10. An End in Sight: Factors in Aging & Dying Flashcards

You may prefer our related Brainscape-certified flashcards:
1
Q

10 Health Tips?

A
  1. Control is everything in the end, but so is acceptance.
  2. Death may be a lot less scary once you get there.
  3. There’s no right way to grieve.
  4. Be wise, and find some meaning…
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2
Q

What is Death? + premature death

A

Irreversible loss of circulation and respiration or irreversible loss of brain function (whole brain [cerebral hemispheres and brain stem]; or brain stem alone).

A death is premature if it occurs before the age of 70 or 75.

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3
Q

What is Death, Psychologically speaking?

A

Death is the “possibility of the impossibility of any existence at all”

  • Difficult concept to grasp, we cannot imagine not existing.
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4
Q

Death - Variations by Disease?

A

The course and length of illness vary greatly from one disease to another.

-> This means that the dying process is quite variable.

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5
Q

Palliative Care?

A

Care intended to reduce pain and discomfort and improve quality of life in patients with chronic/terminal illness; standard form of care in nursing homes, regardless of prognosis.

  • Often initially applied alongside curative care.
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6
Q

Hospice Palliative Care?

A

Hospice care begins when curative care ends. Proves relief of suffering from terminal illness.

Designed to provide warm, personal comfort at the end of life; begins after the treatment of the disease is stopped.

  • Pain is managed and invasive treatments are discontinued.
  • Psychological comfort & increasing social support are key goals.
  • May extend beyond a person’s death to assist in bereavement.
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7
Q

Hospice Care?

A

May occur in palliative care units of hospitals, freestanding hospices, or in homes (home-based hospice services).

Only 16% to 30% of Canadians who die currently have access to or receive hospice palliative and end-of-life care services.

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8
Q

Home Care?

A

Accompanied by improved personal control and availability of support, but can be problematic for family members.

When asked, most Canadians would prefer to die at home in the presence of loved ones.

But nearly 60% of Canadian deaths occur in
hospitals though that number is decreasing.

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9
Q

Research on Palliative Care

Temel et al. (2010) examined 151 patients with newly diagnosed metastatic lung cancer.

  • Randomized patients into 2 groups: early palliative care integrated with standard oncologic care vs. standard oncologic care alone.
  • Palliative care involved at least monthly meetings with a palliative care specialist up until death. Meetings involved evaluations of physical and psychological symptoms, care planning, decision-making, and coordinating care based on individual needs.
  • Researchers assessed quality of life and mood at baseline and 12 weeks following study entry.
A

Mood Symptoms:
Those who reccived early palilitative care had significant lower depression, anxiety and mood disorders.

Survival Rates:
Median survival was longer among patients receiving early palliative care (11.6 months vs. 8.9 months, P=0.02).

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10
Q

Palliative care has been associated with… +$$$

A
  • Lower pain.
  • Improved quality of life.
  • Lower anxiety and depression.
  • Reduction in disease symptomology.
  • Prolonged survival.

There is also evidence that terminal patients who receive palliative/hospice care have significantly lower healthcare costs than those who do not.
- Curative care is far more experince, futual inverventions such as surgerices.

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11
Q

Goals in End-of-Life Care
Avery Weisman’s goals for medical staff working with dying patients:

A

Informed consent: offer knowledge, encourage involvement

Safe conduct: act as helpful guides for patient

Significant survival: help patient make most of time

Anticipatory grief: aid patient and family with sense of loss (debated, might actully make things more difficult)

Timely and ‘appropriate death’: patient should be allowed to die when and how they want, as much as possible.

Help the patient achieve death with dignity.

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12
Q

Disparities in End-of-Life Care?

A

Racialized individuals have lower use of palliative care services, experience worse symptom control, and are less likely to have
end-of-life wishes documented or respected.

Indigenous cultural needs and traditions related to death and dying often go unaccommodated in Canadian hospitals.

