Death and Dying
Causes and Symptoms (Magill’s Medical Guide, Sixth Edition)
Medicine determines that death has occurred by assessing bodily functions in either of two areas. Persons with irreversible cessation of respiration and circulation are dead; persons with irreversible cessation of ascertainable brain functions are also dead. There are standard procedures used to diagnose death, including simple observation, brain-stem reflex studies, and the use of confirmatory testing such as electrocardiography (ECG or EKG), electroencephalography (EEG), and arterial blood gas analysis (ABG). The particular circumstances—anticipated or unanticipated, observed or unobserved, the patient’s age, drug or metabolic intoxication, or suspicion of hypothermia—will favor some procedures over others, but in all cases both cessation of functions and their irreversibility are required before death can be declared.
Between 60 and 75 percent of all people die from chronic terminal conditions. Therefore, except in sudden death (as in a fatal accident) or when there is no evidence of consciousness (as in a head injury which destroys cerebral, thinking functions while leaving brain-stem, reflexive functions intact), dying is both a physical and a psychological process. In most cases, dying takes time, and the time allows patients to react to the reality of their own passing. Often, they react by becoming vigilant about bodily symptoms and any changes in them. They also anticipate changes that have yet to occur....
(The entire section is 785 words.)
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Complications and Disorders (Magill’s Medical Guide, Sixth Edition)
Denial is Kübler-Ross’s first stage, but it is also linked to shock and isolation. Whether the news is told outright or gradual self-realization occurs, most people react to the knowledge of their impending death with existential shock: Their whole selves recoil at the idea, and they say, in some fashion, “This cannot be happening to me. I must be dreaming.” Broadly considered, denial is a complex cognitive-emotional capacity which enables temporary postponement of active, acute, but in some way detrimental, recognition of reality. In the dying process, this putting off of the truth prevents a person from being overwhelmed while promoting psychological survival. Denial plays an important stabilizing role, holding back more than could be otherwise managed while allowing the individual to marshal psychological resources and reserves. It enables patients to consider the possibility, even the inevitability, of death and then to put the consideration away so that they can pursue life in the ways that are still available. In this way, denial is truly a mechanism of defense.
Many other researchers, along with Kübler-Ross, report anger as the second stage of dying. The stage is also linked to rage, fury, envy, resentment, and loathing. When “This cannot be happening to me” becomes, “This is happening to me. There was no mistake,” patients are beginning to replace denial with attempts to understand what is...
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Perspective and Prospects (Magill’s Medical Guide, Sixth Edition)
Every person eventually dies, and the fact of death in each life is one that varies by culture in terms of its meaning. For some cultures, dying is seen as the ultimate difficulty for dying people and their loved ones. For other cultures, it is seen as not difficult at all, but more so like passing on to another realm of existence. In Western cultures, however, dying has very much become a medical process, and it is often a process filled with challenging questions. Patients ask questions that cannot be answered; families in despair and anger seek to find cause and sometimes lay blame. It takes courage to be with individuals as they face their deaths, struggling to find meaning in the time that they have left. Given this, in Western medicine, a profession that prides itself on how well it intervenes to avoid outcomes like death, it takes courage to witness the process and struggle involved in death. Working with death also reminds professionals of their own inevitable death. Facing that fact inwardly, spiritually, and existentially also requires courage.
Cure and treatment become care and management in the dying. They should live relatively pain-free, be supported in accomplishing their goals, be respected, be involved in decision making as appropriate, be encouraged to function as fully as their illness allows, and be provided with others to whom control can comfortably and confidently be passed. The lack of a cure...
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For Further Information: (Magill’s Medical Guide, Sixth Edition)
Becker, Ernest. The Denial of Death. New York: Free Press, 1997. Written by an anthropologist and philosopher, this is an erudite and insightful analysis and synthesis of the role that the fear of death plays in motivating human activity, society, and individual actions. A profound work.
Cook, Alicia Skinner, and Daniel S. Dworkin. Helping the Bereaved: Therapeutic Interventions for Children, Adolescents, and Adults. New York: Basic Books, 1992. Although not a self-help book, this work is useful to professionals and nonprofessionals alike as a review of the state of the art in grief therapy. Practical and readable. Of special interest for those becoming involved in grief counseling.
