Nina Ian John “G” Rachel Mark Jocelle Edo Gienah Jho Kath Aynz Je Glad Nickie Ricobear

Teacher Dadang Niňa Arlene Vivs Paul F. Rico F. Ren Mai Revs Mavis Jepay Yana Mayi Serge Hung Tope Bien Ag

S3 Lec 3: Death, Dying and Bereavement

o Suicide
DEATH AND DYING  UNINTENTIONAL
o Trauma or disease
 SUBINTENTIONAL
DEATH
o Substance abuse, alcohol dependence, smoking
 Absolute cessation of all vital functions
 Universal and unavoidable phenomenon PSYCHOGENIC DEATH
Thanatology  Emotional factors: trigger sudden death
 The study of the experience of death, dying and bereavement o Sudden psychic stress  Vfib/MI
DYING  Voodoo death or death secondary to hex
o Hypothalamic-pituitary-adrenal axis and the ANS
 Process of losing the vital functions
(dysfunctional due to emotional stress)  cessation of
 Developmental concomitant of living vital functions
UNIFORM DETERMINATION OF DEATH ACT LEGAL ASPECTS OF DEATH
 Established that the one who sustained either of the ff is  Death certificate: signed by physicians
considered dead:
 IMPORTANT: state the cause of death
o Irretrievable cessation of circulatory and respiratory
functions
ATTITUDES TOWARDS DEATH ACROSS THE LIFE
o Irretrievable cessation of all functions of the entire
 Children: Abstract
brain, including the brainstem
 Adolescents: Inevitable
CLINICAL CRITERIA FOR BRAIN DEATH IN ADULTS AND  Adults: Readily accept death
CHILDREN
ATTITUDES TOWARDS DEATH ACROSS LIFE
 Coma
Age Attitude to Death
 Absence of pupillary responses to light and pupils at
midposition with respecct to dialtation (4-6mm)
Children
 Absence of corneal reflexes
 Absence of caloric responses
 Absence of gag reflex  Pre-school (5 yrs) (Pre- Animistic
operational)
 Absence of coughing in response to tracheal suctioning
Aware of death but thinks it is similar
 Absecne of sucking and rooting reflex
 Absence of respiratory drive at a PaCO2 that is 60mmHg or 20 to sleep
mmHg above normal base-line values
 Interval between two evaluations, according to patient’s age
Term to 2 mo old = 48 hours  5-10 y/o (Concrete
Operations) Sense of inevitable human normality
>2mo to 1 yr old = 24 hours
Fear that parents will die and will be
>1yr old to <18 yr old = 12 hours abandoned

≥18yr old, interval optional

 9-10 y/o Death: can happen to a child and
 Confirmatory tests
Term to 2 mo old = two confirmatory tests parent

>2mo to 1 yr old = 1 confirmatory test

 Puberty Universal, irreversible, and
>1yr old to <18 yr old = optional
inevitable
≥18yr old = optional
Adolescents Fomal cognitive operations

REACTIONS TO DEATH Death: inevitable and final

 TIMELY Adults Accept that their time has come

o When expected survival and actual life span are
equal Source: Kaplan
 UNTIMELY
o When a person’s death is unexpected or premature
 INTENTIONAL

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 DEATH IN INFANCY
DEATH IN ADOLESCENCE
DEATH IN YOUNG ADULTHOOD
DEATH IN MIDDLE ADULTHOOD
DEATH IN LATE ADULTHOOD
What are the CULTURAL INFLUENCES on our perceptions on death and
dying?
Which is better?
For a man to die after a full life
OR
A young courageous soldier to die defending his country during war time
Has any one person died a better death than the other?
DIVERSE CULTURAL REACTIONS ON DEATH
Depends on religious or cultural backgrounds
 Punishment/Judgment
 Redemption from earthly life of difficulty
 Start of eternal life
 No heaven or hell
Reactions may be profound illness
b. Allow for patient’s emotional
Extreme depression responses
c. Reassure that they will not be
“children should outlive their abandoned
parents” Stage 2 (ANGER)  “why me?”
 Frustrated, irritable and angry at
Romantic view (Bakit ako ang mamamatay? God, family, friends, and his/her
Noooo...Diyos ko, bakit nyo po fate even blame themselves
ginawa sakin to?! Hindi nyo ako  Difficult to treat
Personal table  invulnerability
mahal!)  As doctor:
a. Understand the patient
Risky behaviour  death (e.g
b. Should be empathic, a non-
vehicular accident defensive response can help
defuse the patient’s anger and
Prime of life: unthinkable refocus on their own feelings
that underlie the anger
Terminally ill  outraged at their c. Should recognize that anger
plight desire to control the situation
Stage 3 (BARGAINING)  Negotiate with physicians, friends
Displace anger to caregivers and or God, in return for a cure (they
loved ones (Diyos ko, magpapakabait na po make pledges)
ako, magdodonate po ako sa mga  A doctor:
Sense of realism charity etc...) a. Making it clear: “they will be
taken cared of to the best of the
doctor’s abilities and that
Fear about death
everything that can be done will
be done”.
Less anxious b. Encourage patient’s participation
Stage 4 (DEPRESSION)  (+) clinical signs of depression:
Make preparations for demise withdrawal, psychomotor
(wala na...wala na talagang retardation, sleep disturbances,
magagawa...mamatay na talaga ako hopelessness, suicidal ideation
 Anticipation of the eventual loss of
)
life
 As doctors:
a. Normal sadness does not
require biological intervention
b. Major depressive disorder or
active suicidal ideation may
require treatment (e.g. anti-
depressants, psychotherapy)
Stage 5 (ACCEPTANCE)  Realized that death is inevitable
 Feelings range from neutral to
(Father, into your hands, I commit euphoric mood
my spirit)

