Chapter 19: Life’s Final Chapter
Today, only a small minority of Canadians – typically those who are in advanced old age
or who are gravely or terminally ill – die in their own homes.
Did you know:
• A person may stop breathing and have no heartbeat but still be alive.
o People whose hearts and lungs have ceased functioning can often be
revived using cardiopulmonary resuscitation (CPR).
• The five stages of dying provide insight into the dying process but they should not
be used as a template.
o Though Kubler-Ross identified five stages that dying individuals
commonly experience, other factors also appear to affect the adjustment of
the dying individual.
• Even the medical community is divided on the hot-button issue of physician-
o 84% of highly religious physicians object to physician-assisted suicide.
• People with living wills can hope their wishes will be carried out if they become
unable to speak for themselves.
o A living will may not be carried out for many reasons. Specific advance
directives have a better chance of being carried out than general
• When helping someone cope with a death, don’t expect to have all the answers.
o Sometimes there are no right answers. Simply listening and being
supportive is a wise course of action. Death holds the gift of wisdom.
We parcel thoughts about death and dying into a mental file cabinet to be opened later in
life, along with terms like retirement, Old Age Security, and varicose veins. But death
can occur at any age – by accident, violence, or illness. We can also be affected deeply at
any stage of life through the deaths of others.
Denial of death is deeply embedded in our culture.
How doe we know when a person has died?
Are there stages of dying?
What is meant by the ‘right to die’? Do people have a right to die?
What is a living will?
Is there a proper way to mourn? Are there stages of grieving?
L01: Define death and dying, and evaluate views on stages of dying
Death is commonly defined as the cessation of life. Many people think of death as a part
of life, but death is the termination of life and not a part of life. Dying, though, is a part
of life. It is the universal end-stage of life in which bodily processes decline, leading to
death. Yet life holds significance and meaning even in the face of impending death. Charting the boundaries between life and death
How do we know when a person has died? Is it the stoppage of their hearts? Of their
breathing? Of their brain activity?
• Medical authorities use brain death as the basis for determining that a person has
o Absence of activity of cerebral cortex – flat EEG reading; the sense of self
and all psychological functioning has ceased
• Whole brain death – death of the brain stem which is responsible for certain
automatic functions such as reflex of breathing; a brain dead person can continue
• Death is a legal matter – considered legally dead in Canada when there is
irreversible cessation of breathing and circulation or when irreversible cessation
of brain activity occurs, including activity in the brain stem, which controls
Are there stages in dying?
Overview of process influenced by the work of Elisabeth Kubler-Ross. Common
responses to news of impending death
1. DENIAL. In this stage, people think, “It can’t be me. The diagnosis must be
wrong.” Denial can be flat and absolute, or it can fluctuate so that one minute the
patient accepts the medical verdict, and the next, the patient chats animatedly
about future plans.
2. ANGER. Denial usually gives way to anger and resentment toward the young and
healthy and, sometimes, toward the medical establishment: “It’s unfair. Why
me?” or “They didn’t catch it in time.”
3. BARGAINING. People may bargain with God to postpone death, promising, for
example, to do good deeds if they are given another six months, or another year.
4. DEPRESSION. With depression come feelings of grief, loss, or hopelessness –
at the prospect of leaving loved one and life itself.
5. FINAL ACCEPTANCE. Ultimately, inner peace may come as a quiet
acceptance of the inevitable. This “peace” is not contentment; it is nearly devoid
of feeling. The patient may still fear death, but comes to accept it with a sense of
peace and dignity.
• Offer help by understanding the stages; Retsinas comments that stages are limited
to cases in which people receive diagnosis of terminal illness
• Life and Death Issues: A Blurring Line ~ living longer, delaying death; living
longer does not mean continued quality of life; physician-assisted suicide for
incurable disease (ALS, etc.); consider living wills instruction directive sets
out what types of treatment a person does not want in the event that these
decisions cannot be voiced at the appropriate time; proxy directive allows an
individual to select in advance, someone who can make health care decisions on
• Shneidman agrees that dying people may have same 5 stages of feelings but
generally behave as they behaved before as they confronted stress, failure and
threat L02: Identify settings in which people die, distinguishing between hospitals and
Where people die: a hundred years ago, most people died in their homes, surrounded by
family members. Most people respond that they would prefer to die at home with loved
ones, yet 70% die in hospita.
In the hospital
• Impersonal places to die, function to treat diseases; patients in hospital often face
death alone, cut off from their usual supports; however family may assume that
this is the best place to try to avert death
• Only 16-30% of Canadians who die will have access to or receive hospice
• Demand for these services will continue to rise
• Hospices make final days as meaningful and pain-free as possible
• When necessary, hospices can provide care in inpatient services but most hospice
care is provide in patent’s home
• Hospice workers work in teams – physicians, nurses, social workers, mental
health/pastoral counsellors, home care aides who also work with/for family for
• Bereavement specialists
• Resuscitation or DNR
o Offer palliative care (treatment focused on the relief of pain and suffering
rather than cure)
o Treat person, not disease – all needs: medical, emotional, psychological,
spiritual – of patient and family
o Emphasize quality, rather than length of life, neither hastening nor
o Considers the unit of care to be entire family, not just patient; bereavement
counselling is provided after death
o Help and support available 24/7
Supporting a dying person
• Put yourself at the same eye level and don’t withhold touching
• Be available to listen, to talk, to share experiences
• Give person opportunity to talk about death and to grieve
o Don’t be afraid to talk about the ongoing lives of mutual acquaintances
• Often need to focus on topics other than impending death and some enjoy
• May want to hear about your concerns, joys, worries, etc.
• Emotional state may vary from day to day • Don’t attempt to minimize the person’s emotional pain or need to grieve by
refusing to acknowledge it or changing the subject
• Be sensitive to person’s feelings, offer consolation and support
L03: Discuss various kinds of euthanasia and controversies about them
Euthanasia: Is there a right to die? Euthanasia means good death; mercy killing;
purposeful taking of a person’s life through gentle or painless means to relieve pain or
Active euthanasia: Mercy killing or murder?
• Active euthanasia: lethal treatment (usually drug) administered to cause quick
and painless death; spouse or family administers it
o Voluntary active euthanasia: assisted suicide; illegal in Canada, still in
court process; not illegal in some countries though protocols must be
o Physician-assisted suicide: legal in USA, patients with terminal or
incapacitating illnesses who wish to die, provide lethal doses of drugs
administered when patient is too ill to administer drugs themselves (Dr.
Kevorkian – Dr. Death); most physicians do so without publicity for fear
of legal prosecution
o Involuntary active euthanasia: one person causes the death of another
person without that person’s informed consent (moral, ethical and legal
issues); cases of involuntary euthanasia usually involve patients who are