Corr, Charles A., Clyde M. Nabe, and Donna M. Corr. Death and Dying, Life and Living. 6th ed. Belmont, Calif.: Wadsworth/Cengage Learning, 2009. This book provides perspective on common issues associated with death and dying for family members and others affected by life-threatening circumstances.
Forman, Walter B., et al., eds. Hospice and Palliative Care: Concepts and Practice. 2d ed. Sudbury, Mass.: Jones and Bartlett, 2003. A text that examines the theoretical perspectives and practical information about hospice care. Other topics include community medical care, geriatric care, nursing care, pain management, research, counseling, and hospice management.
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Death and Dying
Introduction (Psychology and Mental Health)
People are unique while they are alive, and that uniqueness extends to death and dying. The manner in which people encounter and cope with a terminal disease and the dying process holds endless variations.
The Hippocratic philosophy of medicine declares that a physician must act in the best interests of the patient seeking care. The goal of medical care is to overcome sickness and relieve suffering, thus preserving life. Sometimes, however, it is necessary to add to a patient’s suffering to achieve ultimate relief, as with cancer treatments such as chemotherapy and radiation, and surgery that may result in periods of debilitation. These treatments are generally acceptable if there is a reasonable promise that they may ultimately reduce or eradicate a disease or condition. When only a small possibility of survival exists, however, patients may decide to end or forgo a particular course of treatment. That decision is generally made by the patient and the family in conjunction with the medical team. Religious and philosophical factors as well as age, family values, and family history may enter into the decision. Generational differences may also affect how the patient and the family approach or ultimately accept a terminal diagnosis.
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Advance Directives (Psychology and Mental Health)
Death is a natural event, but end-of-life experiences are often shaped by new medical, demographic, and cultural trends. Medical professionals have a duty to keep terminally injured or ill patients alive as long as possible by powerful medicines, machines, and aggressive medical care unless the patient desires otherwise. Often, however, patients have not expressed their desires in advance of becoming terminally ill or injured. If patients can no longer speak for themselves, other people must make decisions for them, frequently contrary to what the patients themselves would have wanted. This dilemma can be solved if a person writes a living will or advance directive, a document in which a person’s desires in the case of a terminal illness or injury are recorded in advance of entering such a state.
Advance directives, including durable powers of attorney (DPOA) for health care and do-not-resuscitate orders (DNR), allow legally competent individuals to express their wishes for future health decisions in the event that they are unable to participate directly and actively in medical decisions regarding their care. Patients can also designate a person or surrogate to act as decision maker. Advance directives are valuable because most family members find it difficult, if not overwhelming, to make complex choices about end-of-life care for a loved one. If patients have communicated their wishes about end-of-life care, however,...
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Dying and the Hospice Movement (Psychology and Mental Health)
Most people do not die in a way of their choosing. During the fifteenth century, the Roman Catholic Church introduced a body of literature called ars moriendi, or the “art of dying,” which centered on the concept that people must be aware of and prepare for death during their entire life (this view held that a person’s entire lifetime is a preparation for death). People believed that the only possible attitude toward death was to let it happen once symptoms appeared. The only choice in death was to die in the best way possible, having made peace with God. Over centuries, that concept has evolved into the idea of a “good death,” and programs such as hospices have developed to manage the process of dying and make it as tranquil as possible. Evidence indicates that if they retain their awareness, the dying wish to be treated as human beings until the moment of their death. Preserving the dignity of the dying often means including them in discussions about the decision-making process surrounding their deaths and including them as family members. For a “good death,” or death with dignity, the dying should be treated with compassion, tenderness, dignity, and honesty.
Medical professionals are taught that listening is an important way of gathering information and assessing a patient’s physical and psychological condition. Moreover, listening also is a means of providing comfort. Even when the...
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The Aging Process and Death (Psychology and Mental Health)
The aging process is explained by two main theories: the wear-and-tear theory, which attributes aging to the progressive damage to cells and organs through the process of carrying out their normal everyday functions, and the genetic theory, which holds that aging involves the existence of a genetically predetermined life span that controls the longevity of individual cells, organs, and entire organisms. Environmental factors such as pollutants and toxins in the atmosphere are believed to slowly damage genetic information transmitted by cells, resulting in errors in a cell’s function and leading to its death. Such mutations and cell death are also thought to be caused by free radicals in the atmosphere (unstable compounds that can damage cells) and impeded linkages in people’s deoxyribonucleic acid (DNA). These changes in the organism manifest themselves as aging.
