Death, Dying, and Grief

This is Unit Seventeen, part one, on defining death, how people die, facing death, death across cultures, and end-of-life care. Unit Sixteen closed on the intertwined domains of aging well. Unit Seventeen, the last unit before the capstone, turns to death, dying and grief. Carry one question through this part: who decides how a life ends? Law, medicine, culture and family all claim a part. At the entry on advance directives, the part's last, the answer is the person, in advance, or someone that person names. By the end you will be able to state the two legal definitions of death, and tell brain death from coma. To name four dying trajectories. To state what a large replication found about mortality salience. To name the four parts of a mature concept of death. And to tell hospice from palliative care, and a living will from a health-care proxy.

Three entries on defining death, from the bedside to the law.

Clinical death, and biological death.

HGD 2401 Clinical and Biological Death

Clinical death is when vital organs have stopped but could be resuscitated; biological death is when they cannot be, as when a drowning victim is revived by CPR after clinical death, before biological death set in. Death also has psychological and social aspects, and a thanatologist studies all three.

A new standard of death.

HGD 2402 From Cardiopulmonary to Brain Death

For over a century death meant cardiopulmonary death, heartbeat and breathing stopped beyond restarting. Machines that sustain both required a new standard, brain death, recognized from the late nineteen sixties and seventies: a brain-dead patient breathes and has a heartbeat only with a ventilator and medication.

The legal definition of death.

HGD 2403 The Uniform Determination of Death Act

The Uniform Determination of Death Act, endorsed by a presidential commission in nineteen eighty-one and adopted by most states, defines death in two ways: irreversible cessation of circulatory and respiratory functions, or irreversible cessation of all functions of the entire brain, including the brainstem, determined by accepted medical standards. The misconception is that a brain-dead person is in a coma. A person in a coma is alive; a brain-dead person is legally dead. Standards vary: New Jersey allows a religious exemption, so a person could be legally alive in one state and dead in another. Exam items ask what brain death requires: all functions of the entire brain.

Five entries on how people die: where, of what, at what age, and along which path.

Mortality around the world.

HGD 2404 Mortality Around the World

The mortality rate is how common death is in a population, and in twenty nineteen the WHO put life expectancy in Africa at about sixty-four and a half, with Southeast Asia, the western Pacific, the Americas and Europe all above seventy-one. How governments spend, on sanitation, education, health access and women's status, matters more than national income alone.

Causes of death across countries.

HGD 2405 Causes of Death Across Countries

In twenty nineteen, heart disease was the leading cause of death worldwide, followed by stroke and chronic obstructive pulmonary disease, according to the WHO; diarrhoeal disease led in Angola and heart disease in Canada, causes that follow living conditions. Excess mortality, deaths above the expected number, is how researchers measured the pandemic's toll.

Causes of death by age.

HGD 2406 Causes of Death by Age

In the United States, congenital anomalies lead infant deaths, and unintentional injury leads from ages one to forty-four, with drowning leading for ages one to four and motor-vehicle crashes for five to twenty-four. Fall death rates among adults sixty-five and older rose forty-one percent from twenty twelve to twenty twenty-one.

Dying trajectories.

HGD 2407 Dying Trajectories

Dying trajectories are pathways to death that differ in the nature and rate of decline; Glaser and Strauss proposed three, and Lunney and colleagues described four. Sudden death is an abrupt loss of function, as in a heart attack. Terminal illness keeps a high level of functioning, then brings a steep decline, as often in cancer. Organ failure brings gradual decline with cycles of worsening and improvement, as in heart failure. Frailty is low functioning with steady decline and no recoveries, as in dementia. Terminal illness goes with more depression for the dying person, frailty with heavier burdens for caregivers.

The process of dying.

HGD 2408 The Process of Dying

Death is a series of events over time, even when sudden, and terminal decline, in the last few years of life, varies with prior functioning, disease and depression. In a slow death, eating stops, sleep increases, blood pressure falls, limbs cool, breathing grows irregular and consciousness fades. The course describes these changes without clinical detail.

Six entries on facing death: identity, coping, a contested theory, anxiety, children, and social death.

