PSYC290N - Lifespan Development REFLECTION ASSIGNMENT Required Resources Read/review the following resources for this activity: Textbook: Chapter 20 (Attached below with APA formatted book reference f

chapter 20

DEATH, DYING, AND GRIEVING

chapter outline

1 The Death System and Cultural Contexts

Learning Goal 1 Describe the death system and its cultural and historical contexts

The Death System and Its Cultural Variations

Changing Historical Circumstances

2 Defining Death and Life/Death Issues

Learning Goal 2 Evaluate issues in determining death and decisions regarding death

Issues in Determining Death

Decisions Regarding Life, Death, and Health Care

3 A Developmental Perspective on Death

Learning Goal 3 Discuss death and attitudes about it at different points in development

Causes of Death

Attitudes Toward Death at Different Points in the Life Span

4 Facing One’s Own Death

Learning Goal 4 Explain the psychological aspects involved in facing one’s own death and the contexts in which people die

Kübler-Ross’ Stages of Dying

Perceived Control and Denial

The Contexts in Which People Die

5 Coping with the Death of Someone Else

Learning Goal 5 Identify ways to cope with the death of another person

Communicating with a Dying Person

Grieving

Making Sense of the World

Losing a Life Partner

Forms of Mourning

©Fuse/Getty Images

Paige Farley-Hackel and her best friend Ruth McCourt teamed up to take McCourt’s 4-year-old daughter, Juliana, to Disneyland. They were originally booked on the same flight from Boston to Los Angeles, but McCourt decided to use her frequent flyer miles and go on a different airplane. Both their flights exploded 17 minutes apart after terrorists hijacked them, then rammed them into the twin towers of the World Trade Center in New York City on 9/11/2001.

Forty-five-year-old Ruth McCourt was a homemaker from New London, Connecticut, who had met Farley-Hackel at a day spa she used to own in Boston. McCourt gave up the business when she married, but the friendship between the two women lasted. They often traveled together and shared their passion for reading, cooking, and learning.

Forty-six-year-old Farley-Hackel was a writer, motivational speaker, and spiritual counselor who lived in Newton, Massachusetts. She was looking forward to the airing of the first few episodes of her new radio program, “Spiritually Speaking,” and wanted to eventually be on The Oprah Winfrey Show, said her husband, Allan Hackel. Following 9/11, Oprah provided a memorial tribute to Farley-Hackel, McCourt, and Juliana.

topical connections looking back

In the United States, the leading cause of death in infancy is sudden infant death syndrome (SIDS). In early childhood, motor vehicle accidents are the leading cause of death, followed by cancer and cardiovascular disease. Injuries are the leading cause of death during middle and late childhood, and the most common cause of severe injury and death in this period is motor vehicle accidents, either as a pedestrian or as a passenger. The three leading causes of death in adolescence are accidents, homicide, and suicide. Emerging adults have more than twice the mortality rate of adolescents. For many years, heart disease was the leading cause of death in middle adulthood, followed by cancer; however, since 2005 more individuals 45 to 64 years of age in the United States die of cancer, followed by cardiovascular disease. Men have higher mortality rates than women for all of the leading causes of death. Nearly 60 percent of deaths among 65- to 74-year-old U.S. adults are caused by cancer or cardiovascular disease, with cancer now the leading cause of death. However, in the age groups of 75 to 84 and 85 and over, cardiovascular disease is the leading cause of death.

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preview

In this final chapter, we will explore many aspects of death and dying. Among the questions that we will ask are these: What characterizes the death system, and what are its cultural and historical contexts? How can death be defined? What are some links between development and death? How do people face their own death? How do individuals cope with the death of someone they love?

1 The Death System and Cultural Contexts

LG1 Describe the death system and its cultural and historical contexts.

The Death System and Its Cultural Variations

Changing Historical Circumstances

Today in the United States, deaths of older adults account for approximately two-thirds of the 2 million deaths that occur each year. Thus, what we know about death, dying, and grieving mainly is based on information about older adults. Youthful death is far less common. What has changed historically in the United States is when, where, and how people die. And how we deal with death is part of our culture. Every culture has a death system, and variations in this death system occur across cultures.

THE DEATH SYSTEM AND ITS CULTURAL VARIATIONS

Robert Kastenbaum (1932–2013) emphasizes that the death system in any culture comprises the following components (Kastenbaum 2009, 2012):

• People. Because death is inevitable, everyone is involved with death at some point, either their own death or the death of others. Some individuals have a more systematic role with death, such as those who work in the funeral industry and the clergy, as well as people who work in life-threatening contexts such as firefighters and police officers.

• Places or contexts. These include hospitals, funeral homes, cemeteries, hospices,
  battlefields, and memorials (such as the Vietnam Veterans Memorial wall in Washington, DC).

• Times. Death involves times or occasions, such as Memorial Day in the United States and the Day of the Dead in Mexico, which are times to honor those who have died. Also, anniversaries of disasters such as D-Day in World War II, 9/11/2001, and Hurricane Sandy in 2012, as well as the 2004 tsunami in Southeast Asia that took approximately 100,000 lives, are times when those who died are remembered in special ways such as ceremonies.

• Objects. Many objects in a culture are associated with death, including caskets and clothes, armbands, and hearses in specific colors. In the United States black is associated with death, but in China white is linked to death.

• Symbols. Symbols such as a skull and crossbones, as well as last rites in the Catholic religion and various religious ceremonies, are connected to death.

In 2017, Hurricane Harvey wreaked havoc on Houston, Texas, causing 125 billion dollars in damages. At least 88 people died as a result of the devastating hurricane. ©Steve Gonzales/Houston Chronicle/AP Images

Cultural variations characterize death and dying (Butters, 2017; Guilbeau, 2018; Miller, 2016; Prince, 2018; Wang & others, 2018; Whitehouse, 2018). To live a full life and die with glory was the prevailing goal of the ancient Greeks. Individuals are more conscious of death in times of war, famine, and plague. Whereas Americans are conditioned from early in life to live as though they were immortal, in much of the world this fiction cannot be maintained. Death crowds the streets of Mumbai in daily overdisplay, as it does in the impoverished towns of Page 607 Bangladesh. By contrast, in the United States it is not uncommon to reach adulthood without having talked about death or experienced the death of someone close.

Most societies throughout history have had philosophical or religious beliefs about death, and most societies have a ritual that deals with death (Ahluwalia & Mohabir, 2018; Ballinger & others, 2017; Jones & Nie, 2018; Pun & others, 2018; Schweda & others, 2017). Death may be seen as a punishment for one’s sins, an act of atonement, or a judgment from a just God. For some, death means loneliness; for others, death is a quest for happiness. For still others, death represents redemption, a relief from the trials and tribulations of the earthly world. Some embrace death and welcome it; others abhor and fear it. For those who welcome it, death may be seen as the fitting end to a fulfilled life. From this perspective, how we depart from Earth is influenced by how we have lived.

In most societies, death is not viewed as the end of existence—after the biological body has died, the spiritual body is believed to live on (Hamilton & others, 2018; Inbadas, 2017). This religious perspective is favored by most Americans as well (Gowan, 2003). Cultural variations in attitudes toward death include belief in reincarnation, which is an important aspect of the Hindu and Buddhist religions (Agoramoorthy & Hsu, 2017; Setta & Shemie, 2015). In the Gond culture of India, death is believed to be caused by magic and demons. The members of the Gond culture react angrily to death. In the Tanala culture of Madagascar, death is believed to be caused by natural forces. The members of the Tanala culture show a much more peaceful reaction to death than members of the Gond culture. Figure 1 shows a ritual associated with death in South Korea.

FIGURE 1 A RITUAL ASSOCIATED WITH DEATH. Family memorial day at the national cemetery in Seoul, South Korea. ©Ahn Young-joon/AP Images

In many ways, we in the United States are death avoiders and death deniers (Norouzieh, 2005). This denial can take many forms, including our persistent search for a fountain of youth through diet, surgery, and other means, as well as the tendency of the funeral industry to gloss over death and fashion lifelike qualities in the dead.

developmental connection

Life Expectancy

The upper boundary of the human life span is 122 years of age (based on the oldest age documented). Connect to “Introduction.”

CHANGING HISTORICAL CIRCUMSTANCES

One historical change involves the age group in which death most often occurs. Two hundred years ago, almost one of every two children died before the age of 10, and one parent died before children grew up. Today, death occurs most often among older adults (Carr, 2009). Life expectancy has increased from 47 years for a person born in 1900 to 79 years for someone born today (U.S. Census Bureau, 2017). Today, the life expectancy in the U.S. for women is 81, for men 76. In 1900, most people died at home, cared for by their family. As our population has aged and become more mobile, greater numbers of older adults die apart from their families (Carr, 2009). In the United States today, more than 80 percent of all deaths occur in institutions or hospitals. The care of a dying older person has shifted away from the family and minimized our exposure to death and its painful surroundings (Gold, 2011).

Review Connect Reflect

LG1 Describe the death system and its cultural and historical contexts.