As people age, their bodies change and decrease in complexity, becoming less efficient at carrying out basic processes. For example, as arteries narrow, they begin to lose their ability to carry oxygen and nutrients, and they are less resilient after injury. The ultimate cause of death is generally the result of a progression that involves the entire body: the aging process.
Infection (often in the form of pneumonia) is exceeded only by atherosclerosis (commonly referred to as “hardening of the arteries”) as the leading cause of death of...
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Dying (Psychology and Mental Health)
An innate life force compels the body to continue living, despite the ravages of disease. Ultimately, however, this life force diminishes until it stops completely and irreversibly. As the body begins the dying process, sleeping increases, food and beverage intake gradually decrease, breathing becomes labored and shallow (dyspnea), and periods of apnea (the absence of breathing) become longer and more frequent. Cyanosis, or a bluish discoloration of the skin due to the lack of oxygen and an increase of carbon monoxide, may indicate an impaired circulatory system. Convulsions may also occur as blood pressure falls, oxygen supply to the brain diminishes, and brain cells malfunction. Decaying flesh may also emit an odor, and fever and sweating may occur. The patient may become restless as an increased heart rate attempts to compensate for the lack of oxygen. The exhausted heart ultimately slows and then stops completely. Hearing and vision decrease, and brain activity slows. The so-called death rattle and foaming at the mouth are also indications of the shutting down of the body.
When death has occurred, the person will no longer respond to word or touch. The eyes will be fixed and the eyelids slightly open, the jaw will be relaxed and slightly open, and the skin will assume a dull and lifeless appearance. Medical or clinical death, when the heartbeat and respiration cease, is the oldest means of determining death. Brain death is the...
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Kübler-Ross Stages of Death (Psychology and Mental Health)
Elisabeth Kübler-Ross, a Swiss psychiatrist, revolutionized care of the terminally ill. Credited with helping to end the taboo in Western culture regarding open discussions and studies of death, she helped change the care of many terminally ill patients by making death less psychologically painful. She encouraged health care professionals to speak openly to dying patients about their experiences in facing death, thereby learning from them. This was a revolutionary step because dying was equated with failure by the medical profession.
In her best seller On Death and Dying (1969), Kübler-Ross identified five stages of death based on interviews with patients and health care professionals. The first stage, denial and isolation, occurs when patients are first confronted with a terminal diagnosis and declare that it just cannot be true. Despite overwhelming medical evidence to the contrary, patients will rationalize, thinking that X rays or pathology reports were mixed up and that they can get a more positive diagnosis elsewhere. Patients seek examination and reexamination. Denial acts as a buffer, allowing patients time to collect themselves and digest the shocking news. Denial as a temporary defense is gradually replaced by partial acceptance.
The second stage involves anger, when patients question why they have a terminal condition and feel resentment, envy, and rage. They begin to face reality and...
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Thanatology (Psychology and Mental Health)
Thanatology is the science that studies the events surrounding death and the social, legal, and psychological aspects of death. Health professionals including psychiatrists, forensic pathologists, advanced practice nurses, veterinarians, sociologists, and psychologists are the main members of the thanatology community. Thanatologists may study the cause of deaths, the legal implications of death such as autopsy requirements, and the social aspects surrounding death. Grief, burial customs, and social attitudes about death are frequent subjects. Thanatology also overlaps with forensics when it focuses on the changes that occur in the body in the period near death and afterward.
Some social issues explored by thanatologists, such as euthanasia and abortion, are subject to ethical and legal controversy. Laws set burial, cremation, and embalming requirements and determine rights over the bodies of the deceased. Clinical autopsies are generally required in cases of unexplained or violent death, when suicide or drug overdose is suspected, or when requested by the deceased’s family when a medical error is suspected or to confirm certain diseases.
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Sources for Further Study (Psychology and Mental Health)
Beresford, Larry. The Hospice Handbook: A Complete Guide. Boston: Little Brown, 1993. Extensive introduction to hospice care, discussing basic concepts of palliative care, when hospice is an appropriate choice, how a hospice team operates, and how to choose a hospice.