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13
Q

End-of-life care is often more difficult for medical staff and formal care providers.
Why? (4)

A
  • Emotionally draining.
  • Unpleasant custodial work.
  • Not curative care.
  • Less interesting/stimulating.
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14
Q

There is evidence that working with
dying patients increases burnout. But some studies have shown that palliative/hospice care nurses are less burned out than other nurses.

What would you expect?

A
  • Empahy provides meaning and is a protective facotor.
  • Greater difficult early on, and people learn how to adapt to it.
  • Facing the fact of mortailty, can make people appciate their own life.
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15
Q

Medically Assisted Dying vs.
Euthanasia defintion?

A

A physician knowingly and intentionally provides a person with the knowledge or means (or both) required to end their life, including counselling about lethal doses of
drugs, prescribing such lethal doses
of drugs, or supplying the drugs.

vs.
euthanasia deliberately ending a person’s life to relieve suffering.

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16
Q

What does the
word dignity mean
to you? And to
“die” with

A
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17
Q

Bill C 14 was passed in 2016, permitting?

A

‘medical assistance in dying’ (MAiD) for mentally competent adults who have a serious and incurable illness or disability; are in an advanced state of irreversible decline; and face a “reasonably foreseeable” death
* written request in presence of 2 independent witnesses
* minimum 10-day ‘reflection period’ in most cases
* must be making decision voluntarily, given opportunity to withdraw

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18
Q

Bill C-7 was passed in 2021 , expanding access to MAID by removing?

A

The requirement that death be “reasonably foreseeable.“
- accompanied by 2 safeguards for non foreseeable deaths: 90-day waiting period and consultation with additional physician (expert in area).
- expands access to those whose sole condition is mental illness.*
*Eligibility delayed again to March 17, 2027.

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19
Q

According to the Fourth Annual Report on Medical Assistance in Dying in Canada, in 2022?

A

There were 13,241 cases of MAID reported in Canada, accounting for 4.1% of all deaths in Canada.

There was a 31% increase in MAID cases over 2021 (covid).
- Evidence of increasing interest in most provinces and territories.
- Cancer (over 60%), neurological disorders, respiratory diseases most common.

3.5% of total MAID cases were non-foreseeable deaths (neurological conditions were most common for this group).

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20
Q

What are some of the concerns and criticisms of physician-assisted suicide/medically assisted dying?(6)

A
  • Incompatibility with care provider’s ethics (95% of doctors willingly approve requests of MAiD).
  • Errors in diagnoses or prognoses, very rare!
  • Coercion by family members or physicians, numerous safe guards in place.
  • Suicide contagion effect, nocorrelation between MAiD and non-assisted suicide -> the ohter way around people who would die by suicide now have another option.
  • Disproportionate impacts on vulnerable groups, so far no evidence for this.
  • Impact on the bereaved.
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21
Q

Disproportionate Impacts?

Battin et al. (2007) analyzed rates of assisted dying in Oregon
and the Netherlands.

A

Found no evidence of heightened risk for vulnerable populations:

  • the elderly; women; racial or ethnic minorities
  • the poor, the uninsured (Oregon only)
  • people with low educational status
  • the physically disabled or chronically ill
  • people with psychiatric illnesses including depression

The only group with a heightened risk: people with AIDS.

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22
Q

Could Poverty Play a Role?

There are concerns about people in poverty resorting to MAID due to their challenging circumstances.
But…

A

But an early Ontario study concluded that “MAiD is unlikely to be driven by social or economic vulnerability”.

MAiD was more likely to be taken up by higher
income Canadians.

Another study found that patients with lower socioeconomic status (SES) were less likely to receive medical assistance in dying. They are experincing barriers to MAid, just like other barriers in the healthcare system.

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23
Q

MAiD - Impact on the Bereaved? + exception

A

People bereaved by assisted dying tend to have similar or lower scores on measures of disordered grief, mental illness, and
posttraumatic stress compared to those who die naturally.

One study found that loved ones of terminal cancer patients who died with medical assistance had less intense grief
response and lower posttraumatic stress.

Expetions, when the bereaved are not informed of the process -> percieved control

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24
Q

Reasons for Choosing Death?

