Developmental Psychology - Dying and Bereavement - CH 16

Summary

This script delves into the multifaceted aspects of death and dying, highlighting cultural perspectives and the clinical definitions of death. It explores the differences between clinical death and whole brain death, the role of bioethics, and the evolving concept of euthanasia. The script also discusses the stages of grief as outlined by Elisabeth Kubler-Ross and the unique challenges of grief in various life stages. It touches on the importance of advance healthcare directives and the grieving process, emphasizing the individuality of each person's experience with loss.

Takeaways

• 🌟 Cultural perspectives on death and mourning vary widely, with different practices like New Orleans Jazz Funerals, Ghanaian coffins, and Catholic funeral services reflecting these differences.
• 🏴 Clinical death is characterized by the absence of heartbeat and respiration, which can sometimes be reversed, unlike whole brain death where the brain has irreversibly ceased functioning.
• 🧠 A glucose metabolism study can distinguish between clinical death, whole brain death, and a persistent vegetative state by measuring brain activity levels.
• 📜 Bioethics has emerged to address ethical questions in end-of-life care, including decisions around ventilator use and living conditions, stemming from cases like Karen Ann Quinlan's.
• 调 Euthanasia is divided into active and passive forms, with active euthanasia involving a deliberate action to end life due to terminal illness, while passive euthanasia involves forgoing treatment.
• 💊 Physician-assisted suicide is a regulated process requiring multiple requests, mental competency, and the ability for the patient to self-administer the medication.
• 🌐 In some countries, there are dedicated programs and facilities for end-of-life care, providing a more structured approach to euthanasia compared to the United States.
• 👵 Grief and mourning are distinct; grief is the emotional response, mourning is the cultural expression of that grief, and bereavement is the state of loss.
• 👶 Children's understanding of death is limited by their developmental stage, with pre-operational children struggling with the concept of death as permanent and magical.
• 🧓 As people age, their perception of death changes, with younger adults often feeling a sense of unfairness when others die young, while older adults may view death as a natural part of life.
• 👴 The death of a parent, particularly for adult children, can lead to a significant loss of support and guidance, with the impact varying based on the child's age and the parent's role in their life.
• 📝 Legal documents like living wills, durable power of attorney for health care, and DNR orders are crucial for communicating end-of-life preferences and ensuring they are respected.

Q & A

How do cultural perspectives on death and dying vary globally?

Cultural perspectives on death and dying can vary significantly. Some cultures may view death as a celebration of the beginning of another life, like the Egyptians, while others may focus on the grief associated with the passing of a person. The script mentions examples such as the New Orleans Jazz Festival, customized coffins in Ghana representing one's life, and a traditional Catholic funeral service, illustrating the diversity in cultural practices surrounding death.

What is the clinical definition of death?

Clinical death is defined as a lack of heartbeat and respiration. It is a reversible state, meaning that people can be brought back from clinical death, which is often referred to as 'coming back from the dead' in common language.

How is whole brain death different from clinical death?

Whole brain death is characterized by an irreversible loss of brain function, where there are no more EEG wave patterns, indicating that the brain has died. This is different from clinical death, which is a temporary state of no heartbeat and no respiration but can be reversed.

What is the role of bioethics in end-of-life decisions?

Bioethics involves ethical questions and decisions about life, including the quality of life and the conditions under which people are kept alive. It plays a significant role in discussions about keeping people on ventilators, living conditions, and individual rights to make decisions about their lives, as seen in the case of Karen Ann Quinlan.

What are the two types of euthanasia recognized in the United States?

The two types of euthanasia are active and passive. Active euthanasia involves deliberately ending one's life due to a terminal illness, while passive euthanasia is the desire to not pursue further treatment, such as stopping dialysis or chemotherapy.

How does physician-assisted suicide work in states where it is legal?

Physician-assisted suicide requires a terminal illness diagnosis by more than one person to prevent mistakes. The patient must make oral and written requests separated by at least 15 days and be declared mentally competent. The patient must also self-administer the dose under the guidance of a healthcare professional.

What are the stages of grief as described by Elisabeth Kübler-Ross?

The stages of grief, according to Elisabeth Kübler-Ross, are denial, anger, bargaining, depression, and acceptance. It's important to note that not everyone goes through all these stages or in this exact order, but these are the most commonly observed emotional reactions.

How does the concept of a 'final scenario' influence how people plan for their end-of-life?

A 'final scenario' is a concept where individuals envision how they would like their end-of-life to be, including their funeral and any specific wishes they have. This plan helps provide closure for both the dying person and their family and is often respected to encourage future generations to honor similar wishes.

What is the importance of a living will and durable power of attorney for healthcare?

A living will is a formal document that outlines an individual's preferences for life-sustaining treatments. A durable power of attorney for healthcare designates a person to make healthcare decisions on the individual's behalf if they are unable to do so. These legal instruments are crucial for ensuring that an individual's end-of-life wishes are respected and followed.

How does grief manifest differently across various age groups?

Grief manifestations vary by age group. Preschoolers may not understand the finality of death and grieve in short bursts. Adolescents may experience a heightened awareness of mortality after the death of a peer. Young adults may feel cheated out of life when they lose a partner. The death of a child, regardless of the parent's age, often results in a profound and lasting grief. The loss of a parent can lead to a significant shift in an individual's support system.

What is the significance of discussing grief and mourning in the context of different cultures and age groups?

Discussing grief and mourning across cultures and age groups helps to highlight the diversity of human experiences and the importance of understanding these differences in end-of-life care, mental health support, and social interactions. It also underscores the need for sensitive and informed approaches to supporting individuals and families through the grieving process.

Outlines

00:00

🌏 Cultural Perspectives on Death and Dying

This paragraph discusses the cultural diversity in perceiving and handling death. It highlights three distinct cultural practices related to death: the New Orleans Jazz Funeral, the custom-made coffins in Ghana reflecting one's life, and the traditional Catholic funeral service. The paragraph emphasizes that death is viewed differently across cultures, sometimes as a celebration of a new life or a commemoration of the one lived. It also introduces clinical aspects of death, such as clinical death (lack of heartbeat and respiration), which can be reversible, and whole brain death, which is irreversible. The use of glucose metabolism studies through PET scans to differentiate between these states is explained, illustrating the brain activity in normal, whole brain dead, and persistent vegetative states.

