Dying as a social relationship: a sociological review of debates on the determination of death

Social relations and exclusion among people facing death

In line with current policies and service developments related to palliative care, more people are dying at home. This situation has provoked discussions about the importance of non-medical issues related to death. The process of dying is often long, with many phases, and the social aspect is a major part of it. Our focus in this article is on dying as a social process. Social relationships are significant and play a meaningful role in enhancing the well-being of older adults approaching the end of life. Meaningful social relationships tend to change over time; however, and the process of dying may exacerbate such changes in and challenge these relationships. The aim of our study was to examine how social relationships are experienced and (re)constructed among older adults (70-83 years old) during the process of dying, in a Finnish context. We were interested in the nature and type of these relationships, and in the possible new forms of expression that may emerge during this process. Our empirical data were based on interviews with seven older adults who were close to death. The analysis revealed processes of exclusion from existing relations. At the same time, we observed new and unexpected relations being initiated, which sometimes became meaningful and supportive. The results highlighted the role of expectations and importance of analysing exclusion from a life-course perspective.

Student Nurses' Perception of Good Death and Religious Coping Styles

This research aims to examine the perception of the good death and religious coping styles of student nurses. The research is a correlational descriptive study. The research was conducted with 358 nursing students at a state university in the east of Turkey. It was found in the study that students had a good perception of death (58.83 ± 6.12) and mostly used positive religious coping styles (positive/24.55 ± 3.71, negative/13.31 ± 4.21). As a result of the correlation analysis, a weakly significant positive relationship was determined between good death perception and positive religious coping (p < .001).This study observed that students' perceptions of good death increased along with their positive religious coping styles.

Feeding the family at the end-of-life: An ethnographic study on the role of food and eating practices for families facing death in Portugal

Little has been said about the disruptive impact that the inability to eat and to participate in mealtimes has for patients with a life-threatening illness and their families. The aim of the current study is to overcome this gap and shed light on how food and eating practices are experienced by families at the end-of-life. An ethnographic research was developed in two Portuguese palliative care units: participant observation was conducted during 10 months and in-depth interviews were carried out with 10 patients with a life-threatening illness, 20 family members and 20 palliative care professionals. Food is not only a matter of nutrition in a biological sense, but also an act of giving care to patients with a life-threatening illness. The findings suggest that food and eating practices affect the processes of relationality and of doing family at the end-of-life in Portugal. Attention is particularly paid to gender differences. The study supports recent sociological research which understands the dying process as a relational experience and intends to develop sociological knowledge on the materialities of care.

Family refusal of eye tissue donation from potential solid organ donors: a retrospective analysis of summary and free-text data from the UK National Health Service Blood and Transplant Services (NHS-BT) National Referral Centre (1 April 2014 to 31 March 2017)

OBJECTIVES

Long-standing undersupply of eye tissue exists both in the UK and globally, and the UK National Health Service Blood and Transplant Service (NHSBT) has called for further research exploring barriers to eye donation. This study aims to: (1) describe reported reasons for non-donation of eye tissue from solid organ donors in the UK between 1 April 2014 and 31 March 2017 and (2) discuss these findings with respect to existing theories relating to non-donation of eyes by family members.

DESIGN

Secondary analysis of a national primary data set of recorded reasons for non-donation of eyes from 2790 potential solid organ donors. Data analysis including descriptive statistics and qualitative content analysis of free-text data for 126 recorded cases of family decline of eye donation.

SETTING

National data set covering solid organ donation (secondary care).

PARTICIPANTS

2790 potential organ donors were assessed for eye donation eligibility between 1 April 2014 and 31 March 2017.

RESULTS

Reasons for non-retrieval of eyes were recorded as: family wishes (n=1339, 48% of total cases); medical reasons (n=841, 30%); deceased wishes (n=180, 7%). In >50% of recorded cases, reasons for non-donation were based on family's knowledge of the deceased wishes, their perception of the deceased wishes and specific concerns regarding processes or effects of eye donation (for the deceased body). Findings are discussed with respect to the existing theoretical perspectives.