Review

• What characterizes the death system in a culture? What are some cultural variations in the death system?

• What are some changing sociohistorical circumstances regarding death?

Connect

• You just read about how changes in life expectancy over time have affected our experience of death.
  In earlier chapters, what did you learn about life expectancy and the age span that encompasses older adulthood?

Reflect Your Own Personal Journey of Life

• How extensively have death and dying been discussed in your family? Explain.

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2 Defining Death and Life/Death Issues

LG2 Evaluate issues in determining death and decisions regarding death.

Issues in Determining Death

Decisions Regarding Life, Death, and Health Care

Is there one point in the process of dying that is the point at which death takes place, or is there a gradual transition between life and death? What are some decisions individuals can make about life, death, and health care?

ISSUES IN DETERMINING DEATH

Thirty years ago, determining whether someone was dead was simpler than it is today. The end of certain biological functions, such as breathing and blood pressure, and the rigidity of the body (rigor mortis) were considered to be clear signs of death. In recent decades, defining death has become more complex (Ganapathy, 2018; Greer & others, 2016; Johnson, 2017; Hammand & others, 2017).

Brain death is a neurological definition of death which states that a person is brain dead when all electrical activity of the brain has ceased for a specified period of time. A flat EEG (electroencephalogram) reading for a specified period of time is one criterion of brain death. The higher portions of the brain often die sooner than the lower portions. Because the brain’s lower portions monitor heartbeat and respiration, individuals whose higher brain areas have died may continue to breathe and have a heartbeat (MacDougall & others, 2014). The definition of brain death currently followed by most physicians includes the death of both the higher cortical functions and the lower brain stem functions (Oliva & others, 2017; Waweru-Silka & others, 2017).

Some medical experts argue that the criteria for death should include only higher cortical functioning. If the cortical death definition were adopted, then physicians could declare that a person is dead when there is no cortical functioning in that person, even though the lower brain stem is functioning. Supporters of the cortical death policy argue that the functions we associate with being human, such as intelligence and personality, are located in the higher cortical part of the brain. They believe that when these functions are lost, the “human being” is no longer alive.

What are some issues in determining death? ©Dario Mitidieri/Getty Images

DECISIONS REGARDING LIFE, DEATH,
AND HEALTH CARE

In cases of catastrophic illness or accidents, patients might not be able to respond adequately to participate in decisions about their medical care. To prepare for this situation, some individuals make choices earlier.

Advance Care Planning Advance care planning refers to the process of patients thinking about and communicating their preferences about end-of-life care (Koss & Baker, 2016; Pereira-Salgado & others, 2018; Rietjens & others, 2017; Sulmasy, 2018). For many patients in a coma, it is not clear what their wishes regarding termination of treatment might be if they still were conscious (Abu Snineh, Camicioli, & Miysaki, 2017). One study found that advance care planning decreased life-sustaining treatment, increased hospice use, and decreased hospital use (Brinkman-Stoppelenburg, Rietjens, & van der Heide, 2014). Another recent study revealed that completion of an advance directive was associated with a lower probability of receiving life-sustaining treatments (Yen & others, 2017). Recognizing that some terminally ill patients might prefer to die rather than linger in a painful or vegetative state, the organization “Choice in Dying” created the living will, a legal document that reflects the patient’s advance care planning. A study of older adults found that advance care planning was associated with improved quality of care at the end of life, including less in-hospital death and greater use of hospice care (Bischoff & others, 2013).

Physicians’ concerns over malpractice suits and the efforts of people who support the living will concept have produced natural death legislation. Laws in all 50 states now accept an advance directive such as a living will (Mitchell & Dale, 2016; Olsen, 2016). An advance directive must be signed while the individual still is able to think clearly (Myers & others, 2018; Shin & others, 2016). A study of end-of-life planning revealed that only 15 percent of patients 18 years of age and older had a living will (Clements, 2009). A research review concluded that physicians have a positive attitude toward advance directives (Coleman, 2013).

Page 609 Recently, Physician Orders for Life-Sustaining Treatment (POLST), a document that is more specific than previous advance directives, was created (Hopping-Winn & others, 2018; Lammers & others, 2018; Moss & others, 2017; Struck, Brown & Madison, 2017). POLST translates treatment preferences into medical orders such as those involving cardiopulmonary resuscitation, extent of treatment, and artificial nutrition via a tube (Mayoral & others, 2018; Scotti, 2016; Stuart & Thielke, 2017). POLST involves the health-care professional and the patient or surrogate conferring to determine and state the wishes of the patient. POLST is currently available or being considered in 34 states.

Euthanasia Euthanasia (“easy death”) is the act of painlessly ending the lives of individuals who are suffering from an incurable disease or severe disability (Kanniyakonil, 2018; Miller, Dresser, & Kim, 2018; Preston, 2018; Radbruch & others, 2016; Savulescu, 2017). Sometimes euthanasia is called “mercy killing.” Euthanasia also involves the physician or a third party administering the lethal medication. Euthanasia is legal in Belgium, Colombia, the Netherlands, and Luxembourg, but is not legal in the United States. Distinctions are made between two types of euthanasia: passive and active.

• Passive euthanasia occurs when a person is allowed to die by withholding available treatment, such as withdrawing a life-sustaining device. For example, this might involve turning off a respirator or a heart-lung machine.

• Active euthanasia occurs when death is deliberately induced, as when a lethal dose of a drug is injected.

Technological advances in life-support devices raise the issue of quality of life (Dean, 2017; Goligher & others, 2017; Jouffre & others, 2018). Nowhere was this more apparent than in the highly publicized case of Terri Schiavo, who suffered severe brain damage related to cardiac arrest and a lack of oxygen to the brain. She went into a coma and spent 15 years in a vegetative state. Across the 15 years, the question of whether passive euthanasia should be implemented or whether she should be kept in the vegetative state with the hope that her condition might change for the better was debated between family members and eventually at a number of levels in the judicial system. At one point toward the end of her life in the early spring of 2005, a court ordered that her feeding tube be removed. However, subsequent appeals led to its reinsertion twice. The feeding tube was removed a third and final time on March 18, 2005, and she died 13 days later.

Terri Schiavo (right) shown with her mother. What issues did the Terri Schiavo case raise? ©Stringer/Getty Images

Should individuals like Terri Schiavo be kept alive in a vegetative state? The trend is toward acceptance of passive euthanasia in the case of terminally ill patients (Hurst & Mauron, 2017; Sannita, 2017).

The inflammatory argument that once equated this practice with suicide rarely is heard today. However, experts do not yet entirely agree on the precise boundaries or the exact mechanisms by which treatment decisions should be implemented (Jouffre & others, 2018; Lum & others, 2017; Porteri, 2018). Can a comatose patient’s life-support systems be disconnected when the patient has left no written instructions to that effect? Does the family of a comatose patient have the right to overrule the attending physician’s decision to continue life-support systems? These questions have no simple or universally agreed-upon answers (Chen & Azueta, 2017).

Assisted suicide requires the patient to self-administer the lethal medication and to determine when and where to do this, whereas active euthanasia involves the physician or a third party administering the lethal medication (Hosie, 2018; Miller & Appelbaum, 2018; Vandenberghe, 2018). The most widely publicized assisted suicides were carried out by Jack Kevorkian, a Michigan physician, who assisted a number of terminally ill patients in ending their lives. After a series of trials, Kevorkian was convicted of second-degree murder and given a 10- to 15-year sentence. He was released from prison at age 79 for good behavior in June 2007 and promised not to participate in any further assisted suicides. Kevorkian died in 2011 at the age of 83.

Assisted suicide is now legal in Belgium, Canada, Finland, Luxembourg, the Netherlands, and Switzerland. The United States government has no official policy on assisted suicide and leaves the decision up to each of the states. An increasing number of states now allow assisted suicide: California, Colorado, Montana, Oregon, Vermont, and Washington, as well as Page 610 Washington, DC. Assisted suicide involves the physician giving the patient an overdose of muscle relaxants or sedatives to take, which causes a coma and then death. In states where assisted suicide is illegal, the crime is typically considered manslaughter or a felony.

Even in places where assisted suicide is legal, it is not a common practice. A research review revealed that the percentage of physician-assisted deaths ranged from 0.1 to 0.2 percent in the United States and Luxembourg to 1.8 to 2.9 percent in the Netherlands (Steck & others, 2013). In this review, the percentage of assisted suicide cases reported to authorities has increased in recent years and the individuals who die through assisted suicide are most likely to be males from 60 to 75 years of age.

To what extent do people in the United States think euthanasia and assisted suicide should be legal? A recent Gallup poll found that 69 percent of U.S. adults said euthanasia should be legal, 51 percent said they would consider ending their own lives if faced with a terminal illness, and 50 percent reported that physician-assisted suicide is morally acceptable (Swift, 2016).

Why is euthanasia so controversial? Those in favor of euthanasia argue that death should be calm and dignified, not full of agony, pain, and prolonged suffering. Those against euthanasia stress that it is a criminal act of murder in most states in the United States and in most other countries. Many religious individuals, especially Christians, say that taking a life for any reason is against God’s will and is an act of murder.

