HUMAN LIFE CYCLE

6.01 DEATH AND DYING LE 6

Dr. Buenaventura | March 9, 2017

OUTLINE II. DEFINITION OF TERMS #

I. Statistics of Death Grief (n.):
II. Definitions of Grief, Mourning and o concerned with emotions
Bereavement o very specific feeling of sadness
III. Case of Vanessa and Her Mama o a subjective feeling that is precipitated by
IV. Social Concepts the loss of a loved one
V. Death vs. Dying o normal process of reacting to the loss
a.Dr. Kubler-Ross o experienced as a mental, physical, social or
b.5 Stages of Death and Dying (DABDA) emotional reaction
VI. Death and Dying Across Life Span Mourning (v.):
VII. Fears r/t Death and Dying o the process by which you are supposed to
VIII. Medical Issues adapt to a loss
IX. Institutionalization o each culture has own beliefs, customs, and
X. Comfort Care behaviors related to bereavement
XI. Legal Issues Bereavement (n.):
XII. Preparing and Facing Death o pagdadalamhati
XIII. The Good Death o state of being in grief
XIV. Reasons Why People Wont Talk about Death o period after a loss during which grief is
XV. External Attitudes experienced and mourning occurs
XVI. The Health Caregivers Other Roles o time spent in a period of bereavement
XVII. Focusing on Physician depends on how attached the person was to
a. The Case of the Judge from Bicol the person who died
XVIII. Conclusion o how much time was spent anticipating the
loss
OBJECTIVES:
General Objectives !GCorrelation
To discuss pertinent issues relevant to the dying Take note since these terms are always used in wrong context
process including the 5 stages of emotional responses
and ways to deal with a terminally ill patient. Grief emotion specific in relation to loosing someone via death;
dalamhati
Specific Objectives Mourning duration; period of time;
At the end of the learning activity, the student will be practices resolving the grief;
able: pagluluksa
o To discuss basic concepts of death and dying
o To describe the 5 emotional responses of a terminally Bereavement state of being in grief;
ill patient pagdadalamhati
o To demonstrate the appropriate skills of a physician
needs to develop in interacting with a terminally ill
If your favorite sports team looses in a game, you are not grieving,
patient you are sad because they lost the game. (they did not die)
o To manifest compassion and empathy towards a
terminally ill patient In a wake, we describe the person who has lost someone, the
beareved/ang nawalan. They are the ones suffering from grief. When
Legend: somebody dies and you hold a wake for them, that is part of
mourning.
Remember Previous
Lecturer Book Trans Com
(Exams) Trans
In the Philippines, the period of mourning is one year. A year after
G ! & 4 ! someone dies is called Babang-luksa. Traditionally, if you loose
someone you wear black/ black patch all throughout the year to
signify that you are mourning.
NOTE: This is the only lecture on death and dying in med
school. Hope to make the most of it. (Bueneventura, 2017)
I. STATISTICS OF DEATH III. CASE OF VANESSA AND HER MAMA
Average number of deaths Vanessa is a 29-year-old female who works as a
56 million per year training supervisor in a firm in Quezon City. She was referred
153, 000 per day by a human resources manager of the company she was
6, 390 per hour working for, because she was noted to be crying a lot. Her
107 per minute eyes were really swollen due to this.
1.78 per second

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6.01 Death and Dying HUMAN LIFE CYCLE 2020C

Four months earlier, in August of the previous year, Asian Belief: Issue of reincarnation Do good in this life for in
her grandmother whom she calls mama, died. She was the one the next life you will be rewarded.
who raised and took care of Vanessa ever since she was 3
th
months old up to the time of her death. She was the 4 child V. DEATH AND DYING
and her parents started working abroad by the time she was Death
born. o The inescapable end of life that will touch
everyone at specific point in time
In July, her grandma fell and suffered from hip Dying
fracture. By August, her grandma was hospitalized in the o The process that ends in death
critical care unit of the hospital. At the age of 89, she died of
complications from a hip fracture. Death and dying both have always been complex and
controversial issues.
Vanessa was very close to her grandmother and it
made her feel like shes almost her real mother. It was like
! Dorian Gray
literally loosing her own mother.
original story: Portrait of Dorian Gray
wealthy gentleman who has gained immortality by
Four months after she died, Vanessa is still in grief. having his soul trapped within a painting. He is well knw
She started her grief counseling process because she felt like for his extravangance and debauchery. (Famdom Wiki)
no one could understand her and that she is alone. He never ages but his portrait does. Remains youthful
Another factor that made her feeling even worse is looking and is not going to die unless one will destroy
that she was supposed to get married in December of the its portrait. (Buenaventura, 2017)
same year. But it was postponed to after a year/babang-luksa
because of the sukob, filipino pamahiiin na bawal magsukob/
magsabay (wedding should not fall during the death and before A. Dr. Kubler-Ross
the year of mourning ends or else malas/misfortunes will come
on the couples way).

