Psychology Of Death And Dying Research Paper

Previous research on factors that might influence attitudes toward death and dying focused extensively on fear of death as the variable to be predicted. Other outcome measures in recent studies are the desire to prolong life (e.g., Mutran et al. 1997), frequency of thoughts about death (e.g., Rao et al. 1998), and valuation of life (Lawton et al. 1999). The literature suggests that age, gender, and ethnicity may be variables associated with fear of death. The likelihood of fearing death appears to be slightly higher for younger persons, for women, and for African-Ameri-cans compared with Whites (Mutran et al. 1997).

1.1 The Role Of Religious Activity

Religious activity has been a prominent topic in previous research. Studies have shown that people who engage into devotional activities experience less fear of death (Musick et al. 1998). Trying to explain this relationship, some authors focus on processes of primary appraisal, emphasizing that looking forward to an afterlife that is better than the current situation makes religious people less likely to see their disease as harmful. Focusing on processes of secondary appraisal, others have suggested that feeling close to God is seen as a source of power and strength that can be used in times of trouble. According to Filipp (1999), when processing bad news, religious beliefs may enable people to construct an interpretative reality, i.e., to ascribe subjective meaning and to re-establish a better world to live in. From the perspective of the social cohesiveness hypothesis (Idler 1987) religion can benefit individuals by providing support from clergy or fellow church members. However, studies show that the effects of religious activity are not the same for African-Americans as for Whites. To account for this difference it has been argued that, because the former face greater discrimination and barriers to institutions and status, they must find alternative avenues to success and well-being, and that one such alternative avenue is the church (Hummer 1996). Proceeding from the assumption that church and religious activity serve a special place in the lives of African-Americans, religious activity should have a greater effect for them than for Whites.

1.2 The Role Of Social Support

Given that Kubler-Ross emphasized that processes of coping with death and dying can be assisted by social interaction and that the relationship between social support and health in general is the subject of numerous studies, it is noteworthy that until recently only a few studies investigated the relationship between supportive networks and attitudes toward death and dying.

Mutran et al. (1997) investigated the potential mediating and moderating effects of social support on the desire to prolong life, an aspect of attitudes toward death and dying that is related to, but not identical with, fear of death. In this study, two alternative models were tested in a hospitalized sample of 212 persons with an average life expectancy of six to 12 months. The first model proceeds on the assumption that those who wish to prolong life are characterized by unfinished business and fear of death, two stressors that are influenced by a number of background variables (e.g., education, gender, health, ethnicity). According to this model, the two stressors lead to the mobilization of family support, i.e., increased frequency of contact with family members and increased family salience, two variables which in turn mediate the impact of background variables on the desire to prolong life. In the second model it is hypothesized that contact with family members moderates the relationship between the two stressors and the desire to prolong life only in the case of family salience, a variable which in turn is associated with background variables like education, gender, health, or ethnicity. The results support the second model, indicating that family salience and family contact contribute to the definition of the context in which the stressors of unfinished business and fear of death prompt desires to prolong life, and that family contact has a different impact on attitudes toward death and dying for different ethnic groups.

1.3 Finitude And Valuation Of Life

Rao et al. (1998) emphasize the influence of low spirits and social factors on attitudes toward death and dying. In a sample of community residents aged 81 years and older, those who thought about death more frequently were more likely to be unmarried and to manifest a greater severity of depressive symptoms. In interpreting their results the authors suggest a closer examination of attitudes toward death and dying would be useful in the assessment of depression and suicidal risk. Similarly, from the study of self-definition and time horizon in old age there is evidence that only in a minority of older people are feelings of finitude and finiteness predominant in their conceptualization of their future time perspective (Smith and Baltes 1999, Thomae 1981). An increase in feelings of finitude and finiteness is observed only in cases where life is subjectively supposed to be determined by limits and losses (Kruse 2000).

Lawton et al. (1999) proposed that the relationship between quality of life and years of desired life is mediated by an intervening cognitive-affective schema, ‘valuation of life,’ that may be defined as ‘the extent to which the person is attached to his or her present life, for reasons related to a sense not only of enjoyment and the absence of distress, but also hope, futurity, purpose, meaningfulness, persistence, and self-efficacy’ (p. 407). Since the usefulness of this concept was affirmed in an empirical study of 600 healthy and chronically ill older people aged 70 and older, further research is required in order to understand how health, cultural, social, and psychological factors become transformed into strong or weak valuations of life.

2. Assisting Coping Processes In Institutional Settings

In the last few years, the field of palliative medicine and care has developed new insights and concepts that could be used to improve treatment and care of dying people. However, the currently existing care systems are not sufficient.

Empirical research on factors influencing coping with death and dying underscore the demand for giving more attention to (a) pain therapy (most dying persons could be free from pain or at least be relieved from severe pain when therapy is offered), (b) activating care that enables people to continue to lead an independent and responsible life, even in the final stage of disease, and (c) ambulant care services that offer instrumental and emotional support for the family (Kruse 1991).

