Understanding Death and Dying

• Dying is the process of ceasing to live or approaching death.
• Death is the permanent cessation of all vital bodily functions necessary to sustain life.

Signs of Clinical Death:

• Absence of palpable pulses
• Absence of heart sounds on auscultation or asystole on ECG
• Absence of observed respiratory effort
• Absence of breath sounds on auscultation
• Pupils dilated and non-reactive to light

Trends in Death:

• Fewer people are dying at home.
• There's an increasing trend towards the medicalization of death, with many spending their final moments in intensive care.

Diversity in Death:

• Women generally live longer than men.
• UK life expectancy at birth (2009-2011): Men - 78.7 years, Women - 82.6 years.
• Death rates are decreasing in England and Wales due to improvements in diet and medical advances leading to longer lifespans.
• Death rates for men have fallen by 22% and for women by 18% in the last decade.
• Death rates are highest in older age groups, with 67% of deaths occurring in people aged 75+.
• Death of a child or young person can be particularly difficult to cope with.
• Less wealthy individuals generally experience poorer health and die sooner.
• There are geographic inequalities in socioeconomic status.

Causes of Death in England & Wales:

• Cardiovascular diseases
• Cancer
• Respiratory diseases
• Mental and behavioral disorders
• Suicide
• Accidents
• Nervous system disorders

Diversity in Dying:

• Gradual death with a slow decline in ability and health.
• Catastrophic death through sudden and unexpected events.
• Premature death in children and young adults through accidents or illness.
• Each death is different, even with the same underlying cause.

Fears Associated with Death:

• Physical: helplessness, dependence, loss of physical faculties, mutilation, pain.
• Social: separation from family, leaving behind unfinished business.
• Emotional: being unprepared for death and what happens after death.

Initial Reactions to News of Terminal Illness or Death of a Loved One:

• Most people experience shock, numbness, disbelief, and confusion.
• Grief is the emotion people feel when they experience a loss
• Grief can result from different types of loss, not just death
• It can be hard to accept what's been said.

The 5-Stage Grief Model (Kübler-Ross 1969):

• Denial: ("no, not me") a coping mechanism, respect the desire "not to know".
• Anger: ("why me?") blaming others, searching for alternatives.
• Bargaining: ("Yes, but I'll...") trying to negotiate for more time.
• Depression: ("It's me!") feeling unable to fight any longer.
• Acceptance: ("It's part of life.") getting affairs in order.

Bereavement:

• Grief: a set of psychological and physical reactions to bereavement, a normal reaction to overwhelming loss.
• Mourning: the process of adapting to loss, including funeral rituals.
• Each person experiences stages differently
• Reassuring for people to know that grief passes through various stages and for most people grief will lessen and end.
• Bereavement is associated with increased risk of illness and mortality, particularly in older people who lose their spouse.

Symptoms of Bereavement:

• Physical: shortness of breath, palpitations, fatigue, digestive symptoms, reduced immune function.
• Behavioral: insomnia, irritability, crying, social withdrawal.
• Emotional: depression, anxiety, anger, guilt, loneliness.
• Cognitive: lack of concentration, memory loss, preoccupation, hopelessness, disturbance of identity, visual and auditory hallucinations.
• Within 2 years, 85% adjusted to bereavement & experiencing minimal grief
• The other 15% experiencing chronic grief: anxiety, depression, Post Traumatic Stress Disorder (PTSD)

Death & Medical Practice:

• Most people die in the hospital despite wanting to die at home.
• Relatives often feel unable to provide home care due to lack of support and advice, and concerns about pain management.
• Death should never be routine but more likely to seriously impact on health professional when patient is well known or is like us or like someone we are close to
• Health care providers may feel failure, sadness, guilt, anger, and a reminder of their mortality.
• There is a risk of burnout, and they need to protect themselves without losing empathy.
• Acknowledging loss with relatives, and talking to colleagues/family is important.
• Many doctors report caring for dying patients as a satisfying experience.
• Dying patients and their families need help in redirecting hope toward living without undue suffering, having time with loved ones, and preserving some sense of control and dignity.

Breaking Bad News:

• Be aware of situations where doctors may be called on to break bad news.
• Be aware of individual differences in perceptions of bad news among patients.
• Discuss the implications for patients and carers if bad news is not delivered considerately
• Describe good practice for health professionals when breaking bad news
• Doing it badly, the patients or family members may never forgive, but if done well, they may never forget.

What is Bad News?

• Any information that drastically alters a patient’s view of their future for the worse.
• Situations where there is either a feeling of no hope, a threat to a person’s mental or physical well-being, a risk of upsetting an established life-style, or where a message is given which conveys to an individual fewer choices in his or her life.

Breaking Bad News Situations:

• Terminal prognosis
• Disabling condition
• Traumatic/sudden death
• Infertility
• Antenatal testing
• Intra-uterine death
• Should not make assumptions that the news is entirely bad as patient may get relief at finally having a diagnosis, carer may feel burden lifted.
• Determination that the news is entirely ‘bad’ is for the most part in the mind of the perceiver and may vary according to personal circumstances such as age and familial obligations.

Disclosure:

• It is important to inform the patient when the diagnosis is confirmed.
• Move towards greater openness in the communication of information.
• In the UK 95% of GPs disclose cancer diagnosis
• Patients have a right to get information about any condition or disease from which they are suffering which should be presented in a manner easy to follow and use, and include information about diagnosis, prognosis, treatment options, outcomes of treatment, common and/or serious side-effects of treatment, likely timescale of treatments and costs where relevant.
• Respect the wishes of any patient who asks you not to give them detailed information.