Needed: Better Care for Dying Individuals In the United States, the process of dying is often lonely, prolonged, and painful. Dying individuals often get too little or too much care. Scientific advances sometimes have made dying harder by delaying the inevitable. And even though effective painkillers are available, too many people experience severe pain during their last days and months of life (Buiting & de Graas, 2018; Chi & others, 2018; Hughes, Volicer, & van der Steen, 2018; Montague & others, 2017). A recent study found that 61 percent of dying patients were in pain in the last year of life and that nearly one-third had symptoms of depression and confusion prior to death (Singer & others, 2015).

Many health-care professionals have not been trained to provide adequate end-of-life care or to understand its importance. One study revealed that in many cases doctors don’t give dying patients adequate information about how long they are likely to live or how various treatments will affect their lives (Harrington & Smith, 2008). For example, in this study of patients with advanced cancer, only 37 percent of doctors told patients how long they were likely to live.

Care providers are increasingly interested in helping individuals experience a “good death” (Flaskerud, 2017; Tenzek & Depner, 2017). One view is that a good death involves physical comfort, support from loved ones, acceptance, and appropriate medical care (Krishnan, 2017). For some individuals, a good death involves accepting one’s impending death and not feeling like a burden to others (Carr, 2009). In a recent review, the three most frequent themes described in articles on a good death involved (1) preference for dying process (94 percent of reports), (2) pain-free status (81 percent), and (3) emotional well-being (64 percent) (Meier & others, 2016).

Recent criticisms of the “good death” concept emphasize that death itself has shifted from being an event at a single point in time to a process that takes place over years and even decades (Pollock & Seymour, 2018; Smith & Periyakoli, 2018). Thus, say the critics, we need to move away from the concept of a “good death” as a specific event for an individual person to a larger vision of a world that not only meets the needs of individuals at their moment of death but also focuses on making their lives better during their final years and decades.

What characterizes hospice care? ©Comstock Images/PictureQuest

Hospice is a program committed to making the end of life as free from pain, anxiety, and depression as possible (Fridman & others, 2018; Wang & others, 2017). Traditionally, a hospital’s goals have been to cure illness and prolong life (Koksvik, 2018). By contrast, hospice care emphasizes palliative care, which involves reducing pain and suffering and helping individuals die with dignity (Bangerter & others, 2018; Chi & others, 2018; Cox & Curtis, 2016; Nilsen & others, 2018; Pidgeon & others, 2017). However, U.S. hospitals recently have rapidly expanded their provision of palliative care. One study found that more than 85 percent of mid- to large-size U.S. hospitals have a palliative care team (Morrison, 2013). Hospice-care professionals work together to treat the dying person’s symptoms, make the individual as comfortable as possible, show interest in the patient and his or her family, and help everyone involved cope with death (Bogusz, Pekacka-Falkowska, & Magowska, 2018; Levy & others, 2016; Stiel & others, 2018; Wise, 2017).

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connecting with careers

Kathy McLaughlin, Home Hospice Nurse

Kathy McLaughlin is a home hospice nurse in Alexandria, Virginia. She provides care for individuals with terminal cancer, Alzheimer disease, and other diseases. There currently is a shortage of home hospice nurses in the United States.

McLaughlin says that she has seen too many people dying in pain, away from home, hooked up to needless machines. In her work as a home hospice nurse, she comments,

“I know I’m making a difference. I just feel privileged to get the chance to meet this person who is not going to be around much longer. I want to enjoy the moment with this person. And I want them to enjoy the moment. They have great stories. They are better than novels.” (McLaughlin, 2003, p. 1)

Kathy McLaughlin with her hospice patient Mary Monteiro. Courtesy of the family of Mary Monteiro

A primary hospice goal is to bring pain under control and to help dying patients face death in a psychologically healthy way (Chi & others, 2017; West & others, 2018). The hospice also makes every effort to include the dying individual’s family; it is believed that this strategy benefits not only the dying individual but family members as well, probably diminishing their guilt after the death.

The hospice movement has grown rapidly in the United States. More than 1,500 community groups are involved nationally in establishing hospice programs. Hospices are more likely to serve people with terminal cancer than those with other life-threatening conditions (Kastenbaum, 2012). Hospice advocates emphasize the advantages of controlling pain for dying individuals and creating an environment for the patient that is superior to that found in most hospitals (West & others, 2016). For hospice services to be covered by Medicare, a patient must be deemed by a physician to have six months or fewer to live. Also, some hospice providers will provide care only if the patient has a family caregiver living in the home (or nearby).

Approximately 90 percent of hospice care is provided in patients’ homes (Hayslip & Hansson, 2007). In some cases, home-based care is provided by community-based health-care professionals or volunteers; in other cases, home-based care is provided by home health-care agencies or Visiting Nurse Associations (Abrahamson, Davila, & Hountz, 2018). There is a rapidly growing need for competent home health aides in hospice and palliative care (Anthony, 2018; Boerner, Gleason, & Barooah, 2016; Feldman & others, 2018; Franzosa, Tsui, & Baron, 2018; Ghesquiere & Bagaajav, 2018; Nisbet & Morgan, 2018; Quinn & others, 2016). Also, some hospice care is provided in free-standing, full-service hospice facilities and in hospice units in hospitals. To read about the work of a home hospice nurse, see Connecting with Careers.

Review Connect Reflect

LG2 Evaluate issues in determining death and decisions regarding death.

Review

• What are some issues regarding the determination of death?

• What are some decisions to be made regarding life, death, and health care?

Connect

• In this section, you learned that hospices try to provide dying patients with adequate pain relief. What did you learn earlier about older adults that might help them deal with pain better than younger adults?

Reflect Your Own Personal Journey of Life

• Have you signed an advance directive (living will)? Why or why not?

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3 A Developmental Perspective on Death

LG3 Discuss death and attitudes about it at different points in development.

Causes of Death

Attitudes Toward Death at Different Points in the Life Span

Do the causes of death vary across the life span? Do we have different expectations and attitudes about death at different stages of our development?

CAUSES OF DEATH

Death can occur at any point in the human life span. Death can occur during prenatal development through miscarriages or stillborn births. Death can also occur during the birth process or in the first few days after birth, which usually happens because of a birth defect or because infants have not developed adequately to sustain life outside the uterus. Earlier we described sudden infant death syndrome (SIDS), in which infants stop breathing, usually during the night, and die without apparent cause (Carlin & Moon, 2017; Siren, 2017). SIDS currently is the leading cause of infant death in the United States, with the risk highest at 2 to 4 months of age (NICHD, 2018).

developmental connection

Conditions, Diseases, and Disorders

Nearly 3,000 deaths of infants per year in the United States are attributed to SIDS. Connect to “Physical Development in Infancy.”

In childhood, death occurs most often because of accidents or illness. Accidental death in childhood can be the consequence of events such as an automobile accident, drowning, poisoning, fire, or a fall from a high place. Major illnesses that cause death in children are heart disease, cancer, and birth defects.

Compared with childhood, death in adolescence is more likely to occur because of motor vehicle accidents, suicide, and homicide. Many motor vehicle accidents that cause death in adolescence are alcohol-related. We will examine suicide in greater depth shortly.

Older adults are more likely to die from chronic ailments such as heart disease and cancer, whereas younger adults are more likely to die from accidents. Older adults’ diseases often incapacitate before they kill, which produces a course of dying that slowly leads to death. Of course, many young and middle-aged adults also die of heart disease, cancer, and other diseases.

ATTITUDES TOWARD DEATH AT DIFFERENT
POINTS IN THE LIFE SPAN

The ages of children and adults influence the way they experience and think about death. A mature, adult-like conception of death includes an understanding that death is final and irreversible, that death represents the end of life, and that all living things die. Most researchers have found that as children grow, they develop a more mature approach to death (Yang & Park, 2017).

Childhood Researchers have found that children’s conception of death changes as they develop but that even young children begin to develop views of death that are more cognitively advanced than was previously thought (Rosengren, Gutierrez, & Schein, 2014a, b) For example, a recent study found that as early as 4 to 5 years of age, many young children understand the irreversibility of death and that it involves the cessation of mental and physical functioning (Panagiotaki & others, 2018). At some point in the middle and late childhood years, many children develop more realistic and accurate perceptions of death, such as increasingly viewing its cause as biological in nature (Panagiotaki & others, 2018).

Children’s views of death and their experiences with death vary with the contexts and cultures in which they grow up. As we indicated earlier in this chapter, U.S. children are not exposed to death nearly as much as children in some cultures. In one study, researchers found that higher-SES non-Latino White parents were likely to shield their children from death, while immigrant Mexican American parents thought it was important for their children to learn about death and talk about it (Gutierrez, Rosengren, & Miller, 2014).