CONCLUSION

Eye donation involves distinct psychological and sociocultural factors for families and HCPs that have not been fully explored in research or integrated into service design. We propose areas for future research and service development including potential of only retrieving corneal discs as opposed to full eyes to reduce disfigurement concerns; public education regarding donation processes; exploration of how request processes potentially influence acceptance of eye donation; procedures for assessment of familial responses to information provided during consent conversations.

A Mixed Methods Approach of End-of-Life Care, Social Rites, and Bereavement Outcomes: A Transnational Perspective

The current article focused on examining the potential benefits of the End-of-Life (EoL) informal caregiving, communication, and ritualistic behaviors in adaptation to the conjugal bereavement across two different cultural-background contexts: France and Togo, West Africa. The investigation adopted a transnational approach including a total of 235 bereaved spouses. Despite the variation in the length of time since death, no significant difference was found between the Togolese and French bereaved with respect to the level of complicated grief symptoms. However, the Togolese bereaved perceived a significant postloss growth, fostered by EoL communication with the dying and the performance of ritualistic behaviors. In the French sample, bereaved individuals who had experienced more intimate communication with their dying spouse reported a high level of postloss growth. Moreover, findings showed that EoL caregiving without ritualistic support or communication is associated with poor postbereavement outcomes. These findings suggest a clinical need to promote informal caregiving to the dying, communication with the dying, and ritualistic support during the process of dying as entangled components of EoL care.

Beyond the hour of death: Family experiences of grief and bereavement following an end-of-life hospitalization in the intensive care unit

End-of-life decision-making is an important area of research, and few sociological studies have considered family grief in light of end-of-life decision-making in the hospital. Drawing on in-depth interviews with family members in the intensive care unit (ICU) during an end-of-life hospitalization and into their bereavement period up to six months after the death of the patient, this article examines bereaved family members' experiences of grief by examining three aspects from the end-of-life hospitalization and decision-making in the ICU that informed their subsequent bereavement experiences. First, this article explores how the process of advance care planning (ACP) shaped family experiences of grief, by demonstrating that even prior informal conversations around end-of-life care outside of having an advance directive in the hospital was beneficial for family members both during the hospitalization and afterwards in bereavement. Second, clinicians' compassionate caring for both patients and families through the "little things" or small gestures were important to families during the end-of-life hospitalization and afterwards in bereavement. Third, the transition time in the hospital before the patient's death facilitated family experiences of grief by providing a sense of support and meaning in bereavement. The findings have implications for clinicians who provide end-of-life care by highlighting salient aspects from the hospitalization that may shape family grief following the patient's death. Most importantly, the notion that ACP as a social process may be a "gift" to families during end-of-life decision-making and carry through into bereavement can serve as a motivator to engage patients in ACP.

Ethical challenges in family caregivers of patients with advanced cancer - a qualitative study

Background

Caring for patients with advanced or terminal diseases can confront family caregivers (FC) with ethical challenges. The present study aims at tracing paths connected to ethical challenges among FC of advanced cancer patients by exploring morally troubling situations and related burden, as well as strategies to handle the situation and experience of moral distress from the grieving FC’s perspective.

Methods

Within a qualitative design, interviews with 12 grieving FC were conducted using a semi-structured interview guide. Data were analysed using grounded theory and abductive reasoning.