Recently, she is much better compared to before

when she used to sleep hugging her grandmothers urn, and
smelling her grandmothers clothes. She was able to give away
the clothes of her grandmother. The urn was placed in the
pedestal of her home but she agreed to place the ashes in the
columbarium after the babang-luksa, also in accordance to the
rules of the church. Moreover, she can now talk about her
grandmother without breaking into tears. She was no longer
rejecting the help of her fianc and her siblings.

In a span of 3 months, during the process of grief

counseling, she started to mourn to resolve the grief. Hopefully,
she recovers before the time of babangluksa

IV. SOCIAL CONCEPTS Figure 1. Kubler Rosss book- On death and dying.
Source:https://www.google.com.ph/search?q=on+death+and+dying)
Table 1. Comparison between the traditional and modern concepts of death
Traditional Modern o Swiss psychiatrist who pioneered near-death studies
and as part of her residency training in the Taylor
College, Texas USA
Normal part of life Failure of medicine o Was really disappointed on how Americans handles
Its okay, everybody dies Inability to provide the cure the dying patients
o In 1960s, she started writing and giving lectures on
Eastern cultures
Western cultures how to deal with death and dying
Provide comfort o Promoted and encouraged a more humane approach
Failure to provide cure to the dying patient
Most die at home
Institution o Author of the book On Death and Dying
Welcome relief Talks about better treatment of the dying patient
Want to postpone and a better understanding of the process of
Belief of reincarnation
Finite situation death
Published in 1969
the seminal work first of its kind, ground
breaking

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6.01 Death and Dying
B. 5 Stages of Death and Dying (DABDA)
May not occur in a predicted similar fashion as
predicted. Sometimes, people just go through one or
two or all five stages.
There are individual differences. Not all individuals will
manifest all stages or in the fixed sequence
Do not assume right away that someone who is
terminally may start with stage 1 some of them may
start at acceptance already.
Socio-cultural factors also play a role
Intrapersonal dynamics of the dying process are critical
knowledge and one theory that has received wide
acceptance are the five emotional stages of death and
dying presented by Kubler-Ross in 1969
Persons response to ones own dying, however, is far
too complex to fit neatly into a model of a linear
stepwise progression involving live single emotions from
denial to acceptance
1. Denial
o shock
o Thats not true
o You may be mistaken
o I dont think Im dying
2. Anger
o heightened emotions
o most challenging as far as the healthcare
professionals are concerned
o denial still exists and at the same time they are
angry
o patient can be very combative or aggressive
and they will not listen at all
o they are angry with the physicians, God and
with themselves
o underlying the feelings of anger are feelings of
loneliness, internal conflicts and feelings of guilt
! Notes: For someone who develops lung cancer usually happens
after they have been smoking heavily for a while. For someone who
develops lung cancer but does not smoke, but the spouse does, it is
even more critical. The tendency is to blame the spouse which leads to
internal conflict. The one they loved has caused the cause of her
death.
3. Bargaining
o 2nd most critical stage next to anger
o usually praying
o between stage 3 and 4 there is a movement
away from increase self-awareness and
contact with others so the individual can
become isolated and eventually depressed
! Bargaining and Devotions
If I do this I hope this wont happen.
If I donate to this charity, I hope the symptoms would subside
If I pray all the novenas, I will get better
St. Jude Patron - Saint for The Hopeless, whom Dr. Bueneventura
prayed for Board Exam; para sa mga hindi nagreview
Perpetual Help
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HUMAN LIFE CYCLE 2020C
4. Depression
o Always ask for suicidal intent
o Do not be afraid of asking the patient in a
compassionate manner
Naiisipan mo bang saktan ang sarili mo?/
Do you have plans of hurting yourself?
Naiisipan mo bang magpakamatay? Do
you have plans of killing yourself?
Patient with suicidal plan psychiatric
emergency, hospitalize the patient
urgently for confinement and ask the
psychiatrist to come over
o If the patient is terminally ill and is depressed
automatically he/she has suicidal intent
o Patients who are terminally ill are often not referred
to a psychiatrist so it is our responsibility as
physician to make sure that this patient wont make
no harm to himself
Story at St. Lukes at Cathedral Heights Complex:
! The caregiver know that the patient was depressed and
referred this patient to a psychiatrist, however, on her way to
the psychiatrist the patient jumped out of the building.
Terminally ill and depressed = most likely with suicidal intent
Usually cancer centers must be comprised of multidisciplinary
team of doctors, nurses, grief counselors, psychologists.
5. Acceptance
o Gradual realization of consequences
o Theres a tendency of recidivism or sliding back,
going back to anger
Like cancer patients who suffered the side
effects of chemotherapy
Usually happens because doctors do not
always explain what the expectations are
Figure 2. Kubler-Ross Model of Emotional Response: Change-
Transition Curve. Individual is initially healthy then a terminal
diagnosis is given. From then, note the significant change in the
emotional state of an individual. Common initial stage is denial (shock)
if it persists may lead to heightened emotions. When this subsides, he
may experience bargaining and then depression, where it is important
to ask for suicidal intents. After some realization of consequences,
hopefully the patient will go to stage of acceptance. (Source: Dr.
Bueneventuras ppt.)
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6.01 Death and Dying HUMAN LIFE CYCLE 2020C