Identity, and a terminal diagnosis.

HGD 2409 Identity and a Terminal Diagnosis

A terminal diagnosis changes self-perception, and losing self-care and roles can bring a loss of identity; Christine Bryden, diagnosed with early-onset dementia at forty-six, feared she would become her diagnosis. Terminally ill patients want to be treated as individuals, and treating them only as sick people deepens the loss.

Two ways of coping with bad news.

HGD 2410 Monitoring and Blunting

Suzanne Miller described two coping styles with threatening news: monitoring, seeking information even when it is bad, and blunting, avoiding distressing information, like one patient reading every study on her illness and another asking her doctor to tell only her family. Neither style is universally better.

Terror management theory, weighed.

HGD 2411 Terror Management Theory

Terror management theory, proposed by Greenberg and colleagues in nineteen eighty-six, holds that awareness of death is a source of deep anxiety, and that people manage it by clinging to cultural worldviews and self-esteem. Its central prediction concerns mortality salience: reminded of their own death, people should defend their cultural values more strongly and show more bias against outgroups. Many early experiments reported such effects. The evidence has since weakened. In Many Labs 4, seventeen laboratories with about fifteen hundred participants tried to replicate a classic mortality-salience finding, some with the original authors helping design the study, and could not replicate it under any conditions; a Bayesian reanalysis found evidence against the effect. That does not show that death is unimportant to people; death anxiety is real. It shows how a theory's most famous prediction can fail when tested at scale.

Death anxiety.

HGD 2412 Death Anxiety

Death anxiety is concern about what awaits after death. A cross-cultural study compared Christians, Hindus and Tibetan Buddhist monks, and the monks, whose tradition teaches that there is no enduring self, reported the greatest fear of self-annihilation. Doctrine does not always predict feeling.

How children come to understand death.

HGD 2413 Children's Understanding of Death

A mature concept of death has four parts. Universality: everyone dies. Irreversibility: the dead do not come back. Causality: death has many causes. Nonfunctionality: all body functions stop, the hardest part, because it requires knowing how the body works. Irreversibility is especially hard in Piaget's preoperational stage, as when a four-year-old asks when her dead grandfather will come home for dinner. The misconception is that young children cannot understand death: many grasp universality and irreversibility by five, and family deaths and rituals speed understanding. Exam items ask which part is missing.

Social death.

HGD 2414 Social Death

Social death is being treated as no longer part of society: excluded from invitations, not consulted, talked about in one's presence, often with good intentions, as when relatives discuss a dying man's funeral at his bedside. It also affects people with stigmatized chronic conditions and isolated caregivers.

Six entries on death across religions and cultures.

Religion, and death.

HGD 2415 Religion and Death

Religion can comfort and give meaning, and belief in a happy afterlife lowers anxiety while beliefs framing death as punishment raise it, but secular people do not report more death anxiety or poorer coping than religious people. The very religious and the very nonreligious show similar death acceptance.

Individualism, collectivism, and death.

HGD 2416 Individualism, Collectivism and Death

Individualistic cultures stress patient autonomy and choice at life's end; collectivistic cultures stress group decisions, consensus and trust in authority, as in the Japanese custom of omakase, leaving medical decisions to experts, and families sometimes not telling a patient they are dying. These are tendencies, not rules.

Grief across cultures.

HGD 2417 Grief Across Cultures

Grief expression varies across cultures: open in Egypt, restrained in Taiwan and Bali, while the Achuar of Ecuador try to forget the dead quickly, and Mexico's Día de los Muertos honours ancestors with altars and gatherings. Contexts shape views of death too, such as where deaths are sudden or early.

Brain death across cultures.

HGD 2418 Brain Death Across Cultures

In Japan, China and the Republic of Korea, brain death has been accepted mainly in the context of organ donation, with family approval, and Buddhist holism and belief in reincarnation discourage donation for some families. Some branches of Judaism reject brain death, and some US states accommodate that view.

Native American traditions.

HGD 2419 Native American Traditions

Many Native American nations traditionally treat death as a communal, cyclical event, with practices that differ from nation to nation: the Lakota keeping locks of hair, the Navajo not speaking the name of the dead, and some nations waiting four days to bury. Practices belong to particular nations, not to Native Americans as a single group.