Results

Core phenomena identified were two paths connected to ethical challenges among FC. Ethical challenges occurred in the context of difficult decision-making (Path 1) and in the context of lacking decision-making options when no decision was to be made by FC (Path 2). We found each path to be triggered by distinct sets of morally troubling situations that occurred during the patient’s disease trajectory. In the course of difficult decision-making (Path 1), detrimental external factors could add emotional stress, thus making the decision-making process burdensome. FC used various proactive strategies to overcome those detrimental factors and/or to make the decision. Decisions in conflict with FCs' own moral expectations and values led to moral distress, generating painful emotions. When no decision was to be made by FC (Path 2), FC felt powerless and overrun, which was associated with major emotionality in terms of anxiety and confusion. Either detrimental factors aggravated these feelings to paralyzing shock, or internal resources enabled FC to accept the situation. While acceptance prevented moral distress, paralyzing shock often caused a sense of not meeting their their own moral expectations and values, resulting in moral distress. In both paths, factors were identified that helped FC finding closure and prevented moral residue. Nevertheless, some FC experienced residual moral distress months after the morally troubling situation had occurred.

Conclusion

Findings provide first information towards understanding paths leading to ethical challenges in FC and can help clinicians to minimize associated emotional burden and moral distress.

Alignment and mismatch in role relations at end-of-life: A constructivist grounded theory study

In this Australian, constructivist grounded theory study, we undertook in-depth interviews with 11 dying people and 8 caregivers to examine their perspectives on role relations at end-of-life. We found that situations of role alignment between dying people and their family and friends support positive relational and practical outcomes, whereas role mismatch can cause considerable distress. Factors contributing to role mismatch at end-of-life were: dying people and their caregivers' efforts to shield each other from emotional harm; fear of social exclusion; and unwanted focus on the dying identity. Our findings highlight a need for flexibility and adaptability in end-of-life role relations.

Medicine, Technology, and Religion Reconsidered: The Case of Brain Death Definition in Israel

The introduction of respiratory machines in the 1950s may have saved the lives of many, but it also challenged the notion of death itself. This development endowed “machines” with the power to form a unique ontological creature: a live body with a “dead” brain. While technology may be blamed for complicating things in the first place, it is also called on to solve the resulting quandaries. Indeed, it is not the birth of the “brain-dead” that concerns us most, but rather its association with a web of epistemological and ethical considerations, where technology plays a central role. The brain death debate in Israel introduces highly sophisticated religious thought and authoritative medical expertise. At focus are the religious acceptance and rejection of brain death by a technologically savvy group of rabbis whose religious doctrine––along with a particular form of religious reasoning––is used to support the truth claims made from the scientific community (brain death is death) but challenge the ways in which they are made credible (instrumental rather than clinical). In our case, brain death as “true” death is made religiously viable with the very use of technological apparatus and scientific rhetoric that stand at the heart of the scientific ethos.

Unexpected death in ill old age: An analysis of disadvantaged dying in the English old population

The literature on death expectation in ill old age is mostly medical. A social science standpoint (especially quantitative) is practically absent. However, whether families, social and healthcare services can anticipate, support and prepare for the deaths of ill old adults is not reducible to the biomedical paradigm. Yet it is critical for end of life care (EOLC) policy. This study's aim is to investigate relatives' perception of death as unexpected in relation to both disease-related and care-related factors. Using the English Longitudinal Study of Ageing End-of-life Interviews Wave 6 this paper draws on probit regression analysis of unexpected (vs. expected) death in ill adults aged 50+. Findings are interpreted considering the containment of sudden death and the trajectories of dying in ill old age. The latter display overall visible decline preceding death. On this basis, EOLC literature and policy evidence death's uncertain timing as much as death's certain emergence in the horizon of expectation. Therefore, unexpected death in ill old age was interpreted as a failure to acknowledge dying, rather than the impossibility of discerning its approach. Very old age, dementia diagnoses and supported care environments were found to shape unexpected death.

Social, Economic, and Political Issues Affecting End-of-Life Care

For many decades, Americans showed a preference for delaying death through a technological imperative that often created challenges for nurses in caring for dying patients and their families. Because of their vast knowledge of health and healing, and their proximity to patients' bedsides, nurses are often well positioned to advocate for healthcare reform and legislation to improve end-of-life care. This article provides an overview of the social, economic, and political factors that are shaping end-of-life care in the United States. First, historical perspectives on end-of-life care are presented to enhance understanding of why some clinicians and patients seem to resist change to current practices. Second, end of care issues related to advanced technology utilization, societal expectations of care, clinical practices, financial incentives, palliative care services, and policy reforms are discussed. Finally, future recommendations are provided to encourage nurses and other healthcare providers to improve care for individuals facing end-of-life care decisions.