The death of a parent is especially difficult for children (Bergman, Axberg, & Hanson, 2017; Greene & McGovern, 2017). When a child’s parent dies, the child’s school performance and peer relationships often suffer. For some children, as well as adults, a parent’s death can be Page 613 devastating and result in a hypersensitivity about death, including a fear of losing others close to the individual. In some cases, loss of a sibling can result in similar negative outcomes (Sood & others, 2006). However, a number of factors, such as the quality of the relationship and type of the death (whether due to an accident, long-standing illness, suicide, or murder, for example), can influence the individual’s development following the death of a person close to the individual.

Most psychologists emphasize that honesty is the best strategy in discussing death with children. Treating the concept as unmentionable is thought to be an inappropriate strategy, yet most of us have grown up in a society where death is rarely discussed.

In addition to honesty, the best response to a child’s query about death might depend on the child’s maturity level. For example, a preschool child requires a less elaborate explanation than an older child. Death can be explained to preschool children in simple physical and biological terms. Actually, what young children need more than elaborate explanations of death is reassurance that they are loved and will not be abandoned. Regardless of children’s ages, adults should be sensitive and sympathetic, encouraging them to express their own feelings and ideas.

Three- to nine-year-old children with their mother visiting their father’s grave in Kenya. What are some developmental changes in children’s conceptions of death? ©Per-Anders Pettersson/Getty Images

Also, support programs for parentally bereaved children and their caregivers can be beneficial. In a recent research review, it was concluded that relatively brief interventions can prevent children from developing severe problems, such as traumatic grief and mental disorders (Bergman, Axberg, & Hanson, 2017). One of the most successful programs is the Family Bereavement Program, a 12-session program designed to promote effective parenting and teach coping skills following the death of a parent or caregiver. In a recent experimental study, children and adolescents who participated in the program showed better adjustment up to 6 years following the program (Sandler & others, 2017). In addition, bereaved parents who participated in the program had lower levels of depression, were less likely to have prolonged grief disorders, less likely to have alcohol problems, and have better coping skills up to 6 years after participating in the program (Sandler & others, 2016).

Adolescence Deaths of peers, friends, siblings, parents, grandparents, or great-grandparents bring death to the forefront of adolescents’ lives. Adolescents develop more abstract conceptions of death than children do. For example, adolescents describe death in terms of darkness, light, transition, or nothingness (Wenestam & Wass, 1987). They also develop religious and philosophical views about the nature of death and whether there is life after death.

We keep on thinking and rethinking death after we have passed through childhood’s hour.

—Robert Kastenbaum

Leading Expert on Death, Dying, and Grieving,
20th–21st Century

Adulthood A recent study of young adults and middle-aged adults found that women had more difficulty than men in adjusting to the death of a parent and also that women had a more intense grief response to a parent’s death (Hayslip, Pruett, & Caballero, 2015). There is no evidence that a special orientation toward death develops in early adulthood. An increase in consciousness about death accompanies individuals’ awareness that they are aging, which usually intensifies in middle adulthood. In our discussion of middle adulthood, we indicated that midlife is a time when adults begin to think more about how much time is left in their lives. Researchers have found that middle-aged adults actually fear death more than do young adults or older adults (Kalish & Reynolds, 1976). Older adults, though, think about death more and talk about it more in conversation with others than do middle-aged and young adults. They also have more direct experience with death as their friends and relatives become ill and die. Older adults are forced to examine the meanings of life and death more frequently than are younger adults.

In old age, one’s own death may take on an appropriateness it lacked in earlier years. Increased thinking and conversing about death, and an increased sense of integrity resulting from a positive life review, may help older adults accept death. Older adults are less likely to have unfinished business than are younger adults. They usually do not have children who need to be guided to maturity, their spouses are more likely to be dead, and they are less likely to have work-related projects that require completion. Lacking such anticipations, death may be less emotionally painful to them than to young or middle-aged adults. Even among older adults, however, attitudes toward death vary (Whitbourne & Meeks, 2011).

How might older adults’ attitudes about death differ from those of younger adults? ©Ned Frisk Photography/CorbisPage 614

Review Connect Reflect

LG3 Discuss death and attitudes about it at different points in development.

Review

• What are some developmental changes in the causes of death?

• What are some attitudes about death at different points in development?

Connect

• In “Socioemotional Development in Adolescence,” you read about adolescent suicide. What aspects of that discussion have helped
  you understand causes of death
  and attitudes about death in adolescence?

Reflect Your Own Personal Journey of Life

• What is your current attitude about death? Has it changed since you were an adolescent? If so, how?

4 Facing One’s Own Death

LG4 Explain the psychological aspects involved in facing one’s own death and the contexts in which people die.

Kübler-Ross’ Stages of Dying

Perceived Control and Denial

The Contexts in Which People Die

Knowledge of death’s inevitability permits us to establish priorities and structure our time accordingly. As we age, these priorities and structurings change in recognition of diminishing future time. Values concerning the most important uses of time also change. For example, when asked how they would spend their six remaining months of life, younger adults described such activities as traveling and accomplishing things they previously had not done; older adults described more inner-focused activities—contemplation and meditation, for example (Kalish & Reynolds, 1976).

Most dying individuals want an opportunity to make some decisions regarding their own life and death (Kastenbaum, 2012). Some individuals want to complete unfinished business; they want time to resolve problems and conflicts and to put their affairs in order.

Sustained and soothed by an unfaltering trust, approach thy grave, Like one who wraps the drapery of his couch About him, and lies down to pleasant dreams.

—William Cullen Bryant

American Poet, 19th Century

KüBLER-ROSS’ STAGES OF DYING

We are all born to die, and our lives prepare us for that finality. Dealing with our own death usually becomes the focal point in our life only when we are nearing death, but we live with an awareness of death throughout our lives. However, as indicated earlier in the chapter, people (especially in the United States) often try to avoid thinking about death in any way.

Might there be a sequence of stages we go through as we face death? Elisabeth Kübler-Ross (1969) divided the behavior and thinking of dying persons into five stages: denial and isolation, anger, bargaining, depression, and acceptance.

Denial and isolation is Kübler-Ross’ first stage of dying, in which the person denies that death is really going to take place. The person may say, “No, it can’t be me. It’s not possible.” This is a common reaction to a diagnosis of terminal illness. However, denial is usually only a temporary defense. It is eventually replaced with increased awareness when the person is confronted with such matters as financial considerations, unfinished business, and worry about the well-being of surviving family members.

Anger is Kübler-Ross’ second stage of dying, in which the dying person recognizes that denial can no longer be maintained. Denial often gives way to anger, resentment, rage, and envy. The dying person’s question becomes “Why me?” At this point, the person becomes increasingly difficult to care for as anger may become displaced and projected onto physicians, nurses, family members, and even God. The realization of loss is great, and those who symbolize life, energy, and competent functioning are especially salient targets of the dying person’s resentment and jealousy.

Page 615Bargaining is Kübler-Ross’ third stage of dying, in which the person develops the hope that death can somehow be postponed or delayed. Some persons enter into a bargaining or negotiation—often with God—as they try to delay their death. Psychologically, the person is saying, “Yes, me, but . . .” In exchange for a few more days, weeks, or months of life, the person promises to lead a reformed life dedicated to God or to the service of others.

Depression is Kübler-Ross’ fourth stage of dying, in which the dying person comes to accept the certainty of death. At this point, a period of depression or preparatory grief may appear. The dying person may become silent, refuse visitors, and spend much of the time crying or grieving. This behavior is normal and is an effort to disconnect the self from love objects. Attempts to cheer up the dying person at this stage should be discouraged, says Kübler-Ross, because the dying person has a need to contemplate impending death.

Acceptance is Kübler-Ross’ fifth stage of dying, in which the person develops a sense of peace, an acceptance of his or her fate, and in many cases, a desire to be left alone. In this stage, feelings and physical pain may be virtually absent. Kübler-Ross describes this fifth stage as the end of the dying struggle, the final resting stage before death. A summary of Kübler-Ross’ dying stages is presented in Figure 2.

FIGURE 2 KüBLER-ROSS’ STAGES OF DYING. According to Elisabeth Kübler-Ross, we go through five stages of dying: denial and isolation, anger, bargaining, depression, and acceptance. Does everyone go through these stages, and do we go through them in the same order? Explain. ©Science Photo Library/Getty Images

What is the current evaluation of Kübler-Ross’ theory? According to Robert Kastenbaum (2009, 2012), there are some problems with Kübler-Ross’ approach:

• The existence of the five-stage sequence has not been demonstrated by either Kübler-Ross or independent research.

• The five-stage interpretation neglected the patients’ situations, including relationship support, specific effects of illness, family obligations, and institutional climate in which they were interviewed.

Despite these shortcomings, however, Kübler-Ross’ pioneering efforts were important in calling attention to the needs of people who are attempting to cope with life-threatening illnesses. She did much to encourage attention to the quality of life for dying persons and their families.

Because of the criticisms of Kübler-Ross’ stages, some psychologists prefer to describe them not as stages but as potential reactions to dying. At any one moment, a number of emotions may wax and wane. Hope, disbelief, bewilderment, anger, and acceptance may come and go as individuals try to make sense of what is happening to them (Renz & others, 2013).

