Death and Dying

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Running Head Death and Dying

Death and Dying

Jacqueline Lewis

Medical Ethics

J. Holly.

Outline

Introduction Death and Dying

I. Death

a) Definition

1) Clinical

) Physical

II. Types

a) Physical

b) Clinical

III. Dying

a) Stages

b) Needs

IV. Advance Directives

a) Definition

b) Types

V. Losses / Grief

a) Child

b) Spouse

V I. Conclusion

Death

Death is a cessation of all life (metabolic) processes. Death involves the organism as a whole (Somatic) or is confined to cell and tissues within the organism (physical). Certain criteria determine if death has occurred; loss of a heartbeat, decrease in body temperature, loss of color in the body, and biological disintegration. Some causes of death include but are not limited to injury, acute or chronic disease, and neophasia (cancer).

A physical death is called "Necrobiosis" or death of cells caused by external changes, i.e. an abnormal lack of blood supply (necrosis). A clinical death is known as a "Somatic" death which is the discontinuance of cardiac activity and respirations. This leads to death of all body cells due to a lack of oxygen. However there is a six minute span of time after somatic death in which vital organs have not been damaged and can be revived.

Types

There are only two types of deaths, "clinical and physical" Brain death is another stage of death this is now a legal condition used in most states for declaring deaths. It requires the absence of the behavioral reflux motor functions above the neck, pupillary reflexes, jaw reflex, gag reflex, no response to noxious stimuli, and no respiratory movement for at least twelve hours. Cardiac death is defined as death in which the heart has stopped functioning; this too is considered a legal death. In the United States the top fifteen leading causes of death are, diseases of the heart, cancer, cardiovascular disease, chronic respiratory disease, accidental (unintentional injuries), diabetes, mellitus, influenza and pneumonia, Alzheimer's, nephritis, septicemia, suicide, cirrhosis, hypertension, homicides, and pneumonitis are deaths that occur in larger numbers in the United states yearly.

Dying

The process of dying has been divided into stages. Doctor Elizabeth Kubler-Ross devoted much of her life to studying the dying process. She believes that patient, family members and caregivers all go through these stages. Dr. Kubler Ross states that the stages overlap and may not be experienced by everyone in the stated order, but all are present in the dying patient. (Medical Law and Ethics)

The first stage is, "Denial" a refusal to believe that they are dying. This may be a time when the patient (or family) needs to adjust to the reality of approaching death. This stage cannot be hurried, next is "Anger". The patient may be angry with everyone and may express an intense anger toward God, family, and even health care professionals. The patient may take this anger out on the persons closes to them, usually a family member. In reality, the patient is angry about dying. Third is "Bargaining". This involves attempting to gain time by making promises in return. Bargaining may be done between the patient and God. The patient may indicate a need to talk at this stage. Fourth is "Depression". There is a deep sadness over the loss of health, independence, and eventually life; there is an additional sadness of leaving loved ones behind. The grieving patient may become withdrawn at this time. Finally there is "Acceptance". When this stage is reached there is a sense of peace and calm. The patient makes such comments as, "I have no regrets. I'm ready to die." It is better to let patient talk and not to make denial statements such as, "Don't talk like that. You're not going to die."

Allow the stages to happen naturally and you will find out the patients true wants and needs. Some may express the need for spiritual comfort. At this point patients often take stock of their lives and may contact estranged friends or relatives to address unresolved issues. Spiritual questions and concerns may emerge as a part of a search for personal meaning n their lives. Families should be prepared to listen and encourage patients to address and perhaps resolve unsettled issues.

Patients often need to be able to make choices in the types of medical care they receive. Let them try a limited trial of therapy, like chemotherapy or radiation. The patient's family and physician must be willing to uphold the patient's desire to stop treatment if the patient says so desires. The patient may want to die at home, which is feasible with the necessary support system; hospice care is available in many areas. Hospice is a multidisciplinary system of services for providing palliative care to the terminally ill patient. The hospice philosophy emphasizes quality, not quantity, of life, but it does not advocate assisted suicide. A hospice program offers a primary care physician, skilled nursing care, physical and occupational therapy and counseling for the entire family. Here in hospice is where the planning for the end of life begins.

Advance Directives

Advance Directives are legal documents that state the patients final wishes should the patient not be able to do so themselves. An (AD) tells your doctor what kind of care you would like to have if you become unable to make decisions (if you are in a coma, for example). The goal of advance care planning from the perspective of legal scholars is to assist patients to make treatment decisions for the event of incapacity. From the patient's perspective the advance care planning is more commonly preparing for death and dying. Once a central ritual of social and religious life, death has been hidden, and implicitly made taboo. Advance planning can help people to prepare for death. This tends to help them achieve a sense of control, relieve burdens on loved ones, and reach closure.