05:01

🛡 Ethical Considerations and Euthanasia

The second paragraph delves into the ethical questions surrounding end-of-life decisions, particularly euthanasia. It distinguishes between active euthanasia, where life is deliberately ended, and passive euthanasia, where further treatment is withheld or discontinued. The paragraph also covers physician-assisted suicide, which is legal in some U.S. states and requires stringent conditions, including multiple medical confirmations of terminal illness and mental competency. The discussion highlights the importance of individual autonomy in making these decisions and the cultural differences in the acceptance and practice of euthanasia and assisted suicide worldwide.

10:01

🕊 Acceptance of Death and Grief Processes

This paragraph explores the emotional journey individuals go through as they approach death, focusing on the stages of grief proposed by Elisabeth Kübler-Ross. It explains that people often experience denial, anger, bargaining, depression, and eventually acceptance when faced with their own mortality or the loss of a loved one. The paragraph also discusses the concept of 'final scenarios,' personal preferences for how one's death and aftermath should be managed, influenced by cultural norms and individual beliefs. The importance of emotional support during this process is emphasized, as is the recognition that not everyone experiences these stages in the same order or duration.

15:03

👶 Grief and Developmental Stages

The fourth paragraph examines how grief is experienced and processed at different stages of human development. It explains that children's understanding of death is limited by their cognitive abilities, with preschoolers often viewing death as temporary or magical. The paragraph discusses how children grieve in short bursts due to their pre-operational cognitive stage, in contrast to adults' more continuous grieving process. It also touches on the concept of regression, where individuals may revert to earlier stages of grief when reaching milestones that remind them of the deceased, highlighting the complexity of the grieving process across the lifespan.

20:04

🏥 End-of-Life Decisions and Documentation

This paragraph discusses the importance of having clear end-of-life preferences documented through living wills and durable power of attorney for healthcare. It explains the Karen Ann Quinlan case, which set a precedent for the right to discontinue life-sustaining treatments. The paragraph emphasizes the need for these legal documents to ensure that individuals' wishes regarding life-prolonging measures are respected. It also covers the importance of having a durable power of attorney to make healthcare decisions on behalf of someone who is incapacitated, including making financial decisions for their care.

25:05

🚑 Do Not Resuscitate (DNR) Orders and Their Implications

The sixth paragraph focuses on the Do Not Resuscitate (DNR) orders, explaining their purpose and the importance of having them readily available and recognized by medical professionals. It discusses the variability in state regulations regarding DNRs and the potential consequences of not having a DNR visibly accessible during a medical emergency. The paragraph also touches on the cultural aspects of mourning and bereavement, noting that expressions of grief can differ significantly across cultures and communities.

30:06

🌹 Grief, Mourning, and Bereavement: Cultural and Personal Expressions

This paragraph explores the concepts of grief, mourning, and bereavement, distinguishing between the emotional experience of grief and the cultural expressions of mourning. It discusses how mourning rituals can serve as a communal acknowledgment of loss and provides examples of public mourning practices, such as leaving flowers at memorial sites. The paragraph also emphasizes the importance of recognizing and respecting the diverse ways in which individuals and cultures express and process grief.

35:08

👧 Grief in Childhood and Adolescent Development

The eighth paragraph delves into the experience of grief in children and adolescents, noting that grief is not limited to death but can also occur when a loved one is dying. It discusses the impact of developmental stages on the grieving process, with younger children potentially regressing and older adolescents experiencing heightened fear of death. The paragraph highlights the importance of support groups and grief counseling in schools to help young people navigate the complex emotions associated with loss.

40:08

🧓 Grief and Loss Across Adulthood and Late Adulthood

The ninth paragraph examines the experience of grief and loss in adulthood and late adulthood, discussing the unique challenges and emotional responses associated with different stages of life. It touches on the intense grief associated with the death of one's own child and the complex emotions involved in the loss of a parent, particularly for men who may rely more heavily on their mothers for emotional support. The paragraph also addresses the unique grief experienced by individuals dealing with Alzheimer's disease in a loved one, where the person may feel they have already grieved the loss of their parent's identity before their physical death.

45:10

🏡 Coping with Grief and the Importance of Support in Late Adulthood

The final paragraph discusses the coping mechanisms developed in late adulthood, where individuals have typically experienced multiple losses and have a greater acceptance of death as a natural part of life. It highlights the unique challenge of grandparents hiding their grief for a deceased grandchild to protect their own grieving child. The paragraph concludes the course by encouraging students to reflect on the material covered and to seek support and resources to cope with the complex emotions related to grief and loss.

Keywords

💡Death

Death is the cessation of all biological functions that sustain a living organism. In the video, it is the central theme, with discussions ranging from cultural perspectives to clinical aspects. It is explored through various contexts such as the traditional New Orleans Jazz Funeral, Ghanaian coffins, and Catholic funeral services, highlighting the diversity in how societies cope with and celebrate death.

💡Bereavement

Bereavement refers to the state of having lost someone through death and the grieving process that follows. The video discusses bereavement as a culturally diverse experience, emphasizing the different ways societies express grief and mourn the deceased, which is a significant aspect of coping with loss.

💡Clinical Death

Clinical death is defined as the absence of heartbeat and respiration. In the video, it is distinguished from other types of death, such as brain death. Clinical death is often reversible, and the term is used to illustrate the medical concept of when a person might be brought back to life through medical intervention.

💡Whole Brain Death

Whole brain death is a state where the brain has irreversibly ceased to function, including the brainstem. The video explains that this type of death is different from clinical death because it involves the irreversible loss of brain function, as demonstrated by the lack of EEG wave patterns in glucose metabolism studies.

💡Bioethics

Bioethics is the study of ethical issues arising in the fields of medicine and biology. The video touches on bioethics in the context of making decisions regarding end-of-life care, such as the use of ventilators and the ethical considerations surrounding the Karen Ann Quinlan case, which set a precedent for the right to refuse life-sustaining treatment.

💡Euthanasia

Euthanasia is the practice of intentionally ending a life to relieve pain and suffering. The video differentiates between active euthanasia, where a person's life is deliberately ended, and passive euthanasia, where life-prolonging treatment is withheld or withdrawn. It is discussed in the context of legal and ethical considerations, with references to physician-assisted suicide in states like Oregon and Washington.