In facing their own death, some individuals struggle until the end, desperately trying to hang on to their lives. Acceptance of death never comes for them. Some psychologists believe that the harder individuals fight to avoid the inevitable death they face and the more they deny it, the more difficulty they will have in dying peacefully and in a dignified way; other psychologists argue that not confronting death until the end may be adaptive for some individuals (Lifton, 1977).

developmental connection

Religion

Religion can fulfill some important psychological needs in older adults, helping them face impending death and accept the inevitable losses in old age. Connect to “Cognitive Development in Late Adulthood.”

The extent to which people have found meaning and purpose in their lives is linked with how they approach death (Balon & Morreale, 2016; Kalanithi, 2016). One study revealed that individuals with a chronic, life-threatening illness—congestive heart failure—were trying to find meaning in life (Park & others, 2008). In another study, individuals with less than three months to live who had found purpose and meaning in their lives felt the least despair in their final weeks, whereas dying individuals who saw no reason for living were the most distressed and wanted to hasten death (McClain, Rosenfeld, & Breitbart, 2003). In this and other studies, spirituality helped to buffer dying individuals from severe depression (Park, 2012a, b). Researchers also have found that the closer critically ill patients get to death the more religious they become (Park, 2010).

PERCEIVED CONTROL AND DENIAL

Perceived control may work as an adaptive strategy for some older adults who face death. When individuals are led to believe they can influence and control events—such as prolonging their lives—they may become more alert and cheerful. Giving nursing home residents options for control improved their attitudes and increased their longevity (Rodin & Langer, 1977).

Man is the only animal that finds his own existence a problem he has to solve and from which he cannot escape. In the same sense man is the only animal who knows he must die.

—Erich Fromm

American Psychotherapist, 20th Century

Denial also may be a fruitful way for some individuals to approach death. It can be adaptive or maladaptive (Cottrell & Duggleby, 2016). Denial can be used to avoid the destructive impact Page 616of shock by delaying the necessity of dealing with one’s death. Denial can insulate the individual from having to cope with intense feelings of anger and hurt; however, if denial keeps us from undergoing a life-saving operation, it clearly is maladaptive. Denial is neither good nor bad; its adaptive qualities need to be evaluated on an individual basis.

THE CONTEXTS IN WHICH PEOPLE DIE

For dying individuals, the context in which they die is important (Hemati & others, 2016; Thompson & others, 2016). More than 50 percent of Americans die in hospitals and nearly 20 percent die in nursing homes. Some people, though, spend their final days in isolation and fear. An increasing number of people choose to die in the humane atmosphere of a hospice (Fridman & others, 2018; Wang & others, 2017). A Canadian study found that 71 percent of adults preferred to be at home if they were near death, 15 percent preferred to be in a hospice/palliative care facility, 7 percent preferred to be in a hospital, and only 2 percent preferred to be in a nursing home (Wilson & others, 2013).

What are some positive and negative aspects of dying at home compared with dying in a hospital? ©Photodisc/Getty Images

Hospitals offer several important advantages to the dying individual; for example, professional staff members are readily available, and the medical technology present may prolong life. But a hospital may not be the best place for many people to die. Most individuals say they would rather die at home (Bannon & others, 2018; Carr & Luth, 2016). Many feel, however, that they will be a burden at home, that space is inadequate there, and that dying at home may alter relationships. Individuals who are facing death also worry about the competency of caregivers and availability of emergency medical treatment if they remain at home.

Review Connect Reflect

LG4 Explain the psychological aspects involved in facing one’s own death and
the contexts in which people die.

Review

• What are Kübler-Ross’ five stages of dying? What conclusions can be reached about them?

• What roles do perceived control and denial play in facing one’s own death?

• What are the contexts in which
  people die?

Connect

• In this section, you learned that the extent to which people have found meaning and purpose in their lives is linked with how they approach death. What did Roy Baumeister and Kathleen Vohs say are the four main needs for meaning that guide how people try to make sense of their lives?

Reflect Your Own Personal Journey of Life

• How do you think you will psychologically handle facing your own death?

5 Coping with the Death of Someone Else

LG5 Identify ways to cope with the death of another person.

Communicating with
a Dying Person

Grieving

Making Sense of the World

Losing a Life Partner

Forms of Mourning

Loss can come in many forms in our lives—divorce, a pet’s death, being fired from a job—but no loss is greater than that which comes through the death of someone we love and care for, such as a parent, sibling, spouse, relative, or friend. In the ratings of life’s stresses that require the most adjustment, death of a spouse is given the highest number. How should we communicate with a dying individual? How can we cope with the death of someone we love?

COMMUNICATING WITH A DYING PERSON

Most psychologists argue that it is best for dying individuals to know that they are dying and for significant others to know they are dying so they can interact and communicate with each Page 617other on the basis of this mutual knowledge (Banja, 2005). What are some of the advantages of this open awareness for the dying individual? First, dying individuals can close their lives in accord with their own ideas about proper dying. Second, they may be able to complete some plans and projects, to make arrangements for survivors, and to participate in decisions about a funeral and burial. Third, dying individuals have the opportunity to reminisce and to converse with people who have been important to them. And fourth, individuals who know they are dying have more understanding of what is happening within their bodies and what the medical staff is doing for them (Kalish, 1981).

connecting development to life

Effective Strategies for Communicating with a Dying Person

Effective strategies for communicating with a dying person include the following suggestions:

• Establish your presence, be at the same eye level; don’t be afraid to touch the dying person—dying individuals are often starved for human touch.

• Eliminate distraction—for example, ask if it is okay to turn off the TV. Realize that excessive small talk can be a distraction.

• Dying individuals who are very frail often have little energy. If the dying person you are visiting is very frail, you may not want to visit for very long.

• Don’t insist that the dying person feel acceptance about death if the dying person wants to deny the reality of the situation; on the other hand, don’t insist on denial if the dying individual indicates acceptance.

• Allow the dying person to express guilt or anger; encourage the expression of feelings.

• Don’t be afraid to ask the person what the expected outcome for the illness is. Discuss alternatives and unfinished business.

• Sometimes dying individuals don’t have access to other people. Ask the dying person if there is anyone he or she would like to see that you can contact.

• Encourage the dying individual to reminisce, especially if you have memories in common.

• Talk with the individual when she or he wishes to talk. If this is impossible, make an appointment and keep it.

• Express your regard for the dying individual. Don’t be afraid to express love, and don’t be afraid to say good-bye.

What are some good strategies for communicating with a dying person? ©Stockbroker/Photolibrary

In addition to keeping communication open, some experts reason that conversation should not focus on mental pathology or preparation for death but should focus on strengths of the individual and preparation for the remainder of life. Since external accomplishments are not possible, communication should be directed toward internal growth. Keep in mind also that important support for a dying individual may come not only from mental health professionals but also from nurses, physicians, a spouse, or intimate friends. In Connecting Development to Life, you can read further about effective ways to communicate with a dying person.

GRIEVING

Our exploration of grief focuses on dimensions of grieving, the dual-process model of coping with bereavement, and cultural diversity in healthy grieving.

Dimensions of Grieving Grief is the emotional numbness, disbelief, separation anxiety, despair, sadness, and loneliness that accompany the loss of someone we love. Grief is not a simple emotional state but rather a complex, evolving process with multiple dimensions (Bui & Okereke, 2018; Lichtenberg, 2017; Sheperd, 2018; Waller & others, 2016). In this view, pining Page 618for the lost person is one important dimension. Pining or yearning reflects an intermittent, recurrent wish or need to recover the lost person. Another important dimension of grief is separation anxiety, which not only includes pining and preoccupation with thoughts of the deceased person but also focuses on places and things associated with the deceased, as well as crying or sighing (Root & Exline, 2014; Sirrine, Salloum, & Boothroyd, 2017). Grief may also involve despair and sadness, which include a sense of hopelessness and defeat, depressive symptoms, apathy, loss of meaning for activities that used to involve the person who is gone, and growing desolation (Milic & others, 2017; Schwartz, Howell, & Jamison, 2018). One study found that older adults who were bereaved had more dysregulated cortisol patterns, indicative of the intensity of their stress (Holland & others, 2014). And another study found that college students who had lost someone close to them in campus shootings and had severe posttraumatic stress symptoms four months after the shootings were more likely to have severe grief one year after the shootings (Smith & others, 2015).

Everyone can master grief but he who has it.

—William Shakespeare

English Playwright, 17th Century

The feelings involved in grief occur repeatedly shortly after a loss (Shear, 2012a, b). As time passes, pining and protest over the loss tend to diminish, although episodes of depression and apathy may remain or increase. The sense of separation anxiety and loss may continue to the end of one’s life, but most of us emerge from grief’s tears, turning our attention once again to productive tasks and regaining a more positive view of life (Mendes, 2016).

