PSYC 3570 Unit 3 Chapter 4
Dying: Primped and Medicalized
• We primp dying by using various linguistic maneuvers such as using “expiration date” as a metaphor for
• In the medical world, “dying” is too vague and general to describe all the pathways to death.
• Dying is the world that most clearly expresses the universal mortal predicament that we share with all
who have passed away.
The Moment of Death: Is it Vanishing?
• There is an impulse to draw meaning from the last moment of life, whether that is looking at their last
words or being a believer of various folklore.
• A positive memory or image of the transitioning from life to death can help the survivors come to terms
with the loss easier.
• But what is there is no obvious transition from life to death? For example: a person who slips deeper and
deeper into a nonresponsive condition.
The Slipping Away
• This is how a majority of elder people pass away
• Leads to the traditional ideas about the dying process becoming less descriptive because:
1. Medical advances help people survive for longer with conditions that formerly had been considered
terminal. It has been difficult to determine when the progression of a long term illness should be
2. There is still a tendency for physicians to experience a patient’s death as their own failure
3. Individuals affected with Alzheimer’s or other forms of dementia might not seem present at their death.
4. Sedation can reduce awareness. However, there is the possibility that a person might be unable to
respond but still be aware of the situation.
5. The person often dies alone – while family might visit, if after visiting hours at the hospital, it is not the
hospital’s first priority.
• A study done by Valentine (2007) found that few terminally ill patients in the study were offered last
words, but some “took charge of their own dying and leave talking” and “recovered their own
characteristic selfhood, in some cases becoming more than themselves, to assume an enhanced aliveness,
presence, and relatedness to loved ones”.
• Death can be looked at as an experience that takes many forms, depending on the nature/management of
illness, social support, and the person themselves.
• How and when we die is influenced by societal practices, as well as physical disorders.
• It has been found that hospitalized patients are more likely to die when members of either an
understaffed nursing (Aiken et al., 2002) or medical (Provonost et al., 2002) service have excessive
demands on their time and energies.
• Kiecolt et al. 2002 found that negative emotions have been found to endanger health by undermining or
overwhelming our immune systems. If negative emotions are part of our daily experiences, we are more
likely to encounter life threatening experiences, and more likely to lose that battle.
Dying as Transition
• The transition from life includes interactions that can either be disturbing or be comforting,
communications that can either inform or confuse, and self evaluations that can either undermine or
strengthen one’s sense of identity.
• No two people bring the same thoughts, feelings, accomplishments, and illness related experiences.
Furthermore, no two people have the same set of relationships.
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• The quality of life during the final illness depends much on the quality and availability of the
individual’s most valued relationships.
What is Dying, and When Does it Begin?
Individual and Interpersonal Responses
• The knowledge that “ I am dying” can transform the individual’s view of self and world for better or
Onset of the Dying Process: Alternative Perspectives
• The point when dying begins depends on our frame of reference. The proposition that we die from the
moment we are born might be useful in developing a personal philosophy of life, but also encourages
• Jeremy Taylor suggested that aging might be regarded as slow dying and dying as fast aging.
• Dying usually begins as a psychosocial event. Organ systems fail, but it is in the realm of personal and
social life that dying occurs.
• Contexts in which the onset of dying is discovered or certified:
1. Dying begins when the facts are recognized. This could be being diagnosed with a terminal illness but it
excludes people with terminal illnesses who have not consulted a doctor or people who have a terminal
illness and remain symptom free and functional for some time.
2. Dying begins when the facts are communicated. This can be complicated, as physicians seldom break the
news at the same instant that they reach their diagnosis. In some instances, the physician never tells the
patient, or the patient does not accept the unwelcome information.
3. Dying begins when the patient realized or accepts the facts. Studies have shown that patients tend to
overestimate their probability of survival, which means in their eyes, they are not dying. It is also
people, like those with late stage Alzheimer’s may never fully understand their condition, so it is
suggested that caregivers prepare them in the early stages, to cope with the progression of the disease.