💡Grief

Grief is the emotional response to loss, particularly to the loss of someone through death. The video explores the grief process, including the stages of grief as described by Elisabeth Kübler-Ross, and how individuals may experience denial, anger, bargaining, depression, and eventually acceptance.

💡Living Will

A living will is a legal document that outlines a person's wishes regarding life-prolonging medical treatments. In the video, it is mentioned as a crucial tool for individuals to express their preferences for end-of-life care, ensuring that their choices are respected when they are unable to communicate them.

💡Durable Power of Attorney for Healthcare

This is a legal designation that allows a person to appoint another individual to make healthcare decisions on their behalf if they become incapacitated. The video highlights the importance of this document, especially in emergency situations or when the person is unable to communicate their wishes.

💡Do Not Resuscitate (DNR)

A DNR order is a medical directive instructing emergency medical personnel not to perform cardiopulmonary resuscitation if the person stops breathing or their heart stops. The video emphasizes the importance of having a DNR order recognized and respected by medical professionals, and the need to have it readily available and properly documented.

💡Grief Counseling

Grief counseling is the process of guiding and supporting individuals who are grieving the loss of a loved one. The video mentions grief counseling in the context of school settings, emphasizing its importance in helping young people process the emotions and complexities associated with death, especially when the loss is sudden or unexpected.

Highlights

Cultural perspectives on death vary widely, affecting how we perceive and handle dying and bereavement.

Different cultures celebrate or mourn death in unique ways, such as the New Orleans Jazz Festival, Ghanaian custom coffins, and traditional Catholic funerals.

Clinical death refers to the absence of heartbeat and respiration, which can sometimes be reversed.

Whole brain death signifies an irreversible loss of brain function, confirmed by the lack of EKG wave patterns.

Glucose metabolism studies differentiate between clinical death, whole brain death, and persistent vegetative state through brain activity levels.

Bioethics has emerged in the last 20 years to address ethical questions and decisions about life, death, and end-of-life care.

The case of Karen Ann Quinlan marked the beginning of bioethics studies, focusing on individual rights to make decisions about one's life.

Euthanasia is divided into active and passive forms, with active euthanasia being more legally questionable in the United States.

Physician-assisted suicide is legal in some U.S. states and requires multiple medical confirmations and patient requests.

Cultural differences in end-of-life care are evident, with some countries offering dedicated programs and locations for a dignified passing.

Death anxiety is a common fear that can motivate behaviors, with men generally having a higher fear of death than women.

Elizabeth Kubler-Ross's work on the stages of grief introduced a framework for understanding emotional reactions to dying.

Grief processing can vary by age, with children experiencing fits and spurts of grief differently than adults.

The concept of a 'final scenario' reflects an individual's wishes for how they want their death and aftermath to be managed.

Hospice care can be provided in various settings and is considered one of the most rewarding careers for those comfortable with death.

Legal documents like living wills, durable power of attorney for health care, and DNR orders are crucial for managing end-of-life care.

Grief and mourning are distinct, with grief being the emotion and mourning the cultural expression of that emotion.

The grief process involves five themes that affect how individuals cope and change throughout their lives.

