ThanatologyDr. Najat Al-Saffar
Is The study of the experience of death , dying and bereavement This science carries , medical legal and moral issuesDeath is a universal and unavoidable phenomenon , it arises strong feeling of dread and fear in dying patients as well as in their families and health careproviders
Death may be as considered the absolute cessation of vital functions
Dying is the process of losing these functions , it may be seen as a
developmental concomitant of living a part of the birth -to -death continuum
Clinical Criteria For Brain Death
1- Coma2-absence of:
Motor responses
Pupilary responses to light
• Conical reflexes
• Caloric responses
• Gag reflexes
• Coughing in response to tracheal suctioning
• Sucking and rooting reflexes
Reaction Of Death
This depend on its context e.g. :
• Timely: when death is expected so we are not shocked by it.
• Untimly :when a person death is an expected or premature
like young person, sudden death, or catastrophic death which is associated with violence, or an accident in this type of death there is sever shock and grief.
• Intentional (suicide)
• Unintentional (Trauma or Disease)
• Subintentional (Substance abuse , alcohol dependence
• The Psychological meaning of death for the person and society
Legal aspects of Death
Physicians must sign the death certificate and it's causes and must also attribute the death to natural , accidental , suicidal homicidal or unknown causesPsychological Reaction to Impending Death
5 Stages* Stage l: Shock and denial
Patient and family may reactwith shock , they may appear dazed at first and they may refuse to believe the diagnosis.
* Stage 2:Anger
Patient and or family become frustrated , irritable and angry at being ill , they commonly ask why me? ...The may become angry about God , their fate , friend, family , themselves or may displace their anger to hospital staff and the doctor.* Stage 3: Bargaining
Patient may negotiate with physician , friends or even God in return for cure , like offering more money.
* Stage 4: Depression
Patient show clinical signs of depression -withdrawal, psychomotor retardation , sleep disturbance , hopelessness and possibly suicidalStage 5 : Acceptance
Patient realize that death is inevitable and they accept the universality of the experience their feeling may range from a neutral to a euphoric mood
Bereavement , Grief & Mourning
are terms that apply to the psychological reaction to a significant loss.Grief :is the subjective feeling precipitated by the death of a loved one .
* Mourning : is the process by which grief is resolved it is the societal expression of post bereavement behavioral and practice* Bereavement: the state of being deprived of someone by death and refers to being in the state of mourning
-The expression of grief depends on many factors mainly : a
Cultural norms and expectations: (e.g. some cultures encourage or demand on intense display of emotion where as others expect just the opposite).
A Circumstances of the loss: (e.g. a sudden unexpected death or one that is clearly anticipated
Normal Grief
Usually 3 phases
* Phase 1 : Shock (minutes , days)
Denial and numbness , sense of unreality
Emotional : crying
Somatic Symptoms Throat Tightness , abdominal emptiness
* Phase 2: perception with the deceased (weeks or months )
WithdrawalAnger & guilt
Insomnia
Anorexia
Weakness & fatigue
Dreams
Identification with the bereaved
Phase 3: Resolution (months , years)
Return to workResume old roles
Acquire new roles
Regaining interest in activities .
Forming new relationships.
End Of Life Care
"palliative Care" "Care of the dying" or "care of terminal illness"
imply the focus on care of the whole person who is approaching death rather than on an attempt to cure underlying disease.
Definition : End of life :may be defined as that time when death -whether due to terminal illness , acute or chronic illness or age itself -is expected within weeks to months and can no longer be reasonably prevented by medical intervention.
• physicians have an important role in helping patients understand that their lives are ending .
• patient experience of the end of life are influenced by their expectation about how they will die and the meaning of death many people fear how they will die more than death itself patient report fear of dying in pain, or of suffocation of loss of control indignity Isolation and being burden to their families .
The role of Doctor at the End of life
• eliciting a complete history• examination for signs of physical disease
• making careful diagnosis of treatable conditions
• sharing patient in making decision
• must have good communication skills
• must be expert at delivering bad news and dealing with it's consequences
• he must work to identify understand, and relieve patient physical social , spiritual suffering and psychgenic distress
• communication directly to patient that will care will continue to provide throughout to final stage of life ,
Suggestions for delivery of bad news
prepare an appropriate place and time *address basic information needsbe direct avoid jargon لغة غير مفهومة
allow for silence and emotional ventilation
assess and validate patient reactions
respond to immediate discomfort and risks
listen actively and express empathy التقمص العاطفي
reassure about pain relief
ensure basic follow up and make specific for the future .
Caring for the family
• deal with strong emotions of fear anger shame, sadness and guilt experienced by family friends and partners
• loss of a loved one may create or reveal painful family dynamic
• financial burdens
• increased rate of anxiety depression chronic illness
Doctors behaviors helpful to families of dying patients
• timely frequent and consistent communication• adapting communications to need
• focusing of patients wishes
• being aware of family conflict
• accommodating family grief
• refocusing hopes
• Encouraging planning
• Remaining available
• Following up with family after death
Some Ethical and legal issues
• conflict : a patient may desire a particular medical intervention , the physician may refuse to under take it if it is of no therapeutic benefit (referral to another doctor may then be appropriate• patients have the right to stop unwanted medical treatments once begun as they do to refuse those treatment in the first place
• sufficient doses of required drugs should be given e.g. pain killer like morphine may be given even if there is the potential unintended secondary effect of depressing respiration.
The Specific Tasks of Caring
Maximizing the quality of life - rather than postponing death-is the first priority of care in this context symptoms that cause disability and suffering must be considered medical emergencies and managed aggressively
• pain: is a common problem for patients at the end of life and is what many people say that fear most about dying, it also includes the patient emotional reaction to it the pain is subjective and the goals of pain management is most properly decided by the patient
• Dyspnea : a subjective experience of difficulty in breathing common in dying paticnts-50%- oxygen and opioids should be used anxiolytic may be of benefit.
• Nausea and vomiting ben/odiazepine could help (dronabinol (2.5-20mg orally every 4-6 h ) is very helpful.
• Constipation : lactulose sorbitol , magnesium citrate and enemas can be given as needed
• Delirium and Agitation: halopenidal (l-10mg orally or i.m, i.v twice or 3times a day) thioridazine and benzodiazepine are alternative
• Nutrition and Hydration
Psychological Challenges
Five psychological stages or patterns of emotions that patients at the end of life may experience• Denial and isolation
• Anger
• Bargaining مساومة
• Depression
• Acceptance
In addition to these five stages are anxiety and fear of the unknown