Death and Dying

Death and Dying

Death, the irreversible cessation of life, has always intrigued and frightened mankind. Every known culture has attempted to provide an explanation of its meaning; like birth or marriage it is universally considered an event of social significance, amplified by ritual and supported by institutions. Death has been studied by anthropologists, sociologists, philosophers, psychologists and biologists who have tried to understand its cultural, social or individual meanings.

Death is also a matter of legal and political concern - the Law Reform Commission of Canada has published several working papers on euthanasia, cessation of treatment, and the definition of death and related matters, while Health Canada has published analyses and guidelines for establishing standards for hospital-based palliative care. Answers to problems caused by death have been addressed by religion, philosophy and political ideology (see Buddhism; Catholicism; Mormon of Church).

Mortality Rates

Prior to the Industrial Revolution, mortality rates in Canada were high, extremely variable and dependent upon crop conditions, weather, epidemics, etc. The crude death rate (number of deaths per 1000 people per year) has declined from 22-25 deaths in the mid-1800s to 11.8 in 1923 to just 6.8 in 1995, while at the same time the infant death rate (deaths during the first year) decreased dramatically by 83% between 1951 and 1995 (see population).

Life expectancy at birth has reached 75.3 years for males and 81.3 years for females. Age-specific mortality rates for the native population are higher than those for the Canadian population in almost all age categories; as a result, life expectancy at birth for the native population is about 7 years less than for the population as a whole. Women have lower death rates than men at all ages and have actually increased their life-span advantage over men in the past several decades. Today, a woman who reaches the age of 65 has a 50% chance of living an additional 20 years, while a 65-year-old man has a similar chance of living another 16 years. About 80% of all deaths are of people over the age of 60, and death at an earlier age is frequently considered tragic. Health Canada treats deaths occurring before the age of 70 as premature. Today it is difficult to appreciate that children a century ago could reasonably expect to be orphaned before reaching maturity, or that parents might expect to lose one or several children before the children reached adulthood.

Causes of Death

Causes of death have also changed dramatically since 1867. Deaths from infectious diseases have declined, while those from chronic diseases, especially cardiovascular diseases, account for 37% of all deaths. About 28% of deaths are caused by neoplasms (cancer), and about 1 in 10 is caused by accident, poisoning or violence. Pneumonia used to be called "the old man's friend" because it brought a swift and relatively painless death to the elderly, but today it accounts for only 3.5% of deaths.

Social Institutions

Social institutions have generally evolved to facilitate life and prevent death. Some social scientists have postulated that death in societies with low mortality rates poses a greater threat to the individual than it does in societies with high mortality rates because such societies tend to proscribe social solutions to the problems of mortality. Studies of attitudes toward death have revealed the importance to the dying individual of a secure environment and close family ties.

The fact that dying is now usually the termination of a long, chronic illness, most likely in advanced age, affects not only how people think about death and about their own dying, but the type of care provided to dying persons. The great majority of nonaccidental deaths occur in hospitals, but nursing homes have also become an important place where people, especially women, die. As a result, death is less familiar in the experience of most people and dying is largely a process managed by health-care professionals.

Since the late 1960s, the increasingly technological nature of hospital death has aroused concern. A hospital is perceived as a cold and indifferent setting where existence is often prolonged by technology long after the individual has ceased to enjoy quality of life and where the needs of the dying person and his or her relatives or friends are less important than the smooth functioning of the hospital bureaucracy. Dr Cicely Saunders in England, Dr Elizabeth Kübler-Ross in the US and Dr Balfour Mount of the Royal Victoria Hospital in Montréal have pioneered palliative-care services or "hospice" units which specialize in caring for the terminally ill. St Christopher's Hospice in England, established by Dr Saunders, is a freestanding, 62-bed unit.

Today, smaller units based within hospital settings are more common; often these are linked to community-based home-care services because, although palliative care began as an attempt to humanize dying in hospitals, it has increasingly emphasized community-based care and the use of nonprofessional volunteers. These services share a commitment to providing high-quality care, including an emphasis on adequate pain control; to ensuring emotional support to patients who realize they are dying; to allowing the staff to develop an emotional commitment to the patients; and to recognizing a concern for the relatives and others close to the patients. Some programs also provide counselling and support for staff.

Hospice units, some integrated into hospitals, and palliative-care programs, which support the dying and those who care for them, have spread rapidly in Canada. Whereas a 1981 survey by the Palliative Care Foundation identified 109 palliative-care groups, organization, programs or centres of activity in Canada, the Canadian Palliative Care Directory (1992) identifies 350 programs. Of these, half have no doctors involved.

Research and Teaching

Research and teaching about death and dying, particularly from social-science and health-care perspectives, has burgeoned in North America, perhaps because through science and technology we have gained much more control over the timing of death and are now confronted with the dilemma of determining to what extent and with what measures dying should be shortened or prolonged (see medical ethics). When a course on death and dying was introduced at the University of Calgary in 1969, it was one of about half a dozen such courses in the world. Courses in the psychology of death were introduced about that time at the U of Guelph and York U, and a Canadian journal, Essence: Issues in the Study of Aging, Dying and Death, was published between 1977 and 1982. The major international journals Omega and Death Studies were established in 1969 and 1977. Today, there are hundreds of courses and dozens of textbooks dealing with diverse aspects such as the changing causes of death, clinical help for the dying and the bereaved, the psychological and social impact of death and dying, ethical issues such as euthanasia and clinical decision-making, and philosophical and literary issues. An annual conference on "Death, Dying and Bereavement" has been held at King's College at the University of Western Ontario since 1982. This increased interest has been stimulated by the pandemic of AIDS and the recognition of population aging and the fact that most people who die are old.

Fear of Death

Fear of death is the subject of extensive current psychological and sociological research. The anticipation of personal death apparently initiates preparatory processes in which people try to put their affairs in order and to make sense of their impending death and of their lives. Fear and other attitudes toward death appear to vary by age (ie, anticipated remaining years of life), by education levels and by belief systems. The fear of death can be mediated by a sense of continuity; eg, through biology, through works that will survive the creator, through a belief in a deep relationship with nature, etc.

Counsellors claim that compassion, honesty and reassurance help the seriously ill adapt to the approach of death. Dying persons are often abandoned psychologically by family, friends and doctors. Dr Kübler-Ross has claimed that psychological distress diminishes if the patient is not alone and is able to express feelings and concerns, but her theories that dying patients experience a predictable 5-stage sequence of adjustment after learning of their condition, although held by many health-care practitioners, are rejected by most reputable scholars in this field. Bereavement is now perceived as a normal psychological and physiological reaction to death. Grief can be characterized by somatic distress, guilt, hostility, change in patterns of conduct, etc. In Western societies, individuals, after the initial shock, are typically left to grieve alone and there is no conclusive evidence that religious belief helps to alleviate bereavement.

The new character of death is associated with changes in the way it is experienced; usually it follows a lengthy, chronic illness and occurs late in life. In modern Canadian society it is in many respects hidden, especially from the young, as few people die at home. Formal ritual to mark its occurrence has also changed. Mourning dress is now rare in Canada except among some ethnic communities, and funeral practices are becoming less ornate, frequently reflecting the wishes and prior arrangements of the deceased.