Transcripts

we end our course with dying which of

course is the end of life

when we talk about dying and death one

thing we have to understand is that we

look at it culturally very different

basically in some cases we use death as

an analogy for something or something

that's good or bad but we do find that

death and bereavement and all those

aspects tend to be very different from

culture to culture as you see in the

pictures down here we have three very

different ways we celebrate perhaps or

we show about death so the first one is

sort of a traditional New Orleans Jazz

Festival the second one you may not have

heard about it's kind of fun to look up

in gana the people have customized

coffins made that represent a lot of who

they are throughout their lifetime so in

this case it was a fisherman who had

that coffin made and then the last one

is a pretty traditional Catholic funeral

service in a church cultures really do

view death very differently in some

cases it's a celebration of the

beginning of another life you want to

think about the Egyptians in some cases

it's a celebration of a life that's been

in some cases it is about grief meant

about the passing of a person

but let's look at the more clinical

aspects of death and you do need to

understand what each one of these is for

clinical death were basically talking

about a lack of heartbeat and

respiration so that's what you see here

in this picture this person no longer

has a heartbeat no longer has a

respiration they would be considered

clinically dead now we bring people back

from clinical death all the time this is

when we say people came back from the

dead it's normally from clinical death

whereas whole brain death is very

different it's a reversible loss of

function basically the brain has died we

don't see anymore

EKG wave patterns and in our next one

we'll look at the difference between a

whole brain death and some of the other

ones

I love this image because what it shows

us is the glucose metabolism study and

people quite often ask me you know so we

got persistent vegetative state we've

got whole brain death we've got clinical

death what are they different well as we

already said with clinical death it's

just simply the heartbeat and the lungs

have stopped breathing but we can get

them back from that when we start

talking about whole brain death or we're

talking about persistent vegetative

state how do we know this it all has to

do with the amount of activity that we

see within the brain so when you look at

these three images that we have here

this first image right here I mean use a

different color that didn't show up very

well use yellow this first image right

here is showing a normal brain now how

they do this is that they use glucose

basically this PET scan which is quite

commonly used in psychology or in the

study of the brain is what we do is we

have somebody take a pill that has a

slight radiation in it

we know it's what the brain eats is

glucose so an active brain like this

first one we would see a lot of lighting

up because the brain is active and it's

consuming energy whereas in this second

image we definitely see whole brain

death because we see no more activity

inside the skull it's a very common

image when we know that there is whole

brain death whereas with a persistent

vegetative state you can see there is

some activity but the activity is very

minor basically what we're going to see

is is that we only have enough activity

to keep the body alive and that's how we

know that you're in a persistent

vegetative state so if you ever want to

question you know how do we know my aunt

or uncle is in a vegetative state they

can do a PET scan and they can look at

the actual brain activity of the person

bioethics is something that has become

more popular you might say in the last

20 years as we began to have more

ethical questions and decisions about

our life and what constitutes a good

life and a bad life bioethics is what's

really kind of occur now bioethics also

is something that we look at when we

talk about keeping people on ventilators

or keeping people in certain living

conditions bioethics is basically an

offshoot of some Court decisions that

were made there was a young lady named

Karen Ann Quinlan

and Karen Ann Quinlan unfortunately took

a combination of medications that she

was given and then went and had a drink

with some friends and went into a

persistent vegetative state her parents

fought to have her taken off the

respirators and we'll talk a little bit

more about her later on but she's the

first one who basically got the right to

do that and that's sort of where

bioethics begins as far as a study is

concerned because we do feel that people

have a right and an individual freedom

here in the United States to make

certain decisions about their lives

which brings us to euthanasia now we do

distinguish euthanasia in the United

States and the two types active and

passive now activists deliberately

ending one's life now one thing we must

understand is that in order for it to be

euthanasia it must be the ending of

one's life because they have a terminal

illness and they're not going to come

back from that

so not all suicides would be euthanasia

if I'm perfectly fine body but I am

depressed and decided to kill myself

that is suicide however if I have a

degenerative disease and I'm at the end

of that generative disease or I have

cancer let's say bone cancer which is

extremely painful and I decide that

toward the end that I am suffering and

decide that I want to eliminate living

anymore then that would be active

euthanasia because I am ending my life

based on taking something on I've made

this clear statement but I also have no

way of coming back this is a like I'm

gonna be able to get back from bone

cancer where passive euthanasia is

basically my desire not to get to new

treatment quite often older people who

may have kidney disease decide that they

are going to stop dialysis basically

without dialysis they're going to die

but they say you know what I'm 89 I'm

really tired

I don't want to get this blood done

anymore I'm going to die soon anyway

and I want my last you know a few months

to be pleasant without having to go for

dialysis every day so in that case they

give up available treatment a cancer

patient who decides not to continue with

chemotherapy because they realize at

this point they're not going to get

better

that would be passive euthanasia now

path of euthanasia is legal pretty much

everywhere around the United States

active euthanasia that one is a little

bit more questionable on if you are

allowed to do that or not now a lot of

people will go ahead and do active

euthanasia anyway basically they'll save

up medicine

they'll do other things that will help

them pass away but it isn't legal in all

the states

which brings us to position assisted

suicide

now Oregon and Washington were sort of

the first two states and I believe

there's some more states since then that

have done this now what we talked about

with physician assisted suicide is that

you had to have a terminal illness and

basically it has to be by more than one

person who has determined this so it's

sort of like one person doesn't make a

mistake and tell you you're terminally

ill and you know then you go to another

person who says oh no it's not really

that we can do something for you so it's

not so easy to actually get into a

physicist suicide situation so what we

do know is that generally it requires

that you have to oral requests and there

has to be separate by 15 or more days

you have to make a written request and

you also have to be declared mentally

competent which means that I can't go in

and say hey grandma is really bad and I

think that you know we should assist her

in suicide though not gonna work the

person has to request it themselves

now some people can request it early on

so that as they get worse and they

become to the point where they can't

perhaps make an oral request the request

is already there so again people with

bone cancer may get to the point where

they can't even parley speak but you

also have to give the person the right

to self administer the dose basically

somebody else can mix up the dose for

you but you have to have enough strength

to administer to yourself and there's

all kinds of devices that are used for

that there's a question bill about that

too as far as are we making people

perhaps euthanize themselves earlier

because they're afraid that they won't

be strong enough later on but this is

not a class to debate those type of

things more states in Oregon and

Washington have allowed these types of

situations also do understand because

Florida is a very international area

with our tourism that assistance

physician assisted suicide which is we

call it is not uncommon in the world in

fact we tend to in the United States

view it much less as an option than

other places

many countries have very dedicated

programs like we have a hospice program

they have programs assisted for this

type of situation where they have

doctors and nurses who are all set up

they have whole care systems for this

some people can in some countries they

even have locations where let's say that

I've decided that I've always wanted to

see the ocean or the sunset over the

ocean when I died and they literally

have homes

where a person could go and and have

this they almost always have doctors or

a physician or a nurse or someone who's

on staff there so that when the dose is

administered they can make sure that it

