Date: 11/4/2013

1. Death & Dying
Dr. Reem Al-Sabah
Dept. of Community Med. & Behavioral
Sciences

2. Leading Causes of Death 2006
Kuwait USA
1 Ischemic Heart Disease Heart Disease
2 All neoplasms Malignant Neoplasms
3 Other heart diseases Cerebrovascular
4 Cardiovascular diseases Chronic lower respiratory
disease
5 Transport accidents Unintentional Injury
6 Congenital/Chromosomal Diabetes Mellitus
anomalies
7 Certain conditions Alzheimer’s disease
originating in the perinatal
period

3. Thanatology: the study of death and dying
What is Death?
 Defining death is a difficult.
 WHO definition of death:
“Death is the permanent disappearance of all
evidence of life at any time after birth has
taken place” (United Nations, 1953).

4. Definition of Death
1. The end of life. The cessation of life.
2. The permanent cessation of all vital bodily
functions.
3. The cessation of all vital functions
(traditionally demonstrated by an absence
of spontaneous respiratory and cardiac
functions).

5. When does a human life end?
 The traditional standard, a human being is
dead when the heart and lungs have
irreversibly ceased to function.
 In some cases, permanent loss of
consciousness may precede
cardiopulmonary failure.

6.  Medical technologies (e.g., mechanical
respirators, electronic pacemakers…etc) has
increased the temporal separation between
various system failures.
 Availability of transplantable organs.
 "dead-donor rule": organs necessary for life
may not be procured before donors are dead,
since the removal of such organs would
otherwise cause death.

7.  Two landmark reports helped to generate a
movement away from exclusive reliance on the
traditional standard:
 the 1968 report of the Harvard Medical School Ad
Hoc Committee.
 A 1981 presidential commission report, Defining
Death.
This document included what became the
Uniform Determination of Death Act (UDDA).
 Today the US follows the UDDA in recognizing:
whole-brain death-- the irreversible cessation of all
functions of the entire brain -- as a legal standard of
death.

8. The Uniform Determination of Death Act
(UDDA)
 It states that: "An individual who has sustained either:
(1) irreversible cessation of circulatory and
respiratory functions, or
(2) irreversible cessation of all functions of the entire
brain, including the brain stem is dead.
 A determination of death must be made in accordance
with accepted medical standards."
 This definition was approved by the American Medical
Association in 1980 and by the American Bar
Association in 1981. Today all fifty states and the
District of Columbia follow the UDDA as a legal
standard of death.

9.  A person can be legally dead even if his/her
cardiopulmonary system continues to function.
 A brain-based standard of death: if a
patient's entire brain is non-functioning, so that
breathing and heartbeat are maintained only by
artificial life-supports.

10. Diagnosis of total brain failure
Can be made only when each of the following four
conditions has been met:
1. The patient has a documented history of injury that
does not suggest a potentially transient cause of
symptoms, such as hypothermia or drug
intoxication.
2. The patient is verified to be in a completely
unresponsive coma.
3. The patient demonstrates no brainstem reflexes.
4. The patient shows no drive to breathe during the
apnea test.

11. Islamic definition of death
 A Symposium Held in Kuwait 17-19 December
1996
1. Signs which signify death:
An individual is considered dead in one of the
following two situations:
A. Complete irreversible cessation of respiratory
and cardiovascular systems.
B. Complete irreversible cessation of the
functions of the brain including the brain
stem.
This should be confirmed upon by the accepted in
medical standards.

12. 2. Guidelines for diagnosing brain and brain stem
death:
 The presence of a reliable medical specialist
well experienced in the clinical diagnosis of
brain and brain stem death and the various
implications of such diagnosis.
Prescribed observation necessitates complete
medical coverage in a specialized suitably
equipped institution.
Second opinion should be accessible whenever
sought.

13. The Dying Process
 “A dying individual is a living individual”
 All deaths involve a complex interplay of
cognitive, social, and biological processes.”
(Rebok & Hoyer, 1979)
 Death is a natural part of the life span.
 The dying process is unique to each individual.

14.  Death can occur suddenly or as a process over
time. The signs of approaching death mirror a
slowing down of the body.
 Death is a unique experience for each person
coming in its own time and in its own way.
 Dying happens to the whole person, not just the
body. The individual is affected physically,
emotionally, socially, mentally and spiritually.
 Even though one is physically dying, the emotional-
social and spiritual dimensions have tremendous
potential for growth during the dying process.

15. Mental changes
 Restlessness or agitation which may be a result
of less oxygen to the brain, metabolic changes
or physical pain.
 Occasional or constant confusion which may be
related to separation from the normal routines of
living (may also be the result of a disease, or the
dying process).
 Levels of consciousness (being alert and aware)
may vary.

16.  Sleepiness, with ability to be awakened
and awareness of surroundings.
 The senses may be dulled and there may
be little awareness of what is happening in
the environment.
 Sleep may be so deep that the dying
person cannot be awakened and is
unresponsive.