The grieving process is more like a roller-coaster ride than an orderly progression of stages with clear-cut time frames. The ups and downs of grief often involve rapidly changing emotions, meeting the challenges of learning new skills, detecting personal weaknesses and limitations, creating new patterns of behavior, and forming new friendships and relationships (Feldon, 2003). For most individuals, grief becomes more manageable over time, with fewer abrupt highs and lows. But many grieving spouses report that even though time has brought some healing, they have never gotten over their loss. They have just learned to live with it. One study found that individuals in the early stages of spousal bereavement are at increased risk for distress in situations with special significance for the couple, such as the late spouse’s birthday or a wedding anniversary (Carr & others, 2014).

Long-term grief is sometimes masked and can predispose individuals to become depressed and even suicidal (Miller, 2012). Good family communication can help reduce the incidence of depression and suicidal thoughts. An estimated 80 to 90 percent of survivors experience normal or uncomplicated grief reactions that include sadness and even disbelief or considerable anguish. By six months after their loss, they accept it as a reality, are more optimistic about the future, and function competently in their everyday lives.

However, even six months after their loss, some individuals have difficulty moving on with their lives and continue feeling numb or detached, believing their life is empty without the deceased, and feeling that the future has no meaning. This type of grief reaction has been referred to as prolonged or complicated grief (Glickman, Shear, & Wall, 2016; Holland & others, 2016; Li, Tendeiro, & Stroebe, 2018; Tsai & others, 2018). It is estimated that approximately 7 to 10 percent of bereaved individuals have this type of grief (Maccalum & Bryant, 2013; Shear, Ghesquiere, & Glickman, 2013). Prolonged grief, in which feelings of despair remain unresolved over an extended period of time, is described as complicated grief or prolonged grief disorder (Maciejewski & Prigerson, 2017; Prigerson & Maciejewski, 2014). Prolonged grief usually has negative consequences for physical and mental health (Djelantik & others, 2017; Tang & Chow, 2017; Trevino & others, 2018). A person who loses someone on whom he or she was emotionally dependent is often at greatest risk for developing prolonged grief (Rodriquez Villar & others, 2012). Also, a recent 7-year longitudinal study of older adults found that those who were experiencing prolonged grief had greater cognitive decline than their counterparts with normal grief (Perez & others, 2018). And another recent study revealed that individuals with complicated grief had a higher level of the personality trait neuroticism (Goetter & others, 2018).

Complicated grief or prolonged grief disorder was considered for possible inclusion in DSM-V, the psychiatric classification system for mental health disorders (Bryant, 2012, 2013). Although it ended up not being included as a psychiatric disorder, it was described in an Appendix (American Psychiatric Association, 2013). The argument for not including complicated grief or prolonged grief as a psychiatric disorder was based on concerns that normal grieving would be viewed as a medical condition (Breen & others, 2015).

Recently, there has been a substantial amount of research on complicated or prolonged grief (Breen & others, 2018; Heeke & others, 2017; Li & Prigerson, 2016; Nam, 2016; Nielsen & Page 619others, 2017; Trevino & others, 2018; Wilson & others, 2017). Following are studies that provide information about various aspects of complicated or prolonged grief disorder:

• In a recent meta-analysis, 9.8 percent of adult bereavement cases were classified as characterized by prolonged grief disorder (Lundorff & others, 2017). In this study, the older individuals were, the more likely prolonged grief disorder was present.

• Prolonged grief was more likely to occur when individuals had lost their spouse, lost a loved one unexpectedly, or spent time with the deceased every day in the last week of the person’s life (Fujisawa & others, 2010).

• Adults with depression were more likely to also have complicated grief (Sung & others, 2011).

• Complicated grief was more likely to be present in older adults when the grief was in response to the death of a child or a spouse (Newsom & others, 2011).

• Among individuals diagnosed with complicated grief, 40 percent reported at least one full or limited-symptom grief-related panic attack in the past week (Bui & others, 2015).

• Cognitive-behavior therapy reduced prolonged grief symptoms (Bartl & others, 2018).

Another type of grief is disenfranchised grief, which describes an individual’s grief over a deceased person that is a socially ambiguous loss and can’t be openly mourned or supported (Patlamazoglou, Simmonds, & Snell, 2018; Tullis, 2017; Yu & others, 2016). Examples of disenfranchised grief include a relationship that isn’t socially recognized such as an ex-spouse, a hidden loss such as an abortion, and circumstances of the death that are stigmatized such as death because of AIDS. Disenfranchised grief may intensify an individual’s grief because the feelings cannot be publicly acknowledged. This type of grief may be hidden or repressed for many years, only to be reawakened by later deaths.

A death can sometimes bring out the best in people as they provide support and caring for the grieving person, but in other cases a death can bring out the worst in people (Lightner & Hathaway, 1990). When death brings out the best, mourners feel recognized and consoled, touched by others’ sympathy, and shored up by their kindness. Consider Jennifer Block’s experience. After her husband died, her best friend encouraged her to get out and do things. The friend called Jennifer every day and took her out for ice cream, on walks, and to community events. Jennifer says that she will never forget her friend’s support and caring.

Sometimes, however, friends may say and do the wrong things when someone dies (Lightner & Hathway, 1990). Their grieving friend may feel slighted, insulted, disappointed, and alone when this happens. Perhaps a friend disappears from sight or makes an inappropriate or cruel remark, such as “I thought you two were not getting along that well anyway.” Consider Martha Cooper’s experience. When her husband died, her friend told her to forget that part of her life because it was over. Martha was terribly disappointed at her friend’s lack of empathy. As Martha remarked, you can’t just forget about someone who was a part of your life for 45 years.

Dual-Process Model of Coping with Bereavement The dual-process model of coping with bereavement has two main dimensions: (1) loss-oriented stressors, and (2) restoration-oriented stressors (Stroebe & others, 2017a, b; Stroebe & Schut, 2015, 2017). Loss-oriented stressors focus on the deceased individual and can include grief work and both positive and negative reappraisals of the loss. A positive reappraisal of the loss might include acknowledging that death brought relief at the end of suffering, whereas a negative reappraisal might involve yearning for the loved one and ruminating about the death. Restoration-oriented stressors involve the secondary stressors that emerge as indirect outcomes of bereavement (Caserta & others, 2014; Mulligan & Karel, 2018). They can include a changing identity (such as from “wife” to “widow”) and mastering skills (such as dealing with finances). Restoration rebuilds “shattered assumptions about the world and one’s own place in it.”

In the dual-process model, effective coping with bereavement often involves an oscillation between coping with loss and coping with restoration (Albuquerque & others, 2017; Cantwell-Bartl, 2018; Chen & others, 2018; Stroebe & others, 2017a, b). Earlier models often emphasized a sequence of coping with loss through such strategies as grief work as an initial phase, followed by restoration efforts. However, in the dual-process model, coping with loss and engaging in restoration can be carried out concurrently (Richardson, 2007). According to this model, the person coping with death might be involved in grief group therapy while settling the affairs of Page 620the loved one. Oscillation might occur in the short term during a particular day as well as across weeks, months, and even years. Although loss and restoration coping can occur concurrently, over time there often is an initial emphasis on coping with loss followed by greater emphasis on restoration (Milberg & others, 2008).

Recently, a variation of the dual-process model has been developed for families (Stroebe & Schut, 2015, 2017; Stroebe & others, 2017a, b). The original model focused mainly on the bereaved individual but many people do not grieve in isolation; most do so with immediate family members and relatives who also are bereaved by the loss. This recent extension of the dual-process model also focuses on such matters as reduced finances, legal consequences, and changed family relationships that that have to be dealt with, and seeks to integrate intrapersonal and interpersonal coping.

Coping and Type of Death The impact of death on surviving individuals is strongly influenced by the circumstances under which the death occurred (Lovgren & others, 2018; Tobin, Lambert, & McCarthy, 2018). Deaths that are sudden, untimely, violent, or traumatic are likely to have more intense and prolonged effects on surviving individuals and make the coping process more difficult for them (Creighton & others, 2018; Feigelman & others, 2018; Pitman & others, 2018). Such deaths often are accompanied by post-traumatic stress disorder (PTSD) symptoms, such as intrusive thoughts, flashbacks, nightmares, sleep disturbance, problems in concentrating, and other difficulties (Nakajima & others, 2012). The death of a child can be especially devastating and extremely difficult for parents to cope with (Eskola & others, 2017; Fu & others, 2018; Keim & others, 2017; Stevenson & others, 2017).

Cultural Diversity in Healthy Grieving Some approaches to grieving emphasize the importance of breaking bonds with the deceased and returning to autonomous lifestyles. People who persist in holding on to the deceased are believed to be in need of therapy. However, some doubt has been cast on whether this recommendation to break bonds is always the best therapeutic advice (Reisman, 2001).

How might grieving vary across individuals and cultures? ©Xinhua/eyevine/Redux

Analyses of non-Western cultures suggest that beliefs about maintaining bonds with the deceased vary extensively. Maintenance of ties with the deceased is accepted and sustained in the religious rituals of Japan. Among the Hopi of Arizona, the deceased are forgotten as quickly as possible and life is carried on as usual. Their funeral ritual concludes with a break-off between mortals and spirits. The diversity of grieving is nowhere more clear than in two Muslim societies—one in Egypt, the other in Bali. In Egypt, the bereaved are encouraged to dwell at length on their grief, surrounded by others who relate similarly tragic accounts and express their own sorrow. By contrast, in Bali, the bereaved are encouraged to laugh and be joyful.

