END OF LIFE ISSUES

DEATH, DYING, GRIEF, BEREAVEMENT

Evelyn Ramos-Go, MD, MPH, FPSMS, DSBPP
Head, Section of Adult Psychiatry
Department of Psychiatry and Mental Health
Quirino Memorial Medical Center
 DEATH AND DYING
Definitions

Death – absolute cessation of vital functioning

Dying – process of losing these functions

 DEATH AND DYING
Good death is one that is free from avoidable distress
and suffering for patients, families and caregiver. Is
reasonably consistent with clinical, cultural and ethical
standards.

Bad death is characterized by needless suffering,

dishonoring of the patient or family’s wishes or values.
STAGES OF DEATH & DYING
Stage 1 : Shock and Denial
Stage 2 : Anger
Stage 3 : Bargaining
Stage 4 : Depression
Stage 5 : Acceptance
 STAGES OF DEATH & DYING
STAGE CHARACTERISTICS WHAT TO DO
1. Shock & Denial Initially reacts with shock, dazed; refuse to Communicate respectfully and directly.
believe the diagnosis; deny that something Allow patient’s emotional responses and reassure them
is wrong. that they will not be abandoned.

2. Anger Becomes frustrated, irritable, and angry at
being ill. Commonly ask “why me?”, they
become angry at God, their fate or family
member or themselves. Displace anger to
health worker.
3. Bargaining Negotiate in return for a cure, fulfills one or
many pledges, promises.
Do not take anger personally.
Response should be emphatic and non-defensive.
Anger represents “desire to take control” in a situation
they feel is out of control.
Make clear that they will be taken cared to the best of
your capacity. Patient should be encourage to
participate in the treatment.

4. Depression Show signs of depression … withdrawal, Enhance the dignity and quality of life to somehow
hopelessness, helplessness, change in prolong longevity.
somatic functions

5. Acceptance Realization that death is inevitable Intensify religious beliefs and conviction.
“Fear not death, remember those who have gone
before you and those who will come after
 STAGES OF DEATH & DYING
STAGE CHARACTERISTICS WHAT TO DO
1. Shock Initially reacts with Communicate
& Denial shock, dazed; refuse to respectfully and directly.
believe the diagnosis; Allow patient’s emotional
deny that something is responses and reassure
wrong. them that they will not be
abandoned.
2. Anger Becomes frustrated, irritable, and angry at being Do not take anger personally.
ill. Commonly ask “why me?”, they become Response should be emphatic and non-defensive.
angry at God, their fate or family member or Anger represents “desire to take control” in a
themselves. Displace anger to health worker. situation they feel is out of control.
3. Bargaining Negotiate in return for a cure, fulfills one or Make clear that they will be taken cared to
many pledges, promises. the best of your capacity. Patient should be
encourage to participate in the treatment.
 STAGES OF DEATH & DYING
STAGE CHARACTERISTICS WHAT TO DO
1. Shock & Denial Initially reacts with shock, dazed; refuse to Communicate respectfully and directly.
believe the diagnosis; deny that something is Allow patient’s emotional responses and reassure
wrong. them that they will not be abandoned.

2. Anger Becomes frustrated, Do not take anger

irritable, and angry at personally.
being ill. Commonly Response should be
ask “why me?”, they emphatic and non-
become angry at God, defensive.
their fate or family Anger represents “desire
member or themselves. to take control” in a
Displace anger to situation they feel is out of
health worker. control.
 STAGES OF DEATH & DYING
STAGE CHARACTERISTICS WHAT TO DO

3. Negotiate in return Make clear that they will be

Bargaining for a cure, fulfills taken cared to the best of
one or many your capacity. Patient
pledges, promises. should be encourage to
participate in the
treatment.
4. Depression Show signs of depression … withdrawal, Enhance the dignity and quality of life to somehow
hopelessness, helplessness, change in prolong longevity.
somatic functions

5. Acceptance Realization that death is inevitable Intensify religious beliefs and conviction.
“Fear not death, remember those who have gone
before you and those who will come after
 STAGES OF DEATH & DYING
STAGE CHARACTERISTICS WHAT TO DO
3. Bargaining Negotiate in return for a cure, fulfills one or many pledges, Make clear that they will be taken cared to the best
promises. of your capacity. Patient should be encourage to
participate in the treatment.