Advance Directives come in several forms such as the Durable Power of Attorney for Health Care or DPA. This states who you have chosen to make health care decisions for you. It becomes active anytime you become unconscious or unable to make medical decisions. A DPA is generally more useful than a living will. However a DPA may not be a good choice if you don't have another person you trust to make these decisions for you. A Do Not Resuscitate (DNR) order is another kind of advance directive. A DNR is a request not to have cardiopulmonary resuscitation (CPR) if your heart stops or if you stop breathing. (Unless given other instructions, hospital staff will try to help all patients whose heart has stopped or who have stopped breathing.) You can use an advance directive form or tell your doctor that you don't want to be resuscitated. In this case, a DNR order is put in your medical chart by your doctor. DNR orders are accepted by doctors and hospitals in all states. A patient may also use a living will, another type of advance directive. It only comes into effect when you are terminally ill. Being terminally ill generally means that you have less than six months to live. In a living will, you can describe the kind of treatment you want in certain situations. A living will doesn't let you select someone to make decisions for you.

Advance directives and living wills do not have to be a complicated legal document. They can be short, simple statements about what you want done or not done if you can't speak for yourself. You may change or cancel your advance directive at any time, as long as you are considered of sound mind to do so. Being of sound mind means that you are still able to think rationally and communicate your wishes in a clear manner. Your changes must be made, signed and notarized according to the laws in your state. Make sure that your doctor and any family members who knew about your directives are also aware that you have changed them. If you do not have time to put your changes in writing, you can make them known while you are in the hospital. Tell your doctor and any family or friends present exactly what you want to happen. Usually, wishes that are made in person will be followed in place of the ones made earlier in writing.

Losses / Grief

Grief most commonly comes from the loss of a loved one. In order to understand bereavement, we need to make the distinction between grief and mourning. Grief is a person's internal experience, thoughts and feelings related to the experience of a great loss. Mourning is the external expression of one's grief. Thus, a person may experience extremely painful grief but, because of a need to appear stoic, may not mourn.

Grief and mourning are intensely personal and unique experiences. We often refer to stages of grief, but these often do not occur in an orderly progression. Depending on the situation and the individuals involved, one may not experience some stages, or may cycle in and out of the same emotional state several times.

The dying child does not fear death itself they fear more for their parents and sibs after they are gone. Often times attempting to keep the secret of dying from the child in question creates more problems for the family. Marriages suffer from the stressful demands of treatments for the dying child, many marriages end in divorce. As the illness drags on and death becomes imminent both parents feel the pressure as if they have somehow failed to be a good parent to the child. Most bereaved parents experience one or more of the following emotions tightness in the throat, heaviness in the chest, or a lump in the stomach like a rock, an empty feeling with appetite loss. They might wander aimlessly, forget a thought in the middle of a sentence, neglect to finish tasks, feel restless, look for activity, but cant concentrate. Some may experience respiratory reactions - excessive yawning, gasping, hyperventilating. Parents will have feelings of anxiety, and think they are losing their mind. A parent may even sense the child's presence and expect the child to walk in the door or phone at the usual time of day. They may cry at unexpected times, be unable to cope and then fall back again - a see-saw type of reaction.

Death in the adult or spouse is surrounded mainly by fear. Fear and grief often aggravates itself. Adults may lay in bed worrying, not wanting to deal with the outside world. The list of physical symptoms that can be caused by fear is long, ranging from physiological effects to psychosomatic symptoms. One of the most disturbing losses is the loss of the respect of others that is reflected in their expressions of pity. Unlike feelings of sympathy, pity demeans the person. The loss of respect is aggravated if we patronize, infantilise, or denigrate the patient. Giving the patient space and the ability to be in control is foremost to them.

Conclusion

Dying no matter how clinical it is, is still the cessation of life, be it that of a loved one, a child, a spouse, mother, father, friend, sister, brother. It hurts and makes no sense to the ones left behind. Some say letting a patient go is the most humane thing to do that is until they are the one who has to let go. It has been thought that if your plan for you death it helps the ones you leave behind. No amount of pre-planning will lessen the grief they will feel by the vacancy left from a loved one's passing.

With current approaches in bioethics we have underestimated the importance of social and family ties. Facing death in the context of loved ones may be an important redeeming accomplishment. End-of-life decision making is influenced by culturally shaped values. The principle of autonomy is the domain of ethics in health care.

Reference

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. Bryan-brown, C., Dracup, K. End of Life Care. American Journal of Critical Care.00 July. Bristol-Myers. 00. 1-

. Goodlin, S. Winzeberg. G.Teno, J. Whedon, M, Death in the Hospital. Archives of Internal Medicine 158 no.14. 18 July 7. American Medical Association.18

4. Herbst, L.Lynn, J, Rhymes, A. What do Dying Patients want and need? (Includes related articles). Patient Care no. 4. 15 February 8. Medical Economics Publishing 15. 1-10

5. Martin, D.; Emanuel, L. Singer, P. Planning for the End-of-Life. The Lancet 56 no. 4.The Lancet Ltd. 000.1-8

6. Parkes, Colin Murray. The Dying Adult. (Coping with loss, part 7). British Medical Journal 16 no7140. British Medical Association. 15

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