A 2019 Toronto study found that 64% of patients surveyed cited….

A

… functional decline or inability to participate in meaningful activities as the main factor motivating their MAiD request.

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25
Q

Reasons for Choosing Death?

Reasons patients gave when requesting assisted dying in Oregon have
been consistent in reports for 20 years.

A
  • 90% reported a decreasing ability to participate in activities that made life enjoyable.
  • 90% reported loss of autonomy.
  • 65% reported loss of dignity.
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26
Q

Physical Illness & Suicide

Ahmedani et al. (2017) examined 2674 individuals who died by suicide between 2000 and 2013.

Compared the incidence of disease/illness to the incidence of disease/illness in a population of living people.

Results?

A

17 conditions (including migraines, back pain, diabetes, heart disease, COPD, cancer) were associated with increased risk of
suicide (i.e., more prevalent in the suicide group).

Highest risk of suicide was determined for Traumatic brain injuries, sleep disorders and HIV/AIDS.

Reminder: physical illness already leads to suicide.

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27
Q

Is Depression a Factor?

Chochinov et al. (1995) surveyed 200 palliative care patients with cancer in Winnipeg hospitals.

Results?

A

46 patients had a serious desire to die; 52% of these individuals met the diagnostic criteria for anxiety or depression.

compared to only 20% of those without a serious desire to die suggesting that depression may be a factor in wishing for death.

The depression might be driving the desire to die.

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28
Q

In the media…

Should a person with severe (treatment
resistant) depression be eligible for assisted suicide?

A

In Canada, they will be eligible in 2024; are currently eligible in other countries.

“It’s very difficult for people to intuitively understand what suffering is involved in something that is not ‘quote-unquote’
physiological. … Depression is just, ‘You know what? Get your act together.’ And I think that’s very unfortunate.”
-> tend to minimize and invalidate depression

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29
Q

Stages of Dying? + The principal coping mechanism + imporant to note…
(Elisabeth Kübler Ross, 1969)

A

(model not based on emperical approach, only her personal observations)

Denial
- Lack of belief or acceptance.

Anger
- Expressed towards those who are closest.

Bargaining
- Negotiation for more time or longer life.

Depression
- Despair over the recognition of mortality.

Acceptance
- Mortality and future embraced.

The principal coping mechanism people use during the terminal phase is denial.

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30
Q

Death Acceptance, defintion?

A

A ‘giving in’ and realizing of the inevitability of death; often neither happy nor sad sometimes void of feelings. May involve “letting go” and detaching oneself from events and things we used to value.

No longer in denial; neither depressed nor angry.

Value shift, notice and appciate the small things -> similar to post traumatic growth.

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31
Q

Complexities of Denial

In a qualitative study, Copp & Field (2002) found that…

A

Denial and acceptance were interdependent and fluctuating coping strategies used by hospice patients.

They are not opposing, but they can co-occur and are realtead.

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32
Q

Complexities of Denial

Consider Weisman’s (1972) concept of
‘middle knowledge’…?

A

Death denial is complex (not always detrimental) and often involves
2 opposite (yet simultaneously held) views of death:
(1) Denying death and minimizing the bleakness of a prognosis while
(2) making plans for one’s death (e.g., completing a will).

Denial of death prevents us from being overwhelmed. The denial aids in the acceptence of death, they are interdependent.

33
Q

Importance of End of Life Planning? (video)

A
34
Q

A number of psychological factors/goals become more salient as an individual approaches death…

+ What is driving these factors?

A
  • Sense of Integrity
  • Continuity of Relationships
  • Reduction of Conflicts
  • Wish/Goal Fulfillment
  • Memories, Reminiscence
  • Symbolic Immortality
  • GenerativityWhat is Personal Meaning?
  • Spirituality/Religiosity
    etc.

Driving factors; A desire for meaning and purpose.

35
Q

What is Personal Meaning?

A

“A sense of purpose.” (Oxford University Press)
“Having a purpose in life, having a sense of direction, a sense of order and a reason for existence.”

