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Abstract

The proper psychological preparation for dying is an important process that is often misunderstood or avoided. We generally see death as a time of sadness as compared to the many joyful times in our lives such as birth, various stages of development, marriage and so on. Through understanding of attitudes dealing with death, the death process, death anxiety and the meaning of �dying a good death�, we can better prepare for this life ending event. A good death and peaceful death is possible as long as there is an understandable transition between life and death.

The Psychological Preparation of Death/Dying and the Process of �Dying a Good Death�

Attitudes toward life�s events vary depending on our age, previous experiences, and the event itself. Many of these events are joyful or happy times; the birth of a newborn baby, sometimes referred to as �a bundle of joy�, is one example. The adolescent years have ups and downs, but overall they are rather pleasant. Early adulthood leads to marriage and the starting of a new family. Late adulthood and old age have many joyful times, but, there comes a time when this changes. This time is when we are faced with death and dying. It is a natural reaction to feel sadness and grief during this end of life event. As sad as it may seem, proper preparation for dying is possible. Psychological preparation for dying, both for oneself and for loved ones, can ease the burden and possibly lessen the grievance/sadness during the death/dying process. When faced with the reality of imminent death, there are two paths that can be followed: 1.) one can start feeling remorse, sadness, loneliness, and many other depressed feelings, or, 2.) one can prepare to make the last days the best they can be. The latter option can be associated with �dying a good death�. Proper preparation can help one die a �good death�. (It is important to recognize that dying in the context of this paper is a result of terminal illness which may give a person time for proper planning, instead of a sudden death, such as an accident, in which there is no time for planning). In order to prepare to die, or understand someone who is dying, it is important to understand attitudes toward dying, the process of dying, death anxiety, and what a �good death� may consist of.

Attitudes toward death vary from person to person, and, maybe even more so between generations. According to Seifert, Hoffnung, and Hoffnung (2000), social and technological developments have made death and dying more private, instead of public, removing it from our daily lives, and becoming less familiar than in the past. In the early 1900�s and beyond, many communicable diseases caused death to the young and old. With so many deaths, it was part of most peoples� lives in one way or another. Modern medicine, hospitals, hospice care and other institutional settings have caused a change in attitude toward dying. Because of these advances many family members are not present when a loved one dies or during the last days, weeks, or months prior to death. �As a result, the dying often experience a social death before their biological death� (Kastenbaum as cited in Seifert et al.). We begin to leave the dying alone and not disturb them, and sometimes, really do not know how to act around them. Society as a whole can not even talk about death in a straightforward manner. Instead of saying someone died, we say that they passed away, went to heaven, or returned home (Seifert et al.).

Age may have some effect on attitudes toward dying. S. Catt et al. (2005) found that young people have a more difficult time coming to terms with dying than older people. A possible explanation for this is that older people have lived for many years, experienced life, and in some ways already began preparing for death by buying life insurance, writing wills, etc. In contrast, young people have just begun to experience life. For much of the younger generation, wills and life insurance is something they see on television during an AARP commercial. They don�t want to think about the end before they even get started. Proper preparation for dying may change our attitudes toward dying if we have a hard time accepting this inevitable event, or reinforce our attitude if we have mentally accepted the event.

An understanding of what to expect as death draws closer for either yourself or a loved one can reduce anxiety. Just as attitudes toward death and dying play an important role in preparation for this event, so does an understanding in the process of dying. There are actually two processes that should be considered; the physical process and changes of bodily functions, and the psychological or mental process that takes place. According to the Mayo Clinic (2005), there are two stages in the process of dying, the pre-active stage and the active stage. The pre-active stage usually occurs about two weeks prior to death and may include the following signs: difficulty getting out of bed, restlessness, withdrawal from activities, increased need for sleep, loss of appetite, pauses in breathing, difficulty healing, swelling in the arms and legs, seeing people who have already died, and settling unfinished business. Sometimes a loved one may feel as if death is near which is another indication that one is in the pre-active stage of dying (Mayo Clinic). During this stage, if it has not been done already, your wishes or the wishes of a loved one should be discussed to reduce anxiety after death.

Other signs of death will be shown when death is imminent, usually within three days. Not everyone dies the same way, so signs and symptoms may vary, however, some of the common signs that one has entered the active stage of dying include cool arms and legs, bluish coloration, purple coloration on the legs, no longer eating or drinking, congested breathing (death rattle), irregular breathing, discolored urine, incontinence, blurred vision, limited ability to communicate, and confusion and agitation (Mayo Clinic, 2005). As demonstrated here there are several physiological changes or activities associated with dying, and understanding these will better prepare everyone for death.