Despelder, Lynne Ann, and Albert Lee Strickland. The Last Dance: Encountering Death and Dying. 5th ed. Mountain View, Calif.: Mayfield, 1999. A college-level introductory thanatology text. Contains chapters on grief, bereavement, funeral practices, suicide, attitudes about immortality and the afterlife, the health care system, and cross-cultural perspectives on death and dying.
Green, James W. Beyond the Good Death: The Anthropology of Modern Dying. Philadelphia: University of Pennsylvania Press, 2008. An anthropologist looks at contemporary secular American death practices and provides interpretation of American reactions when death is at hand.
Kessler, David. The Needs of the Dying: A Guide for Bringing Hope, Comfort, and Love to Life’s Final Chapter. 10th ed. New York: Harper, 2007. Gently and compassionately deals with key areas of concern: the need of the dying to be treated with dignity, the need for hope, the need to express emotions, the need for honesty, the need for spirituality, and the need to participate in care. Examines the physical and emotional experiences of life-challenging...
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Death and Dying (Encyclopedia of Surgery)
Death is the end of life, a permanent cessation of all vital functions. Dying refers to the body's preparation for death, which may be very short in the case of accidental death, or can last weeks or months in some patients such as those with cancer.
Risks of surgery
Specific risks vary from surgery to surgery and should be discussed with a physician. All surgeries and every administration of anesthesia have some risks; they are dependent upon many factors including the type of surgery and the medical condition of the patient. The patient should ask the anesthesiologist about any risks that may be associated with the anesthesia. Specific standards are set by the American Society of Anesthesiologists to enhance the safety and quality of anesthesia before surgery, basic methods of monitoring patients during surgery, and the best patient care during recovery.
Overwhelming data compiled in 2001 has confirmed that albumin is an effective marker of general nutrition; low albumin levels can increase the likelihood of post-surgery complications such as pneumonia, infection, and the inability to wean from a ventilator, by as much as 50%. In...
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Death and Dying (West's Encyclopedia of American Law)
Death is the end of life. Dying is the process of approaching death, including the choices and actions involved in that process.
Death has always been a central concern of the law. The many legal issues related to death include laws that determine whether a death has actually occurred, as well as when and how it occurred, and whether or not another individual will be charged for having caused it. With the development of increasingly complex and powerful medical procedures and devices in the middle and late twentieth century, the U.S. legal system has had to establish rules and standards for the removal of life-sustaining medical care. This would include, for example, withdrawing an artificial respirator or a feeding tube from a comatose person, or withholding chemotherapy from a terminally ill cancer patient. Such laws and judicial decisions involve the right of individuals to refuse medical treatmentometimes called the right to dies well as the boundaries of that right, particularly in regard to the state's interest in protecting life and the medical profession's right to protect its standards. The issues involved in death and dying have often pitted PATIENTS' RIGHTS groups against physicians' professional organizations as each vies for control over the decision of how and when people die.
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Death and Dying (Encyclopedia of Nursing & Allied Health)
Death is the end of life, a permanent cessation of all vital functions. Dying refers to the body's preparation for death, which may be very short in the case of accidental death, or can last weeks or months in some cancer patients.
Quality and method of death differs between cultures, circumstances and degrees of preparation. For many years, the terminally ill did not have choices in their manner of death, often enduring excruciating pain before the inevitable end of life. In recent years changes have been made to allow for a better quality for end of life, such as hospice care and preparatory actions by the patient.
It is important to recognize the differences in the ways people grieve. Each culture socializes a person in a certain way to deal with death. Death affects a person cognitively, behaviorally and socially. The death and grieving attitudes of a person affect the subjects of death, dying, bereavement, suicide and euthanasia. While a person may be able to verbalize feelings about death, internal contradictory feelings of anxiousness are common. Each person handles the subject individually, and seeking appropriate assistance will help the person to come to terms with the event in his or her own time and way.
A diagnosis of terminal illness is a sad and traumatic circumstance. Hospice care provides quality, caring services for both the patient and his or her loved ones. Most communities have a variety of hospice providers. A physician or hospital patient services can assist with provider names. The yellow pages of the phone book, or referral services from United Way, the local council on aging, Visiting Nurse Association or the American Cancer Society are other information sources.
