22.3 End-of-Life
Learning Objectives
- List and describe the stages of loss based on Kübler-Ross’s model and describe the criticisms of the model
- Explain the philosophy and practice of palliative care
- Describe the roles of hospice and family caregivers
- Explain the different types of advanced directives
- Describe cultural differences in end of life decisions
- Explain physiological death
- Describe social and psychological death
- Describe funeral rituals in different religions
- Describe the new practice of green burials
Kübler-Ross’ Stages of Loss
Based on her work and interviews with terminally ill patients, Kübler-Ross (1975) described five stages of loss experienced by someone who faces the news of their impending untimely death. These “stages” are not really stages that a person goes through in order or only once; nor are they stages that occur with the same intensity. Indeed, the process of death is influenced by a person’s life experiences, the timing of their death in relation to life events, the predictability of their death based on health or illness, their belief system, and their assessment of the quality of their own life. Nevertheless, these stages provide a framework to help us to understand and recognize some of what a dying person experiences psychologically. And by understanding, we are more equipped to support that person as they die and to face death ourselves when our time comes (Kübler-Ross, 1975).
Denial is often the first reaction to overwhelming, unimaginable news. Denial, or disbelief or shock, protects us by allowing such news to enter slowly and to give us time to come to grips with what is taking place. The person who receives positive test results for a life-threatening condition may question the diagnosis, seek second opinions, or may simply feel a sense of psychological disbelief even though they know that the results are true.
Anger also provides us with protection in that being angry energizes us to fight against something and gives structure to a situation that may be thrusting us into the unknown. It is much easier to be angry than to be sad or in pain or depressed. It helps us to temporarily believe that we have a sense of control over our future and to feel that we have at least expressed our rage about how unfair life can be. Anger can be focused on a person, a health care provider, at God, or at the world in general. And it can be expressed over issues that have nothing to do with our death; consequently, being in this stage of loss is not always obvious.
Bargaining involves trying to think of what could be done to turn the situation around. Living better, devoting oneself to a cause, being a better friend, parent, or spouse, are all agreements one might willingly commit to if doing so would lengthen life. Asking to just live long enough to witness a family event or finish a task are examples of bargaining.
Depression is sadness and sadness is appropriate for such an event. Feeling the full weight of