Viktor Frankl (holocaust survivor)
Life has meaning under all circumstances,
even the most miserable ones.

The desire for meaning is the desire for connection -> connecting with the world around you, especially the meaning we find in relationships.

There are many sources of meaning at the end of life…

36
Q

Autobiographical Activities
Reminiscence?

A

Volitional and non-volitional act of recollecting
memories of one’s self in the past.

In a study of nursing home residents, a reminiscence group demonstrated improvements in depression and loneliness after sharing memories, life events, family history, and personal accomplishments

In some cases reminiscence can look like rumination.

37
Q

Autobiographical Activities
Life Review?

A

Return of memories and past conflicts at end of life; spontaneous or structured reconciliation of one’s life.

38
Q

Cross-Generational Methods
Symbolic Immortality?

A

A sense of continuity or immortality obtained through symbolic means.

e.g., raising a child, teaching or mentoring, giving back or making a difference (donating money, volunteering, starting an organization),
connecting with nature, creative acts, spiritual/religious beliefs

39
Q

Cross-Generational Methods
Generativity?

A

A concern for establishing and guiding the next generation

  • Passing on wisdom to the next generation
40
Q

Religiosity?

A

Endorsing or subscribing to an organized system of beliefs, practices, rituals, and symbols.

Extrinsic (external and self-serving motivations)
vs.
Intrinsic (meaning-based and altruistic motivations, not a means to an end, but an end in itself)

A large amount of research suggests that only
intrinsic religiosity is significantly related to meaning in life.

41
Q

Spirituality?

A

A “personal quest for understanding answers to ultimate questions about life, about meaning, and about relationship to the sacred or transcendent”

Brings with it a lot of baggage, like in some cultures it can refer to ghosts. But here it is referred to as personal development of meaning and purpose. Can overlap with religiosity.

42
Q

What can help in Finding Acceptance and what is it related to?

A

Meaning and purpose can help dying
individuals reach death acceptance.

And death acceptance is related to
well-being and quality of life,
especially in later life.

43
Q

Finding Acceptance - A Paradox?

A

Perceived control is important during the terminal phase, yet so is acceptance.

  • As you reach acceptance, your control over making decisions over your death increases.
  • Accepting is an act of control, asserting you agency and coming to terms of what inevitably is coming to happen.
44
Q

What is the alternative to finding acceptance?

A

Death Anxiety:
Worry, dread, and terror over the prospect and/or process of dying.

“The cessation of consciousness is at the essence of death terror.”

45
Q

The Fear of Death?

A

Older adults are more likely to think about death, but are less likely to fear death than middle-aged or young adults.

This may be due to…
- Having accumulated more experience with loss and death.
- Having lived a long life and accepting death as natural.

Younger adults are more likely to fear death itself, but older adults are more likely to fear the dying process.

46
Q

Don’t worry too much…

Goranson et al. (2017) compared feelings of people facing imminent death with those of people imagining facing death…
Study 1: Breast Cancer Patients
Study 2: Death-Row Inmates

A

Study 1: Breast Cancer Patients
Blog posts of near-death cancer patients were more positive and less negative than simulated blog posts of non-patients.

Study 2: Death-Row Inmates
Last words of death row inmates were more positive and less negative than the simulated last words of non-inmates.

47
Q

Bereavement?

A

The period of suffering a loss through death.

48
Q

Grief?

A

The intense sadness and emotional pain caused by the death of a loved one.

49
Q

Mourning?

A

Refers to public displays of grief.

50
Q

The Survivor’s Acceptance?

A

Accepting the reality that our loved one is physically gone and recognizing that this new reality is the permanent reality.
- Involves learning to live with this reality (and pain).
- Does not involve being “okay” with what has happened.

“Learning to live again.”

51
Q

Integrated Grief?

A

The lasting form of grief in which loss
related thoughts, feelings, behaviours are integrated into a person’s ongoing functioning.

Grief has a place in the person’s life without dominating.

52
Q

Complicated Grief?