While the patient should be the one to choose hospice care, it is always appropriate to discuss all care options. Hospice staff are sensitive to concerns of both patient and family members and assist in the planning process as requested. Most physicians are aware of the services provided by hospice and will cooperate fully.
The hospice program will work closely with the physician to optimize the patient's care. The patient will sign consent and insurance forms, which are similar to those signed for hospital admission. There is also a form that states the patient's understanding that hospice care is aimed at pain relief and symptom control (palliative), rather than curative. Should a patient's condition improve and hospice services are no longer necessary, or the patient is in remission, services can be discontinued and the patient may return to regular care options. There is no obligation to remain with hospice care if it is not necessary. Should the patient need readmission to the program, medical insurance and Medicare may allow additional funding for this purpose.
Once hospice services are approved, the provider will perform a needs assessment, then assist in locating the equipment necessary for the patient's care. Quite often, the earlier needs are minimal, increasing as the illness becomes more serious. The purpose of hospice care is to make the home environment a comfortable haven for the patient.
The hospice team prepares a plan of care that is tailored to the patient. This will address the amount of care necessary to maintain the patient's comfort and wellbeing. The staff visits the home regularly and provides instruction on patient care, as well as answers medical questions and supports the caregivers.
As the illness progresses, care becomes more difficult. Hospice plans provide staff around the clock to consult by phone or to make visits if deemed appropriate. Respite care is also available for exhausted caregivers, so that the home can remain functional.
Hospice patients are cared for by a team of doctors, nurses, counselors, social workers, clergy, and volunteers, among others. Each provides assistance based on area of expertise. Additionally, hospices provide supplies, equipment, medications and other services related to the terminal illness. Hospice does not hasten nor does it delay the death process. However, hospices do provide specialized care that eases some of the anxiety and worry that accompany oncoming death.
The management of pain is very often an issue in terminal illness. The mission of hospice is to address all types of pain, not only the physical. Support is available to assist the patient in achieving the highest quality of life possible under individual circumstance. This may include physical and occupational therapists to keep the patient as self-sufficient and mobile as possible. Music therapy, art therapy, massage and diet counseling are available. The latest medications and devices for relief from pain and other symptoms is available. Also, counselors, some of whom are clergy members, assist both the patient and the family as needed/requested. However, hospice programs are not affiliated with religious groups and do not expect participants to adhere to any particular belief system.
The goal of the hospice program is to keep the patient both as pain free and alert as possible. Constant communication with the patient and caregivers assist in the high success rate of the hospice program. After the loved one's death, hospice programs provide both individual and group support for caregivers for at least one year, longer if necessary.
Preparing for death legally
An advance directive is a way to allow caregivers to know a patient's wishes, should the patient become unable to make a medical decision. People who are admitted to hospitals must be told about advance directives at the time of admission. Description of the type of care for different levels of illness should be in an advance directive. For instance, a patient may wish to have or not to have a certain type of care in the case of terminal or critical illness or unconsciousness. An advance directive will protect the patient's wishes in these matters.
A living will is one type of advance directive and may take effect when a patient has been deemed terminally ill. Terminal illness in general assumes a life span of six months or less. A living will allows a patient to outline treatment options without interference from an outside party.
A durable power of attorney for health care (DPA) is similar to a living will; however, it takes effect any time unconsciousness or inability to make informed medical decisions is present. A family member or friend is stipulated in the DPA to make medical decisions on behalf of the patient.
Whie both living wills and DPAs are legal in most states, there are some that do not officially recognize these documents. However, they may still be used to guide families and doctors in treatment wishes.
Do-not-resuscitate (DNR) orders can be incorporated into an advance directive or by informing hospital staff. Unless instructions for a DNR are in effect, hospital staff will make every effort to help patients whose hearts have stopped or who have stopped breathing. DNR orders are recognized in all states and will be incorporated into a patient's medical chart if requested. Patients who benefit from a DNR order are those who have terminal or other debilitating illnesses. It is recommended that this be discussed with a physician by a patient who has not already been considered unable to make sound medical decisions.
None of the above documents are complicated. They may be simple statements of desires for medical care options. If they are not completed by an attorney, they should be notarized and a copy should be given to the doctor, as well as a trusted family member.