The Ontological Representation of Death: A Scale to Measure the Idea of Annihilation Versus Passage

Since the borders between natural life and death have been blurred by technique, in Western societies discussions and practices regarding death have became infinite. The studies in this area include all the most important topics of psychology, sociology, and philosophy. From a psychological point of view, the research has created many instruments for measuring death anxiety, fear, threat, depression, meaning of life, and among them, the profiles on death attitude are innumerable. This research presents the validation of a new attitude scale, which conjoins psychological dimensions and philosophical ones. This scale may be useful because the ontological idea of death has not yet been considered in research. The hypothesis is that it is different to believe that death is absolute annihilation than to be sure that it is a passage or a transformation of one's personal identity. The hypothetical difference results in a greater inner suffering caused by the former idea. In order to measure this possibility, we analyzed the correlation between Testoni Death Representation Scale and Beck Hopelessness Scale, Suicide Resilience Inventory-25, and Reasons for Living Inventory. The results confirm the hypothesis, showing that the representation of death as total annihilation is positively correlated to hopelessness and negatively correlated to resilience.

The troubles of telling: managing communication about the end of life

Communication about palliative care represents one of the most difficult interpersonal aspects of medicine. Delivering the "terminal" diagnosis has traditionally been the focus of research, yet transitions to specialist palliative care are equally critical clinical moments. Here we focus on 20 medical specialists' strategies for engaging patients around referral to specialist palliative care. Our aim was to develop an understanding of the logics that underpin their communication strategies when negotiating this transition. We draw on qualitative interviews to explore their accounts of deciding whether and when to engage in referral discussions; the role of uncertainty and the need for hope in shaping communication; and their perceptions of how patient biographies might shape their approaches to, and communication about, the end of life. On the basis of our analysis, we argue that communication is embedded in social relations of hope, justice, and uncertainty, as well as being shaped by patient biographies.

Organ donation as transition work: Policy discourse and clinical practice in The Netherlands

An increasing number of patients become eligible for organ transplants. In the Netherlands, at the level of policy discourse, growing waiting lists are often referred to as a persistent “shortage” of organs, producing a “public health crisis.” In this way, organ donation is presented as an ethical, social, and medical necessity. Likewise, policy discourse offers a range of seemingly unambiguous solutions: improving logistical infrastructure at the level of hospitals, developing organizational and legal protocols, as well as public information campaigns. Instead of taking these problem and solution definitions as given, we critically examine the relationship between policy discourse and clinical practice. Based on a historical review, first, we trace the key moments of transformation where organ donation became naturalized in Dutch policy discourse, particularly in its altruistic connotation. Second, based on in-depth interviews with medical professionals, we show how those involved in organ donation continue to struggle with the controversial nature of their clinical practice. More specifically, we highlight their use of different forms of knowledge that underlie clinicians’ “transition work”: from losing a patient to “gaining” a donor.

Thinking beyond rupture: continuity and relationality in everyday illness and dying experience

This article challenges the dominance of a rupture model for understanding how we live day-to-day with life-threatening illness and the prospect of death. It argues that this model acts as a key interpretive framework for understanding dying and its related experiences. As a result, a rupture model upholds a normative and inherently crisis-based view of severe ill-health that reifies dying as an experience which exists outside of, and somehow transformatively beyond, everyday matters of ordinary life. These matters include the minutiae of daily experience which inform and shape our lived identities - as individuals and as relational selves. Drawing primarily on interview data from two family case studies that have contributed to an ethnographic project exploring family experiences of living with life-threatening illness, it will show how mundane, daily life is integral to understanding the ways in which families are produced and able to maintain a sense of continuity during circumstances of impending death. The analysis presented here moves analytical understanding of dying experience towards a theory of how individuals and families 'know' and engage with so-called 'big' life events and experiences. In this way, my study helps generate a novel and more inclusive way of understanding living with life-threatening/limiting illness.