goes correctly generally funeral

arrangements have already been made so

the funeral directors already there and

the family does little to nothing except

for be there for the person who is dying

and for each other there's people

already around to take care of all the

other aspects of that so in the United

States is a little bit different don't

be surprised if you're dealing in a

hospital setting where people are asking

for those types of services if it looks

like that person is going to be close to

death it is just simply culturally a

different way to view death

now what is interesting is that through

our lives we're going to look at death

differently so when we go from formal

operation and remember according to PJ

this is when we have abstract to our

post formal operation this is when we

are in our young adult we tend to get

more emotional about death in our formal

operation it's a little bit more

abstract we've got the concept of it I

mean concrete operational death is death

and they can sometimes be what we might

feel very cold but it's not that as much

as it's much more black-and-white Dead

is dead

the dog is dead that's it and in the

formal operation they suddenly go dog is

dead do they go to heaven do they get

all these wonderful things you know what

happens to them and post off or post

formal operational more are these

thoughts of our even our own death may

begin to occur

now as we get older and we call these

death trajectories different things can

help us sort of begin to deal with one's

own death and begin to think about one's

own death now what's interesting is is

that there's sort of two ways of looking

at this diseases such as cancer which

have terminal phases and we know that

death is coming to us quite often help

us as patients or as the the person

who's dying actually prepare for death

it helps the family prepare for death a

survey taken not too long ago looked at

which ward at a hospital is the least

stressful ward to work on and oncology

actually turns out to be one of the

least stressful for nurses primarily

because it is an instant death people

though it's coming sometimes you get to

know the patients you get to know the

families and as you work through the

process there's sort of an acceptance of

this process and acceptance of the death

coming whereas other ones in which the

death could occur at any time heart

attack

tend to be much more stressful for

people because when Johnny left he was

perfectly fine and now johnny is dead we

didn't have any time to prepare for this

the families are much harder to accept

and deal with this because they didn't

have that time to adjust

it can also be much harder on the

nursing staff because these patients are

often asking questions like why did it

happen could we have done something else

but whereas with the cancer the the

longer-term deaths we've had that time

to sort of work our way emotionally

through those aspects

one of the sort of leaders you might

want to say in looking at death is

Elizabeth kubler-ross

now what's interesting is it depends on

sort of what you read about kubler-ross

and how old it is on how people view it

I think our book talks about her stages

of dying what is interesting is that as

she moved on further it wasn't so much

about the stagings of dying and you'll

see in the next slide it's really more

about the stages of grief that she talks

about the interesting thing that is that

up until she came along nobody really

looked at dying people now what she did

she did these interviews with terminal

patients sometimes they didn't know they

were terminal but what she did find is

that there were five distinct emotional

reactions quite often these are taught

as if everybody has to go through each

one of these in exact order the truth

this is that you that she did not

believe that she did not believe that

everybody went through all of these they

didn't go exactly in this order what she

did produce is what she thought was the

most common order and what I say for the

students who are gonna go into nursing

learn the order and learn it in a

kumbaya way there was something that you

do need to know for your exams and

nursing but in principle it doesn't mean

that it has to happen in the order that

we're going to talk about

so the coop lacrosse grief cycle which

is what it's really much more considered

these days is that we will start with

sort of a denial and what we're talking

about is sort of an informational

communication aspect of the grief

process right here and that's what we're

seeing down here is that in this section

right here what the person who is dying

or his family members first maybe no

this is not right this can't be true I

don't believe it

now what we do want is for people to get

a second opinion we never want someone

to not get a second opinion

but the same point they've got to get

out of denial because if they keep

denying then they're not going to be

able to work through so this process and

the second one that she tended to find

happen as we're going down in sort of

this grief cycle is anger we get

frustrated we get anxious we we're just

pissed off then we get down to sort of

this area right here we call bargaining

and we really need is more emotional

support and the bargaining is trying to

find meaning and tell one story and make

connections

quite often bargaining may also be where

you see people saying if I can live just

to do this or if I can just reach this

so I just want to get to my son's

graduation or I just want to see my

daughter get married I mean how many

times have you heard about somebody who

dies right after a right before some

major event in the family's life and

that's sort of the bargaining phase it's

they're helping themselves get there but

they need a lot of emotional support

that emotional support really does

continue through sort of the depression

stage now depression is the one that

probably shows up most often in

different locations quite often after we

make the bargain we can get a little

depressed overwhelming this hostility

which is why sometimes we really see

that bargaining will kind of fall over

here also but depression is not uncommon

now what kubler-ross found was that

people who were able to get to

acceptance basically we explore our

options were

ready to move on not that we're ready to

die but we've kind of accepted that

we're going to die then what we're

really finding is people who are not

satisfied with life but they're having

an easier time transitioning and so is

the family so I always like to tell the

story of my friend who died of breast

cancer unfortunately she had it twice

and the first time around she battled it

fought it you have to go five years to

be considered to be cancer-free four and

a half years in it comes back and it

came back

roaring Lee it didn't just a little bit

so we think it may have been sort of

inching back a little bit throughout

those four years but not caught it had

gotten up into the brain so this time

around even though she was fighting a

very heart of battle it did come down to

the fact that she was not going to make

it this time the cancer was going to be

overwhelming but yet her birthday was

coming up and so she had accepted that

this time she wasn't going to make it

through this that you know she wanted to

have the quality of life she could have

with her children and she really did

want to try to make it to her son's high

school graduation but as her birthday

came up it was kind of a question of

what do you do she's dying she's not

gonna be here for a second birthday do

we celebrate it do we not and so we

talked to her we said you know what

would you like to do for your birthday

pretty much you get anything you want

this year and she came up with I thought

a really interesting thing and we'll

talk about final scenarios she said she

wanted to have a celebration she wanted

it to be a huge celebration and the

theme was junk food

she said it don't matter what I eat at

this point and so we had every kind of

junk food you could think we had an ice

cream bar we had chip bar we had candy

bar we had cakes we had pies I mean if

you named a junk food it was there and

we invited everybody and their brother

what you were to bring though was a

photo of you and her if you had one and

a story about that photo and if you

didn't have a photo of you and her you

were to bring just a written little

story about something she and you had

done together and when they arrived that

there were all these I'm gonna say

cardboards but they're things like you

have four science projects and you were

to post them on one of those boards and

those boards went to her children so

that after she died her children would

have all these wonderful stories about

her that she wasn't going to be able to

tell and we put him sort of in an age

group in her teens or 20s and and this

on now this turned out to be one of the

most fun things that I can remember

doing because she had accepted it and so

people coming in she knew this was gonna

be the last time she was gonna see many

of them and for many of them it was

gonna be the last time they saw her but

it was a very friendly atmosphere and

lots of people were seeing people they

hadn't seen in a long time

and people didn't stay for you know

terribly long time it's maybe a half an

hour but they were required to eat

something junky even the most fit person

had to eat something junky and we

laughed we cried it was a wonderful time

but she had come to acceptance and

that's what kubler-ross said if you can

get somebody to that point if we can