VI. DEATH AND DYING ACROSS LIFE SPAN
Perinatal/Infancy: Accidental? Illness? Term? Wanted
pregnancy?
o In this stage, there is still no concept of death and
dying
o The impact of the death is on the parents/
caretakers
o The mother who loses a baby can go into
postpartum depression mother can be
actively suicidal
postpartum psychosis (more critical)
o The child who loses a parent or parents, will
require a stable, nurturing substitute.
Adulthood: transitional period; similar to young adults
in terms of invulnerability and anger at being cheated by
death
Middle Age: significant changes in perception; will now
consider possible outcomes in relation to death and
dying
o Hard to deal with from a pragmatic perspective
o Such as fear of a long drawn-out death, pain,
disability
o Increased anxiety over death and dying because
of family, career, bucket list
o Death of a parent vs. a child disruption of natural
order

Less than 5-7 years: the child has no finite concept ! Disruption of the natural order: when the child dies
of death yet; the perception is like sleeping or going before the parent; It is more difficult for a parent to
away accept a loss of child comparing to a loss of parent
o At the stage confirmation and first communion
usually happens because by this time the child is Old Age: more realistic, accepting towards death and
assumed to have developed what dying; welcoming of death; sick and very frail elderly,
concrete thinking? particularly those in adverse circumstances, may
operational thinking? actually welcome death as a release
postformal thought? o Loss of spouse / child / grandchild / other
o Once they develop a better understanding of significant people
death, they will respond emotionally similar to o Less afraid
adults o Most of the time they are used to suffering from
o According to John Bowlby, they will only respond looses
on 3 stages: Protest, Despair, and Detachment.
! One factor of good sense of acceptance is spiritualit, not
The preoperational stage is the second stage religion
in Piaget's theory of cognitive development. This stage
begins around age two and last until approximately age VII. FEARS R/T DEATH AND DYING
seven. During this stage, the child learns to use the
symbols of language. Physical:
o Helplessness
Teens or Young Adults: difficult to handle due to o Dependence
o loss of physical faculties (disability)
feeling of omnipotence or invulnerability
o Stage of recklessness; takes unnecessary risks o mutilation
o pain
o Nothing bad is going to happen; we are young
Social:
Example: A group of teenagers/high school
o separation from family
students went joyriding. (none of them has
o leaving behind unfinished business
the license to drive) They hit a concrete
o being a financial and emotional burden to others
barrier and the car exploded and the all of
them die Emotional:
o Deaths due to accidents/suicide o not being able to reach your goals
o Romantic view of death o being unprepared for death and what happens
after death
o Developing terminal illness results in anger or
feeling of being cheated, as a prominent response
Theres still a whole life ahead of me and yet VIII. MEDICAL ISSUES
here I am diagnosed with illness
o Can have positive outcome encountering death of Overall health
greater appreciation of life when they are not Pain and disability
directly affected Dementia, depression and other mental health concerns
Mother a friend dies will give them an idea Organ donation
that life is short, I have to do well
But when they are directly affected, they
usually do not deal well with it

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6.01 Death and Dying HUMAN LIFE CYCLE 2020C