Vigils for the Dying: Origin and Functions of a Persistent Tradition

This article argues that vigils for the dying owe their origins to traditional wake behavior. By viewing vigils for the dying as wake behavior, the different social conduct observed around vigils for the dying can be viewed more systematically and predictably. Vigils represent so much more than ways to manage loss and grief or to shore up support at a difficult time for the dying and their families. Vigils help establish the reality of death, protect and advocate for the dying person, and can express dissent and re-exert control over the circumstances of dying and death. The implications of these various social functions are discussed in relation to their conceptual limitations and implications for further empirical research.

The end of life and the family: hospice patients' views on dying as relational

The end of life is a highly emotive and critical period in the life course and families often play a central role during this time. Despite significant sociological work on dying as a relational experience, there has been little exploration of the significance of contemporary family structures and relations. In this article, drawing on the accounts of twenty hospice in-patients, we explore how the end of life (in this case within an in-patient unit) is mediated by family dynamics and expectations. Participants' accounts reveal a range of interpersonal experiences, including: pressures and strains on families and patients; differentiation in family responses to and involvement in the dying process; and tensions between individual and family preferences/desires. We argue that family dynamics strongly influence individual experiences near death and that the focus on individual preferences and the management of disease in palliative care contexts must be augmented with sophisticated and nuanced understandings of the family context. We suggest that sociological conceptual explanations of shifts in social and family life, such as individualisation and ontological security, may also help us better understand the ways families approach and respond to the dying process.

The Emergence of Thanatology and Current Practice in Death Education

Thanatology is a recent field that contemplates death studies and employs an interdisciplinary approach to practice. This science emerged in a historical context marked by intense social, economic, and political changes that contributed to the concept of death being excluded from social life. This literature review aims to outline the history and evolution of thanatology in Western society, delineating the contextual circumstances that led to its origin and drawing special attention to current works on death education. In our post-modern society, the call for studies in the field of thanatology appears to be increasing. However, although there have been significant contributions and promising research is underway, there are still many questions to be answered.

On euthanasia, resistance, and redemption: the moralities and politics of a hospice

Euthanasia/assisted dying, the desire to hasten death, and religious supportive care at the end of life are controversial issues that have been heavily debated within the academic and medical communities. Little research has been done on hospice patients' views, despite hospices being political spaces, espousing a range of perspectives on assisted dying, religiosity, and "good deaths." In this article I document the presence, articulation, and significance of these issues as perceived and experienced by 20 hospice inpatients in the last 4 weeks of their lives. Key themes to emerge included polarization in desire for hastened death and assisted dying in the hospice; the hospice as a morally bound space situated within particular notions of "dying well"; and the divisive character of religion as part of formalized hospice care. Theoretically, the participants' perspectives on euthanasia/assisted dying and religiosity in the hospice provide a means of unpacking and revealing the moral economy of modern dying practices and the institutional governance and production of "timely deaths."

On the meanings and experiences of living and dying in an Australian hospice

Drawing on qualitative interviews with patients near death, in this article we explore people’s experiences of living and dying in a hospice in-patient unit. The results illustrate the tensions and complexities of entering into the hospice environment and how its character (i.e. people, interactions and spaces) shapes experiences near death.The results illustrate the hospice in-patient unit as playing a vitally important role in supporting the end of life, but also, the unique challenges this environment presents to individual well-being. Key themes emergent from the interviews were: loss of self and identity nostalgia; liminality and the home/help dialectic; and the performative elements of dying. To explore and unpack these processes, we draw together different facets of previous conceptual work in sociology, working towards a more nuanced conceptualization of the in-patient hospice experience.