In the Hague, Netherlands, euthanasia was legalized in April 2001, and the country became the first in the world to allow doctors to end the lives of patients with painful, terminal illnesses. The Dutch Senate voted 46-28 in favor of the law, which took effect in the summer of 2001.
Prior to the vote, Health Minister Els Borst assured the legislators that euthanasia would not be abused by doctors because of the strict supervision that would accompany the measure. The practice has been discreetly practiced in the Netherland for decades, and preliminary guidelines were established by the country's Parliament in 1993.
In the United States, Oregon has permitted doctors to perform assisted suicides since 1996.
Mourning and grieving among cultures
The death of a loved one is a severe trauma, and the grief that follows is a natural and important part of life. No two people grieve exactly the same way, and cultural differences play a significant part in the grieving process. For many, however, the most immediate response is shock, numbness and disbelief. Physical reactions may include shortness of breath, heart palpitations, sweating and dizziness. At other times, there may be reactions such as loss of energy, sleeplessness or increase in sleep, changes in appetite, or stomach aches. Susceptibility to common illnesses, nightmares, and dreams about the deceased are not unusual during the grieving period.
Emotional reactions are as individual as physical reactions. A preoccupation with the image of the deceased, feelings of fear, hostility, apathy and emptiness, even fear of one's own death may occur. Depression, diminished sex drive and anger at the deceased, as well as extreme sadness may occur. Bereavement may cause short- or long-term changes in the family unit and other relationships of the bereaved.
It is important for the bereaved to work through their feelings and not avoid emotions. If this does not occur through family, friends, or primary support group methods, then a therapist should be consulted to assist with the process.
Various cultures and religions view death in different manners and conduct mourning rituals according to their own traditions. In the Christian faith, bodies of deceased are normally on view at a funeral parlor for one or more days before the actual funeral service. Specific hours are given for visitation or viewing.
Visitors come to express their condolences to the family and to bid farewell to the deceased. At times, funeral services are private. Various ethnic groups host a gathering after the funeral for those who attended. If it is held at the family's home, very often relatives and others will bring food and drink. Others choose to hold this event at a restaurant or some other public venue. It is common for these events to become a celebration of the life of the deceased, which also helps the bereaved to begin the mourning process positively. Memories are often exchanged and toasts made in memory of the deceased. Knowing how much a loved one is cherished and remembered by friends and family is a comfort to those who suffer the loss. Other methods of condolences include sending flowers to the home or the funeral parlor; sending a mass card (for Catholics); sending a donation to a charity that the family has chosen; bringing a meal to the family during the weeks after the death.
In the Jewish culture, bodies are buried as soon after death as possible, even as early as sundown of the day after death. For the Jewish population, this marks a sign of respect to the deceased. A seven-day period of morning follows, which is called Shiva or sitting Shiva. Friends and community visit the family and often bring food, so that the family does not have to worry about meals. Normal activities are suspended for the family of the deceased at this time, so that the bereaved can focus fully on their grief, thus enabling them to re-enter life a bit easier after the period of mourning. The first meal that is served after return from the cemetery is called seudat havrach, prepared by friends and neighbors. Eggs and other round objects are traditionally served. These are objects that are symbolic of life, hope and the full circle of life, which ends in death. Flowers are not traditional; however, donations to charities chosen by the family are acceptable in memory of the deceased.
In the Muslim faith, everyone accompanies the funeral procession to the gravesite. The permitted mourning period for a deceased Muslim is three days, except for a widow, who is permitted to mourn her spouse for four months and 10 days. Traditionally, people leave the gravesite after offering condolences and offering assistance. However, some families do hold gatherings at home. Friends and neighbors bring food and drink to alleviate the family from the worry of providing refreshments. Flowers are often sent after the funeral to the family's home.
Buddhists normally hold a funeral within a week after the death. Flowers or a donation to a charity in the deceased's name are appropriate signs of respect. Caskets are often open, and guests are expected to view the deceased and bow slightly toward it. Friends are invited to call at the deceased's home after the funeral service but not before. The funeral service itself is usually held within 24 hours after the death. Then the body is kept at home until the traditional cremation ceremony. Flowers are acceptable from visitors and are placed at the feet of the deceased. Fruit is also a customary gift to bring to the family.