help with their emotional support and

that guidance then we get to acceptance

and sort of we know this is going to

happen but it doesn't happen out of fear

doesn't happen out of anger it happens

sort of with acceptance and in this plan

to move on so everybody got some closure

that day people who had only worked with

her a little bit got an opportunity to

come by people who hadn't seen her in 10

years got to come by and that is what

she's talking about that if we can get

people to acceptance that this grief

that in only the dying person has but

also their family and allows that

opportunity of you want the best word I

can say is closure

which also then brings us to sort of

death anxiety most people do have this

fear of death anxiety and Freud and many

psychoanalyst said that really this

death anxiety is what tends to motivate

us to keep us going because we have this

fear it's a primary motivator of all of

our behaviors to try to keep us from

dying now when we're younger yes people

take much more risks and we've talked

about younger people have a less of a

version because they think of themselves

as having lots of time and of course the

older we get then the less time we think

we have it is interesting that men have

more fear but women have more fear of

the way they die

as somebody is dying as I talked about a

little bit with kubler-ross what we know

is that people will begin to make

decisions about the formal management of

what they want knowing with their body

but religious services and things like

this people in their head have sort of

this final scenario what what's

everybody gonna do once I'm done and the

older we get the more likely people will

want to talk about that it can be

uncomfortable for others but as I always

tell people my mother has has threatened

me she said when she dies she is to be

buried next to her father and not her

mother and if I put her next year mother

she's going to come back and haunt me so

you know people they have a way in their

head of what they see they want people

to do and that's sort of this final

scenario so you know most of us kind of

see something now it does change there

in our lives quite often what we see

when were younger may be different then

as we get older but we do tend to try to

do what the person asks so one of the

questions this is why is that that we

try to accommodate this person who is

now dead with their final scenario and

what research found is that the reason

that we go out of our way to do these

things so somebody wants to have their

ashes in Alaska and we find some way to

get there it's because in a way what we

want is for the next generation to do

what we want so if they can see that

we're doing what the generation before

or wanted if I take care of my parents

the way my parents have asked me to take

care of them then my children will take

care of me the way I've asked them and

so it becomes sort of this unwritten

script that you know we have this

responsibility to adhere to the person's

last wishes if we want our own last

wishes to be taken care of

we do have to talk about and foremost if

you already know what hospices Hospice

can be done in your own home hospice can

be done at a nursing home hospice can be

done in a hospice location I've talked

to many hospice nurses over the years

and they do say it's one of the most

rewarding careers that they've had as

long as you have the ability to deal

with death because let's face it these

people are going to die but that you

quite often become acquainted with the

family there's lots of good feelings of

the help that you're giving to these

families so it is an area of Nursing for

many of you you might want to look into

and for those of you who are going to go

into health service administration it

may be an area that you want to look

into as far as working as long as you're

comfortable with the concepts of death

the other thing that your book goes into

and I think this is important that we

understand are how we make our

intentions known for end-of-life now a

living will is basically a statement of

how you are willing to be kept alive so

I talked a little bit earlier about

Karen Ann Quinlan now Karen Ann Quinlan

as I said was a young woman she was in

college actually she it was very very

nervous she had gone to her doctor and

said I'm having a lot of anxiety and a

lot of nerves I've moved away from home

and he which was rather calm at the time

gave her a prescription for

tranquilizers and so that night she was

going to a party and she was very

anxious so she took the tranquilizers as

she was supposed to she went to the

party she had some drinks didn't get

overly drunk had a few drinks but as we

now know tranquilizers and alcohol do

not go together

and unfortunately she went into a

vegetative state now her parents fought

a great deal because she basically had

no brain activity but she was being kept

alive by machines and tubes and they

kept saying this is not what Karen would

want Karen wouldn't want to live like

this Karen wouldn't want to live like

this but yet they weren't allowed to

turn off the machines because at that

time that was considered to kill

somebody and doctors had no permission

to do that so they are the ones who went

to court who fought for the right to be

able to take the machines off of their

daughter with the Contin with the caveat

that if she breath could breathe on her

own then of course she would continue to

breathe but if she didn't breathe then

she would be passing away the way that

nature had designed so from that moment

on we basically had the concept of

living wills now living wills are formal

you need to get them done formally I

would always make sure that you have

them at all the hospitals and they're

always asked about them the other one

that people don't know a lot about is

this durable power for health care now

it's a power of attorney for health care

in that there's a power of attorney and

then there's a power of attorney for

health care they are very different for

the power of turn of health care you're

only talking about health care decisions

whereas a regular power of attorney it's

all decisions so make sure

that if you go to do one of these that

you get the one for health care my

ex-husband was a paramedic and I always

talk about this because of the many

times he's had to deal with this anybody

who's got kids there's a good chance

that you do not have this durable power

of healthcare of attorney for your

children and you probably don't think

much about it because you think well if

something happens to me my husband or

wife will go ahead and take care of the

kids if there's an accident of some sort

but as he points as he would point out

to me quite often in a car accident

everybody was in the same car mom dad

kids and the parents died or one parent

dies in the car accident the other one

is completely incapacitated and there's

nobody available to make decisions for

the children because the two adults that

are directly related to those kids are

incapacitated this can delay services to

the children if you do have kids you

really might want to think about getting

with these durable powers of attorney

for health care with somebody who is not

normally with you all the time

after 911 this was also became an issue

because a lot of people were not

available

so 911 happened and people had to go

pick up kids and other things like this

and it becomes a little bit of a mess we

don't think about the fact that we may

not always be available for our children

you can make these very specific this is

just sort of a general one right here

you can even have how long before it

kicks in and you can even say exactly

what they can and can't decide you can

have in there when it would actually no

longer be valid so in my case when my

child was younger I had one that said

that if you could not reach me within 20

minutes that the durable power of

healthcare would kick in and that what

you did reach me that the durable power

of healthcare no longer was valid so

that way if anything had happened to me

or I'm at school and you're unable to

reach me my child isn't waiting for

someone to be able to make it this

healthcare decision now they

the good thing about this especially if

you have older parents and you can get

durable power of attorney for health

care is that if something does happen to

the older parent you can begin to make

some healthcare decision for them but

you can also pay their healthcare bills

which becomes an issue when they don't

pay their bills so it would allow you to

be able to go to the bank you have your

durable power of healthcare attorney and

you could show a bill and you could get

enough money perhaps from their accounts

to pay for those bills or that

medication but you can be their advocate

especially if they're not thinking quite

straight because of certain medications

that are kicked in at the time but it is

something you should look up I do

believe I have a link to one in our

school here talk to you don't have to

have a lawyer to fill one of these out

if you want to talk to a paralegal that

might be good too but really considered

to do that now most people know do not

resuscitate is a DNR

the only thing I do recommend again this

is from having a paramedic as a husband

is that you have to understand that each

state has slightly different rules for

how DNR is work but understand that

what's a paramedic arrives at your door

if they start resuscitation they cannot

stop the only one who can then stop

would be the hospital so if you have a

