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PSYC 3570 (66)
Chapter 4

Chapter 4

7 Pages

Course Code
PSYC 3570
Erin Allard

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Chapter 4 “Dying”: Primped and Medicalized - Much of the time we “primp” dying through various linguistic maneuvers: -> “Expiration date” -> “Buying the farm” - Medicalization serves the purpose of insulating physicians and bureaucrats from the moral realities The Moment of Death - The moment when life passes into death has long been charged with passionate meanings - Last words have often been seized upon as emblems of meaning - A positive memory image might help the survivors come to terms more easily with their own mortality The Slipping Away - Medical advances help people survive longer with conditions that were once considered “life threatening” - Alzheimer’s and related dementias more often accompany people in last phase of life; so afflicted individuals might not seem present at death - Sedation can reduce awareness - Often times the person dies alone; family might have visited but don’t happen to be there at the last moment - How and when we die is influenced by societal practices as well as physical disorders: -> Hospitalized patients are more likely to die when members of either an understaffed nursing or medical service have excessive demands Dying as Transition - The transition from life includes interactions that can either be disturbing or comforting, communications that can either inform or confuse, and self-evaluations that can either undermine or strengthen one’s sense of identity What Is Dying and When Does It Begin? Individual and Interpersonal Responses - We often treat people differently when they are perceived as dying, even if we are not aware of this difference Onset of the Dying Process - Dying usually begins as a psychosocial event - Some contexts in which the onset of dying is discovered: -> Dying begins when the facts are recognized: perhaps, dying begins when a physician concludes that the patient is afflicted with a terminal illness. However, this excludes people who have not consulted a physician -> Dying begins when the facts are communicated: moment at which the physician informs the patient. However, physicians seldom break the news at the same instant that they reach their conclusions -> Dying begins when the patient realizes or accepts the facts: somehow the patient may forget or misinterpret the central facts. Physicians’ communication can be subtle or direct, and the patient may go away either with a clear understanding or in a state of uncertainty and confusion. -> Dying begins when nothing more can be done to preserve life: Physicians might not have classified the person as dying, despite diagnostic signs, because they may feel there are things they can try Trajectories of Dying - All dying processes take time; all have certain paths through time - For one person, the trajectory could be represented as a straight downward line, for another it might be represented more accurately as slowly fluctuating, going down, leveling off, declining again, climbing a little, and so on. Certainty and Time - Four types of death expectation: 1. Certain death at a known time 2. Certain death at an unknown time 3. Uncertain death, but a known time when certainty will be established 4. Uncertain death, and an unknown time when the question will be resolved The Lingering Trajectory - More people on the lingering trajectory are aware of their social death than might be realized - Visits from family members often fall off with lingering trajectory - Somebody in this situation might deny or resist the impending death - The patience of family and/or staff may be strained when a patient fails to die on schedule - The lingering trajectory allows both the patient and the family time to grow accustomed to the idea of dying, make plans, work through old conflicts and misunderstandings, and review the kind of life that has been lived The Expected Quick Trajectory - Pointed trajectory-> patients are exposed to risky procedures that might either save their lives or result in death - Danger-period trajectory-> required more watching and waiting. Question in whether the patient will be able to survive a stressful experience such as high-risk surgery or a major heart attack - Crisis trajectory-> patient is not in acute danger at the moment, but the individual’s life might suddenly be threatened at any time - Will-Probably-Die trajectory-> staff believes that nothing effective can be done. Aim is to keep the patient as comfortable as possible and wait for the end to come, usually within hours or days - The most salient features of the expected quick trajectory are time urgency; intense organization of treatment efforts; rapidly shifting expectations; and volatile, sensitive staff-family interactions The Unexpected Quick Trajectory - The experienced emergency room team adjusts quickly to situations that might immobilize most other people, however in other wards it can spark a crisis - Some unexpected deaths are more disturbing than others-> personnel tend to be more affected by the death of a patient whose life they had tried especially hard to save, or who displayed unusual challenges - The hospital itself can precipitate an unexpected quick trajectory-> confusion in the mobilization of treatment resources, the turning of attention away from other patients to concentrate on an urgent case, accidents attributable to carelessness or poor safety practices, and a variety of problems that can arise when a hospital is understaffed - The combination of time pressure and surprise can lead to “institutional evasions”- eg there may not be time to bring a physician to the bedside. If nurses carry out potentially life-threatening procedures without direct medical supervision, then they will have exposed themselves to possibility of criticism and liability action- but if they don’t act promptly, the patient may die before the physician arrives Life-or-Death Emergencies - A person in good health may suddenly become the victim of an automobile accident, a restaurant patron may choke etc. - Could lead to panic, inappropriate action, misinterpreting the situation, minimizing danger, or being preoccupied by own concerns Guarded Feelings, Subtle Communications - having their own sense of horror to contend with, the staff may respond by erasing the patient’s individuality and humanity Doctor-Patient Communication: The Support Study - SUPPORT: Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment - Intended to help physicians make better decisions about end-of-life issues and to prevent a mechanically supported, painful, and prolonged process of dying - The results could hardly have been more discouraging - The observation phase found that physicians seldom showed interest in the patients’ own preferences - Pain control was ineffective - The Intervention phase of the study attempted to improve this situation by providing the physicians with more information about their patients’ preferences as well as their physical status - Unfortunately, these interventions didn’t work-> communication remained flawed; physicians continued aggressive treatment despite patients’ preferences; pain control was as poor as before Improving Communication - Need for honest communication was expressed by most terminally ill people whose outcomes were followed in the SUPPORT study Suggestions for Communication with People in Life-Threatening Situations - Be alert to symbolic and indirect communications-> dreams reported can help share inner experience and provide additional supportive communication; symbolic and indirect language; leave-taking actions such as sorting through and giving away possessions - Help to make competent and effective behaviour possible-> the progressive nature of terminal illness increases the individual’s dependence on others and limits the range of spontaneous action - Allow the dying person to set the pace and the agenda-> this is no time
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