The primary concern of health care workers in most cases is preserving the life and health of an individual. Severely ill patients may be given nutrition and fluids intravenously or have their breathing supported by a ventilator. In cases in which the heart stops, CPR (cardiopulmonary resuscitation) is performed. In the case of terminally ill, dying patients, the role of health care professionals is to provide palliative care, to ensure that proper arrangements are made for the person after death, and to address the concerns of family members.
The causes of death vary greatly. Injuries, illness and more violent deaths occur routinely. However, as the time of death grows near for the dying, certain signs are common as their bodies begin to shut down. The time variable is as much as a few days and as little as a few hours. There is no particular order of events and not everyone experiences all of them. Support and caring by those surrounding the dying person are essential to make the passing as comfortable and with as little stress as possible.
The health care professional should keep the patient comfortable. Eggshell mattresses or foam cushions can prevent bedsores, as can changing the patient's position in bed. Sheets should be changed at least twice a week. Helping the patient with mouth care often makes him or her feel better.
There will be less interest in eating and drinking. Refusal of food indicates a readiness to die. Fluid intake may be reduced to only as much as will keep the mouth from feeling dry. At this time it is important for caretakers to offer food, drink, and medications, but they should not be forced. Pain may not be an issue when the end is near, so the patient may not feel the need for the medication.
The patient will begin to sleep more and begin to detach from his or her surroundings. The caregiver should not interfere, except to make the patient as comfortable as possible. The caregiver's presence is the most important factor.
Mental confusion may occur as less oxygen reaches the brain. Loss of hearing and vision may occur. The patient may complain of strange dreams. The caregiver should gently remind the patient of the day and time, who is present, and where the patient is at the moment. This should be done in a conversational manner. The caregiver should speak louder than normal if that is necessary, but not draw attention to the patient's loss of senses.
The room should be kept at the light and temperature that the patient requests. All conversations should be carried on as if the patient were aware. Hearing is the last of the senses to leave entirely, even in the case of stroke victims who sometimes appear completely unaware. However, many patients are able to speak even just a few minutes before death and are reassured by loving words.
Secretions may collect at the back of the throat. This may cause a gurgling sound as the patient breathes and possibly tries to cough up mucus. A cool mist humidifier in the room may help. If not, it may be advisable to turn the patient on his or her side, propped up with pillows, so that secretions can drain out of the mouth. The caregiver can cleanse the mouth with glycerin-dipped swabs, mineral oil, or cool water.
Near the end, there may be periods of non-breathing or irregular breathing. As death comes nearer, breathing may resume regularity but become shallow and mechanical. The patient may become agitated, try to get out of bed, hallucinate or pull at the bed linens. The caregiver should calmly reassure the patient and try to prevent the patient from falling if an attempt is made to get out of bed. A massage or soothing music may help.
As circulation slows down, the patient may lose the ability to realize his or her body temperature. The arms will become cool and begin to turn a bluish color. The underside of the body may darken. The caretaker should provide additional blankets or remove them as necessary. The patient should be kept as comfortable as possible.
Loss of control of the bladder and bowel may occur at the time of death. Breathing and heartbeat will stop. The jaw may sag open slightly as it relaxes. The eyelids may close partially, but the eyes will be fixed.
After a patient dies, health care staff allow family members time to grieve with the body before starting post-mortem procedures.
Aminoff, Michael J. "Nervous System." In Current Medical Diagnosis and Treatment. Edited by Lawrence M. Tierney, Jr., et. al. Stamford, CT: Appleton and Lange, 1996, p. 954.
Bennett, J. Claude, and Fred Plum, eds. Cecil Textbook of Medicine. Philadelphia: W.B. Saunders, 1996.
American College of Physicians. "How to help during the final weeks of life." ACP Home Care Guide for Advanced Cancer. 2001. <<a href="http://www.acponline.org/public/h_care/7-final.htm">http://www.acponline.org/public/h_care/7-final.htm>.
American College of Physicians. "What to do before and after the moment of death." ACP Home Care Guide. 2001. <<a href="http://www.acponline.org/public/h_care/8-moment.htm">http://www.acponline.org/public/h_care/8-moment.htm>.
Partnership for Caring. "Talking about your choices." 2001. <<a href="http://220.127.116.11/Advance/talking_choices_content.html">http://18.104.22.168/Advance/talking_choices_content.html>.
Jacqueline N. Martin, M.S.