We all expect to die. We all hope to die when we are old. One of our stereotypes about aging is that older adults think long and often about death.
Cameron et al. (1973) tested this hypothesis and found no differences with age in the likelihood of one’s thinking about death. They did this by interrupting and asking people what they were thinking about in the last 5 minutes - about 20% of men and 25% of women said they had been thinking about death during that time!
Death anxiety refers to our fears about death - it is often reflected in the ways we talk about death.
how do we talk about death?
"euphemisms" include:
succumbed, passed away, was taken, went to heaven, departed this life, bit the dust, kicked the bucket, croaked, passed on, was laid to rest, cashed in, expired, ended his days, is no more, checked out, signed off, breathed her last, returned to dust, went out like a light, ran out of time, brought down the curtain, went on to glory, is pushing up daisies, met the Grim Reaper, heard the trumpet call, is six feet under
as a society, we are very reluctant to talk about death directly - we are a death-denying society - this affects how we confronts our own fears about death, how we talk about death with others, and how we grieve or deal with another’s grief
why is it so difficult to talk about death?
death is more removed from our everyday lives
1. death is for the old:
b) today: biggest killers - heart disease and cancer; of the top 8 leading causes of death in the US, 75% of those deaths occur in people age 65 and over (83% and 70% of the top 2) --> cigarette consumption, associated with about 20% of all deaths is the most preventable cause of death - for people age 1 to 34 accidents or unintentional injury is the leading cause
c) some exceptions - Dr. Kevorkian recently celebrated his 100th assisted suicide, AIDS, SIDS
b) media : by age 15 the average American has seen 13,000 murders on TV
b) we avoid watching caskets lowered into the ground
c) there is an interest in cryogenics
Death anxiety is our fear of death; it is a multifaceted concept and can include fears about the process of dying, death itself, and what happens afterward.
ideal death
we all have our visions of the ideal death - typically it involves no pain, may occur in one’s sleep, at a very old age, in relatively good health with our physical and mental capacities intact - with family conflicts resolved, but most of us will not die as we would like and this is a source of apprehension and anxiety
Leming (1979-1980) has suggested that death anxiety is a multidimensional concept that includes 4 concerns a) the death of the self, b) the deaths of significant others, c) the process of dying, and d) the state of being dead
there are 8 types of death fears associated with our concerns about our death and the deaths of significant others
1) dependencypredicting death anxiety2) pain
3) indignity
4) isolation, separation, and rejection that’s part of the dying process
5) leaving loved ones
6) afterlife concerns
7) the finality of death
8) the fate of the body
age: first off, Erikson suggests that older adults may be more ready to die and hence have lower death anxiety because of their stage of life - and there is support for this, but it’s based on self-report and may also reflect cohort differences; some research indicates that older adults are as fearful as younger adultswhat is death?older adults tend to have less fear than younger people - main fears concern: a long, painful and disfiguring death or death in a vegetative state - isolation, loss of control and dignity
the institutionalized tend to have more fear than those living in the community do
positive attitudes towards death may be associated with greater religiosity, the experience of having worked through others’ deaths, heir life expectations have been met
life threatening illness: it might be thought that those faced with a life threatening illness would make death scarier; but this has not been supported; personality and the way anxiety is measured may have greater predictive power — AIDS patients showed less anxiety when asked directly, but more when asked to complete sentences (an indirect measure)
religion: in some cases it has been found that religiosity has a curvilinear relationship with death anxiety - those with moderate religious commitment experience the most anxiety as measured across these 8 areas; though for those who are religious, they may be likely to fear the process of dying rather than what happens afterward - there is evidence across different cohorts that people tend to become more religious as they age
first of all , there are many types of death
biological death: fetal death, brain death
advantages of slow death by chronic disease:
social death: rituals associated with death - differ across cultures, e.g., for the Kota people of South India one is not socially dead until after the dry funeral, held 11 days after biological death
psychological death: Alzheimer’s
psychological aspects of death
when we focus on the individual and what he or she is going through, we get other insights on death
Kubler-Ross’ (1969) stages of death
focused on the emotional aspects of dying; five stages: denial, anger, bargaining, depression, and acceptance
the theory has been understood to be more rigid than it was envisioned and this has led to some misunderstandings - people have tried to move people through the stages, they have labeled those who don’t show the pattern of reactions as abnormal, or ignored people’s reactions as "just a stage"
middle knowledge (Weisman, 1986) — that in between state between denial and acceptance — when a relapse or other transition occurs, there may be ambivalence manifested by others who "know" that it’s worse than the dying person is willing to admit
Hope reigns eternal even in terminal cases! There is some evidence that those who show a "fighting spirit" and closer relationship with others survive longer; non-survivors are more apt to be self-critical, feel guilt and depression, and fear bodily harm those these results are not always found
how does one’s cultural background influence how we think about our own or others’ deaths?
Besides age, another important in understanding how we think about death is our cultural background - culture includes our death rituals, death taboos, etc.
American way of death: when you’re old and in a hospital or institution, death is often seen as "failure" by medical personnel; socially - fear of "catching" a disease, death taboo - we don’t talk about death with older adults - we expect people to adopt the "sick role" and this can also be seen in the medical establishment
attitude changes — physicians are now more likely to tell a person that they are dying; in a 1961 survey, only 10% of physicians disclosed a cancer diagnosis; in 1994, 95% said they told a patient that they had cancer; greater personal and professional experience are correlated with less fear of death of others — more willing to touch those with terminal illnesses and more willing to work with them.
behavior of medical personnel — implicitly patients are put on a dying schedule or dying trajectory, e.g., "expected swift death," "expected to die on time," "expected lingering while dying," "entry/reentry," and "expected to recover" — medical care was best when the trajectories were followed — even living could be negative when it was not expected
some institutional changes: more focus on palliative care, death education
controlling the timing of death
Advanced directives and DNRs
Problems and concerns:
1) typically not mentioned by doctors, even to those terminal illnesseswith durable power of attorney there are fewer concerns if someone has been appointed before incapacitation and wishes have been discussed; more problems when family members have differing ideas about the course of treatment and when incapacity has to be determined2) talking directly about death may violate cultural norms (e.g., Chinese)
3) people generally don’t like to give up their decision making power
4) changes in health care now make many people afraid they’ll get too little
5) no guarantee that directions will be followed
6) concern about potential lawsuits
Euthanasia and Physician Assisted Suicide
Oregon as an example
http://www.ohd.hr.state.or.us/chs/pas/ar-index.htm
Age-Based Rationing of Care - Ethical or Cost Effective??
3 principles
1) After a person has lived out a natural life span, medical care should no longer be oriented to resisting death.some concerns with this as a practice2) Provision if medical care for those who lived out a normal life span should be limited to the relief of suffering.
3) The existence of medical technologies capable of extending the lives of the elderly who have lived out a natural life span creates no presumption whatever that the technologies must be used for that purpose.
first off, many older adults really want life-saving technologies used on them!
second, sometimes the wrong people may be making the decisions for expensive care (e.g., hospitals [+$$] or nursing homes [—$$])
a brief word on funerals
they’re expensive! It currently costs about $8000 for a burial and $1600 for cremation. It is a business and often one or two funerals a month is all that is needed to keep a funeral home in business.
http://www.acra.org/articles/sacramento/funeral_costs-how_to_survive_the_maze.htm
other information on death and dying