IX. INSTITUTIONALIZATION Acceptance of finality of death

Palliative Care: XIII. THE GOOD DEATH

o Individual voluntarily goes into institution
o to lessen the burden and still provides for cure Sudden
o the goal is to improve quality of life During sleep
At home
Hospice Care: Comfortable
o waiting for the eventuality of dying; Meaningful
o provides only comfort Completed life
Goodbyes done
Home Care: ! Make sure you say goodbyes to your loved ones
o supportive care provided in the home; Life review accomplished
o a bit expensive Surrounded by love
o if the individual wants to die at home, it must be
respected XIV. REASONS WHY PEOPLE WONT TALK ABOUT
DEATH
Respite Care:
o care provided to relatives; a form of support for Fear of being burden to family and friends
the patient and the carer ! Some people are in denial stage or others dont want to
o It gives the carer the opportunity to attend to talk about it.
everyday activities or go on holidays while ! Dont force someone to talk
ensuring your needs are supported. Lack of privacy, particularly in hospital wards
Inner conflict and unfinished business
! There is about 30-35 institutions nationwide costing about Fractured, strife-ridden families
Php 30,000-35,000 per month. Secrets that have never been shared
Denial I dont want to face the truth
X. COMFORT CARE Fear of upsetting relatives
Never been a talker, and dont want to start right now.
Physical comfort Trusting the right person (a dying person may choose
Mental and emotional needs who they want to talk to, and this might not be a
Spiritual issues relative, trained nurse or doctor)
Practical tasks
o Financial considerations ! Cure collusion
o Funeral arrangements Hintaying na lang natin na mamatay sya
o Remembrances
Family members usually collude to the doctors no to tell the person
A lot of terminally ill people want to be involved in the planning that he is terminally ill. Unfortunately, when he does not know that he
as to the kind of funeral which will be made. Unfortunately, is terminally ill, how could he prepared for his death. Medical doctors
when they die, a lot of relatives do not follow these wishes. usually agree to this because the burden of disclosure is lifted from
their shoulder.

XI. LEGAL ISSUES

XV. EXTERNAL ATTITUDES
Advance Directive/ Living Will/ Power of Attorney

! You can state here what you want on how you want to be Close family members are often too embarrassed to
handled when you die. E.g., When your unconscious, whether solicit their elders view on these matters or feel it is
you want to be resuscitated or not. harsh, cold, inappropriate and to form
A lot of health care providers, including doctors and
Substituted Judgment/ Best Interests nurses, are not properly trained in dealing with D&D to
Euthanasia the detriment of the patients well being

XII. PREPARING AND FACING DEATH XVI. THE HEALTH CAREGIVERS OTHER ROLES

Fulfilled goals Death is the end, as we know it, for that person.
Life satisfaction We can only support, listen therapeutically and make
Family is ok the person as physically comfortable as possible.
Spouse / friends / contemporaries are all gone We can also use our knowledge and expertise to
Spiritually prepared strengthen, support and prepare the Family.

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We can refer the Patient and/or the Family for Grief

Counselling. XVIII. CONCLUSION
We can also consider the need for Palliative or
Hospice Care. Death and dying are complex concepts
It is clinically useful to understand the stages of the
XVII. FOCUSING ON PHYSICIAN emotional responses of a terminally ill patient
It is very important for a physician to know the
The sensitive issue of Disclosure: appropriate ways to assist a patient in this phase of life.
o depends on the Patients needs at the point Dying must be a positive way for them to the next
of disclosure. phase/next life.
o We are guided by the patient
consider Intellectual vs. Emotional approach.
o We need to combine both intellectual and MINI QUIZ
emotional perspective
o Ask the patient Ano sa palagay niyo bakit 1. What is the most challenging stage on Kubler-Ross
kayo nagkakaganiyan? Stages of Death?
Explore ones (the Physicians) attitudes towards a. Denial
death, dying, pain and disability. b. Anger
Develop the skills of Compassion and Empathy. c. Bargaining
d. Depression
A. The Case of the Judge from Bicol 2. It is very specific subjective feeling that is precipitated
by the loss of a loved one:
a. Grief
89 years old Judge from Bicol was referred because b. Mourning
he was severely depressed. c. Bereavement
He had been coughing for a long period of time so he d. Maladaptive Coping
went to his family physician who did exams, x-rays, etc. And 3. It is a care provided to relatives; a form of support for
after all the results came in, the family physician said Id like to the patient and the carer:
refer you to a former teacher of mine who is a specialist in a. Palliative care
Manila. So the Judge and the wife went to Manila with all the b. Hospice Care
lab exams. Once they got there, the wife handed all the lab c. Respite Care
results to the specialist, so the specialist browsed through it d. Home Care
and when he saw the x-ray, he said Oo nga may cancer nga
(Yes! He has cancer!) BUT the patient had not been told by
the first physician that he had cancer, he was just told that he Key: B. A. C
needs to be seen by a specialist for a second opinion. The
second physician was confirming what he thought was already
been told to the patient. From that moment on, the patient went
to the dark abyss of despondency. Hindi na nagsalita from that
moment on. Hindi narin naiuwi sa Bicol. And thats the reason
why he was referred to the psychiatrist. So he was treated with
anti-depressant and it took a while before he started
communicating again. Then eventually he went back to Bicol
and was referred to a local psychiatrist for the continuity of
treatment.

*NOTE from the story:

Always clarify. Always confirm.
Do not pass he burden of disclosure to someone
else.
Point of view of compassion: EMPATHY. We
treat our patient the way we want ourselves to
be treated. (If we are going to be diagnosed of
having terminal illness, we should be able to
provide disclosure to our patients the way we
wanted to happen to us.)

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