A

Complicated grief occurs when the grieving process does not progress as expected. Typical symptoms include:
* prolonged acute grief with intense yearning and sorrow.
* frequent troubling thoughts about the death.
* excessive avoidance of reminders of the loss.

53
Q

Prolonged Grief Disorder (DSM 5 TR, APA, 2022)?

A

Persistent grief response following death of loved one; yearning/longing for the deceased and/or preoccupation with the deceased for at least 12 months following the loss.
(can be diagnosed in children after 6 months)

Accompanied by distress and emotional/social challenges.

About 10% who experience a loss classify for this/

54
Q

The Nature of Grief
Today, grief is largely seen as… and Each person’s grieving is…?

A

Today, grief is largely seen as flexible and non-linear.

Each person’s grieving is personal and unique.

There is a wide range of emotions experienced/reported in loss:
intense sorrow, anguish, depression, bitterness, anger, rage, regret, self-blame, guilt, loneliness, pessimism, hopelessness, despair, confusion, emptiness, numbness, fatigue, lack of motivation, low self-esteem, feelings of failure, sense of personal vulnerability, loss of faith, loss of meaning, loss of purpose, alienation, suicidal thoughts, looking forward to death, inappropriate behaviour.

55
Q

Perspectives on Aging?

A

Although the risks of terminal illness and death increase with age, aging and dying are neither synonymous nor parallel experiences.

Aging ≠ dying.

56
Q

Aging and Illness

Adults over the age of 65 are…?

A

Less likely to describe their health as either very good or excellent.

57
Q

Aging and Illness?

A

Aging is the predominant risk factor for most diseases and illnesses that significantly compromise health and/or reduce life expectancy, including most leading causes of death.

58
Q

The Health-Survival Paradox?

A

Despite living longer than men, women experience higher rates of disability and poor health.

This pattern continues into old age and is observed across cultures and nations, including
Canada & the U.S.

59
Q

The Health-Survival Paradox

How can we explain this paradox? (Classroom discussion, no need to memorize exactly)

A

Interaction between biological, psychological, and social factors.

  • Women tend to maintain more social connections over their lifespan, which mitigates the impacts of diseases on mortality and thereby can live longer.
  • Men engage in more risky behaviour and substance use.
  • Differences in willingness to seek out treatment.
  • But women also receive less adequate health care.
  • Changing levels of estrogen in women leads to increased inflammation and poor immune function over time.
60
Q

Key factors found to prevent physical and cognitive decline…?

A

Increasing physical activity and exercise
E.g., In a randomized clinical trial in Canada, aerobic training was found to result in improved brain health among older adults with mild cognitive impairments.

Increasing cognitive activity (inc. cognitive training)
E.g., A recent Canadian study suggested that combining exercise and cognitive training may amplify the benefits of both for the brain.

  • When these two are combined, both effect are amplified.

Also: Stress reduction, social activity, and a healthy diet.

61
Q

The Well-Being Paradox?

A

Despite the changing landscape of stress in old age, studies have found that older adults report less stress, more happiness, and higher life satisfaction compared to younger adults.

This is true even in the face of increasing physical/cognitive decline; confirmed in Canadian samples.

Despite more stress related to illness and loss, older adults appear to cope more effectively with stress.

62
Q

What is success?

A

Success (Oxford University)
The prosperous achievement of something attempted; the attainment of an object according to one’s desire.

63
Q

Successful Aging?

A

Successful aging is a positive perspective
on aging (vs. ‘usual aging’).

Moving away from a focus on decline.

64
Q

How do aging adults define successful aging vs. life satisfaction?

A

Successful Aging:
Physical Activity
Income
Health
Social Interactions
Sense of Purpose
Self
Acceptance
Personal Growth
Autonomy
Environmental Mastery

vs.

Life Satisfaction:
Physical Activity
Income
Health
Social Interactions
- Represents basic needs. A precursor to successful aging.

65
Q

Medical / Public Health Perspectives
Successful aging can be defined as…

A
  1. Optimizing life expectancy.
  2. Minimizing physical/psych./social morbidity.

