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Death and Dying

In the 1800s doctors had to judge life and death on the basis of heart sounds, breathing, pulse, temperature, pallor (paleness) of the skin, and rigor mortis (stiffness which occurs after death). None of these signs was 100% diagnostic. Sometimes people were declared dead, only to revive later.

In the 1800s, fear of being buried alive approached a phobia for some people. Franz Hartmann, in an 1896 pamphlet titled Premature Burial, claimed he had located 700 cases of people buried alive or narrowly escaping it.

The Society for the Prevention of Premature Burial was founded in 1896. In 1897 a patent was issued for a device for allowing an awakened corpse to signal people above ground.

device for signalling from the grave
A device for letting people above ground know they better dig up a casket quickly

By the 1960s, advances in medical technology made it possible to keep a body alive after the brain was dead, using automatic ventilators. Now death had to be re-defined.

In 1968, the International Council of Medical Science established four criteria for diagnosing death:

1. Loss of all response to the environment

2. Complete abolition of reflexes and loss of muscle tone

3. Cessation of spontaneous respiration

4. Abrupt decline in arterial blood pressure

What are modern definitions of death?

In 1981, after lawsuits involving the 1968 criteria, a U.S. presidential commission took up the issue again. The result was the 1981 Uniform Determination of Death Act (UDDA) which defined death as the irreversible loss of all brain functioning, including the brain stem.

Even then, determining "irreversible loss of all brain functioning" remained tricky. The American Academy of Neurology issued guidelines in 1987 and updated them in 2010. According to the 2010 report, no patients have recovered after a brain death declaration using AAN guidelines. These guidelines include:

1. The presence of unresponsive coma

2. The absence of brain stem reflexes

3. The absence of respiratory drive after a CO2 challenge

Doctors must also determine the cause of coma and rule out any conditions that might mimic death, and they must wait for an adequate period of time to ensure recovery is not possible. Dr. David S. Morriz, a trauma surgeon at the Mayo Clinic, explained:

There can't be any diagnostic uncertainty. ...We also need to rule out factors such as locked-in syndrome, epilepsy, alcohol or drug intoxication, and the presence of neuromuscular blocking agents, antidepres­sants, barbiturates and other confounding drugs. ("Brain death still a vexing issue" 2011)

The Mayo Clinic issued a 25 item checklist to use before declaring a patient brain dead. All 25 items had to be checked before making the declaration.

Motivating Power of Death

Death, and our awareness of it, is a primary motivating force for humans. We will do anything to evade it or psycholog­ically counter its reality.

Psychiatrist Ernest Becker (1973) argued in Denial of Death that humans try to negate death through heroism. "The most that any of us can seem to do," he wrote, "is to fashion something–an object or ourselves–and drop it into the confusion, make an offering of it, so to speak, to the life force."

Becker's book was such an offering, mot­ivated by his own impending death. He died of cancer in 1975 at the age of 49.

What was Becker's thesis in Denial of Death?

Erich Fromm (1956) wrote in The Art of Loving that awareness of death was an inescapable part of our greatest human gift: self-conscious­ness. Just as we recognize that we live, we recognize that we will die, and this creates powerful motivation to change the way we live.

Awareness of death creates "existential anxiety," the feeling of being a mortal, insignificant atom in the universe, Fromm argued. There are only a limited number of strategies for combat­ting that feeling.

The panorama of human history shows various attempts to overcome existential anxiety by reaching out to something outside the ego, according to Fromm. The best solutions, he suggested, were creativity and love.

Abraham Maslow faced death when he suffered a severe heart attack in 1957. He went on to live another 13 years, but the experience had a big impact on him. He wrote:

"The confrontation with death–and the reprieve from it–makes everything look so precious, so sacred, so beautiful, that I feel more strongly than ever the impulse to love it, to embrace it, and to let myself be overwhelmed by it. My river never looked so beautiful...

"Death and its ever-present possi­bility makes love, passionate love, more possible. I wonder if we could love passionately, if ecstasy would be possible at all, if we knew we'd never die." (In May, 1969, p.99).

How did Maslow react to a brush with death?

Children do not automatically fear death. In 1897, when G. Stanley Hall administered questionnaires to 2,000 people of all ages, asking about attitudes toward death, he concluded that young children have no inborn fear of death. Fear of death was more predominant in the responses of adolescents and adults.

What did G. Stanley Hall find out about children's fear of death?

Perhaps many children do not grasp the full implications of death. Childers and Wimmer (1971) found that many children below the age of nine regard death as avoidable or reversible.

My youngest son, when 5, asked me if it was true that "dead people don't come back." Many children take death in stride as a natural process, if they have not learned to fear it.

Suicide

While it is arguably a good thing to face the inevitability of death with poise, and to be inspired to live life fully after a brush with death, suicide is another matter altogether. Unless a person faces an agonizing terminal illness, suicide seems like a distressing and puzzling phenom­enon to those who love life.

Suicide is a leading cause of death in the modern era. Worldwide there are nearly a million deaths and 10 million attempts each year, with 60% occurring in Asia.

In the U.S., males committing suicide are more likely to use a gun. Suicides with guns are far more likely to be success­ful than other types such as drug overdoses.

Scientists from many disciplines have worked together to try to understand suicide. Some of their findings confirm previous suspicions and stereotypes, others do not. Among the major findings are these:

1. Suicide is typically not an isolated event in the life of an otherwise normal person. It is most likely to occur in somebody with recurring problems of drug abuse and/or depression.

