We now explore the final part of our lessons; death and dying. We are going to look at aspects of death, palliative care or care for the dying, and the grief process.
There have been changes in leading causes of death in the last 25 years. Life expectancy has increased by about 25 years. In the year 1900, infectious diseases such as tuberculosis and influenza were number one killers. But in 2000, chronic diseases such as heart disease, cancer and stroke are major killers.
The most common causes of death in the United States are heart disease, malignant neoplasms or cancers, cerebral vascular disease or stroke, chronic lower respiratory disease, accidents, diabetes, Alzheimer’s disease, and influenza and pneumonia.
The deadliest diseases worldwide vary depending on the economic conditions of the country. For example, in lower income countries, malaria, diarrheal disease, and perinatal conditions are major causes of death.
There are several aspects of death. Biological death refers to the vital organs ceasing to function. As a person goes through the active process of dying, the body goes through a process of shutting down. This means an increase in sleep, perhaps, the person may stop eating as digestion begins to slow down, the blood may pool on the underside of the body forming dark patches or mottling as circulation slows. And breathing may become more sporadic and raspy. Clinical death occurs when the brain ceases to function.
Social death occurs when others stop visiting or calling on someone who is terminally ill or in the dying process. Even health care providers may spend less time with their terminally ill patients. An informal description I’ve heard when referring to terminally ill patients is that they are “circling the drain” meaning they are on their way out. Most social death occurs because people feel uncomfortable around those who are dying. What do you do for those who are dying? The number one answer is to be there and listen. No one really expects someone to turn it around or offer a solution.
Psychological death occurs when the person begins to accept their death and to withdraw from others psychologically. They may be less interested in normal activities, world events, and social relationships. This can occur much sooner than biological death.
In the late 1960s, Elizabeth Kubler-Ross began to write about death in the United States. She marked the entrance of the hospice movement in her book, “On Death and Dying” published at about that time. Kubler-Ross outlined five psychological stages of coming to grips with one’s terminal illness. These can also apply to coming to grips with the news that a loved one is terminally ill. These five psychological stages include denial, anger, bargaining, depression, and acceptance. We know that there’s no right way to grieve or to come to grips with one’s own death. But what we may find is that a person can visit these more than once, in different orders, or not at all. Nevertheless, these have been very helpful in understanding what to offer a person who is in this situation.
Hospice is a program that offers death with dignity as much as possible. We’ve seen the hospice movement in the United States since the 1980s. The word hospice comes from a root that means hospitality, a place for travelers, a home for the sick.
The modern hospice movement is traced back to London and Dame Cicely Saunders. She believed that people who are dying should be given autonomy of choices about their life, should be allowed to live always, fully, without being ostracized, and should be offered the mechanisms to die peacefully in comfort.
Saunders offers seven pains or seven areas that hospice needs to address: physical pain, spiritual pain (this is often address by a clergy member as part of a team that delivers hospice care); intellectual pain that may be experienced by those with Alzheimer’s or other forms of dementia, emotional pain such as depression needs to be addressed; interpersonal pain or the kinds of rifts that come to the surface when someone is dying-between family members. This also needs to be addressed and often is by a social worker who is part of the hospice team. Financial pain: interestingly enough, this may be one of the biggest concerns of a person who is dying as they worry about what kinds of debts or medical expenses they leave behind for family members. Bureaucratic pain: this refers to the difficult, time-consuming task of trying to get information to insurance companies, to file claims, and so on. The hospice team can offer assistance in all of these areas of pain.
Palliative care is a branch of medicine where the care is focused on the dying. In palliative care, comfort and pain relief are major concerns. Some of the discomforts that those who are dying may experience are nausea, shortness of breath, ulcerated bed sores, physical pain. Pain medication is often offered with some controversy of the ‘double-effect.’ Morphine, for example, can not only bring pain relief, but can also accelerate the timing of death. Palliative care is focused on the philosophy that people should be allowed to die with dignity and with as much control over their death as possible.
Hospice includes a team of individuals all geared toward helping the person and their family members go through this process. The RN provides total care. The social worker tends to focus on family and legal issues. The chaplain may be part of the team and focuses on spiritual issues. The CNA provides bathing and grooming and direct patient care. Of course, that’s in concert very often with family members. The physician oversees medications and volunteers provide a number of services. You can read about these and listen to some examples of these at the end of your lesson.