Chapter 65 Death and dying
The medicalization of dying
Dying and death, like birth, are a normal part of everyday life. Over the past few decades, western society has largely removed death and dying to the confines of institutions such as hospitals and hospices. Care of the dying and the dead is still, for the most part, the remit of professionals such as doctors, nurses and undertakers. As a result, death has become marginalized and stigmatized and, some would argue, increasingly medicalized (Clark & Seymour, 1999). More recently, media images of death, dying and mourning, such as the Princess of Wales’ funeral in the UK and the events surrounding 9/11 in the USA, have gradually reintroduced this topic to the public arena. Public outpourings of grief on national television have become more acceptable.
Place of death
Paradoxically, though we know that most people would like to die at home, in their own beds, surrounded by family and friends, the majority of people do not. UK data on place of death showed that 66% of all deaths occurred in hospital in the year 2000 (Ellershaw & Ward, 2003). A combination of factors, such as poorly controlled symptoms, lack of family support, the burden on carers, badly coordinated services and changes in people’s preferences as their disease progresses, can result in people being admitted to a hospital or a hospice before they die. Thorpe (1993) suggests that improvements in care could enable more people to die at home (Box 1). However, not all patients will want to die at home and to help patients die where they want it is important for doctors to explore patients’ thoughts and fears in order to understand the reasons for their choice (Faull & Woof, 2002).
Stages of dying
Theoretical models have helped us to understand individual psychological responses to death. In her interviews with terminally ill cancer patients, Kubler-Ross (1970) described the dying process as a series of stages that the person passes through before finally coming to terms with his/her imminent death. These stages include shock, denial, anger, bargaining, depression and ultimately acceptance. Similar staged theories have been used to describe the bereavement process (see pp. 18–19). However, not everyone passes through these stages in sequence and individuals may fluctuate between acceptance and denial as they try to maintain hope about their prognosis (Johnston & Abraham, 2000). Carers and health professionals, therefore, need to be prepared for fluctuations in patients’ moods so that they do not misinterpret them.
Viewing the body after the death
Junior medical staff may often be involved in dealing with the relatives after the death. This may involve breaking the news of the death to the relatives and accompanying them to view the body, either on the ward or in the hospital chapel or mortuary where the body has been taken (see pp. 98–99). Although this may be an uncomfortable duty, it is an important part of the grieving process and allows the relative to begin to absorb the loss and to say a final goodbye. It will be especially difficult, however, if the death has been sudden or unexpected.
The good death
Achieving a good death for patients is an important goal for health professionals who work with the dying (Ellershaw & Ward, 2003). Studies of the dying process have led to a debate about the characteristics of a ‘good death’. Table 1
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