4. Show signs of depression: Enhance the dignity

Depression withdrawal, hopelessness, and quality of life to
helplessness, change in somehow prolong
somatic functions longevity.

5. Acceptance Realization that death is inevitable Intensify religious beliefs and conviction.
“Fear not death, remember those who
have gone before you and those who will
come after
 STAGES OF DEATH & DYING
STAGE CHARACTERISTICS WHAT TO DO
4. Depression Show signs of depression: withdrawal, hopelessness, Enhance the dignity and quality of life to somehow
helplessness, change in somatic functions prolong longevity.

5. Realization that death Intensify religious

Acceptance is inevitable beliefs and
conviction.
“Fear not death,
remember those who
have gone before you
and those who will
come after”
 BEREAVEMENT, GRIEF & MOURNING
Psychological reactions of those who survive a
significant loss.
GRIEF – subjective feeling precipitated by the death of a loved one.
MOURNING – is the process by which grief is resolved
BEREAVEMENT – state of being deprived of someone by death and
being in the state of mourning.
 NORMAL BEREAVEMENT REACTIONS
• Protest
• Searching behavior
• Despair and detachment
• Finding psychological and symbolic ways to
keep the memory
• Loneliness - the most lasting manifestation of grief.
 PHASES OF GRIEF
SHOCK and DENIAL Disbelief, and numbness
(minutes, days, weeks) Searching behaviors, pining,
yearning, and protest

ACUTE ANGUISH Waves of somatic distress

(weeks, months) Withdrawal
Preoccupation
Anger
Guilt
 PHASES OF GRIEF
LOSS PATTERN OF Restless and agitated
CONDUCT Aimless and amotivational
Identification with the bereaved
RESOLUTION Have grief
(months, years) Return to work
Resume old roles
Acquire new roles
Reexperience pleasure
Seek companionship and love
again
 STYLES OF GRIEVING
INTRUMENTAL GRIEVING – has a focus primarily on
problem solving task. This involves controlling or
minimizing emotional expression.

INTUITIVE GRIEVING – based on heightened

emotional experience. This involves sharing feelings,
exploring lost relationship, and considering death.
BROKEN HEART SYNDROME

Stress Hormone
 COMPLICATED GRIEF
• If the pain is so severe that it keeps a person
from resume usual life.
• Being stuck in an intense state of mourning.
• Preoccupied on keeping the “loss”
• Disrupts daily routine and
• affects relationships
 COMPLICATED GRIEF
Symptoms:
• Intense yearning for the dead loved one
• Imagining that the dead loved one is still alive
• Intrusive thoughts or images of the loved one
• Searching of the loved one in familiar places
• Extreme anger or bitterness
• Feeling that life is empty or meaningless
• Intense denial of the loss
 BEREAVEMENT
Symptoms may be same as
MDD, but rarely has morbid
feelings of guilt and
worthlessness, suicidal
thoughts, or psychomotor
ideation
Considers self bereaved
Dysphoria often triggered by
thoughts or reminders of the
deceased
DEPRESSION
Presence of 5 of the 9
symptoms of Major Depression
Consider self weak, defective
or bad.
Dysphoria is often autonomous
and independent of thoughts
or reminders of the deceased
 BEREAVEMENT
Onset: within first 2 months of
bereavement
Duration of symptoms is less
than 2 months
Functional impairment is
transient and mild
No family or personal history of
major depression
DEPRESSION
Onset at any time
Symptoms often becomes
chronic, intermittent or
episodic
Clinically significant impairment
Family or personal history of
major depression
 CAN MEDICINES HELP?
General Rule: Normal grief needs no medicines

Antidepressants
- Can relieve but symptoms but do not treat the
cause.
- Numbs the pain but delays the normal process
of grieving.
 WHEN TO SEEK PROFESSIONAL HELP?
When experiencing complicated grief or
depression. If:
- feel like is not worth living
- death wishing
- constant blaming of self
- withdrawn
- difficulty trusting others
- unable to perform usual daily activities
THANK YOU