DNR you need to make sure that those DNR

s are available and can be shown to the

paramedic or to whoever arrives at the

scene again it varies state by state

some states a photocopy would work some

states a photocopy does not work it has

to be the original one that has

basically arrays sealed so if you get a

DNR you can get more than one copy at

that time with a raised seal so you

might want to get four or five they're

usually not much more money there you

said five bucks each you want to make

sure they're at their hospital not only

at your home but one of the things that

I thought was interesting is that he

always said you should have one in your

car and you should label in your car

where it is so people at DNR's would

have put DNR in glove box and they would

look for the DNR and if it was in there

they would not start the wrist

resuscitation but if they didn't see a

DNR even though the person was yelling

this person has a DNR if they did not

see it they would start the recitation

and he said he couldn't tell me how many

times people were yelling at them

because they weren't supposed to do it

but they didn't have any paperwork

that's they shouldn't do it so he had to

start so think about that you want to

keep them at the locations that you are

most likely to be at if you have a DNR

or you know somebody who has a DNR

as far as grieving and mourning and

bereavement are concerned these three

words really do talk about different

states sober even is the state that

we're in grief is the actual emotion and

mourning is basically the way that we

show grief

now what's mourning what is interesting

is is that within a culture we tend to

show grief in the same way so I have

these three images down here and the

first one is after the Dayton Ohio

shooting and you'll notice that there

are lots of flowers and things left by

the door we see colby bryant and after

he died people left flowers and things

and then the other one is princess diana

and while it's england england is a lot

culturally like us and this is an image

after Princess Diana's death so this is

sort of a way we show mourning it's a

way we show our grief quite often for or

unusual or people is through this

process now this is going to be

different for different countries and

different locations again one thing I

was like to point out is that we are a

rather international area here in

Florida so when we have someone who dies

who may not be from this country

understand they may show mourning in a

different week a different way than we

show mourning

however grief will be pretty much the

same around the world and as you saw

grief

generally within six months is where it

is the peak but don't forget it can last

a lifetime

so let's talk a little bit more about

the grief process and how we cope one of

the things that can be really hard is to

acknowledge the loss and reality and one

reason they say the grief is peaks at

six months is that that's about when we

sort of finally process that everything

is done all the loose ends have been

tied up it generally takes us a year for

most of us to get through our first

grief process the reason we say years we

got to get through that first

Thanksgiving that first Christmas that

first birthday that first holiday two

years sometimes also is common but one

to two years for most people is where

our deepest grief and after that grief

may linger off or grief may only happen

on specific days so if you had a mother

who died you may feel grief every time

you reach her birthday but on a

day-to-day basis after a while that

grief isn't there

so with grief what we do know is that

there's sort of five themes of of grief

you know how do we deal with people how

it affects us how it changes our lives

the narrative I think this one's always

interesting this survivors stories about

the decrease the decrease the deceased

so quite often when you have your weeks

afterwards hearing those stories that

people talk about and the kind of

relationship that was there and the

survivors tied to them these are the

five sort of themes of grief as we move

through that process so those of you are

going to go into psychology you'll study

a lot more about this in your death and

dying course for those of you are in the

mental and the physical health fields

the clinical health fields understand

that these are sort of the five things

that you're going to see as you talk to

the family members who are left over

after somebody dies or is about to die

don't forget grief isn't just after

death because kubler-ross noticed that

people begin to go through the grieving

process even as their loved one is

beginning to die

then we're going to look at and your

book sort of then tackles the grief

process or with each generation now this

week I have asked you to go back and

listen to a podcast that specifically

does childhood I really really encourage

you to listen to it you might need a

tissue but it really tackles the issue

of grief and childhood because they do

go out to the sharing place which is a

grief support group for children and to

actually hear children talk about it now

one of the things that people tend to

think is that preschoolers don't

understand death and we do know that

they understand death but they may think

of death as being temporary sometimes

you hear them say well they think death

is magical and we don't really mean

magical what they may not understand

because remember we're talking about

preschoolers these are pre-operational

people the complexities of death so if

we've talked about going to heaven

heaven seems magical it's like this

magical place we see TV shows where

things have gotten hurt and comes right

back they may not understand the

finality of death is what it is also as

we know that children who are grieving

they tend to grieve in fits and spurts

meaning is is that you know when you

have a five-year-old that most that they

may be able to grieve about that death

is five or six minutes and then they go

playing for five or six minutes and then

they grieve again for a little while

they don't grieve like adults do which

is constantly and all the way through so

she said pre-operational they'll tend to

be thinking everyone's sort of thinking

the same thing and they ask you don't

understand sometimes why when they say

hey let's go play and you say no I can't

them too sad they don't understand why

you're sad because they're not sad at

the moment and then a few minutes later

they come out and they're very very sad

and maybe you're cooking dinner and

they're like why can you be cooking

dinner you should be sad because they're

sad now so it's a little bit harder

sometimes for adults for these for us to

go with our kids as far as your pattern

is concerned because it's more of a fit

and stop

or where the adults it's gonna be more

steady the other thing is is that

there's a shift between the children are

in pre-operational versus the concrete

operational thoughts may the concrete

operational thoughts are much more

black-and-white no dead is dead and

they'll equate the death of their cat

and the death of their father almost in

the same way the older we get generally

the better we are at coping things

meaning is that we have a we have a

sense of control over ourselves in the

first place and so we have a better

sense of what we may need to do to work

through our grief where younger children

may need more time to learn to work

through their grief also as you will

learn children will regress so if my mom

let's say died when I'm young then as I

hit these milestones in my life I quite

often may regroup because I would think

when my mother loved me doing this I

would be so great if my mom was here for

this I would really want to tell my mom

how I had done that

so this rege reeving process quite often

happens and people don't always

understand why when the mother may have

died when they were 6 or 7 and now

they're 26 and they're regrouping

they're like basically I haven't gotten

over it and it's not that as much as

they grieve the fact that that person

isn't there to experience these things

with them so that grief will come back

and remember we said everybody grieves

differently

so if we get into adolescents what we do

find and remember adolescence is between

12 and 20 years old that most have

already experienced some death either

family member or a friend quite often a

grandparent by now has died this first

experience of death can be severe if

they it's unexpected if we know a

grandparent is sick we've gotten time to

kind of come to it

but if it's a sudden death then that may

be much harder for them especially if

they are that younger adolescent so

let's say that 10 to 14 year age and

they lose a parent there what's

interesting is is not only do they sort

of cling to their parent but they're

friends now have experienced that death

up until then I may not have thought

about the fact that my parent could die

and now my best friend's parent has died

and I may feel grief for not just my

best friend's parent who I know but I

suddenly become very aware of the death

of my own parents and may become a

little bit more clingy or a little bit

more where are you going you can't do

that that's dangerous because I hadn't

really thought about the death of their

own parent until this occurs so it is

very interesting on seeing how people of

the younger adolescent age handle this

it's also one of the reasons why they

have grief counselors at schools after

the death of somebody in the school

because the grief that somebody may be