No single national view.

HGD 2420 No Single National View

In Nigeria, Christian, Muslim and ancestral traditions coexist and sometimes conflict over death, from its causes to widows' inheritance; one family may explain a death as God's will, another as witchcraft, in the same town. A person's origin is no substitute for knowing the person.

Eight entries on care at the end of life, and on the documents that carry a person's wishes. The opening question is answered at the last of them.

Where Americans die.

HGD 2421 Where Americans Die

In twenty seventeen, about thirty-one percent of US deaths occurred at home and thirty percent in hospitals, with home deaths rising since two thousand three, while hospital deaths make up about a quarter of deaths in the Netherlands but about two-thirds in Japan. The misconception is that most Americans die in hospitals.

Hospitals, and the end of life.

HGD 2422 Hospitals and End-of-Life Care

Hospitals are built to treat and cure, so death is often treated as failure, and aggressive treatment may conflict with a patient's wishes; pandemic visitor limits left patients to die alone. Nurses may feel under-trained for end-of-life care, and families report unclear communication.

Dying at home.

HGD 2423 Dying at Home

Home care offers individual attention, familiar surroundings and flexible visiting, and people dying at home report less physical discomfort and better care, as a family takes shifts at a father's bedside. But homes may lack space, caregivers may be unavailable, and cost, privacy and fear can argue against it.

Hospice care.

HGD 2424 Hospice Care

Hospice care serves people with incurable conditions, typically with under six months to live, managing pain and meeting emotional and spiritual needs of patient and family. Cicely Saunders founded the modern hospice movement in England in nineteen sixty-seven, Florence Wald the first US hospice in nineteen seventy-four, and Medicare began covering hospice in the nineteen eighties.

Hospice, and palliative care.

HGD 2425 Hospice and Palliative Care

Palliative care relieves pain and provides comfort without trying to cure; it can be given to anyone with a serious condition, at any stage, alongside curative treatment. Hospice care is palliative care for the terminally ill, who forgo treatment aimed at cure. So all hospice care is palliative, but not all palliative care is hospice. Quality of life, a person's own view of how good life is in light of their values, is the goal. The misconceptions are that the two are the same, and that hospice is a building; it is a kind of care, given at home, in facilities or in hospitals.

Palliative care's growth.

HGD 2426 Palliative Care's Growth

By twenty fourteen, nearly seventy percent of US hospitals with fifty or more beds had palliative care programmes, and need in England and Wales is projected to rise by up to forty-seven percent by twenty forty, reflecting aging populations and more people living with serious chronic illness.

Wills, and probate.

HGD 2427 Wills and Probate

A will directs the handling of possessions, property and dependants; an executor carries it out, and a probate court oversees distribution and guardianship. Some Jewish families add an ethical will that passes on values rather than property. Dying without a will, intestate, leaves assets frozen until a court decides.

The payoff: advance directives.

HGD 2428 Advance Directives

An advance directive is a legal document stating a person's wishes for when they cannot communicate them, and since death can come suddenly, it matters at any age; it answers this part's question. A living will specifies which life-sustaining treatments, such as dialysis, feeding tubes or intubation, a person does or does not want. A health-care proxy, also called a durable power of attorney for health care, names a person to decide when the patient cannot. A woman with Alzheimer's disease needing consent for minor surgery has a living will that is silent, but a proxy who can decide. The misconception is that a living will covers every decision; a proxy covers the rest.

Look at what you can now do. You can state the two legal definitions of death, circulatory and respiratory, or all functions of the entire brain, and say that a person in a coma is alive and a brain-dead person is not. You can name the trajectories: sudden death, terminal illness, organ failure and frailty. You can state that seventeen laboratories could not replicate a classic mortality-salience finding, though death anxiety itself is real. You can name the four parts of a mature concept of death: universality, irreversibility, causality and nonfunctionality. And you can tell palliative care, comfort at any stage, from hospice, palliative care for the terminally ill, and a living will from a health-care proxy. Part two covers resuscitation orders and the choices at life's end.