17. Emotional-social changes
 Looking back at one’s life in search of meaning
and contributions – life review.
 Saying good-bye to people and places,
forgiving and being forgiven, facing regrets –
life closure.
 Acceptance or coming to terms with ongoing
losses and eventual death.

18. The Grief Process- definitions
 Bereavement : the state of being that results from
the death of a significant other.
 Grief : the outcome of being bereaved and
involves a variety of reactions that constitute the
grief process. (Grief can be the result of loss not
involving death such as loss of job, loss of a limb,
loss of status).
 Mourning: the social prescription for the way in
which we are expected to display our grief and
often reflects the practices of one’s culture (e.g.,
wearing black)

19. Five Stages of Grief (The Grief Cycle)
Elisabeth kübler-Ross

20. Stage Interpretation example
Denial -Usually temporary shock response “I feel fine. This can't be
to bad news. –Isolation from people, happening, not to me!”
even family members, avoiding the
dying person.
Anger Can be expressed in different ways. “Why me? It's not fair! NO!
Angry with themselves, and/or with NO! How can this happen!”
others, especially those close to
them.
Bargaining A brief stage, hard to study because “Just let me live to see my
it is often between patient and God. children graduate. I'll do
anything, can't you stretch it
out? A few more years.”
Depression Mourning for losses . It shows that “I'm so sad, why bother with
the person has at least begun to anything? I'm going to die . . .
accept the reality What's the point?”
Acceptance It takes a while to reach this stage “It's going to be OK.” ; “I can't
and a person who fights until the fight it, I may as well prepare
end will not reach it. realizing that for it.”
death is inevitable.

21. Words of Caution
 Kübler-Ross did not intend this to be a rigid series of
sequential or uniformly timed steps.
 It's not a process (fixed and consistent) as such, it's a
model or a framework.
 People do not always experience all of the five 'grief cycle'
stages. The stages are not linear; neither are they equal in
their experience. People's grief reactions are unique.
 The model is a description not a prescription.
 When we know more about what is happening to us or
other people’s emotions we can deal with it better.

22. The dying Role
3 key elements:
1. Practical: tasks people need to arrange at the
end of their lives.
2. Relational: reconciling the dying role with
other roles
3. Personal: finishing one’s life story

23. Complicated Grief
 It is some compromise , distortion, or failure to
of one or more of the tasks of mourning, given
the amount of time since the death.
 The bereaved is attempting two things:
 To deny, repress, or avoid aspects of the loss, its
pain, and the full realization of its implications for
the mourner;
 To hold onto, and avoid relinquishing, the lost
loved one.

24. Factors related to the mourner that may
increase risk for unresolved grief
 Involvement in a “conflicted” relationship with the
person who died.
 Previous or current mental health problems.
 Perceived lack of social support.
 Unresolved losses from the past.
 A sudden/unanticipated death, particularly when
it is violent or random.
 The cause of death is an extremely lengthy
illness.
 The loss of a child.
 The perception of preventability.

25. Types of Complicated (unresolved) Grief
 Absent Grief -- as if the death never occurred—complete
denial or shock.
 Inhibited grief: Less than expected signs of grieving, and is
usually manifested in the physical body in place of grief
reactions.
 Delayed grief: expression of grief some time after the death.
A different loss may trigger a magnified grief reaction that is
really tied to the earlier one.
 Chronic Grief : the bereaved person continuously exhibits
intense grief reactions which are more appropriate for early
bereavement and last longer than what is considered the
normal grief period

26. Symptoms of Chronic (unresolved)
Grief
 Mummification: Preservation of the
environment just as it was when the person
was alive
 Identification: manifesting symptoms, or
problems, mannerisms that are the same as
those of the deceased prior to death.

27.  Idealization: recalling only positive
characteristics of the deceased . If carried to
the extreme it can be destructive (unlikely to
invest in other relationships).
Idealization and identification of the deceased
is only a problem if it hinders the person’s
ability to resolve their grief over time.

28. Other Symptoms of Unresolved Grief
1. Psychosomatic medical illness.
2. Changes in relationships with friends and relatives.
3. Furious hostility.
4. Lack of emotion.
5. Acts detrimental to social and economic existence.
6. Depression, insomnia, feelings of worthlessness,
bitter self-accusation, need for self-punishment.
7. Inability to discuss the deceased without crying or
having the voice crack.
8. Minor event triggers full-blown grief reaction.

29. Developmental Concepts of
Death
Himebauch A, Arnold R and May C. Grief in children and developmental
concepts of death. June 2005 End-of-Life Physician Education Resource
Center www. eperc.mcw.edu.

30. Age group Understanding of death
0-2yrs (infants) •No cognitive understanding of death
•Behavioral regression due to separation
anxiety
2-6yrs •Death is temporary and reversible
(Preschool) •Magical thinking
6-8yrs •Death is final and irreversible
(School Age) •Not universal or could happen to them
•Somatic complaints may be present
8-12yrs •An adult understanding of death
(Pre-Adolescence) •Final, irreversible, and universal
•Intellectualize death
12-18yrs •Also an adult understanding of death
(Adolescence) •Strong emotional reactions with difficulty
identifying and expressing feelings