Giving assistance for coping with one’s own finitude is complicated when the dying person is suffering from psychiatric disorders. This is especially the case since in the so-called fourth age (from 75–80 years on) vulnerability to chronic physical and psychological diseases increases, and changes in life expectancy go together with a steadily growing number of people dying from long-lasting illness instead of an acute health crisis. As a consequence, institutional care for the dying should be able to rely on psychiatric and psychological expertise. In this context it should be noted that psychiatric disorder (as a kind of serious illness) and the psychological reactions associated with the consciousness of finitude, death, and dying must be differentiated. It is important to distinguish between states of anxiety, despondency, resignation, and de-spair resulting from the confrontation with one’s own finitude and similar emotional states resulting from psychiatric disorders since the diagnosis of a psychiatric disorder might suggest medical treatment. In contrast, the diagnosis of psychological reactions to the confrontation with one’s own finitude suggests nonmedical treatment aimed at optimizing active and self-reflexive coping processes. Since coping with one’s own finitude is an existential challenge for human beings, the temporary psychological reactions that occur during the process of active coping must not be interrupted by medical treatment. However, practitioners are obliged to provide adequate medical treatment when a changing of emotional state helps the patient’s coping process. For adequate medication, differentiated knowledge about the development of psychological symptoms is needed. In order to be able to gain such differentiated knowledge, medical practitioners have to rely on information from caregivers. For this reason, there is a need for cooperation between medicine and care in institutional services trying to give assistance for dying people.

3. Maintaining Self-Responsibility

The treatment and care of dying people suffering from changes of consciousness that prevent them from leading a self-responsible life should be based on the preferences and values articulated or supposed to be held by the patient before the occurrence of changes in consciousness. Medical ethics insist on enhancing the possibility for patients to lead a self-responsible life as long as possible. Self-responsibility can be interpreted in different ways; and at least five aspects of self-responsibility should be distinguished (Kruse 1991).

3.1 Self-Responsibility As Independence In Performing The Activities Of Daily Living

This aspect is too often neglected in discussing the possibilities for helping people cope with their own finitude, since the former is centered around illness and the corresponding possibilities and limits of therapy. However, Kruse (1987) found a close relationship between independence in performing the activities of daily living and the ability to cope with one’s own finitude.

3.2 Self-Responsibility As Self-Determination In Organizing Everyday Activities And Realizing Personally Meaningful Interests

It should be considered that even in the process of dying, most people look for positive emotions and experiences that correspond with a feeling of participation from which they gain support for coping with dying. Studies show that religious activities can be helpful in this context (Musick et al. 1998).

3.3 Self-Responsibility As Autonomy In Choosing Social Contact And Managing Social Relationships

Even if most people wish to die at home, it should be noted that what is to be regarded as an adequate amount of closeness to or distance from family members and relatives can be determined only by patients themselves (Baltes 1996).

3.4 Self-Responsibility As The Ability To Understand The Development Of Illness And The Effect Of The Chosen Therapy

The quality of the interaction between the patient and the medical practitioner is an essential factor for the effectiveness of pain therapy (Lohmann et al. 1998).

3.5 Self-Responsibility As The Opportunity To Decide Where To Die

Individuals cope best when they decide which kind of therapy or care to take and—especially when therapy leads to an extension of the process of dying—to terminate life-sustaining measures.

4. The Problem Of Surrogate Decisions Concerning Life-Sustaining Measures

In medical practice the question often is not whether prolonging life is possible but whether it is justified to provide life-sustaining measures for older people. When the patient is no longer competent, the offspring have to make the decision. According to Cooper-Kazaz et al. (1999) such surrogate decisions often do not reflect the patient’s autonomous wishes, but rather the current feelings of the decision-maker. This is often an emotional reaction which sometimes is not even consistent with the offspring’s own ethical outlook. In a study by Sonnenblick et al. (1993), approximately 50 percent of the offspring believed they knew their parent’s wishes, but most of them did not comply with the previously stated wishes of their parent. Cooper-Kazaz et al. (1999) argue that attitudes toward the dying patient and the treatment appropriate are influenced by cultural, intuitive, and emotional factors. Moreover, exposure to the critical event (when parents become terminally ill) seems to have an impact on the children’s judgement about life-sustaining measures. Those with terminally ill parents were significantly more likely to request the initiation of resuscitation and less likely to prefer that the decision be made by the physician than those who had no terminally ill parents. We therefore need more studies that investigate solutions not only of theoretical dilemmas, but of processes of decision-making under real-time conditions as well as more research on the factors which might influence the decisions of offspring.

5. Future Directions

Recent research suggests that the scope of the stages model is too narrow to account for individual differences in experiencing and coping with death and dying. It could be shown that coping processes depend on a number of personal and environmental factors, e.g., age, gender, ethnicity, social support, and religious activity. However, more research is needed to under-stand the complex interaction between these factors. Moreover, previous research has concentrated much on explaining interindividual differences in fear of death. However, advances in medical technology in particular point to the significance of other outcome variables that have been neglected too long. A broader perspective on attitudes toward death and dying should be helpful to integrate research on attitudes toward death and dying, thus assisting patients to cope in institutional settings, and to maintain self-responsibility and addressing the problem of surrogate decisions concerning life-sustaining measures. This integration is seen as an essential challenge for the psychology of death and dying.

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