REACTIONS TO IMPENDING DEATH

 Elizabeth Kübler Ross: made a comprehensive and useful BEREAVEMENT, GRIEF AND MOURNING
organization of these reactions and stated that some may not
follow the regular series of responses; no established sequence GRIEF
is applicable to all patients  Subjective feeling precipitated by death of a loved one
 Grief period: 6mos – 1 year
STAGES OF DEATH AND DISEASE MOURNING
 Process by which grief is resolved; it is the social expression of
Stage 1 (SHOCK AND DENIAL)  Appear dazed postbereavement behavior and practices
 Refused to believe in the BEREAVEMENT
(Ha?! Hindi totoo yan! Hindi pa ako diagnosis  State of being deprived of someone by death and refers to being
 Doctor – shopping the state of mourning
mamamatay! Ulitin nyo ang mga
test! Magpapa-2nd opinion ako!)  Adaptive or maladaptive: degree
depends on whether the patient
continues to obtain treatment
even while denying the prognosis
 As doctor:
a. Provide basic info about the

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 GRIEVING CHILD GRIEVING PARENT GRIEF DEPRESSION

3 phases:
1. PROTEST – cry for
return; child has desire for
the mother or caregiver
who died.
2. DESPAIR – lose hope;
crying is intermittent and
withdrawal and apathy
sets in
3. DETACHMENT –
relinquish attachment to
the dead parent; exhibit a
reawakened interest in
the surroundings
GRIEF
Normal (Uncomplicated)
Predictable symptoms and
course
Phases:
1. State of shock (minutes to
weeks) (Initial Grief)
2. Preoccupation w/ the
deceased (weeks to
months)
a. Waves of somatic
distress
b. Withdrawal
c. Preoccupation
d. Anger
e. Guilt
f. Lost patterns of conduct
g. Identification with the
bereaved
3. Resolution (months to
years)
a. Return to work
b. Resume old roles
c. Acquire new roles
d. Reexperience pleasure
e. Seek companionship
and love of others
Self reproach is common but
less intense
Survivor guilt – occur in those who are relieved that someone other than
them has died
Identification phenomena – a survivor may take on the qualities,
mannerisms, or characteristics of the deceased person to perpetuate the
person in som concrete way.
GRIEF and DEPRESSION
 Common features:
o Sadness
o Fearfulness
o Loss of appetite
o Poor sleep
o Diminished interest in the work
Similiar to the stages described by Mood Disturbance (+) Fluctuations Pervasive
Kübler Ross.
Minor Remitting
Shame and Guilt “not having done Belief that one is
enough for the wicked or worthless
deceased before
his/her death”
Duration Time limited
Suicidal Intentions Higher
DEPRESSIVE SYMPTOMS
BEREAVEMENT MAJOR DEPRESSIVE
DISORDER
Abnormal (Complicated/Pathological)
Symptoms May meet syndromal Any symptoms as
Abnormal cause criteria for major defined by DSM-IV-TR
depressive episode, criteria
but survivor rarely has
Forms: morbid feelings of guilt
and worthlessness,
1. Absent/ delayed grief
suicidal ideation, or
2. Intense and prolonged grief
3. Grief with psychomotor
a. Suicidal intention retardation
b. Frank psychotic symptoms
Dysphoria Often triggered by Often autonomous and
thoughts or reminders independent of
of the deceased thoughts or reminders
of the deceased
Onset Within the first two Onset at any time
months of
bereavement
Duration Depressive symptoms Depression often
is in less than 2 mos becomes chronic,
intermittent, or episodic
Impairment Transient and mild Clinically significant
distress
Self reproach is more intense
History No family or past With family or past
personal history of personal history of
major depressive MDD
disorder
BIOLOGY OF GRIEF
 Disruption of biological rhythms
 Impaired immune functioning:
o ↓lymphocyte proliferation
o Impaired functioning of the NK cells
 Phenomenology of Grief
o Individual’s personality
o Previous life experience
o Past psychological history
o Significance of the loss
o Bereaved’s relationship with the deceased

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 o Existing social network
o Intercurrent life events
o Health

GRIEF THERAPY
 Contemplation of suicide  psychiatric intervention
o Mild sedative to induce sleep
o Antidepressants or anti-anxiety are rarely given to
normal grief
o Counselling sessions

Brought to you by: Luke Psych-walker

(RPE-JG)

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