A study of 67 teen suicides found that 40% of the victims suffered from "major depression" while at least a third were addicted to alcohol or other drugs.

2. Family problems are undoubtedly a major cause of unhappiness for some people. However, people who commit suicide are just as likely to come from a warm and stable family as an abusive or unstable family. Suicide appears to result from individual psychological factors more than family problems.

3. The best predictor of suicide is a history of previous suicide attempts. About 10-15% of attempters eventually die by suicide.

4. Suicide has a moderate tendency to run in families. "A person from a family of someone who attempts suicide has a higher risk of suicidality than someone from a family with no suicide attempts." (Holden, 1992)

What have researchers found out about suicide?

The risk of re-attempts after a suicide attempt is "highest during the first months and years after the attempt and appears to decline with time." That was the conclusion of a 37-year follow-up study of first-time attempters (Suominen et. al. 2004).

A 2005 review of suicide prevention efforts concluded that two approaches reduced suicide levels. One was doctor awareness of depression; the other was limiting access to means of killing. Public education and screening programs were not effective (Mann et al., 2005).

Among types of psychotherapy, cognitive behavior therapy (CBT) produced the most evidence for effectiveness at preventing suicide. When used with suicide attempters in a randomized, controlled trail, ten sessions of CBT resulted in 50% reduction in repeated suicide attempts (Brown et al, 2005).

One reason CBT works to reduce reattempts at suicide is that CBT targets the distinctive ideation (thinking) behind suicide. Suicidal people are not only depressed; they have a distinctive way of thinking, typically including an irrational conviction that their feelings or circumstances will never change.

That is not literally true. Therefore it provides an opening for a therapy like CBT that specializes in challenging maladaptive thought patterns.

Therapists can point out that, realistic­ally, depression and bad times do not last forever. If a suicidal person can hold out for a while and stay alive, they are likely to be glad they did.

One of the surprising findings from suicide research is the presence of large differences between ethnic groups. Blacks are 60% less likely to commit suicide than whites.

In whites, the probability of suicide (after teenage years) goes up with age. But Eve Moscicki of the National Institute of Mental Health found that for African-American women suicide is "practically nonexistent" in old age.

What are some ethnic differences in the statistics about suicide?

There is a "strong link between adole­scent sexual orientation and suicidal thoughts and behaviors" according to a survey completed in 2000 (Russell and Joyner, 2000). That survey was in the U.S., but similar results were reported from Korea and the Philippines.

Thirty-two young Mormons took their lives after their church announced policies they interpreted as anti-gay in November, 2015 (Wright, 2016). However, social attitudes are changing in many places. The correlation between suicide and sexual minority status may diminish in the future.

Researchers have found that people who attempt suicide are often low in the brain transmitter serotonin. One researcher referred to serotonin as a "brake" for violent impulses.

Suicidal people may be helped by SSRIs (selective serotonin re-uptake inhibitors) and similar anti-depressants that restore serotonin levels in the brain. In the U.S. there was a "dramatic decrease in the youth suicide rate" from 1993-2003, apparently due to increased prescription of antidepressants to teenagers (Gould, Greenberg, Velting, and Shaffer, 2003).

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References:

Becker, E. (1973). The Denial of Death. New York: The Free Press.

Brain death still a vexing issue. (2011) Clinical Updates for Medical Professionals–Mayo Clinic Retrieved from: http://www.mayoclinic.org/medical-professionals/clinical-updates/trauma/brain-death-still-vexing-issue .

Brown, G. K., Ten Have, T., Henriques, G. R., Xie, S. X., Hollander, J. E., & Beck, A.T. (2005) Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. JAMA, 294, 563-570.

Childers, P. & Wimmer, M. (1971) The Concept of Death in Early Childhood. Child Development, 42, 1299-1301.

Fromm, E. (1956). The Art of Loving. New York: Harper.

Gould, M. S., Greenberg, T., Velting, D. M., & Shaffer, D. (2003) Youth suicide risk and preventative interventions: A review of the past 10 years. Child and Adolescent Psychiatry, 42, 386-405. doi:http://dx.doi.org/10.1097/01.CHI.0000046821.95464.CF .

Holden, C. (1992). A new discipline probes suicide's multiple causes. Science, 256, 1761-1762.

Mann, J. J., Apter, A., Bertolote, J. et al (20 more authors). (2005) Suicide Prevention Strategies: A Systematic Review. JAMA, 294, 2064-2074. doi:10.1001/jama.294.16.2064 .

May, R. (1969) Love and Will. New York: Norton.

Russell, S. T. & Joyner, K. (2000) Adolescent sexual orientation and suicide risk: Evidence from a national study. American Journal of Public Health, 91, 1276-1281.

Suominen, K., Isometsa, E. Suokas, J., Haukka, J. Achte, K., & Lonnqvist, J. (2004) Completed suicide after a suicide attempt: A 37-year follow-up study. American Journal of Psychiatry, 161, 563-564.

Wright, J. (2016, January 29) 32 LGBT Mormons aged 14-20 have committed suicide in the wake of new anti-gay policy, group says. NCRM [blog] Retrieved from: http://www.thenewcivilrightsmovement.com/johnwright/32_young_lgbt_mormons_have_committed_suicide_since_early_november_group_says


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