In sum, people grieve in a variety of ways (Bui & Okereke, 2018; Chen & others, 2018). The diverse grieving patterns are culturally embedded practices. Thus, there is no one right, ideal way to grieve. There are many different ways to feel about a deceased person and no set series of stages that the bereaved must pass through to become well adjusted. The stoic widower may need to cry out over his loss at times. The weeping widow may need to put her husband’s wishes aside as she becomes the financial manager of her estate. What is needed is an understanding that healthy coping with the death of a loved one involves growth, flexibility, and appropriateness within a cultural context.

MAKING SENSE OF THE WORLD

Not only do many individuals who face death search for meaning in life, so do many bereaved individuals (Breen & others, 2018; Park, 2016; Steffen & Coyle, 2017). One beneficial aspect of grieving is that it can stimulate people to try to make sense of their world (Bianco, Sambin, & Palmieri, 2017; Kalanithi, 2016). A common occurrence is to go over again and again all of the events that led up to the death. In the days and weeks after the death, the closest family members share experiences with each other, sometimes reminiscing over family experiences. In one study, women who became widowed in midlife were challenged by the crisis of their husband’s death to examine meaningful directions for their lives (Danforth & Glass, 2001). Another study Page 621found that mourners who expressed positive themes of hope showed better adjustment than those who focused on negative themes of pain and suffering (Gamino & Sewell, 2004). And one study revealed that finding meaning in the death of a spouse was linked to a lower level of anger during bereavement (Kim, 2009). In a recent study, meaning-making following a child’s death was examined (Meert & others, 2015). From 8 to 20 weeks following the child’s death, the child’s intensive care physician conducted a bereavement meeting with 53 parents of 35 children who had died. Four meaning-making processes were identified in the meetings: (1) sense making (seeking biomedical explanations for the death, revisiting parents’ prior decisions and roles, and assigning blame); (2) benefit finding (exploring possible positive consequences of the death, such as ways to help others; providing feedback to the hospital; and making donations); (3) continuing bonds (reminiscing about the child, sharing photographs, and participating in community events to honor the child); and (4) identity reconstruction (changes in the parents’ sense of self, including changes in relationships, work, and home).

These restaurant workers, who lost their jobs on 9/11/01, have made a bittersweet return by establishing a New York restaurant they call their own. Colors, named for the many nationalities and ethnic groups among its owners, is believed to be the city’s first cooperative restaurant. World-famous restaurant Windows on the World was destroyed and 73 workers killed when the Twin Towers were destroyed by terrorists. The former Windows survivors at the new venture planned to split 60 percent of the profits between themselves and to donate the rest to a fund to open other cooperative restaurants. ©Thomas Hinton/Splash News/Newscom

When a death is caused by an accident or a disaster, the effort to make sense of it is pursued more vigorously (Park, 2016). As added pieces of news come trickling in, they are integrated into the puzzle. The bereaved want to put the death into a perspective that they can understand—divine intervention, a curse from a neighboring tribe, a logical sequence of cause and effect, or whatever it may be. A study of more than 1,000 college students found that making sense was an important factor in their grieving of a violent loss by accident, homicide, or suicide (Currier, Holland, & Neimeyer, 2006).

LOSING A LIFE PARTNER

In 2015 in the United States, 14 percent of 65- to 74-year-olds, 31 percent of 75- to 84-year-olds, and 59 percent of those 85 and over were widowed (Administration on Aging, 2015). Approximately three times as many women as men are widowed. Those left behind after the death of an intimate partner often suffer profound grief, die earlier, and may endure financial loss, loneliness, increased physical illness, and psychological disorders, including depression (Daoulah & others, 2017; Siflinger, 2017). Consider the following studies that reflect such outcomes:

• In a recent cross-cultural study in the United States, England, Europe, Korea, and China, depression peaked in the first year of widowhood for men and women (Jadhav & Weir, 2017). In this study, women recovered to levels compared to married individuals in all countries, but widowed men continued to have high levels of depression 6 to 10 years post-widowed everywhere except in Europe.

• Becoming widowed was associated with a 48 percent increase in earlier death (Sullivan & Fenelon, 2014).

• Mexican American older adults experienced a significant increase in depressive
  symptoms during the transition to widowhood (Monserud & Markides, 2017). In this study, frequent church attendance was a protective factor against increases in depressive symptoms.

• Widowed individuals who reported having higher marital quality subsequently had more depressive symptoms after their spouse died (Schaan, 2013).

• Volunteering reduced widowed older adults’ loneliness (Carr & others, 2018)

developmental connection

Stress

Meaning-making coping involves drawing on beliefs, values, and goals to change the meaning of a stressful situation, especially in times of chronic stress such as when a loved one dies. Connect to “Physical and Cognitive Development in Middle Adulthood.”

Becoming widowed is likely to be especially difficult when individuals have been happily married for a number of decades. In such circumstances, losing your spouse, who may also be your best friend and with whom you have lived a deeply connected life, can be extremely upsetting and difficult to cope with.

A widow holds the photo of her husband who was killed in Afghanistan. What are some factors that are related to the adjustment of a widow after the death of her husband? ©Peter Power/Toronto Star/Getty Images

Surviving spouses seek to cope with the loss of their spouse in various ways (Bennett & others, 2018; Collins, 2018; Hasmanova, 2016; Park, 2016). In one study, widowed individuals were more likely to intensify their religious and spiritual beliefs following the death of a spouse, and this increase was linked with a lower level of grief (Brown & others, 2004). Another study revealed that finding meaning in the death of a spouse was linked to a lower level of anger during bereavement (Kim, 2009). And researchers have found that widowed persons who did Page 622not expect to be reunited with their loved ones in the afterlife reported more depression, anger, and intrusive thoughts at 6 and 18 months after their loss (Carr & Sharp, 2014). The poorer and less educated they are, the lonelier they tend to be. The bereaved are also at increased risk for many health problems (Jadhav & Weir, 2017).

developmental connection

Community and Culture

For older adults, social support is linked with a reduction in the symptoms of disease and increased longevity. Connect to “Socioemotional Development in Late Adulthood.”

Optimal adjustment after a death depends on several factors (Recksiedler & others, 2018). For example, researchers have found that religiosity and coping skills are related to well-being following the loss of a spouse in late adulthood (Jones & others, 2018; Kristiansen & others, 2016).

Also, for both widows and widowers, social support helps them adjust to the death of a spouse (Dahlberg, Agahi, & Lennartsson, 2018; Hendrickson & others, 2018; Huang & others, 2017; Shankar & others, 2017). The Widow-to-Widow program, begun in the 1960s, provides support for newly widowed women. Volunteer widows reach out to other widows, introducing them to others who may have similar problems, leading group discussions, and organizing social activities. The program has been adopted by the AARP and disseminated throughout the United States as the Widowed Persons Service. The model has since been adopted by numerous community organizations to provide support for those going through a difficult transition. Other widow support groups also are often beneficial in reducing depression in bereaved spouses (Collins, 2018; Recksiedler & others, 2018).

developmental connection

Religion

Religious participation is positively linked to health and longevity. Connect to “Physical and Cognitive Development in Middle Adulthood.”

FORMS OF MOURNING

One decision facing the bereaved is what to do with the body. In the United States, in 2016, 50.1 percent of deaths were followed by cremation—a significant increase from a cremation rate of 14 percent in 1985 and 27 percent in 2000 (Cremation Association of North America, 2017). In 2016, in Canada 70.2 percent of deaths were followed by cremation. Projections indicate that in 2020, 56.3 percent of U.S. deaths will be followed by cremation while Canada will increase to 79.8 percent. Cremation is more popular in the Pacific region of the United States, less popular in the South. Cremation also is more popular in Canada than in the United States and most popular of all in Japan and many other Asian countries.

The funeral is an important aspect of mourning in many cultures. In the United States, the trend is away from public funerals and displaying the dead body in an open casket and toward private funerals followed by a memorial ceremony (Beard & Burger, 2017, 2018).

The funeral industry in the United States has been a focus of controversy in recent years (Beard & Burger, 2017, 2018). Funeral directors and their supporters argue that the funeral provides a form of closure to the relationship with the deceased, especially when there is an open casket. Their critics claim that funeral directors are just trying to make money and that embalming is grotesque. One way to avoid being exploited during bereavement is to purchase funeral arrangements in advance, but many people are reluctant to do this.

(Left) A widow leading a funeral procession in the United States. (Right) A crowd gathered at a cremation ceremony in Bali, Indonesia, balancing decorative containers on their heads. (Left) ©Russell Underwood/Corbis/Getty Images; (right) ©Paul Almasy/Corbis/VCG/Getty Images

Page 623In some cultures, a ceremonial meal is shared after a death; in others, a black armband is worn by bereaved family members for one year following a death. Cultures vary in how they practice mourning. Two of those cultures are the Amish and traditional Judaism (Worthington, 1989).