feeling may not be about the death of

the person who died at school but may

actually be about the fact that they

finally understand what death really is

because remember until we have abstract

thought a lot of this is very iffy and

even the concrete people may name they

may not be quite emotionally there and

so it's a little bit harder for them to

process but if they do process it then

they may have develop a lot of fear all

of a sudden about other people dying

because I hadn't really thought about it

before

in adulthood we do know that we have a

slight difference in viewing it as a

young adult versus an older adult as a

younger adult we quite often think that

especially if the person who dies is a

younger adult they've been cheated out

of life they had so much more to do we

quite often don't feel that way about

grandparents who've had a good and long

life because we have accepted for most

of us that death is part of life but we

feel like you shouldn't die until you've

had this nice long life so as we see

younger people die or we see somebody

maybe even their 30s die we can feel

that that person's been cheated but

losing a partner when you're younger is

actually a little bit more difficult

than losing your partner when you're

older it is sort of quite often

unexpected grief but also it can take a

much longer time for that person to get

over that grief or basically I don't say

get over but move beyond that grief

within their lives so you may see

somebody who's 40 who loses a husband or

a wife and you know within a year or two

they're out dating again and doing

things where she's somebody who's 28 or

30 one who loses a partner they may not

be ready to date again for five or six

years because they're still dealing with

the grief of that connection with that

person

with the death of one's own child

meaning is that you're an adult but your

child has died it's pretty simple this

grief may never go away this grief and

mourning is so intense that we know it

quite often lasts a lifetime what we

have to also understand is that this

grief process not only holds for a child

that we have lost who is alive but it

can also hold for miscarriages it can

also hold for still births it could even

happen when you have been given the

wrong gender for a child so let's say

you went in you had a sonogram and you

were told that you're gonna have a boy

in your head what's happened is is

you've gone home and you have a whole

life planned out for this boy you know

here's Jack and when Jack is born we're

gonna have all this stuff and he's gonna

play t-ball and then we're gonna do this

Jack and we're gonna do that with Jack I

didn't go back a month later and they do

an x-ray and they go oh I guess that was

a pinkie not a penis and Jack is really

a girl

and so now jack has become Emily and

people don't always understand that

there's a mourning for Jack see Jack was

real in their head

Jack was somebody who they were going to

have a life with and it's not that they

don't love Emily and it's not that they

don't want a girl it's just that they've

lost Jack and so there may be that

period of time where they're sad about

that and they're not sad about having a

girl they're sad because they've lost

Jack in fact many people say that once

they have in their heads sort of had the

scenario of who Jack is all that that if

their second child is a boy

they can't name him jack because Jack is

gone Jack died in a way this also

happens to parents who are going to

adopt a child by the way they have this

whole adoption all set up they've got

this whole thing in their head exactly

how it's gonna be they maybe even set up

a nursery room and then the adoption

falls through or the parent

the biological parent decides to keep

the child they will also go through a

mourning period of a loss of a child you

can talk to them 10 years later even if

they've adopted another child they will

still talk about the child that they

lost because that was their child in

their head they had this child they were

raising this child and they want to know

what happened to that child so there's

still a loss just like somebody who may

have biologically had a child who died

in an utrom

the death of one's own parent can lead

to different types of emotional stress

for ourselves it doesn't matter how old

you are when your parent dies what's

been lost is sort of this support and

guidance system that you think of I've

heard six-year-olds who've lost both of

their parents maybe one a little earlier

one a little bit later and when the

second parent dies they'll look at me

and say I'm an orphan now and you don't

think of six-year-olds being orphans but

they are because they no longer have any

parents alive and there is quite often

the struggle of what do I do now who do

I turn to you know where am I going to

go because no matter how old you are

your parents have always been older and

had more experiences and things

six-year-olds who have 80 year old and

85 year old parents will still talk to

them and say hey you know what would you

think Baba and that person isn't there

anymore so that loss is very significant

that second parent loss it is

interesting that some social scientists

have found that men who lose their

mothers is the hardest loss of all the

different combinations we can think of

with parents and that's primarily

because men have depended quite often on

their mothers as being the emotional

support in their life they're the place

who I could go and talk about feeling

bad about something or feeling anxious

you might want to say I may not want to

tell my dad this I mean I want to tell

my friends this because that might make

me look a little less strong than I am

but my mom I could always tell and so

when the mother dies they've lost

perhaps their one emotional support that

they had where they felt comfortable to

be able to express their feelings in a

very non-judgmental place it doesn't

mean that that daughter's don't feel the

death of their mothers as much it's just

kind of interesting in that it may be

actually a little bit harder for the

sons to to come over that grief this

last thing when it talks about

Alzheimer's what social psychologists

have also found is that as parents or as

a parent goes further into the

Alzheimer's

we as the the children of those people

quite often begin to see that or view

them as not being there anymore they've

that isn't my mother anymore that isn't

my father anymore because the person

unfortunately does have such great

dementia but then when they die they

actually die

we kind of grieve again because we've

already grieved the fact that we've lost

who we think of as our parent and now

the parent is actually dead so it is an

area of social psychology that is

studied quite a lot and it does really

vary from person to person how we view

the death of one's own parent also the

age we are as far as the death of one's

parent also makes a huge difference for

those who are studying psychology you'll

have a whole course called death and

dying where you'll study the more

interactions and dealing with these sort

of issues with your clients

that brings us then to late adulthood

notice I didn't say seniors late

adulthood we're basically talking about

people who now are pretty well

established they tend have less death

anxiety primarily because they've

experienced death of friends at this

point or family members it's very rare

for someone to get to be an older adult

and not have had some sort of experience

with death within their community

whether it is a family member

fellow co-worker even people in the

community coping skills quite often have

been developed at this point and the

coping skills are how to deal with the

feelings I may have have been developed

so we have this ability to accept it not

only that but as we get older we begin

to accept that death is part of the

landscape of life there is birth and

death and everything in between you

might want to say so it is sort of more

that acceptance that death happens not

so much my death as much as death within

life happens

the death of one's own child or

grandchild in late hood though is

handled a little bit differently the

biggest problem that you might want to

say that we have to deal with those of

you who are going to psychology

especially and those who are going into

the medical field is that when there's a

death of a grandchild the grandparent

quite often hides their grief why

because their primary focus is on their

childhood their child is still alive

their child is grieving the death of

their to grandchild and so they don't

want to bring any more stress to their

own child so if they don't have a safe

haven to be able to express this grief

if they don't have some place where they

can express them and bring this grief

out it quite often can affect them

negatively as far as a physiological

concern is there so if you happen to

have a neighbor who you hear their

grandchild has died perhaps you can

spend a few minutes with them so they

have someone to talk to about this

because they've hidden it quite often

from their own family especially from

their own child

well that brings us to the end of this

course so if you have an issue listen to

this hopefully you will go on to the

last week of class there are student

evaluations generally for you to take

please take those and then you can

celebrate and reflect because you're

just about ready to take exam for the

last exam of the class I hope you've

enjoyed these and if you need me there's

my email address as usual