The psychological or mental process may not be as easy to identify as the physiological process. Elisabeth Kubler-Ross (as cited in Seifert et al., 2000) suggested there are several stages in the mental process of dying or coping with death including denial, anger, bargaining, depression, and acceptance. Denial is a psychological defense mechanism in which a person faced with a fact that is uncomfortable or painful to accept rejects it instead, insisting that it is not true despite what may be overwhelming evidence (Wikipedia, 2006). We don�t want to accept the truth about dying because this thought is painful. As a result of denial, anger sets in. Anger refers to the emotional aspect of aggression instead of the physical aspect. Anger can range from mild forms such as displeasure to more extreme forms such as rage. During the anger stage of death people wonder why it is happening to them. Bargaining may also take place. A person may come to terms with his or her death but only after a special event day, or situation. This person may say, �okay, just let me live to see my son graduate� (Kubler-Ross, 1969). Depression is also an issue that may surface. The dying person may begin to feel guilt and remorse for putting loved ones through the upcoming agony. They may begin to blame themselves for what is happening. Finally, a person may accept death. Age may play an important role in acceptance of death. According to Seifert et al. (2000) young people see death as reversible, adolescents tend to deny their own mortality, young adults seem to get very angry, and older adults seem to face death and accept it more easily. Acceptance may also lead to what appears to be a lack of will power. It may seem as if the person has given up, but this is not necessarily true. Some people do cease to function prior to actual death because of the lack of mental preparation. There are many others, however, who continue to enjoy the last days to the fullest extent possible, and these people are those who have faced the concept of death and prepared for it.

Death anxiety differs from person to person. Older people tend to accept death easier than young people and have less anxiety. Datell and Neimeyer (as cited in Seifert et al., 2000) suggested that women feel more at ease with death and see it as more peaceful, while men view it as antagonistic. Religion also plays a part in dealing with death anxiety. More religious people tend to have less death anxiety and those who were sporadically religious showed more anxiety (Glass, as cited in Seifert). Anxiety in many can be caused by a need to finish unfinished business or by reflecting on responsibilities that may go unattended if there is not another person who can take over the responsibilities. All of these issues must be considered when proper planning for dying is necessary.

According to Plonk and Arnold (2005) �Our last days can either be our best or our worst�. If this is a true statement, what, exactly, does �dying a good death� mean? Seifert et al. (2000) suggested that a good death is �one that is appropriate to the dying person�. A good death can have many meanings. Some people may have struggles with acceptance of death, want to be alone, and view death as �the stealing of life�. For these people, a good death may mean dying at home, or in an institution, alone, or with very little family support. Others with more positive outlooks, attitudes and acceptance of death my want to die at home surrounded by loved ones, and enjoy every bit of life up to the last second. These people and their loved ones see a good death as a new beginning, or at the very least, a good ending. A good death also means respecting the wishes of the dying person. Most people want to die at home, but some elderly people, want to be hospitalized to avoid the burden placed on the family (Plonk & Arnold).

Although the actual event of dying is regarded as a sad and somber time, the period leading up to death does not have to be so. Both the dying person and loved ones can properly plan for the event. The physical planning includes decisions on where the dying person wants to spend his/her last days, visitation, taking care of financial matters, if not already done, and even burial arrangements. Emotionally or psychologically, the process of death should be understood, attitudes should be developed that lead to a good death, and anxiety should be reduced. This is also a time when the dying person and family look toward spiritual values to help get through this emotional time. All of these processes, along with the will to live every moment to its fullest, help us deal with, understand, and accept death and dying. Isaac Asimov (as cited in Plonk & Arnold, 2005) said it best when he said, �Life is pleasant. Death is peaceful. It�s the transition that�s troublesome�. We need to work on the transition to die a peaceful death.

References

Catt, S., Blanchard, M., Addington-Hall, J., Zis, M., Blizard, R., & King, M. (2005). Older Asults' attitudes to death, palliative treatment and hospice care. Palliative Medicine, 402-410.

Kubler-Ross, E. (1969). Kubler-Ross Model. Retrieved May 5, 2006, from http://en.wikipedia.org/wiki/Stages_of_dying

Mayo Clinic. (2005). Making your loved one comfortable during the last days of life. Retrieved May 1, 2006, from http://www.mayoclinic.com/health/cancer/CA00048

Plonk, W. M., & Arnold, R. M. (2005). Terminal Care: The last weeks of life. Journal of Palliative Medicine, 8(5), 1042-1054.

Seifert, K. L., Hoffnung, R. J., & Hoffnung, M. (2000). Lifespan Development (2nd ed.) Boston, Ma: Houghton Mifflin Company.

Wikipedia. (2006, April 6). Denial. Retrieved May 5, 2006, from http://en.wikipedia.org/wiki/Denial

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