The Amish are a conservative Christian group with approximately 80,000 members in the United States, Ontario, and several small settlements in South and Central America. The Amish live in a family-oriented society in which family and community support are essential for survival. Today, they live at the same unhurried pace as that of their ancestors, using horses instead of cars and facing death with the same steadfast faith as their forebears. At the time of death, close neighbors assume the responsibility of notifying others of the death. The Amish community handles virtually all aspects of the funeral.

The funeral service is held in a barn in the warmer months and in a house during colder months. Calm acceptance of death, influenced by a deep religious faith, is an integral part of the Amish culture. Following the funeral, a high level of support is given to the bereaved family for at least a year. Visits to the family, special scrapbooks and handmade items for family members, new work projects started for the widow, and quilting days that combine fellowship and productivity are among the supports given to the bereaved family. A profound example of the Amish culture’s religious faith and acceptance of death occurred after Charles Roberts shot and killed five Amish schoolgirls and then apparently took his own life in October 2006 in Bart Township, Pennsylvania. Soon after the murders and suicide, members of the Amish community visited his widow and offered their support and forgiveness.

The family and community also have specific and important roles in mourning in traditional Judaism. The program of mourning is divided into graduated time periods, each with its appropriate practices. The observance of these practices is required of the spouse and the immediate blood relatives of the deceased. The first period is aninut, the period between death and burial. The next two periods make up avelut, or mourning proper. The first of these is shivah, a period of seven days, which commences with the burial. It is followed by sheloshim, the 30-day period following the burial, including shivah. At the end of sheloshim, the mourning process is considered over for all but one’s parents. For parents, mourning continues for 11 months, although observances are minimal.

(Top) A funeral procession of horse-drawn buggies on their way to the burial of five young Amish girls who were murdered in October 2006. A remarkable aspect of their mourning involved the outpouring of support and forgiveness they gave to the widow of the murderer. (Bottom) Meeting in a Jewish graveyard. (Top) ©Glenn Fawcett/Baltimore Sun; (bottom) ©Robert Mulder/Corbis/Getty Images

The seven-day period of the shivah is especially important in traditional Judaism. The mourners, sitting together as a group through an extended period, have an opportunity to project their feelings to the group as a whole. Visits from others during shivah may help the mourners deal with feelings of guilt. After shivah, the mourners are encouraged to resume normal social interaction. In fact, it is customary for the mourners to walk together a short distance as a symbol of their return to society. In its entirety, the elaborate mourning system of traditional Judaism is designed to promote personal growth and to reintegrate bereaved individuals into the community.

Review Connect Reflect

LG5 Identify ways to cope with the death of another person.

Review

• What are some strategies for communicating with a dying person?

• What is the nature of grieving?

• How is making sense of the world a beneficial outcome of grieving?

• What are some characteristics and outcomes of losing a life partner?

• What are some forms of mourning? What is the nature of a funeral?

Connect

• In this section, we learned that one advantage of knowing you are dying is that you have the opportunity to reminisce. Which of Erikson’s stages of development involves reflecting on the past and either piecing together a positive review or concluding that one’s life has not been well spent?

Reflect Your Own Personal Journey of Life

• What are considered appropriate forms of mourning in the culture in which you live?

Page 624

topical connections looking back

We have arrived at the end of Life-Span Development. I hope this edition and course have been a window to the life span of the human species and a window to your own personal journey in life.

Our study of the human life span has been long and complex. You have read about many physical, cognitive, and socioemotional changes that take place from conception through death. This is a good time to reflect on what you have learned. Which theories, studies, and ideas were especially interesting to you? What did you learn about your own development?

I wish you all the best in the remaining years of your journey through the human life span.

reach your learning goals

Death, Dying, and Grieving

1 The Death System and Cultural Contexts

LG1 Describe the death system and its cultural and historical contexts.

The Death System and Its Cultural Variations

Changing Historical Circumstances

• In Kastenbaum’s view, every culture has a death system that involves these components:
  people, places, times, objects, and symbols. Most cultures do not view death as the end of existence—spiritual life is thought to continue. Most societies throughout history have had philosophical or religious beliefs about death, and most societies have rituals that deal with death. The United States has been described as more of a death-denying and death-avoiding culture than most cultures.

• When, where, and why people die have changed historically. Today, death occurs most often among older adults. More than 80 percent of all deaths in the United States now occur in a hospital or other institution; our exposure to death in the family has been minimized.

2 Defining Death and Life/
Death Issues

LG2 Evaluate issues in determining death and decisions regarding death.

Issues in Determining
Death

Decisions Regarding Life, Death, and Health Care

• Twenty-five years ago, determining whether someone was dead was simpler than it is today. Brain death is a neurological definition of death which states that a person is brain dead when all electrical activity of the brain has ceased for a specified period of time. Medical experts debate whether this cessation should include the higher and lower brain functions or just the higher cortical functions. Currently, most physicians define brain death as the death of both the higher cortical functions and the lower brain stem functions.

• Decisions regarding life, death, and health care can involve creating a living will, considering the possibility of euthanasia, and arranging for hospice care. Living wills and advance
  directives are increasingly used.

• Euthanasia (“mercy killing”) is the act of painlessly ending the life of a person who is suffering from an incurable disease or disability. Distinctions are made between active and passive euthanasia. Assisted suicide involves the patient self-administering the lethal medication.
  Hospice care emphasizes reducing pain and suffering rather than prolonging life. Page 625

3 A Developmental Perspective
on Death

LG3 Discuss death and attitudes about it at different points in development.

Causes of Death

Attitudes Toward Death
at Different Points in
the Life Span

• Although death is more likely to occur in late adulthood, death can come at any point in development. In children and younger adults, death is more likely to occur because of accidents or illness; in older adults, death is more likely to occur because of chronic illnesses such as heart disease or cancer.

• Infants do not have a concept of death. Preschool children also have little concept of death. Preschool children sometimes blame themselves for a person’s death.

• In the elementary school years, children develop a more realistic orientation toward death. Most psychologists argue that honesty is the best strategy for helping children cope with death.

• Death may be glossed over in adolescence. Adolescents have more abstract, philosophical views of death than children do.

• There is no evidence that a special orientation toward death emerges in early adulthood. Middle adulthood is a time when adults show a heightened consciousness about death and death anxiety. Older adults often show less death anxiety than middle-aged adults, but older adults experience and converse about death more. Attitudes about death may vary considerably among adults of any age.

4 Facing One’s Own Death

LG4 Explain the psychological aspects involved in facing one’s own death and the contexts in which people die.

Kübler-Ross’ Stages
of Dying

Perceived Control
and Denial

The Contexts in Which People Die

• Kübler-Ross proposed five stages of dying: denial and isolation, anger, bargaining, depression, and acceptance. Not all individuals go through the same sequence.

• Perceived control and denial may work together as an adaptive orientation for the dying
  individual. Denial can be adaptive or maladaptive, depending on the circumstances.

• The fact that most deaths in the United States occur in hospitals has advantages and disadvantages. Most individuals say they would rather die at home, but they are concerned that they will be a burden to family members and they worry about the lack of medical care
  at home.

5 Coping with the Death
of Someone Else

LG5 Identify ways to cope with the death of another person.

Communicating with a Dying Person

Grieving

Making Sense of the World

Losing a Life Partner

Forms of Mourning

• Most psychologists recommend open communication with the dying. Communication should not dwell on mental pathology or preparation for death but should emphasize the dying
  person’s strengths.

• Grief is the emotional numbness, disbelief, separation anxiety, despair, sadness, and loneliness that accompany the loss of someone we love. Grief is multidimensional and in some cases may last for years. Prolonged grief involves enduring despair that is still unresolved after an extended period of time.

• In the dual-process model of coping with bereavement, oscillation occurs between two
  dimensions: (1) loss-oriented stressors and (2) restoration-oriented stressors. Grief and
  coping vary with the type of death. There are cultural variations in grieving.

• The grieving process may stimulate individuals to strive to make sense of their world. When a death is caused by an accident or disaster, the effort to make sense of it is pursued more vigorously. Page 626

• The death of an intimate partner often leads to profound grief. The bereaved are at risk
  for many health problems, although there are variations in the distress experienced by a
  surviving spouse. Social support benefits widows and widowers.

• Forms of mourning vary across cultures. Approximately two-thirds of corpses are disposed
  of by burial, one-third by cremation. An important aspect of mourning in many cultures is the funeral. In recent years, the funeral industry has been the focus of controversy. In some cultures, a ceremonial meal is shared by mourners after a death.

• key terms

• acceptance

• active euthanasia

• anger

• assisted suicide

• bargaining

• brain death

• denial and isolation

• depression

• dual-process model

• euthanasia

• grief

• hospice

• palliative care

• passive euthanasia

• prolonged grief disorder

• key people

• Robert Kastenbaum

• Elisabeth Kübler-Ross

THIS BOOK REFERENCE IN APA FORMAT:

Santrock, J. W. (2019). Life-span development (17th ed.). New York, NY: McGraw-Hill Education.