it. Many question their spiritual values and religious beliefs. It is fairly common for teens who experience the death of someone close tothem to engage in risky behaviors - drive fast, use alcohol or drugs, becomesexually irresponsible, and refuse to make future plans. Many teens are angry and have suicidal thoughts. Others simply close themselves off and refuse to think about the death. Many teens also have changes in their sleeping and eating patterns and show poorer physical health after the death of some one close to them.

Teens can be helped by being guided to a trusted adult (not necessarily a family member) who will listen to them and give them permission to grieve. Theyneed to be guided away from risky behaviors and toward impulse control. Whenthey will talk about their feelings, they need adults who will be good listeners, who will accept their feelings as valid, and answer their questions honestly, even if that involves saying "I don't know the answer." Teens will probably regress to younger behavior patterns, and need to be relieved of the burden of adult responsibilities when possible.

Adults experiencing a death feel a whole range of emotions including panic, shock, disbelief, hopelessness, irritability, isolation, and sometimes even relief if the death comes after a long, painful, lingering illness. They need time to go through different stages of grief. Just as with teens, adults may become depressed, and their physical and mental health may suffer. They also may worry about the practical effects the death will have on their life. For example, their financial security may change. Having friends who are good listeners and who offer practical help when needed can ease adults through difficult emotional times. Many people, both children and adults, find short term professional counseling and grief support groups helpful in understanding their emotions and knowing that they are not going through the grief process alone.

After death, virtually all religions and cultures perform some ceremony to mark the death and celebrate the life and memories of the person who has died.There ceremonies and rituals are very important to the survivors. Occasionally before a funeral can occur, an autopsy must be done to determine preciselythe cause of death. Autopsies are usually done in the event of an unexpecteddeath or where criminal activity is suspected. The idea of an autopsy may bevery disturbing to the survivors.

During an autopsy, a specialist medical doctor called a pathologist examinesthe body and submits a detailed report on the cause of death. Although an autopsy can do nothing for the individual after death, The information it provides can benefit the family and, in some cases, medical science. For example, the link between smoking and lung cancer was confirmed from data gathered through autopsy.

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