Compression of morbidity into a shorter, later time period.
This means experiencing illness and disease for the shortest period of time possible and as late in life as possible.

66
Q

A Biopsychosocial Perspective to successfull agining? + suggested addition

A
  1. Avoiding Disease & Disability
  2. Active Engagement with Life
  3. High Cognitive & Physical Function
  • Social relations are a key aspect of engagement with life.
  • One suggested addition to this model is positive spirituality.
67
Q

Lifespan Perspectives

Successful aging involves maximizing… and minimizing…

This can be done by

A

Successful aging involves maximizing
positive outcomes and minimizing negative ones…

Selecting fewer and more meaningful goals.

This is achieved through selective optimization with compensation.
- Compensating for loss of abilities by engaging in new strategies.
- Optimizing existing abilities through practice and technology.

Disengaging from unattainable goals is adaptive, particularly in old age (avoiding goal failure).

68
Q

Goal Disengagement in Old Age? And what do do instead?

A

Goal disengagement appears to be adaptive
in old age, protecting older adults from the effects of depression on disability.

Goal re-engagement, engaging in a new goal is the best approach.

69
Q

Success according to the Eriksons?
Focus of old age (65+) is….

A

Focus of old age (65+) is reflection on one’s life and past events.

  • Success is marked by feelings of wisdom, acceptance of death.
  • Failure involves regret, bitterness.

Wisdom may be a more flexible indicator of success in old age -> less reliance on objective indices.

70
Q

Wisdom, defintion?

A

The coordination of knowledge and experience to improve well-being.

From Joan Erikson:
‘‘What is real wisdom? It comes from life
experience, well digested. It’s not what comes from reading great books. When it comes to understanding life, experiential learning is the only worthwhile kind; everything else is hearsay.’’

71
Q

Socio-Emotional Selectivity Theory?

A

People are increasingly motivated to find meaning as they shift their priorities in the 2nd half of life.

According to this perspective, successful aging can be thought of as a redirected focus on what matters most in life.

And personal meaning is a significant
predictor of psychological well-being
in later life (Fry, 2000).

72
Q

Many Predictors of Successful Aging…

A

Participation in religious activities
Earlier reports of successful aging
Financial status (especially among men)
Physical functioning
Social support and social resources
Happiness & satisfaction with life.
Emotional well-being and security
Personal meaning
Sense of purpose in life
Spirituality and sense of inner peace
Participation in religious activities

73
Q

Telomeres & Aging

A

During DNA replication, some DNA is lost. When cells divide, telomeres shorten.

As telomeres get shorter humans experience aging.

74
Q

Telomeres & Stress?
But…

A

First study to find links between high
psychological stress and shorter telomeres…
One way that stress impacts aging: ↑ stress = ↓ telomere length = ↑ aging

“Women with the highest levels of perceived stress have telomeres shorter on average by the equivalent of at least one decade of additional aging compared to low stress women.”

But…
- Highly stressed individuals who exercised consistently during the week prevented shortening of their telomeres.
- Both physical activity and good nutrition are correlated with telomere length.

75
Q

Anti-Aging Science

A

Multiple labs are working towards the same goal: To make aging a chronic condition we can treat.

76
Q

In the media…
“It’s conceivable that people in my age bracket, their 40s, are young enough to benefit from these therapies. I’d give it a 30% or 40% chance. But that is not why I do this I do this because I’m interested in saving 100,000 lives a day.”

Though controversial, de Grey’s
goal is NOT to extend life indefinitely, but
rather help save lives. Even if radical life
extension is the outcome, can we ethically deny people life saving interventions just because of their age?

A

Ethical dilemma, there is not a point where we can withhold medicine as a function of their age -> people may HAVE to live indefinitely.

Will create disparities

77
Q

Aging & Dying as Diseases?

A

Are aging and dying “ diseases ” to be overcome? There are some who describe them this way and some who believe that we will one day be able to treat them like any other disease.

78
Q
A