Physicians' psychosocial barriers to different modes of withdrawal of life support in critical care: A qualitative study in Japan

Despite a number of guidelines issued in Anglo-American countries over the past few decades for forgoing treatment stating that there is no ethically relevant difference between withholding and withdrawing life-sustaining treatments (LST), it is recognized that many healthcare professionals in Japan as well as some of their western counterparts do not agree with this statement. This research was conducted to investigate the barriers that prevent physicians from withdrawing specific LST in critical care settings, focusing mainly on the modes of withdrawal of LST, in what the authors believe was the first study of its kind anywhere in the world. In 2006-2007, in-depth, face-to-face, semistructured interviews were conducted with 35 physicians working at emergency and critical care facilities across Japan. We elicited their experiences, attitudes, and perceptions regarding withdrawal of mechanical ventilation and other LST. The process of data analysis followed the grounded theory approach. We found that the psychosocial resistance of physicians to withdrawal of artificial devices varied according to the modes of withdrawal, showing a strong resistance to withdrawal of mechanical ventilation that requires physicians to halt the treatment when continuation of its mechanical operation is possible. However, there was little resistance to the withdrawal of percutaneous cardiopulmonary support and artificial liver support when their continuation was mechanically or physiologically impossible. The physicians shared a desire for a "soft landing" of the patient, that is, a slow and gradual death without drastic and immediate changes, which serves the psychosocial needs of the people surrounding the patient. For that purpose, vasopressors were often withheld and withdrawn. The findings suggest what the Japanese physicians avoid is not what they call a life-shortening act but an act that would not lead to a soft landing, or a slow death that looks 'natural' in the eyes of those surrounding the patient. The purpose of constructing such a final scene is believed to fulfill the psychosocial needs of the patient's family and the physicians, who emphasize on how death feels to those surrounding the patient. Unless withdrawing LST would lead to a soft landing, Japanese clinicians, who recognize that the results of withdrawing LST affect not only the patient but those around the patient, are likely to feel that there is an ethically relevant difference between withholding and withdrawing LST.

Brain death, states of impaired consciousness, and physician-assisted death for end-of-life organ donation and transplantation

In 1968, the Harvard criteria equated irreversible coma and apnea (i.e., brain death) with human death and later, the Uniform Determination of Death Act was enacted permitting organ procurement from heart-beating donors. Since then, clinical studies have defined a spectrum of states of impaired consciousness in human beings: coma, akinetic mutism (locked-in syndrome), minimally conscious state, vegetative state and brain death. In this article, we argue against the validity of the Harvard criteria for equating brain death with human death. (1) Brain death does not disrupt somatic integrative unity and coordinated biological functioning of a living organism. (2) Neurological criteria of human death fail to determine the precise moment of an organism's death when death is established by circulatory criterion in other states of impaired consciousness for organ procurement with non-heart-beating donation protocols. The criterion of circulatory arrest 75 s to 5 min is too short for irreversible cessation of whole brain functions and respiration controlled by the brain stem. (3) Brain-based criteria for determining death with a beating heart exclude relevant anthropologic, psychosocial, cultural, and religious aspects of death and dying in society. (4) Clinical guidelines for determining brain death are not consistently validated by the presence of irreversible brain stem ischemic injury or necrosis on autopsy; therefore, they do not completely exclude reversible loss of integrated neurological functions in donors. The questionable reliability and varying compliance with these guidelines among institutions amplify the risk of determining reversible states of impaired consciousness as irreversible brain death. (5) The scientific uncertainty of defining and determining states of impaired consciousness including brain death have been neither disclosed to the general public nor broadly debated by the medical community or by legal and religious scholars. Heart-beating or non-heart-beating organ procurement from patients with impaired consciousness is de facto a concealed practice of physician-assisted death, and therefore, violates both criminal law and the central tenet of medicine not to do harm to patients. Society must decide if physician-assisted death is permissible and desirable to resolve the conflict about procuring organs from patients with impaired consciousness within the context of the perceived need to enhance the supply of transplantable organs.