4. Dying begins when nothing more can be done to preserve life. There is the possibility that the physician
might not classify the person as dying because they haven’t tried all drug combinations or surgical
procedures. This often happens when medical staff have a strong motivation to keep the patient alive
(i.e. a child or a person they feel is similar to them).
Trajectories of Dying: From Beginning to End
• The most common pathway to death is those whose lives end in a health care facility.
• 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
Medical professionals are faced with two questions about every patient whose life is in jeopardy: Will this
patient die? If so, when? These are the questions of certainty and time.
Certainty and time yield 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
2 PSYC 3570 Unit 3 Chapter 4
• Caregivers tend to display a characteristic pattern when a patient’s life is slowly fading. There is rarely a
dramatic rescue scene and people will try to keep the patient comfortable and dell as though they have
done all they can and that the patient has earned death after a long struggle.
• This lingering trajectory may be more accepted because the person was considered socially dead already.
• It is possible that someone in the situation might deny or resist the impeding death (i.e. a son who has a
hard time coming to terms with his mother is now debilitated and inching towards death).
• Proulx and Jacelon (2004)observed that there can be tremendous societal pressure on a dying person to
be a good patient while trying to experience the “good death”.
• A study done by Glaser, Strauss, and Benoleil noted incidents where the next of kin would upset the staff
by showing too much emotion when the patient died. Strong reactions challenge the assumption that
there is little social loss in the passing of a “lingerer”.
• Sometimes family and staff can have their patience tested when a patient fails to die on schedule (i.e. a
daughter is told her dad is dying, so she comes from out of town as soon as possible, but when she gets
to the hospital, her dad is sitting up and playing cards).
• The lingering trajectory allows both the patient and family time to grow accustomed to the idea of dying
but it can also attenuate relationships and creates the perception that the person is not fully alive, but not
The Expected Quick Trajectory
• In this, time is of the essence, and staff should organize themselves to make the best use of the time they
• There are several types of expected quick trajectories:
1. Pointed trajectory – the patients are exposed to risky procedures that might save their lives or they might
kill them. The staff often has enough advance time to organize appropriately. There also might be
enough time for the patient to exercise some control and look at options.
2. Dangerperiod trajectory – requires more watching and waiting. The main question is whether or not the
patient will be able to survive a stressful experience such as surgery or a heart attack. The patient may
not be aware or on be slightly aware of their surroundings.
3. Crisis trajectory – imposes another state of tension. The patient is not in acute danger at the moment, but
the patients life could be threatened at any time. The tension will persist until the patient improves or a
crisis does occur and revive and rescue efforts can be made.
4. Willprobablydie trajectory – the staff believes nothing effective can be dome. The aim is to make the
patient as comfortable as possible and wait for the end, which will usually occur within hours or days.
There may be pressure to move these patients to facilities that require less expensive resources.
• Sometimes the presence of family can make a positive difference to a person who is close to death.
• The most salient features of the expected quick trajectory are time
2. intense organization of treatment efforts
3. rapidly shifting expectations
4. volatile, sensitive staff– family interactions.
• Whether there is a chance to save the patient’s life sometimes depends on the resources that are available
at the crucial time in a particular hospital. For example, the lack of a trauma response team or advanced
diagnostic equipment could make the difference between the will probably die trajectory and one with
• Social stereotypes that hold that one person is more important than another (whether on the basis of age,
gender, race, occupation, economic status, or whatever) can play a decisive role in the death system
when quick decisions must be made about priority and extent of life sustaining effort.
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The Unexpected Quick Trajectory
• There is less preparation for emergency and personnel may experience a “blow up”.
• Staff are more likely to be upset if the person dying has a medically interesting case, if the person dying
is someone they tried really hard to save, or if the person dies for the wrong reasons.
• The unexpected quick trajectory can occur when attention of medical staff turns away from one patient
to concentrate on an urgent case, accidents, carelessness/poor safety practices, and hospital under
• Glaser and Strauss came up with the term “institutional evasions” to describe the combination of
pressure and surprise seen in the unexpected quick trajectory.
• A source of tension within the unexpected quick trajectory is the conflict between doing what seems best